Speaker 1: M Bloomberg Audio Studios, podcasts, radio news.
Speaker 2: Two years ago, John Canyon was working in Corpus Christi, Texas,
Speaker 2: and he still remembers the day he got a call
Speaker 2: that his seventy four year old dad had had an
Speaker 2: emergency about four hours away.
Speaker 1: My mom called me and told me to him a
Speaker 1: dad fell and that they had went to the urgent
Speaker 1: care and they texted me the x ray read and
Speaker 1: they said they saw a nurse practitioner there and they
Speaker 1: said he had broken ribs.
Speaker 2: The nurse practitioner sent John's dad home, but John was
Speaker 2: skeptical that his dad wasn't sent to the er. He
Speaker 2: knew broken ribs at that age could be dangerous, so
Speaker 2: John shared his dad's X ray results and the fact
Speaker 2: he was sent home with a trauma surgeon he knew
Speaker 2: to get his take.
Speaker 1: I showed him the report. I'm like, I can't believe this,
Speaker 1: and he goes so I can't believe it either. He
Speaker 1: needs to go. He needs to be admitted.
Speaker 2: John got in touch with his parents and he told
Speaker 2: them his dad needed a second opinion. He needed to
Speaker 2: go to the emergency room. So John's dad headed to
Speaker 2: the er and got checked out by another nurse practitioner
Speaker 2: and the.
Speaker 1: Emergency department did test. They did a cat scan ofis
Speaker 1: chest and said he had multiple rib fractures and a
Speaker 1: pulmonary contusion, and then discharged from home.
Speaker 2: But back at home, his dad only got worse.
Speaker 1: So he three days later, he's in severe pain, goes
Speaker 1: back to the emergency department. They found that they had
Speaker 1: a ruptured spleen and ended up being life flighted to
Speaker 1: San Antonio.
Speaker 2: John says his dad eventually got great care at the
Speaker 2: trauma center and ended up being okay, But he says
Speaker 2: the way this went down with his dad, two medical
Speaker 2: visits without the right diagnosis should never have happened. His
Speaker 2: dad's life should have never been put at risk in
Speaker 2: this way. And John would know because he's been a
Speaker 2: nurse practitioner for nearly twenty years.
Speaker 1: You know, he shouldn't have been sent home from the
Speaker 1: urgent care. The person there didn't understand the severity of
Speaker 1: rib fractures, and an elderly person, and the person in
Speaker 1: the emergency department who should have known that didn't know that,
Speaker 1: and also discharged him home when he should have been admitted.
Speaker 2: Then what went through your mind when you first heard
Speaker 2: that recommendation to send him home.
Speaker 1: They didn't know what they were doing. They were obviously
Speaker 1: not trained well enough, and they needed more training and
Speaker 1: frustration and agitation and putting someone's life at risk unnecessarily.
Speaker 2: Today on the show, a Bloomberg investigation into the increasing
Speaker 2: reliance on nurse practitioners and American healthcare and what the
Speaker 2: rapid growth of the profession has meant for their training
Speaker 2: and their patients. I'm Sarah Holder, and this is the
Speaker 2: big take from Bloomberg News. So, in the world of nurses,
Speaker 2: there are many different types, and as Bloomberg investigative reporter
Speaker 2: Polly Massen's explains, the kind most people think of are
Speaker 2: registered nurses.
Speaker 3: So a registered nurse, for those who might not know,
Speaker 3: is what you'd most closely associate with, a bedside nurse
Speaker 3: or a nurse that you might encounter in a hospital.
Speaker 3: So somebody who you see when you're receiving care in
Speaker 3: a hospital environment is most typically going to be a
Speaker 3: registered nurse.
Speaker 2: But the story Polly and Bloomberg's Caleb Melby have reported
Speaker 2: out over the last six months is about a different
Speaker 2: type of nurse, the nurse practitioner.
Speaker 1: So a nurse practitioner is probably somebody that listeners have
Speaker 1: been seen more and more in their interactions with healthcare
Speaker 1: in the US. That's a registered nurse who went and
Speaker 1: got an advanced degree and an additional license.
Speaker 2: The nurse practitioner or NP degree is a newer, more
Speaker 2: advanced nursing license. It was created at the University of
Speaker 2: Colorado in the nineteen sixties. Back then, much like today,
Speaker 2: there was a shortage of doctors, and the idea was
Speaker 2: to alleviate some of the pressure on doctors by creating
Speaker 2: a pathway for people with a nursing background to level
Speaker 2: up their skills.
Speaker 1: Nurse practitioners can see patients the way doctors do. They
Speaker 1: can assign care regimens the way doctors do. They can
Speaker 1: prescribe medications in many cases is the way doctors do.
Speaker 1: It is essentially a parallel path for nurses to act
Speaker 1: as doctors often do in American healthcare.
Speaker 2: From that first program at the University of Colorado, NP
Speaker 2: programs started to spread across the country. By the end
Speaker 2: of the nineteen seventies, there were about fifteen thousand nurse
Speaker 2: practitioners in the US. Today, there are more than three
Speaker 2: hundred thousand. The number of nurse practitioners is projected to
Speaker 2: rise by forty five percent by twenty thirty two. It's
Speaker 2: one of the fastest growing professions in the country. What's
Speaker 2: driving that change and what's driving the growth in interest
Speaker 2: in these programs.
Speaker 1: There's a few things we're looking at here. First, the
Speaker 1: need for more providers. The weights for doctors are constantly expanding,
Speaker 1: they're growing, so we need more providers that patients can
Speaker 1: see on a shorter timeframe. But there's also economic and
Speaker 1: financial factors at play too. The time it takes to
Speaker 1: become a nurse practitioner is shorter and more affordable than
Speaker 1: it is to get a medical degree. They are cheaper
Speaker 1: to employ for hospitals and other healthcare providers than doctors are,
Speaker 1: and they are sometimes able to bill insurers at doctor
Speaker 1: rates under certain circumstances. So there's these financial incentives where
Speaker 1: you're getting your labor essentially at nursing prices and your
Speaker 1: revenue at doctor prices, which makes this shift extremely exciting
Speaker 1: to a lot of healthcare providers.
Speaker 2: So there are a number of benefits to having more
Speaker 2: nurse practitioners, shorter wait times for patients, better profit margins
Speaker 2: for healthcare providers, and more career opportunities for registered nurses.
Speaker 2: But how has it been possible for a new category
Speaker 2: of healthcare professionals to grow so quickly? Where are they
Speaker 2: all getting trained? The answer, in part is the introduction
Speaker 2: of a new way to get a nurse practitioner degree
Speaker 2: called direct entry programs.
Speaker 3: So for a direct entry program, you don't necessarily need
Speaker 3: any experience, and in fact, some of those programs are
Speaker 3: actually designed for folks who do not have any experience.
Speaker 3: So in those cases, you don't necessarily need any experience
Speaker 3: or estally any education experience, and you don't necessarily need
Speaker 3: any work experience. With non direct entry programs, they do
Speaker 3: expect you to have studied nursing.
Speaker 1: And I will say too, there's something of a debate
Speaker 1: within the nurse practitioner community. You will talk to some
Speaker 1: of these nurse practitioners who were urns for decades before
Speaker 1: getting their degree, and they will say that experience is
Speaker 1: very important, that makes you a much better nurse practitioner.
Speaker 1: And then there's others who will say, well, actually, the
Speaker 1: job of diagnosing and prescribing that is at the core
Speaker 1: of the nurse practitioner's job, doesn't really happen for you
Speaker 1: as an RN. So maybe as an RN you're getting
Speaker 1: that patient facing time and you're getting a sense of
Speaker 1: how the hospital works, but you're still not accounting for
Speaker 1: those huge new responsibilities you're taking on, and.
Speaker 2: Those responsibilities are huge. In their reporting, Polly and Caleb
Speaker 2: came across a lot of stories, like the one John
Speaker 2: Canyon shared about his father. Some of them had different endings.
Speaker 3: The case of Tiffany Dunbar is I think we can
Speaker 3: all agree as a tragic one.
Speaker 2: Tiffany Dunbar was a mother of three and she was
Speaker 2: pregnant with her fourth child. She was experiencing discomfort and spotting,
Speaker 2: which are symptoms of an ectopic pregnancy. So she scheduled
Speaker 2: an appointment at a women's wellness center at a hospital
Speaker 2: in DC.
Speaker 3: That was somewhere that she had had a medical doctor
Speaker 3: in her life, and she had had three children already,
Speaker 3: so she was pretty familiar with that clinic and with
Speaker 3: women's care.
Speaker 2: She met with a nurse practitioner who had a bachelor's
Speaker 2: and a master's degree from the University of Cincinnati Nursing School.
Speaker 2: The university advertises the master's program as one hundred percent
Speaker 2: online Lawyers for the Healthcare Center said in a filing
Speaker 2: that Dunbar was told to come back for additional testing
Speaker 2: and that since she agreed to come back, the NP
Speaker 2: didn't want to frighten her with a prospect of dying.
Speaker 2: But not long after her appointment with that nurse practitioner,
Speaker 2: Dunbar's right filopian tube turned inside out, causing massive internal bleeding.
Speaker 2: She died of an ectopic pregnancy while on vacation with
Speaker 2: her family in California.
Speaker 3: Her death was ruled as catastrophic by the medical examiner
Speaker 3: on the autopsy.
Speaker 2: In the court case that followed, a jury found that
Speaker 2: the nurse practitioner and the center failed to meet the
Speaker 2: national standard of care and their treatment, and that Dunbar's
Speaker 2: death was completely avoidable. The center appealed the decision, noting
Speaker 2: that Dunbar agreed to those follow up visits but didn't
Speaker 2: follow through, and the case was ultimately settled out of
Speaker 2: court before a judge could make a ruling. Dunbar's case
Speaker 2: is only one of many similar stories Caleb and Polly
Speaker 2: came across where the difference between life and death hinged
Speaker 2: on a nurse practitioner's judgment. They wanted to dig deeper
Speaker 2: into what kind of training nurse practitioners were getting to
Speaker 2: prepare them for those kinds of decisions. What they found
Speaker 2: after the break. Patients in the US are increasingly relying
Speaker 2: on a vast network of nurse practitioners to get their
Speaker 2: medical issues diagnosed and treatments prescribed. But there's another factor
Speaker 2: that's driven this recent explosion of nurse practitioners, a for
Speaker 2: profit industry of nurse practitioner education programs that are accepting
Speaker 2: students at record rates. The biggest players on the NP
Speaker 2: education scene are Walden University and Chamberlain University. They're both
Speaker 2: owned by a for profit company based out of Chicago,
Speaker 2: ad to Lim Global Education. But you might know ad
Speaker 2: to LIM better by its former name DeVry, So.
Speaker 1: When we talk about nurse practitioner education, many times we
Speaker 1: are talking about ad t LIM and its properties in
Speaker 1: Chamberlain University.
Speaker 2: Devrai rebranded to ad Tillem in twenty seventeen as it
Speaker 2: faced lawsuits and government scrutiny over how it advertised its programs. Today,
Speaker 2: those two leading NP schools under ad Tolum's umbrella are
Speaker 2: responsible for training a growing number of nurse practitioners each year.
Speaker 2: But unlike for doctors. There's no one standard for how
Speaker 2: nurse practitioners need to be trained, and a lot of
Speaker 2: NP training programs have an emphasis on online courses. Another
Speaker 2: big difference is in how nps get on the job experience.
Speaker 2: They need to log five hundred hours of clinical training
Speaker 2: time before graduating. That's time shadowing a teacher, usually a
Speaker 2: licensed nurse practitioner in the field, but it's still a
Speaker 2: fraction of the three to seven years that doctors typically
Speaker 2: spend in residency, and NP students are often left to
Speaker 2: their own devices to find people willing to train them
Speaker 2: at all.
Speaker 1: They go out and they knock on doors, They drop
Speaker 1: cookies off at offices. They do all sorts of stuff
Speaker 1: to try to find those people, including paying them out
Speaker 1: of pocket pain to be taught, including paying third party
Speaker 1: matchmaking services to pair them with someone.
Speaker 2: Caleb and Polly reached out to ad Talim, the company
Speaker 2: behind some of the fastest growing nurse practitioner programs in
Speaker 2: the country, to get their comment about how they ensured
Speaker 2: students got adequate training.
Speaker 3: Ad to Lim, a spokesperson told Bloomberg it wants to
Speaker 3: support students who are not successful in identifying appropriate clinical sites.
Speaker 2: The spokesperson also said in an email that ad talim
Speaker 2: quote is committed to ensuring students graduate prepared to pass
Speaker 2: required licensure and certification exams and enter the healthcare workforce
Speaker 2: end quote. Caleb and Polly spoke to dozens of nurse
Speaker 2: practitioners for the story who'd gone through a variety of
Speaker 2: training programs, and many said they didn't feel like their
Speaker 2: training set them up for success.
Speaker 3: Some students didn't feel prepared, and in fact, some of
Speaker 3: them hadn't actually been able to complete their clinical hours,
Speaker 3: So of course they're not going to feel prepared. You
Speaker 3: can't expect them to.
Speaker 1: They get very frustrated that this is their experience, and
Speaker 1: some of them get very scared about what it means
Speaker 1: for them to go and practice on their own after
Speaker 1: those experiences.
Speaker 2: With their emphasis on online education and their challenging approach
Speaker 2: to on the ground learning, nurse practitioner programs are facing
Speaker 2: increased scrutiny from students, medical doctors, and a former NP
Speaker 2: program administrator who raise concerns about student faculty ratios and
Speaker 2: a lack of student support. When Caleb and Polly raised
Speaker 2: some of these issues with the country's largest lobbying group,
Speaker 2: for nurse practitioners. The association stress that nps are filling
Speaker 2: a critical role in the medical system.
Speaker 1: The American Association of Nurse Practitioners told us something that's
Speaker 1: fundamentally true, which is that millions of Americans are getting
Speaker 1: their health care from nurse practitioners right now. The association
Speaker 1: also believes that nurse practitioners are going to healthcare desert
Speaker 1: in rural areas and in cities to not just make
Speaker 1: sure that there's shorter wait times at any hospital, but
Speaker 1: also increasing access broadly in these geographic pockets where it's
Speaker 1: sometimes hard to come across care.
Speaker 2: But the question Caleb and Polly were still grappling with
Speaker 2: was whether the problems that identified with nurse practitioner training
Speaker 2: were impacting the quality of that care. There isn't a
Speaker 2: ton of reliable data out there on nps and patient outcomes,
Speaker 2: but poll came across a working paper first released in
Speaker 2: twenty twenty two that looked at over a million patient
Speaker 2: records from forty four via system emergency rooms, and it
Speaker 2: revealed a troubling trend.
Speaker 3: Those researchers noted that on average, nps used more resources
Speaker 3: but achieved worse patient results as compared to physicians. Now,
Speaker 3: this is still a working paper that does still have
Speaker 3: to go through the peer review process, which can be
Speaker 3: really lengthy, but it is an interesting finding, and it's
Speaker 3: particularly interesting because it does look at emergency where the
Speaker 3: stakes are going to be the highest.
Speaker 2: Polly says. The Association of Nurse Practitioners took issue with
Speaker 2: that paper, in part because it was still being peer reviewed.
Speaker 2: The lobbying group also shared another study that looked at
Speaker 2: patients across five countries including the US, and found that
Speaker 2: nps can actually improve patient outcomes in an er setting.
Speaker 2: I asked Polly and Caleb what they thought the root
Speaker 2: of the issue here was n Like most problems with
Speaker 2: our healthcare system, there isn't just one answer.
Speaker 3: I think it's everything that we've talked about kind of
Speaker 3: compounded on itself. There's a doctor shortage, there's an increase
Speaker 3: in these kinds of for profit educational programs, and there's
Speaker 3: a completely logical, understandable desire to move away from bedside
Speaker 3: nursing in some cases. So I think that all of
Speaker 3: those things, combined along with the many, many eccentricities of
Speaker 3: the American healthcare system, can cause this. I mean, the
Speaker 3: reality is that we have a hugely unique, largely for
Speaker 3: profit American healthcare sope, and it's going to sprout its
Speaker 3: own very unique problems.
Speaker 1: A bad reading of the story would be nurse practitioners bad,
Speaker 1: which is not what the story says. The profession will
Speaker 1: keep blooming. That will not stop. We are all going
Speaker 1: to be getting more health care from more nurse practitioners
Speaker 1: in the future, and the students and professors and nurse
Speaker 1: practitioners we spoke to said there's things that need to
Speaker 1: happen with our education to prepare us universally for those
Speaker 1: increased responsibilities that they will be facing in the future.
Speaker 2: John Canyon, the nurse practitioner we heard from earlier, says
Speaker 2: his dad's experience not getting the kind of treatment John
Speaker 2: thought he should have hasn't made him lose faith in
Speaker 2: nurse practitioners themselves. After all, John is two decades into
Speaker 2: his own career as a nurse practitioner, and he sees
Speaker 2: what he trusts for his own care. But John has
Speaker 2: also channeled his frustration into advocacy. It aims to push
Speaker 2: the profession to improve its education standards and up clinical hours,
Speaker 2: because otherwise he worries nothing will change.
Speaker 1: At the end of this, my dad ended up being okay.
Speaker 1: So while mom and dad were like, well, it's no
Speaker 1: big deal, they were nice to us. So you know,
Speaker 1: we don't want to and like, well, here's the thing.
Speaker 1: If we don't, if we don't at least talk to
Speaker 1: them and let him know what's going on and let
Speaker 1: him know you're upset, then nothing will ever happen, No
Speaker 1: one will ever get additional training. It'll continue to be
Speaker 1: a problem.
Speaker 2: This is The Big Take from Bloomberg News. I'm Sarah Holder.
Speaker 2: This episode was produced by David Fox with Thomas Lou
Speaker 2: and Alex Sugiura. It was edited by Aaron Edwards, Caitlin Kenny,
Speaker 2: and Flynn McRoberts. It was fact checked by Thomas Lou
Speaker 2: and mixed by Blake Maples. Our senior producers are Kim
Speaker 2: Gittleson and Naomi Shaven, and our senior editor is Elizabeth Ponso.
Speaker 2: Nicole bumsterbor is Our executive producer. Sage Bauman is Bloomberg's
Speaker 2: head of podcasts. Thanks so much for listening. Please follow
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Speaker 2: It helps new listeners find the show. We'll be back tomorrow,