"Mid-Level Provider"

[joeDO2]

So hopefully I don't start another typical SDN thread here but I was just curious what you all thought about the term "mid-level provider". I've been using this term to describe NP/PA but I recently discovered some consider it almost a derogatory term now. I'm not sure when that happened since it was just a few years ago when I heard people self-describe themselves as mid-levels and seemed proud of it. I had been using it because I had no idea it was offensive. I guess I will stop using it now? Is this term off limits now?

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[futurepsych0]

I am not in the field of healthcare yet..... But I have seen this topic come up on a couple other forums I frequent. I do know the AANP has formally stated it is against terms like mid-level, physician extender, non physician provider and so on. I have also seen some individuals on AN correct fellow NPs and CRNAs for using such terms. It bothers some and doesn't bother other and my opinion on the matter doesn't matter since I'm not even an RN yet, but I can understand their POV. It can also be the reason some anesthesiologists are against people saying MDA. It isn't derogatory but also isn't what their title is. I have also read some "MDAs" who don't care if they are called that and some who are against it. Personally, I would think working healthcare professionals would have more pressing matters to tend to 8) but what do I know. If I were you, I would just call people by their appropriate title such as NP, PA, CRNA or whatever. After all, that is what they are. I'm sure DO's wouldn't like being called a non MD physician and while the statement may be true there is no point in "causing waves" where you work over such little things. This my my 2¢, take it for what it is worth and just to reiterate, I am still a student so I may be taking out of my anal orifice and not even know!

 

[joeDO2]

I guess that makes sense. Is there another more appropriate term to use when referring to PA/NP/CRNA as a group? I see this forum is called "clinicians" but that includes RNs and various others. Advanced practice providers maybe?

 

[futurepsych0]

I'm not sure what terms different organization like but I'm sure whatever you use someone will complain, lol. You can't please everyone. Maybe some practicing clinicians like RNs NPs CRNAs would care to chime in on that. Personally, I don't care what people call me as I plan on going by my first name as much as possible but that is just my preference.

 

[RedCole]

I think NPs in particular now find the term insulting because "midlevel" tends to mean below the highest level. Since an NP is the "highest level" in the field of nursing, it seems like calling an NP a midlevel is saying that the medical model is the only healthcare model and that NPs fall in the middle of that model (aka: below a physician). Many NPs do not see themselves as midlevel to a physician, as nursing is a separate field. That would be the equivalent of a psychiatrist calling a doctorate prepared counselor/social worker a "midlevel" simply because s/he isn't a physician yet is practicing a similar role in the mental health field.

It may be different for PAs since they follow the medical model, hence a PA really is "midway" to a physician and not the top of their field (medicine). You would have to ask a PA as I don't know.

Disclaimer: This doesn't imply anything about training differences of MD vs PA vs NP, I'm strictly speaking about the different fields and showing proper respect to anyone who has achieved the terminal degree in their field, regardless of how it "compares" to terminal degrees in other fields.

 

[Makati2008]

I personally could care less about being called a midlevel( I think PAs and NPs are just that but I do disagree with the assistant portion of PA) because it is correct.

But it's just my opinion

 

[AnnoyedByFreud]

I understand why people (both NPs and PAs) don't like the term "midlevel". What's wrong with clinician? RNs aren't clinicians, or at least I never see the word used that way.

 

[Denatured]

Many of us PAs don't like it either. Advance practice provider is generally accepted, but I would go for other names. I don't get worked up over it. If I were being introduced to patients that way I might ask if that could change. Mid level provider causes confusion and seems to indicate that the care given somehow isn't up to par. I understand that a NP or PA doesn't have the same level of physician training, but when I do provide care I don't do it any differently than anyone else. I don't do half of an exam, or give a different antibiotic than EBM suggests, so on and so forth.

 

[AnnoyedByFreud]

Many of us PAs don't like it either. Advance practice provider is generally accepted, but I would go for other names. I don't get worked up over it. If I were being introduced to patients that way I might ask if that could change. Mid level provider causes confusion and seems to indicate that the care given somehow isn't up to par. I understand that a NP or PA doesn't have the same level of physician training, but when I do provide care I don't do it any differently than anyone else. I don't do half of an exam, or give a different antibiotic than EBM suggests, so on and so forth.

 

[deleted6669]

Not a fan of the term. also don't like allied health provider.
other terms used that I am ok with that I have been called at various jobs over the years:
Non-physician provider (although don't like the abbreviation NPP as that looks like NP provider. I'm not an NP)
advanced practice clinician
advanced practice provider
affiliated clinician (kaiser uses this)
associate clinician (my current job uses this)

 

[pamac]

The only provider that ever chaffed at me for using the term "midlevel" was a
PA, but that got me in the habit of using "nonphysician provider" or just "provider". Lately if I have to get more specific, I use advanced practice provider, or try to narrow it down to PA or NP. I rarely need to use any reference that mimics "midlevel", because I usually can substitute provider, as in "Hi holly, I'm calling this morning from X unit about mister smith. I think the provider today is Mary Jones. Can I speak to her?" So it rarely is necessary to parse things down to acknowledge a hierarchy.

 

[Therapist4Chnge]

The origin of the terms may shed some light onto which are more appropriate v. pejorative. I believe "physician extender" stems from billing, at least that is how I learned it. I use NP, PA, etc...though I also consider mid-level appropriate, albeit a bit generic. I'd rather specify the training, since each path is slightly different.

 

[badasshairday]

double post

 

[badasshairday]

Most people I know just say PA or NP. Sometimes they incorrectly call a PA an NP or vice versa.

 

[ChillyRN]

I'd prefer to be called a Nurse Practitioner. I have colleagues that don't care. Generally speaking, I think it is falling out of favor.

I don't dislike it for the reasons described above; I dislike it because I think it is disrespectful to RNs. I was a RN for 18 years, eventually rising to the level of expert in my field (critical care). It bugged me then to hear the NPs in our units called "mid-levels" because that made me feel that I was considered "low-level." Now that I am a NP, I don't want to cheapen the contribution of my RN peers, so I discourage use of the term.

My Mom always taught me that it is polite to call people what they want to be called, lol. If an anesthesiologist did not like the term MDA, I would respect his or her feelings and refrain from using it. I'd expect the same respect in return and would ask not to be referred to as a mid-level. Just call me a NP, I'm quite pleased to be one.

 

[CounselortoMD]

I'd prefer to be called a Nurse Practitioner. I have colleagues that don't care. Generally speaking, I think it is falling out of favor.

I don't dislike it for the reasons described above; I dislike it because I think it is disrespectful to RNs. I was a RN for 18 years, eventually rising to the level of expert in my field (critical care). It bugged me then to hear the NPs in our units called "mid-levels" because that made me feel that I was considered "low-level." Now that I am a NP, I don't want to cheapen the contribution of my RN peers, so I discourage use of the term.

My Mom always taught me that it is polite to call people what they want to be called, lol. If an anesthesiologist did not like the term MDA, I would respect his or her feelings and refrain from using it. I'd expect the same respect in return and would ask not to be referred to as a mid-level. Just call me a NP, I'm quite pleased to be one.

You make an excellent point about these rarely considered implications of the term "midlevel provider" on the general career status of Registered Nursing, and also on the particular role-identity of RNs within the healthcare team.

For many years before I enrolled in medical school, I was privileged to work, as an allied health professional, alongside countless amazing RNs. And, not for a single moment, did I ever view these brilliant and compassionate individuals as anything other than well-educated and highly-trained professionals: first-rate experts about the science, clinical skills, philosophy, theory--and also the delicate art--inherent within the vocation of nursing.

When will everyone realize that we are all on the same team???

 

[RedCole]

When will everyone realize that we are all on the same team???

When all of the "team members" stop seeing healthcare as a business and patients as income that they must compete for.

 

[Boatswain2PA]

So hopefully I don't start another typical SDN thread here but I was just curious what you all thought about the term "mid-level provider". I've been using this term to describe NP/PA but I recently discovered some consider it almost a derogatory term now. I'm not sure when that happened since it was just a few years ago when I heard people self-describe themselves as mid-levels and seemed proud of it. I had been using it because I had no idea it was offensive. I guess I will stop using it now? Is this term off limits now?

Those who, for whatever reason, look for disrespect will find disrespect everywhere.

Dr. Stead, the founder of the PA profession (and, in reality, the NP profession as well, but doesn't get credit for it), put it best. "More than a nurse, but not quite a Doctor". Sounds like mid-level to me.

 

[Boatswain2PA]

I am not in the field of healthcare yet..... But I have seen this topic come up on a couple other forums I frequent. I do know the AANP has formally stated it is against terms like mid-level, physician extender, non physician provider and so on. I have also seen some individuals on AN correct fellow NPs and CRNAs for using such terms.

The AANP, and other segments of the nursing mafia, are against anything but calling NP's "Doctor". They are militant in that regards.

 

[Boatswain2PA]

When will everyone realize that we are all on the same team???

Everyone knows we are on the same team. The problem lies with many people who forget that teams need leaders but, by definition, not everyone can be the leader. In today's culture that teaches false self-appreciation (ie: no "losers" in youth sports, so therefore no "winners" either) we have people who feel that it is disrespectful to be a follower, or anything equal to the "leader" of the team (see Chilly's comments above about being upset about the inference that he/she is a "low-level" since NPs are "mid-level").

Doctors (real doctors, not Doctor Pepper doctors) should be the leaders of the health care team. Then the mid-levels, who should have some level of supervision by the doctors, and then the nurses (who are NOT "low-level" anything), and then the techs (who are, again, NOT "low-level").

We, as a nation, have lost the spirit of teamwork, leadership, and the importance of followership.

 

[RedCole]

Everyone knows we are on the same team. The problem lies with many people who forget that teams need leaders but, by definition, not everyone can be the leader. In today's culture that teaches false self-appreciation (ie: no "losers" in youth sports, so therefore no "winners" either) we have people who feel that it is disrespectful to be a follower, or anything equal to the "leader" of the team (see Chilly's comments above about being upset about the inference that he/she is a "low-level" since NPs are "mid-level").

Doctors (real doctors, not Doctor Pepper doctors) should be the leaders of the health care team. Then the mid-levels, who should have some level of supervision by the doctors, and then the nurses (who are NOT "low-level" anything), and then the techs (who are, again, NOT "low-level").

We, as a nation, have lost the spirit of teamwork, leadership, and the importance of followership.

It's fairly clear from your tone that you do not respect your fellow non-physician providers. Calling someone with a doctorate degree in nursing a "Doctor Pepper" type of doctor is extremely disrespectful and shows your biased way of thinking. A "doctor" is anyone who holds a doctorate in their field and is not a term exclusive to physicians no matter how much you wish it were so.

As for your other comment, you're completely off base. A team can have multiple leaders in different fields working together toward a common goal. Becoming a physician does not automatically make someone a guru on every healthcare subject - believe it or not, there are NPs who know more about their field than physicians in another field. It is ridiculous to believe that, even in that case, the two should not work together as equals.

Healthcare is not about "leaders" and superiority - it isn't the military. It's about people from all disciplines coming together as equals to diagnose and treat the people we serve. Sometimes a physician will solve the case and lead the team, other times it will be an NP or PA. Times have changed in healthcare and it's about time physicians stuck in the past embrace that and stop wasting time fighting NPs and PAs under the guise of "patient safety" when we all know the real fear is much less altruistic.

 

[futurepsych0]

Doctors (real doctors, not Doctor Pepper doctors) should be the leaders of the health care team. Then the mid-levels, who should have some level of supervision by the doctors, and then the nurses (who are NOT "low-level" anything), and then the techs (who are, again, NOT "low-level").

Well, you certainly are entitled to your opinion. I, however, give the title of doctor to anyone who has worked hard enough to earn a doctorate in his or her respective field. Yes, not all roads share the rigor or length of training for that matter but I still respect PhDs DNPs MDs DOs PsyDs etc. equally. Your tone appears to contain a lack of respect for other professions with a doctorate and forgive me if I am misreading you. Sure some people will find disrespect anywhere but some also have a right to feel the disrespect. This forum usually bashes other healthcare professionals as inferior to the MD/DO when we all have a role to play. Letters behind an individuals name doesn't make someone a better or superior person. I think too many people in heath care focus more on their title than what's really important. There is even a sense of superiority amongst MDs. This one looks down on this specialty or field and this one looks down on the other. It is childish and uncalled for. To be fair though, this type of behavior is usually only obvious when people can hide behind their computer because in the real world we all depend on each other in some way. Also, I am not alluding that you feel this way or think this way. I am simply replying to an assumption (we all know what happens when we assume).

 

[Boatswain2PA]

It's fairly clear from your tone that you do not respect your fellow non-physician providers. Calling someone with a doctorate degree in nursing a "Doctor Pepper" type of doctor is extremely disrespectful and shows your biased way of thinking. A "doctor" is anyone who holds a doctorate in their field and is not a term exclusive to physicians no matter how much you wish it were so.

As for your other comment, you're completely off base. A team can have multiple leaders in different fields working together toward a common goal. Becoming a physician does not automatically make someone a guru on every healthcare subject - believe it or not, there are NPs who know more about their field than physicians in another field. It is ridiculous to believe that, even in that case, the two should not work together as equals.

Healthcare is not about "leaders" and superiority - it isn't the military. It's about people from all disciplines coming together as equals to diagnose and treat the people we serve. Sometimes a physician will solve the case and lead the team, other times it will be an NP or PA. Times have changed in healthcare and it's about time physicians stuck in the past embrace that and stop wasting time fighting NPs and PAs under the guise of "patient safety" when we all know the real fear is much less altruistic.

Quite the contrary. I respect everyone on the team, from the doctors in charge of the team all the way through the janitors who clean the rooms. EVERYONE has an important role in taking care of the patients. While the janitor is certainly not the leader of the team, they have an incredibly important role. However, are they equals? NO, I do not think they are. An excellent example of how the two are NOT equals occurred last night in my ER. We were slammed for a few hours when suddenly....I was done but the nurse and tech wasn't. I asked the tech what I could do to help her. She looked at me, realized that it would take longer to show me how to do her job than to just do it herself, and told me "nothing". Are we equals? No, in that regard, she knew her job better than I did.

As to the Doctor Pepper comment. Do you think we should call a janitor "Doctor" in a hospital if he/she has a PhD in trombone? What about violin? Or underwater basketweaving?? Of course not. What if he/she "demanded" that we call her "Doctor" because of her PhD in Indian Canoe Making? Should we then cave in and call her "Doctor" while she is in the hospital? How about we confuse the patients even more?

Your comment about the military shows your ignorance about the military. Yes,while there is a command structure, it has nothing to do with ability or knowledge, it is about effectiveness. I was a (very) senior enlisted guy who, while "junior" to every level of Officer, could tell most officer's to go piss up a rope (as long as I was right!) due to my expertise.

Big difference between situational leadership and being the leader of a team.

 

[Boatswain2PA]

Well, you certainly are entitled to your opinion. I, however, give the title of doctor to anyone who has worked hard enough to earn a doctorate in his or her respective field. Yes, not all roads share the rigor or length of training for that matter but I still respect PhDs DNPs MDs DOs PsyDs etc. equally. Your tone appears to contain a lack of respect for other professions with a doctorate and forgive me if I am misreading you. Sure some people will find disrespect anywhere but some also have a right to feel the disrespect. This forum usually bashes other healthcare professionals as inferior to the MD/DO when we all have a role to play. Letters behind an individuals name doesn't make someone a better or superior person. I think too many people in heath care focus more on their title than what's really important. There is even a sense of superiority amongst MDs. This one looks down on this specialty or field and this one looks down on the other. It is childish and uncalled for. To be fair though, this type of behavior is usually only obvious when people can hide behind their computer because in the real world we all depend on each other in some way. Also, I am not alluding that you feel this way or think this way. I am simply replying to an assumption (we all know what happens when we assume).

I have never "bashed" anyone for being "inferior" to anyone else, nor do I "look down" at someone due to their position. I do not think I am "superior" to the housekeeping staff, nor do I think I am an "inferior" person in relation to my attending physicians. I do, however, acknowledge that my attending physicians are the leaders of the health care team.

 

[RedCole]

Quite the contrary. I respect everyone on the team, from the doctors in charge of the team all the way through the janitors who clean the rooms. EVERYONE has an important role in taking care of the patients. While the janitor is certainly not the leader of the team, they have an incredibly important role. However, are they equals? NO, I do not think they are. An excellent example of how the two are NOT equals occurred last night in my ER. We were slammed for a few hours when suddenly....I was done but the nurse and tech wasn't. I asked the tech what I could do to help her. She looked at me, realized that it would take longer to show me how to do her job than to just do it herself, and told me "nothing". Are we equals? No, in that regard, she knew her job better than I did.

As to the Doctor Pepper comment. Do you think we should call a janitor "Doctor" in a hospital if he/she has a PhD in trombone? What about violin? Or underwater basketweaving?? Of course not. What if he/she "demanded" that we call her "Doctor" because of her PhD in Indian Canoe Making? Should we then cave in and call her "Doctor" while she is in the hospital? How about we confuse the patients even more?

Your comment about the military shows your ignorance about the military. Yes,while
there is a command structure, it has nothing to do with ability or knowledge, it is about effectiveness. I was a (very) senior enlisted guy who, while "junior" to every level of Officer, could tell most officer's to go piss up a rope (as long as I was right!) due to my expertise. An example of this ALSO occurred last night when I was in a patient room and my nurse interrupted me and called me out.

Big difference between situational leadership and being the leader of a team.

And now you're comparing a DNP to an underwater basket weaving degree? And you don't think your comments come across as insulting and dismissive of the nursing profession?

Regardless of your qualms the DNP is a clinical doctorate and it is appropriate to use it in a hospital. There are a variety of non-physicians with doctoral degrees in a hospital, and I've yet to hear any of them "hide" their hard earned credentials to avoid patient confusion. Why is it that people only take issue with NPs using it? I've heard epidemiologists, audiologists, psychologists, etc all introduced as Dr. Lastname.

 

[AnnoyedByFreud]

Quite the contrary. I respect everyone on the team, from the doctors in charge of the team all the way through the janitors who clean the rooms. EVERYONE has an important role in taking care of the patients. While the janitor is certainly not the leader of the team, they have an incredibly important role. However, are they equals? NO, I do not think they are. An excellent example of how the two are NOT equals occurred last night in my ER. We were slammed for a few hours when suddenly....I was done but the nurse and tech wasn't. I asked the tech what I could do to help her. She looked at me, realized that it would take longer to show me how to do her job than to just do it herself, and told me "nothing". Are we equals? No, in that regard, she knew her job better than I did.

As to the Doctor Pepper comment. Do you think we should call a janitor "Doctor" in a hospital if he/she has a PhD in trombone? What about violin? Or underwater basketweaving?? Of course not. What if he/she "demanded" that we call her "Doctor" because of her PhD in Indian Canoe Making? Should we then cave in and call her "Doctor" while she is in the hospital? How about we confuse the patients even more?

Your comment about the military shows your ignorance about the military. Yes,while
there is a command structure, it has nothing to do with ability or knowledge, it is about effectiveness. I was a (very) senior enlisted guy who, while "junior" to every level of Officer, could tell most officer's to go piss up a rope (as long as I was right!) due to my expertise. An example of this ALSO occurred last night when I was in a patient room and my nurse interrupted me and called me out.

Big difference between situational leadership and being the leader of a team.

The fact that you don't see how offensive and absurd that comparison is reveals your true attitude towards nurses who have doctorates. We are clearly not talking about people referring to themselves as "doctor" who have a doctorate in a field that has absolutely nothing to do with their career (like a janitor with a doctorate in underwater basket weaving).

You know who else goes by as doctor in a clinical setting where they are working side-by-side with MDs? Psychologists, optometrists, podiatrists, hell even pharmacists occasionally. Let's not pretend that nurses are the only healthcare professionals seeking to be referred to by their title.

 

[Boatswain2PA]

And now you're comparing a DNP to an underwater basket weaving degree? And you don't think your comments come across as insulting and dismissive of the nursing profession?

Regardless of your qualms the DNP is a clinical doctorate and it is appropriate to use it in a hospital. There are a variety of non-physicians with doctoral degrees in a hospital, and I've yet to hear any of them "hide" their hard earned credentials to avoid patient confusion. Why is it that people only take issue with NPs using it? I've heard epidemiologists, audiologists, psychologists, etc all introduced as Dr. Lastname.

I can compare (and contrast) two things without being overly emotionally attached to them. A rock and a hammer are both hard, yet are different. A DNP and a MD both earn the recipient the term "Doctor" in academic settings, but yet they are vastly different. Same with a PhD in underwater basket weaving and a DNP.

The DNP is only a "clinical doctorate" because the nursing mafia has redefined the definition of a "clinical doctorate". Take a quick moment to compare the DNP "clinical doctorate" curricula with that of a MD, PharmD, DPT, etc. They are woefully inadequate.

There is a time and place for usage of our academic titles....and AT NO TIME should these academic titles be used when they could confuse our patients. The janitor with a PhD in trombone should NEVER be allowed to introduce himself to a patient as "Doctor". Same with a nurse, or pharmacist, or physical therapist, or doctorate educated PA. Patients consider a "Doctor" as a physician.

Also, never make the mistake of thinking I am dismissive of nurses. I think good nurses are worth their weight in gold, and I am fortunate to work with several great nurses. Yes, I think the nursing mafia is far too politically powerful, but that in no way interferes with my relationship with nurses.

 

[Boatswain2PA]

The fact that you don't see how offensive and absurd that comparison is reveals your true attitude towards nurses who have doctorates. We are clearly not talking about people referring to themselves as "doctor" who have a doctorate in a field that has absolutely nothing to do with their career (like a janitor with a doctorate in underwater basket weaving).

You know who else goes by as doctor in a clinical setting where they are working side-by-side with MDs? Psychologists, optometrists, podiatrists, hell even pharmacists occasionally. Let's not pretend that nurses are the only healthcare professionals seeking to be referred to by their title.

I don't have a poor attitude toward nurses with doctorates. However I am amused by nurses, with doctorates, who portray their education as equal to that of a physician when it is clearly far inferior.

Psychologists, optometrists, podiatrists, pharmacists, physical therapists (etc) do not have the opportunity to walk into a (fam practice, ED, ICU, hospital, etc) patient room, introduce themselves as "Doctor XXX", perform a complete exam, and take a wholistic approach to medicine like physicians and mid-levels do. Instead they are limited to a particular function (psyche, eyes, feet, etc).

 

[RedCole]

I can compare (and contrast) two things without being overly emotionally attached to them. A rock and a hammer are both hard, yet are different. A DNP and a MD both earn the recipient the term "Doctor" in academic settings, but yet they are vastly different. Same with a PhD in underwater basket weaving and a DNP.

The DNP is only a "clinical doctorate" because the nursing mafia has redefined the definition of a "clinical doctorate". Take a quick moment to compare the DNP "clinical doctorate" curricula with that of a MD, PharmD, DPT, etc. They are woefully inadequate.

There is a time and place for usage of our academic titles....and AT NO TIME should these academic titles be used when they could confuse our patients. The janitor with a PhD in trombone should NEVER be allowed to introduce himself to a patient as "Doctor". Same with a nurse, or pharmacist, or physical therapist, or doctorate educated PA. Patients consider a "Doctor" as a physician.

Also, never make the mistake of thinking I am dismissive of nurses. I think good nurses are worth their weight in gold, and I am fortunate to work with several great nurses. Yes, I think the nursing mafia is far too politically powerful, but that in no way interferes with my relationship with nurses.

I, for one, am glad to have an organization that fights for nurses. They've won many battles on behalf of NPs. Physician groups are just as powerful, yet I would assume you don't refer to them as the MD mafia.

The reality is this: nurses are respected by the healthcare establishment when they "stay in their place" at the bedside taking orders. Once they break away and become independent, all hell breaks loose. Physicians aren't used to seeing nurses function on the same level as them and it scares them. They combat this fear by belittling nursing education much in the same way that you have, boatswain. Fortunately, neither of our opinions matters and NPs, both in supporting and leadership roles in healthcare, are here to stay.

 

[AnnoyedByFreud]

I don't have a poor attitude toward nurses with doctorates. However I am amused by nurses, with doctorates, who portray their education as equal to that of a physician when it is clearly far inferior.

Psychologists, optometrists, podiatrists, pharmacists, physical therapists (etc) do not have the opportunity to walk into a (fam practice, ED, ICU, hospital, etc) patient room, introduce themselves as "Doctor XXX", perform a complete exam, and take a wholistic approach to medicine like physicians and mid-levels do. Instead they are limited to a particular function (psyche, eyes, feet, etc).

What about APNs who work in a specialty, only? Like CRNAs? Or PMHNPs?

PS, I like how you pretend that you respect everyone equally and harbor no illwill toward any particular profession while slipping in pejorative terms like "nursing mafia". Please.

 

[Boatswain2PA]

I, for one, am glad to have an organization that fights for nurses. They've won many battles on behalf of NPs. Physician groups are just as powerful, yet I would assume you don't refer to them as the MD mafia.

The reality is this: nurses are respected by the healthcare establishment when they "stay in their place" at the bedside taking orders. Once they break away and become independent, all hell breaks loose. Physicians aren't used to seeing nurses function on the same level as them and it scares them. They combat this fear by belittling nursing education much in the same way that you have, boatswain. Fortunately, neither of our opinions matters and NPs, both in supporting and leadership roles in healthcare, are here to stay.

Yes, the nursing mafia certainly has won many battles. Including independent practice in many states, and this is WHY I call them the "nursing mafia". They won these battles not by caring about patients, or using good scientific basis for their arguments, but simply by their tremendous political strength. And there is no comparing the political strength of the nursing mafia and the AMA....when was the last time the AMA organized a strike? They don't, but the nursing mafia does it frequently.

 

[Boatswain2PA]

What about APNs who work in a specialty, only? Like CRNAs? Or PMHNPs?

PS, I like how you pretend that you respect everyone equally and harbor no illwill toward any particular profession while slipping in pejorative terms like "nursing mafia". Please.

The same thing with PAs who wok in a specialty...we should work FOR the physicians who are at the top of the profession. I'm not saying that every physician knows more than every mid-level, but I'm saying that the mid-level system has worked well over the past 40 years because it has been a "we work for the physicians" system. I understand that an experienced mid-level is probably more than capable of operating completely independently....but that independence should come from his/her supervising physician (in the form of reduced oversight, increased compensation, etc) rather than legislatively changes that allow a brand new mid-level to open up shop right after graduation.

No pretending necessary to dislike a group's political actions while not harboring ill will toward them. Again, I love nurses. I married one. I bring my nurses chocolate all of the time simply because they do a great job of saving my ***** from making stupid mistakes. But the nursing mafia is different....it is a group of nurses, mostly in academics, who are pushing for independent practice and doctorate level educational expenses.

 

[RedCole]

Yes, the nursing mafia certainly has won many battles. Including independent practice in many states, and this is WHY I call them the "nursing mafia". They won these battles not by caring about patients, or using good scientific basis for their arguments, but simply by their tremendous political strength. And there is no comparing the political strength of the nursing mafia and the AMA....when was the last time the AMA organized a strike? They don't, but the nursing mafia does it frequently.

1. Nurses win their battles by pointing to mounting evidence that states with independent NP practice do not have worse patient outcomes than those that do not while enjoying better provider access. How dare you condemn the tactics of nursing groups while saying nothing about the physician groups using scare tactics under the guise of patient safety to protect their high incomes from competition. Once again, because you place physicians upon a pedestal, they get a free pass.

2. Physician groups do not strike because they are not wage workers. Each salary, benefits package, and working conditions is unique - striking simply makes no sense. Physicians advocate through money, lobbyists, and wielding considerable power with lawmakers and the public. Nurses do not wield that power.

 

[Nasrudin]

1. Nurses win their battles by pointing to mounting evidence that states with independent NP practice do not have worse patient outcomes than those that do not while enjoying better provider access. How dare you condemn the tactics of nursing groups while saying nothing about the physician groups using scare tactics under the guise of patient safety to protect their high incomes from competition. Once again, because you place physicians upon a pedestal, they get a free pass.

2. Physician groups do not strike because they are not wage workers. Each salary, benefits package, and working conditions is unique - striking simply makes no sense. Physicians advocate through money, lobbyists, and wielding considerable power with lawmakers and the public. Nurses do not wield that power.

You're both right ant wrong. Physicians do use ridiculous claims of patient safety to intimidate and manipulate. But nursing political bodies also use lobbying and money to maneuver politically.

Having had intimate experiences on many levels with nursing management the mafia really isn't a bad or inaccurate metaphor at all. But you could also be equally creative with metaphors in describing, for example, the robber baron physician organizations in Florida who don't want NP's stepping on their narcotics trade turf and so forth.

I largely agree with boatswain. And I find the deceptive sheepish behavior of nursing publicists to be disingenuous in the best of terms.

The reason NP's and PA's are safe is because they are given a free residency by physicians. Independent practice attacks the working machinery of the system as a whole by offering the public cheaper labor. It's fine for them. And for those who want to train less on a formal basis and make less investment in a clinical career.

But it is ruthless in regard to the poor schmucks who run American hospitals while everyone sleeps. Nobody wants to talk about that. Not the hiring people. Not the MBA's. Certainly not the nurse's. Not the public. And not even the senior physicians who are in the business of exploiting well trained NP's and PA's.

We need a system that is fair and equitable of everyone. I'm for an path to independence for NPs and and PA's that is commensurate with the effort to become a physician. But as laid out by the teamster-esque policies of nursing political bodies this is hardly, hardly the case.

I recognize they won't be stopped. And that that is good for people looking to not train as hard as we do. Which is why I can say both that I respect the nurses I work with but that their political organizations can go to hell.

If that offends your everyone is a winner sensibilities then perhaps you should carry the pager for 80 hours or more in a typical week in a hierarchy that is unlike anything anywhere military or otherwise.

 

[AnnoyedByFreud]

Ah, I see. So this is all about independent practice. The age old SDN argument. Yawn. I lived in a state with independent practice for NPs and this whole argument would seem very bizarre to the healthcare providers over there. It's just a non-issue. NPs know when to refer out and when to consult. People in that state realized a law telling them to do those things was redundant and made it harder for NPs to practice, so they got rid of it. Years later, things are fine. I even saw an NP who has her own private practice and here I am, alive to tell the tale.

The whole argument that NPs who have independent practice are somehow dangerous or untested would be a lot more compelling if 18 states didn't already grant them that autonomy, some for decades! This isn't anything new, despite the hysteria on SDN.

Also, physician bodies use lobbying and money to maneuver politically as well. That's why lobbies exist. It isn't just the big bad nurses.

 

[Nasrudin]

Ah, I see. So this is all about independent practice. The age old SDN argument. Yawn. I lived in a state with independent practice for NPs and this whole argument would seem very bizarre to the healthcare providers over there. It's just a non-issue. NPs know when to refer out and when to consult. People in that state realized a law telling them to do those things was redundant and made it harder for NPs to practice, so they got rid of it. Years later, things are fine. I even saw an NP who has her own private practice and here I am, alive to tell the tale.

The whole argument that NPs who have independent practice are somehow dangerous or untested would be a lot more compelling if 18 states didn't already grant them that autonomy, some for decades! This isn't anything new, despite the hysteria on SDN.

Also, physician bodies use lobbying and money to maneuver politically as well. That's why lobbies exist. It isn't just the big bad nurses.

You would've just missed that if it was a USMLE passage.

I don't care much about this issue because as you've indicated it will run its course. If you note what I actually said instead what you determined I said without reading you would see that I agree that NP's are safe. They just become so at a fraction of the debt and effort. And we make them safe, not their training.

 

[AnnoyedByFreud]

You would've just missed that if it was a USMLE passage.

I don't care much about this issue because as you've indicated it will run its course. If you note what I actually said instead what you determined I said without reading you would see that I agree that NP's are safe. They just become so at a fraction of the debt and effort. And we make them safe, not their training.

If you didn't notice, I didn't quote you, because that reply wasn't directly to you. But thanks for the USMLE dig, do you feel better now?

And yes, both physicians and experienced NPs have their hands in making new grad NPs safe. I understand that you want a more regulated system for NPs/PAs that has parity with what medical students and residents go through. I doubt it will ever happen, since many believe it is unnecessary.

 

[deleted6669]

If I understand that you want a more regulated system for NPs/PAs that has parity with what medical students and residents go through. I doubt it will ever happen, since many believe it is unnecessary.

PAs are likely headed for mandated postgrad training( "internships" or "fellowships") in addition to specialty exams.
the specialty exams started in 2011 on a voluntary basis in em, ortho, psych, nephrology and CT surg.. this year they added peds and hospitalist/IM.
http://www.nccpa.net/SpecialtyCAQs
the physician model is school/postgrad traing/board exam. we will be forced by physician organizations to adopt this pattern. historiacally docs went through the same evolution. it used to be you could be a doc by apprenticeship, then school was required, then an internship, then a full residency, then board exams.
20 yrs from now I think we will do school/postgrad training/mandated specialty board exam.

 

[AnnoyedByFreud]

PAs are likely headed for mandated postgrad training( "internships" or "fellowships") in addition to specialty exams.
the specialty exams started in 2011 on a voluntary basis in em, ortho, psych, nephrology and CT surg.. this year they added peds and hospitalist/IM.
http://www.nccpa.net/SpecialtyCAQs
the physician model is school/postgrad traing/board exam. we will be forced by physician organizations to adopt this pattern. historiacally docs went through the same evolution. it used to be you could be a doc by apprenticeship, then school was required, then an internship, then a full residency, then board exams.
20 yrs from now I think we will do school/postgrad training/mandated specialty board exam.

Right, and I am actually for PA/NP residencies. However, they are typically one year in length, right? That's not commensurate with what physicians go through (ie: 4 year didactic training + clinical, then 3-4 years residency). My point was that I do not think the system will ever change such that NPs/PAs will be required to go through that length or depth of training.

 

[deleted6669]

Right, and I am actually for PA/NP residencies. However, they are typically one year in length, right? That's not commensurate with what physicians go through (ie: 4 year didactic training + clinical, then 3-4 years residency). My point was that I do not think the system will ever change such that NPs/PAs will be required to go through that length or depth of training.

PA post grad programs are typically either 12, 18, or 24 months.
certainly not equivalent to an md/do full residency but many of the programs(for em at least) are equivalent to an md/do pgy-1 year with all the same hrs, rotations, and responsibilities.
a few of the surg residencies for PAs are at facilities with md surg residencies and the pas and docs do the same things and have the same responsibilities and expectations( Montefiore is the prime example of this).
this is most but not all of them:
www.appap.org

 

[Nasrudin]

Right, and I am actually for PA/NP residencies. However, they are typically one year in length, right? That's not commensurate with what physicians go through (ie: 4 year didactic training + clinical, then 3-4 years residency). My point was that I do not think the system will ever change such that NPs/PAs will be required to go through that length or depth of training.

Nor should they if the public and financial infrastructure is to get what they need--a cheaper clinician.

I'm not digging at you. I know some smart wonderful people who got knocked out of our path because of USMLE racketeering. I don't wish that on anyone. I'm simply painting a picture of our exploitation and the fact that the 2-3 years of free, European style training you will get on the job while making a salary 2-3 times that of a resident is paid for by the tens of thousands of us who invest the time, effort, and training into the healthcare system that makes your competence possible. These are hidden from their proper account. And entirely off the map of consideration for all except those who have to carry the burden of it. Not including the debt and interest that accrues and is currently spiraling out of control while we get cast by the public narrative as greedy overbearing power mongers. A narrative very adroitly utilized by your organizations without compunction.

What I want is a uniform gradiant of training with multiple entry and exit points accessible to all. Why can't an R2 stop training raise kids and work as an NP/PA? Etc.

It won't happen. We are Balkanized and in constant competition for no benefit to any of us. Physicians have the worst political record with regards to its healthcare constituents and defending them isn't my interest.

I'm on board in time to pay back my half a mil in a field that has such need that, as you say, it doesn't matter. But it will matter. Physician education is becoming untenable economically. It will matter.

 

[AnnoyedByFreud]

Nor should they if the public and financial infrastructure is to get what they need--a cheaper clinician.

I'm not digging at you. I know some smart wonderful people who got knocked out of our path because of USMLE racketeering. I don't wish that on anyone. I'm simply painting a picture of our exploitation and the fact that the 2-3 years of free, European style training you will get on the job while making a salary 2-3 times that of a resident is paid for by the tens of thousands of us who invest the time, effort, and training into the healthcare system that makes your competence possible. These are hidden from their proper account. And entirely off the map of consideration for all except those who have to carry the burden of it. Not including the debt and interest that accrues and is currently spiraling out of control while we get cast by the public narrative as greedy overbearing power mongers. A narrative very adroitly utilized by your organizations without compunction.

What I want is a uniform gradiant of training with multiple entry and exit points accessible to all. Why can't an R2 stop training raise kids and work as an NP/PA? Etc.

It won't happen. We are Balkanized and in constant competition for no benefit to any of us. Physicians have the worst political record with regards to its healthcare constituents and defending them isn't my interest.

I'm on board in time to pay back my half a mil in a field that has such need that, as you say, it doesn't matter. But it will matter. Physician education is becoming untenable economically. It will matter.

I think you make an excellent point here. Medical training should be on more of a continuum, where people can stop off, have kids and work a little or whatever, and then come back and keep going if they so desire. I think the medical field has resisted changing its approach towards physician training for so long, that it really has no one to blame but itself for the success and flourishing of NPs and PAs.

I agree with you about the cost of education being a huge problem. It's not just med students, many people in my program will graduate with debt anywhere from 100-180k (especially those with prior degrees and student debt), though most will probably have debt between 50-100k. It's not as bad as medicine, but it really isn't pretty for many of us, especially since our pay typically starts around 80-90k. The cost of attending my program has literally doubled since 2006.

 

[Nasrudin]

I think you make an excellent point here. Medical training should be on more of a continuum, where people can stop off, have kids and work a little or whatever, and then come back and keep going if they so desire. I think the medical field has resisted changing its approach towards physician training for so long, that it really has no one to blame but itself for the success and flourishing of NPs and PAs.

Absolutely true. And we have also drive up our own costs such that something had to be done. NP's are the solution. Arguing against their ascendancy is like arguing against a rising tide.

The writing is on the wall for high dollar physician education. And it's written in fossils and hieroglyphs. The extinction and evolutionary process won't be pretty. Most bottlenecks in populations aren't.

 

[deleted6669]

Absolutely true. And we have also drive up our own costs such that something had to be done. NP's AND PAs are the solution. Arguing against their ascendancy is like arguing against a rising tide.
.

fixed that for you.

 

[Nasrudin]

fixed that for you.

of course. It's just tedious to type it every time. So in regards to the original topic if you could come up with an acceptable terms for the whole that'd appreciated. I like clinicians to refer to all of us together to distinguish what we do from others but there's not a succinct catchy one for our differences. Which seems to arrive ultimately at an approximation of our debt loads.

How about non-suckers?

 

[deleted6669]

Non-physician provider (although don't like the abbreviation NPP as that looks like NP provider. I'm not an NP)
advanced practice clinician
advanced practice provider
affiliated clinician (kaiser uses this)
associate clinician (my current job uses this)

 

[pamac]

The same thing with PAs who wok in a specialty...we should work FOR the physicians who are at the top of the profession. I'm not saying that every physician knows more than every mid-level, but I'm saying that the mid-level system has worked well over the past 40 years because it has been a "we work for the physicians" system. I understand that an experienced mid-level is probably more than capable of operating completely independently....but that independence should come from his/her supervising physician (in the form of reduced oversight, increased compensation, etc) rather than legislatively changes that allow a brand new mid-level to open up shop right after graduation.

No pretending necessary to dislike a group's political actions while not harboring ill will toward them. Again, I love nurses. I married one. I bring my nurses chocolate all of the time simply because they do a great job of saving my ***** from making stupid mistakes. But the nursing mafia is different....it is a group of nurses, mostly in academics, who are pushing for independent practice and doctorate level educational expenses.

In many states (and the number grows each year), NPs don't obtain their independence from physicians. Their professional title isn't a description of their relationship to another profession, and they weren't founded to be connected at the hip with another profession. Stead wanted to use nurses as physician assistants, but nurses decided to go a different route that didn't lock them in like PAs. Maybe PAs should work for physicians for eternity, but that's a discussion you guys will have to have within your own circle. But Stead founded Physician Assisting, and nurses rejected his vision because they had their own idea of how to structure their hierarchy. They never wanted to work FOR physicians or fall under the jurisdiction of the BOM. It works well even in nursing to have nurses be in their own realm. A doc can get me fired (whether I'm right or wrong), but I dont work for the docs unless I'm an employee. I exist outside of the BOM and answer to nursing standards.

NPs (and PAs for that matter), should have no problem existing separate from physicians to a larger degree. You can't blame NPs for not wanting to join you guys in all the red tape and headaches that come with being where you guys are. I don't see a widespread problem with NPs out there pushing to replace physicians. Around the edges you might see some folks advocating for it. Mostly what I see is PAs chaffing as not being brought along for the ride. And if anything, the DNP is going to be a speedbump to masses of NPs being churned out, so embrace it. The problem PAs will have is that there will be more of you guys hittin the market, and yet more numbers won't help you like they have nurses because you guys are stuck in with the physician community, yet they aren't advocating for you.

 

[RedCole]

Nor should they if the public and financial infrastructure is to get what they need--a cheaper clinician.

I'm not digging at you. I know some smart wonderful people who got knocked out of our path because of USMLE racketeering. I don't wish that on anyone. I'm simply painting a picture of our exploitation and the fact that the 2-3 years of free, European style training you will get on the job while making a salary 2-3 times that of a resident is paid for by the tens of thousands of us who invest the time, effort, and training into the healthcare system that makes your competence possible. These are hidden from their proper account. And entirely off the map of consideration for all except those who have to carry the burden of it. Not including the debt and interest that accrues and is currently spiraling out of control while we get cast by the public narrative as greedy overbearing power mongers. A narrative very adroitly utilized by your organizations without compunction.

I take issue with the bolded statement above. I agree that PAs and NPs could not exist without the many wonderful physicians who have taken the time to teach them, and that is something I am sure all NPs and PAs appreciate. The thought, though, that you are a victim and are "exploited" is laughable. It is NPs and PAs that are exploited! While the "on the job training" may have a higher salary than a resident gets, it also rarely goes up much more. Physicians hire NPs into their office so they can profit off of them, and the starting salaries have been going down considerably. I'm seeing people post on AN about being offered salaries in the 60K range - yet their billing 3-4x that. THAT is exploitation.

 

[Nasrudin]

I take issue with the bolded statement above. I agree that PAs and NPs could not exist without the many wonderful physicians who have taken the time to teach them, and that is something I am sure all NPs and PAs appreciate. The thought, though, that you are a victim and are "exploited" is laughable. It is NPs and PAs that are exploited! While the "on the job training" may have a higher salary than a resident gets, it also rarely goes up much more. Physicians hire NPs into their office so they can profit off of them, and the starting salaries have been going down considerably. I'm seeing people post on AN about being offered salaries in the 60K range - yet their billing 3-4x that. THAT is exploitation.

Read more closely. I never implicated an exploiter. I said NP's were opportunists and disingenuous in their public information efforts. So are physicians.

The point I'm making is that the system is built on the backs of the sacrifice of residents. Without ample rewards for enduring the epic costs of becoming a physician the trip is harder to justify.

A rebalancing in the proportion of which type of clinician will be necessary.

We may have further yet to go in the decreasing the amount of effort and costs in producing clinicians. Maybe NP/PA's are overstrained for the bulk of what they do. RN's can certainly order and perform tests. And do under standing protocols is many settings.

It can always be done cheaper.

 

[pamac]

Read more closely. I never implicated an exploiter. I said NP's were opportunists and disingenuous in their public information efforts. So are physicians.

The point I'm making is that the system is built on the backs of the sacrifice of residents. Without ample rewards for enduring the epic costs of becoming a physician the trip is harder to justify.

A rebalancing in the proportion of which type of clinician will be necessary.

We may have further yet to go in the decreasing the amount of effort and costs in producing clinicians. Maybe NP/PA's are overstrained for the bulk of what they do. RN's can certainly order and perform tests. And do under standing protocols is many settings.

It can always be done cheaper.

Would the residents like to fund their own residencies as part of their education costs?