Nurse Doctors will be a part of our futures

[greets fr. nyc]

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With sooo many of us going into primary care...

Here's an interesting article from the Johns Hopkins School of Nursing on the Clinical Doctorate in Nursing (see below). Check out the website too. Obviously I am ambivalent about the issues... I think it might be a positive thing if done correctly (think about the equal status for DO's), or it might be a negative thing conversely, depending how you look at it or what form "quality health care" takes.

Obviously DO's have a path different than MD's *though both are physicians in their own right secondary to length, breadth, and depth of their respective training.

PA's prescribe independently but by nature teams up with physicians. Advanced Practice Nurses can and do practice medicine independently and prescribe all meds in SOME states (and in an increasing larger number of states). The question for the Doctor Nurse Practitioner / DNP / DrNP of the future is not if, but when and in what form.

Whatever you might think, it is indeed something to examine closely.
Indeed as the buddha said, the nature of life is change...


<2 weeks to da Match...
good luck, to one and all!

---------------------------------


http://www.son.jhmi.edu/jhnmagazine/pages/fea_matterofdegree.htm.
Accessed 3.1.2006


A Matter of Degree

By the year 2015, a doctorate of nursing practice will become the required degree for nurses in advanced practice fields, according to a new ruling by the AACN.

What will the new DNP look like?

Nursing leaders at Johns Hopkins—and from around the nation—are
working together now to address that crucial question.

By Tom Waldron


For nurse researchers with academic ambition, the PhD has long been de rigueur. Now their nursing counterparts in clinical practice have an academic pinnacle to call their own.

In a decision of the American Association of Colleges of Nursing, the Doctorate of Nursing Practice, or DNP, will eventually become the required degree for nurses in advanced practice fields, including nurse midwives, nurse anesthesiologists, nurse practitioners, and clinical nurse specialists.

By a margin of 160 to 106, 226 of the 587 AACN member schools voted last October to require the practice doctorate, rather than a master’s, for advanced practice nurses by the year 2015. The move by AACN replicates those taken by other health care professions, including pharmacy and podiatry, as they established practice doctorates.

“Virtually every other health profession has ramped up their terminal practice degree to the doctoral level,” says Elizabeth Lenz, the dean of the Ohio State University nursing school and head of the AACN task force that developed the DNP recommendation. “With the sophistication and complexity of health care, the knowledge required for practice competency at these advanced levels requires a doctorate, and that’s true of nursing as well.”

But the move to require a DNP for advanced practice is not without controversy.

Many nursing school officials across the country fear it could reduce the numbers of nurses earning PhDs, at a time when nursing schools are having trouble attracting qualified faculty. And some nursing school officials worry about the extra costs associated with a new doctorate program, costs that will strain already tight school budgets.

At Johns Hopkins, leaders in the School of Nursing are studying the issue deliberately.
“Virtually every other health profession has ramped up their terminal practice degree to the doctoral level…With the sophistication and complexity of health care, the knowledge required for practice competency at these advanced levels requires a doctorate, and that’s true of
nursing as well.”

—Dean Elizabeth Lenz,
Ohio State University

Dean Martha N. Hill says she appreciates the arguments in favor of an advanced practice doctorate, particularly given the growing complexities of health care. “If nursing is the last of the major health professions to have a clinical doctorate, I ask, why not do it?”

At the same time, she remains concerned about adding a doctoral program that could detract from the school’s well-regarded PhD program. That program, which now enrolls 31 students and involves 25 faculty members, focuses on nursing-based scientific research, not on clinical practice.

“My reaction to all of this is that at the School of Nursing, we must protect the PhD program we have, first and foremost,” Hill says. Hill is also concerned about the feasibility of launching a DNP program.

Hill has named a task force of SON faculty and students, as well as a representative of the Johns Hopkins Hospital nursing department, to examine issues related to the DNP and to make recommendations to the School of Nursing deans. Co-chairing the group are Anne E. Belcher, senior associate dean for academic affairs, and Phyllis W. Sharps, director of the master’s program.

The group is examining DNP programs at other nursing schools and is expected to advise on whether Hopkins should develop a DNP program at this time and, if so, recommend models for a Hopkins DNP.



Among the thornier issues confronting the task force is determining the resources a DNP program would require—including faculty, staff, space, and financial aid.

“The discussion in our task force meetings has been very lively to say the least,” says Belcher.

She and Sharps are stressing the importance of involving the entire nursing community in developing recommendations for if and how to move ahead with a DNP requirement.

“It’s an exciting and challenging decision,” Sharps says. “There are pros and cons on whichever decision we make. How much money will it cost? Not only is there a shortage of nurses, there is a shortage of nursing faculty. Where are they going to come from?”

The task force, which is expected to issue a report by the end of the fall semester, has discussed the DNP issue with a counterpart group at the University of Maryland nursing school. The task force will also explore whether a new DNP program at Hopkins could lead to collaborations with other Hopkins divisions. For example, DNP candidates could, in theory, take courses and collaborate on projects with students in the Doctor of Public Health (DrPH) program at the Hopkins Bloomberg School of Public Health.

As the task force moves ahead, one key voice in the discussions will be hospitals and other nurse employers. There is some concern that nurses who spend the extra time earning a DNP rather than a master’s will not see a commensurate increase in their roles and responsibilities or their salaries.

Karen Haller, the vice president for nursing and patient care services at Johns Hopkins Hospital, says she is eager to see the details of the DNP concept fleshed out. For example, how much clinical experience will new DNP recipients have?

“What positions will they qualify for?” Haller says. “They could have less experience than an expert nurse who has been here 10 years building her knowledge base experientially. Will this be a degree that someone can go straight through and get, and once they do, will they be able to hold a leadership position?”

Johns Hopkins Hospital has 186 nurses with master’s degrees working in advanced practice roles, including nurse practitioners, nurse educators, clinical nurse specialists, and nurse managers. (The Johns Hopkins University School of Medicine also hires large numbers of advanced practice nurses.) Nurses with master’s degrees also work in other key roles at the hospital, for example leading the patient safety program and patient and visitor services.

While the discussion of the need for a DNP degree unfolds, Haller is confident that one thing will not change—the demand for advanced practice nurses.


“Many schools will not be able to afford to do two doctorates well. Many can barely marshal appropriate resources for one.…The thought of trying to mount something of quality in this climateis overwhelming.”

—Dean Linda A. Cronenwett,
University of North Carolina

Although many nursing schools are moving ahead with planning practice doctorate programs, others have yet to embrace the concept due to basic philosophic concerns or because some key questions have yet to be answered. Case Western University, which established the first clinical nursing doctorate in 1979, is now one of 10 nursing schools accepting students into a DNP (or DrNP) program. Another 40 nursing schools are developing DNP programs, according to the AACN.

Schools that now have advanced practice master’s programs are not sure how long such programs will be needed as a DNP program is added. Another concern: Will advanced practice nurses who are working in their fields be required to return to school to complete a DNP? If so, will there be any source of funding to pay for their additional education?

At the University of Pennsylvania, Dean Afaf I. Meleis recently wrote, “At this point, it is difficult to know or fully understand all the implications of this decision for nursing and, specifically, for our school.” Penn, like Hopkins, is planning an ongoing discussion of the issue to hear from the entire nursing community. But Penn does not intend to open a program.

University of North Carolina nursing Dean Linda A. Cronenwett opposed the DNP requirement and worries that it will strain nursing school resources and lead to fewer students pursuing PhDs.

“Many schools will not be able...

(continued next post)

 

[greets fr. nyc]

...to afford to do two doctorates well. Many can barely marshal appropriate resources for one,” she wrote in a position statement presented at a Penn forum in March.

In an interview, Cronenwett said her nursing school, like many others, has undergone significant funding cuts that will inhibit the creation of new programs. “The thought of trying to mount something of quality in this climate is overwhelming,” she says. She adds that nursing schools should move deliberately while the entire nursing school community reaches consensus on how the DNP should be implemented.

Two AACN task forces are studying the long list of issues and questions that arose since last year’s vote.

One task force is considering the logistics of implementing the DNP, focusing, for example, on how programs might allow nurses with master’s degrees to return to school to obtain a DNP That task force, on which Dean Hill sits, will also consider issues related to launching a new DNP program—licensure issues and issues associated with reimbursing advanced practice nurses who return to school to obtain a doctorate.

A second task force is working to develop the essential components of a DNP degree and curriculum. The panel issued a proposed draft of its findings in August. These findings were to be discussed at a series of regional AACN conferences this fall and winter, events designed to generate feedback from faculty, employers, practicing nurses, graduate students, and other stakeholders. The task force will then develop a final proposal to be considered by the members of AACN in 2006. The draft essential components are available at the AACN’s website: www.aacn.nche.edu.

Nursing leaders are stressing that developing the components of a clinical doctorate and implementing the DNP requirement will pose major challenges both at the national level and within individual nursing schools.

“This was meant to be a revolutionary step in the education of advanced practice nurses,” says Dean Hill. “The implications of this for many schools are enormous.”

Tom Waldron is a Baltimore writer. He wrote about the School of Nursing’s international programs for the Spring 2004 issue of Johns Hopkins Nursing.

Johns Hopkins University School of Nursing
http://www.son.jhmi.edu/

 

[inositide]

For primary care it might be ok, but for subspecialities the expertise is lacking and it is scary. There are no clear cut studies that I know of, but there are certainly many anecdotal stories about mismanagement or less than optimal care of patients by people other than the most highly qualified people.

Another thing: Rules for MDs are so tight that in many places even 4th year students must explicitly tell/explain to the patient that they are medical STUDENTS. If nurses with doctorates are allowed to see pt and say "Hi, I'm Dr. John Doe or Dr. Jane Doe," that would be outrageous.

 

[megsMS]

I think that it is scary for all areas of medicine. In order to help prevent the unknowing lay-public from endangering themselves with sub-par medical care, do what you can to fight it. Speak out and let your opinions be heard. Join the AMA - they are trying to fight these same issues. (For all of you who read this post in disbelief, I mean every word.) Please correct me if I am wrong, but I believe that the reason that programs like this are allowed to happen is that there is no one who tells the nursing profession that they are not adequate to provide total healthcare for patients. They only answer to individual state nursing boards. If you have a group of nurses who get together and believe that they know everything there is to know about healthcare and no one, more specifically, physicians, do not tell them otherswise, of course they think they are justified. Why would they not? Certainly they don't think that they're undereducated...as a general rule most people (not just nurses, this applies to almost all walks of life) don't ever think they're inadequate.
I do think there is a place for nurses...the healthcare system certainly could not exist as it does without them. However, nursing school plus a "masters" that includes pharmacology, pathophysiology, and several "nursing theory" classes is a total joke. (Plus 500 hours of clinical experience!! as I've seen advertised for several nurse practitioning programs...if you average that to 40 hours a week, that is only 12.5 weeks...VERY COMPARABLE to the 2 entire years medical school provides, huh.) I am only a third year medical student but I have already seen numerous patients who have left their inadequate "doctors" who actually turned out to be nurse practioners, which obviously wasn't explained to them. I find this heartbreaking that all of these people had trusted their lives to incompetent providers and that they paid for it with their health.

For primary care it might be ok, but for subspecialities the expertise is lacking and it is scary. There are no clear cut studies that I know of, but there are certainly many anecdotal stories about mismanagement or less than optimal care of patients by people other than the most highly qualified people.

Another thing: Rules for MDs are so tight that in many places even 4th year students must explicitly tell/explain to the patient that they are medical STUDENTS. If nurses with doctorates are allowed to see pt and say "Hi, I'm Dr. John Doe or Dr. Jane Doe," that would be outrageous.

 

[u_r_my_serenity]

I already have difficulty differentiating the exact roles between LVN, BSN, RN, CNA, MA, NA, PA, nurse practicioner, RN+MBA, ... etc. I will probably never understand.

 

[APACHE3]

AMA let us down long ago...we now have naturopathic doctors, homeopathic doctors, acupuncture "medical schools", etc. The public gave up on allopathic medicine long ago, and began treating themselves in the Vitamin stores and seeing alternative docs. We (AMA) never put up a fight. We just fought amongst ourselves with residency hour lawsuits and Match lawsuits. All the while the other health professional (which are a bigger constituency then MD/DO's) quietly lobbied for more and more privileges..and got them!!) The nurses will be "doctors", but if the only nurse on the ward is a "Dr" she's still doing the code browns one way or another!!! 😀

 

[DoctorSax]

I think that it is scary for all areas of medicine. In order to help prevent the unknowing lay-public from endangering themselves with sub-par medical care, do what you can to fight it. Speak out and let your opinions be heard. Join the AMA - they are trying to fight these same issues. (For all of you who read this post in disbelief, I mean every word.) Please correct me if I am wrong, but I believe that the reason that programs like this are allowed to happen is that there is no one who tells the nursing profession that they are not adequate to provide total healthcare for patients. They only answer to individual state nursing boards. If you have a group of nurses who get together and believe that they know everything there is to know about healthcare and no one, more specifically, physicians, do not tell them otherswise, of course they think they are justified. Why would they not? Certainly they don't think that they're undereducated...as a general rule most people (not just nurses, this applies to almost all walks of life) don't ever think they're inadequate.
I do think there is a place for nurses...the healthcare system certainly could not exist as it does without them. However, nursing school plus a "masters" that includes pharmacology, pathophysiology, and several "nursing theory" classes is a total joke. (Plus 500 hours of clinical experience!! as I've seen advertised for several nurse practitioning programs...if you average that to 40 hours a week, that is only 12.5 weeks...VERY COMPARABLE to the 2 entire years medical school provides, huh.) I am only a third year medical student but I have already seen numerous patients who have left their inadequate "doctors" who actually turned out to be nurse practioners, which obviously wasn't explained to them. I find this heartbreaking that all of these people had trusted their lives to incompetent providers and that they paid for it with their health.

While I agree that nurses (as they are currently trained) are not equipped to handle all aspects of care for patients, I think that the issue goes far deeper than "they endanger patient care." The issue of the nurse doctors is exactly the same as psychologists prescribing anti-depressants, optometrists doing eye surgery, and pharmacists prescribing antibiotics, the midwives running birth centers, etc--the so-called para-medical professions get frustrated when they have to call a doctor to do stuff that they feel they can do (and in all likelihood, in the vast majority of cases, can do). The problem with all of it is that they lack the capacity to manage the COMPLICATIONS. A psychologist give a patient trazodone and the guy gets a priapism. Then what? Uh....call the doctor? The pharmacist prescribes penicillin and the lady gets an anaphylactic reaction...uh...call the doctor? A woman is in labor and the baby is getting frequent late declerations...uh...do a C-section?

At the same time, there is a problem. Similar to migrant labor and outsourcing to the less-developed world, the NPs, MSNs, and PAs are doing stuff that physicians don't want to do. I don't know statistics, but I would bet that the prison system employs almost entirely PAs to run the health centers. PAs work their butts off for 2 years, and then go out and literally run clinics (well compensated too!). Midwives run birth centers because OB/Gyns get far more compensation for doing complicated cases than by doing the run-of-the mill delivery.

The fact is that we don't want to do that so-called "bread and butter" stuff all the time, and I think that the reason centers on the idea of value. The system as it is values tasks, not knowledge. You know it's true--if you want money, you have to do something to someone--cut, excise, stitch, stick a camera up someone's butt, etc. Remuneration for managing chronic disease (in essence, the foundation of medicine) is piddly squat. As I have heard before, the patient rarely remembers the doc that helped her control her diabetes, but ALWAYS remembers the one who put the scar on her belly. Much of the work of the internist is on managing chronic disease, which a PA or NP can certainly be well trained to do.

What is necessary is a mechanism to forge better partnerships between the medical and para-medical professions. Make sure that the NPs and PAs are well-trained enough to recognize when something should be referred to the physician, and let them practice medicine at the level for which they are trained. The fact is that we are trained to take care of much more complicated stuff, and so we should--I'm not saying that we should abandon our hypertensive diabetic patients and leave them all to be taken care of by PAs, but that if we did, it wouldn't be a disaster as long as everyone knew his or her limits of knowledge. I know plenty of PAs and NPs--they don't want any more responsibility than they already have.

And I've seen plenty of folks in the hospital whose "PCPs" (I hate that term) made some serious errors in judgement. Let's not be too hasty to lable NPs as incompetent. I don't know if medical errors have been as well studied in the NP/PA world, but would be interested to see a side-by side comparison.

In the end, the problem with our union (the AMA) is that it is entrenched in the old hierarchies and the old ideas and is monolithic in its capacity to evolve. Our job as physicians of the future should be to figure out innovative solutions to these problems, not to create adversarial relationships.

Great thread (and great previous post), by the way--I find this issue very interesting because it exposes some of the fallacies of our system and the challenges to its evolution.

DS

 

[carpe diem]

from original post

......." I think it might be a positive thing if done correctly (think about the equal status for DO's), or it might be a negative thing conversely, depending how you look at it or what form "quality health care" takes.

Obviously DO's have a path different than MD's. PA's prescribe independently but by nature teams up with ....... "


The issue brought up about NPs, DNPs, other mid-levels is interesting and relevant, but I would take issue with your original assertion that " obviously DO's have a different path than MD's". DOs don't have a different path in terms of length/depth/breadth of training ( I know some could argue quality of training but this is true among MD schools also) whereas mid-levels, NPs, and DNPs, whatever do have major differences in training........ generally half as much (or less) basic science, half as much clinical training before graduation and no residency requirements. And the basic science and clinical training is not as in-depth either nor as broad as MD-DO training.

I am not saying that NPs and mid-levels cannot be very good clinicians, in fact, the NPs, PAs, and NP,PA-students I've worked with are very good clinically (i.e knowing how to interview and exam patients)..... they just don't always seem to know what to do with what they find on exam or in the interview. Several NP students I worked with recently were frustrated that they are not allowed to treat patients on rotations or in prospective jobs they were looking at. I felt like saying ( but bit my tongue)........ " Why don't you go to medical school if you want to be a physician? "

I was also disturbed by the attitude of the NP students which was very anti-physician........ always saying things like " well, what do you expect, it was the doctor who talked to the patient" , or " of course, it was the nurse who discovered this and followed up on it ". These are just examples (true ones) but they demonstrate the nursing profession's desire to encroach upon physician's territory because they feel they can do it better. In many cases they perhaps do, in fact, do things better which is scary and is why we as physicians and future physicians better learn to listen to patients better and be on top of things with our patients or the patients will begin preferring mid-levels at all levels of care. Based on a recent clinical rotation, this is already happening.

Carpe

 

[greets fr. nyc]

from original post

......." I think it might be a positive thing if done correctly (think about the equal status for DO's), or it might be a negative thing conversely, depending how you look at it or what form "quality health care" takes.

Obviously DO's have a path different than MD's. PA's prescribe independently but by nature teams up with ....... "


The issue brought up about NPs, DNPs, other mid-levels is interesting and relevant, but I would take issue with your original assertion that " obviously DO's have a different path than MD's". DOs don't have a different path in terms of length/depth/breadth of training. ( I know some could argue quality of training but this is true among MD schools also)

Carpe

Carpe,

thanks for the post. let me clarify.
perhaps I shouldn't(?) have placed the DO sentence where it was placed, lest it be misinterpreted as something negative(?). What I meant was this: what is "different" about the training of DO's is that they learn physical manipulation and that indeed is something that is unique and non-existent in most MD programs. Seeing an experienced DO do truely skilled physical manipulation is something I could never do without years and years of special training (which is what they have). This type of thing is not present in us MD's.

Another major thing that is different in path in DO's is that they have a whole different battery of exams they take and a different set of licensing boards as well (COMLEX right)? Is that correct(?) They may opt to take the USMLE's but that's optional right? And arent there a number of DO only residencies? So the WAY in which D.O.'s become physicians can and often is different from us MDs.

So my point is, their path may be DIFFERENT, but the results of competent physicians (overall, minus outliers for both tracks) are the SAME.


*see edit in original post, hope it clarifies a bit more.


(actually I have a number of people who I know who are DO's and have seen in action, and I'd trust them with my family's care anyday. There are plenty of great MD's in my extended family and friends who'd I'd say the same thing likewise).

 

[greets fr. nyc]

thanks all around for making this a energetic and intelligent thread (from people in / going into IM I wouldn't expect anything less).


DS,

in regards to your post:


"While I agree that nurses (as they are currently trained) are not equipped to handle all aspects of care for patients, I think that the issue goes far deeper than "they endanger patient care." The issue of the nurse doctors is exactly the same as psychologists prescribing anti-depressants, optometrists doing eye surgery, and pharmacists prescribing antibiotics, the midwives running... The problem with all of it is that they lack the capacity to manage the COMPLICATIONS... "

point well taken.

In addition to this, I've been thinking that many chronic diseases can be managed well by a non-physician trained in that area... but the thing that's been nagging at me (in addition to the aspect of managing complications) is also this: almost from day one of med school and then into residency, etc etc, we've been trained to think in terms DIAGNOSIS, DIAGNOSIS, DIAGNOSIS and in turn the underlying PATHOPHSIOLOGY....
Now these two essential aspects are things that are truly unique and well-grounded in our training (as MDs or DOs), that I think no other para-medical profession can match in terms of time, breadth or depth devoted to this endeavor. It's just not there. True, something like HTN or diabetes can be managed once ALREADY diagnosed, but what happens if this same person comes in complaining of a chronic dry but sometimes productive cough for 7 weeks. Additional he reports occassional night sweats and loss of weight despite no fever. He states he has had a "really good" appetite +/- feelings of "food coming up sometimes when I swallow"?

What happends to this person when the PCP is a non-MD faced with the diagnostic challenge? Does a differential -- TB vs. some other mycotic infection vs. lung CA vs. lung infection 2/2 immunocompromised state vs. hematologic neoplasm vs. GERD vs. Hiatal hernia vs. esophageal process (ID, neoplastic, structural, congential diverticula, and so forth) -- magically appear? What rational workup does the para-professional begin with? Or do you refer to a gastroenterologist? A pulmonologist? etc etc. That's a real problem for patients who don't come with a diagnosis already given to them.

Now, what happens when a para-medical places the PPD... does she or he have the trainning beforehad to know that the test has moderate to low sensitivities and specificities and the reason why it might be? Does she or he have the training to interpret the evidence in the literature behind that PPD. Ok, so let's say the PPD is negative, I know plenty of untrained people who would say, "that person MUST not have TB."

A similar scenario with other diagnostic tests plays itself out time and time again.

(there are other major real differences in physicians vs. para-professionals that should be also mentioned in another post)


"...At the same time, there is a problem. Similar to migrant labor and outsourcing to the less-developed world, the NPs, MSNs, and PAs are doing stuff that physicians don't want to do...."

**Indeed. I should also say that third party payers also legislate and enact policies to the belief that such care by para-medical professionals is much cheaper (at least clearly on paper)... a valuable analogy to what is happening to engineering jobs, computer programming jobs, white collar positions, middle management jobs in all segments of American society.



"...The fact is that we don't want to do that so-called "bread and butter" stuff all the time, and I think that the reason centers on the idea of value... "

This lack of renumeration is a important reason, as are others such as: primary care may appear to fail to provide enough intellectual interest to sustain lifelong interest, the daily demands are not compatible with lifestyle expectations, our exposure to primary care is within the backdrop of a very complex, constantly changing, and unpalatable beauracratic system.

The lack of MD people going into primary care and the continued disincentives for future appears to remain unchecked for the years to come as well...and it's not just because people don't want to be the primary care provider, cuz' in fact many of these specialists end up becoming the de facto PMD. take for example the cardiologists who have patients in heart failure or s/p ACS and stent who pay regular visits / get checked up by them very often. Or the oncologists with whom people view as the primary doctor to go to in their treatment against cancer. Or the pulmonologist for a patient with chronic COPD or bad asthma. Primary care issues still run constant in these interactions.



"What is necessary is a mechanism to forge better partnerships between the medical and para-medical professions. Make sure that the NPs and PAs are well-trained enough to recognize when something should be referred to the physician, and let them practice medicine at the level for which they are trained... I know plenty of PAs and NPs--they don't want any more responsibility than they already have. "

That is the key... partnerships between groups. Clear and reasoned debate. Selfish, petty antagonism just makes all groups angry. I'd bet though, that it doesn't happen anytime soon, based on the personalities involved.

Also, I think, no matter what the political arm of nurses and other para-medical professionals are clamoring for, the reality of the situation is the majority of the time para-professional know their limits and look to do their jobs extremely well (i mean, few want to be sued or let alone get in over their heads and have to live with it). This has been my experience with practicing NP's and PA's as well. In fact most of my interactions with NP's and what I've seen from attendings working with NP's is real and honest respect from both sides. The extent of which however, remains to be quantified.


"And I've seen plenty of folks in the hospital whose "PCPs" (I hate that term) made some serious errors in judgement. Let's not be too hasty to lable NPs as incompetent..."

I agree.


"In the end, the problem with our union (the AMA) is that it is entrenched in the old hierarchies and the old ideas and is monolithic in its capacity to evolve. Our job as physicians of the future should be to figure out innovative solutions to these problems, not to create adversarial relationships."

I think this is such a key statement. We must be able to see change, be able influence change, and be able to put aside our profession's individual differences (a very tough thing to do in our MD group who've almost been reared since birth to be independent thinkers and doers).


"Great thread (and great previous post), by the way--I find this issue very interesting because it exposes some of the fallacies of our system and the challenges to its evolution."

Definitely. The health care system's future and its evolution is what keeps things interesting and unsettling.


*** Also check out as a beginining, JAMA and the NEJM and do a search for "nurse practitioners." Some interesting opinions on the issue as well. Also check out the nurse practitoner or advanced nurse practitioner journals for some interesting lessons in activism and where the debate and policies are heading.
for example:
http://www.aacn.nche.edu/Education/curriculum.htm

http://www.case.edu/news/2005/8-05/dnp.htm

 

[Furrball2]

A doctorate is a degree, nothing more. The title has more to do with the satisfaction of educational requirements towards a doctoral degree. My wife is a PhD, eg philosophy doctor. A lawyer is a JD, doctor of jurisprudence. What is the goal of the DNP? Is it a clinical parallel to the alrady existing PhD in nursing? If the goal is tobecome a clinical doctor then the DNP would have to be licensed through the state medical board becaue they would be practicing medicine not nursing. I think people are blowing a lot of air over this one.

 

[greets fr. nyc]

good point furrball,
however it must be noted that the fact is, many advanced nurse practitioners are indeed practicing the diagnosis and treatment of illness (in 13 states they have PARITAL or FULL prescribing authority included controlled substances) and are easily and legitimately(?) circumventing those "much vaunted" medical boards.

As one example: check out the Acute Care Nurse Practitioner 2004 competencies published by the AACN (Amer Assoc of Colleges of Nursing), a pdf download from: http://www.aacn.nche.edu/Education/curriculum.htm

on page 25, you'll find in the domains and core competencies: The acute care nurse practitioner...
... 1) demonstrates critical thinking and DIAGNOSTIC reasoning skills in CLINICAL DECISION MAKING... 7) Demonstrates knowlege of pathophysiology of acute and chronic conditions commonly seen in practice... 11) PRESCRIBES medications based on efficacy, safety, and cost...




additionally if you check out the March 2006, Volume 31, Issue 3 of The Nurse Practitioner you'll find the editorial:


What is “True” Professional Autonomy?
[Departments: Guest Editorial]

Kaplan, Louise PhD, ARNP; Brown, Marie-Annette PhD, ARNP, FAAN

Despite legislative gains in scope of practice, the majority of nurse practitioners (NPs) in the United States are not fully autonomous.1

It is easy to lose sight of the factors that constitute full autonomy. Even in states where NPs have legal authority for full autonomy, there are practice barriers that subvert this autonomy. Barriers range from receiving a lower rate of reimbursement than physicians to seemingly small acts of exclusion, such as not being able to authorize disability parking permits.

Full Autonomy = Full Control

Autonomy is considered the basis of a profession.2 Professional autonomy is defined as “socially granted and legally defined freedom to make practice decisions without technical evaluation from sources outside the profession.”3 True autonomy will occur only when NPs have full control of their profession. The ability to attain this control is limited by factors such as the position taken by organized medicine: physicians have the authority to supervise and direct other healthcare professionals.

Each of us must assume responsibility to create a national environment in which each NP is fully autonomous.

According to Safriet, physicians have “[horizontal ellipsis]a monopoly on authority, if not ability. All others, including both long-standing and emerging professions, must constantly choose between two unattractive alternatives: foregoing the safe practice of what they have been educated and trained to do, or risking legal sanction for stepping outside the boundaries of their legislatively defined, static, circumscribed, and outdated scopes of practice.”4

For over a decade, NPs in Washington state lobbied intensively for fully autonomous II–IV prescriptive authority and worked to defuse opposition from organized medicine. Why, then, did NPs compromise in 2000 and accept a II–IV prescribing law requiring indirect physician involvement? Over the years, many NPs had stepped outside the boundaries of their scope of practice using quasi-legal strategies to provide controlled substances to patients. Leaders in the NP field made the strategic decision that the Joint Practice Agreement (JPA) requirement served as an interim step toward fully autonomous prescribing. They planned to lobby for the elimination of the JPA after NPs demonstrated competence and established credibility prescribing II–IV drugs. In March 2005, the governor of Washington signed a law removing the JPA requirement. Washington NPs now have fully autonomous practice including prescribing for legend and controlled substances.

Surviving the Proving Ground

As our research revealed, (see The Nurse Practitioner. 2006;31(1):57–63) the law passed in 2000 created additional barriers for some NPs, such as maintaining a prescribing log or taking an examination to demonstrate knowledge. These additional requirements were a burden, made the NP vulnerable to physician demands, and were another way the profession was diminished. Nurse practitioners are still ‘surviving the proving ground’ much the way our esteemed pioneers did 40 years ago.5 Any barrier, no matter how small, constrains NP autonomous practice and limits access to comprehensive care for millions of patients.

In all 50 states, NPs individually and collectively work to eliminate barriers that restrict practice and prevent full autonomy. Each of us must assume responsibility and participate in a grass roots effort to remove external barriers and create a national practice environment in which each NP is fully autonomous. Concurrently, we must create a paradigm shift in the way we think about ourselves. We are competent, highly skilled professionals who are essential to our nation’s health. It is not just in action but in thought that we create our autonomy.
REFERENCES

References available upon request.
Accession Number: 00006205-200603000-00010


sounds like medicine to me for the NP of the future. And many know it and could care less. just check out the february and january or other issues of Nurse Practitioner for more of this. you can probably access it through you institution's library. or do a google search for a table of contents.

I know a number of very excellent NP's whom I've worked with and they have never been disrespectful or anything less than the consumate professional. However, the editorial is another part of the spectrum, and clearly, autonomy is about respect, internal and external respect, it's a "civil rights movement for freedom," and not about safety, pharmacologic efficacy, let along the inherent danges or prescribing medicines beyond one's understanding or training. I could see someone prescribing flecainide because they can. but then again, maybe that's an overstatement.

 

[DoctorSax]

*** Also check out as a beginining, JAMA and the NEJM and do a search for "nurse practitioners." Some interesting opinions on the issue as well. Also check out the nurse practitoner or advanced nurse practitioner journals for some interesting lessons in activism and where the debate and policies are heading.
for example:
http://www.aacn.nche.edu/Education/curriculum.htm

http://www.case.edu/news/2005/8-05/dnp.htm

Very interesting description of the DNP program by Case. The blurb makes it sound as if the DNP degree is to create more nurse professors--essentially to fill a need for nurse educators in the academic world. I didn't realize that there was a shortage of nurse educators.

Your points are definitely well taken. It's interesting to think about how NPs or PAs would handle the PPD issue--regarding specificity and sensitivity of the test. I often wonder how much we as physicians think about such things when we order them. Being so focused on diagnosis, we sometimes order tests and then don't really know what to do with the results. I mean, I've seen so many ACE levels ordered on guys with questionable CXR findings and cough--we look for the zebras, but if we find something awry we don't always know what the next step is.

I think that one of the rheumatologists at my school summarized it best when he told us stories of all the ANAs, dsDNAs, RFs, etc. that primary care docs had ordered--the "autoimmune panel" I believe it is called? They get a funny result and then say, "whelp, found a high ANA, better send 'er on over to Rheum." He said that there are plenty of referrals that he gets that say "elevated ANA." Not that it's bad medicine at all, but I mean, an NP could do that just as well, right?

I do agree that pathophys is the fundamental difference between our training--it is the foundation of why the emergence of PA/NP-run practices will not negate our existence. However, I do wonder at what point the pathophys becomes inconsequential--a nice factoid, but no more (or if it does at all). Since we enter into "practices" of medicine, one assumes that everyone probably gets better with practice. Doesn't the same apply for the para-medical professions?

I remember hearing a resident remarking to a colleague that "those med students really have us on the pathophys, but what we do way better at is management." PAs pretty much run the HIV clinic at my school. Sure in the end they are working for the HIV specialists, but they can handle the routine HAART changeup and the occasional opportunistic infection and take a huge burden off those folks, who are often traipsing around the country doing research meetings anyhow. I guess my question is this: when management becomes that which we all "practice" and refine into an "art," what distinguishes us from them?

DS

 

[Loopo Henle]

A psychologist give a patient trazodone and the guy gets a priapism. Then what? Uh....call the doctor? DS

I want to see what the psychiatrist is going to do with the priapism Ohh wait, I know, he will call the doctor (Urologist) to fix it.

Sorry about not adding anything intelligent to the discussion. I am way too ADD to read these extremely long posts, but they sound good.

 

[greets fr. nyc]

I remember hearing a resident remarking to a colleague that "those med students really have us on the pathophys, but what we do way better at is management." PAs pretty much run the HIV clinic at my school. Sure in the end they are working for the HIV specialists, but they can handle the routine HAART changeup and the occasional opportunistic infection and take a huge burden off those folks, who are often traipsing around the country doing research meetings anyhow. I guess my question is this: when management becomes that which we all "practice" and refine into an "art," what distinguishes us from them?
DS

DS, good call! Doing some surfing and found this..
The future is here at Columbia Advanced Practice Nursing Associates. Wow, right here in my own neighborhood!

Direct from the website: "CAPNA provide comprehensive primary care by advanced practice nurses. They diagnose and treat illness, perform physical examinations, order diagnostic tests and refer to specialists as needed."

http://www.nursing.hs.columbia.edu/CAPNA/about.html



started up seeing private patients in 1998
check out an article at http://www.aafp.org/fpm/981000fm/nurse.html
from that time period.

As for the GPs & FPs... clearly NPs are in competition, and so it's market forces at work, pure and simple. They get reimbursed comparatively the SAME amount by third party payers, so there goes the argument that they're less expensive, I imagine...

 

[inositide]

Physicians need to be much more pro-active in protecting medical care. Too many people without the requisite training are trying to become de-facto physicians, and they already have. If physicians are not proactive, then more of these allied health people will become de-jure physicians.

I once had a multiple myeloma patient on my service who was admitted from a community hospital in a near-death condition due to severe sepsis. He survived, but when he was finally extubated and able to speak, and throughout his time on the regular ward, he kept asking for his "primary doctor." This "primary doctor" was actually a nurse practioner (NP) in the community hospital's oncology clinic.

If a paralegal secretary starts claiming herself to be an attorney and starts filing briefs on bread-and-butter legal cases, she will be prosecuted. Yet a paramedical person (NP, LPN, etc) is allowed to write prescriptions etc etc just because it is a "bread and butter" medicine case?

Unlike other professions, physicians care more about their patients (clients) than they do about themselves. They expend efforts advocating for the patient and not for themselves. Physicians hope that legislatures and govt bodies will recognize this and reward them for it, but it will never happen. Other groups take advantage of the situation.

 

[Mumpu]

The number of physicians going into primary care is steadily plummeting yet physicians continue to complain about nurses and PAs taking over their primary care jobs... NOT. Docs created that job market and the huge demand is slowly being filled. The solution is not to ban other specialties from entering the market but to make the market attractive to physicians again. Another (IMHO feasible) option would be to abandon that market altogether so all physicians work as highly-paid specialists and mid-level providers do the 30-patients-from-hell-a-day routine.

If AMA is a patient advocate, I'm a three-armed monkey -- they are a lobbying agency intent on protecting incomes and other interests of their members.

 

[MacGyver]

? If the goal is tobecome a clinical doctor then the DNP would have to be licensed through the state medical board becaue they would be practicing medicine not nursing. I think people are blowing a lot of air over this one.

Thats not what state laws say.

State laws state that medical boards regulate "medicine" and nursing boards regulate "nursing"

The problem is that each board decides what its own scope of practice. STate nursing boards have already stated that scripting meds is "nursing" practice and not "medical" practice. Thats the game they play. Nursing boards have SOLE AUTHORITY to determine what "nursing" is, and they use that power to aruge that everything under the sun is "nursing" practice. I guarantee you in 20 years they will be arguing that brain surgery is "nursing" practice and add that to their scope as well

 

[Loopo Henle]

Physicians need to be much more pro-active in protecting medical care. Too many people without the requisite training are trying to become de-facto physicians, and they already have. If physicians are not proactive, then more of these allied health people will become de-jure physicians.

I once had a multiple myeloma patient on my service who was admitted from a community hospital in a near-death condition due to severe sepsis. He survived, but when he was finally extubated and able to speak, and throughout his time on the regular ward, he kept asking for his "primary doctor." This "primary doctor" was actually a nurse practioner (NP) in the community hospital's oncology clinic.

If a paralegal secretary starts claiming herself to be an attorney and starts filing briefs on bread-and-butter legal cases, she will be prosecuted. Yet a paramedical person (NP, LPN, etc) is allowed to write prescriptions etc etc just because it is a "bread and butter" medicine case?

Unlike other professions, physicians care more about their patients (clients) than they do about themselves. They expend efforts advocating for the patient and not for themselves. Physicians hope that legislatures and govt bodies will recognize this and reward them for it, but it will never happen. Other groups take advantage of the situation.

I don't want to be a complete troll here, but threads like this always degenerate into this kind of thing. There always is a quick anecdote about how some NP/PA almost killed somebody by their lack of knowledge and ability. Am I the only one here who realizes that doctors are not infallible, omniscient beings that only care about the well being of their patients. Let me use the above post as an example.
Paragraph 1: Fair enough lead in

Paragraph 2: Classic NP almost killed my patient anecdote. Ringing with self righteousness, as if the poster has never missed a diagnosis. If MD's are so perfect why is malpractice insurance so high. Let me guess it is because of the crooked lawyers and insurance companies. Doctors play no part.

Paragraph 3: Outrageous factoid that is essentially untrue. Nurse practitioners may write scripts with a varying degree of autonomy depending on their state, but I have never seen a Liscensed Practical Nurse (LPN) write anything resembling a prescription unless they are doing it for the doctor so they can sign it. I am willing to bet a good number of posters don't know the difference between a LPN/RN/NP etc... as evidenced by an earlier post.

Paragraph 4: The moral supremacy is dripping from this paragragh and the fact is, it is a load of utopian crap. Doctors don't look out for themselves??? Boy, You could have fooled me.

Am I worried about the ever expanding scope of NP/PA's and how it is going to affect my future practice? Sure. Am I really concerned that they are going to replace me? No. Will the general public really accept the phasing out of physicians in favor of a nurse only healthcare system? I doubt it. Are Doctors going to have to drop some of their pride, and realize they work in an ever evolving healthcare environment/team? I hope so. Please stop acting morally superior to nurses/PA's etc.. Until you have walked a mile in their shoes, you really have no room to criticize (especially if you are a medical student). Just for your info before the flaming begins, I am a 4th year medical student as well as a registered nurse so I have seen both sides of the aisle.

 

[Loopo Henle]

I am not very bright so I tend to think too simply about these complicated subjects. That being said, a couple of questions come to my mind.

1) What is the genesis of this "problem" of over ambitious "mid-levels"? Who do these people work for? How did they get a niche in our exclusive world in the first place? It seems to me that most NP's and PA's work (shockingly enough) for physicians. We use them to make our lives easier. I may be completely wrong, but how many free standing PA clinics are there? How many NP's operate their very own family practice clinics? There always seems to be an MD/DO in the background overseeing things. So they could not exist, at least currently, without our consent. So in one regard, the problem is us. I guess we are worried that they will slip out from under our control and strike out on their own. In other words, become direct competition. If that does happen, there will be complications for them, will there not? Insurance companies including medicare will have to approve it. Their malpractice rates will surely rise dramatically. They will have to prove via evidenced based methods that their care is equivalent to the gold standard. PA's will have to change their name altogether.

2) Is it so horrible that a nurse with a PhD or Doctorate of CLinical Nursing or whatever be called "Doctor". Did you have a problem calling your undergraduate or basic science professors Doctor So and So. I didn't. A PhD degree or equivalent is worthy of respect. As long as the patients are made aware that they are being cared for by a Doctor of Clinical Nursing and not a Medical Doctor or a Doctor of Osteopathy, then I don't see a problem with it. I think this boils down to being an issue of pride and entitlement for MD/DO's.

 

[greets fr. nyc]

I think I am tending to agree with you Loopo Henle.

also, as I've seen it, i think the trend for most hospitals I've worked at has been cooperation rather than competition. I think about the PA aspect as well and it's very much the same type of relationship. in this fragmented health care system of ours, something has to be done on all sides: obviously not just physicians, but of course PA's / NP's / hospital administrators / state, local, federal government politicians / third party payers / and... citizens need to make hard decisions and work together to improve this friggin' behemoth. i'm not optimistic, but still i'm game.



*fact check: NP's/APN's can already practice autonomously on their own in a number of states. most do not, but they can and do. a good example: http://www.nursing.hs.columbia.edu/CAPNA/about.html

*also note: I don't think the OP was flaming, but just voicing an opinion that many people feel to some degree. Perhaps it wasn't the most tactful or most correct in your view, but I still think it was within reasonable limits.

*maybe our generation is in part pissed off that med school is way toooo expensive and we had to jump through too many monkey hoops to get where we are and folks don't feel like they're getting nearly their money's or hard-earned work's worth. Ok, maybe not...Perhaps just talkin' junk in this case!

 

[MacGyver]

The bottom line is that a med school that charges $150,000 to be able to do what an NP with 20% of that debt load can do is guilty of outright FRAUD

Thats really what this comes down to.

An outright admission that medical schools are absolutely ripping people off who go into primary care.

Next time you talk to your medical school dean, ask how they can justify charging such high tuition and such a grueling track when a nurse can do the same stuff in 1/3 the number of years with 20% of the debt load.

Over the long term, money talks. you think primary care is bad now, wait a while. We will eventually get to the point where medical schools will produce ONLY specialists and everybody that wants to do primary care goes into nursing instead

The marketplace will NOT support paying 150k on an education you coulda got for 30k in a much shorter time frame

 

[lateness]

As long as the patients are made aware that they are being cared for by a Doctor of Clinical Nursing and not a Medical Doctor or a Doctor of Osteopathy, then I don't see a problem with it. I think this boils down to being an issue of pride and entitlement for MD/DO's.[/QUOTE]

That is the key thing you said, as long as they know who is being cared for them,... bc obviously patients are likely to get confused when they are in a hospital/clinic setting and have all sorts of people attending o them called doctor.. its ok but you can imagine from THEIR standpoint, that they probably dont know who is a med doctor, nursing doctor, NP, etc...
😎

 

[RastaMan]

Every year of med school I feel like I made an exponential leap in terms of fund of knowledge (except 4th year of course, although I have learned a few things here and there this year too). I remember at the end of 3rd year, I was like wow, I know all this "doctor stuff now," and then 4th year started and I realized how far I still had to go. The learning curve only gets steeper during residency...my point is 6.5 years packed with learning (I counted 4th year as half a year 🙂 ) is not equivalent to 2 years of NP or PA training.

That being said, a number of PAs and NPs have been working in their respective fields (ER, onc clinic, cards, etc) for a number of years. I work in each service for a few weeks and move on...once again, my 2 weeks is not equivalent to the time they have spent in their roles and I have often learned a lot from midlevels during my rotations.

 

[Loopo Henle]

That is the key thing you said, as long as they know who is being cared for them,... bc obviously patients are likely to get confused when they are in a hospital/clinic setting and have all sorts of people attending o them called doctor.. its ok but you can imagine from THEIR standpoint, that they probably dont know who is a med doctor, nursing doctor, NP, etc...
😎

You know, I may have a low view of my patients, but I think the grand majority of patients don't have any idea who anybody is anyway. Most probably don't care as long as they get their percocet. The ones that do care probably are fully capable of reading a nametag or will pester the snot out of everyine that comes in their room to find out who they are. My experience tells me (gross generalization on the way) that most patients see a man come in the room and assume "doctor", they see a woman and think "nurse", they see a hermaphrodite and think "Pat". This is a societal view of the genders that is hard to shake. I think the onus is on the healthcare provider to clearly state who they are when they meet a patient for the first time (or every time if the patient is demented). As for whether a patient wants a "doctor nurse" taking care of them, I don't have an answer for that. My mother-in-law prefers the NP when she goes to the MD office because she thinks the doctor is pompous. We don't often ask patients who they want caring for them anymore. I am willing to bet that a good number of patients would rather have the primary care doctor take care of them when they are admitted to the hospital, but in the age of hospitalists that is no longer the way things are done, so patients are randomized to whoever is taking call for the hospitalist service. So in the end, I think patients have no idea who is taking care of them anyway. This is the future of medicine, and I personally think the greatest threat to the "prestige" of medicine. When patients feel like their doctor has no vested interest in them, then they will have no vested interest in their doctor. Wow that was pretty tangential, but I think I got my point across somewhere in there.

 

[Loopo Henle]

The learning curve only gets steeper during residency...my point is 6.5 years packed with learning (I counted 4th year as half a year 🙂 ) is not equivalent to 2 years of NP or PA training.

That being said, a number of PAs and NPs have been working in their respective fields (ER, onc clinic, cards, etc) for a number of years. I work in each service for a few weeks and move on...once again, my 2 weeks is not equivalent to the time they have spent in their roles and I have often learned a lot from midlevels during my rotations.

Thank God, there is hope after all 🙂

 

[deleted4401]

All you have to do is prove that PAs/NPs provide inferior care. Someone willing to do the study? All this complaining is somewhat nonsensical unless someone can prove mid-levels do a poor job.

I don't know how many people here are interns/PGY1s, but I strongly believe that I don't need the training I've had to do my job. Clearly, a PA could do the same or better. Nothing to do with training, purely to do with experience. A PA with 10 years experience is far more valuable to a medical center than me. I'm a so-called good intern (at least prior to starting the year - good letters of rec, graduated from Tulane, top USMLE scores, top 1/3 of my class), yet I can't handle neutropenic fever as well as a PA with 10 years of experience.

The only reason my job exists is for my educational opportunity. I repeat - my residency exists for educational purposes only. It would be far cheaper (and likely as effective) for everyone (please include the Medicare cost to society that is given to each hospital for each resident) to just hire an NP/PA to do my horrible job. I am here for my education, not for patient care to be better or more effective.

Why? Because, as a PA told me this year - he is a "trained doberman". He can sense patterns, he can follow orders, and he can take care of 90% of everything that needs to be evaluated in his neurosurgery patients. The attending needs to handle that last 10%. A good NP/PA can appreciate that last 10% and call the attending at that point. Calling the neurosurgery PGY-2 is kind of a wash. Think about it.

The Mayo Clinic, an established and reputable, shall I say paragon of medical care, relies heavily on both PAs and NPs, because essentially, they do the things that MDs don't want to - non-emergent clinic visits and follow-ups (at least for rad-onc, urology, and other specialties based on my significant experience there). They have great outcomes. They don't measure it against MDs, but they seem to feel strongly enough about it to continue to increase their role.

If people want to say the sky is falling, i.e. MacGyver for the last 5 years, show me a study that shows NP/PA care is worse. If it is, then I'll join the fight. If not, I'll continue to let these people take great care of my patients, even though my salary is at stake. The ideal is low input of resources, and a high output of health outcomes.

Please e-mail me randomized controlled studies of inferiority of NPs/PAs, and I'll start to worry. Otherwise, people's continual cries will be linked to their decreased incomes rather than poor patient outcomes.

-S

 

[megsMS]

You have a good point. However, the problem is this...the PA probably knew less than you did during their "intern" year, or first year out of school. After 10 years of practice, you will probably know more than a PA with 10 years. Or at least the same amount. I am not dissing PAs here as you can read from one of my previous posts, I think they're great. However, it's VERY silly to compare yourself as an intern to a midlevel with 10 years of practice...of course they will have seen things you haven't. But in the future with those experiences under your belt, your medical background from medical school will allow you to know more and understand more than any NP I could ever imagine.

All you have to do is prove that PAs/NPs provide inferior care. Someone willing to do the study? All this complaining is somewhat nonsensical unless someone can prove mid-levels do a poor job.

I don't know how many people here are interns/PGY1s, but I strongly believe that I don't need the training I've had to do my job. Clearly, a PA could do the same or better. Nothing to do with training, purely to do with experience. A PA with 10 years experience is far more valuable to a medical center than me. I'm a so-called good intern (at least prior to starting the year - good letters of rec, graduated from Tulane, top USMLE scores, top 1/3 of my class), yet I can't handle neutropenic fever as well as a PA with 10 years of experience.

The only reason my job exists is for my educational opportunity. I repeat - my residency exists for educational purposes only. It would be far cheaper (and likely as effective) for everyone (please include the Medicare cost to society that is given to each hospital for each resident) to just hire an NP/PA to do my horrible job. I am here for my education, not for patient care to be better or more effective.

Why? Because, as a PA told me this year - he is a "trained doberman". He can sense patterns, he can follow orders, and he can take care of 90% of everything that needs to be evaluated in his neurosurgery patients. The attending needs to handle that last 10%. A good NP/PA can appreciate that last 10% and call the attending at that point. Calling the neurosurgery PGY-2 is kind of a wash. Think about it.

The Mayo Clinic, an established and reputable, shall I say paragon of medical care, relies heavily on both PAs and NPs, because essentially, they do the things that MDs don't want to - non-emergent clinic visits and follow-ups (at least for rad-onc, urology, and other specialties based on my significant experience there). They have great outcomes. They don't measure it against MDs, but they seem to feel strongly enough about it to continue to increase their role.

If people want to say the sky is falling, i.e. MacGyver for the last 5 years, show me a study that shows NP/PA care is worse. If it is, then I'll join the fight. If not, I'll continue to let these people take great care of my patients, even though my salary is at stake. The ideal is low input of resources, and a high output of health outcomes.

Please e-mail me randomized controlled studies of inferiority of NPs/PAs, and I'll start to worry. Otherwise, people's continual cries will be linked to their decreased incomes rather than poor patient outcomes.

-S

 

[Gharfunkle]

This is how I see it. Back in the day, billions of years ago, unicellular eukaryotes began subspecializing and aggregating to form multicellular organisms. Similarly, thousands of years ago, humans instead of being nomadic, began subspecializing and cooperating to build stationary civilizations. Our roles in society are just going to become more and more subspecialized as time goes on, all for the greater good of the organism known as humanity. Therefore, NPs will perform the sub-specialized role of "bread-and-butter" medicine and physicians will handle the more difficult cases. It's like the NP will be the neutrophils/innate immune system, and physicians get to be big bad T (or B) lymphocytes. So we as physicians can choose to get pissed off and behave like an autoimmune disease, attacking our fellow humans who are also here just to do their job, or we can cooperate, work together and understand our roles... and have a healthy, happy, society. I don't know about you, but being a T-lymphocyte sounds like a pretty cool job to me 😀. Yes, some neutrophils will have myeloperoxidase deficiency and yes we do have myelogenous leukemias, but that doesn't mean we should prophylactically kill all neutrophils... right? Ok, it's getting late. I think I should go to sleep now.

 

[inositide]

just give some high dose prednisone for a while.

 

[lateness]

You know, I may have a low view of my patients, but I think the grand majority of patients don't have any idea who anybody is anyway. Most probably don't care as long as they get their percocet. The ones that do care probably are fully capable of reading a nametag or will pester the snot out of everyine that comes in their room to find out who they are. My experience tells me (gross generalization on the way) that most patients see a man come in the room and assume "doctor", they see a woman and think "nurse", they see a hermaphrodite and think "Pat". This is a societal view of the genders that is hard to shake. I think the onus is on the healthcare provider to clearly state who they are when they meet a patient for the first time (or every time if the patient is demented). As for whether a patient wants a "doctor nurse" taking care of them, I don't have an answer for that. My mother-in-law prefers the NP when she goes to the MD office because she thinks the doctor is pompous. We don't often ask patients who they want caring for them anymore. I am willing to bet that a good number of patients would rather have the primary care doctor take care of them when they are admitted to the hospital, but in the age of hospitalists that is no longer the way things are done, so patients are randomized to whoever is taking call for the hospitalist service. So in the end, I think patients have no idea who is taking care of them anyway. This is the future of medicine, and I personally think the greatest threat to the "prestige" of medicine. When patients feel like their doctor has no vested interest in them, then they will have no vested interest in their doctor. Wow that was pretty tangential, but I think I got my point across somewhere in




i agree with you.... but i think a good doctor would be judged by his compassion and connection and understanding with his/her patients, not be some pompous a hole... (just b/c they are a doc )...