NYT Today: "Nurses are Not Doctors"

[postbacpremed87]

I would posit that most of us came to medicine because we actually care about people. This would be a tough pill to swallow. Which is why NP's have us by the balls.

I mean we will eventually win the debate, but it will take some time. It's the tried and true message of life - EVENTUALLY - those who put in the work and do what is right, shine through. It's a matter of morality really. Why would you not want to educate yourself to the fullest extent in the name of saving/treating your patients? There are no short-cuts in medicine. We aren't taking short cuts. They are and by default we already know the outcome of this. We have to go through the winter first though.

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[PL198]

With regards to the nursing specific chem, why do pre-meds take the normal chem class as everyone else, yet nurses have their own watered down one, which is literally like high school chemistry? I mean if they can practice on their own, I don't see why the requirements would be less. Health care is a right though, so we should all make 50k and hopefully some day an RN can fix the cancer I develop in 50 years.

 

[PL198]

I mean we will eventually win the debate, but it will take some time. It's the tried and true message of life - EVENTUALLY - those who put in the work and do what is right, shine through. It's a matter of morality really. Why would you not want to educate yourself to the fullest extent in the name of saving/treating your patients? There are no short-cuts in medicine. We aren't taking short cuts. They are and by default we already know the outcome of this. We have to go through the winter first though.

I'm not so sure that's the case anymore. Your statement hinges upon the idea that people are rational, or at least will make a rational decision after a bad experience with an irrational one. IMO we are getting further and further away from this and it's only going to get worse for docs. Somehow it'll end up being the physicians fault. It's America. There always has to be a scapegoat, and 9/10 it's going to be the group making the most money.

 

[touchpause13]

With regards to the nursing specific chem, why do pre-meds take the normal chem class as everyone else, yet nurses have their own watered down one, which is literally like high school chemistry? I mean if they can practice on their own, I don't see why the requirements would be less.

Yup we had this at my school too. They also had to do a watered down combined biochem/ochem class. No physics at all.

 

[FiveOClock]

I'm afraid cost-saving will win out over patient-care. Not to start an Obamacare flame war, but the ACA certainly put in place measures that give credence to that concern. MDs are expensive, NPs are less.

 

[tantacles]

I've been taking my time figuring out my opinion about this whole thing, but largely, I've come to agree with this mindset: If nurses wish to practice independently, I absolutely support it. I absolutely support it provided that they are willing to take the USMLE Step II and Step III as an assessment of their clinical knowledge.

I understand that many nurse practitioners have years of clinical experience managing patients and often are incredibly helpful with diagnosis. If they wish to put that into practice independently and be seen as equals, they should be held to similar standards for licensure.

 

[mmmcdowe]

Meh, I'd rather they take the family medicine boards or whatever specialty they are taking on. Step1/2/3/ doesn't seem to really be the issue unless we're also going to let medical students start practicing.

 

[tantacles]

Meh, I'd rather they take the family medicine boards or whatever specialty they are taking on. Step1/2/3/ doesn't seem to really be the issue unless we're also going to let medical students start practicing.

That works too. Similar practice, similar licensure.

 

[NickNaylor]

I've been taking my time figuring out my opinion about this whole thing, but largely, I've come to agree with this mindset: If nurses wish to practice independently, I absolutely support it. I absolutely support it provided that they are willing to take the USMLE Step II and Step III as an assessment of their clinical knowledge.

I understand that many nurse practitioners have years of clinical experience managing patients and often are incredibly helpful with diagnosis. If they wish to put that into practice independently and be seen as equals, they should be held to similar standards for licensure.

I think most reasonable people would agree with you. Unfortunately, that doesn't seem to be the standard that's developing.

 

[PL198]

Actually it's an interesting point. If an NP can pass all 3 steps, can't they also make the case that they deserve to be a doctor?

If a monkey can pass all three steps they deserve to be a doctor. Good luck finding one that will though.

 

[AnonymousD.O.]

I understand your point but, unfortunately, systemically it's rarely this clear. What happens is that NP's usually work under closer supervision as new graduates and are trained to work very collaboratively such that they consult more, they ask their supervisor when in doubt, they work slower with fewer patients, and most of the more obviously complicated patients are filtered from their work schedules. They are constantly aware that they lack what we have and therefore are typically very motivated to learn academic stuff as they go. Very much like us as residents. Only working like proper English gentry and getting paid twice as much.

This is what obfuscates comparisons. Their like parasitic species living in our corpus. It's impossible to isolate them from their host for proper evaluation to determine fitness for independence.



By way of me matching psychiatry and segregating by chief complaint to our service. I suppose I should I wait 2 months for that to be accurate. My apologies, M1.

I see your point. But by granting them autonomy with this law they are pretty much on their own. Sure they work along with physicians very stringently once they start out, but does this replace a physicians residen

I wounder what would happen if we start a database of something like this. I had a middle age female patient present to the ED for cough x 1 month and hemoptysis x 1 week. Saw NP in her PCP clinic who prescribed a Z-pak with no imaging. The problem? History of breast CA with brain mets. Imaging showed extensive lung mets now. Patient expired 3 days later in the ICU. Would it have changed the outcome? Probably not, but the NP robbed the patient of her last week with her family. After all, if you knew that you were going to die really really soon, you would probably spend your remaining time differently than if your life expectancy was still decades.

FYI I made that case up, to prove a point, it's not true. BUT, think of all the diseases that they would overlook. For them to be given autonomy in practice, is ridiculous. The lack of enthusiasm toward primary care, as if it is some joke of a specialty is so unjustified. Just because it doesn't req. as much training in regards of years of residency, doesn't mean we should not be putting doctors on the front lines of medicine i.e. primary care.

I can't stand the NPs who in those comments said something to the effect of they "spend more time with the patients and emphasize prevention blah blah blah" (A very osteopathic principle by the way) BUT GUESS WHAT, none of that matters if you are missing all the things that you are ignorant too because you aren't a doctor! NPs won't be helping prevent disease in primary care, they will be adding to it by creating holes in the front lines

 

[mmmcdowe]

I think we need to refocus that those "non-md" physicians still have to do a residency, and personally I think the residency more than the medical school is what separates peds/fam med physicians from NPs the most.

 

[Anastomoses]

I think we need to refocus that those "non-md" physicians still have to do a residency, and personally I think the residency more than the medical school is what separates peds/fam med physicians from NPs the most.

I believe the NY law states that they have to do a 3 year...um...thingy under doctor supervision first.

 

[Doudline]

I've been taking my time figuring out my opinion about this whole thing, but largely, I've come to agree with this mindset: If nurses wish to practice independently, I absolutely support it. I absolutely support it provided that they are willing to take the USMLE Step II and Step III as an assessment of their clinical knowledge.

I understand that many nurse practitioners have years of clinical experience managing patients and often are incredibly helpful with diagnosis. If they wish to put that into practice independently and be seen as equals, they should be held to similar standards for licensure.

Not that I disagree with you on this topic, but if you hop over to the Canadian forums you'll hear multiple stories of Canadian med students who did fantastic on the MCCEE (Canadian boards), and decided to take the Steps without ample preparation -based on their MCCEE score- and got crushed, sometimes not even passing.

Granted, n=4-5 or something, but it goes to show that the steps are very specifically tailored for American medical education -or the other way around- and that they do not necessarily test competence/knowledge as needed for the actual practice of medicine. (If we consider Canadian graduates to be as competent as American ones, of course... which is not too much of a stretch considering that they can practice in the USA without any additional training.)

 

[tantacles]

Not that I disagree with you on this topic, but if you hop over to the Canadian forums you'll hear multiple stories of Canadian med students who did fantastic on the MCCEE (Canadian boards), and decided to take the Steps without ample preparation -based on their MCCEE score- and got crushed, sometimes not even passing.

Granted, n=4-5 or something, but it goes to show that the steps are very specifically tailored for American medical education -or the other way around- and that they do not necessarily test competence/knowledge as needed for the actual practice of medicine. (If we consider Canadian graduates to be as competent as American ones, of course... which is not too much of a stretch considering that they can practice in the USA without any additional training.)

I agree with you completely, but I'm still of the opinion that if nurses wish to practice, there must be some comparability of training and evaluation. Right now, for nurses, there is too much of a paucity of evaluation (I'll leave training aside for the time-being) for this initiative to make sense.

 

[touchpause13]

Ok which one of you knuckleheads went over there

 

[Lavan]

I'd argue that psychiatry is actually one of the fields most easily taken over by other providers. Look at all the different types of clinical psychologists, therapists, and related psych-associated professions. There are so many of them. If any of them get prescribing rights (imagine a clinical psychologist with prescribing rights) the game is over for psychiatrists.

Sure, as stated above, there will be the select few one-percenters that can afford to demand MD-level treatment. However, setting up this kind of practice will require the perfect location (desirable) and payor mix (rich), and there's likely going to be INTENSE competition to get those patients in your office. Competition for desirable practice set ups such as a cushy cash-only MD child psych in beverly hills are going to go to a very very very small lucky select few.

I wouldn't bank on psychiatry as a specialty that's immune to the discussion in this thread. However, as always, if you love the subject matter, and can see yourself accepting whatever practice environment you get, then sure go ahead and do psych.

Therapy, which most psychiatrists don't want to do much of, has been taken over by cheaper providers (LSWs, etc). Midlevels certainly do exist in the field. That said, psychiatry is still underserved in most areas and the job market is largely good. Most physicians don't want to do psychiatry, but it's one of the rare fields that, if you are good, you can move to cash only private practice. Not a common option. The psych NPs may be left employed by hospitals for expanded medicaid etc.

 

[FiveOClock]

Therapy, which most psychiatrists don't want to do much of, has been taken over by cheaper providers (LSWs, etc). Midlevels certainly do exist in the field. That said, psychiatry is still underserved in most areas and the job market is largely good. Most physicians don't want to do psychiatry, but it's one of the rare fields that, if you are good, you can move to cash only private practice. Not a common option. The psych NPs may be left employed by hospitals for expanded medicaid etc.

Create law requiring NPs to accept Obamacare!?!?!? YES PLEASE!!!

[/sarcasm...?]

 

[Doudline]

I agree with you completely, but I'm still of the opinion that if nurses wish to practice, there must be some comparability of training and evaluation. Right now, for nurses, there is too much of a paucity of evaluation (I'll leave training aside for the time-being) for this initiative to make sense.

Training is irrelevant here imo.

NPs have convinced the political powers (partially at least) of their ability to match physicians' competences.
The only way to reverse the steam is by proving beyond any doubt that their outcomes are significantly worse than physicians'; otherwise, they will keep getting more power in most fields of medicine.

And let's be honest... if their outcomes are relatively equal (we don't know about that yet, but it's a possibility), then their quest is justified. Who the hell cares if they have less training than physicians? If they don't know as much basic science? Results are the only thing that matter, and in this case it would only prove that a significant part of medical education is wasted.

Until such solid studies come around to confirm or deny NPs' claims, our arguments are only smoke and pettiness anyway.

(Which makes me question the average level of maturity around here for this thread to have reached 6+ pages. It SERIOUSLY reads like a 9/11 conspiracy discussion.)

 

[DermViser]

Training is irrelevant here imo.

NPs have convinced the political powers (partially at least) of their ability to match physicians' competences.
The only way to reverse the steam is by proving beyond any doubt that their outcomes are significantly worse than physicians'; otherwise, they will keep getting more power in most fields of medicine.

And let's be honest... if their outcomes are relatively equal (we don't know about that yet, but it's a possibility), then their quest is justified. Who the hell cares if they have less training than physicians? If they don't know as much basic science? Results are the only thing that matter, and in this case it would only prove that a significant part of medical education is wasted.

Until such solid studies come around to confirm or deny NPs' claims, our arguments are only smoke and pettiness anyway.

(Which makes me question the average level of maturity around here for this thread to have reached 6+ pages.)

Their outcomes are based in the span of months on very shaky metrics, sponsored by nurses. Nurses have everything to gain and nothing to lose by publishing their studies, many of which aren't peer reviewed. The buck doesn't end with them. If doctors evaluated and applied the literature the way nurses do with respect to clinical practice, we'd be killing patients left and right.

 

[tantacles]

Their outcomes are based in the span of months on very shaky metrics, sponsored by nurses. Nurses have everything to gain and nothing to lose by publishing their studies, many of which aren't peer reviewed. The buck doesn't end with them. If doctors evaluated and applied the literature the way nurses do with respect to clinical practice, we'd be killing patients left and right.

I would like your comment, but I have no evidence to support or refute your point or the other guy's point, so I'm not going to do that. Your post does make me feel tingly, but only because it makes me feel like I'm right more, so I'm not falling into that trap.

 

[DermViser]

I would like your comment, but I have no evidence to support or refute your point or the other guy's point, so I'm not going to do that. Your post does make me feel tingly, but only because it makes me feel like I'm right more, so I'm not falling into that trap.

You don't have to believe me. Just look at the articles themselves: http://www.ncbi.nlm.nih.gov/pubmed/10632281

No significant differences were found in patients' health status (nurse practitioners vs physicians) at 6 months (P = .92). Physiologic test results for patients with diabetes (P = .82) or asthma (P = .77) were not different. For patients with hypertension, the diastolic value was statistically significantly lower for nurse practitioner patients (82 vs 85 mm Hg; P = .04). No significant differences were found in health services utilization after either 6 months or 1 year. There were no differences in satisfaction ratings following the initial appointment (P = .88 for overall satisfaction). Satisfaction ratings at 6 months differed for 1 of 4 dimensions measured (provider attributes), with physicians rated higher (4.2 vs 4.1 on a scale where 5 = excellent; P = .05).

 

[adenocard]

I've been taking my time figuring out my opinion about this whole thing, but largely, I've come to agree with this mindset: If nurses wish to practice independently, I absolutely support it. I absolutely support it provided that they are willing to take the USMLE Step II and Step III as an assessment of their clinical knowledge.

I understand that many nurse practitioners have years of clinical experience managing patients and often are incredibly helpful with diagnosis. If they wish to put that into practice independently and be seen as equals, they should be held to similar standards for licensure.

This is a very dangerous line of thinking, in my humble opinion. The USMLE's are just that: standardized exams. Three USMLE passes do not a physician make. The culmination of the years of basic science (6 years including undergrad) in addition to the clinical knowledge in the upper years of medical school and beyond are what truly solidify the knowledge of a physician. Step 3 is taken after intern year and is most often reported to be the easiest of the 3 licensing exams - and yet, interns must undergo an additional two years minimum to become an attending.

Upon completing a minimal 3 year residency, the physician will have trained for a total of 20,700-21,700 hours compared to just 3,500 hours for a DNP. That is a difference of over 15,000 hours of training!

We already have good data on the pass rates of the much less involved and watered down Step 3 exams for NP's attending one of the most "prestigious" Universities in the country:

2008 Certification Examination Results - First-time Takers Number Tested Pass Rate DNP Degree Examinees : 45 49%

2009 Certification Examination Results - First-time Takers Number Tested Pass Rate DNP Degree Examinees : 19 57%

2010 Certification Examination Results - First-time Takers Number Tested Pass Rate DNP Degree Examinees : 31 45%

2011 Certification Examination Results - First-time Takers Number Tested Pass Rate DNP Degree Examinees: 22 70%

2012 Certification Examination Results - First-time Takers Number Tested Pass Rate DNP Degree Examinees : 18 33%

http://www.cumc.columbia.edu/nursing/dnpcert/rates.shtml

This should absolutely frighten the general public. I'm more upset that the original author of the NYT article didn't do more research and structure a better argument than he did - he could've dunked it and instead settled for a two foot bank shot that seemed to rim out.

 

[DermViser]

Perhaps america deserves the collapse of primary care. We have treated the practitioners like crap for so long that far less qualified individuals are destroying the art of primary care medicine. In the future maybe we should simply phase out MD primary care, all specialize, and see how that works out for everybody!

Exactly. If the goal is to make primary care miserable for doctors and have it taken over by NPs and PAs who are "better", then remove all those residency positions and shift them over to specialists, so that all doctors can become specialists.

The only reason this probably isn't happening is bc of the outcry from the public if that were to happen.

 

[tantacles]

This is a very dangerous line of thinking, in my humble opinion. The USMLE's are just that: standardized exams. Three USMLE passes do not a physician make. The culmination of the years of basic science (6 years including undergrad) in addition to the clinical knowledge in the upper years of medical school and beyond are what truly solidify the knowledge of a physician. Step 3 is taken after intern year and is most often reported to be the easiest of the 3 licensing exams - and yet, interns must undergo an additional two years minimum to become an attending.

Upon completing a minimal 3 year residency, the physician will have trained for a total of 20,700-21,700 hours compared to just 3,500 hours for a DNP. That is a difference of over 15,000 hours of training!

We already have good data on the pass rates of the much less involved and watered down Step 3 exams for NP's attending one of the most "prestigious" Universities in the country:

2008 Certification Examination Results - First-time Takers Number Tested Pass Rate DNP Degree Examinees : 45 49%

2009 Certification Examination Results - First-time Takers Number Tested Pass Rate DNP Degree Examinees : 19 57%

2010 Certification Examination Results - First-time Takers Number Tested Pass Rate DNP Degree Examinees : 31 45%

2011 Certification Examination Results - First-time Takers Number Tested Pass Rate DNP Degree Examinees: 22 70%

2012 Certification Examination Results - First-time Takers Number Tested Pass Rate DNP Degree Examinees : 18 33%

http://www.cumc.columbia.edu/nursing/dnpcert/rates.shtml

This should absolutely frighten the general public. I'm more upset that the original author of the NYT article didn't do more research and structure a better argument than he did - he could've dunked it and instead settled for a two foot bank shot that seemed to rim out.

I actually agree with every single point you made.

However, I think your post supports my point rather than going against it, namely that the evaluation should be similar, if not the same. Notice that some of the DNPs were weeded out by a less difficult exam. Assuming their training prepares them similarly (no one in THIS forum is assuming that, but DNPs certainly are), they should be able to pass the same examinations we do. If the assumption that their exam is a watered down version of ours is true, an even higher percentage than failed the DNP exam should fail exams based on similar content made for physicians.

No one is arguing that the exam makes the doctor. However, I would argue that if you want to practice like a doctor, you have to pass the exams. At this point, we can't effectively argue that DNP training, for those who complete it and do well on the exam, isn't similar to that of a physician. We can easily argue, however, and without much objection, that objective evaluations in both professions must be matched.

 

[adenocard]

At this point, we can't effectively argue that DNP training, for those who complete it and do well on the exam, isn't similar to that of a physician. We can easily argue, however, and without much objection, that objective evaluations in both professions must be matched.

I would argue that this is the exact point that we need to be making. Those that complete DNP training and may be able to pass the exams are still unequivocally NOT equals. The nuances of differential diagnoses, critical decision making, and complex management of multiple comorbidities are not measurable on exams. The DNP is centered around a nursing philosophy, never a medicine grounding. The two backgrounds are inherently different. The methodology is different. From the very outset the two paths are far divided. I'm not sure you could ever come up with an appropriate metric that would demonstrate equivalency between the two.

 

[tantacles]

I would argue that this is the exact point that we need to be making. Those that complete DNP training and may be able to pass the exams are still unequivocally NOT equals. The nuances of differential diagnoses, critical decision making, and complex management of multiple comorbidities are not measurable on exams. The DNP is centered around a nursing philosophy, never a medicine grounding. The two backgrounds are inherently different. The methodology is different. From the very outset the two paths are far divided. I'm not sure you could ever come up with an appropriate metric that would demonstrate equivalency between the two.

I agree with you 100%. Unfortunately, because we don't have knowledge of the inner workings of both programs, we just can't effectively make arguments about the rigor of the respective programs because we haven't been a part of them. Evaluations and metrics are our best tool, and for now, those are what I would focus on. If the rigor of the programs are the same, DNP pass rates for Step 1, 2, and 3 should approach 95%. Let them try. See how it goes.

 

[Nasrudin]

Exactly. If the goal is to make primary care miserable for doctors and have it taken over by NPs and PAs who are "better", then remove all those residency positions and shift them over to specialists, so that all doctors can become specialists.

The only reason this probably isn't happening is bc of the outcry from the public if that were to happen.

I like this nuclear option. We should flat force them into primary care--the original design of their profession was exactly that. Except what used to be a decade of nursing experience has shrunk disingenuously to 3 year online bridge programs. How they use weak general preparation to specialize is unfathomable.

They should not be allowed to specialize. For the life of me and all that is left holy on this forsaken planet of *****s I cannot understand what that nursing forum member meant when she kept saying "we specialize from the beginning, so of course our training is shorter." The stupidity of that statement leaves me speechless. It's time to pull out our troops from primary care and press the button:

 

[adenocard]

I agree with you 100%. Unfortunately, because we don't have knowledge of the inner workings of both programs, we just can't effectively make arguments about the rigor of the respective programs because we haven't been a part of them. Evaluations and metrics are our best tool, and for now, those are what I would focus on. If the rigor of the programs are the same, DNP pass rates for Step 1, 2, and 3 should approach 95%. Let them try. See how it goes.

I think we may get a glimpse into the rigors of the education by perusing some of the curriculum at even some of the top tier programs:

http://nursing.duke.edu/academics/programs/dnp/curriculum

N652 Transforming the Nation's Health: Dr. Short and Dr. Simmons
N653 Data Driven Health Care Improvements: Dr. Johnson
N654 Effective Leadership:

http://nursing.uw.edu/academic-services/degree-programs/dnp/dnp-10-curriculum-components.html

NSG 530: Professional Identity and Leadership Processes in Nursing
Social Justice (check with your advisor for suitable courses)
NMETH 527: Introduction to Health Informatics & Systems Thinking

http://www.nursing.virginia.edu/media/DNP_FT_POS.pdf

GNUR 8640 Nursing Ethics for Advanced Practice
GNUR 8630 Culture and Health
GNUR 8650 Managing Information Technology
GNUR 8610 Health Promotion & Health Behavior Research

When exactly are they learning all these highly advanced diagnostic and treatment modalities? If these are samples of the curriculum at established Universities, what are the requirements like for the online NP programs?

 

[tantacles]

I think we may get a glimpse into the rigors of the education by perusing some of the curriculum at even some of the top tier programs:

http://nursing.duke.edu/academics/programs/dnp/curriculum

N652 Transforming the Nation's Health: Dr. Short and Dr. Simmons
N653 Data Driven Health Care Improvements: Dr. Johnson
N654 Effective Leadership:

http://nursing.uw.edu/academic-services/degree-programs/dnp/dnp-10-curriculum-components.html

NSG 530: Professional Identity and Leadership Processes in Nursing
Social Justice (check with your advisor for suitable courses)
NMETH 527: Introduction to Health Informatics & Systems Thinking

http://www.nursing.virginia.edu/media/DNP_FT_POS.pdf

GNUR 8640 Nursing Ethics for Advanced Practice
GNUR 8630 Culture and Health
GNUR 8650 Managing Information Technology
GNUR 8610 Health Promotion & Health Behavior Research

When exactly are they learning all these highly advanced diagnostic and treatment modalities? If these are samples of the curriculum at established Universities, what are the requirements like for the online NP programs?

Again, I agree with you. I don't know how to say it any more clearly. I agree. Even if we just let them take Step II, actual Step II, and see how that goes, I bet we would get a clear answer that is hard to refute. I understand that "I'm not good at standardized tests" and "the test doesn't make the practitioner" are going to be common arguments, but this would at least give us objective ammunition to combat the "we get extensive clinical training on the job" argument.

 

[adenocard]

Again, I agree with you. I don't know how to say it any more clearly. I agree. Even if we just let them take Step II, actual Step II, and see how that goes, I bet we would get a clear answer that is hard to refute. I understand that "I'm not good at standardized tests" and "the test doesn't make the practitioner" are going to be common arguments, but this would at least give us objective ammunition to combat the "we get extensive clinical training on the job" argument.

I wasn't trying to argue, merely having a conversation. We're on the same team

 

[BurghStudent]

If they want equal practicing rights, and they think their education is equivalent, then simply take the Steps and the FP Board exams. We need a consistent metric. If they can't pass, the discussion is over.

20 years from now, when patient care has deteriorated, the idiots in Congress will be scrambling to attract MDs to primary care. With all this mayhem, my motto has become, specialize and survive.

 

[DermViser]

At this point, we can't effectively argue that DNP training, for those who complete it and do well on the exam, isn't similar to that of a physician.

Uh...no. Just..no.

 

[tantacles]

Uh...no. Just..no.

I said "effectively" not because we can't convince ourselves, but because we can't currently convince DNPs and the general public. I mean, clearly, we actually CAN'T. We've tried! We've failed!

 

[BurghStudent]

I like this nuclear option. We should flat force them into primary care--the original design of their profession was exactly that. Except what used to be a decade of nursing experience has shrunk disingenuously to 3 year online bridge programs. How they use weak general preparation to specialize is unfathomable.

They should not be allowed to specialize. For the life of me and all that is left holy on this forsaken planet of *****s I cannot understand what that nursing forum member meant when she kept saying "we specialize from the beginning, so of course our training is shorter." The stupidity of that statement leaves me speechless. It's time to pull out our troops from primary care and press the button:

I like this approach. Give the ACA and the NPs what they asked for. No, there will be no MDs on staff to absorb any medical liability. It will be on their backs. And when they screw up, drive up costs and run primary care amuck, we can re-negotiate the terms

 

[adenocard]

I like this approach. Give the ACA and the NPs what they asked for. No, there will be no MDs on staff to absorb any medical liability. It will be on their backs. And when they screw up, drive up costs and run primary care amuck, we can re-negotiate the terms

The problem is the NP's have already infiltrated nearly every subspecialty there is. At my center, NP's are in cardiothoracics, neurosurgery, dermatology, pediatric oncology, RadOnc, hematology, psych. There is no pulling them back from it - this was their original plan all along.

Want to be a dermatologist? Just complete these few hundred hours of clinic time Monday-Thursday 9-5 and collect your certificate and participation ribbon at the door!

 

[BurghStudent]

The problem is the NP's have already infiltrated nearly every subspecialty there is. At my center, NP's are in cardiothoracics, neurosurgery, dermatology, pediatric oncology, RadOnc, hematology, psych. There is no pulling them back from it - this was their original plan all along.

Want to be a dermatologist? Just complete these few hundred hours of clinic time Monday-Thursday 9-5 and collect your certificate and participation ribbon at the door!

So, other specialties will be next? I don't know, on some level I can see NPs dealing with the regular horses that come into the primary care clinic (they can't see the zebras). Things like derm or neurosurgery require clinical prowess.

 

[DermViser]

The problem is the NP's have already infiltrated nearly every subspecialty there is. At my center, NP's are in cardiothoracics, neurosurgery, dermatology, pediatric oncology, RadOnc, hematology, psych. There is no pulling them back from it - this was their original plan all along.

Want to be a dermatologist? Just complete these few hundred hours of clinic time Monday-Thursday 9-5 and collect your certificate and participation ribbon at the door!

If I had a son or daughter who was considering medicine, there is NO WAY I would let them enter this field. I would say either PA or NP for sure. There is way too much risk to enter the MD track. Too much risk, with too little reward. This is esp. the case if they were interested in something like Derm. There are tons of MD applicants who don't match into Derm or self-select out. Meanwhile an NP can self-certify in any field and change at the tip of a hat. At least for right now the ratio of debt to salary is much better in PA or NP.

 

[BurghStudent]

If I had a son or daughter who was considering medicine, there is NO WAY I would let them enter this field. I would say either PA or NP for sure. There is way too much risk to enter the MD track. Too much risk, with too little reward.

What about specialties? I know we have basically handed over our practices to corporations via the ACA, but can you imagine a day that the pay for all specialties will be a single fixed rate? At the moment, for example, going to med school and then becoming a plastic surgeon or spinal surgeon still seems like a good bet.

 

[DermViser]

What about specialties? I know we have basically handed over our practices to corporations via the ACA, but can you imagine a day that the pay for all specialties will be a single fixed rate? At the moment, for example, going to med school and then becoming a plastic surgeon or spinal surgeon still seems like a good bet.

You would have to be borderline delusional to go through 4 years of premed + 4 years of medical school just for the chance to be a Plastic Surgeon, which is predicated on more than just med school performance (which is itself not objective) and board scores.

 

[DermViser]

Contrary to my initial inclination, I made the mistake of reading the comments. Some people seem to understand the subtlety of the issue. Most clearly don't (eg, "the AMA limits physician supply to make big bucks," "nurses have years of bedside nursing experience that makes up for residency training," "nurses can be doctors now that they can get a doctorate" (holy ****), and a whole bunch of other nonsense). It goes to show you how the average person simply doesn't understand how medical training works and has no understanding of what providing basic medical care actually involves. The fact that someone thinks an RN practices any degree of clinical decision making is laughable. That's not a jab at nurses. That's just the reality of the situation. You can see this when you talk to nurses and get a sense of their understanding of what's going on with a patient and their suggestions for a plan based on what they see. Oftentimes they're reasonable, but sometimes they're so off-base that I wonder what they learn in nursing school.

I say let NPs practice if they want to practice. As multiple people brought up in the comments, the proof will be in the pudding. If NPs begin getting sued for malpractice and they begin to realize that perhaps those years of bedside training aren't adequate, things will swing the other way. On the other hand, if they end up having competency and outcomes similar to MDs... well, then perhaps we should reconsider our role.

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More important than reconsidering our role, I think if that is in fact the case, then we should stop *****-footing around. Let NPs take over primary care completely, and let all doctors become specialists who work at the "top of their license". Remove all funding for primary care only residencies and shift them to subspecialties. The only thing stopping this quite honestly, is the public outrage that would ensue of having no PCP and having to see a NP.

Year after year, medical schools waste med students precious academic time with this primary care crud speech and then telling them how wonderful it is, but then who do they celebrate on Match Day? The exact opposite (i.e. look how many people we matched into ENT! Ortho! Plastics! Ophtho! Derm!) Actions speak louder than words. Let those entering IM and Peds be completely tracked into subspecialty medicine. You can't have it both ways on primary care. Oh but wait, Obama and Emanuel and these other academic blowhards, need someone to be the administrator for this PCMH crud that is being pushed, who get none of the credit but all of the blame.

 

[Sephiroth]

Is there any way to get a hold of actual course material? I think this is what is really needed (as tantacles alluded to), though I fear any such thing would fall under copyright protection and no one would be allowed to release it publicly. The duke link doesn't inspire much confidence, with only a few hours, consisting of courses called "changing healthcare" and "leadership" and a third of it being elective and capstone credit.

I still think a good, and more achievable-in-the-short-term response would be to push for an increase in the number of PAs a single FP can oversee, and push for more PA school spots around the country (in a lot of states, PAs aren't very common). That could follow the same argument of increasing access and reducing costs. On top of that, the AMA is already pushing for regulations on requiring it be made clear to patients just who they are seeing (and in advertising as well). I guess with that the next step would be to require that NP-run practices make it clear that there is no physician oversight to patients.

 

[didymus]

I've already started reading some of his blog. Terrible? Not really (so far). Realistic, yes: http://www.pandabearmd.com/2008/04/13/medical-school-pre-clinical-years-twenty-questions-part-3/. So far I'm loving it!

He is the only writer I can say I actually binge-read. Seriously, I sat for several hours and poured over all his blog posts. Seriously good stuff.

 

[swtbrnpelican04]

DAE think their medical school has increased emphasis on empathy in their OSCEs as a reaction to the perceptions that doctors don't care about patients?

I know making empathic statements is a graded portion of our interaction with standardized patients.

 

[didymus]

Someone asked for this information earlier: http://www.aafp.org/news/practice-professional-issues/20130820np-pa-grahamcenter.html
And a second one to supplement the first: http://www.aafp.org/media-center/re...urse-practitioners-physicians-assistants.html

The findings might be seen as contradictory to a report from the American Association of Colleges of Nursing referenced in a July 2013 New England Journal of Medicine Perspectives piece, he added. That article suggested more than 80 percent of nurse practitioner graduates were entering primary care.

“That study differs from ours, however, in that it captured primary care degrees at graduation, not actual practice in a primary care setting,” said Bazemore. “Many nurse practitioners graduate with family, adult or pediatric degrees but then go on to work in subspecialty offices...

In fact, data from the 2010 report of the National Sample Survey of Registered Nurses showed 62 percent of nurse practitioners worked in subspecialty settings and 36 percent worked in primary care settings.

 

[DermViser]

He is the only writer I can say I actually binge-read. Seriously, I sat for several hours and poured over all his blog posts. Seriously good stuff.

I agree. what's great is that he has a great bull**** detector to wade through the **** that medical schools feed students. http://www.pandabearmd.com/2007/05/27/harvard-medical-school-the-not-too-distant-future/

 

[BurghStudent]

DAE think their medical school has increased emphasis on empathy in their OSCEs as a reaction to the perceptions that doctors don't care about patients?

I know making empathic statements is a graded portion of our interaction with standardized patients.

I feel the same way. I don't think empathy can be taught. It can be formulated in a way, like a series of questions, to assure everyone involved that we are indeed being empathetic. But no, what really decides if you are understanding or not was determined years before you entered medical school. People don't change.

 

[radkat101]

Does anyone know how much power/influence mid level providers have in other countries that are generally regarded to have quality healthcare systems? Is this uniquely American?

 

[DermViser]

Does anyone know how much power/influence mid level providers have in other countries that are generally regarded to have quality healthcare systems? Is this uniquely American?

This seems to be a uniquely American concept, that I know of. I have never heard of these type of providers in places like India or China, maybe more Europe.

 

[dap]

Does anyone know how much power/influence mid level providers have in other countries that are generally regarded to have quality healthcare systems? Is this uniquely American?

One of the thing that makes me so interested in working in an international context/global health is that doctors in most other countries I have been are actually respected for the work they do, and the ability/time/effort/sacrifice required to get there.

I haven't seen nurses or mid levels of any kind pursue power, influence, and autonomy the way their professional orgs do in the US. In other places the only problems I have seen b/w docs and nurses is more the occasional physician not valuing the training and skill set of the nursing staff, techs, etc. America seems to be the only country with the opposite problem. Although I have no experience with Western Europe, so I guess it could be similar there too.