"Nurse practitioner specialists"

[vanessh]

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The very concept of a “nurse practitioner specialist” is a joke. It's funny how we have these NP proponents in healthcare saying that NPs are the solution to the primary care shortages in this country when they themselves are pushing for "specialization" within their own field. We have NPs publishing papers where they feel that since they are able to treat "runny noses" and "sore throats" with the same outcomes as physicians it now justifies promoting total independence for their own field. Who is kidding who? They quote that one paper from JAMA so much, it makes you wonder how desperate some quacks can be for gaining prestige.

Don't get me wrong, I have respect for nurses who understand the role of their position in healthcare. I also feel there is a need for midlevels --> but only to a degree. NPs may very well be effective in taking histories and managing basic clinical cases. This relationship is ideal as long as NPs are working under the leadership of physicians. Yet here is the inherent problem - one side isn't ready to recognize their subordinate status. The NP proponents (ie. Mundinger and other nurses with inferiority complexes etc at Columbia) are looking for separate and independent status equivalent to a physician. They are now starting a “DrNP” program so that NPs will be fully independent as "doctors" (nurse-doctors: talk about confusion for the lay person, if anything it highlights the desperate desire of these old nurses for prestige).

Unfortunately, we have many doctors today who are complicit in the game. Many physicians (most notably cardiologists) are making millions in the short term by hiring NPs and placing them in cardiology assembly lines in their private practices – pumping out thallium studies, stress tests..etc. This only indirectly promotes the long term goals of NPs. Once NPs gain full independence in most states, don't be suprised when you will have NPs referring their own patients to DrNP "Cardiologists." There is no loyalty to the physician when it comes to NPs. As hilarious as it sounds it is very possible, unless physicians, residents, and medical students understand the challenges facing healthcare today and take a stand to stop it’s only gonna get more crazy.

Many of my dad’s old patients whom he refers for dermatology consults to a local dermatological practice end up seeing an overly dressed up 58 year old Joan Rivers look-alike NP (who doesn’t mind if the patients accidentally call her doctor and often doesn’t correct the mistake) at the dermatology practice – and the patients my dad refers don’t like it. They prefer seeing the dermatologist at the practice, but the dermatologist is too busy doing the more lucrative procedures. Yet while in the short term it helps him make 1.4 million dollars a year, overtime, patients will get used to the NP and wont see the difference. For them its just another person in the healthcare field with lots of weird initials after their name. The net result is the cheapening of the MD, and the educational background it represents.

Doctors today have successfully shot themselves in the foot. In the pursuit of efficiency and increased income, they have brought in people who are basically getting paid for a form of residency training. Once NPs gain full independence, don’t be surprised if that NP dermatologist leaves that practice and starts her own practice as a dermatological NP with others. The same holds true for all NPs and those seeking “specialization.” If you think I am off base, then please explain the logic behind the DrNP program.

The only approach to stop this pseudo-physician quackery, is for physicians to hire and pursue full relationships with PAs. Despite PAs wanting to get more independence to write prescriptions, etc, they are still under the control of the medical board which will always maintain a certain relationship between the two fields. Nursing is different, they are regulated independently. For them, expanding scope of practice is easy. It will be very hard to stop their expansion once DrNPs start.

I think in the next few years, physicians will realize the long-term goals of these old wacky nurses in their attempts to take over healthcare. Also, one must realize that insurance companies and managed care are playing a huge role in this silent transformation. Just look at Dr. Mundinger (the NP/pHD at Columbia who started the DrNP program there), she has millions of dollars of stock in United Healthcare and is on the board of the company.

In summary: Managed care overburdened physicians. Managed care destroyed the physician patient relationship through paperwork and bureaucracy. Managed care and all its hassles shortened the time for patient visits, and so physicians needed to see more patients in less time. This allowed an entry point for midlevels to enter medicine in larger numbers to help deal with the mess. In the end patients don’t know the value of what it means to be treated by a physician. And nurses want to start being called doctors. Healthcare premiums still go up for patients (averaging $9000/yr), but healthcare still sucks. Insurance companies see double digit profit margin increases per year, and medicare responds to high healthcare by cutting physician reimbursement but increasing pharmaceutical drug company reimbursement.

The end of the golden age of medicine is complete, the start of drive through mcdonalds corporate walmart healthcare is here to stay.

Who do I blame?

I blame physicians for lack of organization, lack of ethics, lack of will, lack of guts for their incompetence in defending the world’s most noble profession. I hope the new generation of docs will change things. Unfortunately, the 1970s to 1990s generations of docs were too busy being millionaires and let managed care make the entry it did. And yes, I know docs with $8-10 million dollar retirement plans, who are now retiring and just don’t seem to care with what may happen to medicine.

 

[deleted6669]

"The only approach to stop this pseudo-physician quackery, is for physicians to hire and pursue full relationships with PAs. Despite PAs wanting to get more independence to write prescriptions, etc, "

appreciate the pa plug...just a little info though....pa's can write for rxs in their own names in every state except ohio and indiana......and the majority of states also allow for pa's to have their own dea registration and prescribing rights as below:

Where Physician Assistants Are Authorized To Prescribe
Jurisdiction Rx
Status Restrictions Controlled Substances
Alabama Rx Formulary
Alaska Rx Sch. III-V
Arizona Rx Sch. II-III limited to 14-day supply with board prescribing certification
(72-hrs. without);

Sch.IV-V not more than 5 times in 6-month period per patient
Arkansas Rx Sch. III-V
California Rx PAs may write "drug orders" which, for the purposes of DEA registration, meet the federal definition of a prescription. Sch. II-V
Colorado Rx Sch. II-V
Connecticut Rx Sch. IV-V; Sch. II-III in hosp, LTC facilities, and some EDs
Delaware Rx Sch. II-V
District of Columbia Rx
Florida Rx Formulary of prohibited drugs
Georgia Rx Formulary Sch. III-V
Guam Rx Sch. III-V
Hawaii Rx Sch. III-V
Idaho Rx Sch. II-V
Illinois Rx Sch. III-V
Indiana
Iowa Rx Sch. III-V; Sch. II (except stimulants and depressants)
Kansas Rx Sch. II-V
Kentucky Rx
Louisiana Rx Sch. III-V
Maine Rx Sch. III-V (Board may approve Sch.II for individual PAs)
Maryland Rx Sch. II-V
Massachusetts Rx Sch. II-V
Michigan Rx Sch. III-V; Sch. II (7-day supply) as discharge meds
Minnesota Rx Formulary Sch. II-V
Mississippi Rx Sch. II-V
Missouri Rx
Montana Rx Sch. II-V (Sch. II limited to 34-day supply)
Nebraska Rx Sch. II-V (Sch. II limited to 72-hr supply)*
Nevada Rx Sch. II-V
New Hampshire Rx Sch. II-V
New Jersey Rx Sch. II-V ( certain conditions apply)**
New Mexico Rx Formulary Sch. II-V
New York Rx Sch. III-V
North Carolina Rx Sch. II-V (Sch. II-III limited to 30-day supply)
North Dakota Rx Sch. III-V
Ohio
Oklahoma Rx Formulary Sch. III-V
Oregon Rx Sch. II-V
Pennsylvania Rx Formulary Sch. III-V. Limited to 30-day supply unless for chronic condition
Rhode Island Rx Sch. II-V
South Carolina Rx Formulary Sch. V
South Dakota Rx Sch. II-V (Sch. II limited to 48-hr supply)
Tennessee Rx Sch. II-V
Texas Rx In specified practice sites Sch. III-V (limited to 30-day supply)
Utah Rx Sch. II-V
Vermont Rx Formulary Sch. II-V
Virginia Rx Sch. III-V
Washington Rx Sch. II-V
West Virginia Rx Formulary Sch. III-V (Sch. III limited to 72-hr supply)
Wisconsin Rx Sch. II-V
Wyoming Rx Sch. II-V

4/11/05

*Sch. II restriction to be repealed 9/05

**Scheduled medication prescriptive authority effective 9/05

DEA Registration
The Drug Enforcement Administration (DEA) has a registration category specifically for physician assistants and other so-called “midlevel practitioners” authorized by state law or regulation to prescribe controlled substances. For more information or to obtain a registration application, contact the DEA Registration Unit at 800/882-9539.

 

[windsurfr]

There is no way that NP's will 'take over' cardiology or other big specialties. The US healthcare system is purely patient driven. Currently they are 'forced' to see midlevels at coumadin clinics, stress tests, etc b/c there is a shortage of cardiologists. Many patients find this acceptable. However, evaluation of acute coronary syndrome and revascularization is a COMPLETELY different topic. No patient in their right mind would let anyone other than a cardiologist do this. Same for other big specialists. Think about your own health or your parents. Would you want them to see an NP for a life threatening condition. It will never happen.

 

[Pose]

But will they not drive the demand of physicians down? Will they not evolve over time to the patient-minded "equivalent" to an MD or DO? Will they not demand higher salaries, more autonomy, and prescribing rights? Do they not WANT all of the above bad enough that they will fight for a short cut until they get it?

I have complete respect for nurses, and PAs, but for me it is quite worrisome for the future demand of physicians, and more importantly the care of the patients that (NP's specifically) are seeking an equivalency to physicians.

I'd really appreciate answers to those questions from an NP and PA, because I'm seeking both sides to this debate. Although I'm not so interested in the "but we aren't looking for short-cuts" or the "we aren't looking to be doctors!" side of things.

 

[lawguil]

But will they not drive the demand of physicians down? Will they not evolve over time to the patient-minded "equivalent" to an MD or DO? Will they not demand higher salaries, more autonomy, and prescribing rights? Do they not WANT all of the above bad enough that they will fight for a short cut until they get it?

I have complete respect for nurses, and PAs, but for me it is quite worrisome for the future demand of physicians, and more importantly the care of the patients that (NP's specifically) are seeking an equivalency to physicians.

I'd really appreciate answers to those questions from an NP and PA, because I'm seeking both sides to this debate. Although I'm not so interested in the "but we aren't looking for short-cuts" or the "we aren't looking to be doctors!" side of things.

Clearly their needs to be awareness campaign about the aspirations of the NP's... With an organized effort, physicians should prevail. Further, if their is a shortage of physicians, it makes sense to develop/create a bridge program for PA's who are trained in the medical model, already have pre-reqs., and were good students capable of medical school to begin with. What better group of people to draw from than the PA community who fall under the medical association umbrella. It might also cause potential students who are considering DrNP to take a second look at PA school which would be shorter, better training, and could offer them the opportunity to someday use the bridge program to become a real physician rather than a pseudo doctor. Just some thoughts. L.

 

[deleted6669]

Clearly their needs to be awareness campaign about the aspirations of the NP's... With an organized effort, physicians should prevail. Further, if their is a shortage of physicians, it makes sense to develop/create a bridge program for PA's who are trained in the medical model, already have pre-reqs., and were good students capable of medical school to begin with. What better group of people to draw from than the PA community who fall under the medical association umbrella. It might also cause potential students who are considering DrNP to take a second look at PA school which would be shorter, better training, and could offer them the opportunity to someday use the bridge program to become a real physician rather than a pseudo doctor. Just some thoughts. L.

I have been talking about the need for a pa to md bridge program for a long time. probably 30% of practicing pa's would do a 2 yr pa to md course. 1 yr of didactic plus 1 yr of clinicals would make a solid pa ready for md boards in my opinion.you would need about 2/3 of 1st yr, 1/3 of second yr and the clinical rotations not done in pa school. it will happen someday. don't know if it will be soon enough to benefit me though.....

 

[FoughtFyr]

I have been talking about the need for a pa to md bridge program for a long time. probably 30% of practicing pa's would do a 2 yr pa to md course. 1 yr of didactic plus 1 yr of clinicals would make a solid pa ready for md boards in my opinion.you would need about 2/3 of 1st yr, 1/3 of second yr and the clinical rotations not done in pa school. it will happen someday. don't know if it will be soon enough to benefit me though.....

I would agree, on the condition that the "bridge" program would only get you to the "M.D." level, that is, residency would still be required. I think that two years (in addition to the two years of PA school) would be sufficent.

- H

 

[deleted6669]

I would agree, on the condition that the "bridge" program would only get you to the "M.D." level, that is, residency would still be required. I think that two years (in addition to the two years of PA school) would be sufficent.

- H

yup-my thoughts exactly. 2 yrs pa to md/do then a normal residency after that.
know anyone who can line that up for me? 🙂

 

[FoughtFyr]

yup-my thoughts exactly. 2 yrs pa to md/do then a normal residency after that.
know anyone who can line that up for me? 🙂

Actually, I don't think it would be that hard to make that fly. You would need to find a school that has both a PA program and a medical college (either MD or DO). I would think that such an institution could certify that the combined coursework of the original PA program and the bridge program together met the AAMC or AACOM requirements. As was pointed out earlier, there shouldn't be any philosophical differerences to raise pedagogic questions (as there would be with NPs).

Interesting question...

- H

 

[hospPA]

Actually, I don't think it would be that hard to make that fly. You would need to find a school that has both a PA program and a medical college (either MD or DO). I would think that such an institution could certify that the combined coursework of the original PA program and the bridge program together met the AAMC or AACOM requirements. As was pointed out earlier, there shouldn't be any philosophical differerences to raise pedagogic questions (as there would be with NPs).

Interesting question...

- H

Let me add that you would have to find a school that has a PA program, a DO/MD program, AND NOT a nursing program. I can't see nursing faculty letting that fly and they seem to have quite a bit of power at most institutions. Just a thought. I use Duke for example, they have all 3. Do you think it would fly there? I think Dr. Stead tried it, didn't he?

Pat

 

[Happy613]

I have been talking about the need for a pa to md bridge program for a long time. probably 30% of practicing pa's would do a 2 yr pa to md course. 1 yr of didactic plus 1 yr of clinicals would make a solid pa ready for md boards in my opinion.you would need about 2/3 of 1st yr, 1/3 of second yr and the clinical rotations not done in pa school. it will happen someday. don't know if it will be soon enough to benefit me though.....

I think this is a great idea. There should be some sort of formal process, including an entrance exam. Not the mcat... obviously making a pa bone up on orgo and physics would be ridiculous; but perhaps a specialized entrance exam specfially for pa's applying to med school? An exam that would test them on thier basic science knowledge from pa school. Such a test would have to be as challenging as the mcats...maybe even a little more. But with solid grades in pa school, good recomendations, and a high score on this proposed exam it would really validate such a transition to the rest of the medical community.

Pa's and md/do's in my experience have worked really well together, if such a path was set up it would prevent any movement (as with np) to independent practice; because it would set up a truly legitimate course of study to become a physician.

🙂

 

[group_theory]

I think this is a great idea. There should be some sort of formal process, including an entrance exam. Not the mcat... obviously making a pa bone up on orgo and physics would be ridiculous;

Why not use MCAT as the entrance test?

I think almost every physician will agree that most material covered on the MCAT has no direct usefullness in practicing medicine. Yet for some reason, every medical school in the United States (and even some Carrib. schools) require the MCAT. The argument that studying orgo and physics is ridiculous because it doesn't relate to practice, but then why require it for med students in the first place? Why create a subgroup of exception? If you exempt PAs, what about NPs wanting to become a doc? or nurses (CNS) with years of experience? what about paramedics?

Basically I'm challenging the premise that "Not the mcat... obviously making a pa bone up on orgo and physics would be ridiculous". Why would the PA not have to bone up on orgo or physics? And why would such exception be limited to PAs?

BTW, I do support a PA-->MD bridge program, but I'm not quite convinced that 2 years would work (perhaps 2.5-3). There must be some missing elements if you only have 1 year of PA school (didactics) and 1 year (didactics) of med school. I wonder how well such bridging program will prepare for USMLE Step 1.

 

[Happy613]

Why not use MCAT as the entrance test?

I think almost every physician will agree that most material covered on the MCAT has no direct usefullness in practicing medicine. Yet for some reason, every medical school in the United States (and even some Carrib. schools) require the MCAT. The argument that studying orgo and physics is ridiculous because it doesn't relate to practice, but then why require it for med students in the first place? Why create a subgroup of exception? If you exempt PAs, what about NPs wanting to become a doc? or nurses (CNS) with years of experience? what about paramedics?

Basically I'm challenging the premise that "Not the mcat... obviously making a pa bone up on orgo and physics would be ridiculous". Why would the PA not have to bone up on orgo or physics? And why would such exception be limited to PAs?

BTW, I do support a PA-->MD bridge program, but I'm not quite convinced that 2 years would work (perhaps 2.5-3). There must be some missing elements if you only have 1 year of PA school (didactics) and 1 year (didactics) of med school. I wonder how well such bridging program will prepare for USMLE Step 1.

I see your point.... maybe the mcat would be a good idea. My point was more that some standard must be created to judge applicants, a standard that would not only be fair but respected by members of the medical community.

 

[zenman]

The net result is the cheapening of the MD, and the educational background it represents.

Perhaps we should also consider "updating" medical education and training so that it meets the needs/wants of patients.

Doctors today have successfully shot themselves in the foot.

Yes, they are partly to blame.

I think in the next few years, physicians will realize the long-term goals of these old wacky nurses in their attempts to take over healthcare.

You seem to be stuck on the phrase "old." Do you realize there are old docs also, some good and some who are way behind the times? Some NPs are in their 20's. Perhaps docs left an opening (need) and nurses saw a chance to jump in, which would not have been a "wacky" move at all.

In summary: Managed care overburdened physicians. Managed care destroyed the physician patient relationship through paperwork and bureaucracy.

Refresh my memory...why did managed care come into being?

 

[FoughtFyr]

Refresh my memory...why did managed care come into being?

I wouldn't go there. In short, managed care came into being through a conflugrenence of events driven neither by physicians nor patients. Public Health experts realized a long time ago that prevention was cheaper than cure. So a system of health promotion through education and lifestyle choices coupled to a health plan was created. Unfortunately, insurance regulations prevented its use. Then ERISA was passed, obstensively to free employers who self-managed there health plans from concerns of liability for medical decisions. This left the "Health Maintainence Organizations" to attempt the "prevention based" health plan. As they came to realize that their members were not willing to forego the Big Macs save the company money, they needed to cut something to keep up profits. What went? The prevention programs. Leaving us with the profit minded monstrousity that is managed care.

- H

 

[fab4fan]

You seem to be stuck on the phrase "old." Do you realize there are old docs also, some good and some who are way behind the times? Some NPs are in their 20's. Perhaps docs left an opening (need) and nurses saw a chance to jump in, which would not have been a "wacky" move at all.

It's not the first time she's been unable to articulate her points without resorting to baseless comments about age/appearance.

 

[adamdowannabe]

The bridge idea is great, but those who think that more then 2 years is needed, you don't give the PA profession enough credit. The prerequisites for PA school are often more extensive then those for medical school, while in first year med students have to study histo, and embryology, the PA students took 2 semesters (sometimes more) of human a&p, Plus, PA school doesn't run in a similar fashion to medical school, while typically med schools have 2 semesters a year, then a summer break (like normal college) PA school runs typically 27 months straight through (a mere two weeks vacation a year), our year of didactic is really three semesters (to a medical schools four) and the rotations are three semesters, (sometimes more) to the MD/DO four semesters........

Plus, a PA would probably have been working for many years before attempting the "bridge", and that is years of learning medicine.

A year of courses, and then some time spent in all the rotations the PA student didn't get to see, should have them able to hit a residency far more proficient then most PGY2's....

And, it would seem benificial to customize the residency to each case, imagine a PA who has been working in family medicine for 10-12 years, is a 3 or 4 year residency really needed as an educational tool? Or would it merely be for the basic thoughts of "every doctor has got to do it, because that's the way it is"

 

[zenman]

I wouldn't go there. In short, managed care came into being through a conflugrenence of events driven neither by physicians nor patients.
- H

DRGs came into being because of rising healthcare cost...which the feds noticed. Part of the contributing factors were (some) physicians and hospitals. Managed care developed to meet the healthcare needs of mainly employees of industries. Then Henry Kaiser came along and developed Kaiser Permanente and the fun began!

 

[FoughtFyr]

DRGs came into being because of rising healthcare cost...which the feds noticed. Part of the contributing factors were (some) physicians and hospitals. Managed care developed to meet the healthcare needs of mainly employees of industries. Then Henry Kaiser came along and developed Kaiser Permanente and the fun began!

Remember that part and parcel of the theory behind managed care was prevention. Without it, the cost savings is never realized. They are supposedly "health maintainence organizations" with the idea that it is far cheaper to keep a healthy worker healthy than it is to cure a sick one. Too bad that real world sociological factors prevented realization of the vision.

DRGs were not related to rising healthcare costs, they were a response to healthcare cost disparities and differences in practice patterns. It is hard to account for these in a federal program. So slam it all into one, non-evidence based, "best guess" by a bureaucrat. Again, not physicians fault or idea (unless the AMA somehow financed the Louisiana Purchase).

- H

 

[deleted6669]

The bridge idea is great, but those who think that more then 2 years is needed, you don't give the PA profession enough credit. The prerequisites for PA school are often more extensive then those for medical school, while in first year med students have to study histo, and embryology, the PA students took 2 semesters (sometimes more) of human a&p, Plus, PA school doesn't run in a similar fashion to medical school, while typically med schools have 2 semesters a year, then a summer break (like normal college) PA school runs typically 27 months straight through (a mere two weeks vacation a year), our year of didactic is really three semesters (to a medical schools four) and the rotations are three semesters, (sometimes more) to the MD/DO four semesters........

Plus, a PA would probably have been working for many years before attempting the "bridge", and that is years of learning medicine.

A year of courses, and then some time spent in all the rotations the PA student didn't get to see, should have them able to hit a residency far more proficient then most PGY2's....

And, it would seem benificial to customize the residency to each case, imagine a PA who has been working in family medicine for 10-12 years, is a 3 or 4 year residency really needed as an educational tool? Or would it merely be for the basic thoughts of "every doctor has got to do it, because that's the way it is"

I think if they ever bring back the accelerated residencies in fp that pa/md's would be prime candidates. the ways these programs worked was the ms4 yr was done as the pgy1 yr so an applicant did 3 yrs of medschool and a 3 yr residency. with a pa bridge candidate they could do 1 yr classroom and a 3 yr residency for a 4yr md/fp cert. this would be the best of both worlds but I don't see it happening because:
a: the accelerated programs were canceled in spite of residents doing well because the american board of family medicine didn't like the stigma of the "shortest path to board certification specialty"
b. schools will never give pa's credit for work done as a pa even if it entails working as a solo pcp at a distant site with minimal md oversight

I think there probably will be a bridge program in the future but I think it will likely be 3 yrs( ms1, ms2, ms4) and require a full residency after completion.

 

[zenman]

Remember that part and parcel of the theory behind managed care was prevention. Without it, the cost savings is never realized. They are supposedly "health maintainence organizations" with the idea that it is far cheaper to keep a healthy worker healthy than it is to cure a sick one. Too bad that real world sociological factors prevented realization of the vision.

Agree with you there, partly.

DRGs were not related to rising healthcare costs, they were a response to healthcare cost disparities and differences in practice patterns. It is hard to account for these in a federal program. So slam it all into one, non-evidence based, "best guess" by a bureaucrat. Again, not physicians fault or idea (unless the AMA somehow financed the Louisiana Purchase).
- H

"Rapid escalation in health care costs and in medical spending has resulted in significant changes in the health care system. Since the 1950’s the health care industry has experienced expansion in volume, intensity, dollars, and personnel. These extensive changes had a tremendous effect on patients and on all who reimbursed or paid for health care. One of the payers that was affected by increasing health care costs was the federal government and consequently, federal legislation was enacted (Grohar-Murray & DiCroce, 1997). In 1983 billing categories and the prospective payment system were established. The first diagnostic related groups (DRG) were defined by the Social Security Amendments of 1983, Law HR-1900 (PL 98-21), Prospective Payment for Medicare Inpatient Hospital Services (Gerchufsky, 1996).

Diagnostic related groups (DRG) are a system of categorizing patients based on the primary and secondary diagnoses, primary and secondary procedures, age, and length of stay. The categories established a uniform cost for each category. DRGs set a maximum amount that would be paid for the care of Medicare patients. Hospitals and health care providers were given a real incentive to keep health care costs down since they would experience a profit only if their costs are less than the amount indicated by the DRG category (Grohar-Murray & DiCroce, 1997)." www.pittstate.edu/artsc/diagnosproced.htm

I remember when hospitals kept patients way too long and some docs had a hand in it also. When drgs hit, hundreds of hospitals closed and nursing staff ratios went to hell as well as a lot of other fringe benefits. There was big time belt-tightening. And my 1 year working in an HMO was 11 months too long!

 

[pushinepi2]

I think if they ever bring back the accelerated residencies in fp that pa/md's would be prime candidates. the ways these programs worked was the ms4 yr was done as the pgy1 yr so an applicant did 3 yrs of medschool and a 3 yr residency. with a pa bridge candidate they could do 1 yr classroom and a 3 yr residency for a 4yr md/fp cert. this would be the best of both worlds but I don't see it happening because:
a: the accelerated programs were canceled in spite of residents doing well because the american board of family medicine didn't like the stigma of the "shortest path to board certification specialty"
b. schools will never give pa's credit for work done as a pa even if it entails working as a solo pcp at a distant site with minimal md oversight

I think there probably will be a bridge program in the future but I think it will likely be 3 yrs( ms1, ms2, ms4) and require a full residency after completion.

Makes sense.

Where did SDN find this EMEDPA guy ? A wizened emergency medicine practitioner who goes to great lengths to articulate cogent / relevant / insightful viewpoints on virtually everything. Seriously, though, its always a pleasure to contribute to forums on which you are active.

I believe this PA to MD theme has surfaced in prior discussions. Since MD and DO educational pathways are standardized, any bridge would have to meet the requirements for both professions. USMLE/COMLEX I scores are required for ERAS and I cannot imagine that pre-requisite being dropped or otherwise altered. Is it possible to prepare for COMLEX I in a year ? Probably so. The difficulty revolves around the fact that the Step I exams are largely theoretical versus clinical in focus and scope. Our school has both a PA and a DO program which often shares faculty. I'm not familiar with the PA coursework per se, but I know that it is condensed into high yield sections. Surely a pathway must exist that would capitalize on the PA's preparation for clinical practice and yet ensure transmission of the "less practical" step one facts.... What about a DrPA / DrPAS program ?!?!?!?! I can hear the rumblings of yet another, 'independent practice' discussion in the making...

 

[deleted6669]

well sonny you are in big trouble now....as soon as I get this hip prosthesis thing all squared away I am going to hunt you down and beat you with my cane!
it's not like I'm a grandpa yet or something.....🙂

 

[Docgeorge]

well sonny you are in big trouble now....as soon as I get this hip prosthesis thing all squared away I am going to hunt you down and beat you with my cane!
it's not like I'm a grandpa yet or something.....🙂

Yikes! I wish your orthopod a very boring day in surgery when you're on the table.

 

[DasN]

I have to say something...
I didnt bother to read most of the cr@p on this board but to all of the NP's and whatever else you want to call yourself. Your not doctors. unless you finish med school you never will be. Why do you feel the need to make pretend? This move for greater responsibility and autonomy is Stupid... especially for you guys. You have a sweet deal now good cash no big educational loans little training time and the most important a nice sheild by a physician. Why f that up? More autonomy = lawsuits (by the way you guys would get torn to shreads)+ overhead + no physician would hire you because you would be a liability( will find someone to take your old spot for half the money) Havent any of you thought of this kind of stuff yet or are you so preoccupied by having someone calling you doctor nurse ( or whatever) that you forgot the sweet deal you got going now. If I were you I wouldnt F that up.

 

[Smittyballz]

I have to say something...
I didnt bother to read most of the cr@p on this board but to all of the NP's and whatever else you want to call yourself. Your not doctors. unless you finish med school you never will be. Why do you feel the need to make pretend? This move for greater responsibility and autonomy is Stupid... especially for you guys. You have a sweet deal now good cash no big educational loans little training time and the most important a nice sheild by a physician. Why f that up? More autonomy = lawsuits (by the way you guys would get torn to shreads)+ overhead + no physician would hire you because you would be a liability( will find someone to take your old spot for half the money) Havent any of you thought of this kind of stuff yet or are you so preoccupied by having someone calling you doctor nurse ( or whatever) that you forgot the sweet deal you got going now. If I were you I wouldnt F that up.

Well its quite clear by what you wrote about doctors that you are not one and dont want to become one. Right... I mean look at all the negatives.....THESE ARGUMENTS ARE RIDICULOUS THE BOTTOM LINE OF ALL OF THIS CONTROVERSY SHOULD BE ABOUT THE PATIENTS AND HOW GOOD OF CARE THEY GET...NOTHING ELSE...NOTHING NADA..IF EVERYONE WOULD STOP BEING SO VAIN AND PUT YOUR EGOS AWAY. I DONT CARE IF THEY CALL ME AS#HOLE or MR PRESIDENT WHEN I ENTER THE ROOM TO SEE A PATIENT AS LONG AS I CAN HELP THEM WITH THE BEST OF MY KNOWLEDGE TO BECOME BETTER....DR NP OR MD OR DO OR DICKHEAD OR LOSER THEY DONT MATTER UNLESS YOU CAN BE THE BEST AT WHAT YOU CAN BE. EVERYONE IS MISSING THE POINT HERE. THERE ARE REALLY GOOD NP'S AND REALLY GOOD MD'S.. I BET SOME NP'S ARE BETTER THAN MD'S. MD'S AND DO'S MEDICAL TRAINING IS MORE INTENSE AND LONGER SO THEY SHOULD HAVE MORE KNOWLEDGE. LOOK AT IT FROM THE PATIENTS STANDPOINT THE ONLY ONE THAT MATTERS. IF YOU BEING A BUM ON THE STREETS CURES SOMEONE OF A DISEASE THEY HAD DO U THINK IT MATTERS WHAT THEIR QUALIFICATIONS ARE...PLEASE...GET YOUR HEADS OUT OF YOUR BUTTS AND KNOW THAT IT IS ALL ABOUT BEING THE BEST THAT YOU CAN BE, NO MATTER WHAT YOUR TITLE. I HOPE THAT CAPS HELPED GET MY POINT ACCROSS. 🙂

 

[DasN]

"Well its quite clear by what you wrote about doctors that you are not one and dont want to become one. "

What ARE YOU TALKING ABOUT? ARE YOU ******ED?
Listen Pt care is understood and unless you are questioning yourself about you career move, it shouldn’t be brought up. I was merely trying to provide some realistic points that should be considered. If you want me to start speaking in terms like some of my physician colleagues about you guys I will. “Everybody knows Nurses are only good for one thing, sucking D. That goes for the male nurses too, because for a guy to have that job he’s gotta be playing for the other team"

 

[DasN]

My bad Smittybalz you are ******ed! your still in college and have no idea of wha anyone on this board is talking about. Please keep to yourself.

 

[DasN]

Oh by the way if your whole Patient care spiel is part of you med school app. id drop it, everyone takes that angle its old and tired.

 

[Smittyballz]

"Well its quite clear by what you wrote about doctors that you are not one and dont want to become one. "

What ARE YOU TALKING ABOUT? ARE YOU ******ED?
Listen Pt care is understood and unless you are questioning yourself about you career move, it shouldn’t be brought up. I was merely trying to provide some realistic points that should be considered. If you want me to start speaking in terms like some of my physician colleagues about you guys I will. “Everybody knows Nurses are only good for one thing, sucking D. That goes for the male nurses too, because for a guy to have that job he’s gotta be playing for the other team"

It is quite clear your ego is ahead of anything else. It is also quite clear that doctors like yourself and your colleagues give other doctors a bad name. You are the one's who care more about status than helping others. Instead of posting your quite negative evaluation of doctors in which you say you are one go and find out how you become better at what you do. Is there anyone out there that wants to have a doctor who calls male nurses homosexuals as theirs. OVBIOIUSLY NOT and I bet you he or she does not tell the patients the way he feels. ITS ALL ABOUT THE EGO.. FOCUS ON THE PATIENTS CARE AND NOT YOUR STATUS. NURSES WILL ALWAYS BE NURSES AND DOCTORS WILL ALWAYS BE DOCTORS, BUT IT STILL REMAINS TO BE SEEN WHO GIVES THE BEST CARE. BY THE WAY IM GOING TO MED SCHOOL NOT NURSING SO... IM GONNA BAD DOCTORS LIKE YOU A GOOD NAME. AND IF YOUR COLLEAGUES TRULY FEEL THE WAY THEY DO ABOUT NURSES HAVE THEM BE A REAL MAN AND SPEAK UP AND TELL THEM THAT...THE ONES THEY WORK WITH...LET ME KNOW HOW THAT WORKS OUT... 🙂

 

[zenman]

I have to say something...
I didnt bother to read most of the cr@p on this board but to all of the NP's and whatever else you want to call yourself. Your not doctors. unless you finish med school you never will be. Why do you feel the need to make pretend? This move for greater responsibility and autonomy is Stupid... especially for you guys.

I just made the decision to go to NP school after 30 years in nursing. I have no intentions of being a physician. My reason for going back to school? I'm sick of most...and I mean most physicians not being able to really look at a patient and comprehend the whole picture. Maybe it's the training, focusing on an outdated reductionist approach or maybe it's reimbursement issues or whatever, but I want to make more of a difference in the patients I see. Someone on this board once stated that NPs would be consulting everyone in th book. Well physicians are doing that also. I just took out some sutures that were almost 30 days old beause all the 3-4 docs on the case kept passing the buck to another doc. Perhaps a course in decision-making would be good.

You have a sweet deal now good cash no big educational loans little training time and the most important a nice sheild by a physician. Why f that up? More autonomy = lawsuits (by the way you guys would get torn to shreads)+ overhead + no physician would hire you because you would be a liability( will find someone to take your old spot for half the money) Havent any of you thought of this kind of stuff yet or are you so preoccupied by having someone calling you doctor nurse ( or whatever) that you forgot the sweet deal you got going now. If I were you I wouldnt F that up.

Nurses carry malpractice because we get sued also. MDs are not much of a shield as they try to blame someone else. Wanna hear about my past work consulting for malpractice attorneys?

 

[zenman]

"Well its quite clear by what you wrote about doctors that you are not one and dont want to become one. "

What ARE YOU TALKING ABOUT? ARE YOU ******ED?
Listen Pt care is understood and unless you are questioning yourself about you career move, it shouldn’t be brought up. I was merely trying to provide some realistic points that should be considered. If you want me to start speaking in terms like some of my physician colleagues about you guys I will. “Everybody knows Nurses are only good for one thing, sucking D. That goes for the male nurses too, because for a guy to have that job he’s gotta be playing for the other team"

That's funny! Maybe I should have been a welder and work with the guys. Instead I work with a bunch of women in a high stress field and you won't believe the great "opportunities" I've had through out the years helping with that stress and really getting "close" to the girls. All of course before I got married. So do you spend all your time with the boys?

 

[zenman]

IM GONNA BAD DOCTORS LIKE YOU A GOOD NAME. AND IF YOUR COLLEAGUES TRULY FEEL THE WAY THEY DO ABOUT NURSES HAVE THEM BE A REAL MAN AND SPEAK UP AND TELL THEM THAT...THE ONES THEY WORK WITH...LET ME KNOW HOW THAT WORKS OUT... 🙂

I agree with you.

Not many doctors have got on my bad side. I'm amazing what a 6'3" 210 pound frame does for your confidence...plus all that military and martial art experience. Anyone want to see my "heal'n or kill'n side? Wanna come sas me? I'll "re-orient" you to reality...after I rip off your head and cr@p in your neck! I'm really a nice guy 😀

 

[pushinepi2]

....Nurses carry malpractice because we get sued also. MDs are not much of a shield as they try to blame someone else. Wanna hear about my past work consulting for malpractice attorneys?

Please. Comments like this one are sure to endear you to your physician colleagues. Until NPs must fork out 50-150K per year and shoulder the ultimate responsibility for patient care, then I will have little sympathy for them. Also, I have no doubt you're capable of doing incredibly wonderful consulting work. Unfortunately, its hard to practice medicine RETROspectively. Bad outcomes are ALWAYS easy to find. Additionally, if bad outcomes were to be used as the measuring stick for a person's competence, then there'd be a lot of NPs as well as MDs on the chopping block.

Not many doctors have got on my bad side. I'm amazing what a 6'3" 210 pound frame does for your confidence...plus all that military and martial art experience. Anyone want to see my "heal'n or kill'n side? Wanna come sas me? I'll "re-orient" you to reality...after I rip off your head and cr@p in your neck!

Finally, with regard to all of the martial art experience... I thought the rightly centered man/woman's confidence comes from an internal source. It usually does not result from threatening other people into submission with your 6'10' 200+ frame. That type of talk does little to impress anyone, regardless of your many years spent dedicated to the exploration of martial arts.

Man, this thread has de-volved.

 

[zenman]

Please. Comments like this one are sure to endear you to your physician colleagues.

I believe in frank and even brutal disclosure if need be(which in healthcare is sometimes the only way to get people to do anything) in order for change. It's like a comparison between analysis and brief psychotherapy.

Finally, with regard to all of the martial art experience... I thought the rightly centered man/woman's confidence comes from an internal source. It usually does not result from threatening other people into submission with your 6'10' 200+ frame. That type of talk does little to impress anyone, regardless of your many years spent dedicated to the exploration of martial arts.

I was trying to stoop to a low level in order for another poster to understand. Sorry, my tongue-in-cheek humor didn't come through. You're right; confidence does come from an internal locus of control but you know who can't understand real talk.

 

[niko327]

"Well its quite clear by what you wrote about doctors that you are not one and dont want to become one. "

What ARE YOU TALKING ABOUT? ARE YOU ******ED?
Listen Pt care is understood and unless you are questioning yourself about you career move, it shouldn’t be brought up. I was merely trying to provide some realistic points that should be considered. If you want me to start speaking in terms like some of my physician colleagues about you guys I will. “Everybody knows Nurses are only good for one thing, sucking D. That goes for the male nurses too, because for a guy to have that job he’s gotta be playing for the other team"

What's wrong....? Did some big bad nurse slap you around the parking lot or something? You sound like an imbecile. Oh by the way say hello to your "physician colleagues" and have a glass of silly punch when you get back to fantasy land you window licker.

 

[zenman]

What's wrong....? Did some big bad nurse slap you around the parking lot or something? You sound like an imbecile. Oh by the way say hello to your "physician colleagues" and have a glass of silly punch when you get back to fantasy land you window licker.

Niko, I'm not from NY. What's a window licker? 😕

 

[niko327]

Niko, I'm not from NY. What's a window licker? 😕

Actually I feel bad about using the term window licker. A window licker is a person who rides the little bus to school, usually with face and tongue planted firmly against the window glass, hence window licker. It was really uncalled for, and insulting to the developmentally disabled. 🙁

 

[awdc]

The bridge idea is great, but those who think that more then 2 years is needed, you don't give the PA profession enough credit. The prerequisites for PA school are often more extensive then those for medical school, while in first year med students have to study histo, and embryology, the PA students took 2 semesters (sometimes more) of human a&p, Plus, PA school doesn't run in a similar fashion to medical school, while typically med schools have 2 semesters a year, then a summer break (like normal college) PA school runs typically 27 months straight through (a mere two weeks vacation a year), our year of didactic is really three semesters (to a medical schools four) and the rotations are three semesters, (sometimes more) to the MD/DO four semesters........

Plus, a PA would probably have been working for many years before attempting the "bridge", and that is years of learning medicine.

A year of courses, and then some time spent in all the rotations the PA student didn't get to see, should have them able to hit a residency far more proficient then most PGY2's....

And, it would seem benificial to customize the residency to each case, imagine a PA who has been working in family medicine for 10-12 years, is a 3 or 4 year residency really needed as an educational tool? Or would it merely be for the basic thoughts of "every doctor has got to do it, because that's the way it is"

Actually, a med school clinical year is pretty much year-round (about four weeks vacation per year) whether they're measured in quarters or semesters or whatever else is out there. Third year starts in July and goes on until June of next year and fourth year begins in July again.

I'm not gonna buy the "we had A&P in undergrad" argument or that your basic sci year was 3 semesters instead of two. Even DC's, PT's, DPM's who've done a couple semesters of anatomy/histo have to sit for those classes. Those with Master's and PhD's in a particular field aren't so lucky either. If there was a bridge that included one year basic sci, just be glad you don't have to repeat the whole thing. The whole point is standardization. And more likely than not, a PA who's been out in practice for ten years is gonna have a hard time with the USMLE Step I without some "re-education." Not to mention that even basic sciences have advanced (I mean, who would have thought genomics or HIV would be such big players twenty years ago?). Going through some of these courses ain't gonna kill you, if anything it'll be a good review and you'll probably realize you've forgotten more than you thought... in which case, you'll probably be glad that it wasn't shorter.

With that said, I also agree that there should be PA-to-MD bridge programs. Two years sounds good. A year of emphasizing on more of the depth and breadth of basic sci that wasn't in PA school. Then maybe half a year of cores and and the rest electives. Since the AAMC is calling for more physicians by the year 2015, the time is ripe for such a program.

The LCME and ARC-PA can just spell out the requirements for such a bridge, but more likely than not, the NP programs would not meet them since they operate on a different model/curriculum. The nursing organizations seem to want to do their own thing anyways. As far as a standardized test is concerned, not sure what I would do about that. Maybe MCAT would have to suffice for now.

So anyone know how to make something like this fly?

 

[DasN]

well I think I just figured out how all of you really think.. All I had to do was push a couple of buttons and look at the response.....
by the way I have a ton of respect for nurses ( was raised by one) just checking the grace of the next generation.. was in question before but now you all have made it clear

 

[Smittyballz]

well I think I just figured out how all of you really think.. All I had to do was push a couple of buttons and look at the response.....
by the way I have a ton of respect for nurses ( was raised by one) just checking the grace of the next generation.. was in question before but now you all have made it clear

Yeah we all busts our butts to be the best we can possibly be no matter what the title. It's all about the patients, and how much support we can give them. You must be pretty excited about the next generation because they seem to be raising the bar....

 

[niko327]

well I think I just figured out how all of you really think.. All I had to do was push a couple of buttons and look at the response.....
by the way I have a ton of respect for nurses ( was raised by one) just checking the grace of the next generation.. was in question before but now you all have made it clear

Do you really think anyone would give a flying crap about what you think of "the next generation" let alone failing YOUR little test. Your posts are obviously self-centric, I'm probably just wasting electricity since you'll have no conception of what anyone is talking about. You should apologize to your mama (or papa), and not just about the nurse sucking D comment. Keep in touch with yourself.

 

[painslayer]

First of all, thanks for the "quack." Although I am an NP, I have to agree with 99% of your postings. It is a joke. I just finished the “training” at one of the nursing schools. This was not much of a training, to be honest. 100% on-line. Done by people (nurse) who have little understanding of medicine (or, for that matter, a common sense). I guess, I could treat a “runny nose,” not much else.
You captured the situation correctly. Market forces favor NPs, now at least. As our malpractice premium begin to skyrocket, you should expect NPs to start leaving medicine just as MDs are doing already.
Yep, we want independence from you, guy and gals. And we are getting it. The situation with the derm “overdressed” NP is not typical. Most patients like NPs. For most “routine” problems we are probably as good as you are (after lots of additional post-graduate training, of course!). Having worked in health care for 20+ years, I am more scared of some physicians (can’t speak English, drink, demented, etc.) that I “practicing” IM in hospitals and nursing homes that I am of some aging red-faced heavy-bottomed “ex-nurse” who is taking out a mole or is Rx-ing a laxative to a nursing home resident. At least she (the NP) knows her limitations. The docs (I mean the old-timers) still think they are gods.
The practice of medicine by lay people (NPs etc). This may look scary in the beginning. I think with time, our training will improve and we will become just yet another titled doctor (in addition to OD, DO, DPM, PsyD) in the maze of the contemporary healthcare. Remember, 20 years ago they were saying the same (“quacks,” “not real doctors,” etc.) about DOs. Look where they are now!
Eventually, the market will correct itself. We are all going to lose. MBAs and HMOs are going to win. Infighting among providers will only hasten our demise.
Can’t we all get along …?

 

[painslayer]

I see your point.... maybe the mcat would be a good idea. My point was more that some standard must be created to judge applicants, a standard that would not only be fair but respected by members of the medical community.

Just take the MCAT and go to medschool! If you can't get into an American one, travel to Mexico or the Caribbean.
Or, you can start of DPA (doctor of physician associates) program. You will still get the title.

 

[lloydchristmas]

First of all, thanks for the "quack." Although I am an NP, I have to agree with 99% of your postings. It is a joke. I just finished the “training” at one of the nursing schools. This was not much of a training, to be honest. 100% on-line. Done by people (nurse) who have little understanding of medicine (or, for that matter, a common sense). I guess, I could treat a “runny nose,” not much else.

I too am a new NP and couldn't agree more. I really don't give a f*ck though as I make well over six figs and have no call, no weekends, and no holidays. I'm in an all cash clinic to avoid those trolls you speak of (HMOs, govt).

 

[fuegorama]

Remember, 20 years ago they were saying the same (“quacks,” “not real doctors,” etc.) about DOs. Look where they are now!

Yeah look at 'em. They took the MCAT interviewed, competed, got accepted, suffered through four years of school, took three sets of boards + now a CS exam, competed for spots again, then did an internship, then a residency. Gosh they really weasled in there!
I dug on most of your post, but please don't demean the title of DO by pushing it as "another provider".
Sorry, I'm sitting here sweating bullets over the first step of the USMLE and I just couldn't let it go.

Fuegorama RN/MSII

 

[2ndyear]

I've been watching this thread for a while. It's cool that there are NP's on here that are willing to contribute. My question to them would be, do you think that when NP's have mandatory doctorates and full independent practice rights they will take over primary care? I think primary care is in a mess right now MDwise, we can't fill up our residencies, pay is down and getting worse, and people still need a primary care provider.

I do, however, have to state that physicians are not taught to be short on patient care. Med schools look for caring, compassionate people to mold into physicians. I guess we pick up bad habits along the way? I think that the pure time to pay ratio dictates the interaction and unfortunately this won't change with an NP or MD.

 

[zenman]

I've been watching this thread for a while. It's cool that there are NP's on here that are willing to contribute. My question to them would be, do you think that when NP's have mandatory doctorates and full independent practice rights they will take over primary care? I think primary care is in a mess right now MDwise, we can't fill up our residencies, pay is down and getting worse, and people still need a primary care provider.

I don't know if they will take over primary care, as NDs, acupuncturists, etc. have not yet done so. But, when one profession sees an opening, they will probably try to fill it.

I do, however, have to state that physicians are not taught to be short on patient care. Med schools look for caring, compassionate people to mold into physicians. I guess we pick up bad habits along the way? I think that the pure time to pay ratio dictates the interaction and unfortunately this won't change with an NP or MD.

This, I think is true. Nurses, NPs, MDs taught one way yet must change to adapt to the screwed up market place.

 

[shaken]

I stumbled over this thread while doing a search on these "nurse-practitioner" people (doctor wannabes is more like it). I was horrified and shocked to find that the doctor I had paid (out of pocket) to see was palming my care off to a nurse practitioner without my permission. The reason I went to see him (head of a gynecological oncology department in a very prestigious cancer care center affiliated with a very prestigious teaching hospital in NYC) was because I was sick and tired of the half-assed, crappy, thoughtless care I was getting from the in-network doctors (who usually hand off everything to their nurse-practitioners or physician's assistants - one of whom ended up being the doctor's niece who needed a summer job and wasn't even licensed to do ANYTHING, much less take blood or interpret ultrasounds). I was willing to pay hundreds and hundreds of dollars to see this guy, who was recommended for his brilliance AND his compassion and care, and then I found out some chick with a power complex was taking everything over, had access to my files which held highly, highly confidential personal information, and I hadn't even been asked for permission.

This was not for cramps, mind you, this is a gynecological ONCOLOGY department. One ought to be able to expect that only doctors will be interpreting your biopsies and ultrasounds at that point in your health care.

I'm so shaken I don't want to go back. I don't know who to trust, or what my rights are, or if it's even worth following through. I feel violated and betrayed, and totally ripped off. I'd rather take my chances and hope for the best than go back and be treated like I'm not even a human being or as if my wishes don't matter and I'm just an opportunity for some doctor wannabe to promote herself.

I just thought you might like some real person input on this. Some of us WANT to see doctors and don't want to place our care in the hands of someone we don't trust or know or who hasn't bothered to invest the time or money it takes to be a real doctor. The commitment to education and training is as important to the training and education itself. If these nurses want to play doctor, they can damned well put in the time, money and effort and get real degrees, otherwise all they're doing is jeopardizing people's health for the sake of their own egos.

Also, if you're going to stick my file on some second-rate caregiver's desk, you damned well better not charge me doctor's fees. That's just fraud and theft.

 

[hospitalistpac]

I stumbled over this thread while doing a search on these "nurse-practitioner" people (doctor wannabes is more like it). I was horrified and shocked to find that the doctor I had paid (out of pocket) to see was palming my care off to a nurse practitioner without my permission. The reason I went to see him (head of a gynecological oncology department in a very prestigious cancer care center affiliated with a very prestigious teaching hospital in NYC) was because I was sick and tired of the half-assed, crappy, thoughtless care I was getting from the in-network doctors (who usually hand off everything to their nurse-practitioners or physician's assistants - one of whom ended up being the doctor's niece who needed a summer job and wasn't even licensed to do ANYTHING, much less take blood or interpret ultrasounds). I was willing to pay hundreds and hundreds of dollars to see this guy, who was recommended for his brilliance AND his compassion and care, and then I found out some chick with a power complex was taking everything over, had access to my files which held highly, highly confidential personal information, and I hadn't even been asked for permission.

This was not for cramps, mind you, this is a gynecological ONCOLOGY department. One ought to be able to expect that only doctors will be interpreting your biopsies and ultrasounds at that point in your health care.

I'm so shaken I don't want to go back. I don't know who to trust, or what my rights are, or if it's even worth following through. I feel violated and betrayed, and totally ripped off. I'd rather take my chances and hope for the best than go back and be treated like I'm not even a human being or as if my wishes don't matter and I'm just an opportunity for some doctor wannabe to promote herself.

I just thought you might like some real person input on this. Some of us WANT to see doctors and don't want to place our care in the hands of someone we don't trust or know or who hasn't bothered to invest the time or money it takes to be a real doctor. The commitment to education and training is as important to the training and education itself. If these nurses want to play doctor, they can damned well put in the time, money and effort and get real degrees, otherwise all they're doing is jeopardizing people's health for the sake of their own egos.

Also, if you're going to stick my file on some second-rate caregiver's desk, you damned well better not charge me doctor's fees. That's just fraud and theft.

Geeze, I'm sorry for you. It sounds like you've been going through alot. I'm not sure what happened to you at this doctor's office. Are you saying you made an appt with a specialist and you did not get to see the Doctor at all? Or are did you see the doctor and also the NP?
As for an unlicensed individual (your Dr's niece) calling themself an NP or PA is illegal. NPs and PAs must sit for boards and maintain licensure after they complete their education.
It seems like you've had some bad run-ins. You do have the right to be seen by a Doctor if that is waht you want. If a pt doesn't want to be seen by me, they will be seen by a Doctor or another provider. When you call for your nest appt just politely tell the office staff that you are requesting an appt with Dr. So and So and prefer not to be seen by anyone else.
But for the record NPs are not wannabe Doctors with ego trips. They are RNs who go on for further medical education who work collaboratively with Doctors to provide excellent pt care!