Doctor shortage: A nurse may soon be your doctor

[oaklandguy]

Oral Hygienists are great at giving cleanings, I think they should go thru 1 more year of schooling, get a Dr. in front of their names, and be allowed to do root canals and fillings.

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[guestdoc]

"I don't think patients are ever confused. People are not stupid," said Linda Roemer, a nurse practitioner in Sedona, Ariz., who uses "Dr. Roemer" as part of her e-mail address.

Calling themselves doctors and wearing white coats... of course patients think it's a nurse seeing them.

Seriously! Not to generalize and call an entire group stupid, but people are stupid. (in the nicest way possible--I'm a person too ) There's no way the average person would know the difference if an NP came in calling themselves doctor. (unless there was a big expose on a scandal of doctors vs. NPs on MTV or HBO or something...)

I was a volunteer in a hospital, wearing khaki slacks and a polo (uniform for the volunteers) and when I would accompany the nurses who were showing me interesting stuff, people would look at me and the nurse after we did something simple and say "thank you doctors!"

If the NP walked in and just told how long their training was, a surprising amount of people still wouldn't know. I can't tell you how many times uninformed (yet educated) people have balked at how long it'll be before all the training to be a physician is over:

"Wait... you're a doctor after you graduate, right?"
"Uh... no... Then I start medical school..."
"Then you're a doctor? That'll be nice to be rollin' in the money!!"
"Well... then I have residency... which is another 3-6 or more years. So basically it's like undergrad was 1st-4th grade, and I'm in fifth grade again, looking forward to High School graduation."
"oh...." **confused face, looking at me like they don't believe me**

 

[cliffhuxtableDO]

Seriously! Not to generalize and call an entire group stupid, but people are stupid. (in the nicest way possible--I'm a person too ) There's no way the average person would know the difference if an NP came in calling themselves doctor. (unless there was a big expose on a scandal of doctors vs. NPs on MTV or HBO or something...)

I was a volunteer in a hospital, wearing khaki slacks and a polo (uniform for the volunteers) and when I would accompany the nurses who were showing me interesting stuff, people would look at me and the nurse after we did something simple and say "thank you doctors!"

If the NP walked in and just told how long their training was, a surprising amount of people still wouldn't know. I can't tell you how many times uninformed (yet educated) people have balked at how long it'll be before all the training to be a physician is over:

"Wait... you're a doctor after you graduate, right?"
"Uh... no... Then I start medical school..."
"Then you're a doctor? That'll be nice to be rollin' in the money!!"
"Well... then I have residency... which is another 3-6 or more years. So basically it's like undergrad was 1st-4th grade, and I'm in fifth grade again, looking forward to High School graduation."
"oh...." **confused face, looking at me like they don't believe me**

haha, yeah! it used to surprise me how many people do not understand the process of becoming a full physician. now, it surprises me if someone does know!

 

[DrBowtie]

Never would.....the name was a joke due to the show....

however, im gonna wear a white coat for 2 reasons-
1. for the pockets
2. to hide the underarm sweat stains

seriously tho--for independent practice and and the title--med school it is.

im fine with practicing under a physician. however no way in hell i, or any other PA, should ever be practicing under the supervision of a doctor nurse

Then make sure you get the short white coat.

 

[ChiDO]

haha, yeah! it used to surprise me how many people do not understand the process of becoming a full physician. now, it surprises me if someone does know!

i have to explain the process everytime I see family members, even though they heard it last time I saw them....now just extrapolate that to the general public....

 

[JaggerPlate]

Oral Hygienists are great at giving cleanings, I think they should go thru 1 more year of schooling, get a Dr. in front of their names, and be allowed to do root canals and fillings.

Ironically enough ... there are some dental mid-levels that are either seeking expanded rights and autonomy or they are granted it in the new bill err something. So again ... wanting something without the work, non-advantageous to patients, etc.

 

[oaklandguy]

Ironically enough ... there are some dental mid-levels that are either seeking expanded rights and autonomy or they are granted it in the new bill err something. So again ... wanting something without the work, non-advantageous to patients, etc.

In all reality, I worked at a dentists office who had a few oral hygienists working there to do cleanings and my state (it might be nationwide) recently began allowing the hygienists to give oral anesthetic shots and they broke so many needles and misplaced the needle a ton. It was pretty bad.

 

[UnlonelyRoad]

I had an EMT tell me the same thing, in regards to everything a nurse learns. It's pretty amazing when people don't know how limited they are.

One of the amazing thing about good midlevels is that most know their limits. I honestly think that DNPs and regular NPs should be able to practice independently. Much like a PCP has to know when to refer to a specialist, NPs should know when they have to refer to a PCP to handle more complex cases.

I think that ultimately that may very well be the way to go. Different levels of expertise for different problems. If I have recurrent abdominal pain, I'm going to want to see a PCP. If I've got a sore throat, I'd rather go see a NP and save the $$$.

 

[Nasrudin]

This. I'm totally okay with more of a market in terms of healthcare. But even if that weren't the case, most docs I know love their NPs... maybe that's because they work with NPs they like, but at least the psych and ED NPs I've worked with seem to be well liked and well appreciated.

Well naturally they're appreciated. As it is now they make money for the physicians' groups they work for. And have usually less to no input into group decisions.

Imagine you're going to work as grocery bagger. And you have an assistant that contributes 15% of their hourly wage to you for the privilege of working next to you. What's not to like. I could tolerate 99% of people for that deal. Especially if they didn't compete with me for a voice in my workplace. Simply acquiescing to my agenda.


Is it any wonder they're gunning for more rights. Economically where it counts. Physician's seemed quite comfortable with their silent monetary contributions to their practices until now. And these physician political bodies expect me to rally behind calls for limitations. Please. And under the premise of patient safety. With no evidence.

Hey AMA. Future physician here. Suck it!

I am with the other poster. Who said we should simply standardize the level of training across the industry. Nurse's who want to be doc's should just take all the same tests and complete a residency. Fair is fair. I would even do it on their terms as long as they can pass the USMLE's.

 

[Dr 14220]

Then make sure you get the short white coat.

actually, i would prefer to wear a suit. but i feel like that would be even more weird. a PA wearing a suit?? i dunno

 

[ragudude]

And then they wonder why none of us want to go into primary care anymore...
The article even mentioned that medicare reimbursements to DNP's are 100% on parity with what PCP's get and Midwife nurses get the same reimbursement as OB/GYN's... and then they wonder why none of us want to go into OB/GYN...

For less time, investment, training (malpractice insurance? source?)... they get paid like a doctor and now even get to put their nose in the air and be called Dr.

Personally, I don't really care at this point, I didn't plan on entering PC to begin with. However, if I were a PCP I'd be very worried. Then again, I do think that they can handle the sniffles, sore throats, etc. This being said, I think there should be less incentive for med students to enter PC, and the resources used to tran docs in PC should be used to expand specialty residencies. I think it would be a better allocation of not only resources, but also talent.

A large part of what PCP's and DNP's do is doctor brokering; they serve as the gatekeepers to see other specialized docs. I don't think these doc brokers need an MD degree to know when they're in over their head. (however, there could be some detrimental consequences here... when a nurse with MD envy like the one in the article here is so over confident that s/he doesn't refer the patient to someone with greater training, but instead has confidence that s/he can treat the patient him/herself.)


That being said, this sets a scary precedent for those entering our profession. When the nurse anesthetists learn of what their NP brethren (sistren?) have accomplished, will they ask to be autonomous of oversight from anesthesiologists? Will surgical nurses start performing surgeries?

If so, can someone please suggest a cheap nursing program?

 

[ragudude]

And then they wonder why none of us want to go into primary care anymore...
The article even mentioned that medicare reimbursements to DNP's are 100% on parity with what PCP's get and Midwife nurses get the same reimbursement as OB/GYN's... and then they wonder why none of us want to go into OB/GYN...

For less time, investment, training (malpractice insurance? source?)... they get paid like a doctor and now even get to put their nose in the air and be called Dr.

Personally, I don't really care at this point, I didn't plan on entering PC to begin with. However, if I were a PCP I'd be very worried. Then again, I do think that they can handle the sniffles, sore throats, etc. This being said, I think there should be less incentive for med students to enter PC, and the resources used to tran docs in PC should be used to expand specialty residencies. I think it would be a better allocation of not only resources, but also talent.

A large part of what PCP's and DNP's do is doctor brokering; they serve as the gatekeepers to see other specialized docs. I don't think these doc brokers need an MD degree to know when they're in over their head. (however, there could be some detrimental consequences here... when a nurse with MD envy like the one in the article here is so over confident that s/he doesn't refer the patient to someone with greater training, but instead has confidence that s/he can treat the patient him/herself.)


That being said, this sets a scary precedent for those entering our profession. When the nurse anesthetists learn of what their NP brethren (sistren?) have accomplished, will they ask to be autonomous of oversight from anesthesiologists? Will surgical nurses start performing surgeries?

If so, can someone please suggest a cheap nursing program?

 

[link2swim06]

There are more residency spots available than there are MDs each year.

They are filled by foreign med students....again there are plenty of med students, be in domestic or qualified international.

 

[Jihad]

You premeds who supported the healthcare bill, what do you think of NPs being your equal peers? If you don't agree with that you should get your stories straight because with an even HIGHER DEMAND created by the healthcare bill, these types of things will be necessary. All along we've been saying that helathcare quality will be reduced. Here's one example and others will show up in the future! I can see this leading to a decrease in physician satisfaction and an even crappier healthcare environment!

 

[Ischemic]

I love how terrible this argument is: "The AMA argues the title "Dr." creates confusion. Nurse practitioners say patients aren't confused by veterinarians calling themselves "Dr." Or chiropractors. Or dentists. So why, they ask, would patients be confused by a nurse using the title?"

Except it's context. When you're in a hospital someone called doctor is either a medical doctor or a doctor of osteopathy. Rarely do you get a visit from a dentist or a veterinarian in the hospital.

It's like saying that if people aren't confused about PHDs in theater being called doctor, then why would they be confused about nurses being called doctor? The title means different things in different contexts.

Also, chiropractors are not doctors. It annoys the crap out of me when people called them that. Many of them are quacks, and the rest are physical therapists with illusions of grandeur (I didn't come up with that).

The idea that they should be given more to do because they're doing a good job already is also fallacious. It's like saying a GP is well suited for minor surgery, so they should be allowed to do open heart surgery. Or in the non-medical field, a person who can drive a Toyota should automatically be licensed to drive a tractor trailer.

(like I said in my last post don't take anything I just said too seriously)

Vets, chiropractors, PhDs etc aren't real doctors

Anyway, I'm just gonna be honest here. I busted my ass and jumped through many hoops just to get into med school and as a matter of pride I wouldn't want a nurse calling themselves Dr. Anything. Yes, people have brought up the educational differences but I'm not gonna be ok with someone who didn't qualify for med school assuming and representing themselves as doctors.

You can call me pretentious or elitist or whatever but I worked hard to be where I'm at and will probably continue to work hard in med school/residency and I'll be damned if I'm going to let someone minimize my accomplishments.

 

[Jihad]

Vets, chiropractors, PhDs etc aren't real doctors

Anyway, I'm just gonna be honest here. I busted my ass and jumped through many hoops just to get into med school and as a matter of pride I wouldn't want a nurse calling themselves Dr. Anything. Yes, people have brought up the educational differences but I'm not gonna be ok with someone who didn't qualify for med school assuming and representing themselves as doctors.

You can call me pretentious or elitist or whatever but I worked hard to be where I'm at and will probably continue to work hard in med school/residency and I'll be damned if I'm going to let someone minimize my accomplishments.

Haha that reminds me, for my cardio phys. class the PhD was introducing himself and the other prof (an MD) before class started. He said my colleague is a Medical Doctor and I'm a Real Doctor.

 

[FlowRate]

more and more i regret not becoming a dentist....

Seriously. At least you won't have hygenists pretending they went to dental school!

For less time, investment, training (malpractice insurance? source?)... they get paid like a doctor and now even get to put their nose in the air and be called Dr.

As much as I love nurses, this is an interesting point that reminds me of academic nurses. Anyone ever notice how some of them list EVERY. SINGLE. QUALIFICATION. they can after their name in emails/correspondence/desk plackards, etc.? These include not only BSN, RN, DNP, etc. but also stuff that essentially means "Took CPR training" "took end of life training" "attended an expensive conference." There is a serious culture of one-upmanship and pride in some areas of nursing. Most nurses I know personally, however, are great people. I think it's the aforementioned faction that is causing all of these "rise up and overcome (the MD's)" problems.

 

[ducki303]

The "one-up-ness" quality may be a trend of the younger nurses. I read in some article that the older Nurses take great pride in their work, and feel that their roles are being de-valued in some way, with all the talk about their roles being "obsolete or so limited."

I had an EMT tell me the same thing, in regards to everything a nurse learns. It's pretty amazing when people don't know how limited they are.

One of the amazing thing about good midlevels is that most know their limits. I honestly think that DNPs and regular NPs should be able to practice independently. Much like a PCP has to know when to refer to a specialist, NPs should know when they have to refer to a PCP to handle more complex cases.

+1... something for all professionals.

 

[DrSmooth]

The level of disrespect and ignorance of the nursing field by many in this thread is disappointing. Most of us are premeds and have no business trying to "put nurses in their place". It's not like NPs or DNPs are going to be taking physicians' jobs. They are stepping up to do what most graduating med students don't want to do, primary care. The truth is that MDs/DOs are overqualified to spend their (and the insurance company's) time diagnosing and treating common ailments. Why not have some other well-trained (and training need not be med school level to be adequate) medical professional like an NP or PA handle the grunt work, and refer more complex cases up to "primary care specialist" IM/FM/Peds docs. This simply makes economic sense.

This is no different than the stratification w/in nursing (and medicine) itself. It used to be that nurses took vitals, changed diapers, emptied bed pans, etc. Now CNAs do that (for practically minimum wage). LVNs, RNs and BSNs all have their respective scopes of practice. The same will be true for DNPs as the profession matures. Scopes of practice will get defined and everyone will settle into their niche. The move toward DNP as the accepted standard for NPs is actually a good thing as it involves more training than masters level NP programs. And whether or not they have a Dr. in front of there name is irrelevant. The initials we earn in [allopathic] medical school is "MD", not "Dr". "Dr." is a generic title that applies to almost any professional who has earned a terminal degree in their field. Why should nursing be any different? If patients don't know the difference between an MD, DO, DNP, PA, or whoever else then that is their problem.

BTW, I can't wait to go see an NP when I move to Seattle, at least come June...

 

[Untraditional]

http://news.yahoo.com/s/ap/20100413/ap_on_he_me/us_med_dr_nurse

"I feel that we get more time with the nurse practitioner," Nunez said. "The doctor always seems to be rushing off somewhere."

You don't suppose this has anything to do with Doctors only being able to bill for office visits?

 

[Suenya]

As much as I love nurses, this is an interesting point that reminds me of academic nurses. Anyone ever notice how some of them list EVERY. SINGLE. QUALIFICATION. they can after their name in emails/correspondence/desk plackards, etc.? These include not only BSN, RN, DNP, etc. but also stuff that essentially means "Took CPR training" "took end of life training" "attended an expensive conference." There is a serious culture of one-upmanship and pride in some areas of nursing. Most nurses I know personally, however, are great people. I think it's the aforementioned faction that is causing all of these "rise up and overcome (the MD's)" problems.

Yeah, the academic nurses are crazy. Most of the APRNs I know bitch about them and make fun of them all the time, as well as the alphabet soup they are trying to foist on the average clinical APRNs to go behind their name. It's pretty ridiculous.

 

[FutureDoc4]

The level of disrespect and ignorance of the nursing field by many in this thread is disappointing. Most of us are premeds and have no business trying to "put nurses in their place". It's not like NPs or DNPs are going to be taking physicians' jobs. They are stepping up to do what most graduating med students don't want to do, primary care. The truth is that MDs/DOs are overqualified to spend their (and the insurance company's) time diagnosing and treating common ailments. Why not have some other well-trained (and training need not be med school level to be adequate) medical professional like an NP or PA handle the grunt work, and refer more complex cases up to "primary care specialist" IM/FM/Peds docs. This simply makes economic sense.

This is no different than the stratification w/in nursing (and medicine) itself. It used to be that nurses took vitals, changed diapers, emptied bed pans, etc. Now CNAs do that (for practically minimum wage). LVNs, RNs and BSNs all have their respective scopes of practice. The same will be true for DNPs as the profession matures. Scopes of practice will get defined and everyone will settle into their niche. The move toward DNP as the accepted standard for NPs is actually a good thing as it involves more training than masters level NP programs. And whether or not they have a Dr. in front of there name is irrelevant. The initials we earn in [allopathic] medical school is "MD", not "Dr". "Dr." is a generic title that applies to almost any professional who has earned a terminal degree in their field. Why should nursing be any different? If patients don't know the difference between an MD, DO, DNP, PA, or whoever else then that is their problem.

BTW, I can't wait to o see an NP when I move to Seattle, at least come June...

sa

I highlighted the a above because that statement doesn't make any sense. This is in fact EXACTLY what they are doing. They are taking the jobs of family physicians (MD/DOs). Maybe it's not the job you wanted, but it is the job of many hard working physicians out there want/have.

I also think this is a slippery slope. I mean, is it going to stop? I imagine we will soon see DNP "specializing" in Dermatology, Rheumatology, Endocrinology (many of the outpatient specialties) Why? Because who is going to stop them? They present a cheaper option. And according to many who buy into their propangda "there training is the same as a physician, remember?"

Give it 4-5 years, this is only the beginning. And do remember, that there are MANY new medical schools opening around the country (without the corresponding expansion in residencies). This is going to force many US graduates into primary care residencies (the overall goal). Now, this new workforce of physicians are going to be competing with DNP for patients in the primary care setting to maintain practices. Of course, everyone will say there is a shortage of primary care, which is true BUT ONLY IN GEOGRAPHICAL AREAS. If you want to work in one of the saturated markets, I imagine it will be very tough to keep your doors open, let alone make a living.

I also think if DNPs want this we should require them to take Step 1-3 and pass. Period. That should be the minimum to practice medicine independently in the United States.

 

[dru2002]

The level of disrespect and ignorance of the nursing field by many in this thread is disappointing. Most of us are premeds and have no business trying to "put nurses in their place". It's not like NPs or DNPs are going to be taking physicians' jobs. They are stepping up to do what most graduating med students don't want to do, primary care. The truth is that MDs/DOs are overqualified to spend their (and the insurance company's) time diagnosing and treating common ailments. Why not have some other well-trained (and training need not be med school level to be adequate) medical professional like an NP or PA handle the grunt work, and refer more complex cases up to "primary care specialist" IM/FM/Peds docs. This simply makes economic sense.

This is no different than the stratification w/in nursing (and medicine) itself. It used to be that nurses took vitals, changed diapers, emptied bed pans, etc. Now CNAs do that (for practically minimum wage). LVNs, RNs and BSNs all have their respective scopes of practice. The same will be true for DNPs as the profession matures. Scopes of practice will get defined and everyone will settle into their niche. The move toward DNP as the accepted standard for NPs is actually a good thing as it involves more training than masters level NP programs. And whether or not they have a Dr. in front of there name is irrelevant. The initials we earn in [allopathic] medical school is "MD", not "Dr". "Dr." is a generic title that applies to almost any professional who has earned a terminal degree in their field. Why should nursing be any different? If patients don't know the difference between an MD, DO, DNP, PA, or whoever else then that is their problem.

BTW, I can't wait to go see an NP when I move to Seattle, at least come June...

I'm fine with most of your post but the bolded is ridiculous. Many patients are ignorant and place there trust in the doctor. So while they may not know about PAs, DNPs and the like they know that when they are seriously ill they go to a doctor. If we allow that title to be used by non-physicians in a clinical setting there will be a great number of patients making ill-informed decisions based on their doctor's advice. While I believe that informed consest is never truly informed, because patients didn't go to medical school, it becomes even less informed if the advice they believe is coming from and MD is actually coming from a PA/DNP.

 

[Jihad]

IMO, what a lot of you are not realizing is that even if we "give them" primary care, they are not going to stop there and be happy. They are in all specialties and will demand more rights based on any new rights they are given.

I agree with the above. Regardless of your opinion on the issue, however, this is a LOWERING of the standards of medical care.

You are giving a caregiver an increase in responsibility without an increase in training or an increase in licensing requirements. I believe it is hasty to simply automatically change the scope of an NPs practice as their whole training program was designed for their current role under doc supervision. I am not opposed to the idea in general because there is a huge trend toward specialization in medicine anyway, but I believe we need to work out the kinks in this idea first and ensure that don't simply lower our standards and "hope for the best".

Also I agree with previous posters. New med schools are being opened up which will allow more ppl who wouldn't normally get into med school. These people will have a good likelihood of filling up more primary care positions. I think this is a better move to correct the PC problem

 

[FlowRate]

IMO, what a lot of you are not realizing is that even if we "give them" primary care, they are not going to stop there and be happy. They are in all specialties and will demand more rights based on any new rights they are given.

Yep. This, exactly.

But how do you stop it? Are these nurses unionized? (Aren't most/all nurses unionized?)

This is why your average lawmaker should not be making laws about things that only specialists (engineers, doctors, etc.) truly understand.

I liked how the article said "in a side-by-size comparison... there was not a significant difference." So there WAS a difference and THEY decided what would be significant. Is several extra deaths/major complications insignificant on the grand scale of things here?



I think part of the problem here is that politicians/media/culture have done such a great job disparaging doctors that the role and qualifications are not nearly as respected anymore.

 

[csmittyB]

I wonder when the malpractice lawsuits against DNPs will start?

 

[Untraditional]

I think part of the problem here is that politicians/media/culture have done such a great job disparaging doctors that the role and qualifications are not nearly as respected anymore.

Well when you let anyone call themselves "Doctor" this is what you get. The PhDs, the Psychologists, the Pharmacists, the Chiropractors and the Hypnotists all call themselves "Doctor"

We need to organize and assert ourselves.

 

[mcgyver]

i'm fine with NPs taking over primary care. but insisting to be called "doctor" is a little beyond me.

 

[Suenya]

Well when you let anyone call themselves "Doctor" this is what you get. The PhDs, the Psychologists, the Pharmacists, the Chiropractors and the Hypnotists all call themselves "Doctor"

We need to organize and assert ourselves.

I may be wrong, but if I remember doctor was originally a honorific for academics, not physicians, so the PhDs have even more of a right to it than us.

I'd feel safe to bet that you likely won't find a psychiatrist bitching that a psychologist (PhD/PsyD/EdD level) goes by the title doctor. Maybe you will, but I'd have to imagine the percentage of psychiatrists that would care is less than 0.1%. It's so incredibly much of a nonissue that the reactions many premeds and other people on these boards are pretty crazy seeming and amusing. They aren't pretending to be physicians, it's just the appropriate title.

I feel like this may be true of alot of the turf stuff in general, but I don't know. Getting upset about psychologists calling themselves Dr. Suenya, or whatever, is just laughable though.

 

[DrSmooth]

They are taking the jobs of family physicians (MD/DOs). Maybe it's not the job you wanted, but it is the job of many hard working physicians out there want/have.

I also think this is a slippery slope. I mean, is it going to stop? I imagine we will soon see DNP "specializing" in Dermatology, Rheumatology, Endocrinology (many of the outpatient specialties) Why? Because who is going to stop them? They present a cheaper option. And according to many who buy into their propangda "there training is the same as a physician, remember?"

There is a difference between doing the work traditionally in the scope of practice of FM docs, and "taking the job" of FM docs. I've yet to hear of a family physician lining up for her unemployment check because a lowly DNP edged them out of business. That is because the demand of patients vastly outstrips the supply of MDs and DOs, with millions more patients preparing to join the ranks. So what is your solution to the PC shortage? Even with an increase in med school seats and residency spots, we will still not have enough PC docs to go around, especially post 2014. The only other option is longer hrs & shorter office visits for docs, and longer wait times for patients, is that what you want? Does anyone have evidence that NPs produce poorer health outcomes within their current scope of practice? If health outcomes are comparable it means that MDs/DOs are simply over-trained for some aspects of PC and in order to optimize the system they need to ramp up their level of responsibility and make room for more affordable healthcare practitioners at the bottom level. I believe that is the idea behind the "medical home model", correct?

BTW, "the slippery slope" is not a sound argument, it's a fallacy. http://en.wikipedia.org/wiki/Slippery_slope

 

[DrSmooth]

I'm fine with most of your post but the bolded is ridiculous. Many patients are ignorant and place there trust in the doctor. So while they may not know about PAs, DNPs and the like they know that when they are seriously ill they go to a doctor. If we allow that title to be used by non-physicians in a clinical setting there will be a great number of patients making ill-informed decisions based on their doctor's advice. While I believe that informed consest is never truly informed, because patients didn't go to medical school, it becomes even less informed if the advice they believe is coming from and MD is actually coming from a PA/DNP.

The fact remains that "Dr." is a generic title, even in a clinical setting. Are you saying that DPTs, Psychologists, and Doctorate level speech pathologists have not earned the title of "Dr.", or somehow don't deserve to be called "Dr." when they step into a hospital or clinic? Patient assumptions are irrelevent, health outcomes are what matter. And a patient is no less informed if the *identical information* is being given from the PA/DNP.

 

[Jihad]

There is a difference between doing the work traditionally in the scope of practice of FM docs, and "taking the job" of FM docs. I've yet to hear of a family physician lining up for her unemployment check because a lowly DNP edged them out of business. That is because the demand of patients vastly outstrips the supply of MDs and DOs, with millions more patients preparing to join the ranks. So what is your solution to the PC shortage? Even with an increase in med school seats and residency spots, we will still not have enough PC docs to go around, especially post 2014. The only other option is longer hrs & shorter office visits for docs, and longer wait times for patients, is that what you want? Does anyone have evidence that NPs produce poorer health outcomes within their current scope of practice? If health outcomes are comparable it means that MDs/DOs are simply over-trained for some aspects of PC and in order to optimize the system they need to ramp up their level of responsibility and make room for more affordable healthcare practitioners at the bottom level. I believe that is the idea behind the "medical home model", correct?

BTW, "the slippery slope" is not a sound argument, it's a fallacy. http://en.wikipedia.org/wiki/Slippery_slope

Just because wikipedia says the old form of the slippery slope argument is a 'fallacy' does not mean that there is not legitimate concern for the original poster's prediction.

If you give a moose a muffin...

 

[PetitAllegro]

There are some solid arguments on both sides in this thread. But those of you getting pissy and self-righteous that some uppity nurse is going to be called the sacred DOCTOR are laughable.

 

[ducki303]

Laughable maybe. Juges and laywers are docterates but they still use the title of their profession. I've yet to met a laywer in my office who has insist on being called "Dctor so and so." They are ok with Mr/Mrs/Ms or even Judge.

 

[jcpenny]

http://forums.studentdoctor.net/showthread.php?p=9538251#post9538251 Doctor Nurse Dermatologist

 

[JaggerPlate]

http://forums.studentdoctor.net/showthread.php?p=9538251#post9538251 Doctor Nurse Dermatologist

LOL I literally just made a post in another forum about how this issue was going to expand to other fields, and used derm as an example.

God I don't know why any of us are voluntarily diving into this ****storm.

 

[JaggerPlate]

Is this a fu*cking joke??? Honestly. What the hell is this? I don't even get how doctors can just bend over and take it up the ass in what feels like monthly intervals.

It's starting to be pretty clear that the role of a doctor with regard to clinical practice is over. The only hope is to manage people in what used to be a doctor's job. They stepped aside and let insurance companies, government, and mid-levels take it over, with very, very little fight.

I'm sitting here with an acceptance in hand, trying to physically convince myself to consider diving into this mess, and I really don't know if I even can. It's a joke.

Somehow the fu*cking nurses were able to lobby enough power to get absolutely everything they wanted, but there isn't a single organization that can muster up enough defense to stop this bull****?

The AMA can't stand up and represent docs for once? The LCME can't threaten to pull the accreditation of schools like USF that set up these - f*uck around in undergrad, become a DNP, skip the debt, get a derm residency, and make 300k a year programs???

This is a joke?

I'd like to thank everyone who made this possible ... I wonder how long before they are performing surgery???



I think I really may not go to medical school. It's pointless at this stage, and it's only going to get worse.

 

[FutureDoc4]

There is a difference between doing the work traditionally in the scope of practice of FM docs, and "taking the job" of FM docs. I've yet to hear of a family physician lining up for her unemployment check because a lowly DNP edged them out of business. That is because the demand of patients vastly outstrips the supply of MDs and DOs, with millions more patients preparing to join the ranks. So what is your solution to the PC shortage? Even with an increase in med school seats and residency spots, we will still not have enough PC docs to go around, especially post 2014. The only other option is longer hrs & shorter office visits for docs, and longer wait times for patients, is that what you want? Does anyone have evidence that NPs produce poorer health outcomes within their current scope of practice? If health outcomes are comparable it means that MDs/DOs are simply over-trained for some aspects of PC and in order to optimize the system they need to ramp up their level of responsibility and make room for more affordable healthcare practitioners at the bottom level. I believe that is the idea behind the "medical home model", correct?

BTW, "the slippery slope" is not a sound argument, it's a fallacy. http://en.wikipedia.org/wiki/Slippery_slope

First of all, bravo with the Wiki citation. Real good evidence based information (btw, Wiki is great for looking up things for yourself but doesn't belong in a philosophical argument... if that's what you're looking to have).
I will no longer use the slipper slope argument if that makes you happy. I will phrase it in the following manner: Although there are a multitude of outcomes to the current changes seen in healthcare, the increased autonomy of the DNP may lead the profession to try to further pursue a broader range of practice without physician supervision for autonomy, prestigue, and increased pay without thought of consequence to patient outcomes.

By the way "I have yet to hear of a family physician lining up for her unemployment check..." is pretty extreme hyperbole...which we all know in todays propaganda (seen on networks such as Fox news) is just used to draw attention away from a lack of a coherent argument. Of course, physicians will have jobs for forever (whether that job pays 50K or 120K will depend if you and other future physicians are willing to "defend your turf"---yes, someone will now point out that isn't a "team approach to medicine" You're right and wrong. In the hospital we all work together as a coherent team, but someone, has to lead that team and be in charge and coordinate all this care. That job use to belong to a physician, in the way things are going, this job will be taken over by others.

I have class in a little so I am only go to a half ass job responding to these "knee jerk" response I have seen over and over:


A) "we will not have enough PC doctors by 2014". As previously said, this is an oversimplification of the problem. It is not a pure numbers issue, it is a distribution issue. The number of doctors and access to care is limited in rural areas and away from the coasts. By opening up new practice rights for DNP there is no way to "force them" to these underserved areas. So, you there may be a whole lot of new providers in an area that was already well served. (the answer to this is provide loan forgiveness incenstives and higher pay in underserved areas for physicians--this is already in the works)

B) "MD/DOs are simply overtrained" If you heard this statement 10-15 years ago people would think you were insane. Overtrained? I want everyone in this thread to raise their hand who wants a practitioner with less training. We MUST stop thinking about pure quantity of care and also think of quality. (If I offer you the following: $60 to go shop at wallmart or $40 to go shop at JCrew (not the best store but pretty good), which one would you choose? Isn't more better? No, quality must factor into any equation). Once we lose quality control than the public has lost faith in us. (Don't jump to the DNP vs. MD/DO quality comparison see below)

C) There are not many studies of DNP versus MD/DO cause of the ethical implications of such research (which I will not dwell on much here just to say that we may be subjecting patients to harm without much benefit and IRBs don't like that much) and the difficutly of controlling for outcomes for patients---what do we measure outcome (to me, this is the most difficult)? HbA1C? HTN control? overall mortality? CVD? MI? Strokes? medical compliance? smoking cecessation (the list goes on) Well, what if the MDs see sicker patients? We can try to control for this but the methodology isn't easy.

D) Now comes the argument about cost-effectiveness. That the more DNPs you have (even if you could force them into underserve areas), would not likely be more cost effective in this Home based team model that you speak of (there is controversy behind this but here is an artcle from JAMA--notice not a Wiki citation). Of course, this article extols the fact that there is a better outcome (but it COSTS) a lot whole more and if your argument that this home based care lead by DNPs are going to be effective and COST saving (which we all know it the point of using a DNP rather than a MD/DO).. think again.

http://jama.ama-assn.org/cgi/conten...re&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT


That's all for now.

I hope you all are at least aware of how these things will (notice, not if) in the future.

 

[Instatewaiter]

I am with the other poster. Who said we should simply standardize the level of training across the industry. Nurse's who want to be doc's should just take all the same tests and complete a residency. Fair is fair. I would even do it on their terms as long as they can pass the USMLE's.

It should be more than just passing the USMLEs. There is so much more training that goes into being competent than just passing step 1,2 and 3. If you cannot pass the steps, I hate to say it but you have no business practicing medicine.

Probably not many know this but the DNPs at Columbia (the most strenuous DNP program) took a watered down version of step 3. They lowered the required passing score, hand picked the questions and took out the more difficult portions of the test (CCS). Nonetheless, 50% failed the exam. This is an easier version of step 3 that >95% of interns pass on the first try (and don't study for much).

There is a saying, 2 months to study for for step 1, 2 weeks for step 2, and bring a number 2 pencil for step 3 (because you don't have time to study for step 3 during your intern year). The steps are necessary but not sufficient to prove someone is a competent provider.

It's not like NPs or DNPs are going to be taking physicians' jobs. They are stepping up to do what most graduating med students don't want to do, primary care. The truth is that MDs/DOs are overqualified to spend their (and the insurance company's) time diagnosing and treating common ailments. Why not have some other well-trained (and training need not be med school level to be adequate) medical professional like an NP or PA handle the grunt work, and refer more complex cases up to "primary care specialist" IM/FM/Peds docs. This simply makes economic sense.

Actually, the nursing lobby is saying exactly that they are equivalent to physicians. They are watering down primary care with much less education. The thing is that you cannot tell what is a "common ailment" without the proper knowledge.

So let's say your female patient comes in for their yearly visit in the winter. They're doing fine but they have some itchy skin. Physical exam elicits no pain and is basically normal except some yellowing of the eyes. Will the nurse think it's normal dry skin that's so common in the winter or will he/she realize this is a classic early presentation of pancreatic cancer and run the appropriate tests?

 

[Instatewaiter]

The move toward DNP as the accepted standard for NPs is actually a good thing as it involves more training than masters level NP programs. And whether or not they have a Dr. in front of there name is irrelevant. The initials we earn in [allopathic] medical school is "MD", not "Dr". "Dr." is a generic title that applies to almost any professional who has earned a terminal degree in their field. Why should nursing be any different? If patients don't know the difference between an MD, DO, DNP, PA, or whoever else then that is their problem.

BTW, I can't wait to go see an NP when I move to Seattle, at least come June...

The DNP actually doesn't involve more relevant training compared to the Masters. Here's some proof. I selected 2 top tier programs that offer either the DNP or the masters level NP- Duke and MGH (Harvard's most well known hospital). Duke offers a masters and Harvard the DNP.

http://nursing.duke.edu/wysiwyg/down...e-mat-plan.pdf
http://www.mghihp.edu/academics/nurs...um/family.aspx

Harvard DNP vs Duke NP
Path- 2 credits vs Path 3 credits
Pharm 3 vs Pharm 3 credits
Population health 3 vs Population based approach 3
Diagnostic reasoning 4 credits vs Diagnostic reasoning 4
“Residency”- 5 credits vs "Residency" 4
Measuring outcomes- 3 credits vs Health outcomes 3
Designing research 2 credits vs Research methods 3
Research analysis 3 credits vs Research utilization 3
Fm health I, II, III 11 credits vs management of health problems 8
Biostats 3 credits vs Statistics 2 credits
Adolescent 3 credits and psych 3 credits vs Child 4 credits and Sexual/reproductive 4 creditis
Screening 2 credits vs Disease prevention 3 credits

Where the extra credits of the DNP go you ask?
18 credits of non-clinical courses: Healthcare policy, leadership, professionalism, Communication, Informatics, Theory of knowledge development, capstone

6 credits of clinical courses: Practicum and diagnostic measures

So in the end, 6 credits of clinically relevant courses separate a clinical masters from a clinical "doctorate."

 

[Instatewaiter]

This is an RN to DNP curriculum from MGH Adult Primary Care.
http://www.mghihp.edu/academics/nurs...mary-care.aspx

Clinically related courses (35- 43 credits)
2 Credits Advanced Pathophysiology3 Credits Advanced Pharmacology
4 Credits Adv Assess/Diag Reas - Adult
3 Credits Chld/Adol Psych Mental Hlth
5 Credits DNP Residency
3 Credits Nsg Mngmt/Adlt: Prim Care I Th
3 Credits Nsg Mngt Adlt: Prim Care II Th
3 Credits Nsg Mgmt Adlt: PC III Theory
3-6 Credits Nsg Mgt Adltrim Care I Clin
3-6 Credits Nsg Mgt of AdltC II Clinical
3-6 Credits NU Mgmt Adlt: PC III Pract


Non-clinical fluff (33-43 credits)!!!!
3 Credits Hlth Care Policy & Politics
3 Credits Leadership for Adv. Nu Pract.
2 Credits Professional Issues
3 Credits Population Health
3 Credits Outcomes measurement3 Credits Survey of Health Care Informatics
2-3 Credits Designing Clin Rsrch
3 Credits Knowledge & Inq Dev for NP
3 Credits NU Research, Analysis & Crit
3 Credits Mentored doctoral practicum
3 Credits Intermediate biostatsitics
2 Credits Capstone project

Here is the medical curriculum at my school (estimated credits using 14h in the classroom as a single credit- ie how every university does it.)

First 2 years:
Clinically related 104 credits
Medical Genetics
Anatomy
Physiology
Histology
Immunology
Behavioral sciences
Neuroanatomy-
Foundations of clinical medicine
Geriatrics
Microbiology
Pharm
Intro to pathogenesis- 1 credit (almost all path is in the organ systems)

Systems: takes pathophys, pharm and micro involved in the organ system
Heme/onc
Endocrine
Renal -
Resp-
Cardio
Behavioral/psych-
Neurology-
Women's health/OB-
GI-
MSK/ortho-


Less clinically related 11 credits
Pop med (statisitcs, etc)
Medical Biochemistry
Ethics

Clinical Hours for which you do not get "credits" in 3rd/4th year
Pediatrics 600 hours
Surgery 650 hours
Neurology 200 hours
Family med 200 hours
OB/GYN- 400 hours
Pysch- 300 hours
IM- 720 hours
ICU- 250 hours
Medicine 2- 300 hours
Electives (min allowed) 640 hours

Total 3rd year clinicals (not including most of 4th year electives) : 4250 hours of clinicals


Notice a good 40-50% of the DNP is fluff courses and nonclinical. While in the MD curriculum it is less than 10% of the first and second year courses are non-clinical and no hospital rotations (3rd and 4th year) are non-clinical. Furthermore there are 1000 hours of clincals (or less) required and these are included in the "credit hours" of the DNP.

 

[Instatewaiter]

So in summary-
The RN--> DNP is 72 credits half of which is fluff. Note the 72 credits includes the 1000 hours of clinicals

The MD is roughly 115 credits not including the 4200 hours of medical school clinicals or the roughly 10,000 hours for residency.

And they want equal rights as a family practice doc? Anyone else have a problem with this?

 

[JaggerPlate]

Anyone else have a problem with this?

Uhhh me.

It doesn't matter though. No one is going to do anything about it. Oh the AMA 'disapproves.' Oh man, the huge nursing lobby must be shaking in their boots. Is this the same organization that supported a health care bill that gave midwives 100% OB/GYN Medicare reimbursement??? Super.

Keep in mind too that the general population hates doctors. They think we are whiny, overpaid, gluttons, who remove limbs for profit and support big, bad Pharm companies. I.E. don't expect any sympathy. Docs are such an easy punching bag ... hit us all you want, cut compensation, let others take our jobs with 1/10th the training, give up autonomy, etc.

Doctors themselves won't do anything about it either. They will bitch on the internet, but there is no real organization or group to stand up and make this stop happening. Nope.

It's over. I'm serious. If this isn't the final nail in the coffin, I don't know what is. Just look at the last few months ... it's unreal.

We are all bright, motivated individuals, and our talents are now better suited elsewhere.

 

[ragudude]

I think I'm still gonna do this because it's ultimately what I want to do...

that being said...for those mother theresa types out there who said "well there's no money in medicine anymore, but hey at least there's the prestige"... bend over and read this article.

I can see JaggerPlate there at home, and out of toilet paper...looking intensely at his acceptance letter haha. Anybody else feel like they may have just had their American Dream ripped out from under your feet?

I feel ya man, I do. I'm not saying this to make fun of you, or to sound self richeous... I myself had to sit around for a while and really think about this... I kinda still am...I never thought I would have to even think about this decision. I thought the greatest decision I would have to make would be school x or school y, not the more broad question of to be a doctor or not to be a doctor.... and I'm scared, I'll admit that. I worry that if I even have to remotely ask this question, then maybe I shouldn't do this.

Honestly, I think the smartest of the smart out there will be those who get into med school, but ultimately decide not to matriculate. Jeez, even in the time it takes me to write this I'm vascillating.

 

[JaggerPlate]

Anybody else feel like they may have just had their American Dream ripped out from under your feet?

Little by little for the past few months ... this one is really the icing on the cake though.

If I do go to medical school ... it will be, like you said, just because it's something I've always wanted to do. I won't do a residency. I may do an internship just to have the option to go back if I ever wanted to, but there's no point in clinic practice anymore (aside from a few lucrative things, which I may look into). Derm was the great white hope, and that's done now. I guess you can still spend 8 years in residency doing Plastics and hope to do something lucrative there ... but keep in mind you'll be 40 when you start.

I'm just going to go into Admin, or consulting, or managing practices, etc. I think anyone with business sense or an interest in business should do the same. Do some volunteer clinic work or work part time in one of the Urgent Care centers you OWN to fulfill that desire to practice 'medicine.'

OR better yet ... get the god damn DNP. Work half as hard, screw around, enjoy yourself, and then become a dermatologist.

 

[ragudude]

What really gets me though is that when I tell people I'm concerned... People first look at me and give me a look as if "how dare you care about money, you should'nt care about money. We shouldn't have to pay you in dollars, you should be happy to receive payment in the form of warm fuzzy feelings." If only I could pay that mortgage with warm fuzzy feelings, I'd be flippin rich.

Then they tell me Docs will be in demand now more than ever. "Don't worry," they say "you'll be paid and paid handsomly, you'll have to there's a shortage... it will all work out." What they fail to realize is that doctors are already in a shortage and where the supply and demand of healthcare currently intersects unfortunately excludes nearly 50m people from the system. When the healthcare bill goes into effect, there is no way that we can do all of the following 3 things at once: a) expand coverage to 32m people, b) cut costs, c) maintain current reimbursements to healthcare providers. No, we can only do any 2 at once, including all three contradicts at least one of the other 2 goals.

To explain my point differently, consider this: when you walk into a doctor's office, what do you see? A reception desk, and a waiting room. Ad hoc, the fact that the waiting room exists implies that the doctor is already at full capacity for the day, and was already plenty busy taking care of patients with the willingness and ability to pay.

I contemplated how this would shake out. How are they going to meet the demand for the extra 32m people? The government is not in the business of paying docs more...in fact they've been paying less ever since 1987. "Hey doc, can you increase your patient load by say 5-10 a day? We'll make it worth your while, we'll pay you an additional $40 per office visit above 30 pts." I don't think it will work that way. Rather they will make it easier to become a doctor to meet the demand.

And I didn't think of this when I first read the article, but this serves the point. They will increase the number of med schools (4 this year) and give more responsibility to nurses who require less cost and time to train. Oh and they even call them Dr. too..

 

[JaggerPlate]

What really gets me though is that when I tell people I'm concerned... People first look at me and give me a look as if "how dare you care about money, you should'nt care about money. We shouldn't have to pay you in dollars, you should be happy to receive payment in the form of warm fuzzy feelings." If only I could pay that mortgage with warm fuzzy feelings, I'd be flippin rich.

Then they tell me Docs will be in demand now more than ever. "Don't worry," they say "you'll be paid and paid handsomly, you'll have to there's a shortage... it will all work out." What they fail to realize is that doctors are already in a shortage and where the supply and demand of healthcare currently intersects unfortunately excludes nearly 50m people from the system. When the healthcare bill goes into effect, there is no way that we can do all of the following 3 things at once: a) expand coverage to 32m people, b) cut costs, c) maintain current reimbursements to healthcare providers. No, we can only do any 2 at once, including all three contradicts at least one of the other 2 goals.

To explain my point differently, consider this: when you walk into a doctor's office, what do you see? A reception desk, and a waiting room. Ad hoc, the fact that the waiting room exists implies that the doctor is already at full capacity for the day, and was already plenty busy taking care of patients with the willingness and ability to pay.

I contemplated how this would shake out. How are they going to meet the demand for the extra 32m people? The government is not in the business of paying docs more...in fact they've been paying less ever since 1987. "Hey doc, can you increase your patient load by say 5-10 a day? We'll make it worth your while, we'll pay you an additional $40 per office visit above 30 pts." I don't think it will work that way. Rather they will make it easier to become a doctor to meet the demand.

And I didn't think of this when I first read the article, but this serves the point. They will increase the number of med schools (4 this year) and give more responsibility to nurses who require less cost and time to train. Oh and they even call them Dr. too..

Here's the problem with all those arguments (you're right to question and be wary):

1. The people who tell you this stuff are *****ic pre-meds. These are the people that are so hard-wired to this alternate reality of only living in semester increments and doing whatever it takes to get into medical school, that they have absolutely no idea what's happening in the real world and how it's affecting their end goal. Frankly, they don't care. Their singular goal is going from pre-med to med student, and NOTHING matters outside of that.

This is where you get laughable statements like, nah dude you'll be making bank. Or, if you go into it for the money you're a sellout. It's obviously completely asinine, and any adult who has spent 5 minutes in the real world knows that ROI and being able to afford life is ... well, pretty much the only thing that does matter.

2. The shortage, in and of itself, is questionable. First, there are only a shortage of certain docs ... i.e. primary care. Furthermore, the real bad shortages are in rural areas. There isn't a shortage of plastic surgeons, or Urologists ... not doctors in general. There is a shortage of PC docs.

Better yet ... what is their solution??? Give the field away to somebody else that is less trained and less able to help people. BETTER yet, add 32 million people into the system, then give it away. Let's not add incentives, or make it a good place for the best and the brightest ... nah. Give it away.

Also, the supply and demand situation with regard to PC is a fallacy. You could be the only PC in Northern America, and if you still took insurance, you wouldn't be doing better than they are now. Insurance pays you certain rates, for certain things. You also have a set number of hours in a day. You can only see a reasonable amount of patients at set reimbursement rates for a set number of hours.

What the hell does it matter if there are 30 million people begging for your care, if you can only see 20 a day and you really can't pick and choose what cases you see??? You could work 18 hour days. You could see 10 patients an hour. How long is that going to last???

Set number of patients, set number of hours, set/bad rates per hour. Doesn't matter how many people are clawing down your door.

Now, if you say fine ... I'm only accepting cash and see who sticks around. Different story.

 

[ragudude]

And Jagger, I know the idea of going into medicine today, with so many unknowns, may seem a little crazy... but the idea of going through all this, and getting an MD degree for any reason other than clinically treating patients, is even more absurd.

 

[JaggerPlate]

And Jagger, I know the idea of going into medicine today, with so many unknowns, may seem a little crazy... but the idea of going through all this, and getting an MD degree for any reason other than clinically treating patients, is even more absurd.

Eh ... it depends. If it gives me a leg up having my MD/DO + MHA in getting a hospital CEO position for example (compared to someone who just has a MHA or MBA) then it's really not absurd, at all. I probably should do a residency because then I have all the non-clinical options + that to fall back on ... but I'm starting to have less and less interest.

 

[ragudude]

wow you write fast. I agree with many of your points. But thats the thing man... we can't do it all alone... they have to increase the number of healthcare providers or add more hours to the number in the day, or ask us to work more quickly, and cut patients off mid sentence while theyre explaining their symptoms and make a quick diagnosis on the spot. ( Lawyers will be thrilled, I'm sure). If this doesn't sound possible... allowing nurses to fill the void may seem plausible.

I hear you on ROI... except there's more to it than that... If it were simply money, that would be one thing. People often forget the ROT, return on time... or ROE, return on effort ( not equity).


Dude, don't worry man... you'll make bank. And if you go bust.. no worries, you'll get a bail out. It's the american way.


Cash only may be difficult to pull off. It would have been easier if health insurance weren't mandated. I also wonder if we'll be legally able to ask for a cash out -of -pocketpremium for our services above and beyond what insurance or medicare/medicaid will pay.