I Am, as Usual, Fuming

To the Editor.  —I am, as usual, fuming after reading an installment of Health Care Policy: A Clinical Approach.¹ These articles insult one's intelligence.Drs Grumbach and Bodenheimer ask the reader to accept as typical this scenario: a cancer patient with persistent vomiting is serially mismanaged by her oncologist and her gastroenterologist. She then sees a nurse practitioner who quickly figures out what's going on and cures the problem, without spending a lot of money! Presumably, because of their training and clinical experience, nurse practitioners (clearly these are archetypes, not exceptional individuals) are better prepared to manage gastrointestinal complications of cancer chemotherapy than either oncologists or gastroenterologists. No evidence is offered to support this, and I can't buy it.Next comes the story about Dr Service's "bet" with Dr Caire. We are told that, by auditing medical charts, "a nurse specialized in quality improvement" was able to determine that