MD vs DNP: 20,000 hours makes a difference

[WheezyBaby]

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Of course it does. You see this all the time with "VIP" patients. At our university hospital, "VIP" patients almost always result in problems; standard processes are changed which can result in substandard care, the expectation of "VIP" care adds a burden on the physicians and the staff, etc. I detest the concept of VIP care on its face, but even beyond that it has tangible impacts on care in a negative way.

This problem is somewhat different but ultimately related to the same issue: patients' perceived quality of care they receive has very little relation the actual quality of care provided. There are some things patients notice which I think do have some relation to quality - e.g., time spent talking with them, feeling like they're being listened to, responsive to complaints, etc. - but patients are ultimately the worst judges of what actually matters when treating patients: the actual medical care.

The entire concept of vip patients is insulting with the implication care for "regular" patients is half assed

 

[NickNaylor]

The entire concept of vip patients is insulting with the implication the care for non-vip patients is getting half assed

In my experience in inpatient psychiatry, at least, there is generally less difference with respect to the actual care provided (at least in theory) and more difference in how strictly policies and procedures are adhered to. A VIP patient, for example, may be admitted after the usual admission time and being allowed to forgo ER clearance while a non-VIP patient wouldn't. VIP patients might have "flexibility" for their visiting hours while other patients wouldn't. There are many other small variations like this which are ultimately not a big deal but which change the fundamental treatment relationship/dynamic, which IS a big deal.

In psychiatry, it is important, when deviating from your normal treatment of patients, to 1) recognize when this occurs and 2) understand why it is occurring. Deviations from usual standards are not inherently bad. Sometimes they are necessary. However, when they're done because a patient is a "VIP," it is not therapeutically helpful. I would argue that it is therapeutically harmful. This CAN result in important differences in treatment, even despite our best intentions. This is why VIP care is problematic.

For some reason we make a big deal out of this in psychiatry but in other fields it doesn't seem to be as big of a deal. But it's arguably more important in somatic medicine because this flexibility can be therapeutically significant. It might mean telling the nurses not to do vital sign checks as frequently or at all to give the VIP patient privacy. It might mean forgoing a skin check on admission to preserve the patient's modesty. It might result in the physician not checking labs as often in order to avoid making the VIP patient uncomfortable. It might mean not pushing back when a VIP patient refuses DVT prophylaxis measures. While the likelihood that any of these things results in an adverse clinical outcome is low, nonetheless it increases the risk in this population. This is how "VIP care" can be harmful.

 

[Yadster101]

My question is, does this stuff really affect future doctors that much?

From my knowledge, PAs and NPs have been practicing the way they currently do since the mid 70's. Talk to a PA and many of them will tell you that after about 5 years in practice they hit a glass ceiling. I actually seriously considered PA school and the reason I decided not to go was because it was obvious to me that being a doctor in the mid-west would give me greater scope of practice, autonomy, and salary. I've shadowed primary care PAs in rural towns where they would be expected to have great autonomy. The PA was awesome, had her own patient panel, and was essentially the FM doc for her patients. Despite this she still had a supervising physician, she admitted that her knowledge base was not as extensive, and I would guess that her supervising physician made almost double her salary.

I would actually prefer to be one of the surgical PAs I shadowed in Chicago, because even though their autonomy was much lower, they still got to do simple procedures, work in a technologically sophisticated hospital, and make much more money than the FM PA (although they also worked far more hours).

 

[Rekt]

My question is, does this stuff really affect future doctors that much?

From my knowledge, PAs and NPs have been practicing the way they currently do since the mid 70's. Talk to a PA and many of them will tell you that after about 5 years in practice they hit a glass ceiling. I actually seriously considered PA school and the reason I decided not to go was because it was obvious to me that being a doctor in the mid-west would give me greater scope of practice, autonomy, and salary. I've shadowed primary care PAs in rural towns where they would be expected to have great autonomy. The PA was awesome, had her own patient panel, and was essentially the FM doc for her patients. Despite this she still had a supervising physician, she admitted that her knowledge base was not as extensive, and I would guess that her supervising physician made almost double her salary.

I would actually prefer to be one of the surgical PAs I shadowed in Chicago, because even though their autonomy was much lower, they still got to do simple procedures, work in a technologically sophisticated hospital, and make much more money than the FM PA (although they also worked far more hours).

Of course it will. While it is true that midlevels have been around awhile, their massive school proliferation has not been. I can't find the exact charts, but they show that just within the past few years, enrollment has skyrocketed several fold.

 

[operaman]

This article brings up an interesting issue and one that applies to MDs as well: what are the limits of how a physician or other practitioner can represent his or her practice? Setting aside the NP debate for just a brief moment, we all know MDs who practice well outside their scope of training. I personally know of OBGYNs doing plastic surgery, ENTs who do breast augs, and countless specialties doing Cosmetic procedures for cash paying patients. Generally speaking, hospital credentialing prevents much of this crossover in more traditional settings and certainly within academia, but there aren't many restrictions on what you can do if you just hang your own shingle and don't overtly lie about your credentials. Apparently malpractice isn't cost-prohibitive either, and I've been told that they are legally more insulated because of the entire definition of "standard of care," namely as the care given by someone with "a similar background and in the same medical community."

For whatever reason, licensing boards haven't seen fit to take aim at docs who step outside their specific area of training. Just like with the OPs article about the peds NP, patients generally can't tell the difference unless they know what to look for and what questions to ask. The medicolegal side won't protect patients either given the definition of standard of care mentioned above. Standard of care for the NP in the article is the level of care given by a similarly untrained nurse practitioner practicing in a general community practice.

I don't think the answer to these issue lies in legislation. We're all old enough to have witnessed legislative bodies at all levels of government continually screw the pooch when it comes to something as complex as healthcare. I don't think nursing boards are going to be any better at restricting scope of practice than we MDs have been with policing our own.

I think the answer lies in accepting certain aspects of this battle as already over, and focusing our efforts on educating patients and finding ways to demonstrate to the public that we physicians do indeed provide a superior service. Perhaps a national ad campaign with a tagline like "always ask to see a real doctor" or "when it comes to my daughter's health, we will only see an MD." [sorry DOs, you got sacrificed upon the altar of cadence!]

 

[Yadster101]

This article brings up an interesting issue and one that applies to MDs as well: what are the limits of how a physician or other practitioner can represent his or her practice? Setting aside the NP debate for just a brief moment, we all know MDs who practice well outside their scope of training. I personally know of OBGYNs doing plastic surgery, ENTs who do breast augs, and countless specialties doing Cosmetic procedures for cash paying patients. Generally speaking, hospital credentialing prevents much of this crossover in more traditional settings and certainly within academia, but there aren't many restrictions on what you can do if you just hang your own shingle and don't overtly lie about your credentials. Apparently malpractice isn't cost-prohibitive either, and I've been told that they are legally more insulated because of the entire definition of "standard of care," namely as the care given by someone with "a similar background and in the same medical community."

For whatever reason, licensing boards haven't seen fit to take aim at docs who step outside their specific area of training. Just like with the OPs article about the peds NP, patients generally can't tell the difference unless they know what to look for and what questions to ask. The medicolegal side won't protect patients either given the definition of standard of care mentioned above. Standard of care for the NP in the article is the level of care given by a similarly untrained nurse practitioner practicing in a general community practice.

I don't think the answer to these issue lies in legislation. We're all old enough to have witnessed legislative bodies at all levels of government continually screw the pooch when it comes to something as complex as healthcare. I don't think nursing boards are going to be any better at restricting scope of practice than we MDs have been with policing our own.

I think the answer lies in accepting certain aspects of this battle as already over, and focusing our efforts on educating patients and finding ways to demonstrate to the public that we physicians do indeed provide a superior service. Perhaps a national ad campaign with a tagline like "always ask to see a real doctor" or "when it comes to my daughter's health, we will only see an MD." [sorry DOs, you got sacrificed upon the altar of cadence!]

Scene opens to Justin Long (from apple commercials). "When it comes to picking the right mechanic who would you rather go with?" "What about when it comes to your health? Make the right decision. Always see an MD."

"Break me off a piece of that O-M-M"

 

[KnuxNole]

What personal attack?

NPs will probably be doing surgery in a few years. If you think NPs can produce similar outcomes as intensevists with 6 years of training, surely they can produce similar surgical outcomes as general surgeons with 5.

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I think so too. And not just retracting either.

 

[LutGholein]

"Break me off a piece of that O-M-M"

I like this spin.

I think so too. And not just retracting either.

How would that even go about? Hello Mr.Jones, I'm your surgical provider Dr. Smith DNP and i'll be performing your appendectomy????

 

[KnuxNole]

I like this spin.


How would that even go about? Hello Mr.Jones, I'm your surgical provider Dr. Smith DNP and i'll be performing your appendectomy????

Pretty much.

"Hey, I'm Joe Smith NP, I'm your provider doing this appy today. There will be another provider, Dr. MD who will walk in to say hi so he can legally co-sign. Time for my CRNA to put you to sleep. Sweet dreams!"

 

[libertyyne]

This article brings up an interesting issue and one that applies to MDs as well: what are the limits of how a physician or other practitioner can represent his or her practice? Setting aside the NP debate for just a brief moment, we all know MDs who practice well outside their scope of training. I personally know of OBGYNs doing plastic surgery, ENTs who do breast augs, and countless specialties doing Cosmetic procedures for cash paying patients. Generally speaking, hospital credentialing prevents much of this crossover in more traditional settings and certainly within academia, but there aren't many restrictions on what you can do if you just hang your own shingle and don't overtly lie about your credentials. Apparently malpractice isn't cost-prohibitive either, and I've been told that they are legally more insulated because of the entire definition of "standard of care," namely as the care given by someone with "a similar background and in the same medical community."

For whatever reason, licensing boards haven't seen fit to take aim at docs who step outside their specific area of training. Just like with the OPs article about the peds NP, patients generally can't tell the difference unless they know what to look for and what questions to ask. The medicolegal side won't protect patients either given the definition of standard of care mentioned above. Standard of care for the NP in the article is the level of care given by a similarly untrained nurse practitioner practicing in a general community practice.

I don't think the answer to these issue lies in legislation. We're all old enough to have witnessed legislative bodies at all levels of government continually screw the pooch when it comes to something as complex as healthcare. I don't think nursing boards are going to be any better at restricting scope of practice than we MDs have been with policing our own.

I think the answer lies in accepting certain aspects of this battle as already over, and focusing our efforts on educating patients and finding ways to demonstrate to the public that we physicians do indeed provide a superior service. Perhaps a national ad campaign with a tagline like "always ask to see a real doctor" or "when it comes to my daughter's health, we will only see an MD." [sorry DOs, you got sacrificed upon the altar of cadence!]

This!
We need to show we provide the superior product/service.
Keep a tight control on hospital bylaws regarding practice.
Possibly show that NPs have higher adverse outcomes or indirectly cost more.
Or go back in time and prevent NPs from getting practice rights.

Pretty much.

"Hey, I'm Joe Smith NP, I'm your provider doing this appy today. There will be another provider, Dr. MD who will walk in to say hi so he can legally co-sign. Time for my CRNA to put you to sleep. Sweet dreams!"

I bet private practice mds would like that, they could run 3 rooms at once and bill for all three.

 

[FindersFee5]

I think the biggest problem with that study is that it's based on a single NP. There are ABSOLUTELY NPs who can manage a lot of conditions as well as doctors. I've met many super competent NPs who I would be happy to have them caring for me. However, all of these NPs also frequently consulted with physicians and I can't imagine them running a clinic entirely by themselves. I think if policy makers spent even a week shadowing, they would realize this too.

I've also seen a lot more variance in NP capability. I've definitely seen dumb doctors ( I worked along side a doctor who DIDN'T KNOW HOW TO USE HIS INHALER) and would be constantly flustered by pretty normal situations. However, he's one of the only physicians I feel that way about; almost a third of the NPs I worked with seemed to be unprepared for their role. If NPs are going to be given more practice roles, they need to have stricter schooling requirements.

 

[deleted407021]

I'm curious -- any Canadian med students or physicians here who can provide comparisons or contrasts between how NPs can practice in the US vs. in the provinces?

 

[Atlas Shrugged]

This!
We need to show we provide the superior product/service.
Keep a tight control on hospital bylaws regarding practice.
Possibly show that NPs have higher adverse outcomes or indirectly cost more.
Or go back in time and prevent NPs from getting practice rights.

I bet private practice mds would like that, they could run 3 rooms at once and bill for all three.

No, we don't. Do you think NPs got to where they are today by showing they provide the superior product or service?

We need an effectual lobby and campaign.

 

[libertyyne]

No, we don't. Do you think NPs got to where they are today by showing they provide the superior product or service?

We need an effectual lobby and campaign.

They got to where they are because they are cheap.

 

[DropMets]

No, we don't. Do you think NPs got to where they are today by showing they provide the superior product or service?

We need an effectual lobby and campaign.

This. Physicians are, by and large, God-awful at organizing and lobbying when compared to nursing groups (or other non-physician groups).

Re: demonstrating superiority, that's something docs should try to push, as it's probably easier than showing that they are economically superior, as mid-levels have strongly adopted that approach, and it's hard to fight piss with more piss. In this case, might actually be useful to bring **** to a piss fight.

Can't remember who wrote this, but a while back there was a thread regarding CRNAs practicing solo in VA hospitals (i.e. No anesthesiologist supervision), and one user mentioned that mid-levels/anesthesiologists is like autopilots/pilots: sure, up in the air when things are easy, autopilot is fantastic. But the hardest parts are the takeoff and landing, and if turbulence hits, you need an actual pilot.

If physicians could lobby to make this point, in addition to getting supportive data on economics (if it actually exists...I'm not informed on current literature), that may help.


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