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DNP (doctor of nursing practice) vs. DO/MD

Discussion in 'Clinicians [ RN / NP / PA ]' started by contessa54, 11.08.06.

  1. DOCTORSAIB

    DOCTORSAIB Ophtho or bust!

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    That statement was made in 2006. Wise beyond his years. Too bad he was banned.
  2. PharmaTope

    PharmaTope

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    hate to break it to everyone, our country is PUSSIFIED.

    Slowly over the years the gov has moved to do that. You will not win this fight. Nurses have numbers to influence your corrupt and retarded representatives in congress.

    Nobody stands up and fights for what they want, they lay back, complain, but ultimately get walked all over. That is what being an American has become.

    There are people in nursing with PhD. Most NP do not want the DNP. The DNP is the result of the out of control education system in this country forcing advanced degrees where not necessary.

    Masters NP vs DNP

    RPh vs PharmD

    It discredits the degrees because graduates are pumped out in large numbers to maintain profits for the schools where as not many would go on to earn those degrees.

    If you want it to stop, you need to get on it and act upon it. The mandatory undergraduate degree in the USA is useless. How many of you use what you learned in undergrad? Not many. Don't ask me about the philosophy classes I had freshman year. I think the problem is the education system that needs to be examined.

    Primary care is going to be taken over by DNP plain and simple.

    cheers
  3. lawalawa

    lawalawa

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    I'm just going to put another opinion out there and hope people have blown off enough steam and take it seriously.
    I graduated from college with a 3.98 GPA and got a 39 on my MCATs. I started to apply to med school, but my heart just wasn't in it. I had heard from enough miserable docs not to go into medicine that I just couldn't do it, and I wasn't ready yet to make the commitment.
    So, I did the fun Europe thing for a couple of years and came back and started nursing school. I know that health care is where I want to be, and nursing is just another gateway into it. And one day, when I am ready, I probably want to take the next step in my profession and become an NP, probably with a DNP based on the new requirements (I don't get the big difference either between NP and DNP, by the way. It's probably just for all us overachievers, myself and most MDs included, who want to push themselves as far as they can in their education/credentials).
    Anyway, I have NO intention or pretense to ever be as clinically experienced as a doctor. I can't imagine MDs ever being threatened by NPs! We are not going to take your jobs, or your titles, or your prestige.
    Also, I know my scope of practice will be much much smaller than yours, and I will be constantly aware of it. I will educate myself as much as possible, but I will know my own limitations. I will work under an MD, and use them as a resource when I need advice. I do consider myself a very intelligent person, so I am expecting to do a very good job WITHIN MY SCOPE OF PRACTICE. Which includes knowing which specialist to pass my patients off to.
    I know that all of you MDs have given so much of your lives to medicine and you deserve every bit of recognition and respect that your years of work, study, and experience merits you. I don't think nurses (at least not this one) are wanting to take that away from you.
    What if we decide to work together in this system that is growing and transforming so quickly? If you treat us in a way that respects our choices and our abilities as clinicians (which I repeat, will never approach yours), then life will just be easier for all of us. I plan to look up to MDs as mentors, not as competitors. And I hope to find MDs who are willing to share some of their experience with me, respect me and my intelligence, and help me become a better clinician one day.
    And please don't give me any of that "wah,wah,wah" bull****! I'm just trying to present a perspective a lot of docs might not have heard from nurses.
  4. sarjasy

    sarjasy I have action potential

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    Allow me to second your entire post.

    I walked away from a successful career in IT to become a Nurse Practitioner (in a BSN program now). I'm wrapping up my first semester and an I'm as irritated as anyone about the nurses who somehow think their knowledge/training somehow approaches that of a physician. I do, however, think that most nurses don't think that way, but I could be wrong.

    The original post was about the DNP, and it is an absolute waste of time for NP's. It is simply a way to, 1) generate revenue for the schools 2) give something to show legislators to expand APN scope of practice further and, 3) further the old, ongoing attempt to justify nursing as a profession independent of medicine.

    My BSN program is full of nursey-nursey fluff, as all BSN programs are (ADN and diploma programs cut to the chase!). The DNP is the same thing. Again, the fluff stuff is there simply to try to justify nursing as a practice/profession independent of medicine.

    As for the argument of only 2 or so years of training in an MSN program, that's does overlook the clinical experience gained at the RN level. No, RN's are not practicing medicine, but you do get relevant clinical exposure at the RN level, thus why the MSN is considered an extension of the RN. In a nursing, you get a lot of exposure to pharmacology, labs, therapies, treatment modalities, presentation/manifestations of disease, nonmedical management of illness, etc. all of which the smart RN can carry with them and build on in an advanced practice degree. In the end, however, it is advanced nursing practice. I do think that the 4 years (not 2) or so years of training that you receive with a BSN/MSN is adequate for basic primary care. This is often overlooked in APN vs. PA debate, but that's another thread. I think PA's rock, BTW. :)

    As for the use of "doctor" in the clinical setting, I would never use it personally, but I don't see it as that big of deal. I don't know what standard practice is at eye clinics where opthamologists and optometrists work side by side, but I see a similar situation there. When it comes to refractions, who cares? Likewise, when it comes to treating a sore throat, a URI, UTI, rash, etc., I don't think its that big of a deal. Different deal if dealing with a diabetic with PVD, decreased renal function, and CHF taking 10+ meds who walks into a family practice clinic presenting with acute neuro symptoms. But the APN role was/is never meant to independently deal with that, except, perhaps, for the very bright few. In such a case it would be wrong to give the impression that you are a physician (because you have "doctor" in your degree title) and lead the patient to believe you are as able to handle his/her condition as adequately as a physician.

    My goal and desire is to extend and offer basic primary and preventative care to rural populations. The key here is basic. I have no aspirations (or delusions) of replacing a physician. Any nurse (short of going to med school) that has such aspirations (delusions), DNP or not, is dangerously ignorant, not to mention an embarrassment to nursing.
  5. wagy27

    wagy27 SDN Mentor

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  6. bradt9881

    bradt9881

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    Residents work more hours to learn. They get paid to learn. They earn less, because they are essentially getting paid for an education.

    There is a solution. Finish residency, and get paid a full wage;).
  7. wagy27

    wagy27 SDN Mentor

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    NP's (and PA) do not undergo post-graduate training yet the minute after graduation are paid full scale wages despite needing time to learn how to to do their job.

    Further, residents, while being educated, still have more responsibility and work more hours than a NP or PA. Just because we will make more money in the future doesn't mean we should be paid less than a PA/NP while we are training if we are more educated, working more hours, and taking more responsibility.
  8. bradt9881

    bradt9881

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    Its more appropriate to say, after graduation, that a midlevel is paid beginning scale wages. Ultimately, the pay is going to be linked to productivity, and if you don't produce, you are gone;). I get paid what I get paid to be a permanent scut monkey and bring in over $350,000 of collections per year. To my boss, its worth it.

    Its a fact, residency positions, whether its physician or PA, pay less because you are essentially getting paid for an education.

    The solution to your jealousy problem is simply to finish training. You will then get paid twice what a midlevel gets for a general med position, and a LOT more for a surgical specialty.
  9. wagy27

    wagy27 SDN Mentor

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    There are several studies that have shown that resident productivity is on par with the productivity numbers you cite. Residency position, while education for physicians, grant us significant independence and responsibility exceeding that of a PA.

    No Jealousy here, I am at the other end of the residency pool and nearly out. I still think there is a signficant problem when less educated, less skilled, and less responsibile providers are being compensated more than a resident, educational status or not. At my institution, attendings request resident over PA/NP coverage hand over fist with the exception being PA's who work solely with one attending full time. That speaks volumes to me as to what they view as a superior provider of medical care. If someone is providing superior care, regardless of their educational status, shouldn't they be paid more.
  10. sarjasy

    sarjasy I have action potential

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    Hey, I don't disagree necessarily. But that's not the fault of PA's or APN's, or RN's, or PT's or OT's, etc. many of whom get paid more than residents. In fact they have nothing to do with it. It's a problem with the structure of medical education.
  11. sarjasy

    sarjasy I have action potential

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    Those simple cases, most of the time, are just that. Physicians make diagnostic decisions everyday based on statistical probabilities. What presents as a cystitis could be bladder cancer, but the odds are against it and most docs would treat it as such and instruct the patient to return if it doesn't improve, at which point a more thorough diagnostic assessment would be completed.

    Based on your reasoning, it would be smarter for someone with symptoms of a URI to go straight to a pulmonologist instead of their family practice doc because the pulmonologist might pick up something the family doc misses because the pulomonlogist has substantially more training in the respiratory system than the family doc.

    I addresses this in a separate post, but let me add: physical therapy assistants get paid more than physical therapy students do when they are in their clinicals. CNA's get paid more than master's degree nursing students doing their clinicals. College football players get paid nothing, yet generate millions in revenue for their schools. Not saying I agree with any of it, but that's just the way it is. Hate the game, not the players, I guess. ;)

    Here's a couple of questions for you:

    1) Should optometrists only be allowed to refract? After all, when doing an eye exam, might they not miss a subtle case of optic neuritis (which could suggest MS) that an ophthalmologist might pick up?

    2) Should APN's be allowed to do any primary care at all, if not, what should their scope of practice be?
  12. wagy27

    wagy27 SDN Mentor

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    While you may think that the simple cases are usually the easy ones, having seen these cases go bad has taught me that a physician needs to be managing these cases. When it's your child who is diagnosed with the flu but has meningitis by a PA/NP then you might understand. Have i seen it, yea. Could the same thing happen with a MD evaluating, absolutely but the likelihood is significantly less due to the level of training. As for the referrals for everything, I don't believe that. I believe that a well trained PCP can be the best front line defense in medicine and can manage almost anything.

    As to your comments about students (i.e pt students, nursing students) realize that residents are not students, having graduated medical school and being licensed physicians. They are charged with significant amounts of responsibility in patient care which is not the case with your examples. As for your comments about optometrist, I'm not in ophto, but my friends that are wish to significantly limit the scope of optometry. They feel that many optometrists have overstepped their bounds and should stick to refracting and let the true practitioners manage the everything else. As for midlevels (PA/NP), I don't think any should have independent practice rights. As physicians, the rigors of our training allow us to treat patients; I find the training of NP's to be not appropriate to allow for independent practice.
  13. sarjasy

    sarjasy I have action potential

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    Look, I agree it is less likely for an MD to miss such a case, as you said. However, anytime there is an atypical presentation there's a risk for misdiagnosis, whether by NP's, PA's and MD's. Also, you have no idea if the pt you mention above in your example would have gotten the correct diagnosis if they were seen by a physician. Both meningitis and influenza are infectious diseases, and thus share symptoms and the patient may not have had symptoms that would differentiate (e.g. nuchal rigidity). You and I could trade anecdotal stories all day (such as the physician I know of that diagnosed a pt with sinusitis who then died two weeks later from leukemia), but that'll get us nowhere.

    OK that you believe that, and that's fine, but my point still stands. Your argument is that more training = more ability to recognize subtle signs that might indicate serious disease. Using that logic, anyone with respiratory issues should see a pulmonologist. Anyone with urinary problems should see a urologist. Anyone with neuro symptoms should see a neurologist, etc. Specialists, by definition, have significantly more training in their areas than a family doc and therefore are more able to deal with symptoms related to a particular body system. That is where your reasoning leads, even if that is not where you intended to go with it.

    Look, I don't know that we really disagree about anything here. I think your arguments that residents should get better pay is valid. My original point was only that it's not the fault of mid-levels that resident pay is poor - they really have nothing to do with it.

    Ah, so you are arguing against independent practice. That's the first that word has come up (unless I missed it from your earlier posts) and is a different animal altogether. It sounded to me like you were arguing NP's (and maybe PA's) should not be involved in providing any primary medical care/treatment at all. Then again, I'm not sure what you mean by "independent."

    I am not in support of NP-run clinics that offer the whole gamut of primary care services with no physician involvement (my definition of independent). But, I have no problem with a) "retail" clinics that offer limited, predefined, basic services such as the treatment of colds, sore throats, school physicals, etc. that are independent, or b) NP's/PA's that work in family practice clinics under the oversight of a physicians where the physician decides how much autonomy the NP/PA has. From what I know, situation B is overwhelmingly the norm.
  14. mooshika

    mooshika

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  15. illegallysmooth

    illegallysmooth Smooth member

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    Every second that this thread, with this title, exists... is a moment that makes me feel even sadder for the state of medicine in America.
  16. Charles_Carmichael

    Charles_Carmichael Moderator Emeritus Bronze Donor

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    Here's a post of mine that you seem to have missed in the preallo thread:

    So, as you can see, NPs/DNPs seem to receive less than 25% of the clinically relevant training that physicians get. It would be literally impossible for NPs/DNPs to gain the same level of knowledge as an attending physician in the same specialty; the rigorous training a physician goes through is there to ensure a high level of competency. Fourth-year med students have more basic science and clinical training than NPs/DNPs receive. Should we allow M4s to practice independently? Shortcutting through that under the guise of "patient care" is deceptive.

    Is that good enough evidence for ya?
  17. mooshika

    mooshika

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    You mean the physician-residents who are less skilled at nursing? Are you a skilled nurse? I'm just wondering about your nursing skills presuming you practice them on a daily basis, as a medical resident. Or do you mean the nurses who are less skilled at doctoring because they are nurses and not doctors? Do you mean the "less responsible" nurses or the less responsible residents who are actually still students? What? Who is responsible for residents not getting decent cash and not being able to practice independently?

    Who decides what is superior care? You?

    You can shout out your opinions all you want but it is very likely that Nurse Practitioners as a whole don't care that so-and-so doctor-resident attending thinks that their training is "sub par" or wholly insufficient for independent practice. You just do not have the level of expertise in that area to make an educated assessment of nursing practice, so opinions from medical students/residents and attendings are just not substantiated with enough professional qualification to be taken seriously. A physician's training in even basic, associates level registered nursing is not only sub-par, it is actually non-existent. (I bolded this cause that's what the smarter actual doctors here do when they want to make a point about how stupid other people are) How you are actually qualified for serious discussion on this matter is not clear.

    I don't remember hearing anyone from nursing bodies officially ask medical students, medical residents, or the medical licensing boards what their opinion is on the matter of Nurse Practitioner. That is what really pisses off folks. They don't care, really, what you think, because it does not actually matter to them, does it. Casual comments and observations are welcome, however. Put them in writing and drop them in the suggestion box.



    Last edited: 05.02.10
  18. mooshika

    mooshika

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    I totally LOLed at this it is so funny. You are so totally right that medical students get more hours studying medicine than nurses get for their nursing degrees. How can that be? I am shocked beyond belief. Can you try to use more of the correct, medical kind of science that is hard to understand here because it is unclear what point other than the obvious you are getting at.

    I had to get help with the big, medical words, but it looks to me that your post proves that you spend many, many idle hours trolling nursing program websites copying and pasting curriculum from programs, then add up lots of credit hours and calculate percentages and multiply things. Most guys are more interested in the pictures of the lady nurses.

    Why would you do that?

    I am also truly appreciative that you pointed out which of the nursing courses are useful and which are not, and which of the Baylor courses are useful and which are not. Since you are not a nurse, I would wager that pretty much all of the nursing courses will never be useful to you, am I right? You did pick out a few, though, which is kind of cute. Kashuik, have I ever told you how cute you are? Well you are very sweet, all your passion...
    Last edited: 05.02.10
  19. Charles_Carmichael

    Charles_Carmichael Moderator Emeritus Bronze Donor

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    Sure, I'd be more than glad to spell it out for you. :)

    When NPs/DNPs claim to be equivalent to physicians (as a lot of quotes in past and recent articles suggest), you would expect them to have a similar level of training. Unfortunately, even a cursory glance at NP/DNP curricula reveals that there is a vast difference in training. I can assure you it did not take me hours to put together that post, nor do I troll nursing websites. A simple search was revealing enough. It doesn't take rocket science to realize that nursing activism, stats, nursing theory, business management, DNP capstone, etc courses do not contain any clinically relevant information.

    I can understand that you've found it amusing that physicians receive much greater medical training than nurses. Unfortunately, NPs/DNPs are blurring the lines between nursing and medicine and are essentially practicing medicine while calling it advanced practice nursing. You can't say you're equivalent to a physician and then say you're practicing nursing. I'm sorry. You can't have it both ways.

    Hope this clarified things for you!
  20. mooshika

    mooshika

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    Just having some good, clean medicine fun shooting flames out my fingers and looking for a victim to slay with my sub-par knowledge...

    Fortunately, I cannot figure out where these bizarre, hostile nurse-hating-resenting-disparaging people come from, because as far as I know, they don't exist in the real world where they have to show their faces and reveal their names and credentials. I truly believe they are few and far between. Most all I have met are pretty nice and not as willing as I to step in the ****.
  21. mooshika

    mooshika

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    Well, I never, ever said that did I? And someone like I who wastes far too much time on this message board posting inane **** on useless, unimportant topics has not much of a leg to stand on calling you out for spending time on websites adding up nursing credit hours.

    Really, did you have a traumatic encounter with a nurse practitioner who ***gasp*** dared to masquerade as a real doctor? No wonder you are so... upset about this stuff. Maybe all y'all should start a support group so you can share your outrage at these renegade nurses who are trying to f**k you up, and you will feel at peace that finally some real, smart, top-notch people who matter are actually taking this stuff seriously.

  22. illegallysmooth

    illegallysmooth Smooth member

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    A lot of pre-meds/med students/residents/attendings are sore about the fact that nursing organizations are pushing for the right to use "Dr" in a clinical setting (for those with DNPs). Personally, I think it's outrageous. I'm not a nurse-hater, but I would not tolerate a nurse attempting to pass herself/himself off as a doctor IN A CLINICAL SETTING just because they got a doctorate in NURSING. By the time I'm an attending, I will have spent 10 years in college (undergrad, masters, med school) and at least 3 in residency, working 80 hrs a week to learn to care for my patients. I do NOT want an NP telling my patient anything to give them the idea they have an equivalent education/training.

    You're taking things too personally here. Kaushik isn't necessarily saying that YOU said these things, he's talking about DNPs as a whole because of the agendas put forth my their organizing bodies. Like it or not, many NPs and DNPs actually contend that they are equivalent to Drs. This has even shown up in journalism reports from major news sites! DNPs telling patients they are "just like doctors but see patients as a whole person," meanwhile claiming patients know the difference. It's all just hogwash. Nursing is nursing, medicine is medicine. Blurring the lines is a stupid idea.
  23. wagy27

    wagy27 SDN Mentor

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  24. wagy27

    wagy27 SDN Mentor

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  25. wagy27

    wagy27 SDN Mentor

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    What you failed to realize is that I wasn't criticizing nursing skills. NP's are claiming that they can practice independently which in my books fall into the practice of medicine. When it comes to practicing medicine, the training provided to a NP is inadequate when compared to that of a resident physician.
  26. illegallysmooth

    illegallysmooth Smooth member

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    This thread should have an IQ minimum.
  27. core0

    core0 Which way is the windmill

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    Actually when comparing roles and pay scales there is really only one important attribute. The ability to bill. The primary reason that there is a difference in pay scale is that NPs/PAs can bill for their services and residents cannot. I don't think that anyone disagrees that residents are horribly underpaid compared to their responsibility and work hours. However, when you look at sources of revenue, its limited to what Medicare pays for resident training. For NPs and PAs its limited to what they bring in for E/M services. The money for E/M services is almost always going to be more than what Medicare pays for resident training (even considering the hours residents work).

    David Carpenter, PA-C
  28. jwk

    jwk AA-C ASA-PAC Contributor

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    Wow, talk about uninformed. You need to learn something about reimbursement. At the moment, you're clueless.
  29. mooshika

    mooshika

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  30. mooshika

    mooshika

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    A grammar school student can tell that an NP has less medical education than a physician. That is not the point. When you use the word inadequate you are expressing your opinion, which comes across as very condescending. There is a difference between inadequate and different level of practice. "This person's training is inadequate for the job they are degreed and licensed for" is a very grandiose statement coming from a non-expert, even though it may actually be true - I do not know, but tend to disagree. Ive seen unreliable people hold all kinds of high-level jobs with a lot of responsibility MD and RN included.

    What I was saying is that the licensing boards for Nurse Practitioners don't base their scope of practice decisions on the opinions of MD/DO's and especially residents or medical students, and that is understandably what I think really gets their noses out of joint, so instead of just saying that, as it would make them appear weak, as you see here, most on the MD/DO side go after nursing credibility on all levels instead. I have an idea that if the licensing boards were to include experts from the medical licensing side to at least consult, and give them a voice at the very least there may not be as much contention.

    It is possible that has been attempted, and the resounding noise, as seen here on SDN, is one of outrage seeking to just shut them down and silence them. So you can see why they aren't interested. Plus, they really don't have to be. That's the way it is going to be.
  31. mooshika

    mooshika

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    I want to see you say all those outrage things you wrote in the first paragraph with a clown suit on. :laugh:
  32. pianoman511

    pianoman511 Member

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    I think part of the problem is that NP licensing boards take the same view as many of the leaders of the NP movement in that they are practicing nursing instead of medicine and therefore they do not need to consult physicians or any physician organizations regarding scope of practice. Many physicians feel that this is an issue because NPs are practicing medicine, period.

    In addition, there is no unified body, standardized testing & standardized curriculum for NP or DNP students. Medical education, testing & curriculum (by comparison) is very standardized and has a common endpoint. It may not be perfect, but it does (for the most part - yes I know there are exceptions) produce competant physicians that have a comparable knowledge base. In contrast, a student in a direct entry NP program with little or no nursing experience has a different knowledge base than a critical care nurse with 5-10 years of experience who then becomes an NP (regardless of DNP vs. NP education).

    I definitely agree that if licensing boards would be integrated with physicians & NPs then there would be more consensus. Until the liberal side of the DNP movement (who think DNP = physician) and the conservative side of the AMA (NP <<<<< MD) can move a little more towards the middle there won't be any progress.
  33. pianoman511

    pianoman511 Member

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    I would just settle for an intelligent debate between a real live representative of the AMA or even a physician and one of the leaders of the DNP movement. So far every TV interview has been a one-sided ad with people who frankly scare everyone.
  34. prairiedog

    prairiedog Junior Member

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  35. prairiedog

    prairiedog Junior Member

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    Quick review on youtube found
    http://www.youtube.com/watch?v=ai0PSXcd6dw
  36. NurseKJ

    NurseKJ

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    Add in a practicing NP who is reasonable and understands the role of NP vs. the role of physician vs. the role of an RN and you might actually be on to something :thumbup:
  37. pianoman511

    pianoman511 Member

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    Indeed, might you have video of a sasquatch or the loch ness monster ? :laugh:
  38. lawalawa

    lawalawa

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    I can understand why all you MDs are so angry about this, but you are not going to eliminate the NP profession or restrict their scope anytime soon. instead of seething and insulting your NP colleagues, why don't you be proactive and help solve the problem? If NPs are really practicing medicine but are not educated enough, as you claim, then why not help educate them just like you educate med students and residents? Not in a structured, classroom setting of course, but just throughout the day. And treat them with respect so they aren't scared to ask you questions. The goal is to protect patients and make sure they get the best care possible.

    The majority of medical training is clinical, and that is why MDs are such good clinicians. Also, the medical profession by nature involves life-long learning. Yes, maybe NPs don't get enough clinical hours in school to prepare them, but they also don't stop learning when they graduate. MDs can either facilitate that, or hinder it.

    Unfortunately, there are not enough primary care docs to meet society's needs, and that is why the NP role was able to come into existence. So the argument that all patients should see MDs for primary care is irrelevant - there just aren't enough docs to go go around. Is it better for a patient to see an NP for their symptoms, or not see anyone because the last time they saw their MD PCP they only got 5 minutes of face time? That was my last check-up.

    Currently, NPs can practice independently as PCPs, but I think one issue that has not been addressed here is when they can start doing that. I don't know the current regulations or statistics, but I think NPs should have to work in a hospital setting or at least in a physicians office for x number of years before doing that. In my opinion (and I am a future NP) an NP would be completely irresponsible to go straight from NP school to independent practice. Perhaps lobbying should focus on creating some sort of time period where hospital work is mandatory (which, I guess, is similar to a residency - further boundary blurring - sorry docs!)

    Moral of the story, NPs are not going to go away. Medicine today is interdisciplinary, and that is not going to change. Our responsibility is to the patients, not to our professional boards and associations. Why don't we stop arguing what our roles are and resisting change, and do the best we can to treat patients?
  39. pianoman511

    pianoman511 Member

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    The problem is that you can't educate an NP if they are in independent practice. As irresponsible as it may be, there is absolutely nothing from preventing a direct-entry NP with no real amount of experience who did their education via the internet from going out and setting up shop (in some states). That's what physicians are concerned about.

    No one is complaining about the current collaborative model where that does indeed happen (i.e. physicians educating NPs/midlevel providers). In addition, no one wants the role of an NP to go away. We need more practitioners, that's not an issue (everyone acknowledges that fact). Midlevel providers are very useful in primary care and you would be hard pressed to find anyone that would argue that. However, instead of ensuring that NPs can take over primary care, call them doctors, equal reimbursement, etc., what physicians want is to get more medical students into primary care because when it comes down to it a physician is the highest level of care and everyone wants to ensure that patients get the best care possible.
  40. AegriSomnia

    AegriSomnia

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    I'm not defending the NPs here, but all the direct entry NP programs I've seen require on site class and clinical with the first year to get your RN and the last 2 for the NP. The only online NP programs I've seen are post MS programs for RNs. Just sayin'.
  41. Therapist4Chnge

    Therapist4Chnge Neuropsych Ninja Faculty Moderator Emeritus

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    Accepting that this is the case (I'm not sure if there is various in direct-entry programs), can someone actually think that is enough training for INDEPENDENT practice? Direct entry and online training are both huge areas of concern (in my opinion).
  42. wagy27

    wagy27 SDN Mentor

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    While the billing issue is true, multiple studies have shown that residents generate income and save hospitals money to the tune of over 200,000 per year (1 current article is up in the general residency forum now). Further, residents often due work that ends up being billed, i.e the H + P that the attending then signs off and dictates to be billed. If you factor in what Medicare pays and what they generate, I would argue they should definately be better paid than a PA/NP.
  43. wagy27

    wagy27 SDN Mentor

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    When I say in inadequate, I mean inadequate. I mean not enough to practice independently. Sure the nursing boards are okay with NP training as it continues to push the scope of practice. As for being a non-expert, am I a physician of 20 years experience. No. But I have been a resident for 3 years and have a fair idea of what indpendent practice entails and I can say that if I am still not ready after 3 years of active training. How can a NP with no post-graduate training and limited education (compared to an MD/DO) be allowed to partice in a similar manner to a indpendent physician.
  44. core0

    core0 Which way is the windmill

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    I can't find the article you referred to but most of the people that I've talked to say that residencies at best make the hospital a little money. There are definitely hospitals that need residents to stay in business.

    As far as attendings billing for work, that would be work that they normally would do. If they are billing for work that they didn't do (ie didn't participate in the critical portions of the encounter) then thats fraud. Hardly a good example.

    Residents have advantages including the fact that they work more hours and more off hours than PA/NPs. Depending on where they are in their residency they will require less or more physician supervision.

    PA/NPs have the advantage that they can bill with or without the physician being present. They also may have the advantage of institutional longevity.

    Bottom line, under the current system collections will almost always be higher with a PA or NP than with a resident unless the system has a large amount of uninsured.

    David Carpenter, PA-C
  45. zenman

    zenman Senior Member

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    MD INDEPENDENT practice

    NP INDEPENDENT practice

    Now, do they both mean the same thing? Anyone cleared that up yet or is the argument just over the word, "INDEPENDENT?"
  46. moneyline702

    moneyline702

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    Very true. They are post-baccalaureate (for BSN holders) programs culminating in DNP degrees. That is just wrong for the level of autonomy they have and the pay they're lobbying for. These online doctorates don't have much in the way of further clinical education and training. There's no advanced training in some. But maybe they'll have a Nurse Residency (complete with matching) someday. :eek:

    It's sad. PA programs aren't online and they aren't nearly as autonomous as the NP. I still believe that NP's are constantly seeking the easy way out. And ultimately those very shortcuts are going to hurt someone. All mid-level practitioners are necessary and do serve a very damn fine purpose.

    For the most part, healthcare providers are paid according to a level of training and education received. An NP program, whether online or in a brick-and-mortar institution, usually lasts 3 years. Up until recently it was a master's degree. With perhaps little to no change in length in education or depth of knowledge it will be mandated that NP's migrate to the doctorate level. They'll want to be paid like a PCP to the tune of $140k or more as well. Maybe they should be, not for me to decide. Personally I believe Primary Care doctors are grossly underpaid.

    I don't want to keep a gripe going. There's enough of that as is. I do have a PERSONAL war with a local CRNA (and very close and dear friend so lay off, we go at it often) and she does get under my skin. The biggest issue here between MD/DO vs NP is scope of practice. That directly will affect pay.

    I would like to see the PA's regulate their training and be as aggressive as NP's. Their education seems more diverse. NP programs are the "foot wide and mile-deep" in that the degree is very much tailored into a specific area (FNP, ACNP, CNS, etc). PA's are the opposite in that they're a "mile-wide and foot deep". Covering a broader spectrum, which is perhaps why there isn't a specific "Emergency Room Physician Assistant" concentration (although I'm thinking you can prefer to specialize).

    I see and hear a lot of shooting down of the ANA's proposal but no alternative solutions. I have one.

    How about this: if an RN does in fact decide to become a Nurse Practitioner that's awesome! I'd like to see training programs do away with the specialties at the onset. Just be a DNP program. Have a one-year didactic portion to learn advanced sciences. Build upon prior undergraduate knowledge and follow with two years of clinical rotations. Then pass a certifying exam and allow the graduates to pursue various specialties and complete a requisite training program in their chosen field.

    There's gonna be a few PA's scratching their head saying "that sounds like my training"..... In looking at it you may be right. You'd know better than I. Regardless of what anyone decides to pursue the keys are clear-cut definitions on scope, standardized training and standardized certification.

    It seems that as of now the battle is in the fields of anesthesia (Anesthesiologist vs CRNA), Eye care (Ophthalmologist vs Optometrist) and primary care (IM/Peds/FP vs FNP/ACNP). No turf wars in surgery. No way you learn that online.

    Please do away with the online schooling for advanced nursing care. Web-based education is fine for getting an MBA but not for learning how to care for people. You learn that by actually caring for people.

    Perhaps I can be a paralegal and in a few years, get a doctorate and say that I can stand in front of a judge (or jury) and plead my case as well as a JD. Damn the state bar. To hell with torts, contracts, civ pro, con law, ethics and the like. Why learn about legal precedence? I am tired of making less than my supervisors and I do research along with many of the summer interns and 1st year associates. Only thing is I don't want to take the LSAT and go to law school for three years... I just want the same pay.
  47. Dr Oops

    Dr Oops

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    http://www.aafp.org/online/en/home/...ident-student-focus/20090702acgme-tstmny.html

    Family Medicine Leaders Urge ACGME to Resist Call for More Limits on Residents' Duty Hours
    "The testimony from Epperly -- who also is program director and CEO of the Family Medicine Residency of Idaho -- and others came in response to recommendations contained in a report released by the Institute of Medicine, or IOM, in December 2008. In the report, the IOM recommended that continuous on-site duty periods for residents not exceed 16 hours unless a five-hour uninterrupted sleep period is provided between 10 p.m. and 8 a.m.
    Other recommendations in the IOM report, "Resident Duty Hours: Enhancing Sleep, Supervision and Safety," proposed reducing residents' workloads and increasing the number of days they would have off each month.
    The IOM estimated that the cost of shifting resident work to other clinicians to comply with the proposed changes would be $1.7 billion a year. A later report from the nonprofit research organization RAND Corp. and the University of California, Los Angeles, estimated those costs at $1.6 billion a year."
  48. zenman

    zenman Senior Member

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    I would like to address this point. Online or distance education has a lot of research to back it up. Since those of us in healthcare tend to think EBM, then we need to consider the research in education. Granted there is a lot of negative opinions about distance education. Saying that PA schools or medical schools do not subscribe to distance education might just mean that they are years behind everyone else. Now, is there specific distance education research on NP programs. Probably not, but you have to look at the distance education research to make some kind of informed judgment. I'd love to see a comparison of tradition and distance ed students from the same school. But, I bet no one has done it yet. As my educator wife says, "If I teach a kid how to study for geography, they should be able to transfer those same concepts over to an English class."

    I've done two masters, one in nursing and one in business. I'm now doing a post masters distance ed psych NP program. I'm trying to rack my brain trying to figure out if my education in learning to care for people has suffered.

    I had two courses where I had to go on campus. One was one day during the first of two psychiatric interviewing classes and the second was two days of doing episodic physical exams.

    I can see my instructors wanting to observe me interviewing a client. However, they videotaped the session. I could have done the same back home and sent them the video. For the physical exam class I had to video tape two exams as well as do the two days in person. It was nice meeting everyone on campus and having NPs from different areas do a review prior to us knocking out 4 exams and having a "live" pelvic exam. However, I'd just as soon sent in more videos of me doing physicals from my home 2,000 miles away. For, homework in that class, we had a lot of videos, including some of my favorites which were online at several medical school sites. Now, that I'm in clinical, has my education served me well? My physician preceptor told me he was impressed with my H & P skills but that I didn't have to "be so comprehensive in real life." He's also told me he has no trouble with my patient skills.

    So, I'm trying to figure out what kind of classes must not be taught via distance education. Give em an example.

    You learn how to care for people...then you actually care for them.

    Would I like to see changes in NP education? You bet. As a psych person, I griped about learning how to do physical exams. I can see the benefits of learning it, and I'm having to do them here on a military base, but I've never seen a psychiatrist in civilian life even think about doing a physical exam. Personally, I'd have rather spent more time on differential conditions that cause psych symptoms.
  49. JeffLebowski

    JeffLebowski Just got Nard-dogged

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    Jesus, this is ridiculous.

    Hey guys, we're going to put out a bunch of nurses with joke degrees in hospitals and let them do your job...also make sure you catch them & correct them when they **** up or patients will suffer...it's all about patient care after all.

    In general, we're good people who will point someone in the right direction when they're off...and we come into contact with them. This is not the same as receiving clinical training (i.e. residency), this is just making sure people don't kill your patients. This informal "hey let's lend them a hand" is not the same as clinical training, and it's scary....SCARY that anyone's even asking us to "facilitate" this kind of bush-league medical practice.

    Well, the only way we're REALLY going to tell how many people are getting hurt is by letting them go hog-wild with full autonomy, then do studies looking at relevant outcomes. It's unethical to just give some new treatment the benefit of the doubt and unleash it on the populace (especially when there's already evidence that it's really unlikely it's as good as the gold standard), likewise it's unethical to just say hey sure take some patients see how you do then if you **** up too bad we'll try to take away your autonomy later (yeah right).

    Well look - medical boards and specialty organizations have by far the most experience determining what components of knowledge, experience, and training are required to be a competent medical provider in a given field. What makes you think just throwing in a few years here or there in some hospital willy-nilly is sufficient, when doctors (the gold standard), are subject to RIGOROUS and high levels of scrutiny to become licensed and board certified? You know how we go about making sure everyone providing care is competent? We have them pass muster from the same, expert, experienced oversight body. And no, they're not going to be happy and willing to all of a sudden say sure, I know you didn't graduate from an LCME accredited medical school, I know you don't have a medical license, I know you never even took licensing exams, not a day in an ACGME residency, but I feel like you were a good nurse before you set your sights on contributing to the "nursing shortage", you seem pretty sharp and you spent a year working at St. Someplace Hospital, that should be fine, yeah why not.

    Throw around as many fun buzzwords as you want, it doesn't change the fact that what is happening is COMPROMISING STANDARDS. If society is comfortable with that, then okay. If society really tells us, "look, we know you're all well-meaning but we really don't think a FP (or whatever else they choose to force themselves into) needs that much training and we're willing to take the risks on a lower standard of care and the fallout that may occur" for whatever reason, whether it's financial or access to care or whatever, then fine, we'll step aside (or be forced aside). If this were really an "interdisciplinary team", we wouldn't have members trying to jockey for higher position in the team like it's some kind of Machiavelli game.

    And we ARE trying our best to treat patients the best we know how - and guess what? The PRIMARY reason we're upset isn't because we're ticked that you're trying to replace us with your lesser training and call yourself doctor and saunter around in your white coat and grin in our faces (although that is offensive and causes resentment), it's because we are trained to critically analyze care paradigms in a way that puts the burden of proof on the NEW, ALTERNATIVE treatment to prove itself as being as good as the gold standard, and that's the way it should be. We believe we give the best care to patients. We believe that a medical degree is necessary, a medical license is necessary, medical residency is necessary, and together they create doctors with the ability to treat patients in a way that is substantially better than having nurses with inflated degrees and fluffy buzzwords and lobby groups push for them to do our job too. Every indication suggests that independent practice NPs and the whole DNP concept is compromising on standards we use to train doctors and honestly, I really don't see how a person can sleep at night knowing they're part of it.
  50. zenman

    zenman Senior Member

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    And yet you have the gold standard do this: My Navy chaplain friend just told me that two of his family practice physician buddies diagnosed him with pneumonia and gave him a paper sack of meds. My chaplain friend just didn't believe he had pneumonia so he went to a third FP. This guy didn't listen to my friend's chest through his shirt like the other two "cream of the crop" physicians did, but actually lifted his shirt, where he noticed an amazingly hairy chest. So sad indeed that such a basic mistake was made.

    Do we need another Flexner report on medical education?
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