Holy poo! Hate for midlevels.

[core0]

Somebody who understands statistics a little more than I do help me out here. This study confuses me a little because they seem to be reporting on the null hypothesis. I always understood that one comes up with a hypothesis that there is a difference between groups and then the null hypothesis is no difference between the groups. Then you look at all your data and get your p-value etc, etc. This is what's confusing me about this study, they report that there is no difference between the two groups which would be the null hypothesis. The way I understood it would be to hypothesize that NP=/=MD, this would make the null hypothesis NP=MD. Then you look at your data etc, etc and get your p-values. A small p-value would be low evidence for the null hypothesis, so you could accept your hypothesis. But in this study the have large p-values which means there is not enough evidence against NP=MD, this however does not prove the NP=MD, it just means there is not enough evidence against it. The report seems to indicate that since there is not enough evidence against NP=MD it must be true, which seems backwards to me. So, if I am missing something please let me know, I have always had problems with stats.

You have discerned one of the major problems of the study. A null hypothesis has no directionality. In this case it could show that the NPs provided worse care or better care than MDs. The null hypothesis is that they provided the same care. However confirming the null is not the same rejecting either of the alternatives.

There are several statistical problems with this. The biggest is the use of multiple T tests without multivariate analysis. If you use more than twenty t-tests with a probability of 0.05 for example there is more than a 96% chance that one of the alternatives that was confirmed will be false.

You are correct that the way the p-values is set up is confusing. The fact that they did not reach significance is not the same as saying that the treatment is equivalent.

The proper trial here given the size of the sample is a non-inferiority trial. If they had done this, they could at least confirm the care was not inferior. By pushing a flawed trial to show superiority they confirmed nothing.

David Carpenter, PA-C

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[DocNusum]

... [brevity edit]...
However, they were timed and you didn't stand much of a chance if you had to flip through a book to find every answer.

Correct...

Also:

His rationale was that if you knew everything on those exams, 100% of the class would have met class objectives.

While I still have a "problem" accepting "test teaching" as the way to go...
In words/concepts "SMOGed" to the appropriate level...
If the student studys and KNOWS 100% of the testable material... then they "passed"...

 

[Taurus]

I know a professor who handed out exams a few days before the actual exam. The "real" exam was the same. His rationale was that if you knew everything on those exams, 100% of the class would have met class objectives.

Multiple choice exams are one of a few ways that physicians are tested. They're convenient for the Steps because you can test 30k people every year that way. You're tested in different ways once you reach the wards. Clinical medicine isn't about multiple choice exams. You're expected to know what questions to ask and what to look for so that you can develop an assessment and plan. It's very open-ended. It feels more like an oral exam when your attending puts you on the spot and starts to pimp you. Your evaluation is based on how well you did the H&P, assessment and plan, and answering pimp questions. You can't be a one-trick pony to do well in medicine.

I've taken open book exams as well. They're fine if you want to test if the students understand the concepts and not so much the little details. I have an engineering BS and several professors did this. However, medicine is both about understanding the concepts and knowing the details. This is what I find challenging about medicine.

Nurses with just 1000 clinical hours can't hold a candle next to a residency-trained physician. Even an NP with 20 years of experience can't compare because they had no one to precept them to let them know what they may have missed on H&P or how they could have developed a better treatment plan.

That's the benefit of supervised training; you have someone with more experience who can give you guidance and feedback. It seems like nurses have trouble understanding that concept. You can't learn medicine solely from a book. You need to read about it and then have someone point it out for you on a real patient. That's why D(NP)'s depend on working with physicians for a few years after graduation so that the physician can point routine things out for them on patients. But the supervising physician won't be able to expose the D(NP) to the same things that the medical students and residents have because there's no formal training infrastructure or process in place.

That's why Mundinger's claims are so laughable. But I welcome the DNP's. It will be one of the biggest mistakes that the nurses have ever made.

 

[zenman]

Nurses with just 1000 clinical hours can't hold a candle next to a residency-trained physician. Even an NP with 20 years of experience can't compare because they had no one to precept them to let them know what they may have missed on H&P or how they could have developed a better treatment plan.

That's the benefit of supervised training; you have someone with more experience who can give you guidance and feedback. It seems like nurses have trouble understanding that concept. You can't learn medicine solely from a book. You need to read about it and then have someone point it out for you on a real patient. That's why D(NP)'s depend on working with physicians for a few years after graduation so that the physician can point routine things out for them on patients. But the supervising physician won't be able to expose the D(NP) to the same things that the medical students and residents have because there's no formal training infrastructure or process in place.

And they are not supposed to be the same as a physician unless they have identical training. NPs must have a supervised training with a preceptor, be it a physician, PA or NP in order to graduate and be certified. I even tried to set up preceptorship with a foreign trained physician from a developed country and was told it had to be an American trained board-certified physician. I guess you are talking more along the lines of a resident type training after becoming NPs. But PA don't do that either to my knowledge; they have their 2,000 or so hours and then are awarded their PA.

Ivory tower nurses think that nursing theories guide a nurse practitioners practice but I bet after a few years there is no nursing theorist guiding an NP in everyday practice. I personally think NPs should be trained to bring something else to the table. Maybe NPs should have more psychology classes and after a physician sees a patient initially, they turn the patient over so the NP, now trained in dealing with non-compliant patients, can follow them. That's just an example.

Thousands of hours doesn't always mean much.
http://axisoflogic.com/cgi-bin/exec/view.pl?archive=153&num=24027

Here we have an example of physicians totally off track and a system run amok. And then, you have Ed Tick using Native American techniques who understands that victims of trauma lose their soul.

That's why Mundinger's claims are so laughable. But I welcome the DNP's. It will be one of the biggest mistakes that the nurses have ever made.

Creating the ADN was way up there on knee-jerk reactions.

 

[Chronic Student]

As a PA, I did my clinicals and then it was off to the real world. Yes I was practicing, however I was (and am) getting constant feedback from my SP.

There are so many nuances, details, variable situations, aggravating/alleviating factors and the occasional wild-ass zebra that I don't think anyone should just be cut loose after school. It does not matter if they are an MD, PA or NP/DNP, it's just not a good idea.

-Mike

 

[prairiedog]

Nurses with just 1000 clinical hours can't hold a candle next to a residency-trained physician. Even an NP with 20 years of experience can't compare because they had no one to precept them to let them know what they may have missed on H&P or how they could have developed a better treatment plan.

That's why Mundinger's claims are so laughable. But I welcome the DNP's. It will be one of the biggest mistakes that the nurses have ever made.

Taurus with all of your experience please explain how a NP/PA with 20 years experience was able to provide a better treatment plan than a residency-trained physician in numerous instances in a clinic where I was working? In fact, I have seen several cases where the PA/NP with 20 years experiecne is guiding the new resident in treatment plans. I have also noted where the MD with 30 + years experience is not considered the expert, rather the patients see the PA as the expert. Help the rest of us explain this to patients so they can see the light.

 

[pkpd]

You know I'm going to ask for evidence of this, especially since I've heard med students talk about rarely attending classes and viewing their lectures online.

so what if they don't go to classes. it is their own lost but they still ahve to pass USMLE step 1 and that determines their specialty,life & future. Even DO students have problem & hard time getting scores like MD students in this exam. (not saying DO students are not as good but maybe the training process during the first 2 years of med school is different)
So no matter how many classes med students missed, they still have to pass the qualification of an MD standardize exam.
Anyone that pass the step 1 can be a family physician, can a RN or NP pass it?? Also, med student need to get at least a 230 score to fight for a anesthesiologist spot...HMmm....i wander what score the NPs students will get??

 

[Jawbone]

Nurses with just 1000 clinical hours can't hold a candle next to a residency-trained physician. Even an NP with 20 years of experience can't compare because they had no one to precept them to let them know what they may have missed on H&P or how they could have developed a better treatment plan."

Maybe in an outpatient freestanding clinic.... but that wouldn't cut it in the hospital where the NP works closely with MDs and PAs in their medical team. Most, if not all of the NPs I've spoken with have had lengthy orientations, as well close supervision with the attendings, at least until the attendings felt confident that A: the NP could function "independently", and B: The NP would not hesitate to seek advice when appropriate. Many of the MDs (residents, house docs) are being mentored by NPs in my unit. They are also heavily taught by the attendings, fellows, etc, but there is a huge level of involvement by the NP staff. An NP with 20 years experience is skilled in their area of expertise....You can only learn so much from the books as you mentioned, and the rest has to come from experience.

Where I work, residents are not permitted to be assigned to certain sicker patients, such as postop open hearts. NNPs are the primary care providers for these patients, and work closely with the NICU fellows and attendings to care for these patients.


"That's the benefit of supervised training; you have someone with more experience who can give you guidance and feedback. It seems like nurses have trouble understanding that concept. "

-We are well acquainted with supervised training. We all had between 1-3 years of supervised clinical training in addition to our didactic courses. Upon graduation we were precepted by experienced nurses, as well as assigned mentors as a resource as we worked on the unit.


You can't learn medicine solely from a book. You need to read about it and then have someone point it out for you on a real patient. That's why D(NP)'s depend on working with physicians for a few years after graduation so that the physician can point routine things out for them on patients

Yeah, thanks "doc" for pointing out "on a real patient" the "routine" things that us dumb bimbo nurses can't understand....

"It will be one of the biggest mistakes that "the nurses" have ever made."

I am really enjoying this forum.... I come on and get all riled up, then vent and feel much better..... honestly though, we're all in this medical field together. You may be working with (and may actually like) nurse practitioners once you become an MD. Why not remain open-minded, rather than stereotyping an entire profession? Not all nurses are mindless drones, and not all doctors are jackasses. We can all strive to provide excellent patient care within our nationally recognized scopes of practice without slinging mud over the very short wall.... Doctors, nurses, PAs and NPs will never be out of a job. Why does it have to be a turf war?

Peace Out.....and flame on.....

JB

 

[Taurus]

but that wouldn't cut it in the hospital where the NP works closely with MDs and PAs in their medical team. Most, if not all of the NPs I've spoken with have had lengthy orientations, as well close supervision with the attendings, at least until the attendings felt confident that A: the NP could function "independently", and B: The NP would not hesitate to seek advice when appropriate.

How much time have you spent in the inpatient setting of a teaching hospital where there are residency programs? These are the worst places for midlevels to work if they want to be able to work independently someday. Why? Because the residents do most of the work. Next time when a team rounds, see who is there. It's usually the attending, sr residents, jr residents, interns, and med students. On occasion, the midlevel tags along. The job of the midlevel in a teaching hospital is typically scutwork. Like making sure this test is ordered, this consult is done, etc. The residents are responsible checking up on the patients each day and coming up with daily plans. That's how you learn medicine. A midlevel helps out by carrying out some of those plans. Even in the outpatient setting, midlevels have to compete with the residents for patients. Guess who the attending will give preference to when it comes to seeing patients and teaching?

Bottom line is that an attending sees a midlevel as just another worker while the resident is a student. The powers that be that are over the attending, ie, chairperson or committee, makes sure that the attending is teaching the residents so that residents satisfy certain learning and procedural benchmarks set out by the national medical organizations. If a residency program does not adequately provide this training, it will lose it's accreditation and hence future residents. Another benchmark of a residency program is how many of its graduates pass their boards. Because of these reasons, many departments place a very high emphasis on residency education.

There is no such mandate when it comes to midlevel training. The attending has no incentive to teach the midlevel beyond that is necessary to get the job done, ie, most routine stuff. If the midlevel wants to improve themselves, it takes a lot of self-motivation, self-learning, asking questions, and a patient and interested attending. There are probably a few midlevels who have done that, but it's a tiny fraction and not representative of the typical midlevel. Most midlevels are happy with seeing the same routine things day in, day out and putting in 40 hours per week. Those are the reasons why they became midlevels in the first place. Our midlevels don't work more than 40 hours per week while residents routinely put in 80 hours.

NP's on here should stop rationalizing and start petitioning their nursing organizations for better clinical education if they want to truly compare themselves to physicians. Arguing that this one time this NP seemed to know more than this resident and that another time...blah blah blah...is pointless. We are talking about what the patient can expect from a typical physician and typical NP. If the nurses want to show off their medical knowledge and clinical skills, the medical organizations already have a certification process in place. I'll be interested to see how many nurses can pass it.

 

[foreverLaur]

I went to see my orthopaedic surgeon today to schedule surgery and also met his 4th year resident and his PA of 14 years. I talked to all 3 of them about my future career.

The orthopaedic surgeon told me that he has become very comfortable with his PA and lets his PA start most procedures, do a lot of things during the procedures, and close. He said his PA does a lot more than his 4th year ortho resident does. His PA sees the patients mostly and the resident tags along, but doesn't really do or say anything.

 

[Taurus]

lets his PA start most procedures, do a lot of things during the procedures, and close. He said his PA does a lot more than his 4th year ortho resident does. His PA sees the patients mostly and the resident tags along, but doesn't really do or say anything.

How many cases have you scrubbed in on? Most 4th year surgery residents are pretty skilled at that point and I suspect he was downplaying his abilities to you. Maybe because you're a pretty girl? Go post this on the surgery forum and see what the surgery residents think.

 

[foreverLaur]

How many cases have you scrubbed in on? Most 4th year surgery residents are pretty skilled at that point and I suspect he was downplaying his abilities to you. Maybe because you're a pretty girl? Go post this on the surgery forum and see what the surgery residents think.

Just posting what I was told in the discussion with the three of them. I have scrubbed in on probably 15-20 ortho cases with 4 different surgeons. I would vote that the residents (all 4th years, coincidentally) did the least. The PAs and the surgeon did the most. I have done my shadowing at Akron General, Akron Children's, and Ohio State Medical Center.

 

[Taurus]

Just posting what I was told in the discussion with the three of them. I have scrubbed in on probably 15-20 ortho cases with 4 different surgeons. I would vote that the residents (all 4th years, coincidentally) did the least. The PAs and the surgeon did the most. I have done my shadowing at Akron General, Akron Children's, and Ohio State Medical Center.

Post this on the surgery forum. I'm sure there are residents from those hospitals on there. I spent time in clinic with several ortho residents from akron last year. I scrubbed in on 2 cases with them and a PA was there too. I can vouch that they're not completely clueless and they do more than you think. They may be just humble because they know a lot more than they lead on.

 

[foreverLaur]

I'm not saying that that they aren't good. They are doctors and 4th year ortho residents. They were obviously near the top of their class in medical school with top board scores.

I am just stating what they talked to me about because I am debating between surgery through medical school, surgery through RNFA (I'd also be an NP) or PA. So, they all provided very insightful information.

The resident, however, is still learning. She said she wants to do traumas, so she wasn't very fond of this rotation because all the surgeries were scheduled. No call, no trauma.

I'm not saying the residents don't do anything. They certainly do a lot. If I didn't know who was who, I probably wouldn't have been able to tell who was the PA, the attending, and the resident while observing the surgery.

However, if I was a surgeon, I would let my PA do more who had been operating with me for 14 years vs a 4 year resident doing a rotation with me.

This may not be the norm, but every person has their own experiences. This just may be how it is in my area and if I want to stay in the Akron area, these are the scenarios I will have.

In my experiences, an experienced PA does more in the OR than a 4th year resident does.

 

[Jawbone]

How much time have you spent in the inpatient setting of a teaching hospital where there are residency programs?

- Three years, most recently at a 1200 bed Ivy league affiliated university hospital


These are the worst places for midlevels to work if they want to be able to work independently someday. Why? Because the residents do most of the work. Next time when a team rounds, see who is there. It's usually the attending, sr residents, jr residents, interns, and med students. On occasion, the midlevel tags along. The job of the midlevel in a teaching hospital is typically scutwork.

- I AM on rounds EVERY DAY! I am fully expected to "present" my patients to the team. The NNPs and PAs each present their respective patients, (hx/px, labs, condition, etc) and recommend a plan of treatment. The attendings and fellows are there to make recommendations, as it should be. No scut work!

Have you started residency yet? Or are you still in med school? Because if you are, you've got a lot still to see in the trenches before making all these broad statements aimed at raising midlevel ire.

On a lighter note, I actually considered taking a cruise ship RN position, but the pay sucked, and I'm sure all I'd be treating is seasickness and Norwalk virus..... Hey! Maybe I can be your Acute Care Cruise Ship Nurse Practitioner... (DNP, of course) ;>P

 

[Chronic Student]

If the midlevel wants to improve themselves, it takes a lot of self-motivation, self-learning, asking questions, and a patient and interested attending. There are probably a few midlevels who have done that, but it's a tiny fraction and not representative of the typical midlevel. Most midlevels are happy with seeing the same routine things day in, day out and putting in 40 hours per week. Those are the reasons why they became midlevels in the first place. Our midlevels don't work more than 40 hours per week while residents routinely put in 80 hours.

Taurus, I agree with you on a lot of things and I realize your post started out talking about midlevels in an academic environment then got into some generalizations.

We all speak from our personal, anecdotal experience as far as these things go and my experience has been different from yours. I have, in different capacities, worked at or learned in a variety of environments from one of the largest teaching hospitals in the US to a ~20 bed hospital in podunk and everything in-between. Let me count, over 15 different hospitals from what I can remember.

I have run across horrible PAs, MDs, NPs, etc and wonderful PAs, MDs and NP's. I would have to say that overall the general quality and consistency of MDs is better than that of mid-levels and I do not think there can be a valid comparison of who is better or more able. I think thats pretty obvious.

However, we all have our place and I would disagree with you about the motivated mid-level being a tiny fraction and not representative of the typical mid-level. I would say that its much closer to fifty percent and I think those of us who are more motivated gravitate away from the larger teaching institutions for just the reasons you mention. The exception are those that utilize PAs in a greater capacity. I'm thinking of Hermann hospital in Houston and MD Anderson cancer center (the largest single employer of PAs) because I'm familiar with them.

Where I work, there are a fair number of PA's for a hospital its size and I know most of them. I only know of a few that work forty hours a week (60 is closer to average) and only a few that are satisfied with the routine stuff.

I routinely put in 60 hours and eighty to ninety not infrequently as the situation arises.

In the past few weeks I have caught arterial insuffeciency as the cause of leg pain vs. radiculopathy. Keep in mind my SP has never diagnosed this in front of me, has never told me to watch out for it and was impressed when I caught it. I'm not patting myself on the back as this is a bread and butter diagnosis for any doctor worth his salt. I mention it because I hear so much about the mid-level only diagnoses what they have seen before, been told to watch out for or is a red-flag in the decision tree. The total absence of thought process that so many claim we have irritates the hell out of me.

We had a trauma patient last week with back pain who was hypotensive after an accident and I asked the ER doc if they got a chest CT to look at the aorta (yes they could have done US, but this ER seems to pan-scan everyone) and he said yes it had been considered and ruled out. He told me he was surprised that it was in my differential and I asked him how it could not be.

We also had two consults today one with large cystic lesions in the brain and Echinococcus was mentioned. I had already asked him about travel outside of the US and whether or not he had consumed raw or undercooked food. In addition, I asked about fever, nightsweats, weight loss, difficulty with breathing, cancer (strong family history of Hodgkins lymphoma), chemical exposure, malaise, smoking, etc. So I was able to present all that info to my doc and the radiologist who were kicking around ideas while we looked over the MRI. So much for the midlevel not considering differentials/jumping at the first diagnosis that seems reasonable.

The second one was a thoracic spine infection and I had already asked about IV drug use, hx of TB, cuts, bruises, abrasions, previous infections, etc.

Now my SP is a great guy, but he is no teacher. In the year and a half that I have been with him I can remember 3 or 4 times that he has really taught me something. He has repremanded me when I screw up, which thankfully is not very often and the rest I have learned by reading, watching and asking questions when I could not find the answer.

The other PAs here are somewhat similar in their motivation and I only know of one PA that wants/has relative autonomy. This is because he worked for a FP doc who retired and asked him if he wanted to buy the practice and has stayed on to supervise for a portion of the time. The rest of us are pretty happy with where we are at.

In the end, I have had to prove myself to my SP by my work ethic, knowledge and he has come to trust my judgement. I only do what I'm comfortable with and if I have any hesitation I ask him and most midlevels I have worked with do the same.

There are some bad apples out there that really make us look bad and I guess in the end I'm just asking you to keep an open mind and judge us by our individual merits instead of lumping us all into one group of mediocre wanna-be docs.

BTW, the reason I became a mid-level was that I was already in a lot of debt, was older and the field I was really intrested in (neurosurgery) would probably not be thrilled to take on a 40+ YO resident if at all.

Rant over.

-Mike

 

[core0]

I'm not saying that that they aren't good. They are doctors and 4th year ortho residents. They were obviously near the top of their class in medical school with top board scores.

I am just stating what they talked to me about because I am debating between surgery through medical school, surgery through RNFA (I'd also be an NP) or PA. So, they all provided very insightful information.

The resident, however, is still learning. She said she wants to do traumas, so she wasn't very fond of this rotation because all the surgeries were scheduled. No call, no trauma.

I'm not saying the residents don't do anything. They certainly do a lot. If I didn't know who was who, I probably wouldn't have been able to tell who was the PA, the attending, and the resident while observing the surgery.

However, if I was a surgeon, I would let my PA do more who had been operating with me for 14 years vs a 4 year resident doing a rotation with me.

This may not be the norm, but every person has their own experiences. This just may be how it is in my area and if I want to stay in the Akron area, these are the scenarios I will have.

In my experiences, an experienced PA does more in the OR than a 4th year resident does.

There are a couple of issues here. One is the way that residents are utilized in private practice vs. how they are used in a University hospital. I can't speak to orthopedics in this case but in general surgery the resident would be expected to be doing some cases by themselves in the fourth year.

In private practice time is money. My experience is not vast but when I scrubbed in private hospitals the residents did much less than in university hospitals. Most residents will tell you the experience is not as good in private practice (although in the era before the 80 hour work week most of the residents regarded the private hospital as a semi vacation). Your mileage may vary.

In orthopedics the time is money philosophy is even more evident. Having the resident do the procedure may take more time will mean the surgeon loses money. They will go with what they have used consistently. That is usually the PA that they are used to. On the other hand in a university system the resident necessarily should be doing more in the OR than the PA. In fact from a billing standpoint you have to use a resident if there is one available. Most private practices are very streamlined with a clear delineation of roles with an emphasis toward efficiency. This usually results in a sub optimal experience for a resident.

David Carpenter, PA-C

 

[Taurus]

I AM on rounds EVERY DAY! I am fully expected to "present" my patients to the team. The NNPs and PAs each present their respective patients, (hx/px, labs, condition, etc) and recommend a plan of treatment. The attendings and fellows are there to make recommendations, as it should be. No scut work!

According to US News, I am affiliated with a top 4 hospital system in the country.

If you're at a teaching hospital, where are the residents then? Every single patient at my hospital is managed by a team composed of residents and fellows supervised by an attending. The midlevels on inpatient mainly do the odd-end stuff, but they aren't assigned any particular patients. They just do whatever has to be done.

There's always a ton of scutwork to be done. Who does them at your hospital then?

 

[Taurus]

However, we all have our place and I would disagree with you about the motivated mid-level being a tiny fraction and not representative of the typical mid-level.

Ok, it was a broad generalization.

Even if the NP or PA wants to learn more, the problem for them is that they need to find an attending who will teach them. To learn medicine, you have to see and do it as well as read about it. Attendings teach residents, sometimes reluctantly, because it's an expectation by the department for the reasons I gave before about resident education. If the attending is under no such constraint like in private practice, most would not go really out of their way to teach because they're so busy and tired already. They may show you some basic stuff or give a superficial explanation, but would most take an hour out of the day to give you a lecture on it? I doubt it. They've got patients lining outside the door waiting for them.

 

[Chronic Student]

Fair enough.

As for the rest I'm finding that out now.

-Mike

 

[Taurus]

However, if I was a surgeon, I would let my PA do more who had been operating with me for 14 years vs a 4 year resident doing a rotation with me.

The PA who has been doing this for 14 years will of course know some more stuff than a resident who is rotating through for 2 months. Attendings know that if a case takes 2 hours for them to do a case alone then it will take 3 hours if a resident is there because they have to teach.

But as I keep pointing out, one major difference between a resident and a midlevel is learning opportunities. The resident is expected to someday function independently. The attending knows that he/she is teaching a future attending while the NP/PA needs to know enough to do the job. After a while, that resident will know more and be able to do more than the PA because of these learning opportunities. The midlevel hits a learning ceiling while the resident keeps growing. Sounds unfair? That's the privilege that someone gets for going through medical school and doing a residency.

As far as I know, I have never heard of a PA or RNFA doing an entire case without an attending. Why? Because the attending only teaches them snippets so that they can assist most effectively.

 

[Miss Mab]

I think I'm going to politely ask young Lauren if she could please try NOT to argue on the side of nursing. Or mid-levels. Or any health care profession for that matter. Frankly, you're making even the best of us look bad.

I think it's fabulous that you are researching different careers but your dizzying array of ever changing interests is making any discussion or argument you put forth sound downright ridiculous.

Just as a highlight, in case you wondered, your very own school offers online degree programs. Does this make the idea of an online NP seem more credible to you?

Also, do you think, perhaps, that MAYBE one of the factors associated w/negative ratings by the supervising PHYSICIANS in that entry level NP study MIGHT be because some of those docs MAYBE had a, let's call it, "tougher" time with an older RN who actually knew a thing or two as opposed to a fresh newbie who might have played into the 'your way is the only right way' game? I highly doubt that their assessment skills were lessened by years of experience. The person judging them --meaning the MD's who determined the study outcome---likely simply preferred a young yes man more than someone who maybe had already actually learned a thing or two in the real world. I don't know if that's the case---just certainly a plausible explanation for the variance that hasn't been suggested.

A much better idea for you, thinking about being a direct entry NP, is to ask around about who gets hired after these DE programs. I can't tell you the # of newly minted NP's I know trying to get hired "just" as an RN because they have no real world clinical experience whatsoever. Very sad to see and not something I bet those DE schools spout off about. I'm aware that this isn't always the case but it is much more common than you've probably been led to believe.

Let's see......med school, NNNP, PNP, CRNA, PA, RNFA, accelerated bachelor's alone or direct entry MSN. In the last four days alone you have claimed, in various forums, that these vastly different career paths are your ultimate goals. Maybe more reading and less typing will help you clarify!!!!

Most of us are truly here to help

And finally, PLEASE don't make any more statements like this:

"I don't think we are any better or worse of NPs than someone who is a long standing RN."

Who is this "we" that you speak of? I wish you good luck in any educational pursuits but last time I checked you haven't even graduated with your FIRST degree, much less been accepted to any nursing program--accelerated BSN, diploma school or otherwise. While I would never argue that admission to nursing school quite rivaled that of the med school process, it's also no walk in the park itself and perpetuating the myth that just anyone with a pulse can one day decide to become a nurse and, voila it's done, does a service to no one.

It's like anything else--first you have to apply, the you see if you get accepted, THEN you head to school. In your case you first need to graduate though....

I do have no doubt that one day you will eventually be an asset to some area of healthcare. I'm sorry if I seem harsh but, well, no I'm really not. I do admire your enthusiasm.

I feel better now....

 

[alpha62]

if the DNP can clear an Axis II screen or prove their Lithium Level is Theraputic, I say let 'em have it, but I've got a better chance of hitting the lottery today.

 

[alpha62]

The PA who has been doing this for 14 years will of course know some more stuff than a resident who is rotating through for 2 months. Attendings know that if a case takes 2 hours for them to do a case alone then it will take 3 hours if a resident is there because they have to teach.

But as I keep pointing out, one major difference between a resident and a midlevel is learning opportunities. The resident is expected to someday function independently. The attending knows that he/she is teaching a future attending while the NP/PA needs to know enough to do the job. After a while, that resident will know more and be able to do more than the PA because of these learning opportunities. The midlevel hits a learning ceiling while the resident keeps growing. Sounds unfair? That's the privilege that someone gets for going through medical school and doing a residency.

As far as I know, I have never heard of a PA or RNFA doing an entire case without an attending. Why? Because the attending only teaches them snippets so that they can assist most effectively.

What do you think is happening in Iraq, Korea, the 'Stan, and a 100 other turdpiles PA's are left out in the bush hanging without support right now ?

 

[deleted6669]

"As far as I know, I have never heard of a PA or RNFA doing an entire case without an attending. Why? Because the attending only teaches them snippets so that they can assist most effectively."

it is actually fairly common practice for surgeons to allow the pa to occassionally run the whole case when the doc is having an off day . I have several friends who are surgical pa's in general and ortho services who have done this on many occassions(after yrs of working with the same doc) with the doc taking a back seat and holding retractors, etc
if you first assist an uncomplicated appy 100 times with the same doc chances are you can do it yourself with the doc standing next to you for moral support.....even with complications it's just not that difficult of a procedure....recall that navy corpsman on submarines do these ocassionally with good outcomes with maybe 10% of the training a surgical pa has.....

 

[Jawbone]

According to US News, I am affiliated with a top 4 hospital system in the country.

If you're at a teaching hospital, where are the residents then? Every single patient at my hospital is managed by a team composed of residents and fellows supervised by an attending. The midlevels on inpatient mainly do the odd-end stuff, but they aren't assigned any particular patients. They just do whatever has to be done.

There's always a ton of scutwork to be done. Who does them at your hospital then?

Oh crap.... we were #6 I believe.....

As I said in an earlier post, the residents round on a totally different team. One team consists of 1-2 attendings, a fellow, PAs, house docs and NNPs. They care for the sicker kids, usually on ECMO, pre/postop open heart (arterial switch, Norwood/Sanos, Blalock-Taussig shunts, etc) plus overflow for the other team.. the other team consists of 1-2 attendings, 3-4 residents, med students, and a fellow. They usually cover non-cardiac postops, preemies, the delivery room/OR, etc. If it's your patient, YOU do the scutwork. I haven't seen anyone doing scutwork for some other resident/NNP/PA without having offered to help out first... everyone pretty much help each other out.

The few (4) facilities I have been employed in have been different in level of midlevel involvement. I'm not sure what the reasons were for the difference. Some were like the one you're in, where the midlevel functions on the "scutwork" level, others were on a "between the resident and fellow" level along with the house docs and PAs, like where I am now. I would never put myself in a place that relegates me to scutwork. Not because I believe for a second that I am better prepared than a physician. It's because I went on and got an postbaccalaureate graduate education in addition to my years of clinical experience that prepared me to effectively manage and provide patient care (with backup, of course). I'm also not going to put myself in a unit that the attendings are managing me, but not mentoring me.

I think the issue here is that people are saying that NP/PAs (particularly the DNP) are the equivalent of MDs. They're not! But they can be a highly trained, valuable addition to the medical team. They don't have to be shoved out of the "rounds circle" or relegated to scutwork. I agree that there are a lot of terrible midlevels, especially from accelerated or online based programs, which is why I moved myself 800 miles to go to a classroom/lab/clinical program. Nursing and healthcare experience have a great impact on future practice as a midlevel. Over the years working in a hospital setting, we see many different cases come in, as well as being able to hone our assessment and procedural skills. A lot of assessment is "gut feeling" as you no doubt have experienced. You can't walk out of an online program and function as a midlevel. You need to have experience, and like you mentioned, a drive to continue to learn.

NP/PA does not = MD.

NP+PA+MD "can" = comprehensive, effective medical care team.

 

[foreverLaur]

There is a difference between a program that offers courses online and a program that is entirely online where you can do your rotations in a completely different state. All online courses I have tkaen at my school still tests that all students had to come and take at the same time on-site. No online exams.

Secondly, I have been accepted to both a DE MSN program and an accelerated BSN program, thanks. My DE MSN program also has extremely high placement rates for graduates. I have also called multiple hospitals and they don't even ask or care someones past prior to becoming an NP with the exception of those jobs that require previous experience, some might consider RN experience. However, I will have 2 years of RN experience before starting an MSN program, so I qualify there too.

Schools dont care if you did your BSN in a typical 4 year program or did it as your second degree. Between the two programs, the coursework is identical and the clinical hours are identical. No reason to discriminate when there are not any grounds to do so. The DE MSN programs are identical in length to a regular MSN program, or at least mine is.

Also, I'm not trying to argue on any sides. I am just presenting things that have been given to me or things that I have been told by health care professionals. So, don't go yelling at me over it. I'll give you the names of the PAs, NPs, and MDs and you can go yell at them and tell them how wrong and idiotic they are. Don't shoot the messenger.

 

[mig26x]

I hate this mundinger person right now!

 

[ForbiddenComma]

I think the issue here is that people are saying that NP/PAs (particularly the DNP) are the equivalent of MDs. They're not! But they can be a highly trained, valuable addition to the medical team. They don't have to be shoved out of the "rounds circle" or relegated to scutwork. I agree that there are a lot of terrible midlevels, especially from accelerated or online based programs,

Few people disagree that midlevels provide a valuable service. The problem is, as you stated, there are a lot of terrible midlevels, and a big reason is because there is no standardization among programs (especially with NP programs.. it isn't as bad with PAs). Really, any schmuck with enough time on his or her hands can become an NP, and therein lies the problem.

Is a new NP who starts today at a given institution competent at taking care of patients? Or are they a complete and utter *****? There is no way of knowing beforehand, because the barriers to the NP certification are so low.

At my place, I have met some decent NPs, and I have met one who was a superstar able to put most MDs to shame. But I have met a large number who could only be described as "incompetent." And they got through because there are such low standards for NPs.

It isn't as bad with PAs because the entrance challenges to PA school are more uniform (although not as uniform as MD school) and they have a universal, national board exam.

Isn't it time that NP schools do the same?

 

[Miss Mab]

wow--you even found stunningly unique nursing schools(2!) who will bypass the most basic pre-req of a previously earned bachelor's degree----applied/accepted---and all in less than a month........

Yep, I stand corrected. You absolutely don't sound foolish. My bad

BTW--i wasn't yelling at ya. If you heard anything at all I can assure you it was laughter...

"Less typing, more listening, process, repeat.


See you in the OR/NICU/PICU/Cath Lab..........

 

[zenman]

if the DNP can clear an Axis II screen or prove their Lithium Level is Theraputic, I say let 'em have it, but I've got a better chance of hitting the lottery today.

People who don't have an Axis II diagnosis can spell therapeutic

 

[Jawbone]

It isn't as bad with PAs because the entrance challenges to PA school are more uniform (although not as uniform as MD school) and they have a universal, national board exam.

NPs do take national certification exams in their specialty upon graduation... the problem I have with it, is that some states don't require it to practice, NY being one of them. I think that the law should be changed so that every NP graduating from school, whether a "lazy slob" or motivated experienced nurse, would be required to take and pass national specialty certification exams before practicing.

JB

 

[deleted6669]

"NPs do take national certification exams in their specialty upon graduation... the problem I have with it, is that some states don't require it to practice, NY being one of them. I think that the law should be changed so that every NP graduating from school, whether a "lazy slob" or motivated experienced nurse, would be required to take and pass national specialty certification exams before practicing.
JB[/QUOTE]"

the problem is that there is more than 1 board for some np specialties so a student can take 2 different board exams and only has to pass 1. I know many local np's and have precepted a few( fnp) and they all take both boards just to increase their chances of passing. I don't blame them, I would too in their situation, but that doesn't change the fact that there should be one and only 1 exam that is must pass to be certified. some states also don't require passage of the exam( as above) or say"must pass cert exam within x yrs of graduation. in some states folks have 5 yrs before they need to pass it.....

 

[foreverLaur]

I do agree that anyone working in health care needs to pass an exam, one exam, and that it must be passed prior to working in that field.

To me, it is like being operated on by a doctor who hasn't gotten around to taking his/her medical licensing exams yet. eek.

 

[Taurus]

the doc taking a back seat and holding retractors, etc

The surgeon is always there as you point out. When someone is walking you through something or supervising your every move, I don't call it doing your own cases. Furthermore, the surgeon is the one who confirmed the diagnosis, decided on whether surgery should be performed, what type, etc.

If you know of examples of RNFA's, PA's, etc who really do their own cases without any surgeon supervision at all, then let us know.

 

[Taurus]

NP/PA does not = MD.

NP+PA+MD "can" = comprehensive, effective medical care team.

Were you reading the same Mundinger article that I was?

practice independently in every clinical setting.

medical knowledge of a physician, with the added skills of a nursing professional.

clinical outcomes comparable to those of primary-care physicians​

I especially like the last statement. The NP's, led by Mundinger, puts out one crap study and suddenly all the NP's believe it like if it was the word of God. They don't know how to properly analyze a study.

I believe that the NP's are copying the same tactics that the CRNA's have been using to achieve their goals. They put out crap studies to show no difference and then they use propaganda to confuse the public and politicians. However, I'm not concerned about the NP's because there is one big difference between NP's and CRNA's. CRNA's control like 98% of the anesthesia midlevel market while the NP's have to share the midlevel market about equally with the PA's. If the NP's piss off the docs, they'll just hire your competitor and rather easily too. Plus, the AMA has enough foresight to see these tactics and respond appropriately. Increasing med school enrollment by 30% yet no change in residency numbers is probably a wise move by the AMA to prevent the NP's from taking over primary care.

So I welcome more articles like Mundinger's. When the dean of a premier nursing school starts to trivialize the training of physicians, many people take notice, albiet maybe not the people that the NP's were looking for. What I personally hope for is that the AMA responds swiftly and forcefully in all areas of medicine to these attempts by the nurses.

 

[kronickm]

Yeah I don't think there are very many doctors out there who don't like midlevels as people or as employees. What they don't like is the idea of mid-levels as equals, thus competing with MD/DOs for patients and salary. Doctors simply aren't used to competition.

People on these boards just get real up in arms about stuff because they see articles and posts from people like mundinger and CRNAs saying, I might as well be a doctor since I can do everything a doctor can. I don't think it is nearly as much of an issue in the real world.

 

[deleted6669]

The surgeon is always there as you point out. When someone is walking you through something or supervising your every move, I don't call it doing your own cases. Furthermore, the surgeon is the one who confirmed the diagnosis, decided on whether surgery should be performed, what type, etc.

If you know of examples of RNFA's, PA's, etc who really do their own cases without any surgeon supervision at all, then let us know.

I agree that in these situations the surgeon is always there.
they are not having to walk the pa through every step, however. I have a good friend who is a residency trained ortho pa. when he and his doc do a b/l procedure(plating b/l wrist fx, etc) the doc does 1 side completely and the pa does the other.

 

[Febrifuge]

... Doctors simply aren't used to competition.

Except of course for college. And MCATs. And all through med school. And then the Match. And probably finding a job. But once they're there, true enough, docs don't care about who has the best schedule, or the nicest office, or the sweetest car. Well, not all of them, anyway.

I'm just taking the p---, as the Brits say. I think in truth, docs are not used to competing for the esteem that comes with their position, which is what this is really about. After a lifetime of being forced to compete, I can see why they'd feel that way, and I would too.

People on these boards just get real up in arms about stuff because they see articles and posts from people like mundinger and CRNAs saying, I might as well be a doctor since I can do everything a doctor can. I don't think it is nearly as much of an issue in the real world.

On this, we agree 100%.

 

[mig26x]

. Doctors simply aren't used to competition.

.

It all starts in undergrad, 33,000 people apply for medschool, only 1/3 are accepted, then in medical school if you are shooting for a competitive specialty you need to be in the top 5% of your class. Then you need to score in the high 230's, 40's or 50's BOTH the usmle if you want a shot at a competitive residency and THEN you have to impress people during the residency interview which you also interview with 5-10 people and THEN you have fellowship which is the same as getting a residency but fewer places!!

Yep, doctors arent used to competition!! LOL

 

[kronickm]

It all starts in undergrad, 33,000 people apply for medschool, only 1/3 are accepted, then in medical school if you are shooting for a competitive specialty you need to be in the top 5% of your class. Then you need to score in the high 230's, 40's or 50's BOTH the usmle if you want a shot at a competitive residency and THEN you have to impress people during the residency interview which you also interview with 5-10 people and THEN you have fellowship which is the same as getting a residency but fewer places!!

Yep, doctors arent used to competition!! LOL

What I meant.

I think in truth, docs are not used to competing for the esteem that comes with their position, which is what this is really about.

Doctors are alone at the top of the health care food chain. They are not used to any competition.

 

[Tiki]

I have tons of respect for midlevels, they have helped me out on the wards on a daily basis since I started my clinical years. I don't pretend to know the requirements for the NP degree, but I will say that the idea of someone only needing 500 hours of clinical experience and then treating patients is very scary to me. I had way over 500 hours of clinical experience after my surgery rotation alone, and in no way would I have been ready to see patients without supervision.

If I averaged 60 hours a week during 3rd year (which for most weeks, it was way over that) and multiply that by the 48 weeks I spent on rotations, that would be about 2800 hours of clinical experience. As a fourth year, I am still in no way prepared to be autonomous. If I was going into a more patient oriented field (I'm actually a future pathologist, and we love love love PAs in path) I would never imagine dealing with all of the issues that one would face as a practicing physician without going through a residency. That is just absurd and down right scary for the patient. I do realize that nurses with years of experience are a lot different than DE NP nurses, and I wouldn't have a problem with one of them treating my URI.

 

[Buckeye4life]

Midlevels being at the same skill level or higher as Physicians is definitely possible, however, much more the exception than the norm. I would equate it to playing tennis. The best players in the world have played since they were old enough to pick up a piece of equipment, had thousands of hours of private lessons, tournaments, the whole nine and now make their sport look easy. Then there are people who pick up the sport later in life and can get to a fairly decent level, but you can almost always tell that there is something fundamentally wrong with one of their strokes. The stroke is not so bad that its gonna take them completely out of the game, but if it is attacked in just the right way, there is an obvious flaw (same with physicians, but it takes a stronger opponent to expose it). Medicine, imo, is just the same as it takes practice to perfect the game (which never is obtained completely), however no matter how much you play it, the person still seems slightly awkward if the foundation wasn't set early on. But, the same awkward person (they learn to adapt) can still be considered a valuable, and respected member of the league, and you can tell if given the right circumstances they definitely have a strong, natural ability to playing the sport and quite possibly would have been a top-ranked player.

 

[Jawbone]

Were you reading the same Mundinger article that I was?
The NP's, led by Mundinger, puts out one crap study and suddenly all the NP's believe it like if it was the word of God. They don't know how to properly analyze a study.

Stop generalizing. You keep putting all NPs in the same basket. There are many excellent researchers out there who happen to be NPs. You assume that because one person puts out a study that all NPs are going to bow down and kiss it... How many NPs (in current practice) are going to fork over the money and use the time it takes to get a doctorate that does nothing to expand their scope of practice? It will be decades before the DNP becomes uniform. It chaps my cheeks when you keep referring to "those nurses" or "those NPs" as if we are less human than you are. Keep in mind that we're the ones you'll be working with over the next 40 years as you pay off those loans....

JB

 

[core0]

Stop generalizing. You keep putting all NPs in the same basket. There are many excellent researchers out there who happen to be NPs. You assume that because one person puts out a study that all NPs are going to bow down and kiss it... How many NPs (in current practice) are going to fork over the money and use the time it takes to get a doctorate that does nothing to expand their scope of practice? It will be decades before the DNP becomes uniform. It chaps my cheeks when you keep referring to "those nurses" or "those NPs" as if we are less human than you are. Keep in mind that we're the ones you'll be working with over the next 40 years as you pay off those loans....

JB

After 2015 all new NPs will have the DNP they won't have a choice.

David Carpenter, PA-C

 

[foreverLaur]

I know this has been discussed elsewhere, but if you don't mind, would you review for me how any such requirement could be enforced? Will all 50 states change their licensing/practice laws to reflect this? Who is driving the bus on this initiative?

It won't. My aunt was in nursing school (75-79) they claimed that ALL nurses would be required to have a BSN by xxxx. Over 30 years later, there are still ASN and diploma prepared nurses. Trust me, it won't actually happen any time soon.

 

[f_w]

You'll be fine as long as you don't cross paths with that McGyver guy.

 

[core0]

I know this has been discussed elsewhere, but if you don't mind, would you review for me how any such requirement could be enforced? Will all 50 states change their licensing/practice laws to reflect this? Who is driving the bus on this initiative?

I would guess that all programs that do not have a DNP after 2015 will not be accredited. One of the aims of the DNP is directly at several NP programs that are run in medical schools and do not issue a nursing masters. Also this is directly aimed at several "for profit" nursing schools.

I would also assume that the ANA will press Medicare to require DNP for new NPI s. This would make the DNP pretty much mandatory. The Masters did not gain any traction until Medicare made it a requirement for getting a new UPIN.

While some of the states changed the requirements for NPs before the Medicare requirement, most simply changed it after all the programs had gone to the masters. I imagine that a similar process will happen here.

David Carpenter, PA-C

 

[Jawbone]

Any citations from important peer-reviewed articles where the NP was the principal investigator?

Why do they have to be the principal investigator? A lot of studies involve a multidisciplinary team, and don't delineate exactly who contributed what. Saying that NPs can't function in valid research is just silly.


The whole point of the DNP idea is to create a "doctorate" and use it as justification to expand scope of practice, not vice versa as you seem to think.

The doctorates currently in place (PhD, DNSc, DNP) did nothing to expand scope of practice. What is left to be expanded on? DNPs will never be asked to mentor/supervise residents/med students, function in the attending role, perform unsupervised surgical procedures, etc. NPs already possess admitting privileges, can operate standalone primary care offices, write orders, and have increasingly broad prescriptive authority. What else is there that NPs want? 100% reimbursement?

 

[Taurus]

What else is there that NPs want? 100% reimbursement?

When the DNP was first rolled out from Columbia, we had a debate about what it meant. The DNP defenders would justify it by saying it would increase the number of nursing educators, make NP's more clinically competent, blah blah blah. For those of us who read between the lines of the rationale and intent of the DNP, we saw something more underhanded at work: a way for NP's to try to place themselves on the same level as physicians because they now have a "doctorate" and will go around introducing themselves as "doctor". The thread is still active so you can read our predictions. The Mundinger article not only confirms what we have been saying but goes beyond by being so blatant. Being the dean of a premier nursing school and an NP leader, what Mundinger says will be taken more seriously than what a bunch of anonymous posters have to say.

Because it is now clear that the NP's do in fact want to proclaim themselves equivalent to physicians, I have a new set of predictions:
1) NP's want to be reimbursed the same as physicians even though you can earn a DNP by working full-time and doing it online. This has been a long-time goal by NP's, even when they were just Master's level. With the DNP, there will be a renewed urgency and stronger push. They will now claim they are "doctors" too.
2) More troubling is that they want to get into the specialties. This is more important because income potential is far higher than what primary care can offer. After getting into residencies, then they want to do fellowships, etc. IM, FM, and peds and hence cards, GI, etc are especially vulnerable.

I have a new insight into how the AMA is responding. We already know that the AMA has increased class size by 30% and both new MD and DO schools are being built without the corresponding increase in residency positions. I can think of two reasons why in the long-term this is beneficial.
1) ~30% of residency positions, mostly primary care, are taken by FMG's and IMG's. With the DNP, the nurses will lobby Congress -- since residency is funded by the federal government -- to allow DNP's to compete for these positions. Their argument will be that since according to Mundinger DNP's are equivalent to MD's why let foreigners take American jobs when you have a group of Americans who can do it. They will make it a patriotism and national security issue. If that 30% is soaked up by expanded MD and DO class sizes, then the AMA has effectively blunted this attack.
2) The AMA may be thinking about creating a new class of a physicians to compete head-on with the midlevels: the non-residency-trained MD or DO graduate. If the number of medical school graduates keep expanding, we may reach a point where there are more graduates per year than residency positions. The AMA should consider creating a new pathway for these individuals. Since they are already better trained than a DNP or PA, the newly minted MD or DO graduate is more than qualified to function in the midlevel position and can probably edge out any PA or NP for these jobs. Furthermore, these individuals are less threatening than a DNP or DrScPA to established MD's. These graduates can use their on-the-job time and training to get fully licensed and pass Step 3 or whatever the AMA decides on. If they want to progress with their career, they just need to complete a residency. Not everyone wants to do residency and either by choice or circumstance some people may not do a residency immediately after medical school. If the residency-trained physician is pretty much the standard definition of a physician today, then it makes sense to create a level below that for those who don't want to do a residency and who just want to go to work after medical school. They can take the role of the perpetual resident much like how some PA's and NP's function now.

I am not worried about NP's. Our AMA leaders have deftly outmaneuvered the nurses on several occasions and this time doesn't seem to be any different. Sure, some battles will be lost such as autonomy and script rights in some states, but the physicians will win the war.