Husband and wife, doctor and nurse, at odds over nurses’ roles

At their home on Drummond Island off the east edge of the Upper Peninsula, dinner-time conversation can take on a distinctly medical flavor.

Donza Worden, a physician, has reservations about allowing nurses with advanced training to make medical diagnoses and prescribe medications without having to collaborate with a physician. Across the table, his wife, Catherine, a nurse practitioner – a specialty that requires a master's degree in nursing - has years of experience that lends her a different perspective.

“Many other states have independent practice (for nurse practitioners) now,” Catherine Worden said. “None of that data can show that there have been any harmful results to patients.”

Her husband issues a more cautionary take on a proposal – standard in 21 other states – that would allow Michigan nurses with a RN license and master's degree in nursing to practice and prescribe drugs for patients independent of a physician.

“In my experience hiring and working with 30 to 40 nurse practitioners over the years, I have not encountered a single nurse practitioner coming out of school who is prepared to practice autonomously,” said Donza Worden, 61. “The most efficient practice model is to have one physician collaborating with two nurse practitioners in rural health.”

Under current Michigan law, nurses must have a collaborative agreement with a physician to prescribe medications and there are some drugs they cannot prescribe, even with that agreement. Catherine Worden has that collaborative agreement with her husband, along with another nurse practitioner in the clinic they share on the east side of the UP, Pickford Medical Center.

More coverage: Giving Michigan nurses more authority to prescribe drugs and treat patients

Catherine Worden, 54, said she draws upon extensive clinical experience and education in deciding which patients she can competently treat and which she needs to refer to a physician.

After earning a bachelor's degree in 1983, Catherine Worden worked as a registered nurse in multiple specialties, including oncology, and as nursing supervisor in three hospitals. She returned to school in 1994 while she raised their two children, earning a master's degree in nursing from Michigan State University in 2000.

“All through school, you hear the words, scope of practice, scope of practice,” she said. “At MSU, I remember hearing that you can do about 80 percent of what a physician can do. You need to be able to recognize that other 20 percent.”

That 80 percent would encompass tasks like routine physical examinations, ordering of X-rays and other tests, treatment of common injuries and infections and managing chronic conditions such as obesity, diabetes and hypertension. The 20 percent might include more complicated conditions including major injuries, serious infections or various heart conditions.

Catherine Worden said her knowledge of her own professional boundaries is reinforced by the training and career track of their daughter, Erin, who is her fourth year of medical school at the University of Cincinnati.

“I know first hand that I don't have the same training as she does. What you need to be able to recognize is when you don't know something.”

In her years as a nurse practitioner, Catherine Worden has been primary care provider for a couple thousand patients scattered across a wide area. She has patients who drive down from Saulte Ste. Marie to see her at the medical clinic in Pickford. Another drives 70 miles from the town of Paradise for appointments. A young woman from Chicago sees her two or three times a year when she returns to visit her parents.

She has occasional frustrations about what she can and cannot do.

She can't sign the death certificate for a patient of hers, even though she may have known and treated the patient for years. She can't prescribe physical therapy. She can't prescribe medication for attention deficit hyperactivity disorder.

“I'm the one who's working with the family and the patient and yet I can't write those. It's very cumbersome for the patient.”

Catherine Worden said she doesn't believe medical practice would change much if Michigan approved full practice authority for nurses with advanced training – it would simply let them serve these patients more efficiently.

“Nurse practitioners generally see their patients for a long time, just like physicians. But a nurse practitioner is not a doctor, that's the bottom line.”

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Comments

EB
Thu, 10/08/2015 - 10:53am
The competency of both doctors and nurses is depicted with bell curves with some nurses on the right side of their curve being more competent than some doctors on the left side of the doctor curve. However, the median competency for doctors is probably far to the right of the median competency of nurses. Sure, you can find examples where a nurse practitioner is competent to be a doctor, but that's the exception. From personal experience I'll see a nurse practitioner when I already know what's wrong and just need the script or a relatively low skill procedure; but, when the diagnosis and the cure isn't obvious, I want a doctor. The current doctor/nurse-practitioner system isn't broke, so, don't fix it.
Rich scott
Fri, 10/09/2015 - 4:34am
The comment by Cheryl roves EB correct. Smart RN and concerned wife were smarter than referring doc. System may be broke because of inability to pass roadblocks in managed care and lack of excision making as joint effort. My relative demanded angiogram after prolonged treatment at major academic center with ct of lungs and many meds. She underwent emergent cardiac surgery immediately. Differential diagnosis of low wbc includes more than antibiotics, and ecertional shortness of breath should require careful valve study. Retired now, I regularly trusted CRNAs more than ologists under whom they practiced. They knew more.
Cheryl
Thu, 10/08/2015 - 2:30pm
I would say I disagree with the comment above. I have personally been a nurse for 12 years and recently obtained my np. I have cared for many people from different ages, different, conditions ect. If you only come to nps when you already know what's wrong and just need an rx I suggest that you stay with your md. I have on many occasions been told by various Dr's that I don't know what I'm talking about. For example, I knew my husband had leukemia and begged our primary care, a hospitalist md, as well as me demanding to see a hematologic and all 3 of those mds with various levels of experience noted that I was crazy, my husband's wbc was down bc of antibiotics and not to worry. After my husband could barely walk, eat, or do anything but sleep I demanded yet another hematologist and noted that I wanted a bone marrow biopsy. Reluctantly they preformed one in which the next day the md that told me I was a crazy np told me how sorry he was that indeed he had leukemia. We went inpatient that same day and once everything was done they noted thank god for that MD that caught this diagnosis bc your husband would have probably only 2 weeks to live if that. Yes thank god indeed but it was for his wife whom is a NP!! One final response is that our system is broke. The mds are not wanting to get into areas such as family practice and rural health bc the pay is so low, nps are willing to bridge and care for those patients who are just as complex. I would love to see statistics showing how nps mis-diagnosis more frequently than mds. I just think you should be fair in realizing any human regardless of their title can make a mistake. NPS on average spend 85% more time with their patients than doctors do. They tend to be more thorough in their examination and management of chronic conditions. I would prefer someone that takes more time with only a few years less education to care for me personally. But to each their own. Our system is broke and it does need to be fixed. Cheryl from ohio
Tom Sanchez, DNP
Thu, 10/08/2015 - 10:10pm
RE: the bell curve depiction of competencies offered by 'Nameless'. The argument assumes that the bell curves would measure the same thing; that the competencies of physicians and Nurse Practitioners are the same. In fact, there are shared competencies and unique competencies for each profession. Those who make these arguments display their limited understanding by trying to pull NPs under the medicine umbrella and assume that NPs are some sort of less-qualified version of an MD or DO. NPs have, for example, patient-centered and system-change competencies derived from Nursing that MDs do not have. Some might offer the retort that they know of an MD who is patient-centered in their practice and that some medical schools are recognizing and migrating toward a patient-centered approach in some of their teaching. Bravo! That means physicians are becoming more like NURSES. The shift in their profession is simply evidence of one profession learning from the other. Just as nurses have learned more about diagnosis and treatment science from medicine, so physicians have learned to gain better outcomes by borrowing patient-centered approaches from nursing. Hmmm there's another historic example of professional shift: Are physicians with MDs or DOs exactly the same? There was once a huge war over the significance of those degrees and we all know how it all came out. Though it isn't exactly over, many battles were fought and each side learned a lot so that we're at a better place now in the whole of the healthcare system with the two working side-by-side. It is also instructive that the vast majority of the public has no idea that an MD vs. DO war even took place and often have to guess which degree their physician has when asked. Cheryl from Ohio presents a real-life example of an NP who was competent in holistically understanding her patient. Even if Cheryl had not been an NP, medicine is often blind in forgetting that the family member is a competent member of the team who "knows their patient" and deserves serious consideration when planning testing, treatment, and recovery. Both Nursing and Medicine do better by the healthcare system when we work side-by-side. To do that more effectively, we need to remove the legal strangle-hold that medicine has on certain aspects of providing care.
Fri, 10/16/2015 - 10:25pm
I love your response. I am not a NP in Michigan but I live in Florida and happened to come across this article looking at topics on independent practice. The current political climate in Florida right now is not that much different and it pains me that people can't see what is happening here in healthcare. NPs are reliable, efficient, intelligent, and highly skilled clinicians that have a Master's degree or Doctoral degree. We are not less educated and we do not have less training....We have different training. It is time for people to stop comparing apples and oranges and start focusing on the issues that matter. The fact is that there are no studies to support or show that NPs are more dangerous to society when they are allowed to practice independent of a physician. It is time to cut the cord and give us what we have earned as we have decades of research to prove that we are excellent providers. I wish the state of Michigan well on its endeavors towards independent practice and I hope to god that Florida can get it together and pass the bill in the coming years!
sue
Thu, 10/08/2015 - 10:16pm
As a very wise Dr once told me ( after I caught a looming crisis with a patient in my care...a lowly LPN am I) " remember Sue if there is the top of the class that means there is a bottom of the class too. Never be afraid to call me if your instincts are telling you something's wrong" This was after the resident chewed me out and told me to "go empty bedpans or something" instead of checking on the patient. There are other instances but like Cheryl, my bro- in-laws case was the latest. Months of pain,various tests, $$$, specialists, antibiotics repeatedly for UTI. I spent 20 minutes essentially taking a history and asking a few pointed questions. I was pretty sure I had a good idea of what was wrong. I wrote out questions, told him to be very specific and to say that he had consulted and it was suggested his Dr should think about a fistula connecting bowel to bladder. Well yes it was but they were initially basing care on his MRI, ultrasound, not actively listening and looking at the patient After surgery and a short hospital stay he was quickly getting back to normal. Not saying all nurses are capable or want the responsibilities of total patient care. I know some NPs who have a comfortable slot and wouldn't move on. But I also know some Drs who are pretty sketchy. Some people need care and would welcome a clinic close to home staffed with a NP. Most visits are pretty routine things not brain surgery. There are ideas that can make this safe and patient centered.
Bruce
Fri, 10/09/2015 - 9:21am
There's been a doctor shortage because for decades we've denied so many people acceptance to Medical School. There is no shortage of people wanting to be doctors, just a shortage of slots into med school.
Mary Anne, PhD,
Fri, 10/23/2015 - 3:02pm
Interesting array of comments. Unfortunately, the real issue is not competency but control and money. Its the elephant in the corner of the room that everyone is aware of, but no one wants to talk about. Nurses have been saving patients daily for decades. We are the "eyes and ears" of physicians after their brief visit. Who initiates the calls or "consults" physicians in the current medical model, nurses most often. We have protected patients from errors, from "baby docs" for as long as any nurse alive can remember. Yet, when it comes to practicing to the fullest of our education, all of a sudden nurses with advanced degrees are now incompetent. We can not possibly "diagnose" bleeding, sepsis, pneumonia!."It 's the end of quality care!" Nurses have always worked collaboratively with physicians and other members of the healthcare team, and patients, and families. I will never be a brain surgeon but I can diagnose, treat and manage patients within my nursing scope of practice. What is the real hold up? Its the money and control. It really comes done to that. Just ask DOs, and the battle that occurred with their model of practice and getting legitimized. It's still an uneasy alliance between MDs and DOs in some cases. When will the patient come first in the eyes and minds of all providers? We have a long way to go!
Mark
Wed, 11/18/2015 - 12:32pm
Mary Anne: Your comments on money AND control are on point. My mother was a nurse for nearly 30 years before her death (during the late 1960s until 1989). If nurses are worried regarding the relationship between docs and nurses (I love your "baby doc" comments and those of Sue regarding the residents--my mother had more than one incident with regarding misdiagnosis and medications). And again, I found that on average, a nurse is pretty quick to sum up your problem and get to the chase far quicker than some with MD's (full disclosure, my brother-in-law is an MD. I've referred people to him, and they have told me thanks because of his straight forward manner and his ability to listen to his patients--an exception to the rule :-) Bringing in the dreaded health insurance companies, I think they should see this as a positive since, on average, the cost of the NP providing services should be less than that of the MD. And in the current state of nationalized health care (my premium for 2016 rose over 30% just to keep my silver plan), any collaborative use of physician/nursing services that results in lower costs, and hopefully declining cost in future premium increases, is a "win-win" for everyone. And ultimately, its the patient that will benefit.
Wed, 07/20/2016 - 3:40pm
I think that for some things nurse practitioners is ok but like Catherine said she should be able to prescribe certain treatments and the doctor who has hired her should be able to have confidence that she is confident to handle certain issue with out running every thing by him from every case. This would help Dr. Worden to spend a little more time with patients that have severe or more complicated issues to deal with. my significant other and myself have been going there for 8 years and have received excellent care and plan on continuing to see the Dr and the nurse practitioners there. So I say they have the knowledge for the 80 percent and trust them for the twenty percent that they will consult with Dr.Worden when and if they don't really know something for sure. If he tried to see every patient he would never be able to go home and sleep or spend time with his family. I think it is a good thing to have two nurses practitioners to share the load at their office and all the wonderful staff there have always treated us with respect and dignity. it is a wonder place from the time you walk through the doors to the end of your visit. So if your looking for a new doctor I highly recommend pickford medical sincerely me