Yesterday, I celebrated the fact that nurse practitioners have achieved independent practice status in New York. That is great news. You may wonder why a physician would take that position, but there are good reasons for it.
Many areas of this country like New Mexico have a severe primary care shortage. Nurse practitioners and pharmacists can fill that gap—especially in chronic disease management. Everything that I recommend is based on evidence, and teams of nurses and pharmacists produce better results in chronic cardiometabolic diseases than physicians in usual care. I worked with a team of pharmacists that managed patients with cardiometabolic disease. They were magnificent. They understand the medications better than anyone and the ones I worked with were all certified diabetic educators. If a patient had a blood pressure over 140 on the top number, they lowered it an average of 29 points.
Chronic disease management fits well with nursing culture. Nurses are used to teamwork, protocols, systems, and care paths. I have worked with nurse case managers, navigators, and coaches. This culture is essential for teams that manage chronic disease. Protocols and systems are essential in this work. I have never seen improvement of cardiometabolic condition management that did not use them. Protocols and systems are necessary to replicate, spread, and scale your successes. A standardized approach is required to get everyone on the team on the same page. Quality is a systems property.
Current American physician culture is different. Of course there are exceptions, but I have worked for 22 years to bring these concepts to my physician colleagues. I was naive enough to think a system that improved performance would be adopted. When I was applying to medical school, candidates were selected on the basis of their grades, test scores, and individual accomplishments. There was no consideration of their ability to collaborate and work on teams. This has carried over to general disdain for systems and protocols which are denounced by many as “cookbook” medicine.
I remember spending an afternoon selling the idea of chronic condition teams and protocols to the medical and administrative leaders of a large, well-known health system. When it was over, the primary care leader—a fellow internist—came over and put his hand on my shoulder and smiled at me. He said “Doctors go to Kaiser Permanente expecting to use system and protocols. That is not how we work here. We hire the best candidates and we depend on them individually to make the decisions that are best for their patients.” His attitude was condescending. “You just don’t understand.” But I do understand. I have never seen substantial improvement of cardiometabolic management in any organization that did not use systems and protocols.
Nurse practitioners can practice independently in half the states in our country. They can create chronic cardiometabolic teams that can improve health and reduce costs almost immediately. When we move to that model, we will finally have patient-centered care.
I see a functional medicine doc because 2 other conventional docs scared me silly about my elevated BP after an accident which required upcoming surgery to repair a crushed wrist. That fear led to a cascade of anxiety that subsequently caused readings all over the place. I am 74. I do EVERYTHING that is recommended for lowering BP and have lived that for many years yet I still get palpitations when the cuff goes on. 1 doc kept raising my med and I just got more anxiety plus an echocardiogram (just age related stuff). I quit going and just chilled into a calmer life. I still get high readings next to lower ones. I am pretty sure I range around 130/90. My functional doc is not particularly worried. We are trying detoxing high lead and arsenic levels plus LDN for thyroid levels. Both are working. I feel safe there and she listens. She has added a NP to the clinic and I’m happy about that. I’m unjabbed and plan to stay that way. Had a very mild you know what January 2021 before jabs. I’m a science nerd so I was led by what I have studied. Interesting articles. The system is such a big mess. I am extremely healthy and haven’t even had a cold in 5 years. No chronic pain and pretty normal tests. Well except for C which I thought was a cold.
Way to go! Bill!