Friday, November 11, 2011

Nurse practitioner they ain't

One of the latest scandals that I have been meaning to write about is the case of the "medicina integral comunitaria".   They are folks that are about to be unleashed as full doctors in the Venezuelan public health system without the knowledge to take care of the people that go to such hospitals.  But before I get into the subject indulge me a personal reminiscence.

One of my very close friends is a Nurse Practitioner (and a PhD in public health).  She is close enough to have visited me 4 times in Venezuela since I left the States which is quite something if you think of it for a US citizen in an academic career.  I met her while she was supporting her PhD expenses working as a NP and I gained then a considerable respect for that degree, thinking it an essential part of the US medical system, a part sorely missing in either the European system (I think) and certainly in Venezuela.  In brief, had I remained in the US she would have got my power of health to make sure that I would be unplugged if worse came to worse.  That much I trusted her medical knowledge.

When I finally got health insurance in the States, I had the opportunity to meet other NP usually placed in "triage" section where in my opinion they were most effective.  See, a NP with some experience is truly a generalist MD, the good kind of doctors for triage as they tend to look at a patient as a whole, something quite missing in US doctors who tend to be a tad too specialized, at least when one comes from other health systems.  For those not in the US you need to know that a NP is kind of like an MD but limited to general practice, a missing link between the mere nurse and the MD.  In many states Nurse Practitioners can even prescribe restricted drugs and participate in all sorts of medical activities alongside MD.  They can have their own practice and can be very helpful in communities who cannot afford many MD, amen of directing the nursing staff so that MD can go unto their real tasks.  Not that they are not well paid: a good NP can buy a home and a car and save for retirement.  Maybe not a golf retirement like an MD but a decent one nevertheless.

It took all of this digression to make sure you understand that I have no preconceived idea about creating a similar type of degree in Venezuela.  Indeed, NP would be ideal to staff Barrio Adentro modules, as a big triage to send the pueblo of the barrio to the adequate hospital, making even the appropriate appointments as these patients sometimes have no idea how to proceed.  Thus a few years ago when in the bloom of Misiones Chavez announced that people would be trained in a special form of medicine adapted to the needs of the barrios I was not as critical as usual.  But as it is always the case in Venezuela these days, even potentially good initiatives have a way to turn into a disaster, creating more problems than what they are supposed to solve.

The degree created (and never validated by the organizations that are in charge of validating degrees, and thus not "legal") is "medico integral comunitario" which can be loosely translated as "complete community doctor".  The degree is taught only in the universities founded by Chavez since 2003 or taken over by chavismo at those dates.  There is no evaluation of either the teaching staff or the cursus followed or the student evaluation.  Rather important because considering that human lives are at stake, a mere "pass" does not quite make it. In other words there is no way to truly evaluate the kids whose first promotions are about to graduate this year.

Still, if the regime were intent only to staff the Misiones in support positions, we could have accepted such title, expecting that with experience and remedial courses their degree could improve and maybe become, well, NP.  But ideology and Venezuelan vices combined and disaster is about to happen: the regime has changed the law that regulates medicine to make sure that the MIC it will graduate this year will be recognized as full doctors, with all the privileges (and obligations I hope).

This is so wrong and for so many reasons that one must start wonder if there is anyone left with common sense in the government, and evaluation agencies since they waited this late to make all of that scandal.

All the serious reviews I have seen claim that the MIC training is lacking in many aspects, too many aspects if you ask me.  They lack in theoretical training ( apparently many classes were simple videos, coming from Cuba or who knows where).  They lack in practical training as at best they seem to have done some nursing work, and certainly no small outpatient surgery or more advanced procedures that even an NP can do in some states of the US.  In short, the tamer criticism I have seen are suggestions of some "remedial" courses and at least a year of training practice.

But the regime was defiant and had the law voted.  Even more, Chavez himself suggested that their starting salary should be around 9.000 Bs.  Which is more that what experience MD make in the public sector.  My SO was even forced to go a support rally for these MIC from which he sent me the picture above.

So imagine if you will for a minute the following situation: people with deficient training will be sent to hospitals to work under doctors that know their office, that have payed their dues, and that may be making less than what the newbies will be making.  You can imagine the havoc in the making...  Compounded by the fact that already patients are asking to be treated by real doctors and refuse to be seen by the MIC that already are completing their "training".

But in all truth I need to mention a vice of the country which has contributed to this disaster in making: in Venezuela everyone wants a degree, a college degree, even if it is meaningless.  Chavez has tapped in that desire and has been providing plenty of empty degrees for people that today can only find work in the public sector as no one in the private sector will hire a chavista university graduate.  Not even because of the ideological potential of the job applicant but because we know their education is incomplete.  This is what is happening with the MIC where a dangerous mix of ideology and "I wanna be a doctor" is brewing a health catastrophe for the country by graduating thousands of people whose basic anatomy lessons are incomplete.

Because let's not be afraid of words: what the regime is doing with its parallel education of ideological degrees is creating two class of citizens with all the conflicts that will result from that, without ignoring all the damage that these fake degrees will do to the country and its people.

We are going to pay for chavismo for at least a generation.


  1. Island Canuck8:27 AM

    Shortly after this was announced last week one of the new "doctors" went on government TV and threw some slurs at the students actually studying medicine in real medical schools.

    I'll say it again - we live in a fantasy world here in Venezuela - a real "Alice in Wonderland" of ridiculous comments & plans, limited services & worsening shortages.

    The 3 new laws - rental, prices & earnings & labour law (announced last night) - will put an end to what's left of the private sector.

    It looks like he wants to push us into full out communism before he dies.

  2. How long does it take to become an MIC? It takes between 6 to 8 years to become an NP, and between 4 and 5 to become a PA here in the US.

    I love the concept of the new health practitioners because it fills a gap which is very needed in patient care services.I see a PA usually( unless I have to go to a specialist) and he is far more patient- oriented than the new family doctors are.A doctor may have more theoretical knowledge but if he doesn't take the time to integrate it with some real life knowledge of the patient- things can get dangerous.My PA spends an hour with me, calls me on the phone, and has a pretty good knowledge of who I am.The doctor I knew before him would not have recognized me on the street.The only drawback is that I have to pay the same price to see my PA as I do the doctor...I guess you exchange time for greater theoretical knowledge.

    What is going on in Venezuela is shocking and sad.I don't think they have to be as obsessive and irrelevantly controlling as we are here in the US but there has to be a minimum of safety standards that I just don't see being met.

    The collapse of Venezuela is beginning to feel imminent to me.

    But one theme I would love to discuss is precisely the theme of how Venezuelans perceive these changes which is the most relevant one to the outcome.

  3. cochonette en feu

    i think they could be compared to PA. but i am not even sure of that.

    the programs started in 2003-2004. you do the math considering the unavoidable delays of the first couple of years until a pensum is set up.

  4. Daniel,

    Incendiary topics -- and I count among them, the discussions of health among the lay public -- beg for precision, when discussed.

    As such, could you identify or elaborate on the surgical procedures -- a vast spectrum broaching a scale of complexities -- that an NP can do in the US?

    Bear in mind, too, that each state has its certification procedures, not all of the states requiring a PhD, but rather, a (normally one-year) Masters.

    When you state "surgery" does that mean, lancing a boil? Does it mean, removing a mole? Does it mean, brain surgery? And are the more complex of the procedures allowed, supervised by a physician/surgeon?

    Perhaps attention to such detail could provide the first step towards educating the public on this valuable option in public health.

    It all boils down to education and the quality of information.

  5. Monsieur Duquenal,

    Off topic: por qué no comentas en algún sitio francés lo que dijo nuestro querido Procurador general? Que Ilich Ramírez no es un terrorista sino un luchador por sus ideales?

  6. Charly10:35 AM

    A cynic would say that some of those fake docs will end up being pretty good at the trade in due course. You see, rather than practice on cadavers as in classical medical schools, they will get to practice on live people. They ought to learn something at some point. Maybe patients should start seeing vets, since the profession has not yet been contaminated by the regime (to my knowledge).

  7. Syd

    You are right, bad wording. I shall correct it when i am back at a computer.

    Indeed in many states NP can do stuff such sewing up people or lancing boils but no brain surgery. My bad though unintended.

  8. so true, Charly!

    Isn't funny that the same folks who decry those who have worked hard for their degrees and associated certifications -- without resorting to shortcuts -- are the same folks that laud degrees, when it comes to their own education, their own health and their own safety.

    Hypocrisy runs supreme.

  9. I think the level of qualification were talking about here is that of an Emergency Medical Technician or at best Navy Medic. Treat minor things and transport to the hospital major ones. Not a bad thing if done right but, 10 years of this sez it won't happen. Also, in Venezuela you can go to a pharmacy and get a diagnosis and drugs without a perscription, this is a service for those who can't afford the drugs?

  10. Roger,

    Dr. Eugene A. Stead of Duke University Medical Center in NC assembled the first class of Physician Assistants in 1965, composed of former U.S. Navy hospital corpsmen. He based the curriculum of the PA program in part on his first-hand knowledge of the fast-track training of medical doctors during World War II.

    As for the pharmacias, you are right- they are dangerous...though I must admit I loved diagnosing and treating myself with the help of a pharmacist.... it seemed so convenient...but in trying to be objective, I know it shouldn't be that way.

  11. Chavez or no Chavez,, is it better to have more pseudo-doctors, of Cuban descent, or not, than less? I mean, the Venezuelan healthcare system has always been less than mediocre, when available at all, for the vast majority of poor people. Going forward, hopefully without Chavez, in the Amazon or Guatire, better to have a bunch of enfermeros chimbos than nothing except malaria, dengue, and easy ailments to treat. You can't expect to have Harvard graduated PHD's in Maracay or Anzoategui anytime soon this century.

  12. A. Barreda3:43 PM

    Basta una frase para describir todos y cada uno de los programas sociales del chavismo: De buenas intenciones está empedrado el camino al infierno.

    Si, todas en el papel suenan bien: escuela bolivarianas, barrio adentro, mision robinson y demás, pero como pueden servir para algo si son manejadas por gente incompetente?

    I'd love to see the opposition candidates how they would fix/improve these social programs.

  13. I congratulate you on your article Daniel.

    I am really appalled at the situation. I know how hard work medical students to get their years, rural, 48 hour wards in the worse see a group earning more than them, with inferior education and the same is just very difficult to accept.

    The medical federation should have reacted LONG ago. Another institution that did not act when they should have.

  14. Dear Josemaria Paulo Jeromino Martin Carvalho-Von Verster, no contractions for your pen name, eh?

    It is a contraction of the words Para Adelante, which mean FORWARD.

    Hence in the caption you can translate it as:

    Forwards Integral Community Medicine.

  15. Anonymous4:04 PM

    Just out of curiosity, how adequate is the training currently available to actual physicians in Venezuela?

    Back in the late 1990s, I received what I considered excellent medical care from a private physician in Caracas. I do not recall where he had been trained, but since his English was nearly flawless I suppose it's possible that much of it was not in Venezuela.

    Are many of the physicians who received their training in Venezuela adequate and still in Venezuela?


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