Nurse Practioners encroaching upon Physician territory?

buuuuuuuuuuuuuuuuuuuulzhit.

Take a few business/econ/management sections, okay? It'll come in handy.

For now, annoy your legislators into NOT promulgating this nonsense.

I think the education of nurse practitioners is too variable to be able to replace the skills of a physician.

Amen brother. Why this has never been brought up before? I don't know.

schrizto said:

I think the education of nurse practitioners is too variable to be able to replace the skills of a physician.

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the education of a "physician" is variable as well. i don't even know what a physician is any more

bleargh said:

the education of a "physician" is variable as well. i don't even know what a physician is any more

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Just look to see if there are MD/DO at the end of their name


Nurse Practitioner are there to take care of the minor stuff, like handing out prescription for a cold or flu, etc. But they still have to consult with the doctor or even bring the doctor in to the case if they want to any other drastic procedure.

The shriner hospital clinic where i volunteer at there is 1 orthopedic doc and 4 nurse practitioners. they do all the little things (see all the minor cases) that save the doc alot of time

bleargh said:

the education of a "physician" is variable as well. i don't even know what a physician is any more

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What I meant is that all doctors go through four years of medical school.

I think it would be a good idea to utilize the resources that they provide (why not? they want to help, let them), but I don't agree with expanding their scope of practice.

bleargh said:

the education of a "physician" is variable as well. i don't even know what a physician is any more

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That's not true. If you look at the curricula of all the medical schools in the US, they pretty much teach the same things (a few minor differences exist between allopathic and osteopathic schools, but look at the general picture). Pretty much the same subjects, the same core clerkships, etc. are taught and the licensing exams are pretty standardized. So the education of a physician is not variable. I don't know enough about NP schools to comment on their curricula but I think you can get an NP online; you can't go to medical school online.

Kaushik said:

That's not true. If you look at the curricula of all the medical schools in the US, they pretty much teach the same things (a few minor differences exist between allopathic and osteopathic schools, but look at the general picture). Pretty much the same subjects, the same core clerkships, etc. are taught and the licensing exams are pretty standardized. So the education of a physician is not variable. I don't know enough about NP schools to comment on their curricula but I think you can get an NP online; you can't go to medical school online.

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what about those outside? and i don't think you can get an NP online. that seems patently ridiculous.

bleargh said:

what about those outside? and i don't think you can get an NP online. that seems patently ridiculous.

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Why does it matter what medical schools outside the US are doing? That's a completely different issue.

My understanding is that NP's need a masters or doctoral degree AS WELL AS board certification, so why does this variability of education come in when they can perform well on a standardized test that is designed to demonstrate their abilities?

I feel like I've known many NPs who are both incredibly skilled and have a wealth of experience. I understand why they can't just become surgeons, but I don't see why they cannot have a status similar to primary care physicians.

If you're talking about the disparity between the cost of education for doctors vs. nurses, well, shouldn't you be addressing that instead?

Narmerguy said:

Why does it matter what medical schools outside the US are doing? That's a completely different issue.

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no it's not as many of them come to the US to practice. i won't even get into the extremely variable residency education as well.

Narmerguy said:

Why does it matter what medical schools outside the US are doing? That's a completely different issue.

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This. We're talking about US med schools and NPs, not of other countries. Of course there might be a few differences in education in any subject in different countries.

And you can get an NP online. Here's an example: http://www.indstate.edu/distance/fnp_specialization.html

"All courses are delivered via the Internet. Clinicals can be arranged in the student's community."

futile, I don't know what you mean they can perform well on a standardized test. Do you mean something like the USMLE? I don't know of any tests that NPs/DNPs take that are anywhere near the difficulty of the USMLE exams. Some DNPs from Columbia University (supposedly one of the best DNP programs) took a very watered down version of Step 3 (which according to many residents/attendings I've talked to is the easiest Step to take and doesn't require that much studying) and only 50% passed. If the cream of the crop of DNPs (which requires you to be an NP) couldn't pass a watered down version of the easiest Step exam, how can you be sure that they will perform equivalent to physicians in the real world? As a resident mentioned in a different thread, "substandard primary care is easy to do, but providing good primary care is hard to do" (or something along those lines).

I absolutely agree that there are some great NPs and PAs out there; I have met several of them. But that n = few does not mean that every PA and NP out there is as spectacular as the ones I've met.

bleargh said:

no it's not as many of them come to the US to practice. i won't even get into the extremely variable residency education as well.

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The variances in residency training that I know of involve different locations and thus, different patient profiles. But I think there is some standard in residency training as well. I'm not completely sure but I think I remember reading somewhere that a certain number of procedures, etc. must be done in order to graduate. Plus, to become an attending, there's the Boards near the end of residency that are supposed to be very hard. These are standardized as well. And IMGs are required to do a residency no matter how long they were attendings for in their respective countries in order to practice in the US.

As I understand from both docs & school officials, the concern w NPs has less to do w/ their training than their mindset. Simply, NPs are nurses 1st and most struggle with the transition to medical practitioner/provider from nursing provider. Other medical providers such as PAs and even, to a degree, EMTs & paramedics are trained 1st as diagnosticians and medical providers, which is similar to a dr's mindset (hence, they make good MD candidates in the case of EMTs or function well as assts to physicians in the case of PAs. NPs, OTH, are trained 1st to provide a different kind of care & often to think less diagnostically and make their own assessments independent of a medical provider. This mindset often stands in the way of their effectiveness as NPs. (This is coming from a number if physicians each w/ decades' of experience supervising and/or training NPs, PAs, MDs & DOs.) This is also why, in terms of clinical experience, some med schools will tell you EMT-B>>>>>>>>>>>>>CNA....

I say, give a backhand right across the face to the next b****-a** nurse who thinks she can come and treat a patient over you (a physician). That'd teach her (or him) to stay in her (or his) place.

apumic said:

As I understand from both docs & school officials, the concern w NPs has less to do w/ their training than their mindset. Simply, NPs are nurses 1st and most struggle with the transition to medical practitioner/provider from nursing provider. Other medical providers such as PAs and even, to a degree, EMTs & paramedics are trained 1st as diagnosticians and medical providers, which is similar to a dr's mindset (hence, they make good MD candidates in the case of EMTs or function well as assts to physicians in the case of PAs. NPs, OTH, are trained 1st to provide a different kind of care & often to think less diagnostically and make their own assessments independent of a medical provider. This mindset often stands in the way of their effectiveness as NPs. (This is coming from a number if physicians each w/ decades' of experience supervising and/or training NPs, PAs, MDs & DOs.) This is also why, in terms of clinical experience, some med schools will tell you EMT-B>>>>>>>>>>>>>CNA....

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I'm honestly confused by this, but it is an interesting statement so could you maybe explain it a little bit more? You say that EMTs and paramedics are trained as diagnosticians and medical providers. Then, you say that Nurse Practitioners are trained to provide a "different kind of care". What is this "different kind of care?" Because they are always going to the doctors to sign off on prescriptions? Because that just sounds like red tape to me.

icevermin said:

http://news.yahoo.com/s/time/20090803/us_time/08599191422200

Points of interest:

But there is an existing group of providers that health reformers are hoping can help fill this gap: nurse practitioners. Depending on the state in which they practice, nurse practitioners, with advanced training often including master's degrees in nursing, can often treat and diagnose patients, as well as prescribe medication. And they can do these things at a lower cost than doctors - Medicare, for example, reimburses nurse practitioners 80% of what is paid to doctors for the same services.


In addition to providing many of the same services more cheaply, nurse practitioners offer something else that makes them darlings to health reformers: a focus on patient-centered care and preventive medicine. "We seem to be health care's best-kept secret," says Jan Powers, health-policy director for the Academy of Nurse Practitioners. Nurse practitioners may have less medical education than full-fledged doctors, but they have far more training in less measurable skills like bedside manner and counseling.

What to think of this? I really don't appreciate the way this is moving

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It's a slap in the face for primary care physicians. This will encourage medical students to enter highly specialized fields since primary care physicians are being squeezed out.

futile said:

I'm honestly confused by this, but it is an interesting statement so could you maybe explain it a little bit more? You say that EMTs and paramedics are trained as diagnosticians and medical providers. Then, you say that Nurse Practitioners are trained to provide a "different kind of care". What is this "different kind of care?" Because they are always going to the doctors to sign off on prescriptions? Because that just sounds like red tape to me.

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I believe that in several states, NPs can practice independently without the need for physician supervision. That's the scary part because they do not have the same training as physicians (who have four years of med school + a minimum of three years of residency training before they're allowed to practice independently).

There are also several direct-entry NP programs that don't require any healthcare experience beforehand. You can graduate from these programs in 2-3 years and become an independent practitioner once you graduate. That's kinda scary when you consider that physicians require nearly a decade of training and thousands of clinical hours where they're practicing medicine (not nursing) under supervision before they're allowed to practice independently.

Kaushik said:

I believe that in several states, NPs can practice independently without the need for physician supervision. That's the scary part because they do not have the same training as physicians (who have four years of med school + a minimum of three years of residency training before they're allowed to practice independently).

There are also several direct-entry NP programs that don't require any healthcare experience beforehand. You can graduate from these programs in 2-3 years and become an independent practitioner once you graduate. That's kinda scary when you consider that physicians require nearly a decade of training and thousands of clinical hours where they're practicing medicine (not nursing) under supervision before they're allowed to practice independently.

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This is what will happen. NP's will corner the market for the medically uncomplicated patients and be paid 80% of that of primary care physicians while the primary care physicians will be left seeing the more medically complicated patients for 25% higher pay. This increase will, however, be offset by the higher malpractice insurance premiums. So in the end the primary care physicians will still see the same number of patients but the complexity will increase quite a bit and the NP's will earn 80% of the doctor's income and have an easier lifestyle.

Kaushik said:

I believe that in several states, NPs can practice independently without the need for physician supervision. That's the scary part because they do not have the same training as physicians (who have four years of med school + a minimum of three years of residency training before they're allowed to practice independently).

There are also several direct-entry NP programs that don't require any healthcare experience beforehand. You can graduate from these programs in 2-3 years and become an independent practitioner once you graduate. That's kinda scary when you consider that physicians require nearly a decade of training and thousands of clinical hours where they're practicing medicine (not nursing) under supervision before they're allowed to practice independently.

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I totally understand your point. It is really important to have a highly qualified professional as a gatekeeper for medical care. At the same time, I feel like it's kind of insulting not to allow NPs with a lot of experience and education to practice medicine independently (especially with a Ph.D.). I can definitely understand different requirements in training, especially with regards to time performing certain procedures and requiring board certification for all independently practicing NPs. I can also understand the frustration at the cost of medical school.

I don't know if doctors can stop the snowballing effect of more and more NPs fulfilling the roles of family doctors. I honestly haven't seen an actual doctor for my primary care in years. This is a complicated issue. We are running out of PCPs because fewer doctors out of medical school can afford to go into family care, and at the same time nurses are gaining more power and placements within clinics.

TopSecret said:

This is what will happen. NP's will corner the market for the medically uncomplicated patients and be paid 80% of that of primary care physicians while the primary care physicians will be left seeing the more medically complicated patients for 25% higher pay. This increase will, however, be offset by the higher malpractice insurance premiums. So in the end the primary care physicians will still see the same number of patients but the complexity will increase quite a bit and the NP's will earn 80% of the doctor's income and have an easier lifestyle.

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Yeah, the pay really should be directly related to the complexity and skillset. Don't most primary care clinics have set office times, though? Why do the nurses have an easier lifestyle?

I hope you don't think I'm just trying to be argumentative. I'm really interested in this subject and I feel like people on these forums have a lot of good insight. I know a lot of nursing students, too, and I rarely if ever get to see them because they're always working, going to school, or doing clinicals.

TopSecret said:

This is what will happen. NP's will corner the market for the medically uncomplicated patients and be paid 80% of that of primary care physicians while the primary care physicians will be left seeing the more medically complicated patients for 25% higher pay. This increase will, however, be offset by the higher malpractice insurance premiums. So in the end the primary care physicians will still see the same number of patients but the complexity will increase quite a bit and the NP's will earn 80% of the doctor's income and have an easier lifestyle.

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No mention blame on the AMA and the shortage of MDs? The NP model works financially IF and WHEN there are enough doctors to go around. As there aren't, NPs are going to take on more and more responsibilities and get better reimbursement as there is simply no one vying for the position. Granted big cities are a different arguement, but not rural US. Look at what the CRNAs have done to anesthesia in small towns...

We really need to address the MD shortage before we get upset at what other positions in the medical community are doing, IMO.

futile said:

Yeah, the pay really should be directly related to the complexity and skillset. Don't most primary care clinics have set office times, though? Why do the nurses have an easier lifestyle?

I hope you don't think I'm just trying to be argumentative. I'm really interested in this subject and I feel like people on these forums have a lot of good insight. I know a lot of nursing students, too, and I rarely if ever get to see them because they're always working, going to school, or doing clinicals.

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Nurses work hard but do you want them to replace MD's? That's what happening. The NP's will siphon off the medically uncomplicated patients and leave the challenging patients for the MD's. The volume of patients and the pay will likely remain the same for MD's but the complexity of each patient will increase and so will the liability insurance premiums.

futile said:

I'm honestly confused by this, but it is an interesting statement so could you maybe explain it a little bit more? You say that EMTs and paramedics are trained as diagnosticians and medical providers. Then, you say that Nurse Practitioners are trained to provide a "different kind of care". What is this "different kind of care?" Because they are always going to the doctors to sign off on prescriptions? Because that just sounds like red tape to me.

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I left my statement somewhat ambiguous so as not to insult any NPs who might be reading this thread. As I am not a nurse myself nor am I an MD/DO, I don't really feel qualified to try and explain or define an NP's traditional or trained-for role in medicine. My understanding, though, is that NPs tend to remain "stuck" in their mindsets as nurses. Physicians have told me it seems to have to do with a more "nursing-minded" than "diagnosis-minded" approach. I suspect what is meant by these statements is along the lines of what you are describing as "only red tape" but that these physicians perceive it to extend beyond just "red tape" (perhaps it started as only that but nurses are trained from the beginning to think from a different mindset than doctors and so it is likely that what may appear to be red tape to someone outside that system is a much deeper self-limiting thought process). That is, they often do not seem to be able to think for themselves in a medical manner. I am told that some NPs are successful in becoming medical practitioners and crossing this line; however, many/most basically end up as "advanced practice nurses" instead of "nurse practitioners."

Does clear things up a bit for you?

And then there's the training issue... We have a Psych NP on these forums somewhere who can tell you all about that. She's actually far better trained than any Psych NP I've interacted with as she has a PhD in Clinical Psych (and has stated she got basically nothing but psychopharm training as an NP -- all her therapy training is from the PhD, so the Psych NP alone is really about as good as getting your Lithium from your GP/FP, which is just a generally bad idea all-around! ...And offers no therapeutic training whatsoever, which is also not going to be helpful to psych px.)

...And don't even get me started on the idea of online medical training or giving someone a 3-year intensive program that takes a BA in History and makes them a masters-level NP in 3 years full-time study (yes, these programs include a BSN on the way AND specialty training). No wonder everyone wants to be an NP! At least PA school has pre-reqs that include years of healthcare experience (most require a minimum of 2000+ hours + a good two years' worth of bio and chem pre-reqs that are much more thorough than those of the med schools).

TopSecret said:

Nurses work hard but do you want them to replace MD's? That's what happening. The NP's will siphon off the medically uncomplicated patients and leave the challenging patients for the MD's. The volume of patients and the pay will likely remain the same for MD's but the complexity of each patient will increase and so will the liability insurance premiums.

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I think the term "MDs" is kind of general here. I don't see anything going in the direction of nurses replacing surgeons, and specialties within internal medicine, but I DO see nurses in the process of replacing a lot of the functionality within internal medicine and family practice. I agree that the shortage of doctors especially in the lower-paying fields has a huge impact on this issue.

This just feels uncomfortably like a "class" issue. In engineering companies often the most skilled workers get promoted to managers, but it is a completely different story in medicine. I understand that this is because it is a matter of human life, but at the same time why are we judging that 4 years of education + 3 years residency is more valuable than 6+ years of education/clinicals + years of experience? If NPs are practicing by themselves after 2-3 years of unaccredited education, this is of course an issue, but if you have a nurse with a Ph.D. with 10+ years of direct experience, why can't we allow them some autonomy?

And to address your statement directly, the pay for family care physicians is already not enough to attract more doctors in this field. I feel like GP's are disappearing, not only because of a lack of MDs going through school but also because fewer MDs can afford to go into family care and even internal medicine. This is a huge issue, and it removes quality care from patients and communities. At the same time, I am having a hard time understanding the functional difference between a highly trained nurse practitioner and a family care doctor. Please note the distinction between licensing in an inordinately small amount of time and the education and qualifications of a nurse who has been practicing for a long time. I fully accept that there is a lot about this I don't know, and any information you can give me would be incredibly helpful in my understanding.

apumic said:

I left my statement somewhat ambiguous so as not to insult any NPs who might be reading this thread. As I am not a nurse myself nor am I an MD/DO, I don't really feel qualified to try and explain or define an NP's traditional or trained-for role in medicine. My understanding, though, is that NPs tend to remain "stuck" in their mindsets as nurses. Physicians have told me it seems to have to do with a more "nursing-minded" than "diagnosis-minded" approach. I suspect what is meant by these statements is along the lines of what you are describing as "only red tape" but that these physicians perceive it to extend beyond just "red tape" (perhaps it started as only that but nurses are trained from the beginning to think from a different mindset than doctors and so it is likely that what may appear to be red tape to someone outside that system is a much deeper self-limiting thought process). That is, they often do not seem to be able to think for themselves in a medical manner. I am told that some NPs are successful in becoming medical practitioners and crossing this line; however, many/most basically end up as "advanced practice nurses" instead of "nurse practitioners."

Does clear things up a bit for you?

And then there's the training issue... We have a Psych NP on these forums somewhere who can tell you all about that. She's actually far better trained than any Psych NP I've interacted with as she has a PhD in Clinical Psych (and has stated she got basically nothing but psychopharm training as an NP -- all her therapy training is from the PhD, so the Psych NP alone is really about as good as getting your Lithium from your GP/FP, which is just a generally bad idea all-around! ...And offers no therapeutic training whatsoever, which is also not going to be helpful to psych px.)

...And don't even get me started on the idea of online medical training or giving someone a 3-year intensive program that takes a BA in History and makes them a masters-level NP in 3 years full-time study (yes, these programs include a BSN on the way AND specialty training). No wonder everyone wants to be an NP! At least PA school has pre-reqs that include years of healthcare experience (most require a minimum of 2000+ hours + a good two years' worth of bio and chem pre-reqs that are much more thorough than those of the med schools).

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Thanks, this is really awesome. I really appreciate you taking the time to explain this to me.

I agree that there is a huge emphasis on problem solving as a medical student. I feel like that's the main reason why the verbal reasoning section on the MCAT is important even for someone BEFORE they go into medical school. I haven't ever thought that NPs should just automatically be doctors out of nursing school, but I've always wondered why there is no way to "climb the ladder" so to speak as a nurse without beginning your education again.

futile said:

Thanks, this is really awesome. I really appreciate you taking the time to explain this to me.

I agree that there is a huge emphasis on problem solving as a medical student. I feel like that's the main reason why the verbal reasoning section on the MCAT is important even for someone BEFORE they go into medical school. I haven't ever thought that NPs should just automatically be doctors out of nursing school, but I've always wondered why there is no way to "climb the ladder" so to speak as a nurse without beginning your education again.

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I don't think it's that there's "no way" to do it, but that the mindset is different. It's the same way if you work in a job and then change positions. Some people adapt better than others but I know I've always found it very difficult to go back "down" the ladder (i.e., from managing people or being an administrator in a program to a lower responsibility position due to downsizing or a seasonal job, for instance). It's simply that adapting to the new restraints of the "lower" position is a difficult transition to make (at least for me). I suspect that it's a similar thing for many nurses when they get this add'l trng to be NPs. Their new responsibilities are so different that they can't really rely upon their past nursing experience. As a result, physicians and other healthcare providers as well as those medical practitioners training NPs become frustrated with the NP's apparent lack of initiative, creativity, and problem-solving capabilities and, as a result, a cycle of poor performance-->poor reviews<-->worse performance begins that ultimately doesn't help the NP improve but is the natural progression when one repeatedly fails to live up to the expectations of direct supervisors. Of course, this cycle is avoided by some NPs but a good number likely fall into such a cycle that ultimately results in them being viewed and utilized as nothing more than an experienced nurse with a few extra legal abilities (i.e., can write a script, at least in theory). All-in-all, I think it's certainly possible for an NP to be trained and legitimately function similarly to a physician, but it does not seem to be the norm. Nursing and medicine generally attract two different types of people and, as a result, those who go into nursing are often not really good fits for medicine (hence why they chose nursing in the first place). The truth is that such a structure of physicians>nurses is somewhat inherent in the job descriptions. Physicians are generally responsible for the planning and gross execution of treatment plans, whereas nurses are generally responsible for the more fine execution of that treatment plan and for giving input on the planning of treatment. The physicians' job, by nature, requires more of the initiative and creative problem-solving aspects. Medicine, believe it or not, is fairly right-brained, whereas nursing is more left-brained in some respects. The physician needs to think "big picture" whereas the nurse needs to think more in details to ensure the physician's tx plan is properly executed. There is simply a difference in the job descriptions that requires more nurses than physicians (you don't need a whole bunch of people taking primary responsibility for each px; you need 1 such de facto case/treatment manager and a few others who carry out the plan of that managing individual and it makes sense that that managing individual is the highest-trained person with the best creative problem-solving ability and widest & most thorough knowledge of human anatomy & physiology and the [potential] effects of various drugs, drug interactions, therapies, procedures, etc. and the interactions of these on each part of the body so as to avoid future problems with the tx plan).

apumic said:

I don't think it's that there's "no way" to do it, but that the mindset is different. It's the same way if you work in a job and then change positions. Some people adapt better than others but I know I've always found it very difficult to go back "down" the ladder (i.e., from managing people or being an administrator in a program to a lower responsibility position due to downsizing or a seasonal job, for instance). It's simply that adapting to the new restraints of the "lower" position is a difficult transition to make (at least for me). I suspect that it's a similar thing for many nurses when they get this add'l trng to be NPs. Their new responsibilities are so different that they can't really rely upon their past nursing experience. As a result, physicians and other healthcare providers as well as those medical practitioners training NPs become frustrated with the NP's apparent lack of initiative, creativity, and problem-solving capabilities and, as a result, a cycle of poor performance-->poor reviews<-->worse performance begins that ultimately doesn't help the NP improve but is the natural progression when one repeatedly fails to live up to the expectations of direct supervisors. Of course, this cycle is avoided by some NPs but a good number likely fall into such a cycle that ultimately results in them being viewed and utilized as nothing more than an experienced nurse with a few extra legal abilities (i.e., can write a script, at least in theory). All-in-all, I think it's certainly possible for an NP to be trained and legitimately function similarly to a physician, but it does not seem to be the norm. Nursing and medicine generally attract two different types of people and, as a result, those who go into nursing are often not really good fits for medicine (hence why they chose nursing in the first place). The truth is that such a structure of physicians>nurses is somewhat inherent in the job descriptions. Physicians are generally responsible for the planning and gross execution of treatment plans, whereas nurses are generally responsible for the more fine execution of that treatment plan and for giving input on the planning of treatment. The physicians' job, by nature, requires more of the initiative and creative problem-solving aspects. Medicine, believe it or not, is fairly right-brained, whereas nursing is more left-brained in some respects. The physician needs to think "big picture" whereas the nurse needs to think more in details to ensure the physician's tx plan is properly executed. There is simply a difference in the job descriptions that requires more nurses than physicians (you don't need a whole bunch of people taking primary responsibility for each px; you need 1 such de facto case/treatment manager and a few others who carry out the plan of that managing individual and it makes sense that that managing individual is the highest-trained person with the best creative problem-solving ability and widest & most thorough knowledge of human anatomy & physiology and the [potential] effects of various drugs, drug interactions, therapies, procedures, etc. and the interactions of these on each part of the body so as to avoid future problems with the tx plan).

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Sure, I understand. This puts into sharp relief the need for more doctors in primary care and general practice. SireSpanky had a really good point.

Kaushik said:

futile, I don't know what you mean they can perform well on a standardized test. Do you mean something like the USMLE? I don't know of any tests that NPs/DNPs take that are anywhere near the difficulty of the USMLE exams. Some DNPs from Columbia University (supposedly one of the best DNP programs) took a very watered down version of Step 3 (which according to many residents/attendings I've talked to is the easiest Step to take and doesn't require that much studying) and only 50% passed. If the cream of the crop of DNPs (which requires you to be an NP) couldn't pass a watered down version of the easiest Step exam, how can you be sure that they will perform equivalent to physicians in the real world? As a resident mentioned in a different thread, "substandard primary care is easy to do, but providing good primary care is hard to do" (or something along those lines).

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Okay, I think I was being ambiguous here, because I don't think in any sense that all nurses should have the opportunity to become doctors, just that there should be some way for experienced and skilled nurses to have the autonomy of a doctor and I don't think that is "encroaching on territory". Nurses have their own boards, which I know are not as difficult as the boards for MD, and I understand and even expect further certification for nurses in higher roles.

Basically, it's not that lower 50% that I am interested in, but that upper tier that performs well but just didn't have the opportunity to go to medical school for whatever reason and switched to nursing because of a passion for patient care. I know at least a handful of technicians at my work who have been promoted to engineers even without a bachelor's degree because they are highly skilled and have demonstrated an ability to problem solve and perform in their work as well as an engineer. I think that "demonstration" for nurses would have to be accredited and tested on a national level to ensure quality care.

I realize this is idealistic and hypothetical, but this topic has always confused me. Regardless, I really feel enlightened by all the responses I've been getting. This conversation has, at the very least, deepened my understanding of the issue.

TopSecret said:

It's a slap in the face for primary care physicians. This will encourage medical students to enter highly specialized fields since primary care physicians are being squeezed out.

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I don't think it's a slap in the face. I think it's more of a relief. There is a primary care physician deficit, and that's because medicine itself has evolved into a more specialized practice.

I think that NPs and PAs are uniquely suited to filling the Primary Care gap. I think that they'll save insurance companies and taxpayers a LOT of money. And they'll free me up to do what I love to do: hospital medicine.

Now, there's a particular nurse administrator at a hospital system near me, that thinks that PA=MD-$$. This nurse administrator, who is a VP, is pressuring our small community hospital to staff the night shift with ONLY a PA to cover our hospital patients.

PAs and NPs are not doctors. They do not equal doctors. However, for the primary care of healthy people, or people with one or two minor, chronic problems, I think that they are well suited to manage these patients with a minimum of oversight. Anything more complicated should be referred to a higher level physician.

And, in my experience, most mid-levels do know when they've hit their care limit.

Personally, I see my doctor about once every five years. For pre-natal care, I see a midwife. In my experience, doctors tend to over treat and over prescribe in a primary care setting. When I go to a hospital, however, I want a f**king doctor. Anything else is a waste of my time, money, and health.

aylaanne said:

I don't think it's a slap in the face. I think it's more of a relief. There is a primary care physician deficit, and that's because medicine itself has evolved into a more specialized practice.

I think that NPs and PAs are uniquely suited to filling the Primary Care gap. I think that they'll save insurance companies and taxpayers a LOT of money. And they'll free me up to do what I love to do: hospital medicine.

Now, there's a particular nurse administrator at a hospital system near me, that thinks that PA=MD-$$. This nurse administrator, who is a VP, is pressuring our small community hospital to staff the night shift with ONLY a PA to cover our hospital patients.

PAs and NPs are not doctors. They do not equal doctors. However, for the primary care of healthy people, or people with one or two minor, chronic problems, I think that they are well suited to manage these patients with a minimum of oversight. Anything more complicated should be referred to a higher level physician.

And, in my experience, most mid-levels do know when they've hit their care limit.

Personally, I see my doctor about once every five years. For pre-natal care, I see a midwife. In my experience, doctors tend to over treat and over prescribe in a primary care setting. When I go to a hospital, however, I want a f**king doctor. Anything else is a waste of my time, money, and health.

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Physicians are trained to recognize red flags, etc. I don't think that NPs are trained enough to be able to recognize these with comfort. Sure, NPs/PAs can manage the healthy and the very minorly (yes I made that up) ill person but what if they miss a red flag for something more threatening? How will they know when something more complicated is occuring in the patient and needs to be referred to a physician when they're not trained to look for all red flags as a physician is?

And NPs do not really save money. I think Medicare reimburses NPs at 80% the rate of physicians. And a vocal group of DNPs, led by Mary Mundinger, is trying to get equal rates of reimbursements as doctors. So I don't really see how having NPs become PCPs is going to save money.

Take away points from 1358695 other threads on this subject:

.NPs only know the algorithms, just like CRNAs.
.A very very small but vocal minority of nurses want to do anything but bedside.
.The political bodies pushing for nurses to equal physicians will not stop with primary care.
.Physicians have no such political body. Whiny AMA folks, yes.
.The nursing political body insists that its constituents are equal --if not superior-- at graduation from a BSN/part-time 2-yr track/ 1 yr in the ICU to a 30+ yrs attending who has seen it all.

Nurses replacing physicians is a bad, bad, bad, bad idea. Nursing will not be reined in, now that it has had a taste of power. (A la the chiros; and/or dentistry and hygenists.)

PAs and AAs aren't the greatest but at least they are under the Board of Medicine.


(See also, degree creep. AKA why is everyone a doctor of something?)

adeline said:

Take away points from 1358695 other threads on this subject:

.NPs only know the algorithms, just like CRNAs.
.A very very small but vocal minority of nurses want to do anything but bedside.
.The political bodies pushing for nurses to equal physicians will not stop with primary care.
.Physicians have no such political body. Whiny AMA folks, yes.
.The nursing political body insists that its constituents are equal --if not superior-- at graduation from a BSN/part-time 2-yr track/ 1 yr in the ICU to a 30+ yrs attending who has seen it all.

Nurses replacing physicians is a bad, bad, bad, bad idea. Nursing will not be reined in, now that it has had a taste of power. (A la the chiros; and/or dentistry and hygenists.)

PAs and AAs aren't the greatest but at least they are under the Board of Medicine.


(See also, degree creep. AKA why is everyone a doctor of something?)

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you have a lot of strong opinions but not a ton of relevant support.

bleargh said:

you have a lot of strong opinions but not a ton of relevant support.

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just summing up the 952085209095 arguments already hashed out. Save time to argue instead of doing a search. My usual boards are super quiet tonight.

bleargh said:

you have a lot of strong opinions but not a ton of relevant support.

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This has been argued to death in other threads, so I guess he was just summing up the data. There are mountains of "relevant support" posted by residents and attendings in the Topics in Healthcare forum.

Strongly oppose nurse practitioner.

bleargh said:

you have a lot of strong opinions but not a ton of relevant support.

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A few articles regarding DNPs:

http://online.wsj.com/public/article_print/SB120710036831882059.html
"More than 200 nursing schools have established or plan to launch doctorate of nursing practice programs to equip graduates with skills the schools say are equivalent to primary-care physicians. The two-year programs, including a one-year residency, create a "hybrid practitioner" with more skills, knowledge and training than a nurse practitioner with a master's degreehttp://allnurses.com/#, says Mary Mundinger, dean of New York's Columbia University School of Nursing. She says DNPs are being trained to have more focus than doctors on coordinating care among many specialists and health-care settings..."

http://www.forbes.com/2007/11/27/nurses-doctors-practice-oped-cx_mom_1128nurses.html
"DNPs are the ideal candidates to fill the primary-care void and deliver a new, more comprehensive brand of care that starts with but goes well beyond conventional medical practice. In addition to expert diagnosis and treatment, DNP training places an emphasis on preventive care, risk reduction and promoting good health practices. These clinicians are peerless prevention specialists and coordinators of complex care. In other words, as a patient, you get the medical knowledge of a physician, with the added skills of a nursing professional...
...To that end, we are working to enable DNPs to take standardized exams similar in content and format to the test that physicians must pass to earn their M.D. degrees. By allowing DNPs to take this test, the medical establishment will give patients definitive evidence that these skilled clinicians have the ability to provide comprehensive care indistinguishable from physicians..."

http://www.ama-assn.org/amednews/2009/06/08/prl10608.htm

'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."'

Hmm..."peerless prevention specialists" and "more focus than doctors...?" And the last quote was regarding DNPs taking a watered down version of the Step 3 and having a 50% pass rate. It looks like DNPs do want be doctors, but don't want to go through the extensive training. I know these articles are regarding DNPs but I believe I read somewhere that NPs are required to become DNPs by 2015 or something like that, so it applies to NPs as well.

And like someone else mentioned, once NPs get a foot in primary care, who is to say that they won't want more? They'll likely try to encroach on other specialties like derm, etc. similar to how CRNAs are pushing to practice pain medicine (which is a subspecialty in medicine) after a weekend seminar, rather than a fellowship that physicians go through.

Anyone else hate slippery-slope arguments?

wanderer100 said:

Anyone else hate slippery-slope arguments?

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What I said isn't completely baseless though. Here's an example of CRNAs trying to bring interventional pain management under their scope of practice: http://www.asahq.org/Newsletters/2008/02-08/stateBeat02-08.html

"...Regarding training, plaintiffs asserted that the curricula of two weekend courses fail to demonstrate sufficient training in the field of chronic pain management procedures..."

It looks like CRNAs wanted to be able to do interventional pain procedures (which is a subspecialty) with 2 weekend courses as their training.

And the whole push of DNPs to be recognized as equivalent to doctors and wanting equal reimbursements as doctors shows that they are trying to get their foot into medicine more and more. If they're recognized as PCPs (ie. as equivalent to family practitioners), how can you say they're equivalent to one type of physician but not another specialist if they have training?

So I'm not just saying this stuff randomly. There is somewhat of a trend towards midlevels wanting to practice more and more of what is traditionally under the scope of medicine.

wanderer100 said:

Anyone else hate slippery-slope arguments?

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I do. But this isn't a slippery-slope argument.

Kaushik said:

What I said isn't completely baseless though. Here's an example of CRNAs trying to bring interventional pain management under their scope of practice: http://www.asahq.org/Newsletters/2008/02-08/stateBeat02-08.html

"...Regarding training, plaintiffs asserted that the curricula of two weekend courses fail to demonstrate sufficient training in the field of chronic pain management procedures..."

It looks like CRNAs wanted to be able to do interventional pain procedures (which is a subspecialty) with 2 weekend courses as their training.

And the whole push of DNPs to be recognized as equivalent to doctors and wanting equal reimbursements as doctors shows that they are trying to get their foot into medicine more and more. If they're recognized as PCPs (ie. as equivalent to family practitioners), how can you say they're equivalent to one type of physician but not another specialist if they have training?

So I'm not just saying this stuff randomly. There is somewhat of a trend towards midlevels wanting to practice more and more of what is traditionally under the scope of medicine.

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I acknowledge the fact that your argument has its basis, and I agree with your statement that nurses are trying to be considered more doctorlike. However, it's really impossible to know one way or another whether they'll keep on pushing forwards with their attempts. In any case, nurse practitioners don't do half the **** that PCPs do (like making tough diagnoses), so I don't think we'll be seeing nurse radiologists anytime soon.

wanderer100 said:

I acknowledge the fact that your argument has its basis, and I agree with your statement that nurses are trying to be considered more doctorlike. However, it's really impossible to know one way or another whether they'll keep on pushing forwards with their attempts. In any case, nurse practitioners don't do half the **** that PCPs do (like making tough diagnoses), so I don't think we'll be seeing nurse radiologists anytime soon.

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It doesn't matter if NPs don't do half the stuff PCPs do. If their movement succeeds, they will be seen as equivalent to PCPs by the general public. A lay person wouldn't understand the differences in training between NPs and physicians. And regarding your statement about nurse radiologists, I got this article when I googled "NP radiology." http://findarticles.com/p/articles/mi_qa3958/is_200308/ai_n9288829/ It's an old article and I don't know how much relevancy there is to it in the present. But it seems to be arguing for NPs being allowed to do certain IR procedures.

bleargh said:

what about those outside? and i don't think you can get an NP online. that seems patently ridiculous.

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Oh but you can get both an NP (masters) and a DNP (doctorate) almost entirely online. You can get a doctor of nursing practice (? doctor of nurse practitioning) without having to set foot more than a few times on campus. All of it is done online.

Dont get me started on their curriculum. First it is only around 80 credits for a "doctorate" which is under 3 years of coursework. Furthermore about 1/3 of those 80 credits are worthless fluff courses that have nothing to do with clinical education. Things like nursing activism, health policy, advanced statistics, theories of leadership, philosophy of leadership clog the 80 credits so that only about 50-60 of them are courses like path, pharm etc.

The path and pharm only end up making a tiny, tiny portion of the education- about 1/10th at most. So, their foundations of pathophysiology and pharm is inadequate so they dont have the flexibility in treatment. This amounts to cookie-cutter medicine.

Their clinical education is obscene. Often they have to set up their "rotations" themselves instead of having very standardized rotations. This makes for very variable education. They also only do around 1000 clinical hours. For reference, in the first 3 months of my third year I had about the same amount of hours as the average DNP gets in their ENTIRE clinical doctorate. By the end of third year I had 3-4 times as many clinical hours as the average DNP. Add another year for med school and then at least 3 years of residency.

futile said:

I understand that this is because it is a matter of human life, but at the same time why are we judging that 4 years of education + 3 years residency is more valuable than 6+ years of education/clinicals + years of experience?

And to address your statement directly, the pay for family care physicians is already not enough to attract more doctors in this field. I feel like GP's are disappearing, not only because of a lack of MDs going through school but also because fewer MDs can afford to go into family care and even internal medicine. This is a huge issue, and it removes quality care from patients and communities. At the same time, I am having a hard time understanding the functional difference between a highly trained nurse practitioner and a family care doctor. Please note the distinction between licensing in an inordinately small amount of time and the education and qualifications of a nurse who has been practicing for a long time. I fully accept that there is a lot about this I don't know, and any information you can give me would be incredibly helpful in my understanding.

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The difference is the foundation. That is why during the first year, interns have no idea what is going on because they just have a solid foundation and are unsure how to fully implement it. By a few years of residency their clinical abilities dwarf even NPs with 15 years of experience. The NP just lacks the solid foundation.

Instead of just saying, "well we dont pay doctors enough to attract new med students, we should let NPs take over primary care" we should start paying PCPs more.

aylaanne said:

I think that NPs and PAs are uniquely suited to filling the Primary Care gap. I think that they'll save insurance companies and taxpayers a LOT of money. And they'll free me up to do what I love to do: hospital medicine.

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currently NPs and PAs get paid less but once they lobby and get increased autonomy they will tehn lobby for equal pay by saying that they do the same job they should get paid the same. The "savings" will eventually go away as their scope of practice comes in line with the PCPs.

So finally, we will have primary care done by people with less training but who get paid like a GP. Wonderful!

Omni said:

I say, give a backhand right across the face to the next b****-a** nurse who thinks she can come and treat a patient over you (a physician). That'd teach her (or him) to stay in her (or his) place.

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Is no one else appalled at this statement? What a complete overreaction.

No one seems to comprehend the fact that the rise of NP's is born of necessity. The article clearly states that there is a 30% shortage of GP's and because of the length of medical education there will be a long lag time before we see a significant increase in GP's. With the coming healthcare reform, the nation can't afford to bar NP's from filling the role of GP in areas that are under served.

Nevertheless, I would of course prefer that the primary care role is filled by PCP's but the reality of the sad state of American health care is that we have no option but to allow NP's to substitute.

sorry you guys, but most of you don't know the reality. my state is one of the ones that is very lax on these issues. NPs can work independent of a doctor here. for most of you, if you didn't know their title, you probably couldn't tell the difference between a NP and a primary care doctor. they can ask for 80% of a doctor for Medicare reimbursements.

NP can't even compare to a specialist, but they certainly can compare to a primary care doc. In states where you see a huge primary care shortage, you see mid-level providers (NPs and PAs) taking the roles of the PCP. the state law allows the mid-levels to do more to help combat that PCP shortage.

TexasFight said:

I do.

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I do too. But even worse, I hate pre meds on pedestals.

Anyway, getting back to discussing things we really know nothing about.

rocketbooster said:

sorry you guys, but most of you don't know the reality. my state is one of the ones that is very lax on these issues. NPs can work independent of a doctor here. for most of you, if you didn't know their title, you probably couldn't tell the difference between a NP and a primary care doctor. they can ask for 80% of a doctor for Medicare reimbursements.

NP can't even compare to a specialist, but they certainly can compare to a primary care doc. In states where you see a huge primary care shortage, you see mid-level providers (NPs and PAs) taking the roles of the PCP. the state law allows the mid-levels to do more to help combat that PCP shortage.

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Let me warn you guys not to drink the cool-aid. NPs were not born out of necessity. They were born out of ambition (NPs are not a new invention). The new DNP further supports this. If you were going to actually try and improve upon the NP model you would logically add foundation courses like more pathophysiology, pharmacology and microbiology as well as many more clinical hours. Instead, they tacked on 6 months of BS coursework and added the title "doctor" so that the NP could call him/herself doctor in the clinical setting. What a joke. Adding the title doctor to basically the same coursework just shows that those leading the NPs are more interested in titles than patient care. Were they really worried about patient care they would fill the vast holes in education with real coursework instead of BS courses.


You could make an argument that if the health care bill passes we will need more PCPs and NPs could fill this role. The problem is that once you allow NPs to be completely independent in all states, you can never go back. You will have ceded primary care to the midlevels. No medical student in his right mind would go into primary care with the knowledge that he could have just done it through 3 years of training instead of 6-7.

Despite the bad rep it gets, primary care is arguably the hardest specialty to do well. To actually do it right, you need a tremendous knowledge base that a midlevel just would not have.

Instatewaiter said:

Let me warn you guys not to drink the cool-aid.

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How can we? You already drank it all.

Instatewaiter said:

NPs were not born out of necessity.

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Right, cause there is clearly a HUGE interest in PC/FP today and we clearly have enough MDs in PC. That shortage you keep hearing about it just made up. Besides, nurses should never be more than bedside butt wipers.

Instatewaiter said:

They were born out of ambition (NPs are not a new invention).

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Nurses aren't supposed to be ambitious?? Silly me, only MDs are allowed to be ambitious.

Instatewaiter said:

The new DNP further supports this.

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I'm missing the correlation.

Instatewaiter said:

If you were going to actually try and improve upon the NP model you would logically add foundation courses like more pathophysiology, pharmacology and microbiology as well as many more clinical hours.

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For my BSN, which by the way was through a low tier state school, I was required to take biology with lab, chemistry with lab, statistics with lab, nutrition, growth and development, anatomy with lab, physiology, patho phys, pharmacology, and medical microbiology before even applying to the program (huge shocker, I know). After acceptance, I completed > 2500hrs of clinical work over the course of 2 years. This meant being at a clinical site Tuesdays and Thursdays at least 8-5. During my senior year, it was at least 40-50hrs week, M-F. All different settings. This is all before graduating with an undergraduate degree.

Instatewaiter said:

Instead, they tacked on 6 months of BS coursework and added the title "doctor" so that the NP could call him/herself doctor in the clinical setting.

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A DNP has to also posses a masters degree in a specific specialty. I do not know of any programs that allow BSNs, or any other people with degree's seeking entry level in the field, to get their DNPs in 6 months. For me to even get a masters, or NP, I would have to complete another two years, full time. And then at least another year for the full DNP. During this time, students have core classes, like acute area in the medial/surgical setting, etc., and clinical hours.

Please link me to the program that is only 6 months...I would be highly interested in this!!!

For clarification, here are some programs that you can complete online, but still, these are not for specialties (like anesthesia) and you still have to do clinical hours. And to whom ever made the comment that cant go to school onlie? PLEASE! Just search this forum for all the medical students who say they skipped pretty much the entire first two years. These same people admit to studying with notes posted online, etc. You cannot do clinical hours online and not one program, anywhere in this country, substitutes online clinical hours for real clinical hours. It just doesn't happen. period. And the program is still longer than 6 months.

Instatewaiter said:

What a joke.

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I missed the joke. Or was your post the joke? Cause it made me laugh. out loud. hard.

Instatewaiter said:

Adding the title doctor to basically the same coursework just shows that those leading the NPs are more interested in titles than patient care.

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Patient care is the cornerstone of nursing and nursing theory. duh.

Instatewaiter said:

Were they really worried about patient care they would fill the vast holes in education with real coursework instead of BS courses.

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Tell me again what you know about coursework..? Name a few core classes that BSNs take.

Instatewaiter said:

You could make an argument that if the health care bill passes we will need more PCPs and NPs could fill this role.

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We need PCPs, both NPs and MDs, NOW. forget after the bill passes.

Instatewaiter said:

The problem is that once you allow NPs to be completely independent in all states, you can never go back.

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Not always a bad thing. You know, sorta like, once you go black, you never go back....?

Instatewaiter said:

You will have ceded primary care to the midlevels. No medical student in his right mind would go into primary care with the knowledge that he could have just done it through 3 years of training instead of 6-7.

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In case you haven noticed, there aren't a bunch of medical students jumping at PC/FP anyway. And NPs and DNPs have 6-7 years of training. Thats 4 years for undergrad, and 2 years for masters = 6 years + more years for DNP = 7+ years. Pretty simple to comprehend...but keep pretending that they do it all in 6 months if thats what makes you feel better.

Instatewaiter said:

Despite the bad rep it gets, primary care is arguably the hardest specialty to do well.

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The first accurate statement in your post. I feel like I should quote it for truth. and then quote it again.

Instatewaiter said:

To actually do it right, you need a tremendous knowledge base that a midlevel just would not have.

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Yeah. All that education, I mean, the 6 years that it required me, all the maths and sciences, the core courses, the clinical hours, were for nothing. In fact, my knowledge base is lower now than when it was before I started college.



I guess I should thank you for perfectly illustrating my point on discussing topics in which you clearly know nothing about. I'll chalk it up to the low oxygen concentrations at the high altitudes your pedestal sits.

these other professions are definitely encroaching on your future territory and you shouldnt be ok with it.

ive seen the coursework and how easily it is to get into a nursing program.... it is in no way comparable to getting into medical school, going through medical school, and eventually getting into residency/getting through residency.