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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. PSYCHNP

    PSYCHNP

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    Just my point EMED. It is generally not in an acute care facility's policies and procedures for nurses to start central lines.

    I guess that's why they don't make the big bucks like MDs.

    Furthermore, why they use the term "healthcare team".
    Last edited: 02.01.11
  2. emedpa

    emedpa GlobalDoc2B2015

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    most places consider an external jugular to be a peripheral line and an internal jugular to be a central line....medics do ej's(that's where I learned to do them).
    I am much more comfortable with femoral lines than IJ or subclavian....it's all about what you have practiced the most...
    very few medics do central lines...seattle medics do subclavians but I don't know of any others that do...
  3. PSYCHNP

    PSYCHNP

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    Precisely my point. Thanks for the clarification.

    I have no problems with a professional covering themself and staying within the boundaries of their scope of practice.
  4. allendo

    allendo Senior Member

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    Like I said nurses are better at nursing, Doctors are better at medicine. Why does it matter what you get reimbursed for a procedure, I thought NP's are more patient centered and want to save the world working in places MD's won't. When I do a procedure in a trauma situation, it's about saving a life, not getting compensated a certain amount. Have fun playing doctor, I hope they give you idiots equal rights, then the patients can sue your @sses along with the rest of us, you can pay outrageous malpractice costs, and give up to half of your income away in taxes. NP's cant even pass the step three exam that was watered down for them, now that's a joke.
  5. Dwindlin

    Dwindlin SDN Gold Donor Gold Donor

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    I did them in Indiana before I moved for school and changed services.
  6. PSYCHNP

    PSYCHNP

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    If you can't start the IV how are you going to get the medicine in the patient's body?

    Since you are an all knowing "doctor", try doing some surgery. You are not trained to do it, nor are you compensated like a surgeon.

    I met clinicians who don't even want to draw blood for labs because of the low reimbursement rates.

    Please.
    Last edited: 02.01.11
  7. Charles_Carmichael

    Charles_Carmichael Moderator Emeritus Bronze Donor

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    PsychNP, I swear, sometimes I have no clue what you're talking about. Please clarify.

    Also, if you want to pull out anecdotes, I'm pretty sure the rest of us can come up with a lot as well.
  8. PSYCHNP

    PSYCHNP

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    My point was that allendo is not a surgeon, nor is he trained or compensated like one. Therefore, I do not expect him to practice as a surgeon. In much the same way I do not expect NPs to insert central lines if they are not required to so as per the policies and procedures of their institution.
  9. Charles_Carmichael

    Charles_Carmichael Moderator Emeritus Bronze Donor

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    Fair enough. And I agree with what you say here regarding procedures. Perhaps I was too quick in making an incompetency joke earlier. My fault.

    Regarding knowledge, I do think that physicians expect each other to have a base level of knowledge, which the avg NP/DNP does not have. It's not outrageous to say that NP/DNP school does not cover basic science topics as deeply as med school does and that it does not provide as many hours of clinical training as medical training does. The obvious conclusion to draw from this is that the basic science/clinical knowledge base of NPs/DNPs is less than that of physicians. It is annoying, however, to hear nursing midlevels claim otherwise or even claim that they're superior to physicians.
  10. Paseo Del Norte

    Paseo Del Norte

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    The act of placing an IV is nothing more than a monkey skill that most anybody can learn and perform well with a little practice. The money shot so to speak is what to do with said IV once it's placed.
  11. allendo

    allendo Senior Member

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    Why would you not put in central lines? You want to wear the white coat and look like a doctor, but not practice like one. I don't want to be a surgeon, I'm happy in my specialty. Your arguments are ignorant. I have respect for those midlevels on this board who went back to medical school and realize what gaps existed in their knowledge base. As for you, ignorance is bliss! I'm not the one who thinks he knows everything. I realize as a physician, especially in the acute care setting, nothing presents like it's taught in a book, and you are continually learning something new everyday. A good physician realizes he doesn't know it all and is constantly looking to learn. Also, I respect the nurses I work with and realize the have certain procedures they are better at, and I have procedures I'm better at. The problem with NP's is they see what we do and see alot of repetition and think that it's so easy. It's the same as when you watch professional sports and you complain about a guy dropping a pass, until your there and get hit like he did, you can't talk $hit. NP's are dangerous simply due to their knowledge deficit and the unwillingness to admit it.
  12. PSYCHNP

    PSYCHNP

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    Well put. I like the football analogy (it being Superbowl Sunday this weekend and all).

    NPs and PAs are in no way better trained and prepared to practice medicine as MDs. In the acute care setting/ER MDs, without a doubt, should be the Medical Director and the leader of the healthcare team.

    With that being said, let's also keep in mind that the MD is very often paid three times as much as a PA/NP, has the most education in the field of medicine, and allowed far more privileges. I can see why they are the ones designated to perform highly invasive procedures like central lines.

    If I ran a hospital why would I have an NP or PA put in cental lines when I have an MD on staff (who I pay three times as much for his expertise)?

    Note that as per the study only 37% of the trauma centers utilized NPs/PAs to insert central lines.

    JAAPA, 2010, reported the following data regarding the role of NPs/PAs in trauma service:


    "The majority of responding trauma centers utilized PAs/
    NPs in trauma resuscitation and in traditional tasks ofna surgical PA/NP (
    Figure 1). A number of these facilities


    reported that PAs/NPs performed invasive procedures such


    as inserting chest tubes (38%), arterial lines (31%), central

    lines (37%), and intracranial pressure monitors (7%). In
    addition to caring for trauma patients, 55.2% of trauma
    PAs/NPs provided direct patient care to nontrauma, critical
    care patients. Only 7.5% of PAs/NPs utilized on responding
    trauma services functioned as members on other specialized






    rapid response teams (eg, code blue, sepsis, and stroke)."



    Last edited: 02.03.11
  13. PSYCHNP

    PSYCHNP

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    Medicine whether performed by an NP, PA, or MD is very much a practice.

    "If you don't use it you lose it."

    I would not expect a psychiatrist, endocrinologist, or dermatologist practicing in the community to be very good at starting central lines or even IVs. Since they do not do these procedures on a regular basis.


  14. pianoman511

    pianoman511 Member

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    But NPs don't practice medicine, they practice nursing...
  15. bibibi

    bibibi

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    You are pre-med, not even in medical school yet. You have a long way to go. Your opinion will change many times. Just saying...
  16. zenman

    zenman Senior Member

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    Almost every study can be ripped apart, but I think you better take a few business courses along with those heavy science courses so you will come to appreciate "patient satisfaction." You better make them happy or they will walk...maybe even to that acupuncture practice down the street.
  17. zenman

    zenman Senior Member

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    I usually turn it on with one hand and count the drops with my other hand.
  18. fab4fan

    fab4fan TiredRetiredRN Gold Donor

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    I'm not so sure about that. To a certain degree, there's an art to starting IVs. I've met some people who couldn't hit the broad side of a barn, and others I call "vein whisperers," who can find veins on people with no apparent circulatory system whatsoever.
  19. VA Hopeful Dr

    VA Hopeful Dr Senior Member

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    Until they actually get sick, then they'll kind of have to find a western practitioner. Not slamming acupuncture mind you, I just think that some conditions are beyond the abilities of even the best practitioner of that field.

    Also keep in mind that satisfaction only matters to certain types of doctors. Radiologists don't have to care, nor do hospitalists as a general rule. Pathologists don't either, and most peds subspecialists are rare enough that they're the only game within a hundred miles. In most states, if you take medicaid, you'll never want for patients no matter how much you may suck at interpersonal relationships.
  20. zenman

    zenman Senior Member

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    You get my point though. Even if you don't have to drag patients in your door, the more satisfied they are the better...and they tend not to sue you for millions just because you accidently scratched them.
  21. Charles_Carmichael

    Charles_Carmichael Moderator Emeritus Bronze Donor

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    Doubt it. Unless you mean that my opinion of NPs/DNPs thinking they're equal/superior to physicians is going to go down even lower than it already is? That's definitely a possibility. With them becoming more and more vocal these days...

    Perhaps I wasn't clear. I was referring to patient satisfaction being useless as a metric for quality care. Patient satisfaction =/= quality care. There is no guarantee there.

    Even then, I would say patient satisfaction is a pretty useless metric in general. Even in those nursing studies, there wasn't much difference between how "satisfied" patients were with physicians compared with nursing midlevels. Just because the minute difference (ie. something like a 3.9 vs. a 4.1) is statistically significant doesn't mean it's clinically significant. You see this a lot with basic science research as well.
  22. Instatewaiter

    Instatewaiter But...There's a troponin

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    Fine but in a scientific study touted to show equal outcomes, patient satisfaction is worthless.

    I could have someone come in with an NSTEMI and not start heparin, a beta blocker, ASA or plavix load them but as long as I was nice, kept coming into their room every hour or so to show I was interested and kept giving them morphine to take their pain away they would think I was the greatest doctor ever... when in fact I what I really was doing was performing malpractice.

    Patient satisfaction is a useless metric. People are generally too stupid to know what quality care is and they don't have the education to spot when someone is delivering crappy care.
  23. VA Hopeful Dr

    VA Hopeful Dr Senior Member

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    This is very true. Its one of the reasons I enjoy primary care - you build up a patient base that likes/respects/trusts you, interactions are then pleasant even in less than great circumstances.
  24. VA Hopeful Dr

    VA Hopeful Dr Senior Member

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    There's a fair chance that you'll just care less.
  25. ChillyRN

    ChillyRN DNP, FNP-BC

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    Re: caring less. Yes, I think that's more than likely true. None of the practicing physicians I know have enough time on their hands to give a sh!t about the finer points of this debate. They seem to just take people as they come and evaluate them as individuals. Then, all the docs I work with are very supportive of NPs and PAs in general, so maybe it's just them.
  26. oldiebutgoodie

    oldiebutgoodie

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    Well, I'm not sure I would agree that people are generally too stupid, I mean, they haven't been to medical school. To expect patients to "know" when they are getting the correct care for the condition is expecting a tad much.

    (Okay, there are some really stupid people out there).

    Oldiebutgoodie
  27. Instatewaiter

    Instatewaiter But...There's a troponin

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    Exactly they don;t know what correct care is.

    So, in the end, what patient satisfaction ends up being is a surrogate marker for amount of time spent with the patient.
  28. Charles_Carmichael

    Charles_Carmichael Moderator Emeritus Bronze Donor

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    That's definitely true. At this point though, I don't think it's very likely. I'm becoming more and more politically active regarding this and have been talking to a WSJ journalist about publishing some of my stuff (although this has been taking a long time and I'm thinking it's pretty unlikely that I'll actually get my NP/DNP vs. MD analysis, etc, published...still gotta try though!).

    I do think that the way to counterattack NPs/DNPs is via the media though. So, I've been doing what I can to get in touch with various media outlets and increasing their awareness regarding this issue as well as attempting to get some of my stuff published. My hope is that, as I go through med school and residency, they'll take me more and more seriously and be more willing to address my concerns (compared to me just being a premed right now). I am also planning on increasing my contributions to physician PACs, etc.

    As you can probably tell, I'm pretty passionate in this area and I think that I'll end up becoming more invested in this rather than caring less in the future. Fingers crossed for not losing my passion! :xf::)
  29. PSYCHNP

    PSYCHNP

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    .

    What a life mission
  30. Therapist4Chnge

    Therapist4Chnge Neuropsych Ninja Faculty Moderator Emeritus

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    Screw hunger, famine, and genocide....we gotta make sure to get the message out about PA/NPs taking over the world!! :laugh:

    ps. At least Kaushik isn't apathetic, which is the worst way to go through life.
  31. Charles_Carmichael

    Charles_Carmichael Moderator Emeritus Bronze Donor

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    Haha yea, I guess what I said did come off a little silly compared to that stuff. All I'm trying to say is that I don't plan on becoming a physician who ignores this encroachment by nursing midlevels. :)
  32. zenman

    zenman Senior Member

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    Have you heard about the dental techs...another mid-level created out of a need?
  33. Charles_Carmichael

    Charles_Carmichael Moderator Emeritus Bronze Donor

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    I have seen that come up a couple of times on SDN and I have spoken out against it. I'm against any midlevels who equate themselves to the profession that has the highest level of training in that field. When I say equate, I mean in the sense of full-equality (ie. complete independence, broadness of scope of practice, etc).

    With that being said, I am not as familiar with the dental tech curricula and the literature regarding their outcomes vs. those of dentists (if such literature even exists). I am, however, familiar with NP/DNP curricula and am fully aware that there's no evidence to suggest that they should have an equivalent scope of practice as physicians do. The best "study" you guys have is the Mundinger one looking at primary care "outcomes" (I put outcomes in quotations because the study used really weird measures to say there's equivalency) after 6 months. Not sure if Mundinger designed the study to be flawed from the start in order to push her agenda or if she just didn't have a good grasp of experimental design (which is ironic since the DNP curriculum spends so much time on public health and research-oriented stuff).
  34. oldiebutgoodie

    oldiebutgoodie

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    Last edited: 02.10.11
  35. zenman

    zenman Senior Member

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    Don't encourage him. He probably barely has time for his homework as it is!
  36. Norick13

    Norick13

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    What a lot of posters seem to not understand is that health care is in a time of tremendous flux right now.

    Residency is creating a bottleneck in physician training right now, and is severely limiting the number of trained caregivers with M.D. after their name.

    So what's happening? PAs, & NPs are filling that void. Along with all kinds of emerging technical staff like AAs.

    Also, most health care institutions, read hospitals, are run not by physicians, but business people.

    So when you have a CRNA who costs you $120,000 a year to employ or an Anesthesiologist who costs you $350,000+ (and that's low) what do you think makes more sense to a business mind? That's right hire 1 Anesthesiologist and have them work with 1-4 CRNAs rather than hire that many Anesthesiologists....profit!

    Just something to keep in mind; the paradigm of Physician with nurses scuttling around beneath them is going the way of house calls. I know there is the chest-thumping-arrogance associated with the 8-ish years of education that goes into an M.D. (I'm currently on several wait-lists to get those initials after my name), but seriously it's not doing anything to advance the debate of how to provide enough care for those being left in the 150,000-200,000 physician void that's looming over the next 20 years or so.

    Kaushik, it may feel great to troll on the internet about contacting media sources about the evils of nursing, but seriously if you're going to be a physician with that mentality I feel bad for anyone who has to work with you. I've met several physicians/residents/fellows with that mentality while working as a NA, and the only person who suffers when you snub the nursing staff is the patient. Grow up, and get over yourself. You're part of a team whether you like it or not, and there will be nurses who are better than you at delivering care, deal with it, and move on. There's nothing wrong with it, and if you can use those people effectively you'll make your care all the more effective; if not you'll have a dysfunctional care-team and your patients will be the only ones suffering.

    Anyway, it's some interesting stuff here in this thread (that WSJ article was a good read). I know I am looking at PA and ACNP as options if I don't get off of these wait-lists.
  37. Dr Oops

    Dr Oops

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    Nurses arent filling the void, theyre using it as an excuse to expand their practice rights for more $$$$$.

    The amount of idiocy in your post is astounding, save it for your personal statement.

    If you ever do get off the wait list and get to experience the "arrogance" of 8 years of education, then you'll have a clue and realize that anyone who says they can do it in two years is either stephen hawkings twin or full of ****.
  38. Charles_Carmichael

    Charles_Carmichael Moderator Emeritus Bronze Donor

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    I will write something up, but it's extremely unlikely that the WSJ will put up something I write. The best I can probably do is to write in the comments section.

    Yea, because spending a couple of minutes discussing a topic of interest means that my entire life revolves around only this issue and that I have no time for anything else. Right?

    The solution is not to fill in the void of highly-trained physicians with nursing midlevels, who have a fraction of the training that a physician receives. Especially in a field like primary care, which demands that you have an extensive medical knowledge base.

    We also need more dermatologists, cardiologists, lucrative-specialty-ologists right? Because I see NP "residencies" opening up in these lucrative fields. Guess they don't care that much about primary care after all...

    I would be more likely to believe this argument if the nursing midlevels who want independence weren't also pushing for equal reimbursement as physicians. If they want to get paid at the same level as physicians, why would you hire them? You're getting someone who costs the same as a physician but with significantly less training. It's a lose-lose (for both the businessman and the patient).

    Actually, I haven't seen that on these forums or in actual clinical settings (at least where I volunteered and shadowed).

    It's pretty clear that you haven't read anything I've written (beyond a sentence or two). Don't put words in my mouth; it makes your arguments seem weaker when you make stuff up. Go back and reread what I wrote. Nowhere did I say that nursing is evil. Nowhere did I say that I had anything against nursing or midlevels in general (in fact, I'm very supportive of PAs and most NPs). Heck, the ED where I used to volunteer had several NPs that I got along extremely well with.

    The group that I am against is the one filled with NPs/DNPs/CRNAs who are continually pushing to have an equivalent scope of practice as physicians. Especially when there isn't any convincing evidence to suggest that this is a good idea (as I previously mentioned, the best NP/DNP study is the Mundinger one, and that is not only heavily flawed in design but also barely has any follow-up looking at long-term outcomes). Do you really think that 2-3 yrs of online school = rigorous MD/DO school + residency? That is the only group I'm against. Like I said, go back and reread my posts before responding.

    It's funny that you're telling me to grow up and to get over myself. Let me ask you a question though: which of these comes off as more arrogant?

    1)
    Me claiming that an NP/DNP who has between 500-1000 clinical hours of training is nowhere close to being equal to a physician who has more than 10000 hours of clinical training (and this isn't even taking into account that physicians receive a significantly greater basic science foundation than nursing midlevels).

    Or,

    2) NPs/DNPs claiming that they're equal/superior to physicians (has been stated many times in media articles...Mundinger herself has been quoted saying that DNPs are superior to physicians) and demanding that they have an equivalent scope of practice and equal reimbursements. Don't mind the fact that they receive only a fraction of the training that an attending receives.

    I'm curious to see if you think choice 1 is more arrogant and to hear your reasons as to why.

    Also, nice job invoking Burnett's Law: "if you believe [insert random opinion], you'll be a terrible doctor and I am scared for your future patients!" Come on...come up with a better "argument" than that.

    If you're referring to the Mundinger letter as being a good read, it unfortunately was not. Her study has been debunked many times in the past, not only on SDN but also in the allnurses forums. I'm not sure why she keeps on referencing it. Not only that, her DNPs at Columbia (supposedly the "cream of the crop") had a 50% fail rate on a watered-down version of the easiest Step exam. This exam was specially catered to the DNPs, the questions were made easier, and the passing score was also lowered. Yet, there was a 50% fail rate. That tells you quite a bit about the rigor of their training. As a note, from what I've been told by residents, most interns take the real Step 3 (you know, not the watered-down one) with barely any studying and have a nearly-100% pass rate.

    Good luck with the waitlists. Letters of interest/intent have worked for others and might help you out as well.

    Edit: Looks like Dr. Oops beat me to it.
    Last edited: 02.09.11
  39. zenman

    zenman Senior Member

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    I bet Kaushik will wind up working here:

    Nurse Practitioner Elected Medical Staff President

    Rebecca Hendren, for HealthLeaders Media, February 8, 2011

    Bob Donaldson is clinical director of emergency medicine and president of the medical staff at Ellenville Regional Hospital in New York. His current projects sound much like any medical staff president's goals.

    What might surprise you is that Donaldson is not a physician but a nurse practitioner. He was elected to this influential position by his physician colleagues and enjoys great support from the hospital's medical staff.

    http://www.healthleadersmedia.com/p...-Practitioner-Elected-Medical-Staff-President
  40. Charles_Carmichael

    Charles_Carmichael Moderator Emeritus Bronze Donor

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    That's nice zenman. I'm sure there are many physicians who disagree with my views. That's fine and they're entitled to their opinions.

    But, for once, why don't you try refuting what I wrote instead of what you did here? Why don't you provide me with some objective data that NP/DNP = physician instead of some news article? Why don't you provide me with some long-term outcome data? Why don't you provide me the results of a prospective, randomized trial comparing patients who were treated solely by nursing midlevels (with no physician intervention whatsoever, even in the more dire situations) with those that were treated solely by physicians? In this era of "evidence-based practice," why don't you provide me with some evidence?

    I don't think I'm asking for a lot here. All I'm asking for is convincing evidence that NPs/DNPs = board-certified attending physicians. I mean, the nursing leaders and vocal nursing midlevels are saying that they're superior to attending physicians. So, why don't you enlighten us all and provide us with this data that supports that view? Really, just provide me with the PubMed ID to one phase III clinical trial comparing nursing midlevels to attending physicians.

    PS. I'm not interested in emergency medicine. ;)
  41. zenman

    zenman Senior Member

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    You can check these out, but I have no interest in doing so :D. However, I do know many mid-levels are begging for someone to design studies that will pass muster with all parties involved. Would you be ready for the results if they are positive towards mid-levels?

    http://www.acnpweb.org/i4a/pages/index.cfm?pageid=3321
  42. Charles_Carmichael

    Charles_Carmichael Moderator Emeritus Bronze Donor

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    I can tell that you don't read clinical literature since all you have "cited" so far have been news articles...

    I have read the majority of the articles in your link already. None of them provide any convincing evidence that NPs/DNPs = board-certified attending physicians and that they deserve to be fully independent. Many of them are actually meta-analyses. And a meta-analysis is only as good as the primary literature it reviews.

    None of them are phase III multi-center clinical trials with a large number of patients randomized to the physician and nursing midlevel arms either. Where's the long-term outcome data? You can't expect me to believe that a 6-month-long study is enough to point out significant differences between nursing midlevels and physicians in the primary care arena.

    Forgive me, but I don't buy into the BS that patient satisfaction = quality medical care (like several of those studies suggest). :laugh:

    Edit: If well-designed prospective trials are undertaken and they don't show clinically significant differences between nursing midlevels and physicians, I'd accept it. At that point, my opinion wouldn't matter much in the face of such evidence. But, until such evidence is presented, you and the nursing leadership/vocal midlevels can't really say that you're equal/superior to physicians. Basically, what I'm saying is, if you're making a claim, provide evidence to support it.
    Last edited: 04.16.11
  43. sheva1968

    sheva1968

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    can you show me any randomized multi center clinical trials showing any difference? No, no one is going to do that the money and political will just is not there and easily 99% of best practice lacks this gold standard.

    If there were significant differences in outcomes they almost certainly have manifested themselves in some observable form by now.

    The real fact of the matter is that as far as I can tell you are a bright individual who has no real experience in which to base any of your decisions. I would be a bit more impressed if you actually PRACTICED in any meaningful way, in the meantime you are at best a really funny Monday morning QB.

    To use the canard "you don't know what you don't know" and you don't know a thing about being a clinician.:laugh:
  44. Charles_Carmichael

    Charles_Carmichael Moderator Emeritus Bronze Donor

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    Looks like they didn't teach you about the concept of burden of proof during NP school. The persons making the claim (in this case, the nursing midlevels claiming to be equal/superior to physicians) are the ones who need to provide data supporting their stance. It's not up to others to disprove them. Absence of proof =/= proof of absence.

    It's a simple concept really. When a new drug is developed, it's up to the company to provide evidence that the new drug is at least equal to the current gold standard. The company that produces the current gold standard isn't the one that needs to disprove the original company's claim.
  45. PSYCHNP

    PSYCHNP

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    The news articles Zenman provided you show you that NPs/PAs are practicing successfully every day.

    NPs have nothing more to prove to you when they are out there, like it or not, successfully practicing "medicine".

    I guess when an NP prescribes something like an antibiotic and cures an infection, it is different than when an attending prescibes the same thing?
    Last edited: 02.09.11
  46. zenman

    zenman Senior Member

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    Actually my nose is buried almost daily in the "clinical literature."

    Having a business background makes me appreciate patient satisfaction more than you, but that's just me. In some aspects of my work patient satisfaction = $2,500 a day plus expenses, but again that's just me laughing all the way to you know where.

    I'm not saying I'm equal/superior to physicians. I'm just saying I'm different...and I prefer to work with people who have not been satisfied (damn, there's that word again) with their current treatment. You see, I stayed awake in business school and can spell "niche market." Other than that, I'll continue to have fun with you. Hope you don't mind. You're a fun fellow.
  47. Dwindlin

    Dwindlin SDN Gold Donor Gold Donor

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    I assure you most physicians are not completely ignorant and believe that patient satisfaction is irrelevant (actually I haven't seen anyone argue that). What they are saying ( and I agree with them ) is that its a crap measure of quality healthcare. What patients want, and what is best for their health is not always the same. . .

    I know quite a few individuals would love nothing more than to enjoy a quadruple baconator for every meal of the day. . .hopefully we can all agree that while this may make them happy and satisfied it is not very good for them.
  48. 476515678234896

    476515678234896

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    Since when did nursing involve science?
  49. Nymphicus

    Nymphicus kane o ke kai Moderator Emeritus Lifetime Donor

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    Way to farm off an ignorant public


    and

    "Years of training is a poor predictor of competence."
    :barf:
  50. PharmBound2011

    PharmBound2011

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    since science became an art:cool:

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