Interesting Nurse Practitioner Document

[Taurus]

Nurses have been providing primary care long before medicine existed.

That's rich. Really rich. Is this what they teach you in nursing school?

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[BMBiology]

First DOs, now nurses want to practice medicine! I am sure DOs have killed many lives.

 

[oldpro]

Wow, you have a very strong opinion of the situation. What facts do you have to back up your stance? Nurses have been providing primary care long before medicine existed. Today, research and patient satisfaction surveys prove NP provide cost-effective, competent care in a variety of settings. I think 7 years plus of education can provide a nurse the tools he/she needs to fill the mass vacancies in primary care.

What? There was Nursing before Florence Nighting Gale? The one who founded Modern Nursing as we know it? In the 19TH CENTURY?

I think you better get your facts straight, There are many mentions of Physicians in ancient texts and yet nothing of "Nurses"

Sumeria
Greece
Then Rome, Uh ever heard of Galan (160 AD)? He study anatomy and founded many successful real techniques of surgery and orthopedics some that are pretty much close to what we do today.

Nurses really do not show up in History until around the 9th or 10th century AD in nunneries around Europe. NUNs took care of the sick 900 or so years after Galan, and over 1000 years from the physicians in Egypt.

Look Nurses are great, 7 years? Try Primary care Docs study 4+4+3 at least

thats at least 11 years, plus part of those seven years are not deep into Medical study ( I know since I'm an RN ) it is deep into Nursing courses, yes some path and some physio but not at the level of Medical school believe me I know! Medical School is to prepare you to practice medicine,

Uh Nursing school is to prepare you to practice Nursing, its not the same no matter what you believe. Patient satisfaction surveys prove ZIP it is unscientific and anecdotal.

Listen to someone who has done both! Please.

 

[oldpro]

i'm not saying call "me" Dr.
but you are denigrating someone's
educational goals, albeit far from your own.
not everyone has to be an MD to be
considered 'up there'.
just like many educational choices,
take away your degree, and what are you?
just like everyone else...
i just think that the AMA doesn't need to (and won't, i'm sure) govern the nursing profession.

Then Nurses should stay out of trying to practice medicine and practice nursing!

 

[brianmartin]

It is not obvious why any of the things that one learns in a DNP program makes one qualified to increase scope of practice.

This really is the bottom line isn't it.

 

[nebrfan]

I think most here are in agreement but the problem is it has been said by the powers trying to drive this that they expect the advanced practice nurses to have the title "Dr" professionally so they expect this in the work place or why else push it?

This is an issue Physicians need to take up on and voice our disagreement on.
Law makers and those in the profession alike need to here from US. I will be a voice if this goes farther.

To me it is an issue of quality and level of care, of my family and ultimately me!

A start would be pushing in every state for legislation similar to what Ohio has on the books (http://codes.ohio.gov/orc/4731.34)

A person shall be regarded as practicing medicine and surgery, osteopathic medicine and surgery, or podiatric medicine and surgery, within the meaning of this chapter, who does any of the following:

(1) Uses the words or letters, “Dr.,” “Doctor,” “M.D.,” “physician,” “D.O.,” “D.P.M.,” or any other title in connection with the person’s name in any way that represents the person as engaged in the practice of medicine and surgery, osteopathic medicine and surgery, or podiatric medicine and surgery, in any of its branches;

(2) Advertises, solicits, or represents in any way that the person is practicing medicine and surgery, osteopathic medicine and surgery, or podiatric medicine and surgery, in any of its branches;

(3) In person or, regardless of the person’s location, through the use of any communication, including oral, written, or electronic communication, does any of the following:

(a) Examines or diagnoses for compensation of any kind, direct or indirect;

(b) Prescribes, advises, recommends, administers, or dispenses for compensation of any kind, direct or indirect, a drug or medicine, appliance, mold or cast, application, operation, or treatment, of whatever nature, for the cure or relief of a wound, fracture or bodily injury, infirmity, or disease.

(B) The treatment of human ills through prayer alone by a practitioner of the Christian Science church, in accordance with the tenets and creed of such church, shall not be regarded as the practice of medicine, provided that sanitary and public health laws shall be complied with, no practices shall be used that may be dangerous or detrimental to life or health, and no person shall be denied the benefits of accepted medical and surgical practices.

(C) The use of words, letters, or titles in any connection or under any circumstances as to induce the belief that the person who uses them is engaged in the practice of medicine and surgery, osteopathic medicine and surgery, or podiatric medicine and surgery, in any of its branches, is prima-facie evidence of the intent of such person to represent the person as engaged in the practice of medicine and surgery, osteopathic medicine and surgery, or podiatric medicine and surgery, in any of its branches.

 

[oldpro]

Awesome!!!!!!!!

 

[Taurus]

The AMA has a resolution for this and 7 states have passed it so far.

Let's hope more will follow.

 

[oldpro]

The AMA has a resolution for this and 7 states have passed it so far.

Let's hope more will follow.

Its sad but we need this to protect the Public From the would be "Doctors"

It undermines the trust real Physicians have

It should be enforced by fines and even taking licenses of the other leveled care givers like NP, PA, DNP, and Natural Pathic Doctors in the states where this passed. This way it will have teeth!

 

[deleted50478]

The AMA has a resolution for this and 7 states have passed it so far.

Let's hope more will follow.

Just joined the AMA!
Will join the AMPAC when my AMA membership is processed!

 

[Taurus]

Check out my signature to see what each state has done.

NP report

 

[m3unsure]

Wow, you have a very strong opinion of the situation. What facts do you have to back up your stance? Nurses have been providing primary care long before medicine existed. Today, research and patient satisfaction surveys prove NP provide cost-effective, competent care in a variety of settings. I think 7 years plus of education can provide a nurse the tools he/she needs to fill the mass vacancies in primary care.

Why don't you deal with the nursing shortage problem first?
I think you have been on Mudslinger's man-gina for too long.

I have already started contacting my US reps and senators to address this issue and how this only adds to the problems of healthcare. Nurses need to be nurses. They can't advance medicine. They don't even do one bit of their own research. They just copy off our guidelines and claim they can do the same job.

 

[Jack Daniel]

They can't advance medicine. They don't even do one bit of their own research. They just copy off our guidelines and claim they can do the same job.

You make it sound like medicine is so compartmentalized and that all knowledge comes from physicians. Of course, as you know, it's much more fluid. Research comes from pharm companies, from PhDs at universities, from MDs...

I'm sure nurses are in there, too. Maybe they're not so good at advancing the science of medicine but I bet they could contribute a lot toward advancing the art of medicine.

 

[Faebinder]

You make it sound like medicine is so compartmentalized and that all knowledge comes from physicians. Of course, as you know, it's much more fluid. Research comes from pharm companies, from PhDs at universities, from MDs...

I'm sure nurses are in there, too. Maybe they're not so good at advancing the science of medicine but I bet they could contribute a lot toward advancing the art of medicine.

Medicine is part art and part science.

Contribute... yes.

Make decisions based on clinical science...

NO! Protocols in the hospitals and recommendations are made by physicians based on evidence (which can be researched by non-physicians). To allow someone else to make these recommendations is foolish.

Who understands the implications of adding an antibiotic or removing a recommended dose for insulin at sugar level 400 more than the physician working with it daily who has trained in that specialty and researched the clinical implications? It certainly is not the pharmaceutical company who researched it, otherwise all our protocols would be dictated by Big Pharm.... it's not the nurses who do not know the details of the histopathology, immunology, cellular interactions and the possibilities... and it's not the PhDs who never worked with patients since their focus is mostly on basic science.

Recommendations at hospital levels are done by physicians that produce papers and evidence to show that what they want is the correct thing for the patients. Sometimes that headbutts with what the hospital wants.. which is not to spend money.

 

[zenman]

Nurses need to be nurses. They can't advance medicine. They don't even do one bit of their own research. They just copy off our guidelines and claim they can do the same job.

Nurses are doing research all the time ..and publishing it.

 

[Taurus]

Nurses are doing research all the time ..and publishing it.

When was the last time nurses decoded the genes responsible for a disease?

When was the last time nurses developed the cure for a disease?

The research I see from nursing is usually, "healing powers of plants to make patients happier" or "red or green carpet, which increases mood?"

 

[zenman]

When was the last time nurses decoded the genes responsible for a disease?

When was the last time nurses developed the cure for a disease?

The research I see from nursing is usually, "healing powers of plants to make patients happier" or "red or green carpet, which increases mood?"

My reply was to the below post, which was incorrect:

Originally Posted by m3unsure
Nurses need to be nurses. They can't advance medicine. They don't even do one bit of their own research. They just copy off our guidelines and claim they can do the same job.

National Institute of Nursing Research, Nursing Research Journal, Journal of Research in Nursing, etc, etc....

 

[ForbiddenComma]

My reply was to the below post, which was incorrect:

His point still stands, though. Nursing "research" consists of demographics, diversity/multiculti fluff, customer satisfaction, and so forth. They do not dabble in the hard sciences. The rare nurse who *is* interested in such things generally must sign on with a research team led by MDs/PhDs.


The nursing establishment... btw, I don't even know why we call them "nurses" because the advanced practice "nurses" we are discussing have nothing but contempt for the RNs who do actual nursing... but anyway, they do not have much regard for real innovation and instead treat medicine as a liberal-arts field.

 

[Faebinder]

His point still stands, though. Nursing "research" consists of demographics, diversity/multiculti fluff, customer satisfaction, and so forth. They do not dabble in the hard sciences. The rare nurse who *is* interested in such things generally must sign on with a research team led by MDs/PhDs.


The nursing establishment... btw, I don't even know why we call them "nurses" because the advanced practice "nurses" we are discussing have nothing but contempt for the RNs who do actual nursing... but anyway, they do not have much regard for real innovation and instead treat medicine as a liberal-arts field.

Indeed, if nurses want to impact the science and research they need to start research into their own protocols and their impact on patient outcome. E.G. The ratio of nurses to patients in general surgery floors vs. vascular surgery patients impacting the incidence of adverse events and mortality... does one require more nurses per patient than the other. blah blah blah...

 

[zenman]

His point still stands, though.

No, his point was: "They don't even do one bit of their own research."

Actually they do, and I called him on that point alone. Now, there are two of you who need to go back and pick up some more liberal arts courses.

 

[zenman]

Indeed, if nurses want to impact the science and research they need to start research into their own protocols and their impact on patient outcome. E.G. The ratio of nurses to patients in general surgery floors vs. vascular surgery patients impacting the incidence of adverse events and mortality... does one require more nurses per patient than the other. blah blah blah...

Already been done...

http://www.nursing.upenn.edu/chopr/research.asp

 

[Faebinder]

.

 

[fab4fan]

His point still stands, though. Nursing "research" consists of demographics, diversity/multiculti fluff, customer satisfaction, and so forth. They do not dabble in the hard sciences. The rare nurse who *is* interested in such things generally must sign on with a research team led by MDs/PhDs.


The nursing establishment... btw, I don't even know why we call them "nurses" because the advanced practice "nurses" we are discussing have nothing but contempt for the RNs who do actual nursing... but anyway, they do not have much regard for real innovation and instead treat medicine as a liberal-arts field.

Thank you for ackowledging that. They really do have nothing but contempt for us, and the feeling is quite mutual.

 

[fab4fan]

Never mind; zenman posted the study I was thinking of, although there are others.

 

[Miami_med]

Thank you for ackowledging that. They really do have nothing but contempt for us, and the feeling is quite mutual.

Is there any sort of backlash within the ANA by the RNs against the DNP (as well as the MSN, CRNA, etc...)? I sort of figured that you guys would eventually get aggrevated subsidizing their malpractice insurance and taking orders from someone who knows absolutely nothing more about practicing medicine than you do.

 

[fab4fan]

Is there any sort of backlash within the ANA by the RNs against the DNP (as well as the MSN, CRNA, etc...)? I sort of figured that you guys would eventually get aggrevated subsidizing their malpractice insurance and taking orders from someone who knows absolutely nothing more about practicing medicine than you do.

None that I am aware of. I am most assuredly not a member of the ANA but I keep my eye on them. I don't get malpractice ins. through the ANA; I get mine through an indep. provider, even though the hospital pinky-swears if I ever really screwed something up they would have my back., so I really don't need to buy ins. Hmmm, and I believe in fairies and unicorns, too!

ANA is a disaster for the nursing profession. I keep hoping one day it will implode from self-importance. As far as taking orders from NPs/DNPs, I really haven't been in a situation where I had to take orders from an NP. Wait, I take that back. In the ED, we used to have some cardiology NPs who would come in and write admitting orders on pts., but they were really low-key people, and the orders were just the usual stuff you'd expect. Half the time the cardiologist would show up within an hour to co-sign the orders, so it wasn't a huge deal. Now if they had been really obnoxious or written stuff that was "iffy," I might have had issues. Otherwise, NPs/PAs aren't utilized in my facility at all; in fact, that particular group no longer comes to my facility, so technically there are no NPs/PAs at this hosp.

 

[zenman]

Is there any sort of backlash within the ANA by the RNs against the DNP (as well as the MSN, CRNA, etc...)? I sort of figured that you guys would eventually get aggrevated subsidizing their malpractice insurance and taking orders from someone who knows absolutely nothing more about practicing medicine than you do.

I don't know of any formal backlash against the DNP. But why did you mention MSN? There are lots of nurses with a masters and they are not NPs.

 

[MedicineDoc]

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[Miami_med]

I don't know of any formal backlash against the DNP. But why did you mention MSN? There are lots of nurses with a masters and they are not NPs.

I was really referring to the MSNs that practice as independent ARNPs.

 

[MedicineDoc]

What does that have to do with anything?

back to topic,

With more studies indicating that NP's are able to provide levels of care that are in par with MD PCP's, the issue of whether NP's "acting" like doctors becomes irrelevant. Like Jack Daniel said, the patients should be the focus of the debate.

What studies are you referring to? "JD" hasn't cited any studies. Even if he had there is a study for every position you could possibly ever want to have. I challenge you to show us a good study performed by a disinterested party showing that a degree that can be obtained on-line gives comparable results to medical school and residency training. In fact nurse practitioners are having increasing difficulty getting malpractice insurance as cited in my thread in this forum. I think this better reflects the reality of the situation rather than some BS study which neither one of you medical students (if "JD" is in fact even a medical student and not a NP student) have yet to produce.

 

[Jack Daniel]

What studies are you referring to? "JD" hasn't cited any studies. Even if he had there is a study for every position you could possibly ever want to have.

Except, I can't find any studies showing that NPs harm their patients. Seriously, do any exist?

I challenge you to show us a good study performed by a disinterested party showing that a degree that can be obtained on-line gives comparable results to medical school and residency training.

I think you're being disingenuous, but maybe you just really don't understand. The DNP is nothing but degree inflation, which it seems that all the health professions are following. Nurse practitioners can already practice independently without a DNP and they aren't trained from online courses. So, the fight against the DNP is irrelevant, at least regarding whether nurses can safely treat patients independently. Now, if you want to gripe about nurses introducing themselves as "doctor", I can understand. But really, that ship has already sailed too, since it seems all the health professions have their version of a "doctor".

In fact nurse practitioners are having increasing difficulty getting malpractice insurance as cited in my thread in this forum.

Yeah, OK. But don't physicians in some areas and some specialties have this same problem?

I think this better reflects the reality of the situation rather than some BS study which neither one of you medical students (if "JD" is in fact even a medical student and not a NP student) have yet to produce.

Doc, why do you keep harping on the fact that I'm a med student? It should be possible for you to have a conversation with those with less training than you.

 

[cpants]

Except, I can't find any studies showing that NPs harm their patients. Seriously, do any exist?

The burden of proof is on the nurses to prove that they provide the same outcomes on undiagnosed patients that MD's do. You can't use "there are no studies that prove NP's harm patients" as justification for calling NP's doctors in clinic or proof that they are just as good as docs. There are no studies showing that the housekeeping staff harms patients either. That doesn't mean they should be allowed to practice medicine.

 

[Jack Daniel]

The burden of proof is on the nurses to prove that they provide the same outcomes on undiagnosed patients that MD's do. You can't use "there are no studies that prove NP's harm patients" as justification for calling NP's doctors in clinic or proof that they are just as good as docs. There are no studies showing that the housekeeping staff harms patients either. That doesn't mean they should be allowed to practice medicine.

I agree with you. Of course, they have produced studies. I understand those studies can be picked apart, but really, what study can't? Taken all together, the studies showing good + the lack of studies showing harm + a 30-year track record + independent practice in many states, as disturbing as it may sound, suggests that nurse practitioners are able to get good results treating patients. Certainly, in another decade or so, we'll have a longer track record to better judge.

However, good results doesn't mean better than a physician. But it does suggest that they can benefit patients by providing lower costs and greater access.

As for the criticism about treating undiagnosed patients, I think that is certainly a good point.

 

[core0]

I agree with you. Of course, they have produced studies. I understand those studies can be picked apart, but really, what study can't? Taken all together, the studies showing good + the lack of studies showing harm + a 30-year track record + independent practice in many states, as disturbing as it may sound, suggests that nurse practitioners are able to get good results treating patients. Certainly, in another decade or so, we'll have a longer track record to better judge.

However, good results doesn't mean better than a physician. But it does suggest that they can benefit patients by providing lower costs and greater access.

As for the criticism about treating undiagnosed patients, I think that is certainly a good point.

First of all if you look at the studies there are exactly two that compare NP practice to that of a fully licensed MD. One was well done but too short (small sample size also). The other had insufficient data to tell anything. The rest compare NP practice to residents when both groups are under the supervision of attending physicians.

Second when you talk about independent practice you are talking about less than 2% of the NP population in practice (by best data). If you look at this group it is highly self selected with on the average more than 10 years of practice. The reason that is impossible to tell if NPs are practicing safely or not is that for the most part their data is submerged within that of the physician practices that they work for. The 2% that is practicing independently is not a large enough sample to generate adverse data points.

Third, when you talk about large amount of studies especially when referencing the Cochrane report, you of course realize that they included a large number of studies on NPs in the UK which are a completely different animal than those in the US.

The gold standard for medical care in the US is the Board certified physician. When you compare the standard of medical care to anyone else that is the standard that should be demonstrated. Its one thing to have an NP that has been in practice for a substantial amount of time open their own clinic. It is another to suggest that a new grad DNP is capable of that same independent practice. To put it in medical education terms there are no states that would license a physician who had completed the equivalent hours of didactic and clinical training.

David Carpenter, PA-C

 

[Jack Daniel]

Hi David,
I enjoy reading your posts and appreciated your above comments.

First of all if you look at the studies there are exactly two that compare NP practice to that of a fully licensed MD. One was well done but too short (small sample size also). The other had insufficient data to tell anything. The rest compare NP practice to residents when both groups are under the supervision of attending physicians.

Second when you talk about independent practice you are talking about less than 2% of the NP population in practice (by best data). If you look at this group it is highly self selected with on the average more than 10 years of practice. The reason that is impossible to tell if NPs are practicing safely or not is that for the most part their data is submerged within that of the physician practices that they work for. The 2% that is practicing independently is not a large enough sample to generate adverse data points.

I realize the studies have weaknesses, and I appreciate you pointing some of them out. I completely agree that the studies have limitations because the NPs are nestled within a physician practice or clinic. Some of the studies I've read stipulate that their conclusions are true only if nurses have access to either other NPs or physicians.

The JAMA study did compare NPs to Physicians and kept the groups separate. It's noted that study also has criticisms, which were published along with the study.

***Here I'm wondering aloud, so someone chime in*** For these NPs that are collaborating with physicians, aren't they de facto independent? I think there would be varying degrees of oversight. Do physicians second-guess every decision a NP makes and review every decision in a timely manner, or is it really just collaboration on paper?***

As to the 2% practicing independently, I definitely agree, that's the group we need to be studying. If the lobbying groups were serious about shutting NP independent practice down, I'd certainly look to this group for missteps.

Third, when you talk about large amount of studies especially when referencing the Cochrane report, you of course realize that they included a large number of studies on NPs in the UK which are a completely different animal than those in the US.

I knew that the studies included UK settings, but as to the NP being a completely different animal there than here, that's interesting and I didn't know that. I wonder how a UK NP differs from a US NP?

The gold standard for medical care in the US is the Board certified physician. When you compare the standard of medical care to anyone else that is the standard that should be demonstrated. Its one thing to have an NP that has been in practice for a substantial amount of time open their own clinic. It is another to suggest that a new grad DNP is capable of that same independent practice. To put it in medical education terms there are no states that would license a physician who had completed the equivalent hours of didactic and clinical training.

Yes, but states aren't giving full-scope medical licenses to nurse practitioners--even if they can practice independently. IOW, just because nurses can practice independently, they can't replace physicians because there are limits to their practice. The DNP isn't expanding this scope.

I view the independent NP as a Jiffy Lube or Midas. I can go there for some things but I go to a mechanic for major stuff. To me it's all about choices for the public and lower costs.

 

[Jack Daniel]

I view the independent NP as a Jiffy Lube or Midas. I can go there for some things but I go to a mechanic for major stuff. To me it's all about choices for the public and lower costs.

I know this just circles back around to the point many others hold: that nurses can't practice independently because without the physician training, they make too many mistakes, miss stuff, etc.

The reason I can support independent NP as a choice for people, even though they have less physician-type training, is because physicians miss stuff, too. If more training eliminated mistakes, then physicians wouldn't worry about malpractice. I think people assume that NPs make more mistakes because they have less training. But the public isn't really protected from mistakes from a physician, either. A medical license just guarantees a certain amount and type of training, not protection from mistakes.

So, IMO, it comes down to choice and an informed public. If people are willing to pay less and spend more time with a NP (with the fact that they have less physician-type training and might miss a lot of stuff), then I support that. If people want more training, and they want to go to a physician, of course I support that.

 

[Taurus]

I agree with you. Of course, they have produced studies. I understand those studies can be picked apart, but really, what study can't? Taken all together, the studies showing good + the lack of studies showing harm + a 30-year track record + independent practice in many states, as disturbing as it may sound, suggests that nurse practitioners are able to get good results treating patients. Certainly, in another decade or so, we'll have a longer track record to better judge.

However, good results doesn't mean better than a physician. But it does suggest that they can benefit patients by providing lower costs and greater access.

As for the criticism about treating undiagnosed patients, I think that is certainly a good point.

Of course, I have to ask the obligatory conflict of interest question: are you related to an NP or in a relationship with one? What year in medical school are you in?

 

[Taurus]

I view the independent NP as a Jiffy Lube or Midas. I can go there for some things but I go to a mechanic for major stuff. To me it's all about choices for the public and lower costs.

Let me point out the obvious: a patient is not a car. If they were, we wouldn't be going to school for so long and nobody would have objections to NP's.

Midlevels can handle routine visits. In fact, many physician practices use them in that manner. However, physician oversight is necessary for those cases that are more subtle or complex. The problem is that patients don't walk through the door with a sign saying if it's a routine or complex case.

NP studies to date have been poorly designed and you can't draw any sound conclusions from them. I want to see a double-blind, randomized, multi-center study with tens of thousands of undiagnosed patients covering everyone imaginable disease process out there. After the NP or physician has evaluated the patient, the study should have a medical panel of experts acting as the gold standard evaluate the patient independently and then the results should be compared. If you did such a comprehensive study, I believe that you will see a) which disease processes can be handled safely by independent NP's b) how many years of practice does an NP need to accumulate before they are competent. Right now, a fresh DNP grad with just 1000 clinical training hours has the same scope as one with 20 years of experience. Who would argue in favor that the fresh DNP grad is competent to independently deal with any patient who walks through the door? That's like saying a fresh med school grad, even with 5000 clinical training hours, can safely deal with "chest pain" or "abdominal pain". Would you trust either one with your life?

If such a study was done, then we can start to identify areas where midlevels can independently function competently and safely and how many years of practice and how many cases they need before they are safe. Trust me, if such a study was done, there would be a restriction of NP scope, not expansion.

I believe that many physicians have issues with the DNP not because it represents a free market alternative to the physician but because the proponents are purposely misleading everyone about their training and clinical competency. Read my signature and follow the links. How many of us would agree with Mundinger's claim that the DNP is equivalent to a residency-trained physician and should be able to work in any clinical setting? So, before you go off defending the DNP, know what they are claiming.

 

[MedicineDoc]

Doc, why do you keep harping on the fact that I'm a med student? It should be possible for you to have a conversation with those with less training than you.

I keep harping on the fact that you are a medical student because you have a very warped perspective of what it takes to actually take care of patients especially in the fields of internal medicine, pediatrics and family medicine and it comes through in every one of your posts. It is not easy and there are no quick and easy ways to become a good physician and that includes sham degrees.

 

[Jack Daniel]

Of course, I have to ask the obligatory conflict of interest question: are you related to an NP or in a relationship with one? What year in medical school are you in?

No, I have no conflict of interest with NPs. I'm a medical student. And it shouldn't matter whether I'm a physician, nurse or student--you should refute my points based on the points, not based on who I am.

 

[Jack Daniel]

I keep harping on the fact that you are a medical student because you have a very warped perspective of what it takes to actually take care of patients especially in the fields of internal medicine, pediatrics and family medicine and it comes through in every one of your posts. It is not easy and there are no quick and easy ways to become a good physician and that includes sham degrees.

Fine, Doc, so I'm a med student with less experience than you. Instead of stating the obvious, how about you respond to the meat of my post:

What studies are you referring to? "JD" hasn't cited any studies. Even if he had there is a study for every position you could possibly ever want to have.

Except, I can't find any studies showing that NPs harm their patients. Seriously, do any exist?

I challenge you to show us a good study performed by a disinterested party showing that a degree that can be obtained on-line gives comparable results to medical school and residency training.

I think you're being disingenuous, but maybe you just really don't understand. The DNP is nothing but degree inflation, which it seems that all the health professions are following. Nurse practitioners can already practice independently without a DNP and they aren't trained from online courses. So, the fight against the DNP is irrelevant, at least regarding whether nurses can safely treat patients independently. Now, if you want to gripe about nurses introducing themselves as "doctor", I can understand. But really, that ship has already sailed too, since it seems all the health professions have their version of a "doctor".

In fact nurse practitioners are having increasing difficulty getting malpractice insurance as cited in my thread in this forum.

Yeah, OK. But don't physicians in some areas and some specialties have this same problem?​

 

[Jack Daniel]

Let me point out the obvious: a patient is not a car. If they were, we wouldn't be going to school for so long and nobody would have objections to NP's.

Midlevels can handle routine visits. In fact, many physician practices use them in that manner. However, physician oversight is necessary for those cases that are more subtle or complex. The problem is that patients don't walk through the door with a sign saying if it's a routine or complex case.

NP studies to date have been poorly designed and you can't draw any sound conclusions from them. I want to see a double-blind, randomized, multi-center study with tens of thousands of undiagnosed patients covering everyone imaginable disease process out there. After the NP or physician has evaluated the patient, the study should have a medical panel of experts acting as the gold standard evaluate the patient independently and then the results should be compared. If you did such a comprehensive study, I believe that you will see a) which disease processes can be handled safely by independent NP's b) how many years of practice does an NP need to accumulate before they are competent. Right now, a fresh DNP grad with just 1000 clinical training hours has the same scope as one with 20 years of experience. Who would argue in favor that the fresh DNP grad is competent to independently deal with any patient who walks through the door? That's like saying a fresh med school grad, even with 5000 clinical training hours, can safely deal with "chest pain" or "abdominal pain". Would you trust either one with your life?

If such a study was done, then we can start to identify areas where midlevels can independently function competently and safely and how many years of practice and how many cases they need before they are safe. Trust me, if such a study was done, there would be a restriction of NP scope, not expansion.

I'd like to see a well-designed study, too. If it suggested NPs were endangering patients, my posting, opinion and tone, would certainly change. Also, I have no problem with limited scope. I think it's obvious that training and scope should correlate. NPs are trained at a certain level. They should perform at a certain level--what's the problem with doing this independently? Society will keep them in check just like it does with physicians, with malpractice.

I believe that many physicians have issues with the DNP not because it represents a free market alternative to the physician but because the proponents are purposely misleading everyone about their training and clinical competency. Read my signature and follow the links. How many of us would agree with Mundinger's claim that the DNP is equivalent to a residency-trained physician and should be able to work in any clinical setting? So, before you go off defending the DNP, know what they are claiming.

I've read the articles you link to and found them interesting. I certainly don't agree with nurse practitioners calling themselves "doctor" with the intent of misleading patients into thinking they are physicians. But restricting the term "doctor" in a clinical setting is a battle the medical profession lost long ago, and it wasn't against the nurses.

I realize that a DNP or nurse practitioner is not equivalent to a residency-trained physician. Because of this, I don't think I have a problem with nurses working in any clinical setting because they still have restrictions on their scope. Whatever their clinical setting, as nurses, they still won't have a license to practice full-scope medicine. I think the DNP is nothing more than nurses jumping on the "doctorate bandwagon". I'm not defending it, but rather independent NPs.

 

[MedicineDoc]

No, I have no conflict of interest with NPs. I'm a medical student. And it shouldn't matter whether I'm a physician, nurse or student--you should refute my points based on the points, not based on who I am.

Kind of like the I don't know what I'm doing or talking about but I did stay in a Holiday Inn Last Night Commercials. Maybe you can testify before Congress given your rhetorical abilities despite your lack of appropriate background. They will of course have to waive the part where you tell them who you are and what your credentials are but of course that will be more than made up for by your entertaining banter.

 

[UCFMOP]

As soon as Jack Daniel said "patient choices" I now have concluded beyond a shadow of a doubt that he is in fact in nursing school to be a NP or married to one etc. And is not in medical school. How could someone defend a profession from entering their own turf and jeopardizing their financial and professional future?

The nursing profession started this website that smacks of the same rhetoric when the AMA launched its litigation center and the S.O.P.P, the scope of practice partnership to combat all of this DNP nonsense. (I couldn't find that website again.)

Simply go to google and type in "scope of practice partnership" the 5th or 6th link is to a power point presentation that has some interesting facts.

 

[Taurus]

I realize that a DNP or nurse practitioner is not equivalent to a residency-trained physician. Because of this, I don't think I have a problem with nurses working in any clinical setting because they still have restrictions on their scope. Whatever their clinical setting, as nurses, they still won't have a license to practice full-scope medicine.

Oh really? In a number of states, NP's can open their own clinics, function autonomously without any oversight of physicians, and can prescribe all the meds that a physician can. If that isn't full-scope medicine, what is?

Follow the link to see what scope each state has.

The goal of Mundinger for the DNP is to make this true in all states, not just a handful of them. She also wants DNP's to be reimbursed equally as physicians instead of 85% and she wants all insurances to accept DNP's. It's just a matter of time before she also argues for creating residencies for DNP's so that they can compete with the physicians in the specialties because that's where the money and lifestyles are at. If DNP's can do primary care, why can't they do cards, GI, or derm?

If she accomplishes these things, how can you argue that NP/DNP's aren't practicing full-scope medicine with all the benefits that a residency-trained physician is entitled to?

That's why I keep arguing that DNP's need to be regulated by state boards of medicine and not nursing. DNP's are not practicing nursing. They're practicing medicine without the strong oversight and discipline that physicians have to operate under. This in fact puts physicians in a disadvantage because these DNP's go to school for fewer years, easier training (nursing school is a joke compared to medical school, part-time, all online), and have fewer regulations, ie, don't need to recertify every 10 years like physicians.

 

[Jack Daniel]

Oh really? In a number of states, NP's can open their own clinics, function autonomously without any oversight of physicians, and can prescribe all the meds that a physician can. If that isn't full-scope medicine, what is?

Follow the link to see what scope each state has.

The goal of Mundinger for the DNP is to make this true in all states, not just a handful of them. She also wants DNP's to be reimbursed equally as physicians instead of 85% and she wants all insurances to accept DNP's. It's just a matter of time before she also argues for creating residencies for DNP's so that they can compete with the physicians in the specialties because that's where the money and lifestyles are at. If DNP's can do primary care, why can't they do cards, GI, or derm?

If she accomplishes these things, how can you argue that NP/DNP's aren't practicing full-scope medicine with all the benefits that a residency-trained physician is entitled to?

That's why I keep arguing that DNP's need to be regulated by state boards of medicine and not nursing. DNP's are not practicing nursing. They're practicing medicine without the strong oversight and discipline that physicians have to operate under. This in fact puts physicians in a disadvantage because these DNP's go to school for fewer years, easier training (nursing school is a joke compared to medical school, part-time, all online), and have fewer regulations, ie, don't need to recertify every 10 years like physicians.

Well, Taurus, you may just have made me a believer.
It is my understanding that NPs, even the DNPs, have to follow guidelines that virtually spell out what they can do, effectively limiting them in their scope. The only way I could be on board with independent NPs is that they don't have an unrestricted medical license. I'll certainly look into just what they can and can't do.

To those of you who think I'm a nursing student, really, I'm not. I think that all medical students, especially those interested in primary care, must address this increasing trend of the independent mid-level practitioner and have a reasoned-through opinion. For my purposes, I was OK with it for the access of care and economic issues it solved. But, if there is no restriction of scope, that's troubling. I'll need to confirm if independent NPs will have, essentially, the ability to practice unrestricted medicine.

 

[Jack Daniel]

Kind of like the I don't know what I'm doing or talking about but I did stay in a Holiday Inn Last Night Commercials. Maybe you can testify before Congress given your rhetorical abilities despite your lack of appropriate background. They will of course have to waive the part where you tell them who you are and what your credentials are but of course that will be more than made up for by your entertaining banter.

Well, this forum is the place to discuss, discourse and hold forth.
I appreciate that you've shared your opinions and listened to mine.

As I responded to Taurus, I think all medical students, especially those interested in primary care, must have a well-reasoned opinion about this and certainly, reading these various posts play a part in helping me understand how others work through this topic.

 

[Taurus]

Well, Taurus, you may just have made me a believer.
It is my understanding that NPs, even the DNPs, have to follow guidelines that virtually spell out what they can do, effectively limiting them in their scope. The only way I could be on board with independent NPs is that they don't have an unrestricted medical license. I'll certainly look into just what they can and can't do.

To those of you who think I'm a nursing student, really, I'm not. I think that all medical students, especially those interested in primary care, must address this increasing trend of the independent mid-level practitioner and have a reasoned-through opinion. For my purposes, I was OK with it for the access of care and economic issues it solved. But, if there is no restriction of scope, that's troubling. I'll need to confirm if independent NPs will have, essentially, the ability to practice unrestricted medicine.

If NP's had maintained their original scope and purpose, to be physician extenders, to work with physicians to deliver the best possible care, then I would be fine with that. If DNP's had followed the DO example of adopting the medical education model, then I would have been fine with that.

However, the DNP represents to me and many others nothing more than a short-cut to practice full-scope medicine. Not only is the DNP training 1/12 that of even a FP, it is a much easier path, with nursing school not nearly as difficult to enter or to pass as medical school, that DNP can be done part-time while they work, and in some programs completely all online. And yet you have to creator of the DNP, Mary Mundinger, writing in Forbes and WSJ that DNP's are equivalent to PCP's and that they should be allowed to work autonomously in all clinical settings, outpatient, inpatient, and ER. To further insult physicians, Mundinger and deans of many nursing schools have paid the NBME to create an exam for DNP's that is loosely modeled after Step 3. You will no doubt start to hear the term, "board-certified DNP" pretty soon.

If the DNP model would provide the same high quality care as physicians, then I would have no problem, but I am dubious about that claim. The best and brightest go into medicine and even after 5000 hours of clinical training during medical school I wouldn't trust them with my life. Yet, you have people with lesser credentials and abilities going to nursing school, give them much less training, and we would allow them to see patients independently? Something doesn't add up.

Furthermore, if we allow DNP's to achieve their goals, then we are putting physicians at a huge disadvantage. FP, IM, peds have to go to school longer, take on more debt, and have a higher level of scrutiny and regulation to work in the same capacity as DNP's. Why are forcing physicians to compete against DNP's with basically one hand tied behind our backs?

If the DNP's want to practice medicine, then they should practice under the oversight of state medical boards. They have the mechanisms to ensure competency and safety of the people who practice medicine.

 

[Faebinder]

The JAMA study did compare NPs to Physicians and kept the groups separate. It's noted that study also has criticisms, which were published along with the study.

I just want to repeat the 900 lb gorilla that everyone ignores about that study. All the patients were pre-diagnosed and mainly diabetes. If you call that primary care then you dont know what primary care is.

 

[Jack Daniel]

I just want to repeat the 900 lb gorilla that everyone ignores about that study. All the patients were pre-diagnosed and mainly diabetes. If you call that primary care then you dont know what primary care is.

Your comment is noted.

I also noted it, in a general way, by posting that the study "has criticisms, which were published along with the study."

About ten others pointed that out, too, in letters to the editor after the study was published.

However, let's also point out that Dartmouth physician, Harold Sox, MD, in the introducing editorial called the study a, "well-designed, well-executed randomized clinical trial." So to completely dismiss the study would be unscientific. I don't think anyone is using this JAMA article to prove anything. It's merely another part of the total accumulating data.

Regardless where you fall on this issue, look at this through the eyes of a policy-maker. Factor all these into one equation:

• the numerous studies suggesting good;
• the lack of studies showing harm;
• current independent practice in eleven states;

As disturbing as it may sound to some, these suggest (I didn't say prove) that nurse practitioners are able to get good results treating patients. At the very least, this accumulation would make it very difficult for states to take away the privileges it has already given NPs.

And before I get deluged in "hate mail" again, I know that many here suspect that the NPs can't diagnose and manage complex cases. I recognize those are good criticisms and I think researchers need to address them in future studies. I definitely welcome more studies, especially focusing on the NPs already practicing independently.

At the moment, I'm more interested in finding out just what the scope of practice for NPs is. Can an independent NP do any primary care procedure or prescribe any drug, as a FM or IM physician technically can? Or do they follow a set of guidelines that gives them finite scope of what they can or can't do and little, if any, wiggle room. Understanding this would certainly help me to form a better opinion.