After banning the traditional free marketing lunches for healthcare providers offered by pharmaceutical reps, the state of Vermont is considering requiring pharma companies to report or even eliminate free drug samples. At a hearing held by the state's attorney general's office yesterday, stakeholders were given a chance to state their opinions about the merits of sampling.

One of those stakeholders was nurse practitioner Dorothy Malone-Rising, who argued that samples help in her diabetes teaching. Here's what she told the hearing (according to an Associated Press report):

"I like to have a patient try a new medication that might have an expensive copay with a sample so we can be sure a patient tolerates the medicine before having to pay for it," said Dorothy Malone-Rising, a nurse-practitioner who works in the northern Vermont town of Johnson.

She said samples are especially important for diabetic patients, from whom preparing and giving themselves a first shot of insulin is often a traumatic experience.

"Having their provider at their side as they give their first injection is essential," Malone-Rising said.

Nancy Crigger, NP, offered a different opinion on drug sampling earlier this year in ADVANCE. What's your position? Do you use samples? Should samples be banned?

I attended the second annual Aesthetic Extender Symposium last weekend, and days later I am left with some distinct and positive impressions about much more than the aesthetics industry.

First, some background. The symposium was cofounded by Krystie P. Lennox, a physician assistant, and David J. Goldberg, a dermatologist who is also a healthcare attorney. These two professionals recognized a need to provide focused education and networking opportunities to the growing number of NPs and PAs who are providing medical aesthetic services. Facing down resistance from various forces in this specialty, they organized the first Aesthetic Extender Symposium in Miami Beach, Fla., in 2008. This year, the symposium brought 42 NPs, 68 PAs, 14 RNs -and 52 physicians - to South Beach.

Don't let the word "extender" in the title fool you. This symposium was focused on presenting the latest information on therapies, procedures and tools - not on who does what. This spirit of camaraderie was also evident in the prestigious faculty, which represented specialties that might not have stood side by side just a few years ago. The presenters included the president of the American Society of Plastic Surgeons (Roxanne Guy, the organization's first woman president) and the president of the American Society for Aesthetic Plastic Surgery (Renato Saltz). Salz described "seismic change" at work in aesthetics, and he urged attendees to embrace it. He also invited NPs and PAs to attend the American Society for Aesthetic Plastic Surgery meeting in 2010, and noted that more than 500 of these professionals attended the group's 2009 workshops. (See http://www.surgery.org/ for information.)

Getting back to those impressions ... I think this symposium represents something that most NPs seek: strong working relationships with colleagues from various specialties and disciplines. I also think the event is an important component of the "medicalization" of aesthetics. Sure, there are potions and magic wands out there -and there are bad results. But in the best aesthetic settings, there is science. And that is exactly what the 2009 Aesthetic Extender Symposium delivered.

(Just as every presenter at the symposium provided disclosures about commercial relationships, I shall do so here: ADVANCE is the official publisher of the Aesthetic Extender Symposium.)

Have you noticed nonchalance about seasonal and H1N1 flu vaccines in young adults? The way that H1N1 is affecting those under 25, and the way that patients in that age group seem to treat their own health, could pose a big challenge to NPs trying to keep them healthy. Some young patients may be shocked to find that they aren't invincible when they get the flu.

The ABC News Web site reported today that most hospitalized cases of H1N1 are in patients under 25 (Swine Flu Sends Mostly Under-25s to Hospital: CDC). According to the CDC, 23% of people who die from H1N1 are under 25, whereas in a normal flu year 90% of deaths are in people over 65.

And pregnant women are extremely vulnerable considering this, because they're often in this younger age group and their immune systems are suppressed. The New York Times ran an article Monday that chronicled the frightening story of Aubrey Opdyke, who nearly died from flu and also lost her baby while she was hospitalized for 4 months (Flu Story: A Pregnant Woman’s Ordeal). That article talks about the nonchalance of a younger crowd to the flu. Even Opdyke's physical therapist, after working with Opdyke on her continued recovery, said she wouldn't get the flu vaccine because she worries about its ingredients.

There may be a bit of sensationalism here, but the threat is real. NPs have the communication skills to really help this patient population understand the importance of protecting their health in the face of the flu. But some patients won't want the vaccines. Will you encourage patients to get the vaccines? If not, what will you recommend?

• Of NSO policyholders, those most likely to be sued are male, are 65 or older, have a doctorate degree or work in a rural practice.
  
  
• The number of years worked as an RN before becoming an NP had no statistically significant effect on the likelihood of being sued.
  
  
• More experience practicing as an NP lessened the likelihood of being sued. Almost half of the claims made against NSO policyholders were made against NPs with less than 5 years experience.
  
  
• NPs who earned their degrees through an online program were neither more nor less likely to be sued than those who attended a traditional program. And the number of clinical hours earned had no effect on likelihood of being sued.
  
  
• NPs who had an NP mentor during their first 2 years of practice were less likely to be sued than those who had a physician mentor.
  
  
• NPs who had claims made against them had less personnel support (from an MA, RN, NP, etc.) than those with no claims.
  
  
• The average number of patients seen per day by all NPs in the survey was 16. Those who had been sued were seeing 18 or more patients per day.
  
  
• Using EMRs limited claims: 72% of those who had been sued used only handwritten records.
  
  
• NPs who worked in states with more autonomy had fewer claims against them. And NPs without prescriptive authority were twice as likely to be sued.

Friday's New York Times article about retail clinics titled "A Quick Trip to the Store for Milk and a Throat Swab" asked readers to comment on their Well Blog about retail healthcare and nurse practitioners. And they sure did. It's worth it to read some of the discussion to stay informed about what misperceptions the public and physicians may have about NPs. And add some comments of your own! Following are a few excerpts from reader comments:

"They billed my insurance a modest $40 but more importantly they provided the kind of simple and prompt medical care that my two other choices, my own doctor or the ER, could not. My experience is that there is a place for this kind of care. As long as patients recognize the limits of these places and followup with their own doctor when needed I think these ‘clinics' are fine."- Paula C.

"I'm just one man with one experience but last night I went to get a flu shot at the closest Minute Clinic and it was a disaster. When I got there there were 12 people waiting in front of me and when after 1/2 hr I decided to cut my losses and go home there were still 11 people in front of me, each and every one with a look of misery and frustration on their faces. My takeaway: MinuteClinic idea better on paper than in practice. Perhaps should be renamed 90 MinuteClinic." - Randy

"Being uninsured, the Minute Clinic IS my doctor. God bless ‘em because there not anywhere else for me to go." - Theodora

"4th year medical students have better training than NPs/DNPs. They have a significantly greater basic science training AND they have a few thousand more clinical hours of training. Would you see a 4th year medical student for your health problems? If no, then why would you see NPs/DNPs without physician oversight? It doesn't make any logical sense." - Student

"As a nurse practitioner in the state of Maine, I am state licensed, nationally certified and an independent practitioner. Do I believe I can practice without the support of a team which includes those with more (and less) education than me? Of course not! But frankly, I wouldn't want a neurosurgeon providing primary care for my family any more than I would want my primary care provider doing my brain surgery. As the author points out, retail clinics have a very specific role and within that role, they are more than able to provide high quality care. Although I strongly support a team approach to health care delivery, I need to point out that I am not a"midlevel" provider or a "physician extender." I do what I do well and recognize my limitations, behavior I expect of all professionals. Sadly, until we address the health care crisis in this country in a manner that ensures access for all to primary care, retail clinics, urgent care centers and ERs will be the only provider for too many folks."- Lisa

"Lisa," the NP whose comment is listed above, responded very coherently to the concerns raised in other comments, and she gave useful information to the people involved in that conversation and the many other people reading. In today's Internet-ruled world, it's a great idea to make your voice heard in venues like blogs, forums, and social networking sites. Get involved online!

What are the most lucrative employment settings for NPs? Based on 5,053 responses so far to the 2009 ADVANCE National Salary and Workplace Survey of Nurse Practitioners, the top five highest paying NP practice settings are aesthetics/skin care, emergency department, house calls, surgery and mental health.

Since we last asked in 2007, aesthetics, surgery and mental health settings each record average salary increases greater than $13,000 -- and aesthetics/skin care compensation rose more than $20,000. We didn't ask about house calls last time, so we'll assess compensation growth in that setting with our 2011 survey.

None of these most lucrative settings employs more than 5% of nurse practitioners. Family practice, which employs more than 23% of nurse practitioners, records an average salary increase of about $16,000 since 2007, but the rest of the top five employers of NPs (hospital, internal medicine, women's health and pediatric settings) each show an increase less than $8,000.

While an $8,000 salary boost over 2 years isn't bad, especially in this economy, we can see that a smaller number of nurse practitioners are seeing much bigger increases. (And just for fun: Gerontology settings increased salaries by more than $10,000, while oncology settings gave only about $4,000 in raises.)

 Be sure to take the survey and be counted! Survey ends at midnight Sept. 30, and we need at least 1,000 more responses to meet our goal.

However, less than 4% of NPs work in convenient care settings. That's according to 2,781 responses so far to the 2009 National Salary and Workplace Survey of Nurse Practitioners. (We're still collecting data, so if you haven't filled out the survey yet, go do it now!) Sure, that 4% is up a percentage point from the 2007 survey, but it's still only about the same fraction as NPs who own their own practice.

Here's how NPs in retail health compare with the population of NPs as a whole:

• The average full-time salary for NPs working in retail health is $87,667 ($86,000 median). That's up 8% from 2 years ago, and it's pretty close to the overall average full-time NP salary of $89,328 ($85,000 median).
  
  
• The average part-time retail health hourly rate is $44 ($46 median), which is close to the overall average hourly NP rate of $46 ($43 median).
  
  
• About 24% of retail health NPs work part time, and 31% of those have more than one part-time position. Overall, 15% of NPs work part time, and 36% of those have more than one part-time position.
  
  
• NPs in retail health are overwhelmingly master's prepared (93%), 2% have a doctoral degree, and 5% have a bachelor's degree as their highest credential. That's compared with 91% of NPs in general who are master's prepared, 4% with a doctorate, 3% with a bachelor's degree, and 2% still practicing with an associate's degree.
  
  
• NPs in retail health write an average of 34 prescriptions each week (30 median), compared with 70 prescriptions on average (40 median) for NPs in general.
  
  
• NPs in retail health seem a bit less satisfied with their jobs than do NPs in general: 81% are somewhat or very satisfied in retail health, while 87% are overall. About 17% in retail health say they are somewhat or very dissatisfied with their job, compared with 12% of NPs in general.

Writing in today's issue of USA Today, Pennsylvania Gov. Ed Rendell champions nurse practitioners as the means to universal access to healthcare.

Together with Tine Hansen-Turton, who is CEO of the National Nursing Centers Consortium headquartered in Philadelphia, Rendell argues that the projected primary care physician shortage could thwart efforts for universal healthcare coverage.

"So what's the solution?"they ask.

"In Pennsylvania, our reform plan advocates using highly skilled and licensed non-physician providers to help fill the physician shortage. More than 3,700 family nurse practitioners graduated from masters-level and postmasters-level programs in the USA in 2007. Nurse practitioners and other nonphysician providers such as physician assistants, nurse midwives and dental hygienists can help stretch our resources.

"Studies have shown that nurse practitioners are capable of managing 80%-90% of the care provided by primary care physicians without resorting to physician referral or consultation. And in all 50 states, nurse practitioners can prescribe medications. They also can diagnose and treat patients, order lab tests and refer patients to specialists."

Rendell has been a friend to the state's NPs since he took office. In July 2007, he kicked off his healthcare reform program by signing five laws expanding NP authority.

The H1N1 virus spreads quickly and could seriously tax our healthcare system this year. Healthcare workers are among the high-priority populations for the vaccine. MSNBC published an article today titled "C'mon, health workers, get your swine flu shots." The article, which reports that only half of U.S. healthcare workers get a flu vaccine, says that nurses and other healthcare providers refuse the flu vaccine for a wide array of reasons:

A study published this week at bmj.com, the online version of the British Medical Journal, reported that nearly half of health care workers surveyed in Hong Kong earlier this year said they would refuse the swine flu vaccine because of fears of side effects and doubts about efficacy.

That study came on the heels of a United Kingdom poll that showed 30 percent of nurses would turn down the H1N1 shots, and researchers believe it's a good indicator of health worker reluctance worldwide.

The reasons health staffers in the U.S. and elsewhere give for not getting flu shots range widely, said Robert M. Pestronk, executive director of the National Association of County and City Health Officials. Some say they never get sick, so they don't get it. Others believe that the vaccine won't work. Others say they'll stay home if they get sick.

"And some say they don't like needles," Pestronk said.

 Just a couple of days ago, the World Health Organization reported that the H1N1 virus has spread quickly: in 6 weeks it's spread as much as the seasonal flu spreads in 6 months.

What will you do? Click HERE to take our two-question survey about flu vaccines.

Based on 1,793 survey responses so far, the average salary for NPs who are women is $87,866 ($85,000 median); and for those who are men, it's $104,009 ($98,000 median). That means NPs who are women currently make 15.5% less than male NPs. Using wage averages from past surveys, it looks like the gender wage gap is getting worse: The gap was 8.7% in 2007 and 11.7% in 2005. ([men's wage - women's wage]/men's wage=x)

With a little more math, we see that the gender wage disparity for NPs is still less than that for the general population. The ratio of women's and men's median (note the switch from means to medians) NP salaries in 2009 is 86.7%. According to the Institute for Women's Policy Research, the ratio of all women's and men's weekly earnings in 2008 was 79.9%. (women's wage/men's wage=x)

NPs' job choices account for the difference, at least superficially. In general, a higher percentage of male NPs are employed in all but one of the highest average salary NP job settings: aesthetics ($110,125; about equal men and women), mental health ($101,213; 7% of men, 4% of women), emergency department ($100, 450; 11% of men, 4% of women) and other hospital settings ($92,760; 25% of men, 14% of women).

Also, more than 9% of male NPs own their own practices as compared with 3% of NPs who are women. And according to our 1,793 respondents, practice owners make $122,134 on average to $88,313 for NPs who work for someone else.

If you haven't filled out the survey yet, please do as soon as possible. The deadline is September 30. The more responses we get, the more representative the results will be.

In response to a survey on treating obesity that ADVANCE ran online in June, 21% of NPs told us they believe the primary reason patients find it difficult to lose weight is lack of exercise. That response was second only to "availability of quick, inexpensive, high-calorie food choices," selected by 34% of respondents.

Well, the solution to lack of exercise might now be here...

A press release just landed in my e-mail in-box with this heading: "As waistlines increase brain size and function diminishes according to new study."

That means that as U.S. workers are getting heavier, they're also getting dumber. The solution for employers looking to maintain a top-notch workforce? The TrekDesk.

The TrekDesk is a treadmill with a desk-like platform. You can see a picture here. Employees can do all their desk-bound work while walking slowly and steadily, instead of just sitting on their duffs. And in case that sounds like sweatshop labor to you, the press release assures us, "There is no thought involved, no will power needed, no dramatic life change, no additional time commitment and no sweating necessary."

As silly as it sounds, maybe it's not a bad idea. I'm not convinced that fat=dumb -- there was no citation for the purported study results -- but I'm always trying to fit in gym time around office time. Do you think it could work? Does anyone use a TrekDesk?

For many NPs, the issues surrounding taking call are mysterious, and the processes for determining compensation are unsatisfying. But in the end, NPs who take call make higher salaries than those who don't. Read on for the numbers.

Based on the 1,759 responses so far to the 2009 National Salary and Workplace Survey of NPs, 25% of nurse practitioners say they take call. This is the same percentage as those reporting in 2007 that they take call. Of those who take call, 32% get paid for their extra duties. This is a drop from the 38% in the 2007 survey who reported being paid for taking call.

On-call pay is determined in a variety of ways: 32% make an hourly wage for call time -- whether this is their regular hourly rate, time and a half, or a nominal fee such as $2 per hour. Another 22% make a specific amount for unlimited hours or calls. And 10% say they make an additional percentage of their salary. Others receive comp time or a periodic bonus.

But whether or not they're explicitly paid for being on call, NPs who do it make more than those who don't: $91,431 per year on average versus $88,569.

How do you feel about taking call? Is an extra $3,000 a year worth it? Are there benefits besides pay to taking call? Would you do it if you didn't have to?

So I turned to the ongoing 2009 National Salary and Workplace Survey of NPs to see what nurse practitioners with DNPs are earning. Here's what I can tell based on 1,675 responses so far. The vast majority of these (91%) are from NPs who indicate that a master's is their highest degree; 4% indicate that they have a doctorate degree.

Here's the breakdown of the types of doctorates these respondents have:

• DNP 45%
• PhD 36%
• DNSc 10%
• EdD 6%
• Another nursing doctorate 3%

And here's what they earn on average (median in parentheses):

• Master's degree $89,287 ($85,000)
• DNP $97,898 ($97,250)
• PhD $97,304 ($93,500)
• DNSc $90,000 ($89,000)
• EdD $116,667 ($125,000)
• Another nursing doctorate $95,000 ($95,000)

So, it looks like a DNP could earn you $10,000 more per year than a master's degree and at least a few $1,000 more than a PhD or other nursing degrees. I don't know what's up with the EdD.

But here's a consideration: Those NPs with master's degrees as their highest degree have practice for 8 years on average (6 years mean), and those with a DNP have practiced 11 years on average (11 years mean). So perhaps it's the extra 3 years' experience that garners the extra $10,000. But then, DNPs have fewer years practicing on average than NPs with other doctorate degrees.

Practice setting seems not to account for salary differences between master's and DNP nurse practitioners -- both groups tend to be equally represented in the most popular employment settings.

It seems to me that a DNP could actually earn you a higher salary. What do you think? Am I missing anything here?

 (Don't forget to take the survey!)