DNP programs spreading...

[la gringa]

now to my alma mater... we gotta get ahead of this issue before it gets ahead of us!!

note that they are also phasing out the master's programs... and cite the need for PCP's in rural areas as a big driving factor, as well as provisions of the ACA..

http://alumni.unc.edu/article.aspx?sid=9439

"UNC’s School of Nursing has been authorized by the UNC System Board of Governors to offer a graduate-level nursing degree, the doctor of nursing practice. Nurses with the advanced degree will be educated to fill critical roles in an increasingly complex health-care environment in which people need better access to primary care, chronic illness management and preventative health services.

Until now, there have been no state-supported colleges or universities offering the DNP degree in North Carolina, in which 91 counties out of 100 are designated as medically underserved areas. The decision enables UNC and five other state-supported schools to join Duke University and Gardner-Webb University in offering the most advanced level of clinical education to North Carolina nurses.

“The health of our nation relies on the availability of a highly educated nursing workforce,” said Debra J. Barksdale, an associate professor in the nursing school and the newly appointed director of the DNP program.

Recognizing that nurses with advanced degrees could address the state’s critical need for skilled primary care providers, Kristen Swanson, dean of the school, worked with her peers from five state-supported schools — Winston-Salem State University, East Carolina University, UNC-Greensboro, UNC-Charlotte and Western Carolina University — to petition the BOG for permission to offer DNP education at each school. Their effort to advance nurses’ education also is expected to help the state prepare to enact provisions of the federal Patient Protection and Affordable Care Act.

DNP students will be able to choose preparation for direct care as nurse practitioners or for leadership roles as nurse executives. Along with three years of coursework, students will complete a capstone project in which they will use the knowledge they gained to study new approaches to improve care delivery or patient care outcomes.

“In addition to coursework and clinical training in advanced nursing practice, students in DNP programs also study population health, patient safety, clinical leadership and health policy,” Swanson said. “This advanced education enables nurses to serve as leaders at the bedside, in the board room or in the Legislature.”

Following the recommendation made by the American Association of Colleges of Nursing, the DNP degree will replace the master of science in nursing degree as the appropriate level of education for nurses to serve in advanced-practice and administrative roles. UNC will be phasing out master’s options for nurses seeking advanced-practice and administrative roles as admissions to the DNP program increases. Currently enrolled master’s students in these areas will be given the option to competitively apply to the DNP program."

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[deleted109597]

The way they're doing it is interesting. While DNP isn't doctor, it's still better than MNP. Maybe they'll fall down the same hole GME has, and require yearly recertification/testing/anal probing.

 

[SeekerOfTheTree]

With this many DNP programs I feel they are going to become like MBAs in business or fresh nurses. There are tons of them but salary different wont be that great and they will still be working their usual roles. Maybe a little more PCP work otherwise most high liability fields such as EM won't be running to them to replace physicians. When you sue a hospital you will have more chances of winning if there wasn't a doc involved in the care. Am I wrong in thinking this?

I still believe we can't continue to be silent politically and must have a stronger voice in politics.

 

[Old_Mil]

It is too late. A fragmented and disorganized lobby like ours has no chance of turning back the advance of a unionized lobby speaking with a single voice...and we are vastly outnumbered. When you speak of quality of care and what is right for the patient, such matters of rigt and wrong are quaintly irrelevant in today's political climate.

 

[Taurus]

I've been warning about this for years.

Primary care, hospital medicine, emergency medicine are at the greatest risk by mid level encroachment, particularly from DNP's who want your title, autonomy, and salary.

 

[la gringa]

I've been warning about this for years.

Primary care, hospital medicine, emergency medicine are at the greatest risk by mid level encroachment, particularly from DNP's who want your title, autonomy, and salary.

if they want to encroach on my lower reimbursing visits and i don't incur risk by having to "supervise" them... then go right ahead. i'm happy to care for the sicker and more complicated folks...

somehow, i don't think that will fly well with ANY EM group that is run by EP's....

as far as primary care - i think it will just widen the gap between the "have" and "have not" in primary care, b/c very few w/ a choice would choose the "dr nurse".

 

[SeekerOfTheTree]

if they want to encroach on my lower reimbursing visits and i don't incur risk by having to "supervise" them... then go right ahead. i'm happy to care for the sicker and more complicated folks...

somehow, i don't think that will fly well with ANY EM group that is run by EP's....

as far as primary care - i think it will just widen the gap between the "have" and "have not" in primary care, b/c very few w/ a choice would choose the "dr nurse".

Many people still can't understand the idea of a female doctor when they come to the hospital. Can you imagine a nurse doctor? Patient satisfaction is important to them. Can you imagine a patient saying I waited 30 mins to be seen by a nurse. I am never gonna come back here again.

 

[Arcan57]

Many people still can't understand the idea of a female doctor when they come to the hospital. Can you imagine a nurse doctor? Patient satisfaction is important to them. Can you imagine a patient saying I waited 30 mins to be seen by a nurse. I am never gonna come back here again.

When you're seeing 1.4 pt/hr you have all kinds of time to socialize with pt and family and keep your PG scores high.

 

[JShephard]

I would say this is basically a competition.

The doctors have a superior product that takes much longer to create and costs much more to deliver. Doctors are also fragmented. *They don't play politics well - they are typically so busy with their careers or research or whatever, that they don't focus on lobbying like the nurses have. *They also have completely fragmented lobbying, 40 different groups with 40 different messages means that no message is ever received.

Enter nurses, they train cheaper and faster - not 10 years but 3-5. *Not only do they train in half the years, they also train in half the hours per week and put out what most doctors would call an inferior product... BUT - it's marketed well, it's backed by lobbying, it's cheaper.

Some people like to eat at a cheap restaurant that's fast even if the food isn't that good. *In fact, lots of people do. *Is it healthy? *That's not the right question, the question is, will they buy the food?

I believe medicine is stuck in their old ways. *We've been training physicians relatively the same way for around 5 decades. *Training doctors could be faster and better. *And forcing people to have an undergraduate degree doesn't help - that only makes it longer and more burden on the student.

Doctors have something they really haven't had to ever deal with - someone offering an alternative to them - and possibly at half the cost. *It's not the doctors that will be doing the hiring, it's the CEOs and government - and they don't care what people get as far as quality - as long as they deliver the care and limit bad outcomes. *It's just like McDonalds doesn't care if their food is healthy.

Edit- not sure how all the *s were added.

 

[SserPrun95]

*We've been training physicians relatively the same way for around 5 decades. *Training doctors could be faster and better. *And forcing people to have an undergraduate degree doesn't help - that only makes it longer and more burden on the student.

You mean my Greek mythology class I took senior year isn't relevant? Botany (part of my required major) was also a beneficial experience... I agree with you and IMHO match us in December of 4th year. Talk about a waste of time and money. It's a nice vacation but an expensive one. I'd rather extend residency by half a year bc atleast then it would be relevant and I'd get paid vs the hemorrhage the other way.

 

[glorfindel]

Training doctors could be faster and better. And forcing people to have an undergraduate degree doesn't help - that only makes it longer and more burden on the student.

People sometimes argue that the undergraduate training is necessary to enable doctors to think or perform at a higher level.

In some actual cases this is almost certainly true -- some doctors (I like to include myself) have had the benefit of an amazing undergraduate education that wasn't narrowly preprofessional. It taught me that the world is complex, and taught me some ways of dealing with that complexity in an intelligent way.

But of course not all doctors have had such a great undergraduate education. Sadly, many doctors have just a connect-the-dots preprofessional undergrad degree that basically consisted of a series of obstacles that had to be surmounted on the way to medical school admission. You know the type: the premed automaton. You may have been one of these yourself -- no offense intended. In this case, the premed degree is probably completely superfluous and should be dispensed with.

Doctors have something they really haven't had to ever deal with - someone offering an alternative to them - and possibly at half the cost. It's not the doctors that will be doing the hiring, it's the CEOs and government - and they don't care what people get as far as quality - as long as they deliver the care and limit bad outcomes. It's just like McDonalds doesn't care if their food is healthy.

Yep, yep, +1. Doctors have already become (well-paid) cogs in the machine. The only thing left is for the machine to inexorably and inevitably grind down the pay. Think it can't happen? It happened to lawyers after the financial crisis of 2008. It will happen to doctors as well. Nothing's really sacred except for profit maximization, and the current average doctor income will, I think, begin to look less and less attractive to the buyers of medical services. These buyers, as you rightly point out, are not the patients.

I'm not against cutting physician pay on principle. If it helps patients and the public's health, sure, let's cut our absurdly high salaries back to something more in line with the rest of what our country's workers make.

But if it helps the CEOs and corporate profits and wall street, without any health benefits, then f*** that s***. CEOs, corporations, and wall street are the only actors that have no grounds to criticize high physician pay.

 

[Taurus]

Nurses Spar With Doctors as 30 Million Insured Seek Care

Nurse practitioners say they can do their jobs just fine without doctors and they’re lobbying lawmakers to end restrictions in more than a dozen of the 34 states that require physician oversight. Despite the need for increased care, doctors are pushing back, fighting for restrictions with their own lobbying efforts as well as with lawsuits across the country, arguing that patients’ basic care is at risk.

 

[JShephard]

Nurses Spar With Doctors as 30 Million Insured Seek Care

Nurse practitioners say they can do their jobs just fine without doctors and they’re lobbying lawmakers to end restrictions in more than a dozen of the 34 states that require physician oversight. Despite the need for increased care, doctors are pushing back, fighting for restrictions with their own lobbying efforts as well as with lawsuits across the country, arguing that patients’ basic care is at risk.

As you said, the writing has been on the wall for years. Shortage of docs but training essentially has remained the same at almost every medical school for decades. Suppressing docs to keep the job in high demand only worlks when there is no alternative.

The good doctors will always be in need. But the profession is no longer immune to encroachment. No longer will being a physician guarantee you what it once did.

Of course this may take a decade more to unfold, but the writing is on the wall.

To the earlier poster commenting on the benefits of an undergraduate degree. I am non traditional and returned after having a non science degree. While I learned a lot, my greatest lessons in life have come from self education. Even if you look at history, some of our greatest thinkers and leaders in America learned throughout life. So the enrichment you speak of is beneficial but not necessary to train a physician IMO. Even so, you could allow medical students to take 3-6 educational enrichment courses during med school which would still not take 4 extra years.

My point is that nurses are meeting government standards (or soon to be standards) in half the time and probably 25% of the hours. If that doesn't cause us to ponder about our system then I don't know what will. There is a huge need and the powers at be decided to not to address it (primary care and under served areas). So now the profession had a huge problem.

Want more primary care docs? Stop paying spine surgeons 600k and a pediatrician 150k. The smartest most accomplished students flock to derm and plastics, or ortho. They follow the money. And our system has happily supported it. I make no judgements though. I'm just analyzing the situation and I'm curious if this group of leaders in medical education and policy can adapt and create a solution. It seems like they don't adapt very well. Blockbuster video is a great example of a company who was on top, failed to adapt and now is in shambles.

 

[DreamingTheLive]

You mean my Greek mythology class I took senior year isn't relevant? Botany (part of my required major) was also a beneficial experience... I agree with you and IMHO match us in December of 4th year. Talk about a waste of time and money. It's a nice vacation but an expensive one. I'd rather extend residency by half a year bc atleast then it would be relevant and I'd get paid vs the hemorrhage the other way.

Ya, agree that much of 4th year is an incredibly expensive waste of time.

Still think the problem is that Physicians in general and the AMA basically refuse to admit that there is ANY competition. In reality, its like the Cold War except only one side is playing...and its not the Docs.

 

[valkener]

I see this more as a threat to PCP, but EM? EM deals with trauma and other "emergency" situations where lives are frequently at risk. It also includes a good amount of procedures. I don't believe EM programs can afford not to have physicians run most of the show.

 

[DreamingTheLive]

I see this more as a threat to PCP, but EM? EM deals with trauma and other "emergency" situations where lives are frequently at risk. It also includes a good amount of procedures. I don't believe EM programs can afford not to have physicians run most of the show.

Sure, EM is probably a lot more insulated than FM or office based-IM...But its only a matter of time my friend. EM is a "specialty" sure, but its not Plastic Surgery or Rad Onc.

 

[e30ftw]

yes it's a threat and everything.. but I work with some great NP's and they have no desire to work as an attending level.. the midlevels carry max 3-4 pts at a time, while residents see 6-8 for pgy1s to 8-10 for a senior resident, while on single coverage times the attending is responsible for everyone in the department (usually 15-20 during single coverage night shifts, up to 40 during double coverage). Not to mention leaving everything at once for an esi 1 patient who rolls in while keeping track of other crashing patient/difficult dispos, repeat trops, non stemi ekg signings, etc.

there is a definite place for mid-levels in the ED. There is also a place for residency trained physicians, and with the looming physician shortage over the next 20 years as baby boomers age and fill hospitals/ICU's with septic/chf/copd/MI/CVA/afibrvr/trauma and other assorted crashing patients, appropriate contracts will always be available for ABEM diplomats.

 

[deuist]

I see this more as a threat to PCP, but EM? EM deals with trauma and other "emergency" situations where lives are frequently at risk. It also includes a good amount of procedures. I don't believe EM programs can afford not to have physicians run most of the show.

You are sadly mistaken if you think that NP's won't come after EM. They already work in urgent care centers and walk-in clinics largely unsupervised. As the "treat and street" patients make up the bulk of our business, there's not too great of a leap to get nurses into the ED. Furthermore, CRNA's (nurses) already perform intubations and I saw a paper recently that talked about RN's learning to place central lines. Pretty soon they will be crying out that chest tubes and thoracotomies are within their scope of practice.

 

[2013anes]

I have heard that the highest percentage of physicians contributing to their PAC was anesthesia at roughly 11%. Here is an interesting quote:

"Robb said that the interests of subspecialty societies are best represented under a large umbrella PAC, the Orthopaedic PAC. The PAC raised $750,000 last year for political contributions from about 10% of the entire orthopedic community. "We cannot afford to fragment this political activity into multiple PACs that may mean well but individually are more costly and much less effective. The orthopedic message would be unclear or conflicting," he said.

The subspecialties have political agendas based on their unique issues, but "few of these issues are truly unique, and few are significant enough that they will be acted upon separately," Robb said. He called orthopedic surgeons the "new kids on the block. We cannot afford to yell five or 10 messages. No one will listen. We need to work together to choose which message has the best chance of being heard and then support the PAC so that the message is tied to political contributions for those who are willing to listen or, even better, support the message."" (http://www.healio.com/orthopedics/b...edic-pac-represents-the-specialty-in-congress)

It is pretty shameful that more than 10% of physicians cannot contribute to their PAC when the nursing PACs have huge support from many members. Complaining on the message boards and warning med students to choose another specialty is not the answer. Contributing and making your specialty what it should be is the answer.

 

[Taurus]

With the encroachment of mid levels inevitable, the question soon will be, are we producing too many ED physicians? When will the job market hit a wall? 3 years? 5 years? 10 years?

 

[DreamingTheLive]

With the encroachment of mid levels inevitable, the question soon will be, are we producing too many ED physicians? When will the job market hit a wall? 3 years? 5 years? 10 years?

"Hit a wall" is subjective so I'm not sure how you're defining it. I still think that with the baby boomers, fall of primary care, etc. that EM is a good business to be in as far as medical specialties go....But theres going to be some battles ahead no doubt.

 

[DreamingTheLive]

yes it's a threat and everything.. but I work with some great NP's and they have no desire to work as an attending level.. the midlevels carry max 3-4 pts at a time, while residents see 6-8 for pgy1s to 8-10 for a senior resident, while on single coverage times the attending is responsible for everyone in the department (usually 15-20 during single coverage night shifts, up to 40 during double coverage). Not to mention leaving everything at once for an esi 1 patient who rolls in while keeping track of other crashing patient/difficult dispos, repeat trops, non stemi ekg signings, etc.

there is a definite place for mid-levels in the ED. There is also a place for residency trained physicians, and with the looming physician shortage over the next 20 years as baby boomers age and fill hospitals/ICU's with septic/chf/copd/MI/CVA/afibrvr/trauma and other assorted crashing patients, appropriate contracts will always be available for ABEM diplomats.

A "couple" great NPs doesn't mean the entire swarm of them isn't lobbying HARD day and night to expand their privis/scope....at physicians expense. Sure, there IS a place for them, unfortunately that "place" that they ultimately want is yours....except with less than half the training and liability coverage of course.

 

[Medalot]

I read these remarks and I see the naivete. Encroachment will happen by midlevels at all levels (even surgeons are seeing it...audiologists placing ear tubes, podiatrists doing knee replacements, optometrists doing scalpel eye surgery, and of course CRNAs doing interventional pain procedures). As responsible physicians, we must protect our patients from NON MEDICAL DOCTORS from practicing MEDICINE....whether they be butchers, plumbers, or wannabe doctor nurses. These "noctors" falsely advertise to the public about being "patient advocates", yet the they make excuse after excuse about why they didn't choose to become a Medical Doctor. If they truly cared about the patients AND they wanted to practice MEDICINE, they would have gone to medical school and obtain the appropriate medical knowledge. Instead, they take a shorter and less rigorous route, while falsely advertising to the public the rigorousness of their training, and lobbying politicians to change laws to work independently and make the same money as physicians.

Physicians of ALL specialties need to oppose midlevel encroachment in ALL specialties even if its not in your own specialty. We need to take a unified stance on this. Training non-physicians to practice "short-cut" medicine is dangerous to our patients and should be considered malpractice. Any physician doing so should lose his/her medical license.

 

[JShephard]

Yeah physicians should not train nurses any longer. They bits the hand that feeds them.

I don't think that only stopping Midlevels is the answer. Training needs to be faster.

And as mentioned above, one advocacy group with one message would be huge.

 

[Old_Mil]

With the encroachment of mid levels inevitable, the question soon will be, are we producing too many ED physicians? When will the job market hit a wall? 3 years? 5 years? 10 years?

I would say that in some sense it already has. A lot of the open positions are open for a reason...a reason that will adversely affect your life if you take it (low pay, bad demographics, located in states like PA, FL, Or IL with awful malpractice situations)