Is the DNP a real threat, or a paper tiger?

[GeraldMonroe]

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As a pre-med medical student, I've seen many posts on the student doctor network about how the NPs, who are occasionally allowed to practice basic primary care with light supervision by a physician, are now trying to become "Doctor Nurses". It is often reinterated ad naseum on these forums that the degree that qualifies them to add the 'Doctor' to their title is not very academically rigorous compared to medical school.

There's lots of hoopla about "militant" NPs demanding essentially unlimited practice privileges without supervision by physicians. "What's next, DNP surgeons?" I hear from a few vocal posters on these forums.

The question I have is this. Medicine, and the amount of knowledge required by practitioners, has grown enormously more complicated in the 74 years since 1935, when medical education for physicians become standardized to consist of undergrad pre-reqs + medical school + internship, with residency required to be any form of specialist. (primary care is a specialty, doctors technically receive an unlimited medical license after just internship in most states)

So, for 74 years, in order to practice medicine one has needed a rigorous education. There have been dozens economic booms and busts over 74 years. Yet, in all this time, no licensing agency has ever significantly lessened the educational requirements to practice medicine merely to save money*.

As a matter of fact, the requirements have gotten more and more rigorous. Family practice docs used to do C-sections and were commonly employed in the E.R. Most surgical training and fellowships were a year or two shorter. Many subspecialties available now did not exist 74 years ago. And so on.

So, what's changed? Does anyone here sincerely believe that the "board of nursing" is going to expand privileges of DNP to the point that they have comparable authority to doctors? It hasn't happened in 74 years, why would it happen now?

One could credibly argue that doctors have gradually needed more credentials and education to practice through all human history. Why would such a trend reverse itself?

(* nurse anethesists don't count : nurses have done anesthesia since the field was invented, they just didn't have formal training)

 

[45408]

People aren't worried that a DNP is going to show up and take all the Whipples and CABGs away. Those are extraordinarily difficult, complex, and come with very high liability and responsibility. People are probably more worried that a DNP is going to show up and poach the low-hanging fruit (such as taking all the low-complexity patients, which can be seen faster and with less liability), leaving the diabetic CHFer with bilateral AKAs, ESRD and schizophrenia to some poor family medicine doc who gets 15 minutes to deal with all of the patient's issues.

 

[EternalMD]

It hasn't happened in 74 years, why would it happen now?

(* nurse anethesists don't count : nurses have done anesthesia since the field was invented, they just didn't have formal training)

So what has changed over time? health care costs have been driven up, tort reform has been an uphill battle forcing some to practice defensive medicine (further driving up costs), rural areas having difficulty attracting practitioners (which has always been the case), etc

If things hadn't changed in 74 years, then why the sudden need to become DNPs? what exactly does the extra degree allow them to do? why are they pushing for independent practicing rights? why do they want to do pain management solely? because they want a bigger piece of the pie. Its quite simple. It's a small percent, but those are the ones who pretend to be doctors by wearing the white coat, have tons of initials after their name to add credibility, argue with attendings about the proper management of patients - these are the ones gunning for a DNP to eventually be called doctor confusing the public

as for nurse anesthetists, while they have been providing anesthesia when it was first invented, it was fairly crude and unsafe back then. Physicians further refined the field leading it to be safer than it has ever been. there are many details to this argument which can be found in the anesthesiology forum

 

[badasshairday]

DNP's claim to be equal to MD/DO. They even have the NBME make them a watered down weak wannabe Step 3. Unfortunately for them, the best DNP program (Columbia) had it's DNP students take the exam and only half of them passed. Obviously they are not equal, but come on, to a patient who goes to the hospital, they know only "doctor" as them most trained person. However, "doctor" in the future will include a bunch of misfit DNPs that don't know their role.

This whole DNP deal is all about deception. They aren't decieving you and me, they are deceiving patients and using this as a backroad to be a "doctor."

 

[phospho]

a DNP is an academic degree... Are they legally allowed to use the title "doctor" in a clinical setting?

For example, does being a nurse and getting a PhD in english give you the right to call yourself "doctor" in a hospital?

 

[Iaka]

The DNP issue has its pros and cons. Ultimately it is a double edged sword. The only argument for it is that it will help address a shortage in primary care (particularly with family medicine). I cant help but feel that it will further help discourage medical students from pursuing this very same field. Taking the more academically rigorous route to become and MD or DO and have the same privaleges and responsablities as DNP makes little sense. Short term, DNP addresses the quantity problem in primary care but long term hurts the overall quality.

 

[MOHS_01]

The DNP threat is real in the absence of strict oversight / required employment arrangements with MD's. They have neither the cost nor the time invested compared to physicians. To be forced into direct competition with them, at their lower cost basis, is akin to private enterprise competing with a subsidized governmental system -- the playing field is not level. Primary care docs are taking their eye off the ball here arguing for redistributionist change when the real threat is from this subversive groundswell....

 

[badasshairday]

a DNP is an academic degree... Are they legally allowed to use the title "doctor" in a clinical setting?

For example, does being a nurse and getting a PhD in english give you the right to call yourself "doctor" in a hospital?

Only 8 states have barred DNPs from using the title "doctor" in a clinical setting. If you read the Pearson Report, the DNP militancy makes it clear that they should push legislation to allow the term "doctor" to be used in those 8 states that ban it.

 

[GeraldMonroe]

So what has changed over time? health care costs have been driven up, tort reform has been an uphill battle forcing some to practice defensive medicine (further driving up costs), rural areas having difficulty attracting practitioners (which has always been the case), etc

If things hadn't changed in 74 years, then why the sudden need to become DNPs? what exactly does the extra degree allow them to do? why are they pushing for independent practicing rights? why do they want to do pain management solely? because they want a bigger piece of the pie. Its quite simple. It's a small percent, but those are the ones who pretend to be doctors by wearing the white coat, have tons of initials after their name to add credibility, argue with attendings about the proper management of patients - these are the ones gunning for a DNP to eventually be called doctor confusing the public

as for nurse anesthetists, while they have been providing anesthesia when it was first invented, it was fairly crude and unsafe back then. Physicians further refined the field leading it to be safer than it has ever been. there are many details to this argument which can be found in the anesthesiology forum

Over 74 years, there have been many changes in financing of health care. The United States has not always been this wealthy. Furthermore, even in dirt poor countries like Cuba or Eastern Europe, they don't use nurses to practice medicine, they train a lot of doctors instead.

Yes, the DNPs are militants. The same with quacks 50 years ago. Obviously, the DNPs are making unreasonable demands : I'm saying that history tells us that they are not going to get what they want. DNPs are probably not ever going to get comparable authority or scope of practice to physicians.

Finally, a nurse anethetist is a tech who administers anesthesia, not someone who researches it. Before the formal training existed, surgeons would use nurses to give the anesthesia at least as often as they would ask another physician to do it.

 

[Iaka]

which are the 8 states

 

[MOHS_01]

which are the 8 states

Google "The Pearson Report" pdf

 

[dilated]

DNPs are probably not ever going to get comparable authority or scope of practice to physicians.

Uh, over half of states allow NPs to practice independently without MD oversight. What exactly is it they're "never" going to achieve?

I fully expect within our careers DNPs calling themselves "Doctor" and claiming equivalence with MDs will become quite common. MDs will roll their eyes and snicker about them behind their backs and otherwise do nothing about it. The public will, as always, believe that whoever spends longer in the room is providing better care.

 

[Cp22kjer]

This whole DNP deal is all about deception. They aren't decieving you and me, they are deceiving patients and using this as a backroad to be a "doctor."

Exactly. Mundinger and crew are exploiting the average patients lack of knowledge on the matter.

 

[Cp22kjer]

So, what's changed? Does anyone here sincerely believe that the "board of nursing" is going to expand privileges of DNP to the point that they have comparable authority to doctors? It hasn't happened in 74 years, why would it happen now?

This has already occurred my friend. PCP turf has and will continue to be invaded.

 

[EternalMD]

Over 74 years, there have been many changes in financing of health care. The United States has not always been this wealthy. Furthermore, even in dirt poor countries like Cuba or Eastern Europe, they don't use nurses to practice medicine, they train a lot of doctors instead.

Yes, the DNPs are militants. The same with quacks 50 years ago. Obviously, the DNPs are making unreasonable demands : I'm saying that history tells us that they are not going to get what they want. DNPs are probably not ever going to get comparable authority or scope of practice to physicians.

Finally, a nurse anethetist is a tech who administers anesthesia, not someone who researches it. Before the formal training existed, surgeons would use nurses to give the anesthesia at least as often as they would ask another physician to do it.

Training doctors in 3rd world countries is cheaper and without the legal constraints of this country (see malpractice). Hell, in some 3rd world countries, its a cash-based system of healthcare with the philosophy of "no money? no health care". So you're comparing apples and oranges and it doesn't work

As others have pointed out, DNPs ARE getting their way and unless physicians stand up against the backdoor entrance to becoming a doctor, they WILL fulfill their goals. You'd be naive to think that just because it hasn't happened in 74 years, it won't happen now.

CRNAs don't do research? hmm, interesting because they have their own research journal claiming to do exactly that. I would love to see your references regarding the frequency of nursing usage vs physician usage for anesthesia and tell me about the morbidity/mortality of that day and age versus now (then tell me what group of people pushed anesthesia to be as safe as it is today)

 

[HouseCall]

DNP's are a very real threat, not just to PCP's but, more importantly, to patients. The DNP's online education is grossly inadequate, relying on fluff classes (e.g. no science) to build the credit load to try to justify a doctorate. It goes without saying that this puts patients in grave danger. Nevertheless, health policy is made by politicians and make no mistake about it, DNP's are politically savvy and will continue to expand their scope of practice unless physicians and patients do something about it. The only way I see of stopping these DNP's is by joining our state medical societies and demanding they take a hard line against these DNP's. We also need to educate the public on just how poorly educated these nurses are. Talk to your neighbors and friends and let them know that nurse practitioners are not adequately prepared to practice medicine. Be polite though. Nurses do serve an important role, but the nurse practitioner role is truly a frightening development.

 

[GeraldMonroe]

Again : what's new. Why didn't they do this 10 years go? 50? 100? It's ALWAYS been possible to save money by spending less time and money training healthcare providers. Always. Yet, the historical trend in every last field of healthcare (not just allopathic medicine, but optometry, podiatry, PT, etc) has been to increase the cost and rigor and length of training. Year in, year out.

I'm predicting that the current situation is just a hiccup, and inevitably DNPs will either have their practice rights severely restricted by some agency (such as health insurance companies or government) or the length and rigor of their training will increase to the point that it is comparable to a year or two of allopathic medical school. (which is how D.O.s became credible, and why podiatrists are now called podiatric physicians)

 

[niranjan162]

Again : what's new. Why didn't they do this 10 years go? 50? 100? It's ALWAYS been possible to save money by spending less time and money training healthcare providers. Always. Yet, the historical trend in every last field of healthcare (not just allopathic medicine, but optometry, podiatry, PT, etc) has been to increase the cost and rigor and length of training. Year in, year out.

I'm predicting that the current situation is just a hiccup, and inevitably DNPs will either have their practice rights severely restricted by some agency (such as health insurance companies or government) or the length and rigor of their training will increase to the point that it is comparable to a year or two of allopathic medical school. (which is how D.O.s became credible, and why podiatrists are now called podiatric physicians)

Healtcare costs werent such a big problem, people werent as unhealthy. The DNP is a sorry excuse for a doctorate level training. As far as i kno there is no level of education higher than that.

Why do you say the current situation is just a hiccup? What makes you think that government agencies will step in and restrict their scope?

Their scope is already limited and they are lobbying for more independence and payment, and they are making headway. What leads you to believe this will be reversed?

 

[GeraldMonroe]

Their scope is already limited and they are lobbying for more independence and payment, and they are making headway. What leads you to believe this will be reversed?

For the exact same reason why family practice doctors don't do C-sections any more.

The reason most FPs don't do C-sections is that
a. Almost no one will pay for it. Hospitals won't give the FP the operating room privileges, and insurance companies and government won't reimburse the FP for the surgery
b. Almost no one will insure the FP against malpractice

On paper, any physician can do any medical procedure, even experimental ones.

The exact same restrictions apply to DNPs, only harsher.

Who's going to give DNPs the liability insurance for performing minor surgeries and dangerous procedures?

Is the DEA even going to allow them to prescribe scheduled drugs without supervision by a physician? Even if they do, a DNP is a magnet for an investigation the moment the write that first oxycontin script.

I think the likelihood of them really becoming de facto primary care doctors is the same as likelihood of internal medicine doctors routinely performing coronary bypass operations. It sure would be cheaper.

 

[niranjan162]

For the exact same reason why family practice doctors don't do C-sections any more.

The reason most FPs don't do C-sections is that
a. Almost no one will pay for it. Hospitals won't give the FP the operating room privileges, and insurance companies and government won't reimburse the FP for the surgery
b. Almost no one will insure the FP against malpractice

On paper, any physician can do any medical procedure, even experimental ones.

The exact same restrictions apply to DNPs, only harsher.

Who's going to give DNPs the liability insurance for performing minor surgeries and dangerous procedures?

Is the DEA even going to allow them to prescribe scheduled drugs without supervision by a physician? Even if they do, a DNP is a magnet for an investigation the moment the write that first oxycontin script.

I think the likelihood of them really becoming de facto primary care doctors is the same as likelihood of internal medicine doctors routinely performing coronary bypass operations. It sure would be cheaper.

I think the reason FP's dont do C-sections is due to the increase in knowledge and techniques, i.e. sterile technique, proper surgical training. As a result of these things FPs cant get reimbursement and coverage.

DNPs do have restrictions but their well organized union is lobbying to get these changed. They can practice independently in approx 14 states. They're not going to start out with liabity coverage for minor procedures, but theyre going to talk over primary care, they will get the easy cases while physicians are required to take the complex ones. Most people wont die from the cold they have. They'll use this as an excuse to say they can practice medicine and attempt to move into other fields of medicine claiming that they are cheaper and just as good.

 

[GeraldMonroe]

I think the reason FP's dont do C-sections is due to the increase in knowledge and techniques, i.e. sterile technique, proper surgical training. As a result of these things FPs cant get reimbursement and coverage.

DNPs do have restrictions but their well organized union is lobbying to get these changed. They can practice independently in approx 14 states. They're not going to start out with liabity coverage for minor procedures, but theyre going to talk over primary care, they will get the easy cases while physicians are required to take the complex ones. Most people wont die from the cold they have. They'll use this as an excuse to say they can practice medicine and attempt to move into other fields of medicine claiming that they are cheaper and just as good.

I'm not following. An FP knows how to do sterile technique : everyone was taught that in medical school. As for proper surgical training, that's all relative. I'm sure an FP could pull off a C-section a good percentage of the time (aka only kill the patient 1% or so of the time) if he or she studied up on the procedure and practiced for a week or two on animals.

Of course, a 1% death rate is so high that if an FP actually tried to do these on a routine basis, he'd lose his license and possibly go to prison.

The same thing goes for DNPs if they actually try to do anything remotely complex or dangerous.

As for colds : look, let's suppose there was a law that said high school physics teachers had to have a PhD in particle physics. And you'd see those teachers spending half their day teaching high school, and half their day in the high energy physics lab. Eventually, someone came along and said "look, with our jumped up master's degrees, we too can be 'doctors' and teach high school physics".

And there was much complaining, because the PhDs were making most of their money teaching high school, not working in the lab. They "deserve" that easy work. Heck, if PhDs didn't teach high school physics, they might miss out on identifying the next budding Einstein.

Maybe it doesn't take a doctor to treat a cold.

 

[UMED122]

Your argument is a little different than the real one as I see it. You’re arguing that nurse practitioners can treat the common cold. That's not an issue (they do that now). The point of importance is, should nurse practitioners be allowed to practice independently as equals to physicians, as they are striving to do.

I also disagree with your notion that this will somehow self-correct, or that some outside party (government, insurance companies, etc.) will intervene before things get bad (think about the recent turn of events on wall street). There is at least one case of where nurses tried to practice a medical subspecialty independently, and it was an effort by the medical profession itself that ultimately stopped them. Bottom line is that you need to be careful about justifying complacency.

 

[EternalMD]

FP most likely don't do deliveries is because of liability. A few old school ob/gyn docs dont even do any more ob-related work due to the liability associated with it and in turn the high malpractice fees. That probably had more to do with the pullback from doing deliveries eventually resulting in the status quo where FP physicians no longer do it because of hospital privileges, etc.

You are COMPLETELY wrong about ANY physician being able to do ANY procedure on paper. Psychiatrists are physicians who can't put in central lines because guess what? their training doesn't require them to get certified in it. You haven't started medical school yet so i dont expect you to know this but for most major procedures such as central line, thoracocentesis, etc, you need to do a certain number in order to be certified. Not all docs are certified in all procedures and thus CANNOT even on paper do procedures.

DNPs aren't trying to get rights to perform surgeries and major procedures currently but the right to practice primary care without physician supervision - that is the issue (NOT your implication that they are trying to become full fledged physicians able to perform surgery). If it were as simple as them attempting to become equal to physicians, then they would have gotten shot down a long time ago. But currently they are trying to use the excuse of "we're just trying to expand our education" to not identifying themselves as nurse but rather "doctor" to their patients, to expanding their primary care privileges.

As for the physics analogy, it made no sense.

 

[GeraldMonroe]

F
You are COMPLETELY wrong about ANY physician being able to do ANY procedure on paper. Psychiatrists are physicians who can't put in central lines because guess what? their training doesn't require them to get certified in it.

I've seen it repeated numerous places that a medical license is a medical license, and gives the holder the ability to do any medical procedure from a legal standpoint. That 'certification' is likely required in order for a hospital to allow the physician to do central lines, but it would not be a criminal act for a licensed physician without certification to put in a central line.

 

[Miami_med]

For the exact same reason why family practice doctors don't do C-sections any more.

The reason most FPs don't do C-sections is that
a. Almost no one will pay for it. Hospitals won't give the FP the operating room privileges, and insurance companies and government won't reimburse the FP for the surgery
b. Almost no one will insure the FP against malpractice

On paper, any physician can do any medical procedure, even experimental ones.

The exact same restrictions apply to DNPs, only harsher.

Who's going to give DNPs the liability insurance for performing minor surgeries and dangerous procedures?

Is the DEA even going to allow them to prescribe scheduled drugs without supervision by a physician? Even if they do, a DNP is a magnet for an investigation the moment the write that first oxycontin script.

I think the likelihood of them really becoming de facto primary care doctors is the same as likelihood of internal medicine doctors routinely performing coronary bypass operations. It sure would be cheaper.

Future doctor Monroe, let me attempt to make the arguments here a bit clearer. They are largely based on having a fundamental understanding of how a medical practice works (something that you in your early stage of training as well as everyone who makes decisions lacks).

Most medical practices have money losers. These are the train wrecks. The reimbursement system in this country is whacked out, so you generally lose money on patients that really need your help. The vast majority of primary care visits are not serious. Most physicians will make up for these complex money pit patients by seeing a lot of relatively healthy patients. When a healthy patient with a cold goes to a physician, they are looking for the expertise to determine that it isn't more serious than a cold. 99% of the time, it's just a cold. The concern is two fold. One, the DNPs will jump all over these easy cases, they will occasionally miss something for someone who thought they were getting physician expertise, but these will be little blips that will not reach statistical significance on any study. Two is that they will refer all of the complex cases back to the physicians, who will end up having to see them anyway due to the legal restraints in our country. In essence, DNPs take all the money makers that can be BSd and punt all of the money losers with real problems. It's a combination system problem mixed with a political problem.

As to why now?

The AMA has become dead weight in Washington, and the physician lobby is now weaker than the nursing lobby. Also, people used to pay for their own medical care (or atleast have a lot more choice) in the past, which means that the government couldn't simply turn more power over to another group. When people actually know what they're getting, they generally would prefer to be seen by a physician.

It's the deception that's the problem. If you want to say that you received an online degree after nursing school and patient's legitimately chose to see you instead of a fully trained physician, I'd say the patient's would get what they asked for. Right now, they often don't know the difference. The very educated portions of my family didn't even know these things existed until I told them, and they certainly didn't understand the training differences. I promise that most people have no idea that a DNP who calls himself doctor isn't the same as a physician.

 

[GeraldMonroe]

Most medical practices have money losers. These are the train wrecks. The reimbursement system in this country is whacked out, so you generally lose money on patients that really need your help. The vast majority of primary care visits are not serious. Most physicians will make up for these complex money pit patients by seeing a lot of relatively healthy patients. When a healthy patient with a cold goes to a physician, they are looking for the expertise to determine that it isn't more serious than a cold. 99% of the time, it's just a cold. The concern is two fold. One, the DNPs will jump all over these easy cases, they will occasionally miss something for someone who thought they were getting physician expertise, but these will be little blips that will not reach statistical significance on any study. Two is that they will refer all of the complex cases back to the physicians, who will end up having to see them anyway due to the legal restraints in our country. In essence, DNPs take all the money makers that can be BSd and punt all of the money losers with real problems. It's a combination system problem mixed with a political problem.

See my analogy of particle physicists teaching high school physics, above. And in my analogy world, the solution is obvious : pay more money for the more complicated work.

 

[MOHS_01]

See my analogy of particle physicists teaching high school physics, above. And in my analogy world, the solution is obvious : pay more money for the more complicated work.

Look, G Money -- the point is that there exists no uniform metric for complexity , and it would be insanely difficult to construct one. The current system, while dysfunctional, only works because of cost shifting mechanisms. If you allow some half baked group o' clowns siphon off the low hanging fruit, those being forced to reach higher and work for it get the ol' shaft. We cannot fight their existence; we can only hope to maintain some form of control. Let them do the "easy" work, just so long as we reap a % of the profits and can afford to stand ready to clean up their messes....

 

[EternalMD]

See my analogy of particle physicists teaching high school physics, above. And in my analogy world, the solution is obvious : pay more money for the more complicated work.

Miami med gives you a fairly logical and succinct explanation and you still refer to your silly analogy which makes no sense..... actually many people have made valid points to no avail which makes me believe that no matter what, some people just don't get it. With that, enjoy medical school - and hopefully it shall enlighten you to the real world

 

[Pghboy18]

Somebody correct me if I'm wrong, but if DNPs are as dangerous and unqualified as they're made to sound in these forums (and I don't necessarily disagree with that perspective), won't the problem work itself out anyway?

If they can't provide quality care, won't patients catch on? They may not be as savvy to the educational requirements as med students and doctors, but surely most will understand the difference between going to medical school and not going to medical school. Won't the legal system catch on? The media?

On the other hand, if so called DNPs can handle the "low hanging fruit" effectively and at less cost to the healthcare system, I'm not sure that they shouldn't be allowed to. After all, everyone I talk to bemoans the shortage of PCPs...

I'm very naive (as a premed who is interested in primary care) when it comes to this issue so feel free to set me straight.

 

[psychbender]

Somebody correct me if I'm wrong, but if DNPs are as dangerous and unqualified as they're made to sound in these forums (and I don't necessarily disagree with that perspective), won't the problem work itself out anyway?

If they can't provide quality care, won't patients catch on? They may not be as savvy to the educational requirements as med students and doctors, but surely most will understand the difference between going to medical school and not going to medical school. Won't the legal system catch on? The media?

You expect patients to know the difference between good and bad medical care? As has been stated before, if you do a crappy job (abx for colds and pain meds for all!), but spend 30 minutes with the patient, they will often think you did a better job than if you did what was needed, but only spent 10 minutes with them.

On the other hand, if so called DNPs can handle the "low hanging fruit" effectively and at less cost to the healthcare system, I'm not sure that they shouldn't be allowed to. After all, everyone I talk to bemoans the shortage of PCPs...

I still haven't figured out how DNPs will be less costly to the healthcare system when they are lobbying to bill the same as physicians.

 

[Pghboy18]

You expect patients to know the difference between good and bad medical care? As has been stated before, if you do a crappy job (abx for colds and pain meds for all!), but spend 30 minutes with the patient, they will often think you did a better job than if you did what was needed, but only spent 10 minutes with them.



I still haven't figured out how DNPs will be less costly to the healthcare system when they are lobbying to bill the same as physicians.

Both good points.

To your first comment, is there no way that DNPs could be held accountable for delivering subpar care?

To your first comment, I've always heard that more DNPs will lead to greater access to primary care, which will supposedly lead to less money being being spent on secondary, tertiary care etc. Moreover, it takes less time and money to train a DNP (ie. you don't have to pay them during residency), so there should be a savings there. So technically they would be more "cost effective" on a large scale than trying to somehow entice medical students into primary care. I don't know how much of this is pure B.S. I guess that doesn't really come out in the way I phrased my last post.

 

[Cp22kjer]

Both good points.

To your first comment, is there no way that DNPs could be held accountable for delivering subpar care?

To your first comment, I've always heard that more DNPs will lead to greater access to primary care, which will supposedly lead to less money being being spent on secondary, tertiary care etc. Moreover, it takes less time and money to train a DNP (ie. you don't have to pay them during residency), so there should be a savings there. So technically they would be more "cost effective" on a large scale than trying to somehow entice medical students into primary care. I don't know how much of this is pure B.S. I guess that doesn't really come out in the way I phrased my last post.

What about looking at this the other way around? Say that these DNPs miss Dx or take longer to Dx complex diseases, cancers, etc. This scenario would lead me to believe that they'd be less cost effective as time progresses. I really don't have a good basis for this but it would be logical to believe it could happen. I honestly don't know enough about the costs of the delayed or misdiagnosed but I know it can't be cheaper! Just a thought and this is assuming widespread DNP use for primary care without supervision.

 

[Sol Rosenberg]

See my analogy of particle physicists teaching high school physics, above. And in my analogy world, the solution is obvious : pay more money for the more complicated work.

I get what you are saying, but you are putting the cart before the horse with your argument. I doubt physicians would have a problem with, and might even welcome, the expanded practice of midlevels if reimbursements were fixed (EDIT: meaning repaired.) However, as time progresses, reimbursements are tending to get more and more broken. So your analogy and the solution that you propose ("Just pay doctors more") isn't really grounded in reality, though it is an obvious solution.

 

[ZincFingers]

If all you need is the middling intelligence, work ethic and training involved in producing a DNP to be a competent PCP, then the DNP is the answer and any MD in primary care is a sucker who should get out now and subspecialize. Some argue that cookbook, flowchart medicine such as what you get at the Minute Clinic actually produces better outcomes than traditional medicine.

But if they're wrong, and if you need the much deeper training of the MD + residency, coupled by the stiff entrance requirements to med school to be a competent PCP, then DNPs should never be allowed to practice independently.

I personally think primary care means more than following diabetes and HTN flowcharts and may actually require critical thinking, but that's just me.

 

[GeraldMonroe]

Some argue that cookbook, flowchart medicine such as what you get at the Minute Clinic actually produces better outcomes than traditional medicine.

How would you go about researching this? And I thought that flowchart medicine and evidenced based medicine are essentially synonymous. Under EBM, if a patient has a particular set of symtoms or an illness in a particular stage, you treat according to what has worked in large clinical trials. You don't use your intuition to change things "this time" and do a different approach if there's no evidence to support that approach.

Example : an E.R. doc gave a presentation in physiology class on hyperthermia as a therapy for protecting the heart from further damage. He explained that the patient has to have suffered a form of MI, and has to be unconscious : if both conditions are met, you can cool the patient's body down using this cool gadget and protect the heart from further damage.

After class, I asked why the patient has to be unconscious : heart muscle is heart muscle whatever the brain happens to be doing. And he explained that maybe this treatment works on conscious patients, but there's no evidence published in a credible peer reviewed journal to support this. So he doesn't do it, even though 'common sense' says it would work.

So yeah, medicine's a cookbook at some level.

 

[gryffindor]

Uh, over half of states allow NPs to practice independently without MD oversight. What exactly is it they're "never" going to achieve?

One of our younger attendings (an orthodontist) told us the other day he had to help his wife set up her private practice. I was incredibly confused, because I was sure his wife wasn't a physician. Finally I asked "How is she going to have a private practice? Doesn't she need a physician to oversee her work?" He replied with this goofy grin on his face "Not here, she can practice as a nurse practitioner on her own and she has her own malpractice insurance." Not buying it, I asked "How is she going to get reimbursed?" His grin got even goofier as he said "CASH."

I was so upset the rest of the morning, I wanted to punch that grin off his face. I spoke up to and reminded him that he would be upset if a dental hygienist moved in and took away all the Invisalign cases from him just because she had a bachelor's degree in Invisalign. I had no idea NPs could practice alone. Now through SDN I have learned about DNPs and I have a very bad feeling medicine is going to get really ugly unless physicians start going CASH ONLY and leave the insurance company messes to these wanna-bes who want to get in on the pie so badly.

 

[MOHS_01]

One of our younger attendings (an orthodontist) told us the other day he had to help his wife set up her private practice. I was incredibly confused, because I was sure his wife wasn't a physician. Finally I asked "How is she going to have a private practice? Doesn't she need a physician to oversee her work?" He replied with this goofy grin on his face "Not here, she can practice as a nurse practitioner on her own and she has her own malpractice insurance." Not buying it, I asked "How is she going to get reimbursed?" His grin got even goofier as he said "CASH."

I was so upset the rest of the morning, I wanted to punch that grin off his face. I spoke up to and reminded him that he would be upset if a dental hygienist moved in and took away all the Invisalign cases from him just because she had a bachelor's degree in Invisalign. I had no idea NPs could practice alone. Now through SDN I have learned about DNPs and I have a very bad feeling medicine is going to get really ugly unless physicians start going CASH ONLY and leave the insurance company messes to these wanna-bes who want to get in on the pie so badly.

Spot on my friend, spot on.🙁

 

[physasst]

One of our younger attendings (an orthodontist) told us the other day he had to help his wife set up her private practice. I was incredibly confused, because I was sure his wife wasn't a physician. Finally I asked "How is she going to have a private practice? Doesn't she need a physician to oversee her work?" He replied with this goofy grin on his face "Not here, she can practice as a nurse practitioner on her own and she has her own malpractice insurance." Not buying it, I asked "How is she going to get reimbursed?" His grin got even goofier as he said "CASH."

I was so upset the rest of the morning, I wanted to punch that grin off his face. I spoke up to and reminded him that he would be upset if a dental hygienist moved in and took away all the Invisalign cases from him just because she had a bachelor's degree in Invisalign. I had no idea NPs could practice alone. Now through SDN I have learned about DNPs and I have a very bad feeling medicine is going to get really ugly unless physicians start going CASH ONLY and leave the insurance company messes to these wanna-bes who want to get in on the pie so badly.

NP's have been seeking independent practice for years, and that is one of the biggest differences between us.

There are some substantial differences between NP's and PA's which I posted about on my blog..

See this post:
http://physasst.blogspot.com/2009/01/american-college-of-cliniciansnp-and-pa.html

I am against independent practice and have always been. I practice with a HIGH, HIGH level of autonomy, and in fact, in one ER, there is no physician present, we run the ED.

THE BIG difference is, we still have a physician on backup call, and someone to talk to when we get up to our elbows. My feeling is, that if you want complete independence, go to medical school.

That being said, there is a lot we can do to treat patients, and keep the system moving.

I have several policy concerns about the DNP degree, which I talked about here as well:

http://physasst.blogspot.com/2009/02/dnp-title.html

Anyway, just my .02 cents, for whatever that may be worth.

 

[DNPDoctor]

NP's have been seeking independent practice for years, and that is one of the biggest differences between us.

There are some substantial differences between NP's and PA's which I posted about on my blog..

See this post:
http://physasst.blogspot.com/2009/01/american-college-of-cliniciansnp-and-pa.html

I am against independent practice and have always been. I practice with a HIGH, HIGH level of autonomy, and in fact, in one ER, there is no physician present, we run the ED.

THE BIG difference is, we still have a physician on backup call, and someone to talk to when we get up to our elbows. My feeling is, that if you want complete independence, go to medical school.

That being said, there is a lot we can do to treat patients, and keep the system moving.

I have several policy concerns about the DNP degree, which I talked about here as well:

http://physasst.blogspot.com/2009/02/dnp-title.html

Anyway, just my .02 cents, for whatever that may be worth.

Thank you for your "opinion". It was a very interesting read.

I've been a long time lurker, and I'm intrigued by all the posts related to DNP.

I'm advocating for DNPs to practice independently and expanding the scope of practice. Whenever I can, I'm actively lobbying for the nurses to gain more power, but at the same time, more and better education to provide an optimal care and treatment for the patients.

It will be done eventually. Constant revisions are being made, and I have a very good feeling that in the future, DNPs will have a lot of clinical hours for training and have more in depth knowledge in science.

Nurse practitioners do use critical thinking. They learn to think critically since nursing school.

Nowadays in numerous bachelor of science in nursing programs (spreading across the country), nursing students also take the following courses in addition to the nursing practice/theory courses: pathophysiology/pharmacology/pharmacodynamics/pharmacokinetics/anatomy & physiology/nutrition/psychology/child psychology/adult psychology/health assessment & physical examination.

There is a lot of misconceptions and underestimation about the skills that the trained specialist nurses can provide.

PAs are also valuable members of the health care team. I can't imagine a hospital running properly without them. They assist MD/DO/(& hopefully DNP in the future) run things in the clinic smoothly.

 

[Cp22kjer]

Nurse practitioners do use critical thinking. They learn to think critically since nursing school.

The contention isn't critical thinking, its that nurses are taught a completely different line of thought progression than doctors from day one.

There is a lot of misconceptions and underestimation about the skills that the trained specialist nurses can provide.

I'm interested to hear you expand on this if you don't mind.

PAs are also valuable members of the health care team. I can't imagine a hospital running properly without them. They assist MD/DO/(& hopefully DNP in the future) run things in the clinic smoothly.

So from this comment you imply that PAs will be assisting DNPs and that DNPs will be = MD.

I'm wondering why you believe that DNPs are more qualified than PAs. Honestly, looking at curriculum I'd say most would agree PAs get the nod in education in terms of practicing as a physician.

Lastly I don't believe you can be serious with the DNP = MD/DO assertion. Have you compared the two pathways? Would you send your child or loved one to a DNP over a Physician when taking into account the training differences? If you wanted to learn how to properly diagnose/ formulate a differential and then treat, why didn't you just go to medical school?

Tagging another year of online coursework and awarding a "Doctorate" to an NP just doesn't cut it for me.

Please note that I think NPs play an essential role the health care system and I'm glad we have them. Everything runs better with them around and its great that they have additional training. Everyone benefits from this!

On the other hand throwing a D in front and thinking they're a doctor is asinine.

 

[physasst]

Thank you for your "opinion". It was a very interesting read.

I've been a long time lurker, and I'm intrigued by all the posts related to DNP.

I'm advocating for DNPs to practice independently and expanding the scope of practice. Whenever I can, I'm actively lobbying for the nurses to gain more power, but at the same time, more and better education to provide an optimal care and treatment for the patients.

It will be done eventually. Constant revisions are being made, and I have a very good feeling that in the future, DNPs will have a lot of clinical hours for training and have more in depth knowledge in science.

Nurse practitioners do use critical thinking. They learn to think critically since nursing school.

Nowadays in numerous bachelor of science in nursing programs (spreading across the country), nursing students also take the following courses in addition to the nursing practice/theory courses: pathophysiology/pharmacology/pharmacodynamics/pharmacokinetics/anatomy & physiology/nutrition/psychology/child psychology/adult psychology/health assessment & physical examination.

There is a lot of misconceptions and underestimation about the skills that the trained specialist nurses can provide.

PAs are also valuable members of the health care team. I can't imagine a hospital running properly without them. They assist MD/DO/(& hopefully DNP in the future) run things in the clinic smoothly.

NP and a PA are equivalent at our institution. We have one DNP on staff, and she is not allowed to use the title Doctor, and her degree is not recognized.

I supervise an NP in my own group, administratively. Anecdotally, I can tell you, that PA students, and PA graduates, at least in EM, tend to adapt and progress much faster than NP students, or NP graduates.

NP's are valuable members of the health team. But PA and NP education is AT BEST equivalent, I cannot imagine any scenario by which a PA would be supervised by an NP. Personally, I think the DNP is going to go the way of the ND....you do remember that nursing degree that was a doctoral level degree that was going to REVOLUTIONIZE advanced practice nursing. I do. What happened to that btw?

 

[physasst]

The PA profession also has a clinical Doctorate.

The Baylor/Army EM residency program is 18 months long. It has a combined total of 5600 clinical hours, and 600 didactic hours, and awards a DSc degree upon completion. With that clinical hour load, I think you could most assuredly call it a "Clinical Doctorate"

http://www.paeaonline.org/index.php?ht=a/GetDocumentAction/i/60863

Also, PA's, just like NP's do far more than merely help the clinic "run smoother". We function pretty much independently in most settings, and call in physician consult, or back up when needed.

 

[Taurus]

PAs are also valuable members of the health care team. I can't imagine a hospital running properly without them. They assist MD/DO/(& hopefully DNP in the future) run things in the clinic smoothly.

DNP's supervising PA's would be like the blind leading the blind. You have one group supervising another group that doesn't know what they're doing either. It would be the destruction of both groups as the public loses faith in both groups.

 

[physasst]

DNP's supervising PA's would be like the blind leading the blind. You have one group supervising another group that doesn't know what they're doing either. It would be the destruction of both groups as the public loses faith in both groups.

Look, I am against completely independent practice for PA's and NP's. However, to suggest that we do not know what we are doing is a rather lofty charge.

You do of course have evidence to back up your assertions, correct? You have studies showing an increased rate of complications, poorer outcomes, decreased patient satisfaction, and/or increased malpractice rates?

If you do, I'd love to see them. Fact is, you don't have any data to support such a baseless accusation. Please let us know when you do. Otherwise, your statements are unfounded, and do not contribute anything of worth to the debate.

 

[Taurus]

You do of course have evidence to back up your assertions, correct? You have studies showing an increased rate of complications, poorer outcomes, decreased patient satisfaction, and/or increased malpractice rates?

After a few years on the job, NP's and PA's achieve a certain level of competence. That's nothing special since most people get good at their job after doing it for a while. However, brand new NP's and PA's and even med grads don't possess enough knowledge or skills to function independently. Most of the knowledge and skills that NP's and PA's develop come from on-the-job training. Who currently trains most newly minted NP's and PA's? Physicians. So the person who trains brand new NP's and PA's is critical because that's how they acquire most of their skills.

I know that you work in the ED. What if your supervisor didn't know more than you when you first came out of PA school? Would you have developed professionally as much as you have today?

Can you just imagine a brand new DNP supervising a brand new PA? 😱 That would be the beginning of the end for midlevels.

Personally, I have no problem DNP's supervising other NP's or DNP's. It just hurts their profession in the end. PA's would be foolish to allow themselves to be supervised by DNP's.

 

[Cp22kjer]

The PA profession also has a clinical Doctorate.

The Baylor/Army EM residency program is 18 months long. It has a combined total of 5600 clinical hours, and 600 didactic hours, and awards a DSc degree upon completion. With that clinical hour load, I think you could most assuredly call it a "Clinical Doctorate"

This is solid. But I still wouldn't say it warrants them to be considered equal to physicians or be called "doctors" in health care settings. In comparison the average physician will have amassed +20,000 clinical hours before starting to practice. This will vary incredibly on the specialty/residency but you get the point.

 

[MOHS_01]

Look, I am against completely independent practice for PA's and NP's. However, to suggest that we do not know what we are doing is a rather lofty charge.

You do of course have evidence to back up your assertions, correct? You have studies showing an increased rate of complications, poorer outcomes, decreased patient satisfaction, and/or increased malpractice rates?

If you do, I'd love to see them. Fact is, you don't have any data to support such a baseless accusation. Please let us know when you do. Otherwise, your statements are unfounded, and do not contribute anything of worth to the debate.

Look, I am a big proponent of PA's/NP's in general, although I would not advocate totally independent practice for either. I cannot see any added value to the DNP degree, unless, as a group, they are deciding to move to an all DNP requirement (similar to the PharmD transition). At this point, it seems gratuitous at best.

That said, the burden of evidence truly falls upon the NP/PA community to demonstrate equivalence, not the other way around. There is no automatic "deemed equivalence". It's the same concept as new drug applications...

 

[physasst]

After a few years on the job, NP's and PA's achieve a certain level of competence. That's nothing special since most people get good at their job after doing it for a while. However, brand new NP's and PA's and even med grads don't possess enough knowledge or skills to function independently. Most of the knowledge and skills that NP's and PA's develop come from on-the-job training. Who currently trains most newly minted NP's and PA's? Physicians. So the person who trains brand new NP's and PA's is critical because that's how they acquire most of their skills.

I know that you work in the ED. What if your supervisor didn't know more than you when you first came out of PA school? Would you have developed professionally as much as you have today?

Can you just imagine a brand new DNP supervising a brand new PA? 😱 That would be the beginning of the end for midlevels.

Personally, I have no problem DNP's supervising other NP's or DNP's. It just hurts their profession in the end. PA's would be foolish to allow themselves to be supervised by DNP's.

They never would.

 

[physasst]

This is solid. But I still wouldn't say it warrants them to be considered equal to physicians or be called "doctors" in health care settings. In comparison the average physician will have amassed +20,000 clinical hours before starting to practice. This will vary incredibly on the specialty/residency but you get the point.

Of course it doesn't, and none of the graduates of that program are going around saying "LOOK how great we are". They are working, as PA's.

NOT MD's.

 

[physasst]

Look, I am a big proponent of PA's/NP's in general, although I would not advocate total independent practice for either. That said, the burden of evidence falls upon the NP/PA community to demonstrate equivalence, not the other way around. There is no automatic "deemed equivalence". It's the same concept as new drug applications...

And that data is lacking, I would agree. I am actually trying to do a CE study on Consultant vs PA in the ED for a limited number of "Level 3" diagnoses. Including renal stones, headache, and minor head trauma with LOC.

However, one would think, that even in the absence of clear data, one would see a rise in malpractice rates for PA's and NP's, if they were practicing beyond their scope, or if they were mismanaging patients. To claim that we are not MD's is completely accurate, and appropriate, to claim that we "don't know what we are doing" is erroneous, and borderline libelous.

BTW, I don't advocate for complete independence.

One of the ER's I moonlight at, is Waseca ER in Minnesota, it is staffed solely by PA's, no physician on site, although we have physician backup when needed. Interestingly, in the fall of 2008, we had the highest patient satisfaction scores in the entire country. Now, I am not naive enough to believe that that is solely due to PA's staffing the ED, but it is an interesting anomaly for sure.