Roles in Healthcare: A Who's Who Guide to the Gray Area

With all of the posturing over who has more training hours, patient-satisfaction scores, positive outcome measures, and cost-effective care, something has been lost in the Dr. Nurse/Dr. Physician debate: Role of the Discipline.

First, let's get the "I-became-a-(MD/DO/NP/CNS)-because-I-want-to-help-people" out of the way. All of the health disciplines help people. So do any number of customer-service driven fields. The practice of any healthcare discipline is both an art and a science where assessment, diagnosis, and intervention are the foundation of every patient encounter.  Likewise, we have moved toward the partnership model of healthcare that includes patient-ceneted care, interpersonal communication, and collaboration with peers. There is significant overlap in scope of practice among many licensed independent providers - chiropractors, physical therapists, and osteopaths, or psychologists, social workers, and psychiatrists are just two of many groupings where this occurs. Why one person chooses a particular path over another is not so much due to the "what" of these care concepts, but to the "how" of delivery.

What is medicine? When you boil it down, the primary purpose in the practice of medicine is treatment of disease. Physicians care for patients through provider-driven interventions to eliminate, cure, or manage acute and chronic disease processes from common to obscure. To be successful at identifying and treating the full range of pathologies for a given system, a physician must have a comprehensive understanding of expected functioning in the system of focus, variants of compensatory measures within and in relation to other body systems, all potential pathological manifestations with their associate therapies, and the interactions of treatment modalities the individual may be employing for all conditions in the body.

When patients complain that all their physician wants to do is order a bunch of tests and offer pills or surgery, they are basically stating that the MD is doing their job.  While holism plays a larger role in DO training than it does with MDs, compartmentalization is a necessary framework for specialty care.  There are so many aspects of endocrinology, neurology, and gastroenterology, that to expect the specialized and general clinician to know all about all systems is unrealistic and unfair.

Physicians also take a lot of criticism for not focusing on more than the barest of nutritional education or other self-directed lifestyle modifications. These are not topics that are emphasized as part of medical training unless pertaining to specific disease processes, such as renal failure or diabetes.  Medicine is interventional at the disease level, thus the training is focused at that level of care.  Of course prevention is included in scope of practice, but there are far more ways for the body to go wrong than there are to go right. Because illness can manifest, complicate, and hide throughout the body, the training to identify and treat must be equally complex. We do not pay them to talk, we pay them to act.

What is nursing? When you boil it down, the primary purpose in the practice of nursing at the advanced level is health promotion and disease prevention.  Nurses care for patients through education, communication, self-care strategies, identification of risk factors, and community-based care of the well person.   To be successful  in this role, engaging in primary (decrease incidence of disease), secondary (decrease prevalence of disease), and tertiary (decrease disability of disease) prevention interventions are performed at both the individual and community level. An understanding of normal and expected health status is essential in this role in order to initiate interventions or refer to the appropriate provider and level of care. "Common diseases occur commonly," thus expected age-related or other predictable illnesses are the focus of prevention and management.

The principles of health promotion and disease prevention also apply at the organizational level and are used to conduct research for quality improvement and to identify gaps in system processes to guide implementation of appropriate solutions. Even at the entry RN level, there are independent aspects to this practice. The nursing diagnosis and individualized treatment plan are determined by the bedside nurse and are typically aimed at providing comfort measures to prevent adverse events and promote healing. From the bedside to the boardroom, nurses run the hospital and are greater in number than any other type of provider. The multiple levels of licensure and practice scope are also unique in comparison to other health disciplines, thus making the role of mentor, educator, collaborator, and researcher essential to fulfill the advanced practice role.

Those who complain that NP training hours do not match those of medical school are basically stating that nurses are not trained to be physicians.  This is 100% true. NP training hours do match the necessary education required to meet the role of the NP. Medical school is not necessary to provide comprehensive, quality well-care, nor is it necessary to conduct process-improvement research and implementation in the clinical setting.  Nursing is rooted in holism. NPs are well prepared to treat mild to moderate levels of complexity in a community, urgent, and acute-care environment, and to provide tailored education on lifestyle considerations for optimal health. While the rare, esoteric, and significantly complex patterns of disease are discussed in NP training, the management of these conditions are beyond the scope of the role, and are included as a basis for referral to the appropriate provider. You cannot practice what you do not know - expert NP clinicians practice nursing, not medicine.

There is role overlap between nursing and medicine, particularly in the tertiary level of preventative care.  Certainly there are NPs that successfully treat complex conditions and physicians who focus on prevention.  Each discipline offers post-graduate training and fellowships to encourage life-long learning. The question is not which type of clinician is better so much as it is which type clinician is most appropriate and better trained for a given set of circumstances.

A patient needs a medication to lower their blood pressure. Does the patient really care if the prescriber views it as treating a disease process versus viewing it as promoting systemic wellness and preventing adverse disease consequences? If it works, probably not. Does this generally healthy patient, who suffers from situational anxiety, could stand to loose 20 pounds, get a few more hours of sleep, and cut down on the nightly ounce of bourbon, require MD care?  An NP is better suited to manage the hypertension and provide tailored education on essential nutrition, exercise, and rest patterns that could result in resolution of the disease and discontinuation of the medication. The NP is trained to do this more effectively and at a lower cost than an MD. This is where nursing is the best choice.

But lets say this person needs 3 different medications to control his blood pressure to just shy of normal. His nightly bourbon is actually 8-ounces and he has the lab values and physical finding to prove it. Sometimes he pops a friend's xanax before going to parties to calm his nerves. He experiences intermittent chest-pain several times a week, and can't get his shoes on anymore because his legs and feet are too swollen. This patient just entered the gray area. An NP could work with this patient, but the complexity of his issues also make referral to an MD appropriate. This is where nursing or medicine can be a good choice, and likely a combination of both.

Now lets have some fun and say this patient also has atrial fibrillation that has resulted in three cardioversions in the past year, recent onset of Type II diabetes, and is a 2-pack-per-day smoker with one hospitalization for pneumonia in the past 6 months. He is not interested in changing habits, has a history of skipping follow-up appointments, and often misses doses of medicine. He has been to the ER twice for thoughts of suicide with one attempt. We now have several chronic diseases effecting multiple systems in a non-compliant patient. Promotion and prevention are still important, but treatment of disease is the priority.  This is where medicine is the best choice.

So lets sum it up: Nurse practitioners should provide care when health promotion and disease prevention are the primary goals of the patient. Physicians should provide care when treatment of disease is the primary goal. Both are appropriate when these goals meet in the middle and each is performing according the purpose of their role. Rather than considering the tired "Us vs. Them," the more accurate perspective should be "Us and Them" on the side of the patient.

VA Hiring Process

Prior to entering the DNP program, I knew I would have to make a choice between expanding my current private practice, or scaling back and seeking full time employment.  I have derived an enormous amount of joy and freedom as an independent provider, and the practice has grown significantly despite an economic recession.  However, an expansion in practice scope calls for major rebranding efforts that can result in more time, money, and emotional expense than starting a business from scratch. With the number of changes to health care coding and billing down the pike, and living in a state where we must have a collaborative (bribed) agreement with a physician to prescribe medications that are rightfully part of our independent scope of practice, I am not as bullish on private practice as I was a couple of years ago.  Plus, it gets lonely working as a solo provider. I miss the camaraderie of coworkers and a stimulating environment that forces you to continually evaluate yourself as a provider, and challenges you to stay up-to-date on research, legislation, and best-practice.

Nurse practitioners have a lot of great options - some of my former colleagues have taken HRSA jobs in underserved areas, others are going academic, and some are like me.  Just prior to graduation, I applied for positions in the VA after being encouraged by a few colleagues that are passionate about serving the veteran population. Having done the bulk of my clinical work with active duty soldiers, and being married to a (handsome, talented) veteran myself, it seemed like a natural fit for me. I was told the VA hiring process for healthcare workers can take a long time, and when I did some casual web surfing, I found the bulk of first-hand accounts came from LPNs and RNs. As a public service to anyone considering an advanced practice nursing career in the VA, I want to share my application and hiring process. Just keep in mind, "if you've seen one VA, you've seen one VA!"

April: I have a great conversation with a current NP who works outpatient and not only encourages me to apply, but provides excellent reassurance and advice regarding boards. Because I am already an FNP and will be eligible to take the PMHNP certification exam in 90-days, I quickly put in an application on April 24th to the one open position psych-NP, emergency and inpatient mental health consultations, to get my name in the system (open period 3/29-6/28). Had I been an RN only, I would not have applied until after graduation on May 25th.

May: I apply for 2 additional positions as they become available through USA Jobs, one on the 10th for an outpatient mental health clinic and the second on the 25th for the homeless veteran program (open period 5/7-9/17 and 5/18-6/18 respectively). In addition to the usual demographic questions, I was asked to provide my resume, 3 references, unofficial transcripts, a separate application for nurses/nurse anesthetists, declaration for federal employment, and copies of all licenses/certifications. Immediately after applying, the status in USAJobs is marked as "application received," and within a week they read "eligible - application referred to selecting official."

June: I have my interview on the 5th, which is conducted by 2 APRNs and 3 LCSWs. Before sitting down they joke about the formulaic nature of the interview, with each one asking standard questions in a round: "Why the VA?" Tell me about a time when you had a difficult patient and resolved it/collaborated for a positive outcome/had a conflict with an MD and managed it?," "What is recovery," "What is evidenced-based practice." Since I am also an acupuncture and Oriental medicine provider, they asked a few seemingly off-the-record questions about my practice. I also had a chance to ask them about why they chose the VA, involvement in national organizations, and what they do and do not love about working for the government. On June 12th, I am sent a disposition letter on the consultation position that another candidate was selected, and the status in USA jobs changes to "not selected." On June 20th I receive and official notification letter on the homeless veteran position stating "We have reviewed your application and found you qualified for the position listed above.  Your name has been referred to the employing agency for consideration.  THIS IS NOT A JOB OFFER."

July: This is where things get confusing. On July 3rd, I am sent an official notification email on the consultation position that states I am eligible (see above) and the status in USAJobs changes to "application referred." July 6th I am sent a disposition letter that I am not selected for the homeless veteran position.  July 18th I am sent both the qualified notification and not selected disposition letters on the clinic job, then on the 30th I receive a notice that my application forms have been received and the USAJobs status changes from not selected to application received. I reach out to one of the APRNs, and am told that while my interview went well, they had an overwhelming amount of applicants who already had certification (my boards were scheduled for later that month) and/or were already VA employees. I am encouraged to keep my eyes out because more positions would become available.

August: All quiet.

September: Ten minutes from boarding a flight to London late in the month, I get a phone call from the VA telling me they would like to speak with me about an open position. After playing some telephone tag, it turns out the consultation position had been re-listed under a different announcement number. I speak with one of the mental health staff members responsible for finishing the hiring process who decides my previous interview is good for this position. I am tentatively given an offer pending credentialing, nurse professional standards board, and VetPro.  Once that is all sorted out, I will be given an official offer. She cautions me that because I have to go through both nursing and mental health services the process can take awhile, and not to get caught up in Grade and Step, but to look at the salary and decide if I want to accept or negotiate. On the 24th I am sent the Qualifications Questionnaire with instructions to brag about my experiences as much as possible, because it can mean the difference of many steps and possibly a grade in overall pay. Up to this point, every person has been helpful and quick to respond to questions and concerns.

October: The first part of the month involves gathering and faxing documents, getting my physical, drug test, and fingerprinting done at the facility, and VETPRO.  They anticipate I should be ready to start by November or December.  I get a call late in the month informing me of my grade, step in salary, which is delightful. The process actually moved faster than expected, but as I have to give my private practice patients notice, I ask to start on December 3rd.

November: I receive my officially signed, in-writing offer letter dated for the 9th with instructions on where to go and what to bring for my first day of orientation.  Hooray! I will have 2 weeks of orientation under nursing services before getting transferred to my official duty station in mental health services.

To sum up, from application to walking into orientation, it took 223 days (7 months and 9 days), though I could have started up to a month earlier if I did not have previous commitments to patients,  conferences, and travel.  Had I been certified as a PMHNP at the time I applied in April, I likely would have been hired initially and started within 90 days, give or take.

I have no plans to blog about my work at the VA from here on out unless it is relevant to nursing practice and complies with all the usual rules and regulations that come with working in government healthcare. As I have done all of this research and policy development on social networking for mental health providers, it would be utterly embarrassing to violate my own guidelines!