DNP Phasing Out PAs?

[SailorNurse]

Word from a Vanderbilt NP student today we are precepting for the next 2 months (Cardiology); supposedly in 2015 the 2 year NP program will be dropped for a 4 year "DNP" program. There will be no Masters 2 year program after 2015, only a 4 year "Doctorate" program. All current NP's will be grandfathered in. Hence, the giant influx of students within the last 2 years.

People will be deterred from the 4 year program. Period. Without increase in pay, the formula is destined to fail. And given the current decline in reimbursements....its a laughing matter.

I have to agree with you. The only reason I have looked at a DNP program is because I teach nursing and if I want tenure I need a doctoral degree. However as a practicing FNP (I work part time in a physician owned urgent care/Family Practice clinic that employs 1 fulltime FNP and another part time PA, its really a great environment), getting a DNP will not change what I do in primary care. Here in New Mexico, NP's have independent practice, the DNP will not change anything as far as actual clinical practice.
So why should I spend $10,000 (that's the cheapest DNP I found) and 2-4 years with some questionable courses? "Those pushing the DNP keep trying to tell me it will "improve my practice and make me more independent". Try telling them good clinician know their limits and when to consult the doc or refer to the specialist. Really, during the winter I see 3-4 patients an hour with a variety or illnesses. Most of those pushing the DNP (Academia) do not understand what clinics like the one I work in focus on and the types of patients we see. Working with this particular doctor, I know my NP education is nowhere at the level of a physician, that's with 34 years nursing experience including ER as an RN. Every day I work I learn something new, especially reviewing labs.
The university I teach at is starting a DNP program. It requires fulltime enrollment (12 credits at grad level) plus "residency hours". It's going to be tough to work even 20 hours per week and do this program that takes 4 semesters to complete. They were hoping to get 12 students for the first cohort but did not. It doesn't make sense. They are also starting a BSN to DNP that is 3 years full time (12 credits) plus the "residency hours."Also, they did not get the 10-12 students they were hoping for. Oh yeah, when I asked what the residency hours would entail, the students go spend time at a clinic with a practicing MD/DO or NP like me!!! Ironic??

---

Members don't see this ad.

 

[medium rare]

Oh yeah, when I asked what the residency hours would entail, the students go spend time at a clinic with a practicing MD/DO or NP like me!!! Ironic??

The entire DNP idea is ironic. Even though the ACCN has called for the DNP to be the entry-to-practice degree for advanced practice nursing by 2015, there is no legal requirement of any type for this to happen as far states' requirements for nursing practice are concerned.

Many schools have transitioned to the DNP only degree, others will offer both MSN and DNP degrees, and others will not offer a DNP, choosing to remain MSN-based. Therefore, there will ultimately be a two-tiered process for becoming a NP in the future - just like with RN's (ASN or BSN).

For a practicing NP like SailorNurse, what is the reason to seriously consider a DNP? To do what? Teach? Be tenured in a college of nursing? OK, perhaps. But for clinical practice? The DNP is entirely unnecessary.

 

[Therapist4Chnge]

For a practicing NP like SailorNurse, what is the reason to seriously consider a DNP? To do what? Teach? Be tenured in a college of nursing? OK, perhaps. But for clinical practice? The DNP is entirely unnecessary.

There are Nursing Ph.Ds for that. Of course, these probably require more rigorous classes and research, so I can see why people don't want to go that route.

 

[medium rare]

There are Nursing Ph.Ds for that. Of course, these probably require more rigorous classes and research, so I can see why people don't want to go that route.

I should have been more specific. Of course there are nursing PhD's - they've been around forever. And the goal of obtaining a PhD in nursing has typically been the same as for any other PhD, to do research in your area of interest.

For nursing schools offering a DNP, the clinical faculty that have generally consisted of MSN-level instructors are now being required to have a DNP or PhD in order to remain on faculty. The DNP takes less time to obtain than a PhD, so most current MSN instructors will go for the DNP if they want to continue teaching.

My point is that the entire process of having to get a DNP is superfluous, contextually speaking. If your institution now requires this and you want to keep your job, then you could argue from a practical standpoint, it might make sense. But academic nursing pays so poorly anyway, who would want to do it?

 

[Therapist4Chnge]

My point is that the entire process of having to get a DNP is superfluous, contextually speaking. If your institution now requires this and you want to keep your job, then you could argue from a practical standpoint, it might make sense. But academic nursing pays so poorly anyway, who would want to do it?

I think the Ph.D. would offer more opportunities outside of teaching in a nursing program. I'd have a hard time taking courses that were superfluous, though maybe others wouldn't care as much.

 

[chimichanga]

...But academic nursing pays so poorly anyway, who would want to do it?

I would, and do...Summers off with my kiddos, home for dinner, and no toxic hospital drama...

After 20 years at the bedside, I am done...Teaching is the way for me!

I got married and had kids later in my career/life, so it's a no brainer...I missed too much of the important stuff when my kids were toddlers, so now, (they are 9 and 12) I am always around, and have the same schedule they do (plus Fridays off!!)

And I am no more hungry now -making half of what I was before...And my bank account balance is the same-We spend (and live) smarter, and I have all the toys I need, from the previous nursing salary (Then - I was making low six figures as a mid-level house manager, shift work, three 12s, plus meetings/committees)

Now I work eight months a year, four days a week...

Doing that math was the easiest decision for me and my family (and my well-being...waaaay too much drama in the hospital, from patients at al)

 

[RDlv]

There are Nursing Ph.Ds for that. Of course, these probably require more rigorous classes and research, so I can see why people don't want to go that route.

Get a PhD nurse into a private conversation about the DNP concept, and you'll hear all this and more.

...unless it is a school administrator (dean, program coordinator, etc) then there is a more enthusiastic response, directly related to the $$$ that a DNP program can bring in to a nursing program.

It's the MSN-prepared NPs who are going to be getting the shaft on this one, and relatively few have been sympathetic to my warnings. Maybe (probably) not by 2015, but it's coming.

 

[FireCloud9]

RDIv,

What will happen to MSN prepared NPs? They have a degree from an accredited institution stating that they are NPs. Are hospitals going to suddenly do without MSN NPs?

 

[deleted6669]

RDIv,

What will happen to MSN prepared NPs? They have a degree from an accredited institution stating that they are NPs. Are hospitals going to suddenly do without MSN NPs?

they will be grandfathered just like the np's who still practice with a bs after the "standard" went to an ms. they may have billing issues with medicare, etc but will still have state licenses.
do a google search for " bs nurse practitioner" and you will get multiple hits for practicing np's who do not have an ms.

 

[FireCloud9]

they will be grandfathered just like the np's who still practice with a bs after the "standard" went to an ms. they may have billing issues with medicare, etc but will still have state licenses.
do a google search for " bs nurse practitioner" and you will get multiple hits for practicing np's who do not have an ms.

I ask because of a situation that I heard a while back. There is a BSN RN working in a local elementary school that will have to leave because the position now requires a masters and they are not being grandfathered.

 

[medium rare]

I ask because of a situation that I heard a while back. There is a BSN RN working in a local elementary school that will have to leave because the position now requires a masters and they are not being grandfathered.

This is an employer-based decision and has nothing to do with the law or being 'grandfathered.' Grandfathering refers to a legal occurrence whereby once there is a change in state law, those practicing under prior regulations are excused from the new requirements and can still continue to practice under the new state law.

Grandfathering only occurs once a state has amended it's practice act; unless this happens, there is nothing to grandfather because nothing has changed from a legal standpoint. So, even if every nursing school in a state has gone to the DNP and no longer offers the MSN, if the state hasn't changed its practice act, then absolutely nothing is different. If a state should change its practice act to require the DNP, then the MSN NPs will be grandfathered in and can continue to practice.

For the DNP to be a universal requirement, this process will have to happen in each of the 50 states. I' m not holding my breath.

 

[deleted6669]

I ask because of a situation that I heard a while back. There is a BSN RN working in a local elementary school that will have to leave because the position now requires a masters and they are not being grandfathered.

that's an individual facility, not a state reqirement.

 

[RDlv]

For the DNP to be a universal requirement, this process will have to happen in each of the 50 states. I' m not holding my breath.

All that needs to happen, in a state with a requirement for certification for an NP to practice, is for the certification provider to change to only offering the certification to DNPs.

I don't claim to have any inside information, I'm just offering up the possibility. But I do know that the DNPs are hot for certification requirements at the state level. My understanding is that all but a few states have passed this requirement. I'll be interested to see what the certification bodies will be doing over the next few years.

 

[medium rare]

All that needs to happen, in a state with a requirement for certification for an NP to practice, is for the certification provider to change to only offering the certification to DNPs.

I don't claim to have any inside information, I'm just offering up the possibility. But I do know that the DNPs are hot for certification requirements at the state level. My understanding is that all but a few states have passed this requirement. I'll be interested to see what the certification bodies will be doing over the next few years.

This is correct - to an extent. There are multiple accrediting bodies for NPs, not just one. Accrediting bodies generate a substantial amount of their revenue through the board certification process. They have no intrinsically vested interest to change to support only the DNP as the minimal educational standard.

 

[NYRN]

The title says it all. I was told today by a new grad ICU nurse that her preceptor (a graduating nurse practitioner) claims that the move to the DNP was in an effort to phase out PAs. Of course that's ridiculous and I stated as much but it's also infuriating and insulting to hear (especially since the other nurses there share the same view). I told her that PA education comes from a medical and not nursing background and is usually considered more rigorous than NP education. On the national average PAs make more (due to specialties) and are governed by a different board than nurses.

The new grad replied that NPs have more education due to obtaining a doctoral degree and are more widely used so it makes sense that they would be replacing PAs altogether. My main question is: how do you all (mainly asking PAs here) handle these sorts of rumors and accusations? I know I shouldn't be bothered by petty misconceptions but how can I not be annoyed at the very least when someone spews stuff like this and then defends it?

/rant over

In her dreams. I have not seen this in clinical practice at all. PA's are more flexible and trained in various specialties, while NP's may have a wealth of experience to contribute. In my hospital we use both NP's and PA's, but there are far more PA's here than NP's despite a local NP program with a lot of nurses enrolled and a strong nursing union. They are all excellent and the nurses and doctors really enjoy working with them. Each facility or MD who is looking for a midlevel provider will make the choice on who to hire, most likely based on how comfortable they feel with that individual and how they perform. It is not going to happen that when DNP's start turning out that PA schools are going to close or something. That will never happen, and it shouldn't.

 

[Sneezing]

I've seen the training of both, more so with PA's, and have worked with both, too.

I intend to open my own practice.

Should I feel the need to hire a midlevel in the future it will only be a PA due to their superior training.

I believe the move to a DNP will only hurt their field.

 

[GeneValgene]

PAs should be safe for years to come. They have solid training (no degree creep), there are no shortcuts to training (online), and they aren't trying to bite the hand that feeds.

no doubt...we do not, and can not, exist without physicians. i'm confident in my abilities, but i know my place and limitations.

 

[Summer1207]

Ya, you all seem like *******s to me. Not once, did any of you mention patient care. It is sad that today, health care to you, has become a challenge in the clear division among who took the most clinical hours and “since they are in doctorate school, they just want to prove more”. It’s ****ing pathetic. Instead of spending your free time researching clinical hours spent by the DNP and PA, hey why not research how Haiti still has over half a million people living in tents? How can you help the pandemic of cholera in Haiti? No your right, I’ll sit here and look up reasons why a higher education is better. I respect anyone that wants to further their education and skills. Shouldn't you? In reality, you all suck and everyone knows that success through interdisciplinary teams, requires the upmost respect and equality for EVERYONE you work with, thus providing the highest patient outcome. So shut the **** up and remember why you became a doctor,NP, DNP, PA, RN, ****ing intern, or nurses aid. My leadership skills are speaking to my spirit, saying you all may lack focus and especially desire? Oh and I hope I see none of you on my floor.

 

[Summer1207]

Ya, you all seem like *******s to me. Not once, did any of you mention patient care. It is sad that today, health care to you, has become a challenge in the clear division among who took the most clinical hours and “since they are in doctorate school, they just want to prove more”. It’s ****ing pathetic. Instead of spending your free time researching clinical hours spent by the DNP and PA, hey why not research how Haiti still has over half a million people living in tents? How can you help the pandemic of cholera in Haiti? No your right, I’ll sit here and look up reasons why a higher education is better. I respect anyone that wants to further their education and skills. Shouldn't you? In reality, you all suck and everyone knows that success through interdisciplinary teams, requires the upmost respect and equality for EVERYONE you work with, thus providing the highest patient outcome. So shut the **** up and remember why you became a doctor,NP, DNP, PA, RN, ****ing intern, or nurses aid. My leadership skills are speaking to my spirit, saying you all may lack focus and especially desire? Oh and I hope I see none of you on my floor.

 

[Simann]

Ya, you all seem like *******s to me. Not once, did any of you mention patient care. It is sad that today, health care to you, has become a challenge in the clear division among who took the most clinical hours and “since they are in doctorate school, they just want to prove more”. It’s ****ing pathetic. Instead of spending your free time researching clinical hours spent by the DNP and PA, hey why not research how Haiti still has over half a million people living in tents? How can you help the pandemic of cholera in Haiti? No your right, I’ll sit here and look up reasons why a higher education is better. I respect anyone that wants to further their education and skills. Shouldn't you? In reality, you all suck and everyone knows that success through interdisciplinary teams, requires the upmost respect and equality for EVERYONE you work with, thus providing the highest patient outcome. So shut the **** up and remember why you became a doctor,NP, DNP, PA, RN, ****ing intern, or nurses aid. My leadership skills are speaking to my spirit, saying you all may lack focus and especially desire? Oh and I hope I see none of you on my floor.

Equality is the main reason why some are against the DNP programs as the "doctorate" label looks to be used loosely by the nursing programs. The fact of the matter is that the entire doctorate program didactics pales in comparison to a masters (PA) program in a medical school. For the type of duties the NP provides, the DNP fullfills no more of that same job description as a NP. So it at its very core is clearly a "nametag" debate.

The problem i personally see is that the quality of research and field study of students coming out of NP programs versus students out of PA programs is drastically different, yet for some reason NP are given more autonomy/ privledge than a PA. The title the DNP comes out of school with is just not correct. I would rather see it kept at NP P.h.D frankly. Its misleading to patients. It forms a false sense of trust. When people come to my clinic, they want to see the Doctor, not the NP. Its a trust thing.....

 

[facetguy]

Ya, you all seem like *******s to me. Not once, did any of you mention patient care. It is sad that today, health care to you, has become a challenge in the clear division among who took the most clinical hours and “since they are in doctorate school, they just want to prove more”. It’s ****ing pathetic. Instead of spending your free time researching clinical hours spent by the DNP and PA, hey why not research how Haiti still has over half a million people living in tents? How can you help the pandemic of cholera in Haiti? No your right, I’ll sit here and look up reasons why a higher education is better. I respect anyone that wants to further their education and skills. Shouldn't you? In reality, you all suck and everyone knows that success through interdisciplinary teams, requires the upmost respect and equality for EVERYONE you work with, thus providing the highest patient outcome. So shut the **** up and remember why you became a doctor,NP, DNP, PA, RN, ****ing intern, or nurses aid. My leadership skills are speaking to my spirit, saying you all may lack focus and especially desire? Oh and I hope I see none of you on my floor.

Utmost, for future reference. Please have your leadership skills convey that to your spirit.

 

[deleted6669]

hey why not research how Haiti still has over half a million people living in tents? How can you help the pandemic of cholera in Haiti?

don't know how much of your rant was directed at me but I have made 4 trips to Haiti since 2009 including the week after the earthquake and last june to staff a cholera treatment center. I am going back again this summer and am working on a doctorate in health science with a global health emphasis. I will be doing my field research in Haiti on the post earthquake recovery process.
How many times have you been to Haiti?

 

[Makati2008]

don't know how much of your rant was directed at me but I have made 4 trips to Haiti since 2009 including the week after the earthquake and last june to staff a cholera treatment center. I am going back again this summer and am working on a doctorate in health science with a global health emphasis. I will be doing my field research in Haiti on the post earthquake recovery process.
How many times have you been to Haiti?

The mods need to do what they do best and ban summer good sir.

 

[Therapist4Chnge]

Utmost, for future reference. Please have your leadership skills convey that to your spirit.

I guess I just got caught up on the low hanging fruit.

Ya, you all seem like *******s to me. Not once, did any of you mention patient care.

Advocating for higher standards is about patient care. It is about ensuring that patients receive high-quality care.

It's ****ing pathetic. Instead of spending your free time researching clinical hours spent by the DNP and PA, hey why not research how Haiti still has over half a million people living in tents? How can you help the pandemic of cholera in Haiti?

You are assuming that people don't...help? Really? Or that people don't give some of their time for free? I am sure everyone here has examples...I have been a disaster response volunteer for countless hurricanes, house fires, etc. Also...why does it have to be international? Are people right here in the USA not worthy enough for help?

No your right, I'll sit here and look up reasons why a higher education is better. I respect anyone that wants to further their education and skills. Shouldn't you?

You're.....

I think most people here support a person's desire to further their education, but the DNP is CLEARLY politically motivated and NOT about enhancing patient care. If people just cared about gaining advanced skills....why not just take CMEs? Why is there a need to award a degree? If you are SERIOUS about gaining advanced skills....do a fellowship. If you want to do research...get an MS or Ph.D. from an established program. If you want to work in the administration....get an MPH or MPA.

In reality, you all suck and everyone knows that success through interdisciplinary teams, requires the upmost respect and equality for EVERYONE you work with....

...and there it is, the real crux of the issue. You want everyone to be treated with respect? So do I! You want equality for everyone? Yet another "you do XYZ, we do XYZ! You do ABC, we do ABC! You are called doctor, we should be called doctor!" If you put in the same amount of time as other real doctorates, maybe you will be treated equally.

I constantly attend CME talks, seminars, take classes, conduct research studies, work on teams to track patient outcomes, and a host of other things that are included in the typical DNP program...where is my DNP-like degree?

 

[ChillyRN]

My last post in this thread was 11 months ago. I didn't take that job, btw. I got a better one which I love, love, LOVE. I still haven't ever heard anyone say a bad word about PAs or NPs or DNPs. Where do you all live that there is all this bad blood?

And I'm still pluggin away at the DNP. I'd really like to know where all these schools are where you can finish in 8 weeks or whatever the most hyperbolic current rumor is. My anticipated graduation date is December 2013, making it 9 semesters. In all fairness, I could have done it in 7, and that was the original matriculation plan, but I was invited to do a one yearfellowship* in a specialty area, which slows me down a bit. I have no intention of practicing in this specialty area full time, but we see enough of it in primary care that I'd like to be better working with those patients, and I was flattered to have been invited, so what the heck. I'll sleep when I'm dead, right?

I still love my DNP program and have no regrets about pursuing it. I find the course work interesting, and the additional clinical experience is providing me a lot of opportunity I would not have had otherwise. I've been able to network with a lot of internal medicine and specialty physicians all over the city, which has been a great boon to my referrals. They know me now and know what my project is, so they are sending me every patient that they think might qualify, lol. I've been in practice less than 6 months and my panel is full. I've used the DNP clinical hours to get extra training in things that I only got to do a few times as a student: arthrocentesis, intra-articular injections and colposcopy so far, and am looking for additional learning opportunities. That is what it is all about, after all! I feel weak sometimes in working with patients taking a lot of anti-psychotics. I have a lot of guys just out of prison, and I can't get them into mental health in a timely manner. It seems like they are possibly a tad over medicated in prison, but I am so unsure about messing with that cocktail. Point being that some time with an expert in that realm is next up on my list. What say you Zenman?

I guess those that are of the mind can snicker all you like. I'm gaining knowledge and insight and learning skills and enjoying the hell out of myself, so I get the last laugh. I'm heading out to observe Mohs surgeries all day tomorrow, though no, I won't be doing them in my little clinic. Hopefully I'll learn a little more about recognizing skin cancers and getting them treated by the REAL dermatologist sooner. That is the plan, nothing nefarious. It really is about me being a better provider and my patients having better outcomes.

*I know you guys freak out that they call it that, but I can't help what they call it and I can't go around making up new words for stuff. I guess I could rephrase and say I am doing one year of intensive study and clinical training in a specialty area.

My point is, I can say with assurance that I am not driving any PAs out of practice! I don't have any bones to pick with PAs, physicians or other NPs. I'm just over here in my corner of the world trying to learn as much as I can and do my best. I'll keep at it until I know everything there is to know about everything and am the smartest, most awesome DNP in the whole wide world. Or until I'm dead, or senile, whichever comes first.

 

[deleted6669]

Sounds like a good program chilly, best of luck.
I am currently pursuing an academic doctorate due to an interest in global health and disparities in health care delivery. I may do a clinical pa residency in the future. I have a tentative offer to join the faculty of a new pa em residency program. they would bring me on at a regular salary and I would do all the off service rotations then work full time with the em pa residents in the main er. seriously considering it.

 

[ChillyRN]

I like it. I think it's been a good choice for me. I suspect, that as with most things, you get out what you put in. There will always be those who want to skate by and do the minimum, I can't help that. I've always agreed the bar ought to be set a bit higher to account for the underachievers, lol.

My point stands however, that DNPs and those of striving to become DNPs aren't trying to push anyone else out. The whole unfortunate thread began due to the ignorant comments of one person, who isn't even an NP, much less a DNP.

 

[prairiedog]

I like it. I think it's been a good choice for me. I suspect, that as with most things, you get out what you put in. There will always be those who want to skate by and do the minimum, I can't help that. I've always agreed the bar ought to be set a bit higher to account for the underachievers, lol.

My point stands however, that DNPs and those of striving to become DNPs aren't trying to push anyone else out. The whole unfortunate thread began due to the ignorant comments of one person, who isn't even an NP, much less a DNP.

wondering why you think making intelligent statements without being nasty to others would actually be tolerated within the context of this thread?

 

[Simann]

*I know you guys freak out that they call it that, but I can't help what they call it and I can't go around making up new words for stuff. I guess I could rephrase and say I am doing one year of intensive study and clinical training in a specialty area.

....like a Ph.D. (Doctorate of Philosophy, a broad spectrum liberal arts doctorate).

My point is, I can say with assurance that I am not driving any PAs out of practice! I don't have any bones to pick with PAs, physicians or other NPs. I'm just over here in my corner of the world trying to learn as much as I can and do my best. I'll keep at it until I know everything there is to know about everything and am the smartest, most awesome DNP in the whole wide world. Or until I'm dead, or senile, whichever comes first.

 

[RDlv]

I like it. I think it's been a good choice for me. I suspect, that as with most things, you get out what you put in. There will always be those who want to skate by and do the minimum, I can't help that. I've always agreed the bar ought to be set a bit higher to account for the underachievers, lol.

My point stands however, that DNPs and those of striving to become DNPs aren't trying to push anyone else out. The whole unfortunate thread began due to the ignorant comments of one person, who isn't even an NP, much less a DNP.

I sometimes have to check myself, and make sure I emphasize that my opposition is purely towards the DNP as entry-to-practice for NPs. I have no desire to denigrate the degree or those who pursue it. Good on you for enjoying your program and getting value out of it.

I have no problem with the DNP as a non-PhD doctoral option for nurses. But I plan on vigorously opposing the DNP-as-entry-to-practice, focusing on my State level but nationally as needed.

 

[FireCloud9]

There's a school around here that has ABSN, ELMSN, and DNP programs and are considering combining their programs to offer what is the equivalent of an Accelerated ELMSN / DNP (18 months) for those with a masters in other professions (they're flooded with demand from other professions - law, engineering, business).

It follows the same model as the ABSN 12 month program for those with a previous non-healthcare degree, but is 6 months longer.

The concern seems to be that many candidates will continue choosing the ABSN 12m program because it costs less and is shorter with the same / similar compensation potential.

That would be pretty cool if it came to pass. I'd certainly go for it - 18 months and collect all the alphabet soup

 

[zenman]

I feel weak sometimes in working with patients taking a lot of anti-psychotics. I have a lot of guys just out of prison, and I can't get them into mental health in a timely manner. It seems like they are possibly a tad over medicated in prison, but I am so unsure about messing with that cocktail. Point being that some time with an expert in that realm is next up on my list. What say you Zenman?

Sometimes they are over medicated in the guise of "population control." Sometimes that's good; sometimes not. Prison today is becoming the new mental health clinics and in some places prisoners get better mental health care than the outside poor population.

I'd get Stahl's Illustrated Antipsychotics: Treating Psychosis, Mania, and Depression as well as Psychiatry Essentials for Primary Care. Take them off as much meds as possible. Most probably need the older cheaper stuff which is probably what they were getting in prison.

 

[ChillyRN]

Sometimes they are over medicated in the guise of "population control." Sometimes that's good; sometimes not. Prison today is becoming the new mental health clinics and in some places prisoners get better mental health care than the outside poor population.

I'd get Stahl's Illustrated Antipsychotics: Treating Psychosis, Mania, and Depression as well as Psychiatry Essentials for Primary Care. Take them off as much meds as possible. Most probably need the older cheaper stuff which is probably what they were getting in prison.

Yes, I think population control sums it up. I saw a guy a few weeks ago who seemed as gentle as a ***** cat. He was in his late 50s and had been locked up since 20. He had dismembered quite a few people back in the day. He said the voices still talked to him, but they weren't telling him to hurt anyone anymore, they just tell him he is "stupid and ugly." He broke my heart, but I don't want to see him off his meds. He could be quite dangerous I guess. The state gave him 30 days in a halfway house but he's on the street now. He gets his meds for free from the coalition for the homeless. He said they make him sleep all the time, which was fine when he was in prison, but he has no where to lay down now and he just wanders around the city in a daze.
Please, tell me what on earth a primary care FNP -less than a year out of school- is supposed to do for this guy?
What I did do for him was spend two hours on the phone calling every psych NP in town literally begging until I found one that would see him, and then he no showed. It was probably too many bus transfers, etc. I may never see him again, but there will be others.
I'll get the reference book, thanks.

 

[Makati2008]

Yes, I think population control sums it up. I saw a guy a few weeks ago who seemed as gentle as a ***** cat. He was in his late 50s and had been locked up since 20. He had dismembered quite a few people back in the day. He said the voices still talked to him, but they weren't telling him to hurt anyone anymore, they just tell him he is "stupid and ugly." He broke my heart, but I don't want to see him off his meds. He could be quite dangerous I guess. The state gave him 30 days in a halfway house but he's on the street now. He gets his meds for free from the coalition for the homeless. He said they make him sleep all the time, which was fine when he was in prison, but he has no where to lay down now and he just wanders around the city in a daze.
Please, tell me what on earth a primary care FNP -less than a year out of school- is supposed to do for this guy?
What I did do for him was spend two hours on the phone calling every psych NP in town literally begging until I found one that would see him, and then he no showed. It was probably too many bus transfers, etc. I may never see him again, but there will be others.
I'll get the reference book, thanks.

Not to sound like a jerk but this is a perfect case where expert consultation(your supervising Physicians) should have been handed care. No questions asked. Too many medical pitfalls I could see coming form this guy.....and if th docs refused to at least help you with this problem then no comment.....

 

[ChillyRN]

I do agree he needed an expert, which is why I went to great lengths to get him seen by one.
I don't have supervising physicians.

 

[Makati2008]

I do agree he needed an expert, which is why I went to great lengths to get him seen by one.
I don't have supervising physicians.

Smh. Further proving my point on why ALL MLP's need one(I am a PA fyi). Did you at least ask the help of the Physicians you work with or for?
PS-Pysch NPs are not expert consultation in my opinion it should be Physician first then NP/PA in this case but oh well.

 

[zenman]

Smh. Further proving my point on why ALL MLP's need one(I am a PA fyi). Did you at least ask the help of the Physicians you work with or for?
PS-Pysch NPs are not expert consultation in my opinion it should be Physician first then NP/PA in this case but oh well.

What point are you proving? I think she did what was appropriate since she is primary care and she linked him up with psych. If he's been in prison he's likely to have better physical and mental healthcare than many in the community so should just need tweaking. He probably doesn't have the means to afford any meds but the older ones that are typically used in prison...and are mostly as effective as new expensive ones. In my role as Psych NP it's me first, then any consultation if I feel I need it. My med director expects me to know what I'm doing and not to wear her out "bothering" her. Just saying. In my new job I have run into 2 PAs; one who said she didn't know what to do for a psych patient admitted for medical problems and another one who wrote orders to transfer a depressed patient (with medical problems) to the psych unit. I helped both and explained why every depressed patient doesn't need to go to a psych unit. Cancelled that order btw.

 

[Makati2008]

What point are you proving? I think she did what was appropriate since she is primary care and she linked him up with psych. If he's been in prison he's likely to have better physical and mental healthcare than many in the community so should just need tweaking. He probably doesn't have the means to afford any meds but the older ones that are typically used in prison...and are mostly as effective as new expensive ones. In my role as Psych NP it's me first, then any consultation if I feel I need it. My med director expects me to know what I'm doing and not to wear her out "bothering" her. Just saying. In my new job I have run into 2 PAs; one who said she didn't know what to do for a psych patient admitted for medical problems and another one who wrote orders to transfer a depressed patient (with medical problems) to the psych unit. I helped both and explained why every depressed patient doesn't need to go to a psych unit. Cancelled that order btw.

1.)Just stating we as MLPs need supervision(and for a story about something a NP did to show you both professions has it weaklings-> A NP tried to give someone in my family Medrol Dose Pak for gastritis smh. Luckily that person was smart enough to throw away the rx and get treated for H. Pylori by a Physician lol. Or one I know that literally couldn't treat CHF or do admit orders and said NP's aren't trained enough for that)
2.)With his history(if she really meant he was so violent as she said) if I was a Physician that had any responsibility for her I would want to know about his care at least? What if for some unknown reason he decided to go off and have another violent episode right after leaving the clinic both her and the Doc take the hit on that one.

Again just trying to say that ALL nonphysician providers need some sort of oversight.

 

[ChillyRN]

2.)With his history(if she really meant he was so violent as she said) if I was a Physician that had any responsibility for her I would want to know about his care at least? What if for some unknown reason he decided to go off and have another violent episode right after leaving the clinic both her and the Doc take the hit on that one.

Again just trying to say that ALL nonphysician providers need some sort of oversight.

Just want to clarify, that I didn't ever say any such thing. I said he had been violent in the distant past, and I implied concern that the potential may still exist.

And further, again, that no physician (or any other person) has any responsibility for me whatsoever. I understand clearly that you do not think that is the way it ought to be. However, it is the way it is.

To your question, did I approach my physician colleagues for advice about how to deal with this patient? The answer is no, I didn't have to. I know full well any one of them would have said "I'd refer him to psych." The referral was appropriate. It is just a pity that he did not keep his appointment.

 

[deleted87716]

did I approach my physician colleagues for advice about how to deal with this patient? The answer is no, I didn't have to. I know full well any one of them would have said "I'd refer him to psych." The referral was appropriate. It is just a pity that he did not keep his appointment.

Actually, you said you referred him to a psych NP, not a psychiatrist. You said that you called "every psych NP in town." You never mentioned trying to refer him to a psychiatrist (e.g, MD/DO).

Sounds like we have the makings of a double standard of care here. See an NP for one thing, see an NP for everything. Not exactly the ideal collaborative model.

 

[ChillyRN]

Quote:
Originally Posted by ChillyRN
did I approach my physician colleagues for advice about how to deal with this patient? The answer is no, I didn't have to. I know full well any one of them would have said "I'd refer him to psych." The referral was appropriate. It is just a pity that he did not keep his appointment.

Actually, you said you referred him to a psych NP, not a psychiatrist. You said that you called "every psych NP in town." You never mentioned trying to refer him to a psychiatrist (e.g, MD/DO).

Sounds like we have the makings of a double standard of care here. See an NP for one thing, see an NP for everything. Not exactly the ideal collaborative model.

No, no double standard. I refer to all kinds of providers. A psychiatrist wasn't an option for him due to the payment system and the providers accepting his (special state vouchers for mental health care-not traditional medicaid). Surely you cannot blame me or my profession for the fact that so few psychiatrists are opting to provide care to this under served population?

Quote:
Originally Posted by ChillyRN
It is just a pity that he did not keep his appointment.

So...you're just letting it drop? "AMFYOYO?" Have you made any attempts to contact him? Have you tried to get him back into the office? Have either you or the psych NP tried to reschedule his appointment there? Have you tried to enlist the help of community resources (e.g, community mental health, social services,etc.)?

Your patients are still your patients even when they aren't in your office, and even when they aren't doing what they're supposed to do. Nearly all patients with chronic diseases require collaborative care for optimal outcomes. Primary care ain't a one man (or one woman) show. As his PCP, you're supposed to be the team leader. Or, somebody is...

He is homeless. As in, he lives on the street. He did say he sticks close to the University as the students are kinder to him than others. I guess I could just start cruising the streets looking for him. I am required to hand him a list and tell him "go to psych." What I did was to spend half the morning trying to find him a provider, made the appointment and mapped out the bus route and gave him bus fare (yes, out of my pocket).
When they emailed me about the no show, I left a message for him at the coalition for the homeless where he picks up his free meds. Unless you really think I ought to go physically searching for him in my free time, I'm not sure what more you would have me do.

I think you just want to pick a fight. I am confident I did everything I could for him that day. We even gave him lunch. If he doesn't come back, I am not sure what else I can do, but I am more than willing to hear your ideas!

Edited to say I don't know why the quote is so messed up, but this is in response to BlueDog, whom has since edited his original comments, which is perhaps why it won't quote properly. Sorry for the confusing format.

 

[ChillyRN]

Blue Dog, I don't know what is going on with the board, seems as though there is a glitch. I see the comments I thought you had redacted have returned. Sorry for the confusion. Nope, they are gone again. Wow, there is a bug in the system today!

Just to clarify, my post above is totally devoid of snark. If anyone does know how to reach out to homeless patients and find them when it appears they are lost to care, I really would love some suggestions. I have two such patients (that I know of).

 

[deleted87716]

I think you just want to pick a fight.

No, I don't...which is why I edited my post (22 minutes before you posted your reply).

The followup issue is tangential to my main point that you should not be referring to midlevels. If something's over your head, you should be referring to physicians.

 

[ChillyRN]

No, I don't...which is why I edited my post (22 minutes before you posted your reply).

The followup issue is tangential to my main point that you should not be referring to midlevels. If something's over your head, you should be referring to physicians.

??? My apologies if the timing of my reply is somehow irksome. Respectfully, I don't see how that the fact the you edited in the interim suggests anything about me just because I was responding to the original, especially when I did not know you edited until after I replied. I'm distracted by pretending to be a doctor here while playing SpongeBob Operation with my kids.

I disagree with the blanket statement that all referrals should go directly to physicians (as would they!). Just as often a NP or PA in the specialty area is the best first choice. They will turn the referral over to the specialist physician if they deem it necessary or prudent. When something is over my head, I aim to find someone more qualified than I. That is what I did in this instance. I don't approach situations with hard and fast ideas about whom the initial specialty referral should go to first, especially when I can almost always get them in with a PA or NP much faster and I suspect, get the crux of the issue addressed weeks or months sooner. In any event, I utilize the resources I have for each case, individually.

I am inferring (perhaps incorrectly, in which case please forgive the misunderstanding) that you think I have somehow failed this patient. I agreed from the outset that I am not the best choice of person to manage his psych meds (I can, and did, address his COPD and HTN). I did my very best to get him to someone better suited. I simply do not agree with anyone who would assert that I failed to meet my legal, ethical or moral responsibility to this patient.

This whole scenario really has nothing to do with the fact that I am a FNP, and everything to do with the fact that there are too few resources for people in his circumstance. Had he seen one of the MDs in my office he's have been handed the list and shooed out the door, without lunch or bus fare (that may have been used for cigarettes, ETOH or drugs for all I know-I'm Polyanna so I'm choosing to believe it was for supper). However, I concede that the outcome would have been the same, i.e. no psych follow up for the patient. The difference is, my physician colleagues would have not wasted hours trying to affect a different outcome. One of them told me to figure out whom can be helped and whom cannot and to appropriate my time accordingly. They didn't teach me how to discern that in NP school and my instinct for it is underdeveloped. I guess that does mark him as smarter, or at least more pragmatic, than I.

I am not discouraged. I'll keep giving 110% to everyone. That is the beauty of being Pollyanna; too obtuse to know better.

If you have suggestions about how I might better serve this patient population given the constraints, I would be most grateful to have them. I shan't entertain more of what appears to be commentary aimed at launching criticism without making it constructive enough to be helpful for future such interactions

Regards.

 

[Makati2008]

No, I don't...which is why I edited my post (22 minutes before you posted your reply).

The followup issue is tangential to my main point that you should not be referring to midlevels. If something's over your head, you should be referring to physicians.[/QUOTE]

Agreed. That is also one of the problems I see with the DNP. I foresee NPs trying to use it as a way to gain more practice rights. Why not form a NP to MD/DO bridge if you guys want to truly be a "Doctor". Matter of time until we see more bad outcomes and more patient led suits to hopefully deter states where DNP/NP have gained full practice rights.

 

[deleted87716]

I disagree with the blanket statement that all referrals should go directly to physicians (as would they!)

I wouldn't necessarily assume that.

 

[deleted432032]

I believe it is unfortunate that the Nursing boards have sold themselves as a low cost alternative to physicians, and were able to politically aligned themselves with those that want to save money or make more money without considering the overall cost to the patient. The power trip that MOST NP's have, not all, I hope can come to an end soon before patients are truly harmed long term. I believe there is a place for all levels, but nurses should not be practicing medicine. If you want to do that o to Medical School. There are no short cuts to this, but there can be some very bad outcomes.

Please keep in mind that an NP is still a Nurse governed by the board of Nursing and regardless of what political tactics or alignments are used NP's are indeed practicing medicine without a license (I will continue to believe this until NP's are sanctioned under the medical boards and not nursing boards).

Attack away

 

[Dranger]

1.)Just stating we as MLPs need supervision(and for a story about something a NP did to show you both professions has it weaklings-> A NP tried to give someone in my family Medrol Dose Pak for gastritis smh. Luckily that person was smart enough to throw away the rx and get treated for H. Pylori by a Physician lol. Or one I know that literally couldn't treat CHF or do admit orders and said NP's aren't trained enough for that)
2.)With his history(if she really meant he was so violent as she said) if I was a Physician that had any responsibility for her I would want to know about his care at least? What if for some unknown reason he decided to go off and have another violent episode right after leaving the clinic both her and the Doc take the hit on that one.

Again just trying to say that ALL nonphysician providers need some sort of oversight.

I think your anecdote is more or less an example of individual shortfalls rather than a shot at MLPs in general. Even as a lowly Pre-Med/BSN if someone asked my opinion on reoccurring peptic ulcers or gastritis I would suggest blood work, endoscope and a H. Pylori stool sample test early on as well as the subsequent triple threat therapy if it was indeed positive.I must agree though I believe even with independent/semi independent practice there should at least be a relatively close physician to collaborate with at all times. Really Medrol? Lol what?

 

[deleted87716]

Really Medrol? Lol what?

"Gastritis" ends in -itis, which means "inflammation," right? At least someone was paying attention in medical terminology class.

 

[Dranger]

"Gastritis" ends in -itis, which means "inflammation," right? At least someone was paying attention in medical terminology class.

Haha sorry this O-chem review is hurting my brain, Yes and yes inflammation and all that good stuff but I thought anti-inflamm were usually pulled in the case of gastritis, or at least NSAIDS? Sorry off-topic...maybe the NP took it too literally