Interesting Nurse Practitioner Document

[Jack Daniel]

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I was looking into NP scopes of practice and found this amazing document.

The full document plus executive summary:
http://futurehealth.ucsf.edu/pdf_files/NP Scopes discussion Fall 2007 121807.pdf

The chart that sums it all up:
http://futurehealth.ucsf.edu/pdf_files/Chart of NP Scopes Fall 2007.pdf

My .02:
I think the information above is interesting for a number of reasons. As a med student, I have precious little understanding about the NP profession, but I'm frustrated by the rising costs of medical tuition--especially since I want to practice primary care. I like this quote from page 5 of the introduction:

Opposing groups, such as state Boards of Medicine, typically argue that NPs are not competent to practice more independently, or that they are insufficiently educated and trained to perform the disputed procedures safely. Those who oppose expanded NP scopes of practice out of concern for public protection, however, are often also motivated by hidden competitive self-interests. Some health professions, for example, may view
NPs as financial threats, and thus commit to block any legislation that would recognize overlapping scopes of practice among professions.​

I say, expand the NP scope because I think most opposition comes from turf protection rather than what's best for the patient. I think competition (i.e. choice among providers) is good for patients and good for lowering costs. If NPs can provide good primary care similar to physicians (and I think they can) maybe this country needs more midlevels and fewer physicians. As a group, physicians would either need to cede primary care to cheaper forms of practice and education or start figuring out how to lower educational costs.

 

[chapaquito]

With all the respect to the Nursing career,and exactly because of that ,I think the prospect of a nurse acting like Doctor is completely absurd,unethical,and completely out of the line,like playing to be doctors,I personally do not care who o who does not agree with me,it does not matter.This is like a Doctor will try to play to be a nurse, it will be unethical.I am sick and tired to read of this the AMA should act promptly and stop this nonsense. Why they do not hire international medical graduates,they are more than qualified to perform well.Also the National Boards of Medicals examiners should easy the requirements for foreign physicians,grant they visas so they can fill the so bad needed spots,also the medicals schools can eliminate many medical subjects or same rotations that are not really necessary and increase the time in Primary care rotations,if the Board needs to modify something I am sure that they can do it.I think above all the whole thing is moved more than anything for nothing BUT psychological ambition, a sense of inferiority nothing else,I think this way as I said above exactly for respect to the nursing career, because I think every doctor would have sometime a good memory to being helped by a nurse during his or her medical career.😎

 

[dfk]

With all the respect to the Nursing career,and exactly because of that ,I think the prospect of a nurse acting like Doctor is completely absurd,unethical,and completely out of the line,like playing to be doctors,I personally do not care who o who does not agree with me,it does not matter.This is like a Doctor will try to play to be a nurse, it will be unethical.I am sick and tired to read of this the AMA should act promptly and stop this nonsense. Why they do not hire international medical graduates,they are more than qualified to perform well.Also the National Boards of Medicals examiners should easy the requirements for foreign physicians,grant they visas so they can fill the so bad needed spots,also the medicals schools can eliminate many medical subjects or same rotations that are not really necessary and increase the time in Primary care rotations,if the Board needs to modify something I am sure that they can do it.I think above all the whole thing is moved more than anything for nothing BUT psychological ambition, a sense of inferiority nothing else,I think this way as I said above exactly for respect to the nursing career, because I think every doctor would have sometime a good memory to being helped by a nurse during his or her medical career.😎

you're a health student, correct?
do you have any first-hand experience with either being an MD or RN?
how about their roles as providers?
yea, that's the answer, involve the AMA.
and yea, the other answer is to bring more FMGs in and take away from qualified citizens to be proficient providers.
please...

 

[devilpup]

you're a health student, correct?
do you have any first-hand experience with either being an MD or RN?

please...

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.

The real problem lies in the unfair compensation practices involved with Primary Care in general. If the push for increasing the scope of practice for NP’s is successful, hypothetically, you would have NP’s earning more similar incomes to MD’s, without having to experience the long grueling process of earning the MD along with the $$$ debt. This problem could easily be alleviated by increasing the standard payments for MD PCP’s. In fact, there are proposals in legislation tables aimed at alleviating the income discrepancy across specialties (which obviously have historically favored surgical specialties and disfavored primary care) by favoring increasing payment schedules for PCP MD’s.

So what is the big problem? Specialty fields are reluctant in allowing better reimbursements for PCP’s. Why? Because increasing payment standards for PCP’s will decrease reimbursements for other specialties. Why? Because pay hikes must be budget neutral with MediCare (what does MediCare have to do with anything? Private insurance providers tend to base their reimbursements schedules on MediCare standards.

In regards to the turf war debate- I doubt MD’s would look at NP’s as threats if they could earn more equitable incomes when compared to their specialty buddies.

Lowering educational costs like JD said is a possible solution and increasing FMG’s in the primary care field would also have moderate effect, but increasing reimbursement to MD’s in primary care would have an even greater impact in lessening the grunts associated with the NP vs. MD debate.

 

[chapaquito]

you're a health student, correct?
do you have any first-hand experience with either being an MD or RN?
how about their roles as providers?
yea, that's the answer, involve the AMA.
and yea, the other answer is to bring more FMGs in and take away from qualified citizens to be proficient providers.
please...

A FMG is a Doctor in Medicine =MD,nothing more ,nothing less,besides this is situation like the intended DrNP is completely unethical, we will discuss more when you graduate as an MD, and yes answering your question about wheter or not I have experience in Medicine ,yes I do. Money can not buy Ethics or Moral.😎😎

 

[dfk]

A FMG is a Doctor in Medicine =MD,nothing more ,nothing less,besides this is situation like the intended DrNP is completely unethical, we will discuss more when you graduate as an MD, and yes answering your question about wheter or not I have experience in Medicine ,yes I do. Money can not buy Ethics or Moral.😎😎

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.

 

[Taurus]

If dealing with nurses can be a pain now because they think that they know medicine when they don't, can people imagine what it will be like when these nurses start to proclaim, "Well, I'm a doctor too and I'll do as I please". There will be constant bickering from these DNP's because they no doubt want to run the show too. This is a very good reason why more states need to restrict the use of the title "doctor" in a clinical setting. There should be no confusion as to who is in charge of patient care.

 

[onthego]

If dealing with nurses can be a pain now because they think that they know medicine when they don't, can people imagine what it will be like when these nurses start to proclaim, "Well, I'm a doctor too and I'll do as I please". There will be constant bickering from these DNP's because they no doubt want to run the show too. This is a very good reason why more states need to restrict the use of the title "doctor" in a clinical setting. There should be no confusion as to who is in charge of patient care.

+1👍

 

[Salamandrina]

If dealing with nurses can be a pain now because they think that they know medicine when they don't, can people imagine what it will be like when these nurses start to proclaim, "Well, I'm a doctor too and I'll do as I please". There will be constant bickering from these DNP's because they no doubt want to run the show too. This is a very good reason why more states need to restrict the use of the title "doctor" in a clinical setting. There should be no confusion as to who is in charge of patient care.

With all due respect, no one in health care should be saying "I'll do what I please." And this "running the show" business is also poppycock. Patient care is a team sport. Nurses, doctors, pharmacists, techs, dieticians, PT, OT, and on and on are all involved to get the best outcome. Your issue seems to be one of ego, either your own ego or the one you imagine the NP brings to the table. I can't understand why you think that having a nurse that is more educated is such a threat.

I have seen very effective NP - MD partnerships.

 

[Tired]

With all due respect, no one in health care should be saying "I'll do what I please." And this "running the show" business is also poppycock. Patient care is a team sport. Nurses, doctors, pharmacists, techs, dieticians, PT, OT, and on and on are all involved to get the best outcome.

So you want to share the decision making, but not the liability. Typical.

See, this is the standard nonsense you get from the NP crowd. You take a normal, sensible idea ("Health care is a team sport, and everyone is involved in getting the best possible outcome for the patient"), and you mutate that to mean that NPs should be functioning as physicians.

It's sad, because in the rest of the world, people do their job and are proud of it. Marines take orders, go where they're told, shoot who they're told, and consider themselves heroes. Nurses historically took care of patients, executed physician orders, and were loved by everyone.

Now a little subset of med school rejects comes along and gets everyone riled up by saying that they should be making the decisions. The sad thing is that now we have all these excellent nurses starting to believe that if you're not the one making the decisions, you're not important.

 

[Salamandrina]

So you want to share the decision making, but not the liability. Typical.

I didn't say anything of the kind. We weren't talking about liability and I didn't shirk any. I think your ego is way too wrapped up in this if you honestly think that you can independantly collect all the information you need and provide all the care your patients need single handedly.

See, this is the standard nonsense you get from the NP crowd. You take a normal, sensible idea ("Health care is a team sport, and everyone is involved in getting the best possible outcome for the patient"), and you mutate that to mean that NPs should be functioning as physicians.

Nice try. Mind citing where exactly I said NPs should be functioning as physicians? I said that I have seen NPs and physicians work together with great results.

It's sad, because in the rest of the world, people do their job and are proud of it. Marines take orders, go where they're told, shoot who they're told, and consider themselves heroes. Nurses historically took care of patients, executed physician orders, and were loved by everyone.

Oh...so now nurses don't take care of patients, execute physican orders and presumably aren't loved by everyone because there are NPs. That's a facinating theory. Too bad it isn't anything close to true. They still are providing patient care and they still are executing physician oders and yep...they still pretty much loved by everyone and are top gallup's poll on the most respected professions.

Now a little subset of med school rejects comes along and gets everyone riled up by saying that they should be making the decisions. The sad thing is that now we have all these excellent nurses starting to believe that if you're not the one making the decisions, you're not important.

Oh no, my friend. It is YOU that thinks if you aren't making the decisions you aren't important. This is why the very idea of NPs chaps your ass so fiercely. Regardless of the fact that NPs provide good patient care, you stamp your little foot and shake your little fist and say "NPs are trying to function as physicians. They want to make decisions and have no liability. They should just follow orders. God, why can't they just FOLLOW ORDERS!"

Might want to unload that chip on your shoulder.

 

[wisconsindoctor]

So you want to share the decision making, but not the liability. Typical.

See, this is the standard nonsense you get from the NP crowd. You take a normal, sensible idea ("Health care is a team sport, and everyone is involved in getting the best possible outcome for the patient"), and you mutate that to mean that NPs should be functioning as physicians.

It's sad, because in the rest of the world, people do their job and are proud of it. Marines take orders, go where they're told, shoot who they're told, and consider themselves heroes. Nurses historically took care of patients, executed physician orders, and were loved by everyone.

Now a little subset of med school rejects comes along and gets everyone riled up by saying that they should be making the decisions. The sad thing is that now we have all these excellent nurses starting to believe that if you're not the one making the decisions, you're not important.

First off, healthcare is not a sport. The best healthcare outcome results with people working as a TEAM. I have no problem with nurses getting Ph.D.'s. Can nurse doctors help out wih the shortage of physicians in primary care to help the citizens of our country? Sure, if they are willing to get a Ph.D. and spend a year in residency. But a nurse in no way should function as an Internest, Radiologist, etc.

When a patient needs to be on a specific diet for a period of time, then should talk to the person who is the expert in that area. If a patient is worried about passing on a mutated gene to an off spring or wants to know if they have a BRCA1 mutation, they should be sent to a person that is an expert in that area. If a patient needs physical therapy after an injury, they need to be seen by a person that is an expert in that area. If a person needs to be on an some type of respiratory care while having a CT done, the person that is trained in the area of respiratory care should take the role of that part of patient care. In the role of a CT scan, the trained tech will do the scan and the doctor will read the scan.

It seems like there are so many people (mostly pre-meds) on SDN that don't understand how healthcare is done.

 

[mshheaddoc]

Moving this to Topics in Healthcare where this is the proper venue for this discussion.

 

[oldpro]

you're a health student, correct?
do you have any first-hand experience with either being an MD or RN?
how about their roles as providers?
yea, that's the answer, involve the AMA.
and yea, the other answer is to bring more FMGs in and take away from qualified citizens to be proficient providers.
please...

You criticize another and yet post an Ignorant statement........ FMG's are MD's and we have take the USMLE 1,2 and 3 and do residencies here in the USA, I Also am Doing my clinical rotations here in the USA. We are just as qulaified as anyone else and so are other Foreign Doctors, in fact many foreign Doctors have practiced for years before coming to the USA and taking all three steps and then doing another residency here, curve your bias please.

Oh And I'm an RN (20yrs) and think that NP's and PA's need to collaborate with MD's or DO's, they are not Physicians and are not licensed to be such nor did they attend Medical school like a MD or DO. NP's and PA's should not practice on their own IMHO.

Giving them more responsibility is not the right thing to do, its like giving a Cop the right to Judge someone guilty or innocent.

There is level of training and education and experience here.

Would you like to have Neurosurgery performed on your brain by a PA or a Neurosurgeon (MD or DO) ?

Think before you post!

 

[oldpro]

Oh no, my friend. It is YOU that thinks if you aren't making the decisions you aren't important. This is why the very idea of NPs chaps your ass so fiercely. Regardless of the fact that NPs provide good patient care, you stamp your little foot and shake your little fist and say "NPs are trying to function as physicians. They want to make decisions and have no liability. They should just follow orders. God, why can't they just FOLLOW ORDERS!"

Might want to unload that chip on your shoulder.

Yes NP's and PA's can and do provide excellent and thoughtful care, what gets Medical students and Docs alike thinking and sometimes upset is the thought by some that they should be independent of Doctors (MD and DO's).
That is not what they were intended to be, MD and DO are the top of the Medical Ladder not on an equal step with NP and PA, the education is not the same nor is the License.

Just to make this clear, I do not have a chip but a Voice, and just because some on here may not like what I think or believe does not mean I do not respect nor like to work with NP's or PA's we all are part of the Care of the Patient but the MD and the DO are still the Physicians.............

 

[oldpro]

With all due respect, no one in health care should be saying "I'll do what I please." And this "running the show" business is also poppycock. Patient care is a team sport. Nurses, doctors, pharmacists, techs, dieticians, PT, OT, and on and on are all involved to get the best outcome. Your issue seems to be one of ego, either your own ego or the one you imagine the NP brings to the table. I can't understand why you think that having a nurse that is more educated is such a threat.

I have seen very effective NP - MD partnerships.

It is not a Sport, patient lives are at stake, you want your care in the ICU ( the care for you) To be rotated to Timmy a DNP who has little experience because it is his turn and oh well oops...........................................

It is absurd to think that we must always pat everyone on the back and send them in as a Team, When a Doctor makes a decision it is not after running it by each "Team member" it is after reading and asking for the information from each care provider and then using the Data to formulate a Diagnosis and Treatment in which they are qualified to do by the License and experience of a Physician.

MD's and DO's do not take "Online Medical School" By the way this is highly questionable as to the quality of the education, it seems NP's can do this?

It is not "PoppyCock" that the MD or DO Runs the Show, they do period.
NP's and PA's are not Licensed to Practice Medicine.......................

 

[Salamandrina]

Yes NP's and PA's can and do provide excellent and thoughtful care, what gets Medical students and Docs alike thinking and sometimes upset is the thought by some that they should be independent of Doctors (MD and DO's).
That is not what they were intended to be, MD and DO are the top of the Medical Ladder not on an equal step with NP and PA, the education is not the same nor is the License.

Just to make this clear, I do not have a chip but a Voice, and just because some on here may not like what I think or believe does not mean I do not respect nor like to work with NP's or PA's we all are part of the Care of the Patient but the MD and the DO are still the Physicians.............

I have no problem with anything you said. There are and should be limits to what NPs and PAs do based on the level of training required to fill each role. I don't think that physicians can be replaced by NPs. However, there is a role for NPs in patient care as a part of a team.

And, unless your alter ego is Tired, I wasn't saying you have a chip on your shoulder. My comments were intended for one specific person: the one I quoted.

 

[Salamandrina]

It is not a Sport, patient lives are at stake, you want your care in the ICU ( the care for you) To be rotated to Timmy a DNP who has little experience because it is his turn and oh well oops...........................................

It is absurd to think that we must always pat everyone on the back and send them in as a Team, When a Doctor makes a decision it is not after running it by each "Team member" it is after reading and asking for the information from each care provider and then using the Data to formulate a Diagnosis and Treatment in which they are qualified to do by the License and experience of a Physician.

MD's and DO's do not take "Online Medical School" By the way this is highly questionable as to the quality of the education, it seems NP's can do this?

It is not "PoppyCock" that the MD or DO Runs the Show, they do period.
NP's and PA's are not Licensed to Practice Medicine.......................

First, yes I know medical care is not a sport. I was making an analogy. I thought it would be understood, but I guess not. I in no way think that patient care is as trivial as a game of ping-pong and I wasn't intending to imply such.

That said, it is a team effort. You cited getting all the information from the other care providers and that is a part of it. I am not suggesting that MDs or DOs "run diagnoses by other care providers" either. What I am saying is when MDs or DOs make input from others unwelcome, they set the stage for poor communication and poorer outcomes. It isn't only MDs and DOs that do this. This can be lateral as well as hierarchical.

I am not saying that it is poppycock that MD or DOs run the show, it was just a poppycock argument because it had nothing to do with the points I made. I said nothing of who was running the show or of liability. Tired brought that up as though they were points of contention building the argument he wanted to address rather than the one I was making. That is what made the comment poppycock.

 

[Taurus]

I've seen so many nurses with inferiority complexes in person and many more on SDN. Can people imagine what would happen if you elevated and gave authority to these little Rodney Dangerfields with their inferiority complexes? DNP's are just so giddy with the idea that they can go around calling themselves "doctor" now. They think that getting the equivalent of an MPH puts them on par with a PCP. I can just imagine that they will constantly argue with the residents and attendings about what they think should be done for the patient. This is where teamwork disintegrates. Everyone can contribute their ideas, but there has to be no confusion as to who is in charge. The DNP's are intent on making everyone, especially the patient, believe that they are just as good as the physician in charge.

 

[Salamandrina]

I've seen so many nurses with inferiority complexes in person and many more on SDN. Can people imagine what would happen if you elevated and gave authority to these little Rodney Dangerfields with their inferiority complexes? DNP's are just so giddy with the idea that they can go around calling themselves "doctor" now. They think that getting the equivalent of an MPH puts them on par with a PCP. I can just imagine that they will constantly argue with the residents and attendings about what they think should be done for the patient. This is where teamwork disintegrates. Everyone can contribute their ideas, but there has to be no confusion as to who is in charge. The DNP's are intent on making everyone, especially the patient, believe that they are just as good as the physician in charge.

Taurus, do you have any evidence that this happens or that disagreements are more common? STFU if you don't.

 

[Taurus]

Taurus, do you have any evidence that this happens or that disagreements are more common? STFU if you don't.

It doesn't take an Einstein to see this down the pike. Just like it didn't take an Einstein to see what the nursing establishment was up to 4 years ago.

Thank you, Ms. Mundinger, for accomplishing more in 2 articles than I could in 4 years of posting. 👍

 

[Salamandrina]

It doesn't take an Einstein to see this down the pike. Just like it didn't take an Einstein to see what the nursing establishment was up to 4 years ago.

Thank you, Ms. Mundinger, for accomplishing more in 2 articles than I could in 4 years of posting. 👍

Nice one. It amounts to: "the merits of my opinion are so OBVIOUS I don't need to back them up with facts."

 

[Miami_med]

Nice one. It amounts to: "the merits of my opinion are so OBVIOUS I don't need to back them up with facts."

The fact is, that there are no real long term studies regarding DNP quality. We are forced to rely on common sense, because randomized controlled trials cannot be performed with things that barely exist at this point. However, I don't need to do a randomized controlled trial on whether my arm hurts after I cut it to know that it is going to hurt. The problem that EVERYONE I know on the MD side is expressing is not that there isn't work for an NP. It is that the DNP is not equivalent to an MD, and that is its ultimate purpose. NPs already practice with some autonomy, make decisions, do more than the average RN, etc... The only reason to add a second degree is to claim equivalence. This of course is an equivalence claim with no real merit.

The only "trials" that I have seen were done by the nursing groups (indicating an obvious bias) and were based on the ability to follow treatment protocols in previously diagnosed patients. This simply shows that NPs can create literature showing that they can possibly equivalently perform the lowest level functions of MDs. There is no "proof" either way.

I'm fond of competition, but I am against both misrepresentation and double standards. If we want to get rid of all medical licensing, go for it. We'll let the accreditation bodies and consumer reports like graders judge what we need and anyone can try and practice. However, mandating that certain groups can get a functional medical license with less training than other groups makes no sense. Also, most NPs who try to practice independently are essentially taking the trust that most people put into traditional physicians, because most people don't understand the difference. A lack of understanding doesn't prove that the difference doesn't exist.

It is not obvious why any of the things that one learns in a DNP program makes one qualified to increase scope of practice. It also doesn't make sense that we should give DNPs independent practice rights at the same time as many states are starting to mandate that ALL physicians complete 3 years of residency to even start moonlighting AND most insurance companies won't reimburse MDs that aren't certified. A DNP can collect 85% from Medicare, but an MD with 2 years of residency can't even practice in many states? It makes no sense at all.

 

[oldpro]

I have no problem with anything you said. There are and should be limits to what NPs and PAs do based on the level of training required to fill each role. I don't think that physicians can be replaced by NPs. However, there is a role for NPs in patient care as a part of a team.

And, unless your alter ego is Tired, I wasn't saying you have a chip on your shoulder. My comments were intended for one specific person: the one I quoted.

I did not think you said I had a chip on my shoulder, I however have posted a strong belief before and been told I have one.

To be honest Being in Nursing for 20 years I have seen the starch white uniform go into sloppy attire and poor self esteem of nurses, they are beaten up by Joint commission and bullied by review nurses, constantly stabbed in the back by other Nurses and then there are nurses who think they know more then the Doctors, You cannot tell me this is not so I have worked a long time and different places, enough to not just say this I have been there with these comments, actions and conversations, not once but 100's of times. Nurses say that Doctors do not respect them, this is true with some Doctors, but to earn respect you must also do your job well, there is so much messed up with nursing now that modern Nurses do not know how to do the job well like they used to.

here's some points:

1. Nurses #1 job is to follow orders accurately and understand them well, if misunderstood or thought to be out of the ordinary or may cause harm then they are to question and clarify. (many times this is not done I know I have caught this on rounds)

2. Nurses are overworked by penny pinching stupid organizations, they are shorted CNA's to the point that there may be none to assist in the job, bogged down by endless stupid rules and at times told to go home early so $20 can be saved, making the work and patient load unsafe at times

3. Nurses in academia are not helping the Nursing profession that well. They have in the past try to eliminate needed Nurses from the work force and turn bedside nursing into someone else's job: they wanted
A. LPN LVN schools eliminated
B. ADN nurses not to be RN's but Bedside care nurses ( Has not happened)
C. BSN to be the Managers ( no bediside care)
D. Now pushing advanced practice to the PHD level and call Nurses Doctors.

None of the above is patient care focused really it is to make nurses more "Professional" The goal of Nursing is Patient Oriented and Professionalism comes from being an expert at Bedside Patient care, Dressing changes, Medication delivery, Personal Care obstacles that are overcome by this expertise. Ect.....

NP's play a vital role so much that I plan on hiring one in my practice later, to help deliver the best care in a RURAL area, You see I cannot just an RN out to help with rounds or see patients in the clinic and have them write orders, an NP or PA can do this (But taking care of the Patients the way I judge they should be per my guidelines, yes the NP can use judgment but they will understand how I like care to be delivered) we can take care of more people and yes work together. But I still will be the MD for the Patients and ultimately responsible.

Nurses should worry more about the NURSING and less about Medical Practice.

 

[Salamandrina]

The fact is, that there are no real long term studies regarding DNP quality. We are forced to rely on common sense, because randomized controlled trials cannot be performed with things that barely exist at this point. However, I don't need to do a randomized controlled trial on whether my arm hurts after I cut it to know that it is going to hurt. The problem that EVERYONE I know on the MD side is expressing is not that there isn't work for an NP. It is that the DNP is not equivalent to an MD, and that is its ultimate purpose. NPs already practice with some autonomy, make decisions, do more than the average RN, etc... The only reason to add a second degree is to claim equivalence. This of course is an equivalence claim with no real merit.

I think you misunderstand the purpose on the DNP. By 2015, all NPs are to be doctorate prepared. From my understanding, this is not to further advance the role of the NP, but rather to advance the training required to be an NP. You are assuming that it is to encroach on the physician role and to claim equivalency, and though I cannot say that no NP would claim equivalency, I will say that I don't claim equivalency. I can only speak for myself.

Further, I agree that to use the title "doctor" in a hospital setting carries a very specific expectation and should not be used to describe NPs regardless of whether or not they are doctorally prepared. So if you want to say NP smith is not to be called "Dr. Smith" I will co-sign.

The only "trials" that I have seen were done by the nursing groups (indicating an obvious bias) and were based on the ability to follow treatment protocols in previously diagnosed patients. This simply shows that NPs can create literature showing that they can possibly equivalently perform the lowest level functions of MDs. There is no "proof" either way.

On the contrary, there is a great deal of literature around the effectiveness of NP care. Here is one published by JAMA.

Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians
A Randomized Trial

Main Outcome Measures Patient satisfaction after initial appointment (based on 15-item questionnaire); health status (Medical Outcomes Study Short-Form 36), satisfaction, and physiologic test results 6 months later; and service utilization (obtained from computer records) for 1 year after initial appointment, compared by type of provider.

Results No significant differences were found in patients' health status (nurse practitioners vs physicians) at 6 months (P = .92). Physiologic test results for patients with diabetes (P = .82) or asthma (P = .77) were not different. For patients with hypertension, the diastolic value was statistically significantly lower for nurse practitioner patients (82 vs 85 mm Hg; P = .04). No significant differences were found in health services utilization after either 6 months or 1 year. There were no differences in satisfaction ratings following the initial appointment (P = .88 for overall satisfaction). Satisfaction ratings at 6 months differed for 1 of 4 dimensions measured (provider attributes), with physicians rated higher (4.2 vs 4.1 on a scale where 5 = excellent; P = .05).

Conclusions In an ambulatory care situation in which patients were randomly assigned to either nurse practitioners or physicians, and where nurse practitioners had the same authority, responsibilities, productivity and administrative requirements, and patient population as primary care physicians, patients' outcomes were comparable.

JAMA, vol. 283, No. 1. January 5, 2000.

I'm fond of competition, but I am against both misrepresentation and double standards. If we want to get rid of all medical licensing, go for it. We'll let the accreditation bodies and consumer reports like graders judge what we need and anyone can try and practice. However, mandating that certain groups can get a functional medical license with less training than other groups makes no sense. Also, most NPs who try to practice independently are essentially taking the trust that most people put into traditional physicians, because most people don't understand the difference. A lack of understanding doesn't prove that the difference doesn't exist.

I see an NP for my gyn needs and my birth control scripts and I don't see that an MD is necessary for such standard care. If there were consistently poorer outcomes, I think everyone would agree that NPs shouldn't be entrusted with that level of patient care. However, to date, there has been no such data to support that NPs are under qualified. I am not saying that NPs should be replacing neurosurgeons (as someone mentioned) but with more chronic and primary care, I see no reason not to incorporate NPs as a part of a physician lead team.

It is not obvious why any of the things that one learns in a DNP program makes one qualified to increase scope of practice. It also doesn't make sense that we should give DNPs independent practice rights at the same time as many states are starting to mandate that ALL physicians complete 3 years of residency to even start moonlighting AND most insurance companies won't reimburse MDs that aren't certified. A DNP can collect 85% from Medicare, but an MD with 2 years of residency can't even practice in many states? It makes no sense at all.

If you want me to agree that the way that residents are treated sucks (80 hour work weeks, lack of a decent salary, the way the you are stuck with where you match, etc.) you got it! But it sounds to me like your complaint is not with DNPs so much as it is with a system that doesn't recognize or compensate you sooner.

Or are you really saying that they are right not to compensate MDs with 2 years of residency because you feel that they don't deserve compensation until year three?

 

[oldpro]

It is not obvious why any of the things that one learns in a DNP program makes one qualified to increase scope of practice. It also doesn't make sense that we should give DNPs independent practice rights at the same time as many states are starting to mandate that ALL physicians complete 3 years of residency to even start moonlighting AND most insurance companies won't reimburse MDs that aren't certified. A DNP can collect 85% from Medicare, but an MD with 2 years of residency can't even practice in many states? It makes no sense at all.

If you want me to agree that the way that residents are treated sucks (80 hour work weeks, lack of a decent salary, the way the you are stuck with where you match, etc.) you got it! But it sounds to me like your complaint is not with DNPs so much as it is with a system that doesn't recognize or compensate you sooner.

Or are you really saying that they are right not to compensate MDs with 2 years of residency because you feel that they don't deserve compensation until year three?

No I do not get that from this, I get that it is a process that we have to go through and it takes time and a lot of resources to get to be a Physician and these Nurse Educators are saying "Come here you can be a Doctor in a fraction of the time just join us"

We talk about Diploma Mills at times and this to me is just another SHortcut in the making, and it is wrong.

 

[Salamandrina]

I did not think you said I had a chip on my shoulder, I however have posted a strong belief before and been told I have one.

Fair enough 🙂

To be honest Being in Nursing for 20 years I have seen the starch white uniform go into sloppy attire and poor self esteem of nurses, they are beaten up by Joint commission and bullied by review nurses, constantly stabbed in the back by other Nurses and then there are nurses who think they know more then the Doctors

I agree that there are a great deal of problems internal to nursing. And I hate the fact that Scrubs nurses wear 1) don't differentiate nurses from other staff so as to be easily identifiable 2) that you can wear scrubs covered in a logo of some kind (whether it is a football team or sponge bob, I think both are unprofessional).

And I regretfully acknowledge that nurses stab one another in the back I did mention that the disrespect wasn't limited to being hierarchical but can be lateral or reverse hierarchical.

Nurses should worry more about the NURSING and less about Medical Practice.

This sounds almost like you are saying that there should be no NPs but that contradicts what you wrote about wanting to hire one. So….this statement confuses me.

 

[oldpro]

Quote:
Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians
A Randomized Trial

Main Outcome Measures Patient satisfaction after initial appointment (based on 15-item questionnaire); health status (Medical Outcomes Study Short-Form 36), satisfaction, and physiologic test results 6 months later; and service utilization (obtained from computer records) for 1 year after initial appointment, compared by type of provider.

Results No significant differences were found in patients' health status (nurse practitioners vs physicians) at 6 months (P = .92). Physiologic test results for patients with diabetes (P = .82) or asthma (P = .77) were not different. For patients with hypertension, the diastolic value was statistically significantly lower for nurse practitioner patients (82 vs 85 mm Hg; P = .04). No significant differences were found in health services utilization after either 6 months or 1 year. There were no differences in satisfaction ratings following the initial appointment (P = .88 for overall satisfaction). Satisfaction ratings at 6 months differed for 1 of 4 dimensions measured (provider attributes), with physicians rated higher (4.2 vs 4.1 on a scale where 5 = excellent; P = .05).

Conclusions In an ambulatory care situation in which patients were randomly assigned to either nurse practitioners or physicians, and where nurse practitioners had the same authority, responsibilities, productivity and administrative requirements, and patient population as primary care physicians, patients' outcomes were comparable.
JAMA, vol. 283, No. 1. January 5, 2000.

I find this interesting... And I disagree that this proves that NP's are equal to MD or DO

the criteria tested is not good enough to draw that conclusion:

Main Outcome Measures Patient satisfaction after initial appointment (based on 15-item questionnaire); health status (Medical Outcomes Study Short-Form 36), satisfaction, and physiologic test results 6 months later; and service utilization (obtained from computer records) for 1 year after initial appointment, compared by type of provider.

Twice satisfaction was measured, and the only real hard fact is the test results but what if the right tests were run or not run how about:

1. Mobitity and Mortality
2. Diagnoses old and new
3. Other parameters like VS
4. Level of care provided.

What about a critically ill patient?
What about other serious injuries and Illneses?

How would they really stack up?

 

[Salamandrina]

No I do not get that from this, I get that it is a process that we have to go through and it takes time and a lot of resources to get to be a Physician and these Nurse Educators are saying "Come here you can be a Doctor in a fraction of the time just join us"

We talk about Diploma Mills at times and this to me is just another SHortcut in the making, and it is wrong.

So, would it be better and more acceptable if NPs couldn't get compensated until they were three years out?

I think you'll agree (correct me if I'm wrong) that NPs should be in practice and should be compensated. So what is your solution for correcting the discrepancy for how NPs and new MDs are compensated?

 

[oldpro]

Fair enough 🙂


This sounds almost like you are saying that there should be no NPs but that contradicts what you wrote about wanting to hire one. So….this statement confuses me.

NP and nurses are not the same, We know that, just as CRNA's are not just RN's ( no offense) but I started an NP track before Medical School and the focus when I started was the "Wellness of Humans" "prevent disease and promote health" In medical school we do focus on this but also the Diagnosing and treatment of disease, Pathology is a Large part of medical school.

 

[Salamandrina]

I find this interesting... And I disagree that this proves that NP's are equal to MD or DO

I don't know how to make this more clear, so I will just keep repeating myself. I do not believe that NPs are equal to MDs or DOs

Twice satisfaction was measured, and the only real hard fact is the test results but what if the right tests were run or not run how about:

1. Mobitity and Mortality
2. Diagnoses old and new
3. Other parameters like VS
4. Level of care provided.

What about a critically ill patient?
What about other serious injuries and Illneses?

How would they really stack up?

A good point. Though I would not be surprised if such a study exists. I just felt limited to citing a med source as Miami Med said all the liturature is from a nursing bias. This was in no way exhaustive research on my part, just a quick and dirty check to see if there was material published in a medical source and as it turned out, there was.

 

[cpants]

On the contrary, there is a great deal of literature around the effectiveness of NP care. Here is one published by JAMA.

JAMA, vol. 283, No. 1. January 5, 2000.

[FONT=verdana,arial,helvetica,sans-serif]Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians: A Randomized Trial.
[FONT=verdana,arial,helvetica,sans-serif] Mary O. Mundinger; Robert L. Kane; Elizabeth R. Lenz; Annette M. Totten; Wei-Yann Tsai; Paul D. Cleary; William T. Friedewald; Albert L. Siu; Michael L. Shelanski
JAMA. 2000;283:59-68.

The complete citation. Funny. The study you quote has the ringleader of this DNP push as its primary author. Just as Miami_med said, this study was done by someone with a political agenda, and it only measures outcomes of previously diagnosed conditions. Try again.
.

 

[oldpro]

So, would it be better and more acceptable if NPs couldn't get compensated until they were three years out?

I think you'll agree (correct me if I'm wrong) that NPs should be in practice and should be compensated. So what is your solution for correcting the discrepancy for how NPs and new MDs are compensated?

Heck no, I think it was not clearly stated ( I could be wrong) but in the new article I read NP's soon will be at the PHD level to practice and Hence called Doctors, they should go to medical School for this privilege, Or just call them NP PHD or something, they are not Physicians. To me thats the point, we are taking a good functioning role and mudding the waters with this issue.

It's not my fault or yours its the Nurse Educators out there with PHD's who feel inadequate and push this nonsense on us!

 

[oldpro]

I don't know how to make this more clear, so I will just keep repeating myself. I do not believe that NPs are equal to MDs or DOs

.

Yea I understand I just wanted to make that point.

I think the study is a start but flawed

I do for the record again think that NP's are awesome as are PA's I just do not think they should be completely autonomous in practice I would however agree to the higher level of Collaboration verses directly supervised.

 

[Salamandrina]

Heck no, I think it was not clearly stated ( I could be wrong) but in the new article I read NP's soon will be at the PHD level to practice and Hence called Doctors, they should go to medical School for this privilege, Or just call them NP PHD or something, they are not Physicians. To me thats the point, we are taking a good functioning role and mudding the waters with this issue.

It's not my fault or yours its the Nurse Educators out there with PHD's who feel inadequate and push this nonsense on us!

Oh, I completely agree. I think "dr" should always mean "physician" in the hospital.

But I will say too, that I spoke with a nursing recruiter for a graduate nursing program (irony) and she said "I'll believe it when I see it" of the 2015 PhD or DNP requirement for being an NP. I think that nursing is going through a lot of growing pains and they have a lot of things to sort out.

 

[Salamandrina]

The complete citation. Funny. The study you quote has the ringleader of this DNP push as its primary author. Just as Miami_med said, this study was done by someone with a political agenda, and it only measures outcomes of previously diagnosed conditions. Try again.

It was also authored by four MDs so are you saying all of their credibility is in question?

This is really absurd.

*edit* if there were no MDs you'd have a point. But I would argue that if there were no NPs the study would lack credibility. Both groups should be and were represented. And again, it was published in JAMA not a nursing journal.

 

[cpants]

It was also authored by four MDs so are you saying all of their credibility is in question?

This is really absurd.

It is just a poor example when you are trying to prove that all the research is not done by NP's. She is the dean of the Columbia School of Nursing, and has recently been quoted in the WSJ pushing the idea that DNP's are equal to if not better than MD's.

It is also a piss poor study. It wasn't properly controlled, and it certainly does not show that NP's are in any way equivalent or deserve the same autonomy that MD's have. Read the letters to the editor in response to that study, published a few months later in JAMA.

 

[oldpro]

Oh, I completely agree. I think "dr" should always mean "physician" in the hospital.

But I will say too, that I spoke with a nursing recruiter for a graduate nursing program (irony) and she said "I'll believe it when I see it" of the 2015 PhD or DNP requirement for being an NP. I think that nursing is going through a lot of growing pains and they have a lot of things to sort out.

LOL thats my point, this is a lot of PHD level Nurses getting together trying to "Better Nursing" and Save all of us in Primary care, the NP is doing that just as I said, I will hire one and work with them gladly since we can see at least 50% more in the practice then. I will also expect a high level of practice from them too. And give them recognition and even Bonuses when we are successful.

 

[oldpro]

It is just a poor example when you are trying to prove that all the research is not done by NP's. She is the dean of the Columbia School of Nursing, and has recently been quoted in the WSJ pushing the idea that DNP's are equal to if not better than MD's.

It is also a piss poor study. It wasn't properly controlled, and it certainly does not show that NP's are in any way equivalent or deserve the same autonomy that MD's have. Read the letters to the editor in response to that study, published a few months later in JAMA.

But the Patients were satisfied, it said that twice.😀

 

[oldpro]

My solution is simple

NP PHD Or RN PHD

thats what they should be,

Some would be "RNC ADN BSN MSN PHD" Yea I can see that on the name tag........LOL

I have seen a lot of initials to tell me the person has done a of classroom time, I just need two Letters..............MD

 

[cpants]

I really have no problem with nurses getting a doctorate level academic degree. The important thing is differentiating that with a medical doctorate. There really is precedent for this too. For example, there is a guy with a PhD in Biochemistry in my class. When we are in clinic, he can't go by Dr. Smith. It makes sense. He is a medical student, and we wouldn't want patients to be confused. The same thing should go for nurses. In the classroom, at home, at the supermarket they can be Doctor, but in the clinic they should be Nurse.

 

[oldpro]

I really have no problem with nurses getting a doctorate level academic degree. The important thing is differentiating that with a medical doctorate. There really is precedent for this too. For example, there is a guy with a PhD in Biochemistry in my class. When we are in clinic, he can't go by Dr. Smith. It makes sense. He is a medical student, and we wouldn't want patients to be confused. The same thing should go for nurses. In the classroom, at home, at the supermarket they can be Doctor, but in the clinic they should be Nurse.

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!

 

[Salamandrina]

It is just a poor example when you are trying to prove that all the research is not done by NP's. She is the dean of the Columbia School of Nursing, and has recently been quoted in the WSJ pushing the idea that DNP's are equal to if not better than MD's.

oh for chrissakes will someone change the record? I do not think that NPs are equal to MDs or DOs. I also don't think that the journal article I cited tried to say that there were equal. It said, for the role the NP played, they had roughly equal outcomes. That is not the same as saying they are equal, it is saying that when doing what they are both trained to do, they had equivalent outcomes. NPs don't replace doctors nor do I think they should. Okay? Is that clear?

It is also a piss poor study. It wasn't properly controlled, and it certainly does not show that NP's are in any way equivalent or deserve the same autonomy that MD's have. Read the letters to the editor in response to that study, published a few months later in JAMA.

I read the letter to the editor that you are referring to and the author does bring up some important points. However, even letter writer didn't advocate for completely discrediting the article as you seem to. It is imperfect. It is population specific, it doesn't indicate the level (if any) of consultations that were used, and there was potential for a Type 2 error. I understand all that. And I agree that the research could have been improved.

So what's your point? Is you point that we can therefore wholesale discredit their reseach and say instead that your gut instinct that doctors must have better outcomes is truth? pfbbbbt.

 

[Taurus]

[FONT=verdana,arial,helvetica,sans-serif]Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians: A Randomized Trial.
[FONT=verdana,arial,helvetica,sans-serif] Mary O. Mundinger; Robert L. Kane; Elizabeth R. Lenz; Annette M. Totten; Wei-Yann Tsai; Paul D. Cleary; William T. Friedewald; Albert L. Siu; Michael L. Shelanski
JAMA. 2000;283:59-68.

The complete citation. Funny. The study you quote has the ringleader of this DNP push as its primary author. Just as Miami_med said, this study was done by someone with a political agenda, and it only measures outcomes of previously diagnosed conditions. Try again.
.

Everytime there is a discussion about NP practice, a nurse always pulls out this article like if it is the ultimate study.

David Carpenter does a fine job of explaining why this study is garbage. Bottom line is that the study is junk. Not enough power. Using pre-diagnosed patients to measure patient satisfaction. Subsequent studies appeared in 3rd and 4th level journals. Etc, etc.

The only thing that this article proves is that nurses don't know how to read scientific literature critically.

My take is that the sole purpose of this article is for Mundinger to justify the creation of the DNP and her statements like:

This doctoral degree enables advanced-practice nurses to gain the knowledge and skills necessary to practice independently in every clinical setting.

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

If we want a real study, let's design a double-blind randomized placebo-controlled multi-center study comparing the diagnosis and management of tens of thousands of undiagnosed patients by NP's and physicians.

 

[cpants]

If we want a real study, let's design a double-blind randomized placebo-controlled multi-center study comparing the diagnosis and management of tens of thousands of undiagnosed patients by NP's and physicians.

I agree, there needs to be study that compares diagnostic abilities and long-term patient outcomes. How do you give a patient a placebo NP though?

 

[Taurus]

I agree, there needs to be study that compares diagnostic abilities and long-term patient outcomes. How do you give a patient a placebo NP though?

The answer is you can't. It would be considered unethical to knowingly provide the patient something that is substandard. Patient can suffer or die.

However, a solution to this is to have a panel of experts evaluate the patient after the NP or physician has seen the patient. The panel would be considered the gold standard to which the NP or physician is compared to. The results would be to see how close the NP or physician comes to the gold standard.

Honestly, if such a study was done, I believe it would show that for simple cases such as strep throat that there would be little difference. However, I would expect for the complex cases that there would be a difference. The difficulty is that you can't always tell a simple from a complex case unless you have as much training and experience as a physician. Hence why you always need physician supervision.

Furthermore, such a study probably would reveal that NP's need X years of experience before they meet even the minimal level of competence. Right now, the laws in some states don't distinguish a new grad NP (which may have been done part-time and online) from one with experience, which is pretty scary since both have the same scope. Therefore, I believe that a study would force states to require X years before NP's could even assume their current level of scope. So NP's better be careful of what they wish for.

 

[Tired]

I agree, there needs to be study that compares diagnostic abilities and long-term patient outcomes. How do you give a patient a placebo NP though?

An NP is a placebo physician.

 

[JACOBI8]

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.

 

[cpants]

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?

 

[chapaquito]

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!

Awesome post👍👍👍👍