Letters to the Editor
Article Outline
- Dear Editor
- Dear Editor
- Author's Response
- Dear Editor
- Dear Editor
- Dear Marsha Siegel
- Dear Editor
- Section Editor's Response
- Copyright
Dear Editor
I read with great interest the argument on pronouncing death and whether NPs are suited for such a role (“Should APRNs Be Allowed to Pronounce Death or Certify Cause of Death?” JNP February 2010). As an RN for 20 years, a retired commanding officer of a large city major crime/homicide unit for 19 years, and a second-year FNP student, there is absolutely no doubt in my mind that a well-educated and practicing NP would not have any difficulty in this advanced role of pronouncing death. In fact, in order for the NP profession to move forward and be mutually respected as quality providers of primary care medicine, NPs should unite and support state-by-state legislation attesting to this very point.
I am often amazed each month when I read how many of my peers argue that the NP profession should be limited in function, (such as) “no death certificates” or “must have MD collaboration” and so forth. The self-reflection and countering opinions are honorable, but providing ammunition to those who oppose us or want to limit us in our roles as APRNs is just poor strategy in regard to unification and progression as a profession.
John G. Brenner, RN, MS Westport, CT
Dear Editor
I read with great interest the article in the JNP February 2010 issue “Concierge Medicine: The Perfect Storm?” I had not previously heard of this trend. I thought, once again, people with the entrepreneurial spirit that made this country great are finding more and different ways to bring a service to the market. However, I did find it somewhat disturbing that the article had a seemingly obvious theme—anticapitalism.
In the past, I responded to a commentary by Dr. Thad Wilson regarding the viability and direction of our healthcare system (JNP, July/August, 2009). In his article, Dr. Wilson proposed that profit should be considered as a secondary motive for providing healthcare to Americans. I, on the other hand, suggested that without profit, there would be little to no incentive for delivery of that care and, soon, healthcare would diminish in quality and quantity.
In the exposé on concierge care, the authors have made some attempt to be objective in their reporting on this trend of healthcare delivery. The title, however, sets the mood for the piece with a negative connotation. Subheadings continue to set the stage with “Disparities Worsened” and “The Menace: A Perfect Storm.” Such statements as, “…the greater the growth of this delivery model, the greater will be the threat to the healthcare system in the United States” and “…concierge medicine serves the well-to-do and perpetuates a two-tiered healthcare system based upon ability to pay” ignore, in my opinion, the true debate—the effects of government intervention (read nationalized healthcare) in a free enterprise system.
Concierge medicine, or boutique medicine as some call it, is one more response to overregulation by the government in an attempt to “level the playing field,” in this case, access to healthcare services. There are many in this country that believe government intervention is the only means of bringing equity and justice to all, ensuring everyone is given access to resources for their health. To date, we have Medicare, Medicaid, and state- and community-run “free clinics” available to those in need. How successful have these programs been? Medicare is broke, Medicaid is broke, and many community-based services are frequently underfunded and understaffed.
How much more money and resources must we as a country and citizenry spend before we realize that government-mandated and taxpayer-funded programs will not solve all the problems? Similar to President Johnson's “War on Poverty” some 40 years ago, President Obama's “War on Healthcare Poverty” will require trillions of dollars the country does not have. Has poverty been solved in this country? No. Turning over nearly 18% of the country's gross domestic product to those that have a track record of mismanagement and failure seems foolish to me.
If a person has discretionary monies that they choose to spend on healthcare, they have the right to do so. Replacing this system with a government-run and -mandated, one-size-fits-all approach is antithetical to the American model of freedom. To repeat myself from the previous letter, profit is not bad; profit drives the engine behind advancement; without profit, we have no future.
Ronald R. Haggett, RN, MNSc, ACNP-BC, OCN, Little Rock, AR
Author's Response
In writing this article, we wanted to introduce and initiate a dialogue about the practice of concierge medicine within nursing. Because our search of the nursing literature revealed nothing about this practice model, we believed that nurses were not paying attention to it. We wanted to draw their attention to a delivery model that does have several potential unintended negative consequences. We addressed the possibility that healthcare disparities might increase if concierge practices continue to grow as physicians cater to those who can afford luxury care. In any economic system, whether capitalist or not, there will be those with many resources and those with few resources. Unless there are alternative practices available for vulnerable populations (those with few resources), they will likely be the ones who suffer.
We also addressed the possibility that nurse practitioners could provide high-quality primary care and thus ameliorate some the negatives of concierge practice. This solution fits well into our current system.
We find it gratifying that the dialogue has begun. While not in total agreement with this author about the “anti-capitalist theme” of the article, we, as nurses, readily admit that we do not believe that profit should be the primary motive for providing healthcare to Americans.
Jackie Hastings Jones
Dear Editor
I agree completely with your editorial (“NPs Continue to Be Under the Physician Microscope,” JNP, March 2010) and every study that states that NP care is similar to and outcomes are similar to physician care. However, there will never be a way that NPs' training and education will compare to physician training and education—even with the DNP included. Just compare clinical hours of training: the NP hundreds of hours to the physician thousands of hours are almost laughable. It is debatable if all that training and education is necessary to practice primary care, but it is the benchmark by which physicians are measuring NPs, and it is the basis for all the negative physician statements, articles, and biases. Unfortunately, we fall woefully short in comparison.
It is time that NPs prepare and publish their own Flexner Report (not a DNP white paper on leadership, scholarship, and collaboration [AACN, 2006]). Everything, and I mean everything, needs to be standardized. Clinical hours need to be increased; nurse “practitionering” is a clinical profession—we take care of people, not organizational systems and conceptual models of care. There are plenty of NPs working in acute care settings so that NPs can and should have a “real internship” that rivals a physician internship. If we position ourselves as primary care experts, the internship doesn't need to be 24 hours per day, but it can be just as intensive and rigorous.
The key to the NP/physician turf war is to claim primary care as our own. Physicians don't want it, and we are good at providing it. It doesn't mean that we can't provide acute care, and it doesn't mean physicians can't provide primary care. But we need to position ourselves as the primary care experts with education, rigor, and clinical training to match our stated expertise. Then and only then will the lens of the microscope be lifted.
Robert Woodard, APRN, West Hartford, CT
Dear Editor
Carolyn Buppert has provided two excellent case studies in her January 2010 column, “NPs Sued for Failing to Diagnose Breast Cancer,” that illustrate potential legal problems for nurse practitioners who evaluate breast masses. The importance of having an algorithm or protocol for managing any woman with a breast mass cannot be underestimated. Breast cancer is a major public health problem. An estimated 192,370 women are diagnosed annually and 40,170 women die from the disease each year (American Cancer Society [ACS], 2009). Breast cancer incidence and death rates generally increase with age. Approximately 95% of new cases and 97% of breast cancer deaths occurred in women age 40 and older (ACS, 2009).
Because of the high incidence of breast cancer, nurse practitioners need to consider all women at risk and evaluate all breast abnormalities thoroughly. Mammography is highly accurate, but it is not perfect. It is estimated to detect about 80% to 90% of the breast cancers in asymptomatic women (source: American Cancer Society. Breast Cancer Facts & Figures 2009-2010. Atlanta, GA, 2009). Mammography is more accurate in postmenopausal than in premenopausal women. The small percentage of breast cancers that are not identified by mammography may be missed because of high breast density, inadequate positioning of the breast, or simply failing to see the small early signs of an abnormality. Nurse practitioners cannot assume that a negative mammogram concludes the work-up of a breast abnormality.
An excellent algorithm that nurse practitioners should become familiar with can be found at the National Comprehensive Cancer Network (NCCN). Oncology professionals regularly consult these guidelines for the management of a variety of issues in cancer care. There are guidelines not only for treatment of most of the major cancers and symptom management but also for prevention, screening, and early detection for many of the common malignancies. These guidelines are reviewed and updated on a regular basis and are evidence-based. A free account must be set up once, but then, with a user name and password, the guidelines can be downloaded or viewed online at any time. For many, using the online version is easier as links move the user through the algorithm easily. In the back of the algorithm there is an explanation of the rationale and scientific evidence.
All of these guidelines would be a most valuable tool for nurse practitioners and can be accessed at www.nccn.org. When reviewing the guideline “Breast Cancer Screening and Diagnosis” (source: The NCCN Clinical Practice Guidelines in Oncology Breast Cancer Screening and Diagnosis [version 1.2010]. Available at NCCN.org) for both cases described by Buppert, the recommendation would have been more aggressive follow-up and biopsy, which, hopefully, would have resulted in earlier detection and more successful treatment of the breast cancer.
Suzanne M. Mahon, RN, DNSc, AOCN, APNG St. Louis, MO
Dear Marsha Siegel
I read “Cultural Changes,” (From the President, March 2010) with great interest. I do agree that as a profession we should be governing ourselves independently, working directly with legislators, unencumbered by the medical profession trying to set limitations. If the medical profession feels they should have a word in our legal management, then the reverse should be true, because whatever legal guidelines affect the medical profession, if we are “under” medical collaboration/supervision, affect us also. So we need to have a say in whatever legislation affects the medical profession as well.
As to our titles, they are confusing and are holding us back. Being called advanced practice RNs, etc., is like saying college graduate and high school graduate. Everyone knows that, to graduate from college, you need to have graduated from high school, so why repeat it in the title? The word nurse in nurse practitioner also has restrictive connotations. RNs have totally different focuses and objectives than NPs. I strongly believe the word nurse should be totally out of our title because our focus is no longer on practicing nursing—we now leave that to the professional nurse. We practice medicine. As to the specific terminology, I do not know—medical practitioner, practitioner of medicine? There are surely good suggestions from among the profession.
We need to cut the umbilical cord, stand up, and begin walking. Our profession has metamorphosed; we must be willing to accept the new creature we have become.
Thank you for the opportunity to voice my opinion.
Aline Taniguchi, NP
Dear Editor
After so many years of dialogue, discussion, and debate, over 70 stakeholders for the NP profession have given input and produced a strong model for nurse practitioner regulations (APRN Consensus Work Group & the National Council of State Boards of Nursing APRN Committee, Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education, available at http://www.aacn.nche.edu/Education/pdf/APRNReport.pdf). This action brings the NP profession closer to removing the illogical and inconsistent morass of varying state regulations that needlessly limit NP contributions and patient access.
I was disappointed to see the March issue of JNP with a Point/Counterpoint discussion of whether or not collaborative practice agreements (CPAs) should be required. This issue has been addressed by the profession and in the consensus model. To continue to hash out this argument and to poise the discussion as one of requirements does not serve the profession well. Barbara Resnick's well-reasoned essay highlights the benefits of a formalized written agreement—a good business practice always—but does not really address whether it should be required, although it is placed in the journal as an argument for requiring CPAs. Let us all get behind the model developed through the consensus document and work together to create meaningful improvements in state regulations so we can serve our patients better.
Nancy Rudner Lugo
Section Editor's Response
Dear Nancy,
I am truly sorry that you were disappointed by the Point/Counterpoint column topic of the March issue. I welcome your willingness to share your opinion. I agree that the issue of a required written collaborative agreement has been addressed in the Consensus Model for APRN Regulation. I personally applaud and support the tenets of the consensus model. Merely addressing the topic in model regulation does not necessarily reduce the level of interest in the topic. Many states continue to require such agreements as a condition for NP practice. Many state NP organizations and others continue to fight to eliminate what has often evolved into a burdensome requirement that delays NP employment and decreases access to care. The column is supposed to address controversial issues of interest to NPs. In my opinion, this was a timely and important topic, intended to stimulate thought, not disappoint readers.
Barbara Resnick addressed the issue of requirement of such an agreement from the perspective of a Medicare provider who regards the written collaborative agreement as a beneficial, albeit at times cumbersome, way to address this requirement. Some may not agree with her opinion, but we should applaud her willingness to share it.
Janet Selway
PII: S1555-4155(10)00225-4
doi:10.1016/j.nurpra.2010.04.011
© 2010 American College of Nurse Practitioners. Published by Elsevier Inc. All rights reserved.
