Is the DNP a real threat, or a paper tiger?

[Rendar5]

Still, there's an exceedingly obvious way to set things up.

The primary care clinic of the future could have a staff of about 5 to 10 midlevels. Each midlevel would be specialized in one thing - so if the patient has minor heart problems, they see the cardio PA. Colds - the infectious disease PA.

If the patient has complex multiple disorders or has a problem that the PA/DNP can't figure out, the patient is sent down the hall to a physician.

In turn, that physician can refer to a specialist physician. And so on.

I have an issue with overspecializing and then just going in to see a specialized NP. The clinic patient I saw today with a cough, sore throat, and some atypical musculoskeletal-type chest pain , but also had a pulse of 110-120? Would the ID NP know to even consider a PE in this patient's differential? I doubt it. You need a broader knowledge base to work someone up from scratch.

That isn't to say I have anything against NP's (I use one as my PCP for basic stuff). Just saying that the way you imagine such a clinic working isn't ideal at all.

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[Thisplaceisfun]

BS. You have something against NPs. It's a lack of respect. You have no data for that assumption. Just your own bias against NPs and being very self-impressed.

 

[womp]

BS. You have something against NPs. It's a lack of respect. You have no data for that assumption. Just your own bias against NPs and being very self-impressed.

Kettle, pot, black.

 

[Rendar5]

BS. You have something against NPs. It's a lack of respect. You have no data for that assumption. Just your own bias against NPs and being very self-impressed.

Is that a reply to my post, because if so I don't think my point was clear at all.

 

[Miami_med]

I'll remind everyone to keep the debate civil. Name calling is against the TOS.

 

[Instatewaiter]

Instatewaiter : I looked at a curriculum for a family practice residency. Essentially, they rotate for few weeks through nearly every specialty. It's 3 years of straight rotations. It truly is a training program intended to create a "jack of all trades, master of none". I mean, did you get to do anything really after a rotation in medical school? Then how much more would you be able to learn after a mere additional 6 weeks in that specialty as a resident?

Generally the FM residencies have a core curriculum of FM/IM, peds, ob and then some electives. The rotations may seem "different" but generally fall under the core curriculum. For instance they may do a MICU/MRICU month- this is basic adult care. They may do a few weeks in a newborn nursery- peds. In the end, they spend much, much more time in each area of their curriculum than just 6 weeks. Their electives give them more insight into the complex diseases and issues they will be faced with, and will see, during their FM/IM months.

Even looking at hours- lets take your example. 6 weeks working as a resident is about 500 hours. That is roughly half of the ENTIRE clinical education a DNP gets. Dont forget there is a ton of overlap there in the FM residency rotations.

So using your tired quip about FM being the jack of all trades and master of none... that would make your specialized DNP as a jack of 1 trade and a master of none. 5 of these instead of 1 doc... I dont see how this is better or more cost effective

Also the role NPs students take in rotations is very different than the role a resident takes- the NP students basically take on the same role as the medical students- not the resident. These, as you will realize when you get to medical school, are very different roles.

The primary care clinic of the future could have a staff of about 5 to 10 midlevels. Each midlevel would be specialized in one thing - so if the patient has minor heart problems, they see the cardio PA. Colds - the infectious disease PA.

If the patient has complex multiple disorders or has a problem that the PA/DNP can't figure out, the patient is sent down the hall to a physician.

In turn, that physician can refer to a specialist physician. And so on.

Is this the way a clinic of the future will run? Maybe, maybe not. In general, however, increasing specialization is inevitable. Specialization creates more LOW skill specialized jobs as well as highly skilled ones. Once upon a time, 'short order cooks' for the diners of the day actually needed real skill. Now, fast food workers barely need to know more than how to flip a burger. In this day of the internet, there are now people who are paid to sit around collecting digital loot in video games. There are people who spend all day filling in CAPTCHAs so that millions of people can be sent unwanted junk mail. And so on.

The model of the family physician who runs a clinic with the help of 1 or 2 assistants, seeing the same patients for decades and visiting them in the hospital and making housecalls is long gone.

Since I figure you havent gone to medical school yet I will give you the benefit of the doubt but your example would be terribly inefficient. It would cost significantly more money to run a clinic like that.

Patients, especially those repeat offenders you often see in primary care dont come in with just heart problems, or stomach problem, or respiratory problems. They come in with multiple co-morbid issues that one person- their PCP- needs to deal with. When you fractionate care like with multiple midlevels only trained in 1 field, things slip through the cracks. This is why a PCP is so important, because they orchestrate all of the care a person receives.

 

[physasst]

I have an issue with overspecializing and then just going in to see a specialized NP. The clinic patient I saw today with a cough, sore throat, and some atypical musculoskeletal-type chest pain , but also had a pulse of 110-120? Would the ID NP know to even consider a PE in this patient's differential? I doubt it. You need a broader knowledge base to work someone up from scratch.

That isn't to say I have anything against NP's (I use one as my PCP for basic stuff). Just saying that the way you imagine such a clinic working isn't ideal at all.

Don't pat yourself on the back too hard. Most PA's, and likely NP's would have considered it as well.

Cough, atypical chest pain, and tachycardia automatically place PE in the differential. Especially if it's a female.

That's one most PA students should pick up as well. If you really think we can only perform well exams, or chronic medical checkups, well, I don't what to say to that.

Especially considering my two closest friends in PA school own their own practices. One, owns an occupational medicine practice, and the other owns a family practice in Florida. Both hire their supervising physicians.

As for myself, I work at an ER where there are NO physicians on site. Primarily because it is a level IV trauma center, and a critical access hospital, and the volumes cannot justify a full time physician.

Yesterday, I managed several rather acutely ill patients, all by myself, and admitted 3 of them. But, I guess I'm not capable of these things.

Even sent one to the surgeon for an appendix...and GASP....I didn't get a CT scan....OMG.....

 

[Thisplaceisfun]

Don't pat yourself on the back too hard. Most PA's, and likely NP's would have considered it as well.

Cough, atypical chest pain, and tachycardia automatically place PE in the differential. Especially if it's a female.

That's one most PA students should pick up as well. If you really think we can only perform well exams, or chronic medical checkups, well, I don't what to say to that.

Especially considering my two closest friends in PA school own their own practices. One, owns an occupational medicine practice, and the other owns a family practice in Florida. Both hire their supervising physicians.

As for myself, I work at an ER where there are NO physicians on site. Primarily because it is a level IV trauma center, and a critical access hospital, and the volumes cannot justify a full time physician.

Yesterday, I managed several rather acutely ill patients, all by myself, and admitted 3 of them. But, I guess I'm not capable of these things.

Even sent one to the surgeon for an appendix...and GASP....I didn't get a CT scan....OMG.....

Ha! I like you! Sticking up for the little guy (or girl) with sarcastic humor to boot! I take back all the rude things I said to you and I apologize. I get a little heated under the collar when I think I see people talking down to nurses.

 

[GeraldMonroe]

All this is supporting my point. My "clinic of the future" might work just fine. And it would heavily rely on information technology - if you enter certain symptoms into the EHR, it would automatically search a database and list the usual differentials for that symptom set.

NO, computers can't totally replace knowledge - but they can darn sure help. So far I've noticed that every disease mentioned in the "clinical correlations" comes up within seconds of a google search if you type in a couple of the symptoms.

 

[Rendar5]

Don't pat yourself on the back too hard. Most PA's, and likely NP's would have considered it as well.

Cough, atypical chest pain, and tachycardia automatically place PE in the differential. Especially if it's a female.

That's one most PA students should pick up as well. If you really think we can only perform well exams, or chronic medical checkups, well, I don't what to say to that.

Especially considering my two closest friends in PA school own their own practices. One, owns an occupational medicine practice, and the other owns a family practice in Florida. Both hire their supervising physicians.

As for myself, I work at an ER where there are NO physicians on site. Primarily because it is a level IV trauma center, and a critical access hospital, and the volumes cannot justify a full time physician.

Yesterday, I managed several rather acutely ill patients, all by myself, and admitted 3 of them. But, I guess I'm not capable of these things.

Even sent one to the surgeon for an appendix...and GASP....I didn't get a CT scan....OMG.....

My point had nothing to do with that at all. My point was that you don't set up a general medical clinic by having ppl see focused specialists before they see a generalist. I don't care if the specialists are NPs, PAs, or physicians. This is why I don't understand why someone would make a comment saying I don't respect NPs or PAs when I never suggested such a thing.

 

[Rendar5]

All this is supporting my point. My "clinic of the future" might work just fine. And it would heavily rely on information technology - if you enter certain symptoms into the EHR, it would automatically search a database and list the usual differentials for that symptom set.

NO, computers can't totally replace knowledge - but they can darn sure help. So far I've noticed that every disease mentioned in the "clinical correlations" comes up within seconds of a google search if you type in a couple of the symptoms.

I used to have diagnosaurus on my old PDA. It was exactly such a program. No offense, but it was kind of useless because it never altered management.

Edit: (not trying to discourage you, this is also something I had thought was a good idea in my pre-clinical years. I didn't realize that this concept didn't work that well in practice until I got to clinical years)

 

[Thisplaceisfun]

My point had nothing to do with that at all. My point was that you don't set up a general medical clinic by having ppl see focused specialists before they see a generalist. I don't care if the specialists are NPs, PAs, or physicians. This is why I don't understand why someone would make a comment saying I don't respect NPs or PAs when I never suggested such a thing.

You stated in your post that you doubted a NP would have correctly diagnosed the ailment you encountered with a patient. Your doubt was not based on any data, but merely appeared to be an unsubstantiated opinion. However, you then claimed you had nothing against NPs. The tenor of your comment, which called into questioned the abilities of NPs without introducing any evidence to support your skepticism (not even anecdotal evidence), suggested to me you have an underlying prejudice against NPs. Perhaps I did not understand your post and I apologize if my tone earlier was overly aggressive.

 

[Taurus]

My "clinic of the future" might work just fine. And it would heavily rely on information technology - if you enter certain symptoms into the EHR, it would automatically search a database and list the usual differentials for that symptom set.

If you've ever developed systems, which I used to in my prior career, you would know that the system is wholly dependent on the accuracy of the input. If the person's clinical skills aren't up to snuff because of inadequate training, they won't know to enter that diastolic murmur, pleural rub, or bulla. If the person doesn't know what questions to ask, then you won't enter valuable input and waste time during the pt encounter. You can have the world's greatest algorithms and user interface, but if you have garbage in, you get garbage out.

 

[Rendar5]

You stated in your post that you doubted a NP would have correctly diagnosed the ailment you encountered with a patient. Your doubt was not based on any data, but merely appeared to be an unsubstantiated opinion. However, you then claimed you had nothing against NPs. The tenor of your comment, which called into questioned the abilities of NPs without introducing any evidence to support your skepticism (not even anecdotal evidence), suggested to me you have an underlying prejudice against NPs. Perhaps I did not understand your post and I apologize if my tone earlier was overly aggressive.

Yeah, I can see how I got myself into trouble there. I meant someone who only dealt with ID when I said an ID NP. Same could have been said of an ID physician. The anecdote was more meant to say that when you deal with a patient in a general clinic who walks like a URI and talks like a URI, there's more than ID on the differential. Better example would've been the patient who came in with persistent vomiting whose story was a pretty obvious panic disorder (when asked further, had every symptom of a panic attack at the time of each vomiting episode). Saw every specialist before coming to a general clinic with extensive GI workups. Pretty extreme example, but another situation where being prematurely shuttled into specialists was a mistake because he got shuttled to the wrong specialist based on his chief complaint. This was not a patient I saw or caught, just heard about from one of the other docs in clinic.

 

[Forthegood]

You can have the world's greatest algorithms and user interface, but if you have garbage in, you get garbage out.

Your doubt was not based on any data, but merely appeared to be an unsubstantiated opinion.

And your data on patient outcomes by mid-level providers is???? I have read one (terribly flawed) study showing similarity in outcomes from NP to MD... but that is it. Fortunately, the Cochrane group did a wonderful job in discrediting the study. So let us not point fingers... there is not evidence to support NPs as there is no evidence to discredit them. So it basically boils down to money at this point, not ability, at least not yet. I know that you didn't say anything to that effect, but you can't bash the guy for sharing his opinion (it is what we do here).

So with money in mind, how will NP replacement effect reimbursement from the aging, chronically ill? It won't. And therein lies the problem. Not that GPs are paid too much, but that the shortage is growing and not matched by compensation. Flooding the system with mid-levels is not a solution, but a deferment. And without evidence to support the efficacy of said providers, one can not pretend we can effectively weight the risk/benefit. Hoping without data is a good way to do harm. NPs may very well be qualified to be gatekeepers, but as of yet, we don't know if that is true or not. And until then, unsupervised practice is irresponsible.

We are supposed to advocate safety in public health. You wouldn't blindly prescribe a drug without evidence, likewise we shouldn't outsource to less-educated individuals without thorough analysis.

 

[womp]

And your data on patient outcomes by mid-level providers is???? I have read one (terribly flawed) study showing similarity in outcomes from NP to MD... but that is it. Fortunately, the Cochrane group did a wonderful job in discrediting the study. So let us not point fingers... there is not evidence to support NPs as there is no evidence to discredit them. So it basically boils down to money at this point, not ability, at least not yet. I know that you didn't say anything to that effect, but you can't bash the guy for sharing his opinion (it is what we do here).

So with money in mind, how will NP replacement effect reimbursement from the aging, chronically ill? It won't. And therein lies the problem. Not that GPs are paid too much, but that the shortage is growing and not matched by compensation. Flooding the system with mid-levels is not a solution, but a deferment. And without evidence to support the efficacy of said providers, one can not pretend we can effectively weight the risk/benefit. Hoping without data is a good way to do harm. NPs may very well be qualified to be gatekeepers, but as of yet, we don't know if that is true or not. And until then, unsupervised practice is irresponsible.

We are supposed to advocate safety in public health. You wouldn't blindly prescribe a drug without evidence, likewise we shouldn't outsource to less-educated individuals without thorough analysis.

Thisplaceisfun has a habit of questioning the conservative opinions of others as if to discredit them, when he is the one advocating dramatic change based solely on his own self-evaluation and without any real evidence (either of quality comparisons or cost effectiveness) to support them. He doesn't seem to realize that the burden of proof is on him.

 

[Terpskins99]

Simple solution: require DNP's to pass USMLE.

If you can get through all 3 steps including clinical skills then hey, by all means, do what you want with the blessing of the AMA.

Same deal with PA's.

 

[Cp22kjer]

Simple solution: require DNP's to pass USMLE.

If you can get through all 3 steps including clinical skills then hey, by all means, do what you want with the blessing of the AMA.

Same deal with PA's.

I'd love for this to be the requirement.

 

[niranjan162]

Simple solution: require DNP's to pass USMLE.

If you can get through all 3 steps including clinical skills then hey, by all means, do what you want with the blessing of the AMA.

Same deal with PA's.

but dont you learn more than just wat is on the test in med school?

And given enough time and study materials couldnt anybody pass the test?

 

[Rendar5]

but dont you learn more than just wat is on the test in med school?

And given enough time and study materials couldnt anybody pass the test?

Step 3 is usually taken during residency. At my program, it's a requirement to start the 2nd year. It's also not really a pure knowledge test. It's a test of how to handle different patient situations in terms of diagnosis, treatment, and management. I'm not sure how different it is from Steps 1 and 2 though.

 

[Terpskins99]

but dont you learn more than just wat is on the test in med school?

Yes, but that training isn't necessarily standardized across every medical school. Boards is the one universal measuring stick. And it is really the only minimum competency test we use.

And given enough time and study materials couldnt anybody pass the test?

Sure. And if someone has used that time and study materials to the point where they can pass all step exams... then I'd feel just fine with them practicing family medicine.

 

[mig26x]

I laugh at nurses who state that they are getting a DNP because there's a primary care physician shortage!! and what the hell do they call the nurse shortage that is getting closer to 50,000 in the next few years???

They are after two things: money and power. They dont care about bedside work.

 

[Rendar5]

and/or administration and/or academic teaching =p Not that those go against ur point about it not being about bedside work.

 

[zenman]

I laugh at nurses who state that they are getting a DNP because there's a primary care physician shortage!! and what the hell do they call the nurse shortage that is getting closer to 50,000 in the next few years???

They are after two things: money and power. They dont care about bedside work.

I'm working towards NP and don't care about the DNP. I also don't care about money or power. What I did care about was being caught between hospital admin, doctors, patients and families.

So yes, for probably most of us it's about getting away from the bedside. Many new nurses are giving it up after only a few years. I can't even remember the number of times I've injured my back, but I do remember three ruptured discs. I also remember friends having back surgery and one who, at the start of her career, was advised by the neurosurgeon who operated on her neck injury to get out of nursing.

So soon, I'll have the power to walk onto a unit, visit patients and then leave...you know, like physicians do, he, he.

 

[mig26x]

Its a threat. Look at NP and minute clinics opening all over the country. Although I laugh at the DNP been call a clinical diploma since not even 10% of the classes are towards improving clinical knowledge.

Let them take the DNP but let them pay malinsurance/malpractice like us and let them be responsible for problems/troubles etc.

 

[Cp22kjer]

Its a threat. Look at NP and minute clinics opening all over the country. Although I laugh at the DNP been call a clinical diploma since not even 10% of the classes are towards improving clinical knowledge.

Let them take the DNP but let them pay malinsurance/malpractice like us and let them be responsible for problems/troubles etc.

Yeah really, future lawsuits will hopefully right the ship and shut this DNP show down (wishful thinking).

 

[YourGoldTeeth]

While expanding scope of practice is definitely a motive for the DNP change, another motive seems more obvious to me.

It creates a bigger barrier to becoming an NP. Fewer NP's = more demand, more money, more job security.

Lengthening training has another benefit: more money for the nursing boards and more money for the nursing schools.

 

[Taurus]

Mundinger confirms that nursing wants to claim medicine for themselves.

in the Jan. 16 Chronicle of Higher Education. Mary O'Neil Mundinger, DrPH, RN, dean of Columbia University School of Nursing in New York, was quoted as saying: "If nurses can show they can pass the same test at the same level of competency, there's no rational argument for reimbursing them at a lower rate or giving them less authority in caring for patients."​

This is coming from a group where their students can earn their DNP online, spend only 700 hours in training, and 50% of the creme de la creme DNP's fail a watered-down Step 3 where they intentionally lowered the pass cutoff. Who among the medical students, residents, or attendings here will continue to support a less qualified group that is determined to undermine you and take your positions?

DON'T HIRE NP'S!!!!

 

[YourGoldTeeth]

This is coming from a group where their students can earn their DNP online, spend only 700 hours in training, and 50% of the creme de la creme DNP's fail a watered-down Step 3 where they intentionally lowered the pass cutoff.

Wait, you didn't get your degree online?

 

[Cp22kjer]

Mundinger confirms that nursing wants to claim medicine for themselves.

in the Jan. 16 Chronicle of Higher Education. Mary O'Neil Mundinger, DrPH, RN, dean of Columbia University School of Nursing in New York, was quoted as saying: "If nurses can show they can pass the same test at the same level of competency, there's no rational argument for reimbursing them at a lower rate or giving them less authority in caring for patients."​

Wow. She can't be serious... I think you'll find nurses rolling their eyes at this. It's embarrassing for the majority of them too.

 

[dragonfly99]

So if an NP gets reimbursed @the same rate as a FP physician, then the argument that NP's will be more cost effective fails, doesn't it?

 

[mig26x]

Wow. She can't be serious... I think you'll find nurses rolling their eyes at this. It's embarrassing for the majority of them too.

that lady is on crack!!!

 

[RGMSU]

Primary care docs are taking their eye off the ball here arguing for redistributionist change when the real threat is from this subversive groundswell....

Yep, they don't know what they're wishing for. I talked to an FP the other day who was just thrilled about the coming changes in healthcare. I felt like telling him - "Bud, I don't think this is all going to be as great for you as you think. $40 per office visit all day long ain't gonna pay the bills, especially when you're competing with every doctor wanna-be who decided to hang up a family practice shingle."

On a side note with reference to another earlier post, the DNP will get all the easy cases and the MD will get all the tough cases, and they'll get paid the same. Not really fair. And, the MD will be paying off twice as many school loans. Not really fair either. The giant elephant in the room that nobody wants to talk about is the reality that NOBODY would go to a DNP program if they believed they had a realistic chance of becoming an MD/DO. NOBODY. Therefore, the same quality of person is simply not there. Not that they're all stupid and incompetent, but they are nowhere near the level of someone who becomes a physician through a US medical school. But, honestly, folks, as soon as a lot of these people who want to play doctor start getting sued like doctors, paged like doctors, charged malpractice insurance rates like doctors, being responsible for overhead like doctors, we might not have as much to worry about as it seems. Honestly, if somebody is ignorant enough to depend on lower-level practitioners for their healthcare, they deserve what they get as a patient.

 

[badasshairday]

Yep, they don't know what they're wishing for. I talked to an FP the other day who was just thrilled about the coming changes in healthcare. I felt like telling him - "Bud, I don't think this is all going to be as great for you as you think. $40 per office visit all day long ain't gonna pay the bills, especially when you're competing with every doctor wanna-be who decided to hang up a family practice shingle."

On a side note with reference to another earlier post, the DNP will get all the easy cases and the MD will get all the tough cases, and they'll get paid the same. Not really fair. And, the MD will be paying off twice as many school loans. Not really fair either. The giant elephant in the room that nobody wants to talk about is the reality that NOBODY would go to a DNP program if they believed they had a realistic chance of becoming an MD/DO. NOBODY. Therefore, the same quality of person is simply not there. Not that they're all stupid and incompetent, but they are nowhere near the level of someone who becomes a physician through a US medical school. But, honestly, folks, as soon as a lot of these people who want to play doctor start getting sued like doctors, paged like doctors, charged malpractice insurance rates like doctors, being responsible for overhead like doctors, we might not have as much to worry about as it seems. Honestly, if somebody is ignorant enough to depend on lower-level practitioners for their healthcare, they deserve what they get as a patient.

Great post.

 

[fireguyrick]

The giant elephant in the room that nobody wants to talk about is the reality that NOBODY would go to a DNP program if they believed they had a realistic chance of becoming an MD/DO. NOBODY. Therefore, the same quality of person is simply not there. Not that they're all stupid and incompetent, but they are nowhere near the level of someone who becomes a physician through a US medical school.

Well, I am not one to troll forums, so I am sorry if this may come off that way.

Nobody would go to a DNP program if they could get into a Med school? Seems like you would have us believe that people that, but there is in fact more to making that decision then just grades and knowledge.

I offer up my wife as an example. She obtained a double major in Nursing and Biology and maintained a GPA of 3.85 out of 4.0. She did this because at the time she was not certain if she wanted to be just a nurse or attempt to become a physician. She did take the MCAT and obtained a composite score of 38. She applied to Medical Schools and was in fact accepted to the Medical School in our area. Yet, she hesitated. We talked about the options out there and she decided not to attend medical school, and instead she finished a master's degree to become a Women's Health Nurse Practitioner specializing in prenatal care.

Why would she do this one might wonder. Well, having a family creates other priorities in a person's life. She desired to allow me to finish my education as I got a late start due to military service, and she also wanted to spend time raising our child. It was her belief that she could not dedicate the time needed to do all these things and still go to medical school.

Why did she not stay a RN? She desired to move beyond the simple scope of practice that an RN has into something she felt was more rewarding. Does she believe she is on par with MD/DO? Absolutely not. She knows that her education does not provider her the same training and knowledge base that an MD/DO has. This does not mean she is not competent to do what she does.

Honestly, I understand the anger towards this DNP thing, and both my wife and I agree it is crazy. She has no desire to have that level of responsibility (like a physician), and neither do any of the NP's she trained with and knows.

This DNP thing really just shows how divided nursing is as a community. Just take for example the different levels of nursing they have right now" Associates Degree Nursing, Bachelor's Degree Nursing, Master's Degree Nursing (which is divided into subsections such as NPs of varying specialties, CNS's of varying specialties, education, research, Midwives, CRNAs, Clinical nurse leader, Health care leadership...), and then this silly DNP thing. This DNP thing is viewed by many in the nursing community as nothing more then to validate some silly acadamia thing, because at the moment to be a clinical nursing instructor you need merely to have a MSN, and there have been VERY few PhDs teaching nursing classes. Hey, schools need to find ways to make more money all the time right?

Nurses want to move out of the shadows of the physician, which is a great thing, but the people in charge are going about it the wrong way. Often times they seem like they have some sort of hatred to docs. Maybe it stems from the old concept that the nurse was the sex object and was expected to stand up when a doctor entered the room. Who knows where this comes from, but the issue that is most troubling is that nursing in general has been trying to validate itself anyway possible, and honestly it does not need to. I would be SHOCKED if any one of you residents, Fellows, or Doctors would state that nurses are useless and you could provide adequate medical care without them.

I can understand how the NP's that have posted on this board feel though, as I am currently a NREMT-Paramedic working in a hospital ER. Many of the nurses I work with have this opinion that I am trying to 'steal' their job from them. The reality is that, while yes, I can do many things they can do and in some cases I can do things they are not allowed to do in our facility (Intubation for example), I will NEVER replace them. I had an instructor once that gave a correlation of knowledge between Paramedics and a typical RN. Paramedics knew only a very narrow section of medicine/healthcare, but that narrow section they knew really well. Nurses knew a very wide section of medicine/healthcare, but only a very shallow amount of it. I kind of see this as how you can compare NP's to MD's (not to the same scale mind you), but take your typical NP graduate and MD graduate. The NP will have selected a specific area of care (yes, I am aware FNPs have a broad area, and I am not a fan of FNPs) and the new MD will have no specialized area (is that not what residency and fellowships are for?).

The facts remain that NP's are here for good, they have a solid 30 year accredited track record at minimum and are expanding all the time. Is DNP here to stay? God we can only hope not.


Rick

Oh yes, now for a few trolling comments

1) Hey, get over the "only people that have a medical degree should be called doctors" comments. Philospher's were called doctors long before MDs were. Sure, you guys can have it in the clinical setting, and demand the DNP's not refer to themselves as such, provided you demand it of any other doctorate leveled healthcare provider that is not a MD/DO (Chiro, dentist, psych, and so on). No double standards please.

2) Crazy people exist in nursing. Crazy people exist in medicine. Crazy people exist.

3) There are bad nurses, good nurses, and excellent nurses. There are bad docs, good docs, and excellent docs. Sometimes we see the excellent and sometimes we see the bad. Are you claiming you would rather have a bad doctor treat you then an excellent nurse?

4) Hey, don't piss off nurses. Do you really want them calling you all the time (and especially 2 hours after you got home from a long shift) to report a change in a patients energy field? Yes, one of my complaints about nursing is that they have their own diagnosis, and Altered energy field is in fact a NANDA approved diagnosis.

 

[MOHS_01]

Rick,

Absolutely no disrespect to your wife, but GPA's are not comparable or standardized in any form or fashion. Again, not to detract from anyone, but a "3.9" for some is not a "3.9" for all. Further, I agree with many here that a line must be drawn in the sand that would clarify and define roles and responsibilities in the healthcare arena; in that vane I do not believe that mid-levels have adequate training or competence to be turned loose on an ill informed and unsuspecting public and practice independently.

 

[fireguyrick]

You are absolutely correct in that not all GPAs are equal, and I merely made it in addition with my statements of MCAT and acceptance to medical school she recieved (Medical College of Wisconsin if I need be specific). My main point with all of that was that the reason some people decided not to go to medical school can be multifactorial, and that RGMSU was incorrect in his sweeping generalization.

Also remember another thing all of you docs and aspiring docs, you best pray that the nursing body in the US does NOT get organized. There are MANY MANY more nurses then physicians, and with politics it tends to be the group that can bring more votes to the table that gets heard the most.

You do not want midlevels turned loose for independant style practice, I can understand this, but in many ways you can blame your peers for this too. In my state NPs need to collaborate with a Physician and to prescribe they need to havea physician sign off of sorts. Because of this it is not at all uncommon for NPs to open up a practice and hire a MD to collaborate with. The MD has pretty much nothing to do with anything other then just being in paperwork. I think this is where the independant status issue comes from in many ways.

Rivalry is great and all, but at the end of the day we all DO need to work together. My issue here is that many of you refuse to offer any sort of insight or suggestions as to what might be a better solution. Instead you sit here, profess to be all knowledgable, and basically come off like a upset child.

The fact remains that there is a need for midlevel providers right now. How do we solve this?

More NPs and PAs with extended SOPs? Many of you do not like that because by your estimation they do not have the knowledge.

How about creating more medical schools and accepting more applicants? Is not some of the logic behind making it difficult to get into medical school to obtain the best and brightest possible? Would expanding the amounts of new docs created, by the amounts needed, cause these high standards to be dropped?

What are the other options? Make suggestions instead of complain and run off with chicken little.

Rick

 

[radslooking]

threat to what? there is more than enough work for everybody. at least in my realm.


edit:::: agree with MOHS that their scope needs to be pretty tightly defined. You don't want people doing things they are unqualified for. That was understood with my above post....

 

[MOHS_01]

Rick,

Since you are new here you do not benefit from the experience or history of previous discussions over time. Any ideas that do not fit neatly with conventional wisdom and current practice are repeatedly shot down here.

*Donning the flak jacket and riot gear*

NP's and PA's scope of practice need be restricted. Collaborative agreement clauses constitute loopholes that allow for independent practice. My state has them as well and I have witnessed on more than one occasion the peril it provides.

As for suggestions: some of us are actively working toward a better system. Want more affordable healthcare? Make it cheaper to provide. We need a model that affords efficiency and ensures quality. This cannot easily occur within current medical practice constructs. The third party payer system is counterproductive for the majority of patient-physician interactions. It is too convoluted, intrusive, and labor intensive. For "medical" office visits (for this discussion that would include E&M services and very minor procedures, which constitutes the majority of interactions) there are two good models. The first (and most efficient) operational model would involve "buy here, pay here". Third party financing, with its regulatory hoops, should be relegated to higher cost procedures, testing, treatments, and pharmaceuticals. The second would involve cheap (preferably free) software, universal and readily available, for third party billing so that charges can be billed and paid efficiently.

I would also argue that there needs to be a paradigm shift in the thought processes of most physicians, but primary care in particular. I believe that the current focus on primary care, while well-intentioned, may be ill-placed. A cheaper construct (for all of medicine) would employ appropriate utilization of mid-levels (under the supervision of a MD) performing the tasks that do not necessitate MD-level training. The system must provide some form of safeguards to ensure best medical practices are being followed. It must also afford the physician the time necessary to appropriately address the more difficult or complex cases while affording some level of protection from the revenue / volume generation pressures.

... and taking the MCAT and getting accepted was the easiest portion, involving the least stress and effort of anything along the way. It was the bunny slope. Some of us did both on few hours sleep and slightly hungover....

 

[docgnosis]

I have often thought about getting an NP, and have also looked at the DNP criteria, syllabi, and course content at several schools locally. My mouth dropped open in surprise. I agree wholeheartedly that there isn't advanced basic science and clinical coursework advantages in the DNP programs I looked at. I was even disappionted in many NP course loads. As such I think there needs to be a revamp in the DNP programs to sufficiently train them for their perspective roles as Primary Care Providers, essentially a new basic science program, and equivalent residencies in their direct specialty. But it should not necessarily be the same as an MD/DO training.

The allopathic and osteopathic professions are designed to be able to take on any specialty they may choose to enter, with various factors contributing to their decisions and positions as I am led to understand. However a DNP will never be a Cardiovascular Surgeon, they must know what they do in reports and progress notes, but the skill set is unneccessary. With that said, does a DNP need to know every single anatomical landmarkd within the human body to be an effective independant PCP? I am not positive this is the case. I have never needed to know the position of someone's ansa cervicalis, but I do, as this structure isn't even consistent within a certain person's body from left to right.

This point is directly related to other sub-doctoral specialties such as Dentists, and podiatrists. They are trained directly with the amount of knowledge and skill sets to demonstrate their respective competencies.

I have spoken with many physicians about this point, most of them agree that they would have much preferred to study in a program that directly related to what they were going into rather than the broad spectrum education they were given in Medical School and the intern/residency process, but not all ofcoarse. Many have arguements against independant nurse practitioners in general. Their biggest hang up isn't related to competence or quality of education, but rather "If they can effectively do this, then why did I have to go to school and learn things that weren't directly related to my chosen specialty."

I believe the situation would be best served by the AMA and AOA if instead of directly opposing the invention of a third primary practice doctorate, than pushing, lobbying and supporting the education and perhaps creation of a DNP training protocol that directly trains nurses in this specialty.

These posts reminded me of a good point. Realize that some nurses have been in practice for 10 years and have learned, and experienced a great deal in patient care. We deliver the treatments, assess and reasses the patients condition far more than physicians do, and we repeatedly are sometimes called to inform interns and residents of appropriate treatments and recommendations by which they will ultimately be responsible for. We also go over the patients situation in more detail individually than any of the primary care or specialty physicians when taking care of acute and critically ill patients. Thus, while our initial trianing is lax compared to a MD/DO we still perform many of the same functions, and indeed share a great deal of the actual workload on individual patients. If say a nurse still wished to provide bedside care, but also wanted to be a primary care provider he/she with this degree might make that possible.
Say a critical care DNP writing her own orders, AND performing these tasks. That could eliminate much congestion in physician shortages, as the nurse, if trained and educated properly, might say start a central line, prescribe the treatments, and order the tests necessary to keep her patient alive and well. It is a possibility. This is a function I don't believe anyone has addressed yet. Primary care bedside nursing/healtcare, a subspecialty right there.

There definately needs to be a better standardized entry test, and educational program for developing a true DNP program. Some students come directly from a BSN program while others have years of experience and are fairly competant. This new educational program would help to close knowledge deficits created with different nurses with regards to experience and education.

In short, there could be a great place for a DNP, in a clinic, at the bedside, in the hospitals supporting and collaborating with physicians to ensure a better patient outcome. DNP's will never be surgeons, so why have a surgical rotation? A DNP will never be a Cardiologist, so do they need a full track like an intern does, yes, as they need to know what to do after say a patient has a stent, to better coordinate the recovery efforts and deliver a good discharge from the hospital.

1) DNP's are here, and they aren't going anywhere, so let's get a good training system going for education and clinical work.
2) The AMA and AOA have already lost the battle of NP independance in many states (please see the 2009 pearson report) and have historically failed to prevent other burdgeoning professions from grabbing their doctorates, please see historical references to DO's, DDS, DPT, DC, and several others. This is a fight that has yet to be won in finality YET!
3) Use your Lobbyists and pressure for better educational training of the DNP. This fight has been one with respect to the Chiropractic profession, they were forced to change thier basic science curriculum to better reflect anatomy, physiology and other basic sciences. This is the really only feasible victory that will likely have any bearing in the long term.

I will continue to study and hope to educate myself so that should these changes happen in my lifetime I can proudly get an NP and perhaps a DNP and advance my profession to be in league with MD/DO colleagues.

Thank you for reading, if you read it all. Sorry for the rambling novel

 

[deleted6669]

nice post. as someone who trains pa, np, and med students as well as residents I also would like to see more clinical medicine and less fluff in the np curriculums out there. np students shouldn't have to arrange their own rotations. pa students and med students are presented with a list of sites and preceptors for each required rotation and come up with a wish list based on their goals. it should be the same for np programs. clinical hrs should be increased to a min of 2000 to be in line with the 2nd yr of pa school or the third yr of med school. np students should have to do a full time clinical yr and not have enough free time during their clinical yr to work 20+ hrs/week as many programs allow.
in my dept(em) pa students, md/do students and residents rotate through 40-60 hrs/week for 5-6 weeks and the np students do 24 hrs/week for 2 weeks as their entire exposure to em. that's not a rotation, that an orientation.
there are several fine np programs out there(ucsf and u.wa come to mind) but there needs to be a set standard/consistency across the board so every program meets the same criteria for clinical exposure. some programs have as little as 350 hrs, a typical program has 500 hrs and an exceptional program has 800-1500 hrs. we can do better than that. set the bar at 2000 hrs.

 

[RGMSU]

I give up. As soon as I am an attending, I will not only find a DNP and gladly call them "Dr. So and So," but I will also hire them to watch my pager for me at night while I go home They want it, they got it. Let 'em have all the bull crap that goes with it.

 

[docgnosis]

Well I was looking at an NP school program, but then I learned of a very nice LECOM primary care program that can be completed in 3 years. Although admission is very strict. I might rethink medical school again.

For those who don't know I was accepted to medical school in Michigan, but decided not to attend at that time, as I was tired of school and wanted to live for awhile.

 

[mydodger]

Do not ignore the dangers of a paper tiger!

 

[zenman]

How long did it take you to do that?

 

[fab4fan]

Wow. She can't be serious... I think you'll find nurses rolling their eyes at this. It's embarrassing for the majority of them too.

Of course it is, but Taurus keeps banging the drum like all of us nurses believe everything that comes from Mundinger as gospel. I think she's a whack job. There are bigger reasons why nurses are leaving the bedside, and many of them have little to do with power-grabs or greed. No one wants to get serious about the real issues, though; it's just easier to fear-monger.

 

[New Vocab]

Don't pat yourself on the back too hard. Most PA's, and likely NP's would have considered it as well.

Cough, atypical chest pain, and tachycardia automatically place PE in the differential. Especially if it's a female.

That's one most PA students should pick up as well. If you really think we can only perform well exams, or chronic medical checkups, well, I don't what to say to that.

Especially considering my two closest friends in PA school own their own practices. One, owns an occupational medicine practice, and the other owns a family practice in Florida. Both hire their supervising physicians.

As for myself, I work at an ER where there are NO physicians on site. Primarily because it is a level IV trauma center, and a critical access hospital, and the volumes cannot justify a full time physician.

Yesterday, I managed several rather acutely ill patients, all by myself, and admitted 3 of them. But, I guess I'm not capable of these things.

Even sent one to the surgeon for an appendix...and GASP....I didn't get a CT scan....OMG.....

Brilliant.

They should abolish medical school altogether and just have psuedo doctors with dramatically less specificed education on the subject who make as much or MORE than most doctors do the surgeries.

 

[Taurus]

Of course it is, but Taurus keeps banging the drum like all of us nurses believe everything that comes from Mundinger as gospel. I think she's a whack job. There are bigger reasons why nurses are leaving the bedside, and many of them have little to do with power-grabs or greed. No one wants to get serious about the real issues, though; it's just easier to fear-monger.

Fear monger?

Take a look around SDN and see what people are saying about the health reform package. You know, the one where the nurses have convinced politicians to equate NP's and PA's with primary care physicians. What's the purpose of that? This sums it up nicely.

In the recently released House health-reform bill, nurse practitioners (and physicians' assistants, another relatively new, but smaller, category of medical professionals who can perform medical procedures and often prescribe medication) are listed alongside doctors as primary-care providers. Nurse practitioners lobbied hard for this legislative language in meetings with White House health officials, including Nancy-Ann DeParle, Obama's health-reform czar. The nurse-practitioners lobby is hoping such federal recognition of the central role the profession can play in a revamped health system will exert pressure on states to ease restrictions. A patchwork of state laws now dictates how much freedom nurse practitioners have, ranging from states like Alabama, where nurse practitioners can work only under the supervision of a physician, to Oregon, where nurse practitioners are permitted to run their own private practices.​

I can hardly care what nurses think. My goal is to educate the public about the training differences and qualifications between physicians and non-physicians. I especially hope to reach out to physicians and physicians-in-training since they are the ones who eventually hire and train these non-physicians. I also hope to inform the insurance and trial lawyers out there. I want to make it so risky and expensive for non-physicians to practice independently because I think the solution to non-physicians wanting autonomy is in the marketplace and not laws. Even though I have a license to practice medicine and surgery, I know better than to do surgery on patients. Likewise, let NP's and PA's go independent. A clear and loud message will be sent to them and their insurance companies after a few of them are taken to court and handed huge settlements. You already see this with high liability in ob and midwives. You may see 99 routines cases and the 100th could bankrupt you. That high liability system needs to be extended to all non-physicians who want to practice autonomously. That's why physicians should point out malpractice to patients when they see it. That's why if NP's and PA's want to go independent then physicians should steer clear away from them so they don't hit by liability accusations. Obama is a lawyer and he has said he doesn't support tort reform. In this environment, neither do I.

 

[New Vocab]

Fear monger?

Take a look around SDN and see what people are saying about the health reform package. You know, the one where the nurses have convinced politicians to equate NP's and PA's with primary care physicians. What's the purpose of that? This sums it up nicely.

In the recently released House health-reform bill, nurse practitioners (and physicians' assistants, another relatively new, but smaller, category of medical professionals who can perform medical procedures and often prescribe medication) are listed alongside doctors as primary-care providers. Nurse practitioners lobbied hard for this legislative language in meetings with White House health officials, including Nancy-Ann DeParle, Obama's health-reform czar. The nurse-practitioners lobby is hoping such federal recognition of the central role the profession can play in a revamped health system will exert pressure on states to ease restrictions. A patchwork of state laws now dictates how much freedom nurse practitioners have, ranging from states like Alabama, where nurse practitioners can work only under the supervision of a physician, to Oregon, where nurse practitioners are permitted to run their own private practices.
​

I can hardly care what nurses think. My goal is to educate the public about the training differences and qualifications between physicians and non-physicians. I especially hope to reach out to physicians and physicians-in-training since they are the ones who eventually hire and train these non-physicians. I also hope to inform the insurance and trial lawyers out there. I want to make it so risky and expensive for non-physicians to practice independently because I think the solution to non-physicians wanting autonomy is in the marketplace and not laws. Even though I have a license to practice medicine and surgery, I know better than to do surgery on patients. Likewise, let NP's and PA's go independent. A clear and loud message will be sent to them and their insurance companies after a few of them are taken to court and handed huge settlements. You already see this with high liability in ob and midwives. You may see 99 routines cases and the 100th could bankrupt you. That high liability system needs to be extended to all non-physicians who want to practice autonomously. That's why physicians should point out malpractice to patients when they see it. That's why if NP's and PA's want to go independent then physicians should steer clear away from them so they don't hit by liability accusations.

From this quote, it seems less that Taurus is "fear-mongering" as providing what he feels to be accurate interpretation of what the organizations that represent NP's are lobbying to do to the healthcare industry. They are in a unique position in which they hold pole position, and they're exploiting their power so that they can match doctors. Why the hell would anyone become a doctor when they can just become an NP and do the same thing as a doctor while making the same or more money? Why spend 8 years when you can spend 3?

 

[fab4fan]

From this quote, it seems less that Taurus is "fear-mongering" as providing what he feels to be accurate interpretation of what the organizations that represent NP's are lobbying to do to the healthcare industry. They are in a unique position in which they hold pole position, and they're exploiting their power so that they can match doctors. Why the hell would anyone become a doctor when they can just become an NP and do the same thing as a doctor while making the same or more money? Why spend 8 years when you can spend 3?

Taurus's posts depend more on hyperbole than reality, something you'd know if you'd been around long enough to have the misfortune of reading his never-ending rants.

You should spend the 8 years because you'll be better educated than a mid-level provider. Most nurses know this. Taurus takes quotes from fringe members of nursing like Mundinger and spouts them as if everyone in nursing believes her words to be gospel. If fact, in most circles, she's thought a fool.