Nursing Emergency residency

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M.Furfur

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Yup!!! USF is starting residencies in many medical specialties. So apparently they are not only after primary care. Time to smell the coffee and start acting.

Contact AMA, AAEM and USF NOW!!!!!


Clinical Residency Concentrations


The USF College of Nursing has established selected, broad, supervised residency concentrations designed to meet each resident's individualized professional and clinical practice goals. Each clinical residency concentration is a variable credit tract with a minimum requirement of 500 clinical hours beyond the Master's level clinical hours. The Dermatology and Cardiovascular residency concentrations require a minimum of 1000 hours beyond the Master's level clinical hours. Residency concentrations are broadly defined by the following clinical specialties:

Dermatology*
Cardiovascular
Family Practice
Occupational Health *
Internal Medicine
Endocrinology
Neurology/Pain Management
Psychiatry
Pediatrics
Neonatology
Emergency Medicine
Acute Care

* Additional criteria may be required for admission
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southerndoc said:
Wow, 500 hours compared to the 10,000+ hours of residency training for physicians.
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Which makes it even more urgent for physicians to wake up and start some action...
 
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Hello, I'm Dr. XXX, I'll be your board-certified emergency medicine provider this morning...



Let's take look at the curriculum:

Total credits: 52
NGR 6673 Epidemiology for Advanced Nursing (3)
NGR 7841 Statistical Methods Nursing Research I or
EDF 6407 Statistical Analyses for Educational Research or
PHC 6050 Biostatistics (3)
NGR 7951 Scientific Writing-Publication (3)
NGR 7103 Evidence Based Practice (3)
NGR 7141 Pathophysiology for Adv Practice II (3)
NGR 7766 Leadership & System Analysis (3)
NGR 7881 Ethics in Research and Practice (3)
NGR 7892 Health Policy Issues in Nursing and Health Care (3)
NGR 7974 Evidence Based Project (4)
NGR 7945 DNP Residency (9)

NGR 7176 Pharmacotherapeutics (3)
NGR 7209 Diagnostic Reasoning (3)
NGR 7767 Practice Management (3)
Electives (6)


So a whopping 10% of their didactic training involves learning the "meat" of their chosen subspeciality. And at 500 clinical hours, they'll achieve the equivalent of less than 2 months experience of a PGY-2.

:thumbdown:
 
As most of you know I'm not very much of an optimist but I think that EM will be one of the specialties that will be insulated to some degree from this. For most specialties anyone who is empowered by state law to practice medicine (i.e. these DNPs) can just rent an office and hang up a shingle. EM is a little more complex.

In EM it's all about getting the contract with a hospital. At this point there are diminishing roles for non-EM boarded physicians. I don't think it's likely that a group of DNPs would be able to secure a hospital contract. It also seems unlikely, not impossible, but unlikely, that many groups would have these DNPs working independently in an ED without a physician around. I can see groups using these DNPs as the midlevels they are but that's a different issue. There would be some billing ramifications with that.
 
docB said:
As most of you know I'm not very much of an optimist but I think that EM will be one of the specialties that will be insulated to some degree from this. For most specialties anyone who is empowered by state law to practice medicine (i.e. these DNPs) can just rent an office and hang up a shingle. EM is a little more complex.

In EM it's all about getting the contract with a hospital. At this point there are diminishing roles for non-EM boarded physicians. I don't think it's likely that a group of DNPs would be able to secure a hospital contract. It also seems unlikely, not impossible, but unlikely, that many groups would have these DNPs working independently in an ED without a physician around. I can see groups using these DNPs as the midlevels they are but that's a different issue. There would be some billing ramifications with that.
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With all due respect I don't think that living in denial is going to solve any problems. Acting that one field of medicine is protected is a disservice for every colleague of yours and for every student who busted their *** to get into medical school and then a residency program.

The bucket won't stop at emergency medicine nor at any other specialty. First they were filling the void in primary care, now it's 10 more specialties.
It's time to stop this encroachment while we can.
 
A nurse practitioner doing a residency in a specialty does not equate to autonomous/independent practice. PA's have had residencies for years and they don't practice autonomously.

I think there are two issues here. DNP's wanting autonomous practice privileges should be the focus of our efforts, not residencies to advance their education and facilitate employment in their respective areas of practice.
 
docB said:
I don't think it's likely that a group of DNPs would be able to secure a hospital contract.
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CRNA groups have already done so. No specialty is insulated.
 
southerndoc said:
I think there are two issues here. DNP's wanting autonomous practice privileges should be the focus of our efforts, not residencies to advance their education and facilitate employment in their respective areas of practice.
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DNPs already have autonomy in many states. There is nothing whatsoever that can stop them from adding hours to their training and claiming more privileges and more procedures....
 
Anyone who wants to assume the liability, professionally and financially, of unsupervised patient care with insufficient training is welcome to let the rubber meet the road.
 
M.Furfur said:
With all due respect I don't think that living in denial is going to solve any problems. Acting that one field of medicine is protected is a disservice for every colleague of yours and for every student who busted their *** to get into medical school and then a residency program.

The bucket won't stop at emergency medicine nor at any other specialty. First they were filling the void in primary care, now it's 10 more specialties.
It's time to stop this encroachment while we can.
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Look I'm not in denial, I just don't see this threat as it pertains to EM the same way you do. This isn't news. This has been going on for years and everytime it gets some press there are dozens of threads that spring up across the site by panicked people trying to protect their cheese.

As for some disservice to the ass busting required to become a doctor no one cares. That is not going to sway any public opinion our way. Are you going to got out on the speaking circuit with the message "We had it rough, you should pay more for us." That's gonna go down in flames.

So as for "stopping the encroachment while we can" can we? What guns do we have to push the idea that people should pay more to see us than some DNP who makes the patients think they're a doctor?

I'll answer that question for you. We will need some data showing that their outcomes are worse than ours. Not just clinical endpoints but the economic endpoints that insurers care about like hospital days overstayed. Most importantly we need to show everyone that a DNP is really not that much cheaper than a doctor. They're not going to work for peanuts after they went to the trouble of erecting this facade. And they're going to have to refer all kinds of stuff that (hopefully) a doc wouldn't.

But my point is we are going to need data and dollars. No one in the general public, the insurance companies or the political arena gives two whoops about how hard it was to get into med school.
 
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caspian said:
CRNA groups have already done so. No specialty is insulated.
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That's a good point but EM and anesthesia contracts differ significantly. The trend has been for decades now for more demand for BC EPs. It could happen but it would be down the road compared to several other hurdles they'd have to clear first.
 
docB said:
Look I'm not in denial, I just don't see this threat as it pertains to EM the same way you do. This isn't news. This has been going on for years and everytime it gets some press there are dozens of threads that spring up across the site by panicked people trying to protect their cheese.

As for some disservice to the ass busting required to become a doctor no one cares. That is not going to sway any public opinion our way. Are you going to got out on the speaking circuit with the message "We had it rough, you should pay more for us." That's gonna go down in flames.

So as for "stopping the encroachment while we can" can we? What guns do we have to push the idea that people should pay more to see us than some DNP who makes the patients think they're a doctor?

I'll answer that question for you. We will need some data showing that their outcomes are worse than ours. Not just clinical endpoints but the economic endpoints that insurers care about like hospital days overstayed. Most importantly we need to show everyone that a DNP is really not that much cheaper than a doctor. They're not going to work for peanuts after they went to the trouble of erecting this facade. And they're going to have to refer all kinds of stuff that (hopefully) a doc wouldn't.

But my point is we are going to need data and dollars. No one in the general public, the insurance companies or the political arena gives two whoops about how had it was to get into med school.
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Absolutley agree that data will be necessary to differentiate our services from those of DNPs. However, note that studies may fall on the deaf ears of our legislators.

My prediction is that initially DNP Emergency Medicine specialists will work under physicians as per status quo. As their respective residencies add more clinical hours, and more schools expand, so too will their perceived confidence to practice independently. Years from now in addition to obtaining DNP-only contracts in rural care hospital centers, they may begin to open urgent care centers, freely practicing under scope laws defined by the boards of nursing.

Patients will be the first to suffer! Not us.
Indeed, entire clinics have been sued into extinction because of sub-par care offered by autonomous nurse practitioners. Patients were harmed, a rural community lost access to care, and nobody wins (except the malpractice lawyers).

http://communitynewspapergroup.com/...y_register/news/doc4b192e803bc1b397045202.txt
 
Members don't see this ad :)
docB said:
Look I'm not in denial, I just don't see this threat as it pertains to EM the same way you do. This isn't news. This has been going on for years and everytime it gets some press there are dozens of threads that spring up across the site by panicked people trying to protect their cheese.

As for some disservice to the ass busting required to become a doctor no one cares. That is not going to sway any public opinion our way. Are you going to got out on the speaking circuit with the message "We had it rough, you should pay more for us." That's gonna go down in flames.

So as for "stopping the encroachment while we can" can we? What guns do we have to push the idea that people should pay more to see us than some DNP who makes the patients think they're a doctor?

I'll answer that question for you. We will need some data showing that their outcomes are worse than ours. Not just clinical endpoints but the economic endpoints that insurers care about like hospital days overstayed. Most importantly we need to show everyone that a DNP is really not that much cheaper than a doctor. They're not going to work for peanuts after they went to the trouble of erecting this facade. And they're going to have to refer all kinds of stuff that (hopefully) a doc wouldn't.

But my point is we are going to need data and dollars. No one in the general public, the insurance companies or the political arena gives two whoops about how had it was to get into med school.
Click to expand...

I couldn't have said it better myself.
 
caspian said:
Years from now in addition to obtaining DNP-only contracts in rural care hospital centers, they may begin to open urgent care centers, freely practicing under scope laws defined by the boards of nursing.
[/URL]
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I can see how exactly that scenario would actually turn out to be a good thing. So many of the following:

"I've had back pain for 10 years. Nothing has changed recently, but I thought I'd come get it checked out at this ED"

"Please take care of this altered nursing home resident that we dumped on you just because we are having a bit of a busy night here."

"HELP!!! My vicodin level is dangerously low!!!!"

would be taken over by these mid level run centers. This would leave EPs to practice more EM. And I dont mean trauma, but more like:

"I've had this sudden onset of chest pain/abdominal pain/head ache/blindness starting 4 hours ago."
 
docB said:
I'll answer that question for you. We will need some data showing that their outcomes are worse than ours. Not just clinical endpoints but the economic endpoints that insurers care about like hospital days overstayed. Most importantly we need to show everyone that a DNP is really not that much cheaper than a doctor. They're not going to work for peanuts after they went to the trouble of erecting this facade. And they're going to have to refer all kinds of stuff that (hopefully) a doc wouldn't.

But my point is we are going to need data and dollars. No one in the general public, the insurance companies or the political arena gives two whoops about how had it was to get into med school.
Click to expand...

I have started a thread in the general residency forum about starting a plan of action.

How do you think We should start? Lobby respective boards of medicine. Talk to the AMA?
 
M.Furfur said:
I have started a thread in the general residency forum about starting a plan of action.

How do you think We should start? Lobby respective boards of medicine. Talk to the AMA?
Click to expand...

The AMA knows about it. The reason not much is being done is that it's a very hard sell as I mentioned. It boils down to us trying to tell the public they should be willing to pay more for us because we're better. However we all try to fight it it's gonna be expensive. That's why so many are waiting to see what the impact of all of this really is before we committ huge sums of cash to it. You have to note that DNPs have not actually gotten any new priveledges. This latest panic is because the DNPs are just creating expanded coursework for themselves. I could put together a program to teach endoscopy to plumbers but that doesn't mean they'll be allowed to do colonoscopies.

I do think that we should lobby the BOMs to be ready to go when the time comes. It's pretty clear that anyone calling themselves a doctor and practicing medicine autonomously should fall under the BOM's jurisdiction. That will be an easy sale. The BOMs have lots of physician representation so they will understand the fake out going on and getting any burearucracy to expand its own power is a no brainer.

I also think we should be ready with a good attack ad campaign ready to go in each state where the DNPs make a play. Point out, dramatically, that these people are not doctors even though they are trying to play them in real life. They are taking advantage of the elderly and the sick, etc. etc.
 
gro2001 said:
"I've had back pain for 10 years. Nothing has changed recently, but I thought I'd come get it checked out at this ED"
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Situation bears further scrutiny. Something must have happened recently to manifest a new clinical picture to motivate the patient to seek care.
MEDICINE

gro2001 said:
"Please take care of this altered nursing home resident that we dumped on you just because we are having a bit of a busy night here."
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Thank goodness the differential for altered mental status is so small!
Alzheimer disease, heatstroke, hypoglycemia, thyroid storm, encephalitis...
MEDICINE

gro2001 said:
"HELP!!! My vicodin level is dangerously low!!!!"
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I can't think of a more lucrative way for DNP's to celebrate their newly found EM autonomy than by running nurse pill mills. CRNAs have caught on. Unscrupulous MDs figured that one out a long time ago...

These cases while time consuming and unglamorous are still well within the scope of medicine. Sure DNPs can refer out for anything even remotely nonroutine, but in an EM setting where time is of the essence, is this the best delivery of care?
 
I agree overall with DocB and Caspian. WHen NP's have pushed autonomy, they have then been exposed to greater litigation, with the expected steep rise in malpractice premiums. Consequently, most retreat to narrow specializations or under groups or hospitals w/ MD supervision like PA's.

Also, many NPs are resisting the push for DNP, b/c it does not add to their scope of practice or compensation. The degree only adds to their debt and ego. The drive to make entry level for NPs a doctorate level is driven by academia and not practicing NPs.

A group of NPs tried to negotiate w/ the trial lawyers and malpractice insurers to reduce liability -- and they were ignored. This is not an issue to get too wrapped up about.

Also, there is a deeply ingrained societal belief that anyone calling themselves a Doc who is not an MD/DO, is a fraud. Just like SW and nurse educators wearing long white coats.
 
DogFaceMedic said:
Also, many NPs are resisting the push for DNP, b/c it does not add to their scope of practice or compensation. The degree only adds to their debt and ego. The drive to make entry level for NPs a doctorate level is driven by academia and not practicing NPs.

A group of NPs tried to negotiate w/ the trial lawyers and malpractice insurers to reduce liability -- and they were ignored. This is not an issue to get too wrapped up about.
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This is only partially correct.
The DNP programs springing up, while being pushed by academia are unique now in that they are clinically focused for nurse practitioners. This is different from the highly unpopular Doctor of Philosophy Nurse PhD programs that are now being phased out for DNPs. These PhD programs failed for the reasons you stated: did not expand score of practice, did not offer a return on investment, too focused on courses like "Professional Communication for Nurse Executives."

With DNP programs like USF, the integration of (minimal) requirements in pharmacology, pathophysiology, diagnostic reasoning, and of course the clinical "residencies" will only add to the nursing boards' emboldended stance that they can continue to expand scope of practice.

Trial lawyers laugh them away now because of piss-poor degree standardization. Just skim through the different curriculum's:

http://www.aacn.nche.edu/dnp/dnpprogramlist.htm

Credit hours vary from 30-40 to over 60. Some require basic sciences, some dont. Some require a focused clinical residency, some dont. USF takes specialization to the extreme by offering derm and emergency medicine.

This variability will likely diminish as program directors optimize which courses to keep, what clinical hours to add, and how to educate their graduates to minimize liability in field. I predict that more programs will begin to follow USF's model as students flock to them after seeing just how successful a DNP-operated derm/EM/IM practice can be.
 
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A lot of other specialty forums are going ape-$hit over this.

We should be very vigilant and we should really do our best to avoid the crna/anesthesiology problem by nipping this issue at the bud.

The question is how?

Simply sending letters to our organizations?
 
I Guess the first step is to contact our organizations. What they should do is work on the level of the boards of Medicine to establish a scope that nurses cannot overlap with.
The other thing is how can a nurse do a residency in emergency medicine??? Shouldn't it be emergency nursing?
 
docB said:
The AMA knows about it. The reason not much is being done is that it's a very hard sell as I mentioned. It boils down to us trying to tell the public they should be willing to pay more for us because we're better. However we all try to fight it it's gonna be expensive. That's why so many are waiting to see what the impact of all of this really is before we committ huge sums of cash to it. You have to note that DNPs have not actually gotten any new priveledges. This latest panic is because the DNPs are just creating expanded coursework for themselves. I could put together a program to teach endoscopy to plumbers but that doesn't mean they'll be allowed to do colonoscopies.

I do think that we should lobby the BOMs to be ready to go when the time comes. It's pretty clear that anyone calling themselves a doctor and practicing medicine autonomously should fall under the BOM's jurisdiction. That will be an easy sale. The BOMs have lots of physician representation so they will understand the fake out going on and getting any burearucracy to expand its own power is a no brainer.

I also think we should be ready with a good attack ad campaign ready to go in each state where the DNPs make a play. Point out, dramatically, that these people are not doctors even though they are trying to play them in real life. They are taking advantage of the elderly and the sick, etc. etc.
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As has been seen with CRNA's, the Board of Nursing simply deems the practice of medicine as the practice of nursing and retains jurisdiction.
 
If these nurses want to be doctor-equivalents so bad, they should just go into medical school like the rest of us.

Geez.
 
pinipig523 said:
If these nurses want to be doctor-equivalents so bad, they should just go into medical school like the rest of us.

Geez.
Click to expand...

Don't you think they tried? If I had a nickel for every nurse who said "Oh, I could have gone to med school, but I liked nursing better..."

... only to have them shove off to CRNA school or whatever.

By the way, this is a purely American phenomenon. No other country has sold out the way this one has. The AMA is toothless - and hardly ever acts in the interest of Emergency Medicine, anyway.
 
Probably the future. There's the long-standing physician shortage in the country. The residency programs aren't opening new seats so this is the perfect opportunity for mid-levels to fill the gap. It's cheaper and faster to train and pay a PA to cover the fast-track in the ER than to have a physician do it. Most of the PAs and NPs I've worked with are mostly autonomous with the exception of someone having to sign off their charts and the end of the week or day. Not to mention they are fairly mobile and able to re-train quickly in any area of health care where there is a demand unlike a physician who would have to complete another 2-5 years of training. If they can prove they have the same outcomes then there's no reason for the government to oppose. I predicted physicians in the future will train in very specialized areas while mid-levels cover the rest of the playing field.
 
GreenShirt said:
Probably the future. There's the long-standing physician shortage in the country. The residency programs aren't opening new seats so this is the perfect opportunity for mid-levels to fill the gap. It's cheaper and faster to train and pay a PA to cover the fast-track in the ER than to have a physician do it. Most of the PAs and NPs I've worked with are mostly autonomous with the exception of someone having to sign off their charts and the end of the week or day. Not to mention they are fairly mobile and able to re-train quickly in any area of health care where there is a demand unlike a physician who would have to complete another 2-5 years of training. If they can prove they have the same outcomes then there's no reason for the government to oppose. I predicted physicians in the future will train in very specialized areas while mid-levels cover the rest of the playing field.
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I think that any specialists who complain that EM *physicians* calls too many consults will absolutely *love* any independently practicing nurses in the ED. (If that's ever allowed, which I hope it won't be. But what do I know?)
 
Raryn said:
I think that any specialists who complain that EM *physicians* calls too many consults will absolutely *love* any independently practicing nurses in the ED. (If that's ever allowed, which I hope it won't be. But what do I know?)
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I was thinking the exact same thing :smuggrin:
 
Veers had a good post in another thread:

GeneralVeers said:
Even scarier is that "Naturopathic Physicians" can now prescribe REAL medications in many states:

http://www.thefreelibrary.com/Oregon+legislature+passes+naturopathic+formulary+bill.-a0211561634

These people with a college degree and a BS degree in natural medicine will now be able to write for any prescription medications in the state of Oregon. Is anyone else as frightened by this as I am?
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That thread is actually about the ABPS EM "board certification" so I didn't want to hijack that thread but this post got me thinking.

In EM we are the ones who have no choice but to deal with the complications of these "pracitioners" be they naturopaths, DNPs, witchdoctors, etc. I just saw a woman 2 weeks ago who has been seeing a homeopath for a year while her belly swelled up. I took one look at her and told her, actually laid it out to her after looking at her for 10 seconds, that she had ovarian CA. CT confirmed huge ovarian mass, mets, and carcinomatosis. This dudes been screwing around for a year with hair samples and vitamins and I get to tell her she's gonna die.

Think how many patients we get referred into the ED by home health nurses, quick cares, nurse advice lines and so on. What will it be like once all the primary care is being done by someone who won't want to be the final word on anything?
 
docB said:
...Think how many patients we get referred into the ED by home health nurses, quick cares, nurse advice lines and so on. What will it be like once all the primary care is being done by someone who won't want to be the final word on anything?
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The number of patients an EM physician sees has always been interesting to me. Would it be that hard to create a database for this? Or if you have an EMR already, couldn't you search patient histories for "homeopath" and like terms? You could at least get a handle on the number of people coming in with problems either generated by, or ignored by these quacks. Then you'd compare the length of stay and survival of patients seeing NDs, homeopaths, and so on against a random sampling of patients with PMDs. I think you'd build a convincing case pretty quickly.
 
RxnMan said:
The number of patients an EM physician sees has always been interesting to me. Would it be that hard to create a database for this? Or if you have an EMR already, couldn't you search patient histories for "homeopath" and like terms? You could at least get a handle on the number of people coming in with problems either generated by, or ignored by these quacks. Then you'd compare the length of stay and survival of patients seeing NDs, homeopaths, and so on against a random sampling of patients with PMDs. I think you'd build a convincing case pretty quickly.
Click to expand...

If you had the right kind of EMR you could mine such data. It would be weakened by underreporting of these modalities by the patients and by misses due to nurses/docs not asking specific questions about it. Any study would be at risk of selection bias for those reasons.
 
docB said:
If you had the right kind of EMR you could mine such data. It would be weakened by underreporting of these modalities by the patients and by misses due to nurses/docs not asking specific questions about it. Any study would be at risk of selection bias for those reasons.
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Still not sure how an NP would do all the functions of a real doctor. In their 500 hours of training are they trained in complex laceration repair? How about tying off of small arterial bleeds? Fracture reductions? Transvenous pacers? Traumatic c-section and delivery?

Until they are trained in all of these procedures and demonstrate proficiency, I find it hard to believe they will replace us anytime soon.
 
GeneralVeers said:
Still not sure how an NP would do all the functions of a real doctor. In their 500 hours of training are they trained in complex laceration repair? How about tying off of small arterial bleeds? Fracture reductions? Transvenous pacers? Traumatic c-section and delivery?

Until they are trained in all of these procedures and demonstrate proficiency, I find it hard to believe they will replace us anytime soon.
Click to expand...

Caspian's point about CRNA groups landing hospital gas contracts was a good one. It made me reevaluate my initial opinion. I could see some administrator somewhere deciding that a DNP with an EM "residency" is better than using non-EM boarded IM and FM docs. You can imagine the billboards now "All EM residency trained doctors!" ('cause we already have billboards with stuff like "FastER!" :smuggrin:)

It wouldn't affect us here because the community standard is boarded EPs and no hospital subsidies, we just eat what we kill in term of payer mix. In areas where the EM groups depend on hospital subsidies I could imagine a situation where a nocter group could make a play.
 
docB said:
If you had the right kind of EMR you could mine such data. It would be weakened by underreporting of these modalities by the patients and by misses due to nurses/docs not asking specific questions about it. Any study would be at risk of selection bias for those reasons.
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You'd have more controls (PMDs) than sCAM patients, sure, but the point would be more to determine the differences in quality of care and delays in care, not total numbers. Incidence is important info, but a "testing the waters" type chart review won't generate good numbers on that anyways, and a little selection bias towards bad cases would enhance the likelihood of a positive result. ;)

This is different from comparing NPs vs MD/DOs, etc.
 
GreenShirt said:
If they can prove they have the same outcomes then there's no reason for the government to oppose.
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I agree. But you will never get a randomized trial to test this, and a retrospective study doesn't really do the issue justice given that for now the physician is omnipresent as a backup.

But how about the proof of the many years of (what in retrospect was) poor medical care in the pre-residency era?

The major question is if as a medical system/society we'd like to revert back to the era where physicians didn't have residency training and simply learned on the job from similarly "trained" superiors. That's essentially what these "midlevels" want, and want to do it with a much poorer knowledge foundation relative to newly minted medical graduates. I love how all the PA programs describe their training as being "in the medical school model" to imply parity with physician education. That's like saying I taught my little boy to fly his RC airplane in the jet fighter pilot training model.
 
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GeneralVeers said:
Still not sure how an NP would do all the functions of a real doctor. In their 500 hours of training are they trained in complex laceration repair? How about tying off of small arterial bleeds? Fracture reductions? Transvenous pacers? Traumatic c-section and delivery?

Until they are trained in all of these procedures and demonstrate proficiency, I find it hard to believe they will replace us anytime soon.
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I doubt they are looking to do complex lacerations, traumatic deliveries, and emergency thoracotomies...not yet anyway.
They are ambitious but not stupid.
Their programs simply are not up to snuff to handle "all the functions of a real doctor" and frankly, why would they want to handle more complex (read: litigious) procedures?

No, DNPs are not looking to take over level 1 trauma centers. However, as their programs become more standardized, their lobbying groups better formed and funded, and with future patient pool increases, BONs are almost certain to deem it within in their perview for their graduates to practice emergency medicine. (whoops, I mean emergency nurse practitioning :cool:). But instead of doing so under a physician's chain of command, they will seek to obtain exclusive contracts in sure-to-be rural centers or set up their own shop as DNP-run urgent care centers.

Following the precedent set by CRNA's:
DNP-only contracted ER centers: 100% possible
DNP-owned and operated urgent care centers: 100% possible

In a continuation of the CRNA analogy, there are two ways to prevent this from happening.

A) The preventative strategy:
Establish scope-of-practice review committees at every state's supreme court, to better aid the court's interpretation of defining the practice of medicine. The AMA is currently in the very early stages of implementing this. http://www.ama-assn.org/amednews/2010/01/18/prl20118.htm

State bar associations established similar committees for defining the practice of law, expediting unauthorized practice of law lawsuits against paralegals, brokers etc.
EXAMPLE: http://www.txuplc.org/


B) The retroactive strategy:
In a piecemeal fashion, and only after patients are harmed by nurses, BOMs will sue individual nurses, practicing individual specialties, doing individual procedures. These individual cases will be slow, bitter, and very VERY expensive.
EXAMPLE: http://www.asahq.org/Newsletters/2008/02-08/stateBeat02-08.html
 
It will be interesting to see how insurers deal with nurses. Hopefully they will pay more in rates due to potentially higher liability.
 
GeneralVeers said:
It will be interesting to see how insurers deal with nurses. Hopefully they will pay more in rates due to potentially higher liability.
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You can insure a pair of socks. You can insure a DNP. Some firm out there will do it.

Looking at CRNA malpractice premiums, it's unlikely EM-DNPs will pay more. I think 2-6K/yr is typical for a CRNA. Compare that to 20K and beyond for an anesthesiologist. CRNAs will tell you it's because they are equal/better/safer :rolleyes:
 
GeneralVeers said:
It will be interesting to see how insurers deal with nurses. Hopefully they will pay more in rates due to potentially higher liability.
Click to expand...

This has already occurred. Several DNP advocates tried to negotiate a halt in rising liability for NP's who act independently last year. The lawyers see an easy target, and the insurers have no intention of taking a loss on DNPs. NPs w/ low rates, work for docs, just like PAs.
 
caspian said:
I doubt they are looking to do complex lacerations, traumatic deliveries, and emergency thoracotomies...not yet anyway....

B) The retroactive strategy:
In a piecemeal fashion, and only after patients are harmed by nurses, BOMs will sue individual nurses, practicing individual specialties, doing individual procedures. These individual cases will be slow, bitter, and very VERY expensive.
EXAMPLE: http://www.asahq.org/Newsletters/2008/02-08/stateBeat02-08.html
Click to expand...

That's an interesting example. In that case the CRNA's wanted to be able to do complex pain management procedures (epidurals, etc) "under the orders" of a referring physician...which means that the nurses themselves aren't making a diagnosis and prescribing treatment, something that is illegal under LA law. Reading the ruling, seems like the Louisiana State Board of Medical Examiners then did an end around and banned doctors from "prescribing" these procedures to nurses. Of course now they're getting more aggressive and want to do the diagnosing and prescribing themselves...so that trick won't work.
 
DogFaceMedic said:
I agree overall with DocB and Caspian. WHen NP's have pushed autonomy, they have then been exposed to greater litigation, with the expected steep rise in malpractice premiums. Consequently, most retreat to narrow specializations or under groups or hospitals w/ MD supervision like PA's.

Also, many NPs are resisting the push for DNP, b/c it does not add to their scope of practice or compensation. The degree only adds to their debt and ego. The drive to make entry level for NPs a doctorate level is driven by academia and not practicing NPs.

A group of NPs tried to negotiate w/ the trial lawyers and malpractice insurers to reduce liability -- and they were ignored. This is not an issue to get too wrapped up about.

Also, there is a deeply ingrained societal belief that anyone calling themselves a Doc who is not an MD/DO, is a fraud. Just like SW and nurse educators wearing long white coats.
Click to expand...


Some great points there. I think you have summed it up well w/ this:

"The drive to make entry level for NPs a doctorate level is driven by academia and not practicing NPs."

Totally true. People don't want to add to their educational debt-burden w/o any reasonable expectation of compensation. Tripping off of a mere title is ridiculous as well.

Most Advanced Practice Nurses are no where near the threats that are being pulled out here. Most of them will tell you straight out that if a person wants to become a physician, he or she needs to go to medical school, etc. That's really how most of us nurses think, period.

What you are fearing is that miniscule % of academic elitists and/or idealists. The sky is not falling, but reimbursements will continue to be the bigger issue, period.
 
bulgethetwine said:
Don't you think they tried? If I had a nickel for every nurse who said "Oh, I could have gone to med school, but I liked nursing better..."

... only to have them shove off to CRNA school or whatever.
Click to expand...

I LOLed at this comment. I LOLed because it's true. If I had a nickel for every time I heard the following from a nurse/PA (always unsolicited, mind you):

"I applied and got into med school. And it was a good school, too. But I decided not to go because nursing was better for me at the time."

Or

"I had good grades, I graduated at the top of my class in undergrad. And I did really well on the MCAT. But I decided not to apply to med school because nursing was my true calling..."

etc.

You don't have to brag to me about your past potential - coulda/woulda/shoulda. AWESOME that you were a top student. HOORAY for your fantastic "MCATs." It doesn't mean anything, and it certainly doesn't make you a doctor-by-default. The bottom line is that you chose a different career, either because your "calling" was something else, or you didn't want to put in the amount of time, money, committment, brain power, and work it takes to complete medical school and residency.

I could've been a nurse. I could've probably gotten me into nursing school somewhere. But I didn't apply to nursing school, I haven't taken any nursing licesnsing exams, or been through training for nursing. I don't claim to know how to do your job...why is the reverse ok?
 
LadyWolverine said:
...I could've been a nurse. I could've probably gotten me into nursing school somewhere. But I didn't apply to nursing school, I haven't taken any nursing licesnsing exams, or been through training for nursing. I don't claim to know how to do your job...why is the reverse ok?
Click to expand...
OMG. Now you're just being an arrogant doctor. You don't know me. I feel sorry for your patients. I'm going to report you!

:laugh:
 
elftown said:
I read this argument in another thread and thought perhaps it held some weight:

If DNP's are qualified to independently practice medicine, shouldn't a 4th year medical student be qualified as well?
Click to expand...


No, b/c it's not just about didactics. It's about working with both the didactics and the clinical and developing clinical judgment and such.

I mean we could argue until the cows come home about what this means. To me, it is very individualized; since some RNs that went to school to become advanced practice nurses have incredibly strong clinical experiences from some intense places over a long period of time, whilst others have maybe been RNs for a few years and then went directly to school for advanced practice. Big damned difference IMHO.

And so this is yet another reason I lean in favor of physicians in that their residency training is more intense, more uniform, and better mentored and supervised. Of course there are exceptions to all situations, but I am talking in general.

So long as physicians continue to maintain strong residency programs with great support and excellent mentoring, guidance, leadership, and very specific guidelines in terms of expectations and guidelines, they WILL continue to have the edge over many advanced practice nurses and PAs for that matter.

The intense and tight clinical experience and exposure makes the difference; but it is also part of what gives many NPs an edge over a number of PAs IMHO. (Lord, I better take cover, but I'm only giving my honest opinion.) Of course I say that with the caveat that the NPs to which I would be referring had had strong and intensive real life/real time acute/critical care clinical practice with accountability--and of that, many years worth of clinically merged experiences from high level centers prior to going on to NP Programs. IMO, there is just too much to be learned and gained by working at busy, high level acute and critical care areas. You almost have to be an idiot to NOT learn substantial clinical understanding and insight by working in these areas for a number of years. OK, some people may surprise me on that, but in general, I'm just saying. . .


At any rate this whole "us versus them" mentality is idiotic, b/c it seems like more of an issue than it actually is. It's a lot like the idiotic power-money struggle between hard-line allopathic pro-pharm-funding medicine and integrative medicine. Look at the bigger, better, and wiser picture is all I'm saying. It's sad, b/c in the end, the bigger piece of all this seems to be about money and power. Only advanced practice nurses with no lives are going to get all hype about the money and so called power. Much of prestige and power is an illusion anyway. It is productive influence that really matters.

Some grow and get that, while others stay stuck and never do.
 
Last edited:
jl lin said:
The intense and tight clinical experience and exposure makes the difference; but it is also part of what gives many NPs an edge over a number of PAs IMHO.
Click to expand...

by "intense and tight" you mean "fewer hrs in fewer disciplines"?

as a pa student I ended up with more clinical hrs in fp than an fnp AND more clinical hrs in EM than an enp AND more surgical and inpt hrs than an acnp or anp or rnfa.
so if you had to hire someone for family medicine would you want someone with 500-800 hrs of fp(the fnp) or someone with 500-800 hrs in each of several specialties including fp( the pa)?

most np programs have 500-800 clinical hrs or so(many programs also allow the student to arrange their own rotations.....).
most pa programs have 2000-3000 hrs or so.
the same individual(let's say an experienced rn) going to a pa program will get more clinical exposure as a pa than they would as an np. they would get even more in an md/do program.

don't mean to start a flame war here but you knew someone had to respond to your statement and point out its inconsistencies, right?
 
docB said:
Veers had a good post in another thread:
In EM we are the ones who have no choice but to deal with the complications of these "pracitioners" be they naturopaths, DNPs, witchdoctors, etc.
Click to expand...

I realize that the level of hyperbole in your post is related to the anger you feel toward NP encroachment, but seriously? Witch doctors equated to a nurse practitioner? How about PA's? Are they witch doctors? How about a DO? An IMG? Where is your fine line from legitimate practitioner to witch doctor?

There is a serious lack of physicians in rural America. I'm currently transitioning from RN to PA to work in my home town in an EM role. If physicians would rather have the job, take it. You will get the luxury of serving a county 2/3rds the size of the state of Connecticut, with a population of 15,000. That's roughly 8 people per square mile. We have 2 stop lights in the entire county. It was actually big news when we got our second stop light. Would you like to work here? No? Not wanting to work in rural areas seems to be a prevailing theme for physicians. I can't blame you though. Compensation is not the greatest in rural America.

Take a look at any rural heath care setting. You will find a linty of PA's and NP's working along side physicians as part of a health care team. Your "witch doctors" provide safe, proficient care in rural communities where physicians are less apt to work.

You made excellent points about the outcomes with a physician compared to a midlevel. Obviously someone with a more robust education is going to be a more proficient practitioner. However, it is the onus of physicians to prove this through examining heath care outcomes. Perhaps if there was clear health care outcome evidence we could enact policy's to increase the number of physicians? Of all research I have read about patient outcomes there has been no significant difference found between physician care and midlevel care. This isn't to suggest that there is no difference, but rather that it is next to impossible to prove, significantly, a difference in outcomes.

Even if we concede that physicians provide a higher level of care, is this better care? What is the definition of better? This becomes very debatable depending on specialty. In family practice studies have shown that there is a greater patient satisfaction with a NP or PA [1]. Why is this? Similar studies showed that PA's and NP's spent significantly more time per visit with the patient than a physician did. Is this mere coloration or causation? I do not know. Ultimately we are a customer satisfaction driven industry. If people like going to a NP or PA, their demand will increase.

I do sympathize with physicians who feel that their specialty is being encroached on. I think it is silly that NP's state that they practice 'nursing' and not medicine. Because of this they can stay under the board of nursing. This is silly of course. I'd welcome bringing everyone under the board of medicine, so long as it is done with patient outcomes in mind, not physician pocket books. I have a sneaking suspicion that the BoM would reign in APN's not to promote positive patient outcomes, but gain control over them.

Ultimately we should look for collaboration and understanding between all members of the health care team over division. We have an excellent opportunity to discuss ideas on this forum. This opportunity seems to be wasted by uninformed, spiteful posts that ultimately do nothing to promote understanding of other health care roles. If you are going to post, why not post an intelligent discussion over the pros and cons of the midlevel instead of slander with no beneficial outcome?

Reference
[1]: Patient satisfactionwith primary care: does type of practitioner matter?[SIZE=-1]


[/SIZE]
 
Duluth said:
In family practice studies have shown that there is a greater patient satisfaction with a NP or PA.
Click to expand...

And studies have also shown that patient satisfaction with their physician correlates poorly with the quality of their care.

My hospital is the tertiary referral center for 20+ counties filled with those little rural 2-stoplight EDs. It is not infrequent to be the 2nd or 3rd opinion for patients after fruitless visits to one of those small hospitals. Sometimes we find things they miss. Sometimes it changes outcomes.

I'm sure PAs and NPs deliver excellent care, up to a point. If you haven't put the hours in and been tested on the uncommon presentations of life-threatening illnesses, well, you simply don't know what you're missing.
 
Duluth said:
I realize that the level of hyperbole in your post is related to the anger you feel toward NP encroachment, but seriously? Witch doctors equated to a nurse practitioner? How about PA's? Are they witch doctors? How about a DO? An IMG? Where is your fine line from legitimate practitioner to witch doctor?

There is a serious lack of physicians in rural America. I'm currently transitioning from RN to PA to work in my home town in an EM role. If physicians would rather have the job, take it. You will get the luxury of serving a county 2/3rds the size of the state of Connecticut, with a population of 15,000. That's roughly 8 people per square mile. We have 2 stop lights in the entire county. It was actually big news when we got our second stop light. Would you like to work here? No? Not wanting to work in rural areas seems to be a prevailing theme for physicians. I can't blame you though. Compensation is not the greatest in rural America.

Take a look at any rural heath care setting. You will find a linty of PA's and NP's working along side physicians as part of a health care team. Your "witch doctors" provide safe, proficient care in rural communities where physicians are less apt to work.

You made excellent points about the outcomes with a physician compared to a midlevel. Obviously someone with a more robust education is going to be a more proficient practitioner. However, it is the onus of physicians to prove this through examining heath care outcomes. Perhaps if there was clear health care outcome evidence we could enact policy's to increase the number of physicians? Of all research I have read about patient outcomes there has been no significant difference found between physician care and midlevel care. This isn't to suggest that there is no difference, but rather that it is next to impossible to prove, significantly, a difference in outcomes.

Even if we concede that physicians provide a higher level of care, is this better care? What is the definition of better? This becomes very debatable depending on specialty. In family practice studies have shown that there is a greater patient satisfaction with a NP or PA [1]. Why is this? Similar studies showed that PA's and NP's spent significantly more time per visit with the patient than a physician did. Is this mere coloration or causation? I do not know. Ultimately we are a customer satisfaction driven industry. If people like going to a NP or PA, their demand will increase.

I do sympathize with physicians who feel that their specialty is being encroached on. I think it is silly that NP's state that they practice 'nursing' and not medicine. Because of this they can stay under the board of nursing. This is silly of course. I'd welcome bringing everyone under the board of medicine, so long as it is done with patient outcomes in mind, not physician pocket books. I have a sneaking suspicion that the BoM would reign in APN's not to promote positive patient outcomes, but gain control over them.

Ultimately we should look for collaboration and understanding between all members of the health care team over division. We have an excellent opportunity to discuss ideas on this forum. This opportunity seems to be wasted by uninformed, spiteful posts that ultimately do nothing to promote understanding of other health care roles. If you are going to post, why not post an intelligent discussion over the pros and cons of the midlevel instead of slander with no beneficial outcome?

Reference
[1]: Patient satisfactionwith primary care: does type of practitioner matter?[SIZE=-1]


[/SIZE]
Click to expand...

a) While I should obviously let DocB speak for himself, I think you misinterpreted the post, to me the use of "be they" implies that the following things are not related, except in reference to the preceding subject. Hence, DNPs and witchdoctors are not equated.

b) You are correct that it would (will?) be extremely difficult to prove physician-provided care improves outcomes - the logistical details are probably insurmountable, partly because when anyone gets really sick, he or she ends up getting cared for by a doctor, often an EM doc, which is what the post in question was getting at.

c) We may be becoming "a customer satisfaction driven industry", but we shouldn't.

d) "Ultimately we should look for collaboration and understanding between all members of the health care team over division." ---I'm not sure this sentence actually means anything.

Sorry I'm so crabby - I just spent ten hours fixing a lot of other people's screw-ups.
 
xaelia said:
And studies have also shown that patient satisfaction with their physician correlates poorly with the quality of their care.

My hospital is the tertiary referral center for 20+ counties filled with those little rural 2-stoplight EDs. It is not infrequent to be the 2nd or 3rd opinion for patients after fruitless visits to one of those small hospitals. Sometimes we find things they miss. Sometimes it changes outcomes.

I'm sure PAs and NPs deliver excellent care, up to a point. If you haven't put the hours in and been tested on the uncommon presentations of life-threatening illnesses, well, you simply don't know what you're missing.
Click to expand...

I absolutely agree. I do not believe NP or PA's should replace physicians. The care is simply not the same, regardless of patient satisfaction. However, NP and PA's are a required part of our health care system until we can train an extra two-hundred thousand physicians who will be willing to work for 70k a year.

WilcoWorld said:
a) While I should obviously let DocB speak for himself, I think you misinterpreted the post, to me the use of "be they" implies that the following things are not related, except in reference to the preceding subject. Hence, DNPs and witchdoctors are not equated.
Click to expand...

Given the tone of these DNP threads, to me the grouping was derogatory, and I don't particularly like the role of DNP. I love EM and love reading DocB's post. I certainly do not think he really believes that NP's are witch doctors. I just took offense to the hyperbole.


b) You are correct that it would (will?) be extremely difficult to prove physician-provided care improves outcomes - the logistical details are probably insurmountable, partly because when anyone gets really sick, he or she ends up getting cared for by a doctor, often an EM doc, which is what the post in question was getting at.
Click to expand...
It is next to impossible for exactly the reasons you have stated. I will concede that the care is, on a whole, better if we measure heath care outcomes. I do believe that there is likely to be more satisfaction with a midlevel, however. Midlevels have been shown to spend much more time with patients when compared to physicians in a family practice setting. The general public is more interested in this longer interaction and less interested in their own health care outcomes. One can look to people who visit naturopaths for cancer treatment to see this. They are happy with their treatment until the day they die. It doesn't mean the care was better.

c) We may be becoming "a customer satisfaction driven industry", but we shouldn't.
Click to expand...
I agree, but we also have to understand the realities of our industry.

d) "Ultimately we should look for collaboration and understanding between all members of the health care team over division." ---I'm not sure this sentence actually means anything.
Click to expand...
Its important for everyone to work together. No practitioner is an island unto themselves. Arrogance towards, and attacks on midlevels isn't constructive. Everyone should be working towards a goal of improving patient outcomes. That's all. It's frustrating to see people focused on themselves and not on the patients they are serving. In heath care the people we see, patients, are the ultimate bosses.

Sorry I'm so crabby - I just spent ten hours fixing a lot of other people's screw-ups.
Click to expand...
I don't see your post as crabby. It's civil and well thought out. It's rather pleasant to have reasonable civil discussion over hyperbole and arrogance :)
 
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