Equal pay for Equal Work NP

[DrMaccoman]

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So if NP's earned Equal pay for Equal work in Oregon and increasingly in other states, Does that mean an adjunct professor with a masters degree deserves equal pay for equal work compared to a tenured doctorally trained professor?

Does that mean an LPN who can basically do everything an RN can do deserve the same pay and scope of practice that a bachelors or associates trained RN?

Does that mean an EMT who received 100 hours of training and passed the EMT Boards aka the EMT certification deserve the same pay as a paramedic who spent 2000 hours/2 years of training because a paramedic is basically an EMT, but can put in an IV which isn't too difficult?

Does this mean that a paramedic who has a similar if not more advanced scope of practice as an ER RN, Earn the rights to practice in hospitals with the same duties/pay as an ER RN?

Add your own thoughts, comments, or critiques about equal pay for equal work.

 

[FrkyBgStok]

I once had a doc explain to me his argument for the NP/MD stuff. He argued that the big problem is that NPs want the same pay for the same work because they are actually doing the same work and they shouldn't be, and that is the fault of the FPs. He was a family practice doc that was arguing that we physicians have been operating below our level because of the system and the NPs should be doing the well adult checks and the ear infections, while the physicians should be doing the more complicated patients that the NPs don't feel comfortable taking. The system isn't set up this way, but he argued that it should shift so instead of FPs and NPs operating at 5/10 difficulty all the time, the NPs operate at a 5 all of the time and the FPs operate at an 8. Then we wouldn't be worried about encroachment.

I haven't really delved more into the issue, but it always seemed like an interesting take on it to me.

 

[Perrotfish]

I once had a doc explain to me his argument for the NP/MD stuff. He argued that the big problem is that NPs want the same pay for the same work because they are actually doing the same work and they shouldn't be, and that is the fault of the FPs. He was a family practice doc that was arguing that we physicians have been operating below our level because of the system and the NPs should be doing the well adult checks and the ear infections, while the physicians should be doing the more complicated patients that the NPs don't feel comfortable taking. The system isn't set up this way, but he argued that it should shift so instead of FPs and NPs operating at 5/10 difficulty all the time, the NPs operate at a 5 all of the time and the FPs operate at an 8. Then we wouldn't be worried about encroachment.

I haven't really delved more into the issue, but it always seemed like an interesting take on it to me.

I have no earthly idea how you would achieve this kind of triage in primary care. I'm a primary care Pediatrician and on a normal day my schedule is a bunch of kids with innocuous sounding complaints, and I know that odds are one of them will actually be very sick. The 1-3 sick needles in the haystack of 20 patients reveal themselves during the history and exam. Even on those rare days when I know a patient has a serious illness walking in the door that's not the patient I need all the medical training for. When I know what they have figuring out what to do about it is usually pretty easy.

 

[FrkyBgStok]

I have no earthly idea how you would achieve this kind of triage in primary care. I'm a primary care Pediatrician and on a normal day my schedule is a bunch of kids with innocuous sounding complaints, and I know that odds are one of them will actually be very sick. The 1-3 sick needles in the haystack of 20 patients reveal themselves during the history and exam. Even on those rare days when I know a patient has a serious illness walking in the door that's not the patient I need all the medical training for. When I know what they have figuring out what to do about it is usually pretty easy.

and maybe it is impossible. like i said, i haven't looked into at all. sounded good, but you are right. it doesn't seem feasible.

 

[allantois]

If they are doing the same work, then there's no good argument against equal pay.

If it wasn't for NPs and PAs, people would be dying because they wouldn't get to see their doctor on time. The medical training system is too elitist and ineffective to provide affordable care to 300 million people.

 

[cbrons]

If they are doing the same work, then there's no good argument against equal pay.

Except the one made in post #1? You need to be able to read though. Can you read?

Sent from my SM-N910P using SDN mobile

 

[OnePunchBiopsy]

Although work may be equal in some cases, pay is dependent on liability as well as work.

Weird example, but look at lifeguarding. I was once a 16 year-old making $10 an hour to sit and watch people swim, while my friends working at fast food restaurants made minimum wage, and arguably worked much harder. Why the pay difference? Because someone could die in a swimming pool under my watch, while there is less chance of this happening at a McDonald's. (Seriously though, lifeguarding is over-glorified babysitting 95% of the time)

One major reason physicians make more is because they assume the most liability for patient care. If something goes wrong, the buck stops with them. They are the ones who sign the bottom line.

 

[deleted702880]

Admittedly, I know little of how nurse practitioner education works aside from some of the schools being online.
Do they pay the same malpractice insurance premiums? If not and they demand equal pay then it's only fair to need to pay the same (or greater, due to less training increasing liability) costs. And everyone who recommended NP/PA to me stated it is supposedly less strenuous and more forgiving for medical professionals seeking more family time so it strikes me as odd that equal work can be a thing unless you are a particularly zealous NP.

In any case, there needs to be a balance in how changes like this are enacted and I don't think that simply increasing NP pay for "the equivalent work" is an intelligent decision, especially since it isn't equal work due to differences in training and subsequent responsibility. If a NP could reach MD/DO levels of training through a post-NP institution (of comparable total cost to actual medical school and not online) and take the required boards to practice as a special NP then I'd be more confident about giving those NPs equal pay for their work as they will have actually earned it. As it stands, straight up increasing pay would make going NP way more favorable than the traditional family medicine route at the potential cost of patient safety.

 

[deleted480308]

I once had a doc explain to me his argument for the NP/MD stuff. He argued that the big problem is that NPs want the same pay for the same work because they are actually doing the same work and they shouldn't be, and that is the fault of the FPs. He was a family practice doc that was arguing that we physicians have been operating below our level because of the system and the NPs should be doing the well adult checks and the ear infections, while the physicians should be doing the more complicated patients that the NPs don't feel comfortable taking. The system isn't set up this way, but he argued that it should shift so instead of FPs and NPs operating at 5/10 difficulty all the time, the NPs operate at a 5 all of the time and the FPs operate at an 8. Then we wouldn't be worried about encroachment.

I haven't really delved more into the issue, but it always seemed like an interesting take on it to me.

the problem is they always "feel comfortable" doing more than they should

 

[ProfMD]

I do not support equal pay for APNs. Physicians are more valuable to the system, have invested more time and money and should be paid for it.

I also want to mention a couple other things. First, there are no online only APN programs. They all require clinical hours.

Second, statements like APNs "always" feel more comfortable than they should or "never" ask for help when they need it are demonstrably untrue. I can provide plenty of examples to the contrary. We have no data to tell us if APNs are more or less likely to ask for help. In my experience, it is the former.

 

[Mad Jack]

I once had a doc explain to me his argument for the NP/MD stuff. He argued that the big problem is that NPs want the same pay for the same work because they are actually doing the same work and they shouldn't be, and that is the fault of the FPs. He was a family practice doc that was arguing that we physicians have been operating below our level because of the system and the NPs should be doing the well adult checks and the ear infections, while the physicians should be doing the more complicated patients that the NPs don't feel comfortable taking. The system isn't set up this way, but he argued that it should shift so instead of FPs and NPs operating at 5/10 difficulty all the time, the NPs operate at a 5 all of the time and the FPs operate at an 8. Then we wouldn't be worried about encroachment.

I haven't really delved more into the issue, but it always seemed like an interesting take on it to me.

Nothing but complicated nightmare patients day in and day out? Sounds like a good way to lose your damn mind and have your liability jacked up through the roof. Bread and butter keeps you sane- difficult patients are difficult to deal with all day long.

 

[Mad Jack]

If they are doing the same work, then there's no good argument against equal pay.

If it wasn't for NPs and PAs, people would be dying because they wouldn't get to see their doctor on time. The medical training system is too elitist and ineffective to provide affordable care to 300 million people.

>medical training is too elitist because it turns out top-notch providers that can give patients the best care possible, therefore we need a second system that provides substandard care

So what's your alternative, making medical training worse so that everyone gets substandard care? Russia did that after the revolution, look at where that got their medical system.

 

[username456789]

I do not support equal pay for APNs. Physicians are more valuable to the system, have invested more time and money and should be paid for it.

I also want to mention a couple other things. First, there are no online only APN programs. They all require clinical hours.

Second, statements like APNs "always" feel more comfortable than they should or "never" ask for help when they need it are demonstrably untrue. I can provide plenty of examples to the contrary. We have no data to tell us if APNs are more or less likely to ask for help. In my experience, it is the former.

We get it, you make your money on the backs of mid levels.

Just don't keep chiding people here who resent you a little bit for selling our profession up the river.

 

[username456789]

Nothing but complicated nightmare patients day in and day out? Sounds like a good way to lose your damn mind and have your liability jacked up through the roof. Bread and butter keeps you sane- difficult patients are difficult to deal with all day long.

Exactly. The people who make the arguments above about doctors only seeing the most complicated patients clearly haven't thought it through.

 

[deleted480308]

I do not support equal pay for APNs. Physicians are more valuable to the system, have invested more time and money and should be paid for it.

I also want to mention a couple other things. First, there are no online only APN programs. They all require clinical hours.

Second, statements like APNs "always" feel more comfortable than they should or "never" ask for help when they need it are demonstrably untrue. I can provide plenty of examples to the contrary. We have no data to tell us if APNs are more or less likely to ask for help. In my experience, it is the former.

As profession it's absolutely true that they feel comfortable with more than they should. You can't demonstrate otherwise to anyone with more than a cursory knowledge of the legislative lobbying efforts

 

[Mansamusa]

If they are doing the same work, then there's no good argument against equal pay.

If it wasn't for NPs and PAs, people would be dying because they wouldn't get to see their doctor on time. The medical training system is too elitist and ineffective to provide affordable care to 300 million people.

Literally in every field in existence pay is commensurate with background experience, educational paygrade, etc. For example, a research tech in my lab makes 17% more than I do because he has a masters. We do the exact same job and I have more experience than him, but he has more training. If I want to get to his pay level, I can go get the degree necessary

And NP and PAs will still be doing their job if pay continued at the same level, so I don't understand the second line. All the PAs and NPs I know make $100-150K. My sister is pulling over $100K at 25 and she was able to work in school, so she has no debt either. That is more than adequate compensation for someone with a masters degree and no additional training.

Edit: And what do you suggest NPs and PAs make? Do you think they should be at ~$200K+? Would you chose to go to med school if PAs and NPs made salaries like that?

 

[ProfMD]

We get it, you make your money on the backs of mid levels.

Just don't keep chiding people here who resent you a little bit for selling our profession up the river.

I use the mid levels to enhance the efficiency of the practice. However, I still work longer hours, make bigger decisions, take more liability, and bring in more revenue. Therefore, I get paid more. Would you suggest that a CEO make the same money as a VP or department manager? Isn't the CEO simple making money off the backs of his employees?

As I read these forums, particularly with regard to mid-levels, I see most of the arguments against them are made from one of several questionable angles:
1) APNs go to school less so must be worse. Truth is that many APNs go to school only to learn primary care - not surgery, labor and delivery, intensive care, oncology, all the other things physicians need exposure to. Therefore, less school is not necessarily inappropriate.

2) Medical school is competitive and therefore doctors are smarter. While this may be true on average, you cannot apply this to individuals. Just as we individually evaluate med school grads to decide if they can practice, the same approach can, should, and is used to evaluate APNs.

3) It is not fair; I spent more time in school; I paid more money. This argument is a non-starter. It is about you. What the arguments need to be about are the APNs and patients.

4) There are online only APN programs. This statement is simply false.

5) Physicians who support APNs are traitors and sell-outs and I resent them. Ad hominem attacks do not support your position. Also, am I supposed to be bothered by something anonymous posters on an Internet forum, most of whom are still in med school, say about me?

 

[allantois]

I realized that my original post didn't really address the topic. So, here's my take on it: I don't know what anyone should be paid, I think that should be set by the market. If, however, an NP is doing the exact same job as an FP, then it would seem fair to me that they get paid at the same rate. I do no agree that education in itself entitles one to any level of pay; if I chose to go to school for 10 years to get a degree in basket weaving, that doesn't mean that I'm entitled to any level of pay. In my opinion, people are paid to perform a specific job; they are not paid just because they went to school for any number of years.

My original comment meant to point out that NP and PA programs bloomed precisely because the traditional medical system failed at meeting the demand in the market (especially in areas of anesthesiology and primary care). The more any given specialty tries to restrict the supply of physicians into the specialty, the more effort there will be to provide that care by alternative providers. If an NP or PA can in fact do the same job as a physician, it really tells us something about the medical training. If one can get from NYC to Boston in 1 hour (NP), there's no reason for why your driver should first take you to Philly so that he can then demand a higher fee for the trip (MD).

 

[deleted480308]

I use the mid levels to enhance the efficiency of the practice. However, I still work longer hours, make bigger decisions, take more liability, and bring in more revenue. Therefore, I get paid more. Would you suggest that a CEO make the same money as a VP or department manager? Isn't the CEO simple making money off the backs of his employees?

As I read these forums, particularly with regard to mid-levels, I see most of the arguments against them are made from one of several questionable angles:
1) APNs go to school less so must be worse. Truth is that many APNs go to school only to learn primary care - not surgery, labor and delivery, intensive care, oncology, all the other things physicians need exposure to. Therefore, less school is not necessarily inappropriate.

2) Medical school is competitive and therefore doctors are smarter. While this may be true on average, you cannot apply this to individuals. Just as we individually evaluate med school grads to decide if they can practice, the same approach can, should, and is used to evaluate APNs.

3) It is not fair; I spent more time in school; I paid more money. This argument is a non-starter. It is about you. What the arguments need to be about are the APNs and patients.

4) There are online only APN programs. This statement is simply false.

5) Physicians who support APNs are traitors and sell-outs and I resent them. Ad hominem attacks do not support your position. Also, am I supposed to be bothered by something anonymous posters on an Internet forum, most of whom are still in med school, say about me?

https://www.southuniversity.edu/onl...practitioner-master-of-science-in-nursing-msn

 

[Mansamusa]

I realized that my original post didn't really address the topic. So, here's my take on it: I don't know what anyone should be paid, I think that should be set by the market. If, however, an NP is doing the exact same job as an FP, then it would seem fair to me that they get paid at the same rate. I do no agree that education in itself entitles one to any level of pay; if I chose to go to school for 10 years to get a degree in basket weaving, that doesn't mean that I'm entitled to any level of pay. In my opinion, people are paid to perform a specific job; they are not paid just because they went to school for any number of years.

My original comment meant to point out that NP and PA programs bloomed precisely because the traditional medical system failed at meeting the demand in the market (especially in areas of anesthesiology and primary care). The more any given specialty tries to restrict the supply of physicians into the specialty, the more effort there will be to provide that care by alternative providers. If an NP or PA can in fact do the same job as a physician, it really tells us something about the medical training. If one can get from NYC to Boston in 1 hour (NP), there's no reason for why your driver should first take you to Philly so that he can then demand a higher fee for the trip (MD).

The point is that they can't do the same job and that because of their level of education, there will be things that they miss because they simply don't have the knowledge needed to catch them.
That's why you absolutely 100% should get paid according to your education. I go to dental students to get my dental care, they do the exact same work that a dentist would have done, should they charge the same amount? If I need guidance for constructing a contract, who should charge more- a paralegal or a lawyer who specializes in contract law? They both are doing the same thing but on completely different levels

And there is projected to be a surplus of CRNAs by 2020, so if we are going by markets, CRNAs should be getting pay decreases.

 

[ProfMD]

https://www.southuniversity.edu/onl...practitioner-master-of-science-in-nursing-msn

That program must have a way of getting its students clinical hours. No clinical hours, no certfifcation. No certification, no practice.

And as far as lobbying goes, I am not sure of the point or how that trickles down to individuals wanting to practice. Lobbyists as a general rule push an agenda that is not always supported by strict evidence. I am sure this happens with APNs, just as it happens with environmental activists, coal mining lobbyists, lobbyists for or against free trade, lobbyists for defense contractors, lobbyists for health insurance companies, etc.

People seem to be arguing that all nurse practitioners want to practice outside their scope. I am saying that this is untrue because all or none statements often are. There are good APNs, there are bad APNs just as there are good doctors and bad doctors. This is why we have government regulators, hospital credentialing committees, and individual supervisors to oversee the practices of individuals and weed out the bad ones. Of course this system is not perfect - that is why there are still bad APNs and bad physicians out there.

 

[Mansamusa]

That program must have a way of getting its students clinical hours. No clinical hours, no certfifcation. No certification, no practice.

I agree, but programs that require you to set up your own clinical rotations like many NP programs do, don't have much oversight or regulations of standards. It's actually a big problem in NP education- and one that many NPs and NP leaders admit to and want to reform.

 

[VA Hopeful Dr]

If they are doing the same work, then there's no good argument against equal pay.

If it wasn't for NPs and PAs, people would be dying because they wouldn't get to see their doctor on time. The medical training system is too elitist and ineffective to provide affordable care to 300 million people.

That's an awful lot of wrong squeezed into a single post. Bravo

 

[Law2Doc]

Even if an NP does the identical job function during the day, it's not the same work if it doesn't come with the underlying training and expertise. By that argument you should be paying every inexperienced person the same as someone with vastly more training and knowledge. For example, if I bring my medical knowledge and skill to bear, weigh the benefits and risks for that patient in particular and society in general, and ultimately decide a patient needs a z-pack while the NP at CVS Minute Clinic just follows their daily algorithm without a second thought and prescribes a z-pack, the same "work" has occurred but the patient hasn't had the benefit of anything close to equivalent service. You don't pay a house painter the same as a classically trained artist even though they both "paint" right? Or pay the taxi driver the same as a NASCAR race car driver because they both "drive"? It's a silly argument. The pay is for getting someone to bring their skillset and training to bear, not the wearing a white coat and scribbling on a prescription pad. So it's a just an absurd argument to make.

Law has done a very good job of defining what constitutes "the practice of law" in each state, and has aggressively sued and criminalized paralegals, realtors and accountants who have tried to cross those lines. Doctors should lobby for the same.

 

[ProfMD]

I agree, but programs that require you to set up your own clinical rotations like many NP programs do, don't have much oversight or regulations of standards. It's actually a big problem in NP education- and one that many NPs and NP leaders admit to and want to reform.

Then rather throw out the entire concept of an APN, why not help reform the education? Institute stricter standards for accreditation, especially if APN leaders are already on board. There was a time - nearly a century ago, when medical education was substandard. Then came the Flexner report and education reform.

If or until that happens, offices and hospitals looking to hire APNs or state agencies looking to license APNs have the right and responsibility to dig into the practitioners education/work history and experience, just as they do for physicians.

 

[VA Hopeful Dr]

I use the mid levels to enhance the efficiency of the practice. However, I still work longer hours, make bigger decisions, take more liability, and bring in more revenue. Therefore, I get paid more. Would you suggest that a CEO make the same money as a VP or department manager? Isn't the CEO simple making money off the backs of his employees?

As I read these forums, particularly with regard to mid-levels, I see most of the arguments against them are made from one of several questionable angles:
1) APNs go to school less so must be worse. Truth is that many APNs go to school only to learn primary care - not surgery, labor and delivery, intensive care, oncology, all the other things physicians need exposure to. Therefore, less school is not necessarily inappropriate.

2) Medical school is competitive and therefore doctors are smarter. While this may be true on average, you cannot apply this to individuals. Just as we individually evaluate med school grads to decide if they can practice, the same approach can, should, and is used to evaluate APNs.

3) It is not fair; I spent more time in school; I paid more money. This argument is a non-starter. It is about you. What the arguments need to be about are the APNs and patients.

4) There are online only APN programs. This statement is simply false.

5) Physicians who support APNs are traitors and sell-outs and I resent them. Ad hominem attacks do not support your position. Also, am I supposed to be bothered by something anonymous posters on an Internet forum, most of whom are still in med school, say about me?

1. I just went to a party with an NP who trained to do primary care. She now works in the pediatric CVICU. See unlike us, what they trained in doesn't matter for what they are allowed to do - that's a problem.

2. And who do we go about doing this? For doctors we have licensing exams and board certification exams, and God help us all, MOC. Do NPs have the same rigorous certification process?

3. I'm in agreement here

4. There are programs that are entirely online except clinical experience (I helped an RN at my last job with her homework quite often). Those clinical experiences were not standardized at all - she was literally calling up local NPs and asking if they would precept her. People think some DO schools do a poor job at this but they are nurturing havens compared to this women's experience.

5. I wouldn't go that far, but it has lead to our current situation. Just ask the anesthesiologists about that.

 

[deleted480308]

5) Physicians who support APNs are traitors and sell-outs and I resent them. Ad hominem attacks do not support your position. Also, am I supposed to be bothered by something anonymous posters on an Internet forum, most of whom are still in med school, say about me?

I'm fine with APNs. I'm not fine with unsupervised APNs..

 

[ProfMD]

1. I just went to a party with an NP who trained to do primary care. She now works in the pediatric CVICU. See unlike us, what they trained in doesn't matter for what they are allowed to do - that's a problem.

2. And who do we go about doing this? For doctors we have licensing exams and board certification exams, and God help us all, MOC. Do NPs have the same rigorous certification process?

3. I'm in agreement here

4. There are programs that are entirely online except clinical experience (I helped an RN at my last job with her homework quite often). Those clinical experiences were not standardized at all - she was literally calling up local NPs and asking if they would precept her. People think some DO schools do a poor job at this but they are nurturing havens compared to this women's experience.

5. I wouldn't go that far, but it has lead to our current situation. Just ask the anesthesiologists about that.

1) I am not aware of any APN practicing in the CVICU without physician oversight, nor do I think they should. Interns practice in the CVICU even though that are not trained for this. Also, where I work, we have APNs in the ICU - they round with the intensivists and house staff then carry out the plan that the intensivists devise. Many of them have been there for years, decades even, and know their stuff better than the freshly minted intern who has more prescribing rights. However, the APNs will never practice in the ICU independently.

2) APNs also have certification exams, licensing, continuing education, and recertification requirements.

3) Glad we can agree on something.

4) See my response above regarding reforming APN education.

5) I agree that the anesthesiologists did not stop the CRNA train soon enough. However, CRNAs do serve a role, just as APNs do. They increase efficiency but must be properly supervised - I know many anesthesiologists and surgeons who feel this way.

 

[deleted480308]

1) I am not aware of any APN practicing in the CVICU without physician oversight, nor do I think they should. Interns practice in the CVICU even though that are not trained for this. Also, where I work, we have APNs in the ICU - they round with the intensivists and house staff then carry out the plan that the intensivists devise. Many of them have been there for years, decades even, and know their stuff better than the freshly minted intern who has more prescribing rights. However, the APNs will never practice in the ICU independently.

2) APNs also have certification exams, licensing, continuing education, and recertification requirements.

3) Glad we can agree on something.

4) See my response above regarding reforming APN education.

5) I agree that the anesthesiologists did not stop the CRNA train soon enough. However, CRNAs do serve a role, just as APNs do. They increase efficiency but must be properly supervised - I know many anesthesiologists and surgeons who feel this way.

We also said they would never practice medicine independently at all not too long ago....and we said the CRNAs wouldn't practice independently.

As I stated before, they just keep pushing for more

 

[criticalelement]

s. If an NP or PA can in fact do the same job as a physician, it really tells us something about the medical training. If one can get from NYC to Boston in 1 hour (NP), there's no reason for why your driver should first take you to Philly so that he can then demand a higher fee for the trip (MD).

You are completely missing the boat. Most of medical decision making is THINKING and CRITICAL THINKING AND EVALUATING. A NP does not critically think as well as a physician because of the inferior training. THey just dont know enough to do that stuff.

 

[ProfMD]

We also said they would never practice medicine independently at all not too long ago....and we said the CRNAs wouldn't practice independently.

As I stated before, they just keep pushing for more

I agree. It is incumbent on us to set limits. You and I just disagree on what those limits should be. I think that APNs should, for the most part, perform in a supervised role. The one exception is primary care in underserved areas as long as the APN spends supervised time with a physician first and that physicians signs off on them. I also think that APNs should be able to prescribe narcotics, PT, OT, home health equipment, etc - all things that my state does not allow them to do currently. Even the APNs in supervised roles cannot do these things.

As I said in a post on a different thread, we cannot alway use the slippery slope argument. If we did, nothing would change for the better while we are trying to avoid the worse.

 

[criticalelement]

Even if an NP does the identical job function during the day, it's not the same work if it doesn't come with the underlying training and expertise. By that argument you should be paying every inexperienced person the same as someone with vastly more training and knowledge. For example, if I bring my medical knowledge and skill to bear, weigh the benefits and risks for that patient in particular and society in general, and ultimately decide a patient needs a z-pack while the NP at CVS Minute Clinic just follows their daily algorithm without a second thought and prescribes a z-pack, the same "work" has occurred but the patient hasn't had the benefit of anything close to equivalent service. You don't pay a house painter the same as a classically trained artist even though they both "paint" right? Or pay the taxi driver the same as a NASCAR race car driver because they both "drive"? It's a silly argument. The pay is for getting someone to bring their skillset and training to bear, not the wearing a white coat and scribbling on a prescription pad. So it's a just an absurd argument to make.

Law has done a very good job of defining what constitutes "the practice of law" in each state, and has aggressively sued and criminalized paralegals, realtors and accountants who have tried to cross those lines. Doctors should lobby for the same.

Great post and hits at the issue. The problem that physicians are finding is that there are soooo many people that are against us politically . This is why we are seemingly losing the battle. its ok for a NP to intubate someone elses father/mother in the icu but if its yours call the bd certified anesthesiologist. I watch the mediocrity in which a lot of mid levels practice on a daily basis and let me tell you the gaps in knowledge is cringe worthy

 

[criticalelement]

The veterans affairs department (VA hospitals) are trying to pass legislation to make ALL advanced practice nurses (nurse practicioners) LICENSED INDEPENDENT PRACTICIONERS. THe bill is in the comment period. If you oppose this and are disgraced by physician knowledge being marginalized please go to this link and express your outrage and oppose this legislation.

Here is the link

https://www.regulations.gov/#!documentDetail;D=VA-2016-VHA-0011-0001

 

[VA Hopeful Dr]

1) I am not aware of any APN practicing in the CVICU without physician oversight, nor do I think they should. Interns practice in the CVICU even though that are not trained for this. Also, where I work, we have APNs in the ICU - they round with the intensivists and house staff then carry out the plan that the intensivists devise. Many of them have been there for years, decades even, and know their stuff better than the freshly minted intern who has more prescribing rights. However, the APNs will never practice in the ICU independently.

2) APNs also have certification exams, licensing, continuing education, and recertification requirements.

3) Glad we can agree on something.

4) See my response above regarding reforming APN education.

5) I agree that the anesthesiologists did not stop the CRNA train soon enough. However, CRNAs do serve a role, just as APNs do. They increase efficiency but must be properly supervised - I know many anesthesiologists and surgeons who feel this way.

The independent part is all I care about so we're on the same page there.

Their recertification requirements are a joke. 75 hours of CME every 5 years (this increases to 100 next year). As a family doc, I have to have 150 every 3 years. They don't have to retake their exams or anything else. Even the NBPAS requires 100 hours every 4 years, and truthfully they don't impress me all that much. You'll forgive me if I'm unimpressed.

Why should we reform their education? If we say that what they're doing isn't good enough they will fix it themselves.

 

[deleted480308]

I agree. It is incumbent on us to set limits. You and I just disagree on what those limits should be. I think that APNs should, for the most part, perform in a supervised role. The one exception is primary care in underserved areas as long as the APN spends supervised time with a physician first and that physicians signs off on them. I also think that APNs should be able to prescribe narcotics, PT, OT, home health equipment, etc - all things that my state does not allow them to do currently. Even the APNs in supervised roles cannot do these things.

As I said in a post on a different thread, we cannot alway use the slippery slope argument. If we did, nothing would change for the better while we are trying to avoid the worse.

1. They never ask for just primary care in just underserved areas
2. If it's not good enough legally for downtown it's not good enough for the people in the country. Why is it ok for someone on a dirt road to get substandard care that isn't acceptable for metropolitan america?

 

[Law2Doc]

Great post and hits at the issue. The problem that physicians are finding is that there are soooo many people that are against us politically . This is why we are seemingly losing the battle. its ok for a NP to intubate someone elses father/mother in the icu but if its yours call the bd certified anesthesiologist. I watch the mediocrity in which a lot of mid levels practice on a daily basis and let me tell you the gaps in knowledge is cringe worthy

It's less that everyone is "against doctors politically" so much as cost and ignorance. Health care costs are too high. So an easy fix for politicians is to replace some of the expensive parts with cheaper shoddy alternatives that look "close enough" to the average layman. No elimination of service, just quality. Same white coat, same prescription pad. But until the public gets that they are not getting equal value it's a losing battle.

The way you contest this is to educate the public in what they aren't getting. The public is more than happy to pay more for things they regard as better quality. We do it every day with cars, appliances, groceries, even toilet paper. But somehow something that matters as much as health care they're just not appreciating that they are being given a cheap substitute. And it's up to doctors to show them, not just hope/assume they'll figure it out. Show what it takes to be a doctor. Show how CVS and Walmart uses their army of NPs to push pharmacy products under the guise of health care. Highlight whenever NPs drop the ball on things someone better trained would be less likely to miss. We all hear about Doctor errors but hardly a peep about NP errors -- but we all know it happens, even with all the cherry picking that goes on. Probably a lot. And this should be the "expose" on one of the cable news shows every month until the public cares.

The AMA or other lobbying group should start an ad campaign telling the public to ask about the credentials of their "doctors". Something with a tag line "It takes 7-14 years of medical school and training to create a qualified doctor. But some practitioners never even went to med school -- did yours? Or your children's? -- Ask!"

 

[ProfMD]

1. They never ask for just primary care in just underserved areas
2. If it's not good enough legally for downtown it's not good enough for the people in the country. Why is it ok for someone on a dirt road to get substandard care that isn't acceptable for metropolitan america?

Because there is no evidence that it is substandard care - that is your assumption. The restrictions I have proposed would hopefully make sure it is not substandard by evaluating APNs as individuals, no a whole class.

And, even if it was less than what people in cities get, I still would argue that it is better than no care. I know you will say it isn't, but again, that is your assumption with no evidence to back it up.

Finally, and I know this may be hard to hear, but not all doctors are good. In my experience, the ones in metropolitan areas tend to be better than the ones on dirt roads. There is no evidence that putting APNs on dirt roads where there are no doctors hurts anyone and it would likely help if done right. As I have said before, if a particular doctor wants to be on that dirt road, I would support the doctor over the APN.

And saying they always ask for more - that is the slippery slope argument I referenced above. You cannot always use that argument. It is a consideration, but should not be used as the primary reason to say no to change.

 

[ProfMD]

The independent part is all I care about so we're on the same page there.

Their recertification requirements are a joke. 75 hours of CME every 5 years (this increases to 100 next year). As a family doc, I have to have 150 every 3 years. They don't have to retake their exams or anything else. Even the NBPAS requires 100 hours every 4 years, and truthfully they don't impress me all that much. You'll forgive me if I'm unimpressed.

Why should we reform their education? If we say that what they're doing isn't good enough they will fix it themselves.

I am okay with them reforming their own education. But, I would rather physicians be involved to ensure standards are met.

My state medical board requires 20 hours of CME per year for physicians to remain licensed. Board certification requires 150 every 3 years, but you do not need certification to practice - only licensure.

This is not to say that APNs should not be required to do more - perhaps they should. I also think the physicians in my state should be require to do more. I am just saying that the minimum requirements for APNs and physicians are not that different.

 

[deleted480308]

Because there is no evidence that it is substandard care - that is your assumption. The restrictions I have proposed would hopefully make sure it is not substandard by evaluating APNs as individuals, no a whole class.

And, even if it was less than what people in cities get, I still would argue that it is better than no care. I know you will say it isn't, but again, that is your assumption with no evidence to back it up.

Finally, and I know this may be hard to hear, but not all doctors are good. In my experience, the ones in metropolitan areas tend to be better than the ones on dirt roads. There is no evidence that putting APNs on dirt roads where there are no doctors hurts anyone and it would likely help if done right. As I have said before, if a particular doctor wants to be on that dirt road, I would support the doctor over the APN.

But they haven't, and never will, argued that they should be only allowed independence when there isn't a doctor around. They aren't asking for a "as long as there isn't a doc within 15miles" license. And they don't disproportionately move in the rural areas, it's a marketing ploy to get support from legislation. They don't have any more desire to live in the middle of nowhere than the docs do.

And saying they always ask for more - that is the slippery slope argument I referenced above. You cannot always use that argument. It is a consideration, but should not be used as the primary reason to say no to change.

But they do, please name a nursing organization proposal in which they have argued against increasing their autonomy and scope....

 

[ProfMD]

But they haven't, and never will, argued that they should be only allowed independence when there isn't a doctor around. They aren't asking for a "as long as there isn't a doc within 15miles" license. And they don't disproportionately move in the rural areas, it's a marketing ploy to get support from legislation. They don't have any more desire to live in the middle of nowhere than the docs do.



But they do, please name a nursing organization proposal in which they have argued against increasing their autonomy and scope....

Of course they will always ask for more. That's not the point. The point is, what would I, as a physician, support. With the available evidence and my personal experience, I have outlined it in a way that is enforceable. I am saying that the "if we give them this then they will ask for more" argument does not work for me. People usually want more than what they have.

 

[deleted480308]

Of course they will always ask for more. That's not the point. The point is, what would I, as a physician, support. With the available evidence and my personal experience, I have outlined it in a way that is enforceable. I am saying that the "if we give them this then they will ask for more" argument does not work for me. People usually want more than what they have.

I think I'm understanding our miscommunication. The reason I oppose this is not because I think they will end up asking for more autonomy.

I simply don't think they have equivalent training and should not be autonomous. full stop. Every instance in which they operate without physician supervision is wrong. Separately from that fact, I don't think they will stop and they are better at lobbying than we are so statements like "they'll never practice independently in the ICU" are not likely true.

We may disagree on if they should have any autonomy, but I think we've reached understanding.

 

[ProfMD]

I think I'm understanding our miscommunication. The reason I oppose this is not because I think they will end up asking for more autonomy.

I simply don't think they have equivalent training and should not be autonomous. full stop. Every instance in which they operate without physician supervision is wrong. Separately from that fact, I don't think they will stop and they are better at lobbying than we are so statements like "they'll never practice independently in the ICU" are not likely true.

We may disagree on if they should have any autonomy, but I think we've reached understanding.

Agreed - I think we now understand each other. We may not agree - but that is normal in civilized society.

 

[Yadster101]

Making all these predictions is useless. Let's talk about facts. The fact of the matter is PA/NPs are NOT paid the same as FM docs. PAs working FM make ~100k while new FM docs make about 160k (in a saturated market). After ~3 years in practice the FM doc can be pulling 180k. The highest paid PAs, working looong hours, make ~150k. An FM doc working similar hours would hit 200k+.

NPs/PAs have been around for years. They will almost certainly continue to gain more power, but it will take decades before they start making salary equal to a physician.

 

[cbrons]

Admittedly, I know little of how nurse practitioner education works aside from some of the schools being online.
Do they pay the same malpractice insurance premiums? If not and they demand equal pay then it's only fair to need to pay the same (or greater, due to less training increasing liability) costs. And everyone who recommended NP/PA to me stated it is supposedly less strenuous and more forgiving for medical professionals seeking more family time so it strikes me as odd that equal work can be a thing unless you are a particularly zealous NP.

In any case, there needs to be a balance in how changes like this are enacted and I don't think that simply increasing NP pay for "the equivalent work" is an intelligent decision, especially since it isn't equal work due to differences in training and subsequent responsibility. If a NP could reach MD/DO levels of training through a post-NP institution (of comparable total cost to actual medical school and not online) and take the required boards to practice as a special NP then I'd be more confident about giving those NPs equal pay for their work as they will have actually earned it. As it stands, straight up increasing pay would make going NP way more favorable than the traditional family medicine route at the potential cost of patient safety.

Obviously it is not equal work.

If NPs made as much as MDs in the same field, there would be 0 reason to go to medical school.
Many MDs supervise the NPs, whether that is an officially listed part of their job or not. Ask the anesthesiologists.

 

[cbrons]

It's less that everyone is "against doctors politically" so much as cost and ignorance. Health care costs are too high. So an easy fix for politicians is to replace some of the expensive parts with cheaper shoddy alternatives that look "close enough" to the average layman. No elimination of service, just quality. Same white coat, same prescription pad. But until the public gets that they are not getting equal value it's a losing battle.

The way you contest this is to educate the public in what they aren't getting. The public is more than happy to pay more for things they regard as better quality. We do it every day with cars, appliances, groceries, even toilet paper. But somehow something that matters as much as health care they're just not appreciating that they are being given a cheap substitute. And it's up to doctors to show them, not just hope/assume they'll figure it out. Show what it takes to be a doctor. Show how CVS and Walmart uses their army of NPs to push pharmacy products under the guise of health care. Highlight whenever NPs drop the ball on things someone better trained would be less likely to miss. We all hear about Doctor errors but hardly a peep about NP errors -- but we all know it happens, even with all the cherry picking that goes on. Probably a lot. And this should be the "expose" on one of the cable news shows every month until the public cares.

The AMA or other lobbying group should start an ad campaign telling the public to ask about the credentials of their "doctors". Something with a tag line "It takes 7-14 years of medical school and training to create a qualified doctor. But some practitioners never even went to med school -- did yours? Or your children's? -- Ask!"

 

[The Kraken]

The best evidence literally shows equivalent or better outcomes for NPs, why is this so hard to accept? Currently, physicians have more liability and in many locations have oversight, hence the current pay discrepancy. Every single NP thread will talk about anecdotes of NPs missing things or not understanding concepts or how the great MD/DO caught that rare disease, but where is the data to support this? It doesn't exist.

Are we as physicians a specialized furniture maker to the department store furniture NPs or are we a fancy bottle of water that is the exact same as water from the NP tap? The best evidence from primary care outcomes shows we're the same and that's hard for me to accept. We all have a ton of money and time invested into this career to be a physician, but if we're practicing evidence based medicine, maybe it's time for soul searching.

 

[qwerty89]

https://np.reddit.com/r/nursing/comments/2kwk37/why_the_doctorate_of_nursing_practice_is_a_giant/

"I became a registered nurse a few years ago.. I worked at the bedside of pretty sick patients. A guy got attacked by a deer and ended up with compartment syndrome, a guy fell off his motorcycle and degloved his foot (awesome), a lady was shot a bunch by her husband and then she lived and kicked ass. It was exhausting, and sometimes I despised the paperwork and long hours. Mostly, though, I loved it. Eventually, I moved to a bigger city and worked in an Intensive Care Unit. I got to put leeches in an open neck dissection (please try leeches sometime, it. is. the. best), take care of countless strokes, and become pretty proficient with the drain we use to help make sure your head doesn't explode.

Then, I decided to become a Nurse Practitioner. I wanted to have a broader understanding of the pathophysiology underlying the disease and treatment I was applying per the physician's orders. I wanted to delve into WHY the medications worked and HOW they affected the human body. It was the obvious next step in my career. With the certification and licensing as a NP, I would be expected to grasp all these concepts as I was doling out antibiotics and referrals to my patients.

Getting my Master's in Science of Nursing with a specialty as an Adult- Gerontology Nurse Practitioner was a breeze and practically no one failed out. I went to one of the top nursing schools in the country. I'm thinking, people in medical school fail out all the time. I barely did anything in my clinical time, which was minimal (approximately 16-20 hours/wk x 36 weeks). There were some really stupid, not smart people in my classes who somehow graduated with me. Why are we, as a profession, trying to get the same goods as physicians, but our academic preparation doesn't reflect that? There were just as many nurse practitioners graduating from my university as there were registered nurses. As a result, when I went to look for a NP job, the market has become completely saturated with us. Meanwhile there remains a bedside nurse shortage. We are pushed and pushed to get a terminal degree (don't even get me started on the fact that physical therapists need a doctorate now). And because the Ivory Tower Nurses are advocating so desperately for that penultimate list of fancy letters behind every nurse's name, there is no selectivity anymore. You get a doctorate! You get a doctorate! You get a doctorate! (Obviously, in Oprah's voice). They want everyone to have a master's or doctorate, so we can prove to the world that we are not the "doctor's handmaiden." Let's prove to the world that we aren't a doctor's handmaiden by knowing our **** and having way harder, science-based preparation.

The AANP, along with other nursing organizations, are calling for all Nurse Practitioners to be doctorally- prepared. Most MSN programs have been replaced by DNPs. In concept, this is a wonderful idea to increase the practical knowledge base of advanced providers. In practice, it is more politically strategic. Do I think I need an education beyond a master's degree to be at the top of my game as an advanced provider? Absolutely! Do I think the DNP provides the kind of education needed to be a great advanced provider? Negative.

The DNP is a fluffy degree, with really no discernible difference from the PhD. There are no additional pharmacology classes, physiology classes, assessment classes, or clinicals/residencies. What I assumed was that I would be able to spend more time gaining clinical hours with an expert in the field, similar to how a medical doctor performs residency. The DNP is about additional research courses, learning about health disparities, and a singular practice project in which I apply research to my current work setting. Learning about how to provide equitable care is important in healthcare, however it will not help me diagnose the patient sitting in front of me. My patients care more about me having a firm handle on their illness, and the social worker can help take care of their financial concerns.

Now, why is this a strategic political move? Because NPs strive for autonomy. We want to eat from the same plate as physicians without the same training. So, if we can push NPs to get their doctorate of nursing practice then we can all say we are Doctors and The Man can't tell us that we have a limited education. "I'm Dr. Nurse. I learned all about how Hispanics generally receive less care than white people, that is why I can prescribe medicine now. Now let me DECIDE YOUR FATE."

The problem is- We have a limited education. I love NPs. I love me and my colleagues and friends! I prefer experienced NPs over doctors when it comes to primary care because they generally have more time available, tend to be more open, communicative, understanding, and thoughtful about social and community factors in connection with one's health. However, how much education do we really need shoved down our throats' about how socioeconomics and culture affect the body? If the DNP had reached its full potential of being a MEDICAL EDUCATION to supplement the NURSING FOUNDATIONS that I have already studied for 6 years, then it would be an excellent addition to what is already an incredible profession. Instead, it is a worthless degree created to increase revenue and social standing instead of improving upon the skills needed to be a competent medical provider."

 

[Law2Doc]

The best evidence literally shows equivalent or better outcomes for NPs, why is this so hard to accept? Currently, physicians have more liability and in many locations have oversight, hence the current pay discrepancy. Every single NP thread will talk about anecdotes of NPs missing things or not understanding concepts or how the great MD/DO caught that rare disease, but where is the data to support this? It doesn't exist...,

Agree with your last sentence above but not your first sentence. The data doesn't exist. NPs cherry pick simpler cases and then claim equivalent or better outcomes but I think we all know that if anyone did a study and controlled for complexity the data would not be as you suggest. I mean if you pick 100 basically healthy people who go to the CVS Minute Clinic and prescribe them all zpacks the outcome is going to look pretty darn good compared to the Family med practitioner whose patient base contains more comorbidities. But it's not a statistically fair comparison. It's like the breast surgeons who say they can read mammograms as well as a radiologist, ignoring the fact that if there are only 4 cancers in 1000, anyone could say negative on every study and already be scoring 99%.

Unfortunately doctors seem to shrug and have yet to challenge the assertion you made in your first sentence. But that's not the same as saying it's not bogus. It just means, as you said in your last sentence the data doesn't exist... Yet.

 

[pulmoblast]

In my practice, NPs exist because I have to pay them less. If I have to pay NP as much as MD, I will hire MD


Sent from my iPhone using SDN mobile app

 

[VA Hopeful Dr]

The best evidence literally shows equivalent or better outcomes for NPs, why is this so hard to accept? Currently, physicians have more liability and in many locations have oversight, hence the current pay discrepancy. Every single NP thread will talk about anecdotes of NPs missing things or not understanding concepts or how the great MD/DO caught that rare disease, but where is the data to support this? It doesn't exist.

Are we as physicians a specialized furniture maker to the department store furniture NPs or are we a fancy bottle of water that is the exact same as water from the NP tap? The best evidence from primary care outcomes shows we're the same and that's hard for me to accept. We all have a ton of money and time invested into this career to be a physician, but if we're practicing evidence based medicine, maybe it's time for soul searching.

Head on over to the Clinicians subforum where an NP posted some of these "best" studies, then note my response where I tear said studies apart.

As for studies showing they are worse than we are, those aren't going to get done. Just try getting a study past the IBR where you hope to show that the intervention group (NP care) is worse than the control group (MD care).