Interesting Nurse Practitioner Document

[Taurus]

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.

Read the NP report link that I posted. It has all the data you need.

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[Jack Daniel]

Read the NP report link that I posted. It has all the data you need.

Maybe this is just semantics, but to me, full scope medicine means more than just opening your own clinic and being autonomous. I mean, so far, you could be describing a podiatrist or naturopath, right?

As to the drugs, and the procedures, that's what I really want to clarify. According to the NP link you posted, the scope of practice for Alaska, one of the states NPs have independent practice rights, it says:

when delivering health care services the APN shall have in effect a written plan that is kept current at the practice site and made available to the BON at any time requested. The plan must describe the SOP, list the method and documentation process for routine consultations and referrals including the listing of at least one physician (appropriate to the APN’s focus of practice if it includes medical diagnosis and treatment) who is available for consultation and referrals, list the name of a pharmacist for potential use of dispensing privileges, and describe the process for quality assurance to evaluate the practice (including a written evaluation of the quality assurance review with a plan for corrective action)​

So, I realize this could include a lot, but would it really cover everything a physician does? For the AK NPs, the report says they can prescribe class II-V drugs. That does seem to suggest a very wide scope.

 

[Taurus]

Some more excellent links listing current NP scopes in each state:

Chart Overview of Nurse Practitioner Scopes of Practice in the United States) (2007)

Overview of Nurse Practitioner Scopes of Practice in the United States – Discussion (2007)

One of their key conclusions: in those states where NP's are regulated by both boards of nursing and medicine, the NP's have had a harder time expanding their scope. Their recommendation is to have NP's regulated only by BON's. Gee, I wonder why.

 

[RNMedic911]

In Michigan the scope of practice for all nurses (NPs included) is defined by the statue very broadly as:
All nurses are responsible and accountable for recognizing the limits of their knowledge and skill.
In the state of Michigan, nurse practitioners practice within a scope of practice defined by their specialty education and training. The depth of scope of practice is further defined by the knowledge base of the nurse practitioner, the role he/she is in, and the client population within the practice environment.


As an overview, the following are generic functions applicable to most nurse practitioner roles:

• Comprehensive physical examination and health assessment
• Promotion and maintenance of health
• Prevention of illness and disability
• Management of health care during common acute and stable chronic illnesses
• Assessment of clients that includes analysis, synthesis, and application of nursing theories and modalities
• Health counseling and guidance
• Admission of clients to hospitals/long term facilities with management within these facilities
• Consultation and/or collaboration with other health care providers or community resources
• Referral to other health care providers and community resources
• Diagnosis of health/illness status
• Application of evidenced-based practice and research skills
• Prescription and/or administration of medications, therapeutic devices and measures
• Ordering and interpreting lab tests and X-rays
• Client advocacy

This web site may help you understand the Michigan Scope of Practice for nurses http://www.minurses.org/apn/apn-npfaq.shtml#scopeofpractice

I think the point that is missed in this discussion seems to be that NO provider acts independently. Not a doctor, nurse, pa, chiropractor, physical therapist, pharmacists.

It takes all of us working together to provide our patients with the care they need. We all work in collaboration with each other. Each provider has his or her own area of expertise and experience level. Once the patient gets too complicated for their practice they should be referred to someone with the necessary expertise. A pharmacist may send someone looking for OTC cold medication to their primary care provider to get a antibiotic, that provider may send them to a cardiology practice to treat their irregular heart rate and the cardiologist may refer them to a physical therapist for post open heart surgery rehabilitation.

We don't provide care in a vacuum and should treat all of the other providers types with the same respect would like profession to be treated.

 

[docB]

We don't provide care in a vacuum and should treat all of the other providers types with the same respect would like profession to be treated.

Does that include saying that we can do the other professional's job just as well with less education?

 

[RNMedic911]

Does that include saying that we can do the other professional's job just as well with less education?

No.

Care to discuss the state of healthcare that makes this a poingant enough statment that you include it in your signature?

Emergency Medicine - Saving the world from seeing its primary care doctor.

 

[Taurus]

Each provider has his or her own area of expertise and experience level. Once the patient gets too complicated for their practice they should be referred to someone with the necessary expertise.

Let me see if I understand this. So, autonomous NP's want to cherry-pick off the routine and easy cases and send off the complex cases to the physicians. That's what the pharmacists also want. If all the routine and easy cases which make up probably 80% of visits are gone, what's left? Physicians have to fight for the 20% left because a) NP's don't have enough training to deal with them b) they don't want the liability from not being trained well enough to deal with them. Sounds like a pretty good deal if I were an NP. I call it the cherry-picking model of advanced practice nurses. However, are the physicians going to hand this over to the NP's on a silver platter? I don't think so.

Being a free-market supporter, I believe in letting the public decide what they want.

Health Clinics Inside Stores Likely to Slow Their Growth

In a strategy that combines both elements, Wal-Mart plans to partner with hospital systems to open as many as 400 co-branded store clinics by the end of 2010, up from about 50 sites in operation now. That approach is a departure from an earlier strategy under which Wal-Mart leased space to operators like CheckUps that weren't associated with hospital systems.​

Apparently, the consumer still believes in seeing physicians for their health needs and they aren't exactly flocking in huge numbers to health clinics staffed only by NP's. Even as health clinics become more popular, these clinics realize that the best model is to partner with brand-name hospitals and their physicians.

 

[Taurus]

No.

Care to discuss the state of healthcare that makes this a poingant enough statment that you include it in your signature? [/B][/I]

Now, that's interesting. In your first post ever, you listed yourself as "Health student". Now, you're an "MD/PhD student"? By your writing style and logic, I believe you're the former and not the latter.

 

[RNMedic911]

That is just simply fuzzy logic. You make it sound as though there are a tremendous number of primary care providers fighting for this supposed 80%. Not so. There are simply too many patients and not enough providers.

This is the reason that docB has that message in his signature. The EM providers aren't fighting over these patients. The patients go there because there is no place else for them.

As for the accusation of cherry picking. Isn't the model all PCPs use? The complex cases go to those with the training and expertise to deal with them more proficiently.

Not that it matters, but I am pursuing my DNP and didn't see this as a choice when I registered.

 

[ForbiddenComma]

This is the reason that docB has that message in his signature. The EM providers aren't fighting over these patients. The patients go there because there is no place else for them.

They go to the ER because they either can't, or they won't, get insurance. It has nothing to do with PCP availability.

So tell me. Do DNP students such as yourself see the DNP as just as demanding and vigorous as the MD/DO degree? Just curious.

 

[Taurus]

Not that it matters, but I am pursuing my DNP and didn't see this as a choice when I registered.

Then why are you still listing yourself as a MD/PhD student?

 

[RNMedic911]

They go to the ER because they either can't, or they won't, get insurance. It has nothing to do with PCP availability.

Not true, they go because it takes days to weeks to get into thier PCP for acute illness or injury. More PCPs would reduce the number of innapropriate ER visits and reduce the cost of healthcare so that more people could afford insurance.

So tell me. Do DNP students such as yourself see the DNP as just as demanding and vigorous as the MD/DO degree? Just curious.

I don't know; I've never been through a MD/ DO program. Although I would have to say probably not. I also don't have any notions that as an NP that I can handle every case, providers from all disciplines are needed to meet the needs of my patients.

 

[RNMedic911]

By your writing style and logic, I believe you're the former and not the latter.

Care to point out the flaws in my logic?

 

[ForbiddenComma]

I don't know; I've never been through a MD/ DO program. Although I would have to say probably not. I also don't have any notions that as an NP that I can handle every case, providers from all disciplines are needed to meet the needs of my patients.

That's certainly true. Some patients will need specialists from multiple fields, no matter what letters the PCP has after their name.

But do you feel that DNPs will be the equal to MDs in primary care such as family practice?

I believe this is the crux. If a DNP education is indeed all you need to be a great primary care doctor, then that means MDs are overeducated, and we should overhaul the medical education system so that all new primary care doctors receive just 2 years of medical education and no residency. Believe me... as an (almost) fourth-year med student with loans up the wazoo, the idea of already being an independent provider by this time definately has its appeal, instead of having to wait another 4 years.

It also means the stiff entrance requirements to med school are not necessary for being a primary care doctor. No need to excel in undergrad, no need to take the MCAT, no need to pass the USMLE steps... obviously, this too has appeal for anyone considering medicine as a career.

So what do you think? In primary care, does DNP = MD/DO?

 

[RNMedic911]

But do you feel that DNPs will be the equal to MDs in primary care such as family practice?[/quote]

The reality of the healthcare arena is that Masters level NPs are already providing primary care independantly. As a DNP I will have a greater ability to treat even more complex cases, and will have to refer fewer patients to a family practice doctor or internist.

It also means the stiff entrance requirements to med school are not necessary for being a primary care doctor. No need to excel in undergrad, no need to take the MCAT, no need to pass the USMLE steps... obviously, this too has appeal for anyone considering medicine as a career.

The entrance requirements for all graduate programs are stiff and all seeking admission must excel in undgrad and take a graduate admission exam (GRE / MCAT). This ensures that only the best students are accepted for admission.

So what do you think? In primary care, does DNP = MD/DO?

In short, no. Their will always be opportunities for DNPs to refer extremely complex patients to MD/DOs from every specialty. Collaboration among all providers is the key. A MD/DO could also refer a patient to a DNP. "Mrs Smith, I can't see you today but I could reccomend my associate Suzi DNP across the hall. She sees lots of patients with these types of problems.

This is would be a practice environment where every patient's needs are addressed by a provider that is not only qualified but recognizes their personal practice limitations and makes appropriate referrals.

 

[UCFMOP]

I can say that I will never NEVER give any referrel to a nurse who claims to be a doctor that got half of their education online. You know in other countries, there is non of this DNP, PA, NP nonsense because patients see DOCTORS! What a novel concept. Doctors do everything a midlevel does and more. We would we need a DNP if we have plenty of doctors?

AMA and AOA have seen the writing on the wall, and that is why more and more medical schools are popping up. With a flood of doctors hopefully the new grads will saturate the market and make a DNP's marketability very weak.

 

[RNMedic911]

I can say that I will never NEVER give any referrel to a nurse who claims to be a doctor that got half of their education online.

With such a negative attitude toward them I'm sure none of them will be referring patients to your practice either.

 

[MedicineDoc]

With such a negative attitude toward them I'm sure none of them will be referring patients to your practice either.

If things turn out the appropriate way you will be submitting your referrals to a primary care physician not a specialist.

 

[RNMedic911]

If things turn out the appropriate way you will be submitting your referrals to a primary care physician not a specialist.

Some patients will present with a clear need to see a specialist and not another primary care provider. You should feel free to refuse to see them as some docs in my area do. They won't accept referrals from us simple minded "mid-levels". We send our referrals to those providers who will respect our level of training as much as we respect theirs.

 

[Taurus]

Care to point out the flaws in my logic?

When I have to point out to you that you shouldn't be calling yourself a "MD/PhD student" when you're not even in medical school, this tells me you're just a troll.

 

[RNMedic911]

I was trying to find the descriptor that best fit my status as a doctoral student, PhD was as close as I could get. BTW, I did change it back to health student to avoid further confusion even though it doesn't really represent my actual status.

 

[Taurus]

I was trying to find the descriptor that best fit my status as a doctoral student, PhD was as close as I could get. BTW, I did change it back to health student to avoid further confusion even though it doesn't really represent my actual status.

Doctoral student?!

Are you going for a PhD? No.

You're going for a DNP, which people on this board have shown repeatedly is merely a traditional NP curriculum with some MPH classes thrown in, merely 1000 clinical hours which is 1/12th of a FP and also less than a PA, and nothing more than a power grab by Mundinger et al.

Are DNP students seriously trying to equate their degree with a PhD or MD?

This should give all med students, residents, and attendings an idea of the mindset they can expect when they encounter DNP's. You will have little prima donnas running around in a long white coat who think they are just as good at diagnosing and treating as a residency-trained physician.

I''ve personally have made the commitment of never hiring a DNP. Why do that when you can hire a PA who does the same job? Best yet, PA's are under the boards of medicine.

 

[APRV]

I posted the following on another thread. It needs to be posted here as well.

"Not that many years ago, many physicians graduated from medical school, did a one year rotating internship, and then went out and did general practice. When it became obvious that with increasing complexity of dealing with patients of all ages in a primary care setting more training was necessary, the specialty of family practice was developed, and physicians began doing THREE YEARS of residency training to meet this need.

Maybe someone can explain to me logically, how a "practicioner" can independently practice primary care without going to medical school (which involves two academic years of clinical training), and then doing a three year residency?????? In fact some physicians felt that even a three year FP residency was not extensive enough training to truly care for both children and adults and the med/peds combined residency was developed."

Medicine becomes increasing complex everyday. I don't care what is passing for primary care these days from NP's. The solution to the primary care PHYSICIAN shortage is to address that with incentives to get medical students to go into primary care, (such as LECOM six year program) not to have NON-PHYSICIANS try to take over this role.

 

[RNMedic911]

So, in your opinion, what would be the equivalent degree to a doctorate in nursing practice ?

 

[cpants]

"Health Student" is a lot closer to DNP than "MD/PhD" is. You do realize you are talking about a 2 year program that can be taken entirely online and not a 6+ year ordeal which earns two doctorate level degrees. Troll.

 

[RNMedic911]

Do you realize that my Doctorate level degree in nursing practice is a two year program that follows 3 years of associate degree nursing courses, followed by 2 years of baccalaureate degree nursing courses followed by another 2 1/2 years of graduate level coursework. So a total of 9 1/2, 4+ at the graduate level years only 1 year of that can be done "on-line".

Health student is a pretty poor descriptor for someone pursuing a doctoral degree of any sort.

 

[docB]

The reality of the healthcare arena is that Masters level NPs are already providing primary care independantly. As a DNP I will have a greater ability to treat even more complex cases, and will have to refer fewer patients to a family practice doctor or internist.

In short, no. Their will always be opportunities for DNPs to refer extremely complex patients to MD/DOs from every specialty. Collaboration among all providers is the key. A MD/DO could also refer a patient to a DNP. "Mrs Smith, I can't see you today but I could reccomend my associate Suzi DNP across the hall. She sees lots of patients with these types of problems.

This is would be a practice environment where every patient's needs are addressed by a provider that is not only qualified but recognizes their personal practice limitations and makes appropriate referrals.

It is clear that DNPs think that their future is to assume all of primary care. These statements show that the ultimate goal is to be able not only to treat more complex cases but to become specialists that receive referrals from other providers as well.

While I echo the sentiment that either DNPs and NPs are undertrained or physicians are overtrained it won't ultimately make any difference. The fact is, as I've said before many times, people want the absolute best health care they can get without paying anything for it. From here on in cost will trump all else. That and the fact that physicians as a profession can not (legal barriers) and will not (egos) organize is why we are doomed.

 

[RNMedic911]

It is clear that DNPs think that their future is to assume all of primary care. These statements show that the ultimate goal is to be able not only to treat more complex cases but to become specialists that receive referrals from other providers as well.

HuH?

 

[RNMedic911]

9 1/2 years is a long time. Just curious...what was the 2 1/2 years of graduate level coursework in?

Health Promotion and Disease Prevention
Pathophysiology for Primary Care
Decision Making in Health Assessment
Theories and Concepts of Advanced Practice Nursing
Pharmacology for Advanced Practice
Role of the Nurse Practitioner in the Health Care Delivery System
Women’s Health Care
Primary Health Care I: Acute and Common Problems
Research
Care of the Childbearing Woman
Primary Health Care II: Chronic Problems
Primary Health Care III: Advanced Diagnostics and Urgent Care
Primary Care of Children
Primary Health Care IV: Psychosocial Problems in Primary Care
Skills for Primary Care
Advanced Skills for Primary Care
Health Care Policy and Financing
Primary Health Care V: Complex Health Problems in Primary Care

Followed by 700+ hours of clinical.

 

[fab4fan]

The reality of the healthcare arena is that Masters level NPs are already providing primary care independantly. As a DNP I will have a greater ability to treat even more complex cases, and will have to refer fewer patients to a family practice doctor or internist.



The entrance requirements for all graduate programs are stiff and all seeking admission must excel in undgrad and take a graduate admission exam (GRE / MCAT). This ensures that only the best students are accepted for admission.

You seem like a nice person and someone with good intentions. But I have to tell you, I wouldn't feel comfortable as an RN having you directing the care of a complex medical patient. In the back of my mind would be the constant thought, "I wonder if "Dr. Smith" would do it this way?"

I have to admit that I am not at all on board with the DNP program and that if the mandatory component comes to fruition, that will end my pursuit of becoming an NP, something that is already on shaky ground at best. I have to question why I would become an NP when I myself would not choose an NP as my own primary care provider.

 

[ForbiddenComma]

Health Promotion and Disease Prevention
Pathophysiology for Primary Care
Decision Making in Health Assessment
Theories and Concepts of Advanced Practice Nursing
Pharmacology for Advanced Practice
Role of the Nurse Practitioner in the Health Care Delivery System
Women's Health Care
Primary Health Care I: Acute and Common Problems
Research
Care of the Childbearing Woman
Primary Health Care II: Chronic Problems
Primary Health Care III: Advanced Diagnostics and Urgent Care
Primary Care of Children
Primary Health Care IV: Psychosocial Problems in Primary Care
Skills for Primary Care
Advanced Skills for Primary Care
Health Care Policy and Financing
Primary Health Care V: Complex Health Problems in Primary Care

Followed by 700+ hours of clinical.

Check again. Are you SURE you didn't accidentally sign up for an MPH program instead?

Because you realize that half the courses that you listed are not about medicine or taking care of patients.

For instance, I gather that the course "Theories and Concepts of Advanced Practice Nursing" is worth exactly jack squat in terms of practical use.

Now, I appreciate the value of a liberal arts education. Don't get me wrong. My bachelor's was in a fluffy non-scientific field.

But we are no longer in liberal arts. We are training to be doc -- er, I mean, healthcare providers.

That course catalog you just posted guarantees you will remain a laughingstock on this board. Please say that you posted an MPH curriculum by accident... I cannot believe that people wanting to be called "doctor" have such coursework instead of a real medical education.

BTW, on that note, care to see what the coursework of an actual medical school looks like compared to your own?

 

[fab4fan]

Do you realize that my Doctorate level degree in nursing practice is a two year program that follows 3 years of associate degree nursing courses, followed by 2 years of bacceloreate degree nursing courses followed by another 2 1/2 years of graduate level coursework. So a total of 9 1/2, 4+ at the graduate level years only 1 year of that can be done "on-line".

Health student is a pretty poor descriptor for someone pursuing a doctoral degree of any sort.

I don't mean to be unkind, but if you cannot spell "baccalaureate" correctly, then you really aren't going to do much for stating your case to these guys.

 

[cpants]

Do you realize that my Doctorate level degree in nursing practice is a two year program that follows 3 years of associate degree nursing courses, followed by 2 years of baccalaureate degree nursing courses followed by another 2 1/2 years of graduate level coursework. So a total of 9 1/2, 4+ at the graduate level years only 1 year of that can be done "on-line".

Health student is a pretty poor descriptor for someone pursuing a doctoral degree of any sort.

Ok, if you want to count every day of your schooling since high school, we could do that for MD/PhD candidates also. That turns 6+ into 10++. All of these candidates completed undergraduate degrees, most of them in hard science at difficult programs. Many of them also have masters degrees. Just their doctoral degrees will take them 6+ years, vs. 2 years for you.

"Health student" is actually a good descriptor, if a little vague, for anyone pursuing a degree in a health related field. In contrast, "MD/PhD student" is a completely inappropriate descriptor for a DNP student.

I don't mean to be unkind, but if you cannot spell "baccalaureate" correctly, then you really aren't going to do much for stating your case to these guys.

 

[Taurus]

Found this on another thread.

I've always thought that it was suspicious that these NP's and CRNA's with just their 2 years could claim that they were just as safe as a residency-trained physician. Now we now it was just smoke and mirrors and they were doing to try to expand their scope.

http://www.nurseweek.com/news/Features/05-03/Malpractice.asp

Nurses once were, for the most part, outsiders in the physician-led fight to reduce malpractice insurance rates. Sheltered no more, nurse practitioners are finding their annual malpractice costs tripling, nurse-midwives are facing annual premiums as high as $35,000, and only one company is willing to write policies for nurse anesthetists, says Janet Selway, RN, DNSc, CRNP, instructor at Johns Hopkins University School of Nursing, Baltimore.

Selway, a state affiliate representative and board member of the American College of Nurse Practitioners, was among the nurse leaders who, out of concern, quickly convened a recent meeting in Washington on the topic.
"We wanted to have a dialogue between the insurance industry and representatives of the major national nursing organizations, just so we had a clear idea of what was going on," Selway says.

Nursing industry legal experts, representatives from the American Association of Nurse Anesthetists and American College of Nurse Midwives, as well as representatives from three nurse practitioner malpractice insurers, met to discuss the problem of rising rates and why rate hikes are hitting advanced practice nurses. Representatives from several nursing associations attended, including the American Association of Critical Care Nurses, the National League for Nursing, and the Emergency Nurses Association.

The meeting was successful in that representatives of the national nursing organizations in attendance are now armed with information to take back to their memberships, Selway says.

Some key points from the roundtable:

• Malpractice suits against advanced practice nurses are rising in number and increasing in severity, according to malpractice insurers. APNs need to learn about the basics of malpractice, including their liability, options with malpractice coverage, and legislative issues like tort reform. Associations, colleges, and societies are often good resources.
• Some 20% to 30% of nurse practitioner care is delivered by phone, exposing APNs to a liability that they might not have previously considered.
• In deciding these cases, courts must establish what's reasonable for a prudent APN. They establish "reasonable" by looking at policies and procedures and the literature existing at the time of the event, then look at national standards and causation: Was the action or inaction actually caused by the APN?
• APNs named in lawsuits should consider calling the American Association of Nurse Attorneys for counsel or advice even if they are covered under their employers' malpractice policies. Nurse attorneys might have a better grasp of the legalities involved with nursing practice.
• Malpractice insurers' profitability in covering APNs has dropped, perhaps because more nurses are being sued these days.
• APNs working in practices and clinics should ask to see their employers' malpractice policies to make sure they're named in the documents. They should consider having their own policies as well, especially if they moonlight.
• APNs should be aware that if they practice with a physician who is under- or uninsured, the nurse might become the deep pocket — the one who is covered for the highest amount and, therefore, is the more attractive to name in a lawsuit. Lawyers representing the injured have been known to go after anyone who might have provided care to the patient — anyone whose name is on the chart.
• Factors resulting in more malpractice claims and higher premiums aren't all due to big jury awards — experts say the nursing shortage is putting undue stress on hospital staffs, increasing the chances for drug errors and medical mistakes. What's more, fewer physicians are going into practice nowadays, which means a bigger patient load for current health care workers. The greater the patient load, the greater the chance for error and, ultimately, liability.

Sadly, state boards of nursing may be underreporting unprofessional behavior and incompetence to the National Practitioner Data Bank, according to one government representative who spoke at the meeting. APNs who've had a lot of claims against them and have settled out of court can often work in different states without fear of retribution because of confidentiality agreements.
In short, the Washington roundtable was an eye-opener for many nurses. Selway herself is quick to admit to that. "I think I have a better understanding of why the premiums are going up, and it's not just greed," she says. "The sad fact is that [because of increased lawsuits] we're not a profitable group to insure anymore."

 

[zenman]

BTW, on that note, care to see what the coursework of an actual medical school looks like compared to your own?

Sure, slap it up!

 

[ForbiddenComma]

Sure, slap it up!

Ok, just for you, zenman!

http://med.stanford.edu/md/curriculum/

I picked a relatively new-age hippy-dippy systems-based curriculum. For instance, Stanfurd calls its MS4 year "Translating Discoveries," which is sheer comedy gold. They also have one of their courses online, which is one of the main criticisms against the NP program. In other words.. I'm trying to make it easy for you here.

Here is a more typical state-school program: http://www2.kumc.edu/mesu/curriculumdiagram.html where all the useless navel-gazing stuff is confined to the "Issues in Clinical Medicine" class.

Either way, go ahead and compare it to the DNP program above and see what you think.

 

[RNMedic911]

The courses above were only for the Masters level courses. There are two more years worth of courses for the DNP.

 

[Taurus]

The courses above were only for the Masters level courses. There are two more years worth of courses for the DNP.

Yeah, everyone here is well-versed on the DNP coursework. We've examined it very closely.

As we've said, the DNP is an NP curriculum with some MPH classes thrown in + 1000 clinical training hours that you call "residency". And the nurses have the audacity to call it a "doctorate". Your degree should really say, "NP, MPH-lite", not "DNP".

 

[silas2642]

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.

I guess I'm with a few of the other posters in my state of slight shock and disbelief because I've found that most people in the medical profession tend to believe that in order to practice medicine one should prove his/her competence first rather than his/her lack thereof. You simply don't give unrestricted authority to nurses to practice medicine and wait to see what happens to the patients-- it's totally unethical, especially when the outcome can be predicted. How do you compare their education to a physicians? You can't.

Mundinger is leading this DNP battleground, and she wants DNPs to be the equivalents of MD's/DO's. You're naive if you think differently, but everyone is entitled to their own opinion.

 

[zenman]

Ok, just for you, zenman!

Here is a more typical state-school program: http://www2.kumc.edu/mesu/curriculumdiagram.html where all the useless navel-gazing stuff is confined to the "Issues in Clinical Medicine" class.

I just wanted to see if you'd do it, lol! So, in return here is a local medical school here:

http://www.bmc-bd.org/html/course_curriculum.asp?page=Course Curriculum

Either way, go ahead and compare it to the DNP program above and see what you think.

I personally don't like the DNP. NP or basic nursing education. I'd like to see changes in all. But you know how this profession is...

I'm leaving today for over a month in Peru getting educated with my shaman bros. It's heck of a lot more fun than any of the above curriculum.

Try not to discuss anything interesting while I'm gone...

Almost forgot. Years ago nursing came out with the DNS (Doctorate of nursing science) which had more of a clinical focus than the research oriented Ph.D. Wonder what's happening with that degree now?

 

[Jack Daniel]

By the way, for all of you out there who claim that the null hypothesis (APNs are just as good as MDs/DOs in delivering primary care) is proven by the fact that there are currently no studies that prove they provide worse care than MDs/DOs is called an argumentum ad ignoratium, an argument from ignorance, and is a logical fallacy that I see most frequently in APNs and the Bush administration. But hey, ignorance is to be expected from the DNP curriculum.

Yes, yes, but completely allowed by the rules of rhetoric, which, IMO, is how most debates are won.

 

[Jack Daniel]

By the way, for all of you out there who claim that the null hypothesis (APNs are just as good as MDs/DOs in delivering primary care) is proven by the fact that there are currently no studies that prove they provide worse care than MDs/DOs is called an argumentum ad ignoratium, an argument from ignorance, and is a logical fallacy that I see most frequently in APNs and the Bush administration. But hey, ignorance is to be expected from the DNP curriculum.

Just for the record, I think this is a minority viewpoint.
I think I'd argue that they can offer good care (not better or necessarily as good as), and, perhaps can serve as a cheaper alternative for people to choose. People should be fully informed and be allowed to get what they pay for.

 

[Jack Daniel]

I guess I'm with a few of the other posters in my state of slight shock and disbelief because I've found that most people in the medical profession tend to believe that in order to practice medicine one should prove his/her competence first rather than his/her lack thereof. You simply don't give unrestricted authority to nurses to practice medicine and wait to see what happens to the patients-- it's totally unethical, especially when the outcome can be predicted. How do you compare their education to a physicians? You can't.

Mundinger is leading this DNP battleground, and she wants DNPs to be the equivalents of MD's/DO's. You're naive if you think differently, but everyone is entitled to their own opinion.

For me, that's precisely the point I'm trying to clarify and understand better. I'm not entirely convinced that NPs have or will have an unrestricted medical license, though I understand many of you think that this is what they essentially have in a few states, and are trying to lobby for in the rest.

For me, I'm still trying to determine if what they can already do, in the most favorable NP states, is equal to what a primary care physician can do. I must say, if the ANP lobbying arm can pull this off, with half the training and little or no residency, wow. Just wow.

 

[Jack Daniel]

I guess I'm not sure yet how they will be cheaper. From a medicare standpoint, they currently reimburse ~85% of what physicians do, and Mundingle is pushing to get 100%. If they get 100%, how will that be cheaper?

Excellent point. I was thinking more along the lines of: cheaper training, thus able to charge less than most physicians would find possible--not just the Medicaid group.

 

[Jack Daniel]

I also read on allnurses that a FNP (and presumably by extension a DNP) cannot run a labor/delivery, at least in some states. They can apparently participate in prenatal care but not the actual delivery. Obviously this is state by state and can change in the future.

Interesting, huh? They draw the line when it comes to crowding out existing nurse midwives.

And, apparently, taking on the high liability areas.

 

[cpants]

I guess I'm not sure yet how they will be cheaper. From a medicare standpoint, they currently reimburse ~85% of what physicians do, and Mundingle is pushing to get 100%. If they get 100%, how will that be cheaper?

And also, it is possible that they would consult and order tests that an MD/DO may not, thereby also driving up costs.

I have no data regarding the consult/lab thing, just something I can foresee.

I read an interesting post on allnurses.com today about NPs who bill Medicare and private insurance as if a physician were "incident to" a patient encounter, which I guess reimburses more. Obviously we have no way of knowing how many do this, but one of the reasons for having these practitioners in the first place is to keep costs down, but already we are seeing some who are going after the dollar (I realize the account on allnurses is heresay, but still).

They will shoot themselves in the foot if they get medicare to pay 100% and private insurance follows suit. Then the insurance companies will encourage or require patients to see MD's to avoid the higher level of referrals independent NP's will produce.

 

[RNMedic911]

to avoid the higher level of referrals independent NP's will produce.

Can you back this up with some sort of evidence?

 

[APRV]

Can you back this up with some sort of evidence?

Why don't you address the issue I have brought up in two different threads.

Not that many years ago, many physicians graduated from medical school, did a one year rotating internship, and then went out and did general practice. When it became obvious that with increasing complexity of dealing with patients of all ages in a primary care setting more training was necessary, the specialty of family practice was developed, and physicians began doing THREE YEARS of residency training to meet this need.

Maybe someone can explain to me logically, how a "practicioner" can independently practice primary care without going to medical school (which involves two academic years of clinical training), and then doing a three year residency??????

Is medicine becoming less complex?

 

[cpants]

Can you back this up with some sort of evidence?

Well the argument your gang seems to make is that there is no risk to having NP's practice independently, because any complex or overly difficult case will be referred to an MD for evaluation. If the insurance companies have to pay the same thing for an NP as they do for an MD, they will prefer MD's to hopefully avoid some of the referrals. Every referral is another provider to pay.

 

[Taurus]

Can you back this up with some sort of evidence?

Over on auntminnie.com, a website for radiologists, they have a current thread about NP's.

Got a phone call from a NP who practices independently. She had ordered a pelvic ultrasound on a patient and was perusing my dictated report. I was queried about the exotic diagnoses of uterine fibroids and endometriomas. She had never heard of either.... What in the world was she to do with this patient????

I am becoming increasingly alarmed about sharing liability with these " colleagues" who are now firmly embedded in
the primary care arena. They have 2 years of formal training and many are not terribly bright. A lot of them are operating with little ( if any ) physician oversight.

What to do? Refuse their elective referrals?
Insist that any of their patients who have real pathology see an MD specialist and request a copy of their referral letter ?
Document in your report you have discussed the case with Muffy Jackson NP and told her to refer the patient ?​

It's not just us. Physicians everywhere are noticing that many NP's don't possess even basic medical knowledge. How does it reduce healthcare costs if autonomous NP's can't handle but the simplest of cases and have to refer out constantly? You don't. Whereas before it could have been taken care of in one visit to the PCP, now it takes two: one to the NP who refers out to the PCP.

I scratch my head and wonder how we got to this situation. If a drug company wants to put out a new drug, it has to do studies to show that it is at least as good or better than what's out there. If that drug proves to be unsafe such as Vioxx, the FDA pulls it from the market.

How did we allow an unproven group of people to work autonomously? It's crazy to think that a fresh NP grad has the same autonomous scope and privileges as one with 20 years of experience. How many heart attacks, strokes, cancers have gone unnoticed or had delayed diagnoses because the NP wasn't qualified? How many people have died? See my previous post about how more and more advanced practice nurses are getting sued. If the public demands answers for such cases as Vioxx, why shouldn't they also demand accountability from NP's?

The medical establishment needs to protect the public. We need real large-scale studies based on solid science, like the ones they do for drugs, to determine when non-physicians should be allowed to work autonomously. If we did do such a study, it would show a) which disease processes can be handled adequately by autonomous NP's b) how many cases and hence years that an NP needed to work up under supervision before autonomy should be allowed.

With the results in, then physicians can go to the states and show them what dangers they are exposing the public to by allowing NP's autonomy. The nurses will fight a losing battle if the evidence is clear. The benefit of doing such a study is that it avoids having to wage political fights from state to state.