An Experience in Sub-Optimal Care from an NP

For a recent article on the Rise of Advanced Practitioners, Mary Christ, a physician, member of the Physicians Practice editorial advisory board, and healthcare IT physician executive consultant, spoke with us about a challenging experience she encountered in obtaining optimal care from a nurse practitioner (NP) who was added to her sister’s long-term sub-specialist’s staff.  She reported that it became nearly impossible for her sister to interact directly with her doctor, and she often felt as if she had to become her sister’s personal physician when the NP consistently proved to be incapable of handling her care.  Below are her thoughts on the experience, where NPs fit into today's medical practice, and more:  

My sister’s suboptimal care by an NP did not "cloud" my judgment about the entire NP profession, but it was the instigating event that made me start to think about the entire NP/physician equation.  It actually gave me the impetus to do some research to understand how NPs are trained and then used as adjuvant practitioners.   

I try very hard in my life not to stereotype a group by the actions of a few, so it never occurred to me [after my sister's visit] that all NPs were incompetent or undertrained.  Interestingly, right after my sister’s poor experience with an NP, my initial thought was that her doctor was the flawed piece of the entire puzzle.

I felt as if her physician was pushing off her ‘difficult’ patients, or her patients possibly requiring extra time and/or effort, onto the NP.  Ultimately, this resulted in the NP appearing ill-equipped to properly care for this doctor's particular set of patients.  Like I said, I didn't blame the NP, but I felt as if the physician sorely misjudged the areas where an NP can be tremendously useful.  

This particular physician's patient population includes people with long-term, chronic, rare diseases requiring an exceptionally high degree of medical knowledge, research, etc. This turned out to be a completely wrong place to inject an NP.  And, it's not that there's anything wrong with NPs, it's just that they are not educated or equipped for every role in clinical practice.  After all, my sister’s doctor is a sub-sub-specialist, so how on earth would an NP have much value-add?

Overall, my sister’s relationship with her long-term physician ended because she persisted in trying to offload her work on NPs who merely wasted patients' time and added another level of distance from the doctor.  I discovered a couple of years later that many patients left her practice when they were forced to first make an appointment with the NP, and then could only actually see the physician if the NP deemed it necessary.  This might work with the common cold, but definitely not in an area dealing with rare, wholly-debilitating diseases.

From my perspective, this particular experience allowed me to examine a situation that I may never have given a second thought.  For instance, I've worked with NPs in the ED for years and they are terrific in their roles doing specific, common, repetitive tasks.  A prime example in my ED was a tremendously professional NP who specialized in performing "rape kits" on unfortunate victims; she was wonderful with the patients, and became an expert in performing the tedium inherent to the rape kit procedures.  Similarly, we had NPs who would counsel teens on birth control and administer contraceptives.  

I think the bottom line is we must use NPs appropriately in areas commensurate with their actual training and abilities.  And, even more importantly, there should be close monitoring with specific guidelines as to which procedures, dispensing of advice and medications, and so on they are allowed to do.  One would think this would be an obvious approach to bringing adjuvant providers into the mix, but I fear those steps have been completely overlooked.