Nurse practitioners are staffing retail health clinics, diagnosing and treating ills from strep throat to conjunctivitis. They’re giving flu shots and prescribing drugs. And the influential Institute of Medicine says they should not only work side by side with physicians, but replace them in some cases.

But a survey published on Wednesday shows a huge gap between what nurse practitioners think they can and should do, and what doctors think. And that’s bad news for patients, Karen Donelan of the Mongan Institute for Health Policy at Massachusetts General Hospital says.

“We were surprised by the level of disagreement reported between these two groups of professionals," says Donelan, who led the survey published in the New England Journal of Medicine.

Her team’s survey of 467 nurse practitioners and 505 physicians found both groups agree that nurse practitioners should practice “to the full extent of their education and training.” Where the disconnect comes is just what this training should allow them to do, and how much they should get paid for it.

Only 17 percent pf physicians agreed that nurse practitioners should coordinate a patient’s care as a leader of a “medical home”, versus more than 82 percent of the nurse practioners, the survey found. And only 3.8 percent of doctors felt that a nurse practitioner should be paid the same for providing the same service as a physician, compared to 64 percent of the nurse-practitioners.

“At the core of the controversy is whether nurse practitioners have the education and experience to provide high-quality services and lead clinical practices without supervision by a physician,” Donelan’s team wrote.

The Institute of Medicine tried to settle that question in a 2010 report, saying that nurses can handle much of the strain on the health care system and should be given both the education and the authority to take on more medical duties.

But the American Medical Association, which represents about 120,000 practicing physicians and students, rejected the idea immediately.

"Nurses are critical to the health care team, but there is no substitute for education and training," the AMA said at the time.

The Association of American Medical Colleges estimates that by 2015, the United States will be short about 62,100 physicians. Many experts are looking to the 180,000 nurse practitioners now in the field to help cover the gaps.

When the Robert Wood Johnson Foundation set up a series of meetings among doctors’ and nurses’ guilds to try to smooth out the disagreements in 2011, things looked up until the organizers issued a report urging less hierarchy, says John Iglehart of the journal Health Affairs in a separate commentary in the New England Journal. “The `captain of the ship' notion  … needs to be eliminated, focusing on the patient as the driver of care,” the report read. “A physician, nurse, social worker or other provider may take the lead in a given situation.’

The American Academy of Family Physicians,  American Osteopathic Association and the American Academy of Pediatrics pulled out and the whole attempt collapsed, Iglehart says.

Dr. David Blumenthal and Melinda Abrams of the Commonwealth Fund said the survey confirmed that doctors and nurse practitioners often “inhabit different universes”.  And clearly they have different training and skills. Nurse practitioners, often referred to as advanced practice registered nurses, usually have a four-year bachelor's degree with at least a master's degree and sometimes a doctorate beyond that, depending on the requirements of their state.

But nurse practitioners can fill the growing gap in the supply of health care prviders for the U.S., they argued. “The existing literature shows that nurse practitioners provide care similar to that of physicians with respect to health outcomes, resource utilization, and cost, and the same studies show that nurse practitioners get higher grades than physicians with respect to communication with patients seeking urgent care,” they wrote.

Jan Towers, policy director for the American Association of Nurse Practitioners, saw it coming. “There is nothing surprising there,” she said in a telephone interview. “The disconnect has been there a long time.”

She thinks relationships will improve as doctors and nurse practitioners work together more. A bigger issue, Towers says, is the way the U.S. healthcare system pays for care. “How do we institute value-based purchasing so that we look at outcomes rather than who is performing the task?” she asked.

Once the medical system evolves toward taking care of a patient’s health, instead of the current system of paying for each individual test, treatment or consultation, the differences should even out, she predicts.

Donelan isn’t so hopeful. “Our findings suggest that a substantial number of primary care physicians are unlikely to embrace policy recommendations aimed at further expansion of the roles and supply of nurse practitioners,” her team wrote.

“In particular, physicians' concerns about the likely effect of an expanded workforce of nurse practitioners on several aspects of health care quality need to be addressed in discussions of strategy for the development of the U.S. health care workforce.”

Peter Buerhaus, director of the Center for Interdisciplinary Health Workforce Studies at Vanderbilt University and a registered nurse with a Ph.D who worked on the survey team, agreed.

"It is unsettling that primary care physicians and nurse practitioners, who have been practicing together for several decades, seem so far apart in their perceptions of each other's contributions. I am concerned that these large gaps in perceptions will inhibit efforts to redesign care delivery and to improve the productivity and configuration of the primary care workforce,” Buerhaus said in a statement.

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By Trevor Stokes
MyHealthNewsDaily
Doctors have similar levels of bias against people who are overweight as the general public, a new study says.

Additionally, physicians are likely not aware of their own biases, the study showed.

"The most striking thing is that physicians are like others in society, and hold negative attitudes about weight," said study researcher Janice Sabin, an assistant professor at the University of Washington. "Our study did not look at behavior, so we don't know whether or not this actually affects the patient-provider relationship," she added.

Previous research identified weight biases in doctors, but the new study found that their level of bias is similar to that of the public.

Sabin and her colleagues included nearly 360,000 participants in their study, including 2,284 medical doctors. The researchers used a computer test designed to measure both explicit biases, of which people are aware, and implicit biases, which people do not recognize they hold.

Results showed that female doctors were less biased against obese people than male doctors. "Even though there was a slight difference, bias was strong among both men and women," Sabin told MyHealthNewsDaily.

Obese doctors were generally more sympathetic to overweight people, the study also found.

Weight bias could affect the nearly two-thirds of people in the U.S. who are overweight or obese, according to researchers.

Rebecca Puhl, director of research at the Rudd Center for Food Policy & Obesity at Yale University, said the study underscores the need to educate doctors about weight bias, and provide them with strategies to reduce bias in their interactions with patients.

"Weight bias jeopardizes patients' emotional and physical health, and that some patients may even avoid future health care because of weight bias in the health care setting," said Puhl, who was not involved in the study.

Weight bias can show up in many ways — doctors may use derogatory language, blame health problems on weight and even deny certain medical procedures based on weight, Puhl said.

But patients have several options if they feel stigmatized by health care providers. They can express their concerns to doctors, and should be specific and assertive in what they would like to see change, Puhl said.

Bringing along a friend or family member to an appointment can also help. "If patients are reluctant to speak to their provider, or feel that attempts to do so have been unsuccessful, patients can alternatively voice their concerns to the Patient Advocate at their health center," Puhl said.

Sabin noted that the study did not demonstrate that overweight or obese patients are actually treated differently by their doctors.

"Just because a person has bias does not mean that they are going to discriminate, and that's something important that I always try to emphasize," Sabin said.

The study was funded by Project Implicit, a nonprofit organization that examines unspoken biases, and is published online today (Nov. 7) in the journal PLoS ONE.

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By Sarah Barr
Kaiser Health News

Few doctors think of themselves as rich, and only about half think they’re fairly compensated, according to survey results released this week by Medscape.

The annual survey isn’t scientific – and perhaps, not surprising, either — but it offers insights into what nearly 25,000 physicians earn, and how they view that number. In 2011, compensation self-reported by surveyed physicians ranged from an average of $156,000 for pediatricians to $315,000 for radiologists and orthopedic surgeons.

The survey showed that 51 percent of all physicians — and 46 percent of primary care physicians – think they’re compensated fairly.

Only about 11 percent of doctors consider themselves rich, mostly because of their debts and expenses, according to Medscape.

The survey also offers a glimpse at how physicians view coming changes to the health care system, such as efforts to improve quality or offer care through accountable care organizations, which are integrated systems included in the federal health law.

More than half said they expect their incomes to decline because of ACOs (although very few were participating in such a system), and only 25 percent said quality measures and treatment guidelines will improve patient care.

Overall, 54 percent of physicians said they would choose medicine as a career again. Only 41 percent said they would choose the same specialty and 23 percent would choose the same practice setting.

Others groups that survey physicians about their income include the Medical Group Management Association and Merritt Hawkins. A 2011 MGMA report, for instance, which looked at data from 2010, found the median compensation for radiologists was $471,253 and $192,148 for physicians in pediatric/adolescent medicine.

Medscape surveyed 24,216 physicians across 25 specialty areas from Feb. 1-17, 2012 using a third-party online survey collection website.

Physician compensation in 2011:

Pediatrics -- $156,000
Psychiatry -- $170,000
Obstetrics/Gynecology -- $220,000
General surgery -- $265,000
Plastic surgery -- $270,000
Cardiology -- $314,000
Orthopedics -- $315,000
Radiology -- $315,000

For complete chart: http://capsules.kaiserhealthnews.org/wp-content/uploads/2012/04/doc-salaries-500.png

This story was produced in collaboration with Kaiser Health News, an editorially independent program of the Kaiser Family Foundation, a nonpartisan health care policy research organization which is unaffiliated with Kaiser Permanente

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Last June 19, four people died in a brutal massacre in a drugstore on Long Island. After getting a 911 emergency call, Suffolk County homicide detectives found four people shot dead at Haven Drugs in Medford, 60 miles east of New York City. Addiction to prescription painkillers played a key role in this horrible event. 

Now the family of one of those killed is calling the doctors who prescribed drugs for the convicted murderer to account. Antonia Mejia, mother of the youngest victim, 17-year-old Jennifer Mejia, has filed a lawsuit alleging negligence on the part of Stan Li, Eric Jacobson and Mark Kaufman, all doctors who allegedly wrote pain med prescriptions for the killer.

She is right to pursue this novel legal strategy.

Jennifer, who worked at the store, pharmacist Raymond Ferguson, 45, and two customers, Jaime Taccetta, 33, and Bryon Sheffield, 71, were shot dead by David Laffer.  He walked into the drug store last Father’s Day, minutes after it opened, and rapidly shot the pharmacist, Jennifer and the two customers at close range. He then filled up a backpack with 10,000 prescription painkillers and fled. All of this was caught on the store’s video recorder.

Suffolk County Police Commissioner Richard Dormer said, “In all my law enforcement experience and in the experience of the police that are involved in this investigation, this is one of the most heinous, brutal crimes we have ever encountered.”

Laffer was quickly caught and convicted.  It became clear during his trial that he had a long history of addiction to painkillers and an equally long history of doctors prescribing drugs to him.

The abuse of pain medication in the U.S. is out of control. While illegal street drug use has declined, abuse of prescription medications, especially painkillers, has been increasing. Emergency department visits for nonmedical use of opioid analgesics climbed by 111 percent between 2004 and 2008, and jumped nearly 30 percent between 2007 and 2008 alone, according to a 2010 report by the Centers for Disease Control and Prevention.  

Who is partly to blame for this mess? Certainly some doctors should be. The key source of painkiller abuse is the medical establishment. A few bad apples prescribe painkillers to anyone who comes in the door, often giving them multiple prescriptions.

Jennifer’s mother has no doubt about the role played by doctors in feeding the drug habit of Laffer. She told the Long Island newspaper Newsday, "The main reason we came to this point [filing a lawsuit] is because the doctors fed his [Laffer's] addiction -- they know what they are creating when they write these prescriptions."

There will be an impassioned defense by the doctors named in the lawsuit. It may turn out that they did nothing wrong in prescribing for Laffer. But there are reports of docs who write scripts for cash for pain pill addicts, though those are, admittedly, rare. It may also turn out that Laffer is partly a creation of bad medicine.

Not so long ago, the world focused in on the role played by Michael Jackson’s personal physician, Dr. Conrad Murray, who was found guilty of involuntary manslaughter after giving Jackson the dangerous and powerful anesthetic propofol to help him sleep. 

It is long past time to move past the odd celebrity physician case and hold doctors accountable for the damage they do in misprescribing far less exotic drugs than propofol. 

If we can all spend so much time and energy worrying about and hoping for justice for the Conrad Murrays of the world, shouldn’t we create a public policy and legal doctrine that hold accountable those doctors who prescribe these potent painkillers indiscriminately?

Arthur Caplan, Ph.D., is director of the Center for Bioethics at the University of Pennsylvania.

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Everybody lies — even doctors. 

"Our findings raise concerns that some patients might not receive complete and accurate information from their physicians," the researchers write in the February issue of the journal Health Affairs. The findings also question whether patient-centered care — which is a philosophy of medicine that respects the preferences, needs and values of patients — is possible without more openness and honesty, the researchers from Harvard Medical School said.

While the ultimate effect of such untruths is not known, they could make patients "less able to make health care decisions that reflect their values and goals," the researchers said.

To be fair, the researchers acknowledged not knowing the circumstances under which physicians lied, and communication regarding health issues can be complex. Physicians must often wade through conflicting and confusing information as a case goes on. Telling a patient something that turns out to be wrong might not be helpful, the researchers said.

More research is needed to better understand when and why physicians feel justified in a lapse of honesty.

Dr. Arthur Caplan, a medical ethicist at the University of Pennsylvania and msnbc.com contributor, told the Associated Press that to withhold a mistake is "inexcusable," adding that a physician's "care now has to be different because of what happened."

In a poll for msnbc.com, Truth On Call asked 100 physicians, including those in family practice, cardiologists and neurosurgeons if they've ever kept a serious medical mistake from a patient. Twenty one percent admitted they kept an error from the patient, 55 percent say they disclosed the mistake and 24 percent say they've never made a serious medical error.

In fact, 55 percent said that they had "described a patient’s prognosis in a more positive manner than warranted," in the last year, and about 28 percent said they had "intentionally or unintentionally revealed to an unauthorized person health information about one of [their] patients."

In addition, about 35 percent of doctors did not agree with the statement that physicians should " disclose financial relationships with drug and device companies to heir patients."

Women and minority physicians were more likely than white, male doctors to say they agreed with the principles of honesty and openness, according to the study. This may be because, as underrepresented groups in medicine, women and minorities feel more compelled to comply with such professional codes, the researchers wrote.

Some physicians might not tell their patients the whole truth because they don’t want to upset them, worry them or cause them to lose hope, the researchers said.

"Especially in the context of life-threatening illness, physicians might not tell patients the complete truth because of lack of training, time limitations, uncertainty about prognostic accuracy, family requests and feelings of inadequacy about their medical interventions," the researchers said.

Some physicians may also wonder about revealing errors when no harm came of them. However, studies show that "informing patients fully about medical errors can reduce anger and lessen patients’ interest in bringing malpractice lawsuits," the researchers said.

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A database of disciplinary action against doctors and other medical professionals that was closed in September has been restored, but with new restrictions intended to prevent reporters from using it to “out” individual doctors with troubled track records.

As detailed almost two months ago in Open Channel, the Health Resources and Services Administration, or HRSA, an agency of the Department of Health and Human Services, eliminated access to the National Practitioner Data Bank after discovering that reporters had managed to link the data, which masks identifying information, to local malpractice cases and disciplinary cases.

The New York Times reported Thursday that it was taken down “in response to a doctor’s complaint,” and ProPublica published this account.

In any case, HRSA on Wednesday restored the database, but with a new requirement that anyone who uses it agrees not to cross-check it against other public information, such as court files, to put names to the numbers.

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In a statement accompanying the restoration, HRSA Administrator Mary K. Wakefield said that the database remains an important tool “to protect patients from incompetent, unprofessional, and often dangerous health care practitioners.” But noting that federal law restricts the confidential information identifying individual doctors, she said that if the agency discovers a journalist or other individual has used the public version in combination with other sources to identify a problem doctor, “HRSA will ask for the data to be returned.”

Her statement provided no details on how such a demand would work, but it presumably it would occur only after publication of a story linking the data to an individual doctor.

The Times quoted Charles Ornstein, president of the Association of Health Care Journalists and a reporter with the nonprofit investigative news organization ProPublica, as saying that's one reason the rule appears to lack teeth.

“It’s troubling that a federal agency is telling reporters what they can or can’t do,” he told the newspaper. “And how are they going to enforce this?”