NP World News: We Are on the Edge of Tomorrow

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For Nurse Practitioner World News, March-April 2009
By Carla Mills, ARNP

Editors’ note: The last issue of NPWN profiled Carla Mills, a nurse practitioner and founder of Maverick Health. This is the first of a regular, ongoing feature by Carla Mills herself.

Health and health care are in big trouble. Despite strenuous efforts, neither doctors nor government agencies have succeeded in finding effective ways to stop the exploding growth of chronic diseases. The “experts” are looking high and low for answers, but thus far they have overlooked nurse practitioners. Could NPs really be the answer to the health care crisis? Yes! NPs are an untapped national resource, and we are the last best hope for a health care system that has completely lost its way.

Nurse practitioners are unique primary health care providers. Because we possess both medical training and nursing skills, we are on the edge of tomorrow. The edge of tomorrow is the place where medical treatment plans end and patients’ adoption of them begins. It is not enough for health professionals to order appropriate treatments. Until patients truly understand and execute those treatments, there is no hope of reducing or preventing chronic diseases.

Physician care keeps getting more and more specialized, and physician time more and more expensive. The result is that more and more primary care has shifted to NPs. Thus far, however, NPs have not been allowed to practice to the full extent of our training and expertise. Despite over 40 years of proven safety, efficacy, and patient acceptance, prescriptive and practice restrictions continue to handicap NP effectiveness. Organized medicine has used its mighty political clout to maintain an authoritarian stranglehold on the health care system, and that has thwarted innovation.

How might NPs, free to practice independently, improve health care in this country? In a world where doctors are leaving primary care for specialty practices and where alarming physician shortages already exist (and loom even larger in coming years), lifting prescriptive and practice restrictions on NPs should be an urgent and necessary part of reform of the health care system.

In coming issues of NPWN, I will explore ways nurse practitioners can successfully bring about health care reform. I will discuss the challenges we face, both internally and externally, and how we can overcome them. I will detail actions we can each take in our everyday practices that will begin to bring about this reform. I will outline simple and specific measurement s to prove that what we do works. Finally, I will present a vision for the future in which NPs possess full practice and prescriptive authority and are free to innovate new and better solutions to the health care problems that plague us as individuals and as a society.

My Story

Besides being a nurse practitioner, I am an author, entrepreneur, and social reformer. I have spent the last 23 years as a nurse clinician: 10 years as an RN and 13 years as an NP. All of my time has been in direct patient care; I have not held positions in academia or administration. My areas of interest and expertise are risk factor reduction and chronic disease management. I share a private internal medicine practice with a DO in Naples, Florida.

I spent 10 years writing a book called A Nurse Practitioner’s Guide to Smart Health Choices. I researched it in my spare time, outside my clinical practice hours. I wrote this book for patients because I couldn’t find a high-quality, easy-to-understand medical reference that enables people to direct their own health and health care intelligently. And I put “nurse practitioner” in the title because I want to bring greater recognition and respect to our profession.

I founded a company called Maverick Health, a direct-to-consumer enterprise dedicated to creating a health care system to complement our current sick care system. The mission of Maverick Health is to reduce chronic diseases and prevent catastrophic health events in both individuals and populations. Maverick Health takes a practical and measurable approach to teach people with no prior medical knowledge how to effectively and efficiently manage their own health and health care. I chose the name for this company because mavericks are people who go their own way and make up their own minds about things. They determine the plan of action that’s best for them and follow through on their plan.

With my book and Maverick Health, I have tried to create a framework in which patients and health care professionals can share a common language of health. The Maverick Health approach is simple and available to everyone, laymen and health professionals. Medicine is complex, but health shouldn’t be.

Following the herd in today’s world will almost inevitably lead to illness. But self knowledge and self-directed care is a path that can lead away from unhealthy social norms to smarter choices and better health. Shifting our culture in a healthier direction is the task at hand, and it starts in our own homes. When we begin to want things that nourish and enrich our health rather than things that degrade and erode it, the tide of chronic disease will finally turn. This is the future I am working toward, both in my life and in my practice.

Historical Perspective

When stepping into an unknown future, it is helpful to look to the past for guidance. Healing was practiced long before curing came along. Nurses have practiced our art and science for as long as there has been human life; doctors, on the other hand, are relatively late arrivals. The nursing profession as we know it today was founded and formalized on the backs of social reform movements begun by nurses.

Consider 2 iconic nurses, Florence Nightingale and Lillian Wald, founder of the Henry Street Settlement in New York City. Neither of them asked for, nor were they given, “permission” to do what they did. Both saw a need and went to work. They each realized that lifestyle behaviors can cause disease, and so they went to the places where people we re stricken and taught how to correct those behaviors.

Most of the diseases that are ruining health in today’s world are caused directly by our lifestyle choices. This is a nursing problem, not a medical one. That is why doctors have been so unsuccessful at controlling chronic disease. Teaching lifestyle change is not doctors’ area of expertise— it’s nurses’!

If NPs are to heal the lifestyle ills that are sickening society, we are going to need all our courage and a stiff resolve. We should not expect to be invited to take the bold actions that are necessary. And we should expect to meet resistance from those who wish to continue to dominate and control us. But we must not get discouraged, and we must not be deterred. Most importantly, we must continue to work tirelessly and without compromise to obtain full practice and prescriptive authority as soon as possible. Then we must use that authority to attack chronic diseases and the lifestyle behaviors that produce them. It is our moral obligation to society as NPs.

Lillian Wald wrote “Reform can be accomplished only when attitudes are changed.” If we are to succeed in reforming society, we must first reform ourselves.

Stepping Over the Edge

I believe that if health and health care are to be reformed, we must step boldly over the edge of where we are today, into a new tomorrow. I believe that taking a timid approach to the changes that need to occur will not accomplish the work that is ours to do.

In my next column I will discuss our NP image: how we see ourselves and how society sees us. Having influence in today’s world depends on articulating a clear message and being a recognized and trusted brand. For all that NPs have to offer, we have not yet been successful in articulating our value to the public, nor have we distinguished ourselves as a unique brand of health care provider independent of physicians.

Our greatest asset as NPs is our ability to assimilate the vast complexity of medicine and distill it into simple, lifesaving steps than anyone can understand and follow. That is what I do in my practice and what I have tried to do in my book. I suspect it is what every NP does in his or her practice, too.

This is an exciting time for NPs, full of opportunity and challenge. If we can come together as a unified tribe and hone our message of health to a sharp point, I believe we can pierce the heart of chronic disease and slay it. I invite you to join me by adding your voice and ideas to mine.

Your comments are welcome.

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2 comments so far. (Post your own)

#1 | On May 13, 2009, mgyoung said:

While your comments are thoughtful, and informative they fail to address ( as many of us do…) one of the real issues in what holds us back as NPs nationally… As a doctoral prepared NP with over 30 years of clinicl and academic involvement it is clear to me that the greatest barrier to success for nursing is the lack of standarized educationl policies… How can we as a profession ever expect the other professions that are similar in that there is a didactic, and clinical apprentice process take ours seriously when we have slimmed down the education of nurses, ie: the masters level entry in nursing… and the DNP…. there is one way to become a physician, a lawyer etc…
questions that need to be answered relate to how can comparisons be made between a baccalaureate level trained nurse who progresses on to the masters level, then on to the doctoral level ever be compared to a MEPN with a one year DNP ??? !!!  This is very much the concern that the AMA and our physician colleagues have… I certainly do as a senior level, long time practicing BSN-MSN-Dr.NP….  the complexities of medical practice, and the patients that we treat warrant a higher level of training and fundamental experience than nursing has standarized today.

#2 | On May 17, 2009, Carla Mills said:

Thanks for taking the time to comment.

I have purposely chosen not to address the issue of educational shortcomings in NP training in my NPWN columns. In my opinion it is not our lack of education that holds us back, it’s our inability to put value in our own clinical expertise or articulate our value to society. Those are the issues I am exploring in my column.

As a master’s prepared NP with more than 20 years of clinical experience, I am far more interested at this stage in my career in improving health care delivery to patients than I am attacking or defending NP educational standards.

I absolutely would have appreciated and benefited from better clinical training in both my BSN and MSN programs. But I compensated long ago for those shortcomings with many years of rigorous and extensive clinical experience. Educational reform, while relevant to NPs still in training, is irrelevant to many senior clinicians like me.

The real danger I see for NPs is that an interminable divisiveness and lack of interdisciplinary respect – like that of some educators and some newly minted DNPs toward seasoned master’s educated NP clinicians – will destroy a profession that appears to outsiders not to believe in itself.

Carla Mills


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