Should I fear the growing number of NPs?

[CantStop]

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Yeah, but will docs always be able to break even on medicaid and medicare? I have had doctors tell me they can't even break even on the cost of supplies for some procedures.

I like the second bolded statement. Very good point.

If it's any consolation, the increase in Medicaid payments to match medicare payments (at least, for Primary Care docs) should help somewhat.

 

[dbeast]

Sorry for jumping in this thread so late, I'm at work and didn't have time to read everything yet.

How do PA's fit into this situation? Should doctors fear the increasing number of PA's? Or should PA's fear the increasing NP/DNP responsibilities more than physicians should?

And I obviously don't believe this, but based on the prevailing logic of this thread, shouldn't MD's be worried about the increasing number of DO schools?

Basically my point is that I really doubt physicians will have enough patients stolen by NP's to cause a noticable drop in business. There will obviously be competition as long as there is enough patient population to support it. And even if that were the case, it seems like only FP doctors (and maybe 1 or 2 other specialties) have anything to worry about, right? No matter how much NP's fight for it, a NP will never be leading a surgery.

 

[JaggerPlate]

Sorry for jumping in this thread so late, I'm at work and didn't have time to read everything yet.

Before I even reply, I do recommend doing some research on the issue because, no offense, your replies/comments below show some big gaps in understanding

How do PA's fit into this situation? Should doctors fear the increasing number of PA's? Or should PA's fear the increasing NP/DNP responsibilities more than physicians should?

PAs are regulated by medical boards and must, by law, work under a physician's license. PAs are great and should be supported at every step of the way. Should PA's fear the increasing number of NPs/DNPs more than physicians?

No, not really. The issue here is that DNPs (a far less trained practitioner than a PA or DO/MD) want completely independent practice rights in all 50 states. For all intents and purposes, they want to practice medicine without having attended medical school. PAs aren't allowed to do this, and since DNPs have no real intent of working with/under a physician's license, they aren't competing for positions with PAs, so really don't pose a threat (how I see it).

And I obviously don't believe this, but based on the prevailing logic of this thread, shouldn't MD's be worried about the increasing number of DO schools?

Why would physicians worry about an increase in the number of ... physicians? DOs are fully trained, licensed, residency trained, board certified physicians. If you're referring to saturation, that's a different discussion altogether and doesn't have to do with untrained, non-physician providers practicing independent medicine.

Basically my point is that I really doubt physicians will have enough patients stolen by NP's to cause a noticable drop in business.

Why not? The DNP can wear the white coat, advertise an independent practice, and even call him/herself Dr. ____. Frankly, most patients aren't going to know the difference, and if they happen to live near a DNP, are referring to a DNP by a friend, see that a DNP has shorter wait times, etc, there is really nothing stopping the average health care consumer from switching it up. After all, according to the NP/DNPs, the only difference between them and a physician is that "they care about patients and are paid less."

Additionally, what ABOUT the patients? This matter equates to more than a simple drop in business. No matter how many flawed studies the AANA puts out, the FACT of the matter is that the DNP has no where near the clinical training/experience of a DO/MD, and patient care will suffer. Period.

This is very important and should NOT be overlooked based on sufficient 'volume.'

There will obviously be competition as long as there is enough patient population to support it.

Depends on where you want to practice. Like I said earlier, try to open a FP office in the middle of a city like LA and tell me you feel like the market is wide open. Additionally, there is nothing wrong with competition in a free market sense of the term, but, AGAIN, the game entirely changes when two practitioners are competing for patients ... not clients/customers. If they are both sufficient practitioners, then that's fine. If one's not, claims to be, and unknowing patients are hurt in the process ... we (physicians) dropped the ball.

And even if that were the case, it seems like only FP doctors (and maybe 1 or 2 other specialties) have anything to worry about, right? No matter how much NP's fight for it, a NP will never be leading a surgery.

This type of mindset is exactly what allows NPs to nudge further and further. A few points:

1. An attack on any area of medicine should be seen as a threat to physicians in general. Dermatologists shouldn't sigh in relief when NPs go after FP territory and skip over the derm market; they should see it as an assault on their PROFESSION as a whole. This 'hide and hope it doesn't hit me' or 'specialize until it can't hit me' attitude is awful and needs to stop.

2. FP + 1-2 specialties? First, this is incorrect. Like I said before, NPs have no interest in FM if it's not where the money is at. Like everyone else, they will follow the reimbursements. Additionally, it's far, far from PC fields + a few others. Anyone who thinks pain management, cardiology, dermatology, anesthesiology (fields medical students are DYING to enter) are basic, simple fields and where the DNP integration will stop are dreaming. It's going to keep spreading, it's going to follow the money, and it's not going to limit itself to fields that medical practitioners feel are too complex to be affected.

3. Surgery comment ...

Not only have I heard this before, and discussed the issue of specializing until it can't hit you above, but it's blatantly false.

Why can't NPs find their way into surgery??? What's to stop a 'nursing surgery residency' akin to the 'nursing dermatology' residency at USF? Frankly, I don't think it would be impossible to envision a supervised surgical type scenario.

Put it this way ... if you told an Anesthesiologist 25 years ago that one day a nurse would be able to perform the job they went to 4 years of medical school and 4 years of residency to do (assuming no fellowship) they would have laughed in your face and said 'they can't get into gas.'

Look where the CRNA issue is today.

Don't assume anything.

Listen, altogether I know this issue sucks and is scary, frustrating, irritating, etc, but it's a reality and trying to skirt around it, bury heads in the sand (not saying you're doing this) or justify it isn't going to make it go away. It needs to be handled head on.

 

[dbeast]

[Multiple points]

Cool thanks for taking the time for the thread Cliff's Notes, very interesting stuff. I had no idea DNP's could practice anestesiology, derm, cards (or anything other than primary care really) independent from a physician whereas PA's don't get that luxury. Seems kinda screwy to me.

Yes I 100% agree that NP's should not be acting as physicians when they are not trained as such. I was gonna say you're putting to much faith in the ignorance of the patient population, assuming that nobody would ever choose to see a nurse over a doctor, even for primary care type stuff...

But then I realized it could be cheaper/closer/more convenient than seeing a MD... And if the nurse calls themselves Dr. and rocks a white coat, patients will pretty much believe anything for the purpose of convenience. The original question just sounded kind of bitter at first, but now it makes sense. Excellent post.

 

[randomusername]

Saw this in the allo board and thought it pretty relevant to the discussion.
http://www.latimes.com/news/local/la-me-nurses-20110329,0,7035150.story

 

[Prncssbuttercup]

My NP misdosed my thyroid meds, had to go back to the endo, so now the endo takes care of the meds, NP basic health. A woman I know is currently getting a Ortho NP license, I do not know what that will allow her to do but it seems she could possibly cast, etc... I do agree that the clinical side of medicine is different than the clinical side of NP->DNP training. Since you can get a DNP 100% over the internet if you are already an NP, it is obviously 100% theory vs any additional clinical training. This is why many NPs are fighting going this method. It increases some book knowledge, but little to no practical clinical knowledge... I'm not concerned about the space in the field, but it does concern me that they could label themselves as Drs in a medical sense...

 

[taylormade2006]

My NP screwed up my thyroid meds, had to go back to the endo, so now the endo takes care of the meds, NP basic health. A woman I know is currently getting a Ortho NP license, I do not know what that will allow her to do but it seems she could possibly cast, etc... I do agree that the clinical side of medicine is different than the clinical side of NP->DNP training. Since you can get a DNP 100% over the internet if you are already an NP, it is obviously 100% theory vs any additional clinical training. This is why many NPs are fighting going this method. It increases some book knowledge, but little to no practical clinical knowledge... I'm not concerned about the space in the field, but it does concern me that they could label themselves as Drs in a medical sense...

She'd probably do things like casting and splinting, but also would handle ortho cases, order imaging, manage joint issues, etc. The intent is probably to have other providers refer ortho cases to her.

 

[JaggerPlate]

NPs in Orthopedic surgery huh ...

1. Thank God they are filling that unwanted gap (as we're all well aware, AOA/ACGME Ortho residencies are going unfilled right and left and we're having a REALLY hard time getting students into this field).

2. Impossible for NPs to nudge their way into surgery huh???

 

[taylormade2006]

I know this sounds like arrogant behavior, but maybe doctors should just emphasize their doctor title and differentiate themselves and their training. I'm guessing any sort of ad campaign would catch some legal heat (e.g. Wilk vs AMA) and some workplace chemistry disruption, but there's gotta be something to do.

 

[Prncssbuttercup]

Personally, to me this is like Chiropractic vs MD/DO, both have earned a "Doctor" title but what does a patient think that means? DPTs? Do they want to be called Dr? There is going to have to be a line drawn about who is a Dr and who has a doctorate but isn't a medical doctor. For me, it is simply an issue of the general public having no clue what DNP vs MD vs DO, etc mean, they see Dr. Suchnsuch at their MEDICAL clinic and likely will not know that the person isn't a medical doctor (MD/DO) they are a Dr of Nursing...

 

[JaggerPlate]

3-4 times now, lobbying groups like the AMA have tried (and are currently trying to) pass legislation to increase patient awareness, make physician versus non-physician more obvious in the market, require degree title displays, etc. From what I've heard, guess what groups shoot it down each time???

Patient confusion and a blind faith in the 'doctor' title is an advantage when you aren't a medical doctor, but are trying to practice medicine with MD/DOs. They know this, and aren't about to advertise the fact that NPs can become 'doctors' (DNPs) via online coursework.

 

[Prncssbuttercup]

My coworkers (biotech people) think it should be delineated as physician, mid-level practitioner, nurse, other stuff

 

[JaggerPlate]

My coworkers (biotech people) think it should be delineated as physician, mid-level practitioner, nurse, other stuff

Sounds fair. Various hospital systems are essentially starting to adapt a similar identification system with nametags. Essentially, the tags are color coded, have the individual's name, and title right under it. Example:

DO/MD
-Big red stripe
-JOHN DOE, DO
-PHYSICIAN

NP
-Big green stripe
-Mary Noctor, NP, DNP, LOL, TGIF, CCARNAP, PB&J
-NURSE PRACTITIONER

 

[munchymanRX]

I understand that there's much reason to fear for us docs, but from the standpoint of a policymaker, examining only the statistics and possessing little understanding of the medical profession.

it would make sense from a cost perspective to afford NPs expanded rights. Sure, there's a zebra every once in a while, but 99% of the time you see horses.

That's what scares me. When the laws are passed they're going to be looking at the outcomes as a lumped whole, and they're not going to be concerned with things like patient safety and standards of care.

 

[NurWollen]

Sounds fair. Various hospital systems are essentially starting to adapt a similar identification system with nametags. Essentially, the tags are color coded, have the individual's name, and title right under it. Example:

DO/MD
-Big red stripe
-JOHN DOE, DO
-PHYSICIAN

NP
-Big green stripe
-Mary Noctor, NP, DNP, LOL, TGIF, CCARNAP, PB&J
-NURSE PRACTITIONER

 

[Sinfest]

The "PB&J" is what got me

 

[Prncssbuttercup]

Wtf is CCARNAP?? I liked the LOL/TGIF as well as PB&J 😉 good job 😉

 

[CantStop]

Sounds fair. Various hospital systems are essentially starting to adapt a similar identification system with nametags. Essentially, the tags are color coded, have the individual's name, and title right under it. Example:

DO/MD
-Big red stripe
-JOHN DOE, DO
-PHYSICIAN

NP
-Big green stripe
-Mary Noctor, NP, DNP, LOL, TGIF, CCARNAP, PB&J
-NURSE PRACTITIONER

This sounds like a good compromise.

 

[JaggerPlate]

I understand that there's much reason to fear for us docs, but from the standpoint of a policymaker, examining only the statistics and possessing little understanding of the medical profession.

it would make sense from a cost perspective to afford NPs expanded rights. Sure, there's a zebra every once in a while, but 99% of the time you see horses.

That's what scares me. When the laws are passed they're going to be looking at the outcomes as a lumped whole, and they're not going to be concerned with things like patient safety and standards of care.

When they want physician level reimbursement, require higher malpractice premiums, and still require the facilities to have physicians on staff to monitor in some sense, they won't even up saving anything in the end.

Wtf is CCARNAP?? I liked the LOL/TGIF as well as PB&J 😉 good job 😉

I hit random letters while holding shift.

 

[Prncssbuttercup]

Gotcha... I was confused... 😉

 

[DuxburyPembroke]

I think University of Phoenix offers the PB&J online?
http://www.phoenix.edu/colleges_divisions/nursing/programs/pb&j.html

 

[painmd87]

I understand that there's much reason to fear for us docs, but from the standpoint of a policymaker, examining only the statistics and possessing little understanding of the medical profession.

it would make sense from a cost perspective to afford NPs expanded rights. Sure, there's a zebra every once in a while, but 99% of the time you see horses.

That's what scares me. When the laws are passed they're going to be looking at the outcomes as a lumped whole, and they're not going to be concerned with things like patient safety and standards of care.

I'm not a fan of the "NPs can handle the horses; it's the zebras that they'll screw up." It assumes a basic competence to handle the simple cases. Why do we assume this? The lack of an ability to treat difficult patients does not correlate to excellence in treating easy ones.

For example, my university's health center was staffed by NPs. I didn't know it at the time. A number of friends had been diagnosed with mono my freshman year, and I had felt like crap for a few days so I went to the health center. The NP did a blood test, gave me a "You have mono" talk like she was telling me I had cancer and gave me a handful of prescriptions.

I didn't have mono. I had a bad cold. The test was positive because I had previous exposure and immunity to mono. I got pumped full of steroids because she was used to mono-infected horses.

NPs absolutely play an essential role in healthcare, but their basic knowledge and clinical abilities are not on par with those of physicians, in general.

 

[Prncssbuttercup]

Why? What specifically about your wife being a midwife is telling me I should be afraid... Elaborate please 🙂

 

[JaggerPlate]

As an advanced practicing nurse, she is knowledgeable about the legislative efforts through various Boards of Nursing and APRN lobbying groups to 1) graduate more APRN's and 2) create greater independent practice for APRN's. While I don't specifically believe that IM docs should be concerned, there should be great concern for FP docs. NP's are generally seen as "junior doctors", as they can do the job of an FP MD/DO and do it cheaper. While they do not have as great of an education as a MD/DO does, mid-level providers have acceptable outcomes and are appealing when considering the decreased cost of their services.

As an aside, my wife does consider CNM's to be separate from FNP's, ANP's, PNP's, NNP's and CRNA's, as midwives have existed since the beginning of the human race and are an independent discipline apart from MD/DO's. Unlike other APRN's, CNM's are not merely "junior doctors". CNM's enjoy a very positive relationship with OB's (in general) and the ACNM and ACOG work closely together. CNM's realize that they will never be able to be completely and truly autonomous, as they will always need someone to do their sections. So, they have a vested interest in maintaining a positive working relationship with ACOG, whereas the other NP's don't necessarily have that motivation.

Tell your "wife" 🙂rolleyes🙂 this rant is just a bunch of pro-nursing midlevel, propaganda drivel.

Additionally, OBs are starting to catch on to midwives game just the same. They recently lobbied for, and won, full medicare reimbursements at the OB/GYN level for delivers in NY and are fighting for more and more independent practice all the time.

Frankly, none of these groups have a positive relationship with physicians, unless they need to be trained of course, then our money hungry, over trained, heartless knowledge is of use to them, and considering them 'junior doctors' (which no one does by the way) is just a perfect example of what they care about, and how they are going to try to make things proceed.

As to whether or not we should fear the movement, yes, we definitely all should, but don't for a SECOND think it's because we fear their knowledge, skills, or think they are 'jr' doctors who can do it 'just as good, but for cheaper,' it's because they have a ruthless, slimy, liberal lobbying group pushing for them 100% at all times.

 

[Prncssbuttercup]

If someone is the enemy, its insurance companies (including medicare/medicaid) because they are the orgs continuously trying to make their costs less. Mid-level practitioners have their place, we've discussed this, they ARE important to the functioning of our clinics and hospitals. I question whether you have ever worked in or volunteered in a hospital? The mid-levels can take on many cases that are less urgent allowing physicians time to see the more critical patients. They aren't out to 'steal' our (potential) jobs. Viewing them with such disdain can only be a detriment to you Jaggerplate, it will not benefit you. However, being closed-minded rarely helps a person, unless we're talking about hiding our heads in the sand...

 

[JaggerPlate]

Wheww, this is going to take a minute, but let's see what I can do here ...

Wow, I don't really know what to say to that. We have had numerous thorough conversations about this topic and I do not at all believe that she or her peers are "ruthless and slimy"

Let me rephrase then ... the people who represent your wife's profession are ruthless and slimy. If she doesn't want to be portrayed this way, she should petition for people like Mary Mundinger to step down and show a bit more parity, instead of constantly running a doc smear campaign and depicting nurse practitioners as humble servants who just want to serve in "rural" areas and "fill crucial gaps in Primary Care."

It's all great and good to hear your anecdotal experiences of what individuals NPs tell you, but all I can base my opinions (and yes, they are evidence and researched based thoughts, but they are still opinions and you are free to disagree with them) on is what I hear from the leadership and their goals/thoughts are quite clear.

They are people (not "the enemy"), and they absolutely have their patient's interests at heart. You are obviously approaching this from a very ultra-conservative and narrow point of view and like most ultra-conservatives, your mind is completely made up.

Do they have the patient's best interest at heart? Are individuals who are far, far less trained than physicians playing doctor, running independent practices, pushing into fields like Anesthesiology, Cardiology, Dermatology, Pain Management, etc, really the best thing for an unsuspecting patient?

That is fine with me as I am not here to convince you. You will see when you graduate from medical school and enter your residency, and finally become an attending, how the relationship between APRN's and MD/DO's is diverse, and that contrary to your own belief, they are not "the enemy". Or maybe you should just wed a nurse. Gives you instant compassion for their plight. 🙄

My aunt and grandmother are both RNs - excellent nurses, work well within the team model, and both think the NP/DNP movement is an absolute joke.

Additionally, aren't you a pre-medical student? From your previous posts, it looks like you're still trying to get into medical school, so I'm curious as to what makes you so privy to the world of the APRN: physician relationship???

Is it the fact that you've had it explained to you by an APRN? Because to me, this seems inherent with just a pinch of bias, and I'd love to hear where your inside knowledge of this comes from.

If someone is the enemy, its insurance companies (including medicare/medicaid) because they are the orgs continuously trying to make their costs less. Mid-level practitioners have their place, we've discussed this, they ARE important to the functioning of our clinics and hospitals.

I truthfully don't even want to get into a discussion about insurance costs right now, but I do want to straighten one thing up ...

I'm not anti-midlevel, at all. I'm anti-nursing midlevels who want independent practice. PAs, AAs, etc, bring it on. These individuals not only work within the confines of the board of medicine (which I think is appropriate for someone who wants to practice medicine), but they SUPPORT and play a role in a team-based model which is an EXCELLENT thing.

PAs don't want a takeover, they don't want to be called 'Dr' in a clinical setting, they don't promote smear campaigns, AND, from what I've seen, they are very, very well trained and competent (which is far more than what I've seen in my experience with NPs)

I question whether you have ever worked in or volunteered in a hospital?

No, I've never been in one, but I hope to some day. I'm sure you were able to really hone in on the intricate internal gears of an NPO hospital during your stay as a volunteer, so any info you can give me on 'how it works' would be greatly appreciated.

The mid-levels can take on many cases that are less urgent allowing physicians time to see the more critical patients.

This is how they get a foot in the door - we'll take the less urgent, simpler patients that others don't want to see and let the physicians take on the others. Let me explain why this is false:

1. It's absolutely insulting to patients

2. These 'simpler' patients are the bread and butter of 99% of primary care practices - if you take away all the horses and only let the physicians bill for the 1/100 zebras, you can't stay in business.

3. If the NPs only want to 'help out' and see the 'easier patients' why are they pushing for independent practice? Why are they handling more and more complex Anesthesiology cases? Why are they pushing for injection rights in pain management? Why does the University of South Florida 'nursing dermatology residency' include training in diagnosing skin cancers???

Doesn't sound overtly simple or like they are just 'chipping in' to me. Again though, I've never volunteered in a hospital, so maybe you can fill me in on this too.

They aren't out to 'steal' our (potential) jobs. Viewing them with such disdain can only be a detriment to you Jaggerplate, it will not benefit you. However, being closed-minded rarely helps a person, unless we're talking about hiding our heads in the sand...

Your 'head in the sand' comment is too ironic to even touch.

However, all I can say is hit me up in 10 years and let me know if you feel the same way.

This is TheRunner's wife to add a little bit of perspective. 😉 I was told about this little spat and am here to clear up some things.

Hello Runner's wife 🙂

1) I have absolutely no desire to be called "Dr.". I have no desire to be an MD. My first undergrad is in a "hard" science, not in nursing, so I had this option. Choosing to have kids and a family took precedence over any inklings I had to go to med school. I had absolutely no desire to perform surgery, so I went back to get my RN and then MSN. If I wanted to be called "Dr.", I would have gone to medical school, period.

Sigh ...

1. This is literally a page out of the 'frustrated NP' playbook:

"I could have gone to medical school if I wanted to, but I wanted X instead"

"I majored in HARD science"

"If I wanted to be X I would have gone to medical school"

This type of justification, in my OPINION, is the exact APRN type of mentality that leads to the "I'm just as good as a doctor because I COULD have done this, or I DID this too, so I SHOULD be able to practice medicine without going to medical school; my patients SHOULD call me doctor" etc.

If I were to ever go back to school to get a PhD, I would not allow anyone to call me "Dr." in a hospital setting as it is misleading. Patients should know when they are talking to me that I am not an MD, but a CNM. It would be deceitful for me to make people call me "Dr. X" as that would imply that I'm a medical doctor, which is not the case.

This is great, but unfortunately, and like I said earlier, the people who represent YOU (and by you I'm referring to a general APRN, NP, DNP situation - vague, but eh) portray the EXACT opposite. Why else would they push for independent practice rights and insist their graduates have doctorate degrees?

Additionally, in regards to white coats, if you haven't noticed, everyone in the hospital is wearing a white coat nowadays. The nutritionist, the pharmacist, the interpreter, the nurse manager, everyone is wearing a white coat. IMO, only those with prescription privileges should wear white coats, but that's just me. I have no special attachment to my white coat, and neither will you after you've been in practice for several years. It's an accessory and has nothing to do with my job. Who I am and what I do are what commands respect, not any piece of clothing that I wear.

So ...

1. You do wear a white coat. Is this a requirement? BTW, I don't give a crap at all about the white coats. I use them to add a little 'spice' to my NP rantings. I'm only a medical student and I already can't wait until the day when I never have to wear another one of those damn things again.

2. Thanks for telling me how it's going to be when I'm in practice, didn't know we were entering the same field. 🙄

3. I find it funny that you still draw a line of distinction with regard to the white coat even though you allegedly dislike it - "oh this ole thing, just part of the territory."

So only people with prescription rights should be able to wear it? So cut the techs, cut the nutritionist, cut almost every one else you'd see in a clinical setting and just put ... OH, the DO/MDs AND mid-level nurses in white coats. Totally. Ugh.

2) The DNP degree is ridiculous. It's just degree inflation. NP's are making it mandatory and I think it's bizarre. What is the purpose of the degree? It doesn't make any sense. Is this going to increase their pay? Increase their autonomy? Both answers are no, and so it's a pointless degree. Keep it a master's and be done with it. CNM's aren't requiring DNP's. There are very few CNM DNP's. The terminal degree should be a PhD which is a research doctorate, not a practice doctorate as it's irrelevant.

I'd bet a 100 bucks that the CNMs and various other nursing groups are planning to do the exact same thing. Also, I agree, it's an absolute joke. You can literally get it online.

3) The previous poster is right- If you want someone to hate, hate the insurance company. I don't want your job. I want *my* job- and my job is not your job. It's my opinion that a system in the US similar to that in Europe would be a superior system, where low-risk patients see midwives and higher risk patients see OB's. What's prohibiting this from happening? Insurance companies.

I don't want to discuss the insurance companies and I'd really, really prefer not to discuss specific European (I don't know what country you're even referring to) health service systems.

However, I'm curious as to a certain scenario here:

From my knowledge, CNMs pushed really, really hard to get equal reimbursements (at OB/GYN) levels for deliveries in states like New York. If you don't want the physician's job, the physicians' job responsibilities, the physician's payments (which are an inherent part of the job), why would you push for this?

If I went into family practice and lobbied congress for years to allow me to obtain malpractice and hospital privileges equivalent to that of Neurosurgeons, do you think the NS guys would believe me when I say I wanted MY job and not THEIR job???

In order to understand why, you would have to understand billing and coding, and as MickJagger here has not yet even graduated from medical school, much less had to learn anything about billing and coding, he wouldn't really understand this. I'll try to dumb it down for you, but if you still don't get it, maybe ask your professors. There are levels in billing/coding dependent upon what you do- examination, write a script, procedure, level of acuity of the patient, etc. Problem is that once a patient reaches a certain level of acuity (Level 5), it doesn't really matter how complicated that patient is, you still can't really bill for anything higher, in other words there is no Level 6. So, let's say in one given hour I can knock out 3 Level 4 patients, and can bill for all of those patients. But my partner gets hung up on 1 Level 5 patient who is very complicated, and it takes him the whole hour with that patient. He can only bill for that patient for that hour, and the Level 5 billing is only somewhat higher than the Level 4 billing. So, it looks like I'm taking the "easy" patients and leaving him the "hard" patients, and he's generating less revenue than I am.

1. ROFL

2. I'm about 80% done with my Masters in Health Admin, so, despite what you may think about my 'noobness,' I've had quite a bit of classroom based exposure to these types of matters - but thanks for 'dumbing it down' for me

3. I don't want to blatantly insult you here, but your binary code description of insurance policies represent a big, big difference in the mindset, training, and thought process between a physician and nurse:

Frankly, while you're taking course in how insurance codes work (not sure if you take these exact courses, but you're route memorization of this 'concept' leads me to believe that you've either taken some type of masters course in it during your nursing training, or you've done quite a bit of billing paperwork during your clinical work) and learning that 'pushing X medication produces Y result,' medical students and residents are studying the biochemical basis of the disease; learning how to review, comprehend, analyze, and diagnose; recalling knowledge from Path, Physio, Gross Anatomy, information learning during the 3-7 years of residency, the 15,000 hours of clinical rotations, etc, etc, etc.

Frankly, you can bash me all you want for only being a 'medical student,' but from what I've seen, heard, and can definitely believe, unless you want to go back (because we all know you could - you told us straight up), you'll 'never know what you don't know,' and this is where the big differences between the training of a physician and nurse shine through.

Why don't you handle the most complex cases? Why do CNMs deliver the uncomplicated births and call for the OBs when **** hits the fan? If you can answer these questions and not blather back some pseudo-clinical, insurance drivel, then maybe I'll change my mind as to why I take issue with NPs telling me they are 'just as good as physicians, but get paid less'

I can see that argument as being a valid one, but I still don't think that's a very convincing reason why a practice shouldn't utilize mid-level providers. The goal of the practice/hospital is to be as productive as possible in the most cost-efficient way possible, and if I can churn out the "easier" patients fast for cheaper pay thereby freeing up the MD to see the more difficult patients, then I'm of benefit to the practice as a whole.

See above ... and, like I said before, I'd fully support this model with PAs who work with physicians and under the BOM

4) I am surprised by the lack of respect from several posters (including MickJagger) given to mid-levels. Many CNM's teach medical students (MD students) and are associate professors and faculty at medical (MD) schools. (I am not familiar with DO schools, but this could be the case at DO schools as well.) Additionally, if you go into OB, you will likely need an attending at each of your intern deliveries. In these academic hospitals that employ CNMs, many times CNMs have the authority to act as an attending at your delivery. It is in your best interests to foster positive relationships with the CNMs in this situation. While we are "mere nurses" (how juvenile), we are very knowledgeable, especially those of us who have been practicing for 25-30+ years. A wise medical student would glean information off of the academic CNM, as her knowledge-base, at that point in your education, will be superior. Just a little piece of advice from me to you. 😉 Good luck in your pursuits.

Respect is earned and reciprocal. NPs, DNPs, etc, have 0 respect for physicians, so don't act surprised when you (not you specifically, but, again, the NP-esque individuals) crap all over them and they don't thank you for 'chipping in.'

Additionally, thank you again for the odd inferiority complex, but I've never once said there isn't something I can learn from a CNM who has been doing deliveries for 30 years. However, because I'm training to be a physician, I'd, no offense, want to be taught and trained by physicians ... I'm sure you understand.

Altogether, I hope this doesn't insult any of you on a personal level too greatly, though I'm sure it will. I don't know if I'll reply, or much less read, any further responses, but let me just state that I didn't come to this opinion overnight. I've followed this mid-level encroachment issue for YEARS, and definitely tried to see it from various different ways before forging my thoughts on the matter.

 

[JaggerPlate]

PS ...

Just read through my absurdly long post and realized the multi-quote thing went a bit nutty (this happens to me on SDN from time to time), and some of the things SB said (and I responded to) were quoted as Runner, etc.

 

[OzelloPiRat]

Just knew it was going to be some good reading w Jagger on the line!

FYI. Had both babies at home by CNM. Was amazing! Did so bc I have been an OB nurse and did not want that experience for me, my personal descision. Those CNM, in my mind, play a completely separate roll from those in the Docs office. Ins did not pay, we did. I feel the same about NPs in hospice and nursing homes. They are there doing great evaluations and giving care, none have ever wanted to be or take on a roll as a doc. On the other hand, went with the Hubs to an appt and he had an NP. He called him Doc five times on purpose, was never corrected. There does appear to be a mind set change between those having to work under a doc and those that do not.
Sigh...wrote way more than I intended to get into. Do not have time for SDN! Must.....study......

 

[JaggerPlate]

So ...

I wrote my response a while ago, and after thinking about it for a bit (and allowing it to distract from studying), I've realized that in certain parts, it's probably too harsh (though I'm going to leave it up unedited).

Frankly, it's very clear how I feel about this issue - I support a team based approach and think midlevel practitioners play a role in our health care system, but I don't think this role should be independent medical practice, nor do I think patient confusion and physician 'badmouthing' is a way to achieve this.

My point here really isn't to insult anyone, claim some sort of physician monopoly over knowledge, treatment, etc, but more to advocate a physician run system and definitely call a 'spade a spade' with regard to issues like the DNP mentality, how they will actually affect health care costs, where they will end up providing care, etc, etc.

It's clear I'm passionate about this issue, but I assure everyone that there is a reason for this and I highly encourage everyone to research the issue as thoroughly as possible (even if your conclusion differs from mine). I'm not sure what the future holds, but I do know that I will continue supporting my view on the issue, but will also be the first to state that it's not my intent to insult, come off as extremely arrogant, act like a dictator, dehumanize, etc.

 

[painmd87]

I think JaggerPlate needs a vacation

 

[Charles_Carmichael]

The more important question, IMO, is not whether physicians should be afraid of NPs/DNPs, but rather, whether patients should be.

As of now, there is no well-designed study that suggests NPs/DNPs provide care at a level equivalent to that of physicians. There are several flawed studies that look at measures such as patient satisfaction and equate that (wrongly) to quality care. There are also a couple of studies that, even though they were funded by the nursing leadership, suggest that NPs take longer to reach the same diagnosis as physicians do and that NPs tend to refer out to specialists more than primary care physicians do.

It's only recently that the AAFP has been really pushing for quality studies to be undertaken comparing board-certified physicians to NPs/DNPs.

Question for you guys: do you think it's a good idea to let medical students practice independently after they finish 3rd year of med school? By the end of 3rd year, medical students receive far superior basic science training and several-fold more clinical hours of training than any NP/DNP program in the US provides. So, if you're in support of NP/DNP independence, it only makes logical sense that you would also be in support for giving full scope of practice to M4s. Perhaps we should be lobbying for that instead?

 

[digfast]

---------

 

[Prncssbuttercup]

For whatever reason I just thought of this... If it were not for midwives, the value of handwashing would not have been determined as fast as it was... Doctors were 'above' washing their hands after touching patients, and many more of their patients died as a result. Midwives washed their hands and had a fraction of the fatalities that the doctors had...

I am curious jagger, so you are saying that a PA's MS degree is superior to an NP's MS degree? In order to become an RN the person had to take anatomy, physiology, pharmacology, etc, then they must work a minimum of 2 years as an RN before they can take MS level courses, (both didactic and clinical) in order to become a NP (or APRN, etc). To become a PA, you have a BS in xyz, take A/P, pharma, etc, and have 1 year of clinical training. Where is a PA superior? Additionally, you are saying that NPs aren't regulated, hmmm interesting... Wonder why my NP has a license to practice?? Some one must be regulating her practice; she didn't get it from a cracker jack box! For the record, I will say outright, I have met more PAs I didn't like as caregivers than NPs. I have yet to meet an NP that was snippy etc... however, I routinely meet PAs that I'd like to bitch slap for being snotty/pissy/etc...

Edit: to the above poster... that's ONE NP, and I can say the same thing about several doctors. I could have my sister-in-law tell you about her doctor that accused her, to her face, of being a drug addict... Accused because the MD REFUSED to do an ultrasound on her abdomen when she was complaining of abdominal pain FOR A YEAR, and kept telling her she had gas pain. She was accused of being 'drug seeking' because she came in again for pain, but the doc failed to notice a key point. The RX for the pain meds was over a year old, and had never been refilled. My SIL filed a complaint with the clinic in regards to this. I told her to try an NP, she did, the NP DID the ultrasound and confirmed MY (NOT EVEN A MED STUDENT'S) suspicion of gallstones... Gee... we can go round and round and round about bad providers, they live in both camps

 

[sylvanthus]

"then they must work a minimum of 2 years as an RN before they can take MS level courses, (both didactic and clinical) in order to become a NP (or APRN, etc). "

Wrong. Do you know how many NP programs out there let you skip past a great amount of this (direct entry after BSN, etc with NO clinical experience) and how many DNP programs are largely online? There are NO online PA programs to my knowledge. Furthermore, look at the amount of clinical hours an average PA student receives compared to an average NP. I think you will be surprised.

 

[Charles_Carmichael]

For whatever reason I just thought of this... If it were not for midwives, the value of handwashing would not have been determined as fast as it was... Doctors were 'above' washing their hands after touching patients, and many more of their patients died as a result. Midwives washed their hands and had a fraction of the fatalities that the doctors had...

I am curious jagger, so you are saying that a PA's MS degree is superior to an NP's MS degree? In order to become an RN the person had to take anatomy, physiology, pharmacology, etc, then they must work a minimum of 2 years as an RN before they can take MS level courses, (both didactic and clinical) in order to become a NP (or APRN, etc). To become a PA, you have a BS in xyz, take A/P, pharma, etc, and have 1 year of clinical training. Where is a PA superior? Additionally, you are saying that NPs aren't regulated, hmmm interesting... Wonder why my NP has a license to practice?? Some one must be regulating her practice; she didn't get it from a cracker jack box! For the record, I will say outright, I have met more PAs I didn't like as caregivers than NPs. I have yet to meet an NP that was snippy etc... however, I routinely meet PAs that I'd like to bitch slap for being snotty/pissy/etc...

Edit: to the above poster... that's ONE NP, and I can say the same thing about several doctors. I could have my sister-in-law tell you about her doctor that accused her, to her face, of being a drug addict... Accused because the MD REFUSED to do an ultrasound on her abdomen when she was complaining of abdominal pain FOR A YEAR, and kept telling her she had gas pain. She was accused of being 'drug seeking' because she came in again for pain, but the doc failed to notice a key point. The RX for the pain meds was over a year old, and had never been refilled. My SIL filed a complaint with the clinic in regards to this. I told her to try an NP, she did, the NP DID the ultrasound and confirmed MY (NOT EVEN A MED STUDENT'S) suspicion of gallstones... Gee... we can go round and round and round about bad providers, they live in both camps

You're wrong on several accounts. PAs are superior, IMO, to NPs/DNPs because not only do PAs receive a stronger basic science foundation, but they also have several times as many clinical hours of training compared to what NPs/DNPs receive. NP/DNP programs tend to require 500-1000 hours of clinical training. PAs tend to receive more than 2000 hours of clinical training. That's why they're considered by many to be superior to nursing midlevels.

You're also wrong that NPs must work as an RN for 2 years prior to starting the NP program. There are many direct-entry NP programs where you can earn your NP within 2-3 years without any prior healthcare experience at all. More and more of these programs are cropping up these days.

Your NP has a license to practice because of politics. The biggest reason why NPs/DNPs are able to practice independently in several states currently is because the nursing lobby is immensely powerful. This independence is not based on sound evidence nor is it based on logic.

 

[Charles_Carmichael]

For those of you who might be unaware of the (inadequate) training that nursing midlevels get, here's an old post of mine comparing NP/DNP curricula with that of med school curricula:

"Here's a sample curriculum from a BSN-DNP program (at Duke): http://nursing.duke.edu/wysiwyg/down...t_MAT_Plan.pdf

You need 73 credits to go from a college degree to a doctorate. That turns out to be less than 3 years.

Courses taken: Research Methods (3 credits), Health Services Program Planning and Outcomes Analysis (3 credits), Applied Statistics (2 credits), Research Utilization in Advanced Nursing Practice (3 credits), Data Driven Health Care Improvement (4 credits), Evidence Based Practice and Applied Statistics I & II (7 credits), Effective Leadership (2 credits), Transforming the Nation's Health (3 credits), DNP Capstone (6 credits), Health Systems Transformation (3 credits), Financial Management & Budget Planning (3 credits).Population-Based Approach to Healthcare (3 credits), Clinical Pharmacology and Interventions for Advanced Practice Nursing (3 credits), Managing Common Acute and Chronic Health Problems I (3 credits), Selected Topics in Advanced Pathophysiology (3 credits), Diagnostic Reasoning & Physical Assessment in Advanced Nursing Practice (4 credits), Common Acute and Chronic Health Problems II (3 credits), Sexual and Reproductive Health (2 credits), Nurse Practitioner Residency: Adult Primary Care (3 credits), Electives (12 credits).

So, out of the 73 credits needed to go from BSN to DNP, a significant portion of courses are potentially not clinically useful. In addition, the number of required clinical hours is 612 hours (unless I miscounted something)!! Wow! And the NP program is designed the same way and requires 612 hours as well: http://nursing.duke.edu/wysiwyg/down...rriculum_2.pdf

Here are the curricula to several other programs:

• University of Arizona: http://www.nursing.arizona.edu/OSA/P...ndout_2008.pdf
  
• Loyola's MSN to DNP: http://www.luc.edu/nursing/dnp/curriculum.shtml (where are the basic science classes? They're all public health classes!!)
• MGH BSN to DNP: http://www.mghihp.edu/nursing/postpr...ulum.html?cw=1 (35/72 credits for Adult DNP are potentially not useful clinically while 46/83 credits for DNP in FM aren't)

It's kinda scary how inadequate that training is in order to practice medicine independently. You can't really count prior nursing experience as time practicing medicine because you weren't practicing medicine. Nursing clinical hours might help you transition into medicine but they are NOT a replacement for medical clinical hours.

Now, just for comparison, let's look at a med school curriculum. Here's an example from Baylor School of Medicine for M1/M2 (http://www.bcm.edu/osa/handbook/?PMID=5608) and for M3/M4 (http://www.bcm.edu/osa/handbook/?PMID=7463):

Courses taken: Patient, Physician, and Society-1 (4.5 credits), Patient, Physician, and Society-2 (6 credits), Bioethics (2.5 credits), Integrated Problem Solving 1 & 2 (10 credits).

Foundations Basic to Science of Medicine: Core Concepts (14.5 credits), Cardiovascular-Renal-Resp (11.5 credits), GI-Met-Nut-Endo-Reproduction (14 credits), General Pathology & General Pharmacology (6.5 credits), Head & Neck Anatomy (4.5 credits), Immunology (5 credits), Behavioral Sciences (6.5 credits), Infectious Disease (13 credits), Nervous System (14 credits), Cardiology (4.5 credits), Respiratory (3.5 credits), Renal (4 credits), Hematology/Oncology (5 credits), Hard & Soft Tissues (3 credits), Gastroenterology (4 credits), Endocrinology (3.5 credits), GU/Gyn (3 credits), Genetics (3 credits), Age Related Topics (2.5 credits).

Core Clerkships during M3: Medicine (24 credits, 12 weeks), Surgery (16 credits, 8 weeks), Group A selective (8 credits, 4 weeks), Psychiatry (16 credits, 8 weeks), Neurology (8 credits, 4 weeks), Pediatrics (16 credits, 8 weeks), Ob/Gyn (16 credits, 8 weeks), Family & Community Medicine (8 credits, 4 weeks), Clinical Half-Day (includes Clincal Application of Radiology, Clinical Application of Pathology, Clinical Application of Nutrition, Clinical Evidence Based Medicine, Longitudinal Ambulatory Care Experience, and Apex -- 23 credits).

So, without even taking into consideration M4 electives and required subinternships (which are usually in Medicine and Surgery), medical students already have a far superior medical training than NPs or DNPs. Other examples of med school curricula:

• UMich M1/M2: http://www.med.umich.edu/lrc/medcurr...gram/m1m2.html
• UMich M3/M4: http://www.med.umich.edu/lrc/medcurr...gram/m3m4.html
• Duke: http://medschool.duke.edu/modules/so...index.php?id=2

You can get a BSN to DNP in about 3 years according to many programs I've looked at. Medicine involves 4 years of medical school and a minimum of 3 years of residency before allowing independent practice. Here's the math:

BSN to DNP: 2.5 - 3 years of training; longer if courses taken part-time; 600-1000 clinical hours!
BS/BA to MD/DO: 4 years med school + 3-5 years residency: 7-11 years of training; not possible part-time; clinical hours > 17000

Clearly those NP/DNP programs are rigorous with lots of clinically useful courses and lots of clinical training, right? 🙄

 

[sylvanthus]

Hehe glad someone else jumped on specific examples, too busy studying for a repoductive exam to look it up.

 

[JaggerPlate]

Similar experiences here. I've seen NP's fake a lot of it. They give the aura of being a "doctor" but not much substance. To uninformed patients (most of them), they can't distinguish between an NP and a family doc unless they're looking at the name tag. In the case that they can distinguish them, the patients still often can't ascertain the quality of the the things the NP vs MD says regarding their medical conditions. In contrast, any medical student who understands the process of diagnosis (esp the differential) can probably instantly tell the difference between and NP and a REAL DOCTOR.

Just this week I went to my health clinic and was seen by an NP. The NP faked a lot of the visit (including misreading my BP - I know what my BP ranges - as well as being about 25 bpm off my true HR which I double checked immediately after the visit). Even though she walked down the 50 feet of the hallway with me to her room, she insisted on doing gait testing for the exam (where I walked 3 feet). I needed labs for residency employment.... she said that I couldn't have my Hep B titer and BMP checked at the same time (residency employment documents) because if I had Hep B then that would throw off my LFT's - so I should get the Hep B titer first and then based on those results do my LFT's, and strongly warning me that if I was Hep B positive that I should not be drinking even a single glass of alcohol. HUH??? When I asked for Hep C antibody (for work), she told me that it was a really rare and complicated test (it's an elisa) and that I don't need it because I probably don't have Hep C. I told her again that I just needed it for work, but she just wouldn't budge. Terrible bedside manner, totally condescending, and worst of all, a fake. I was proud of myself for holding it together for the entire visit without showing my disdain. As soon as I got out of there I made an appointment for a REAL DOCTOR the next day. Had my appointment with the MD, 10 minutes, got everything done, easy.

If you're ok with seeing an NP over a real doctor, I say that you are playing with fire.

Sorry... just had to vent about a stupid NP.

Seen two NPs before (University health clinic, had no choice) and both experiences were on par with this. I won't even go into the anecdotal details, because of course someone else can counter it with some bad MD experience.

For whatever reason I just thought of this... If it were not for midwives, the value of handwashing would not have been determined as fast as it was... Doctors were 'above' washing their hands after touching patients, and many more of their patients died as a result. Midwives washed their hands and had a fraction of the fatalities that the doctors had...

If it hadn't been for barbers, we wouldn't have surgeons. You think I should schedule open heart surgery at Super Cuts? 😉

I am curious jagger, so you are saying that a PA's MS degree is superior to an NP's MS degree?

Absolutely

In order to become an RN the person had to take anatomy, physiology, pharmacology, etc, then they must work a minimum of 2 years as an RN before they can take MS level courses, (both didactic and clinical) in order to become a NP (or APRN, etc).

They had to take undergrad anatomy, phys, and pharm ... I've heard people fall back onto this argument before, and it simply doesn't hold weight. Just because a class is called 'anatomy' doesn't mean it's equivalent to any real anatomy class.

Anecdote - I have a friend who happened to take 'anatomy' at a community college at the same time I took my first quarter of med school gross, and obviously just in discussions of the course, what he learned, what he had to do, etc, it was very clear that this course was not in the same galaxy as my gross anatomy course, but technically we both took 'anatomy'

Furthermore, I fail to see how working 2 years really holds much weight either, as pre-meds don't have such requirements and I don't think you'd make an argument that nurses have superior medical training to physicians.

The steps nurses take before becoming an NP are, from what I've seen, wildly unregulated, and the quality/requirements of NP/DNP programs are even less uniform. Like I said before, you can earn a DNP online.

To become a PA, you have a BS in xyz, take A/P, pharma, etc, and have 1 year of clinical training. Where is a PA superior?

Have you looked at the difference between the actual PA school versus NP school requirements? The PA model is rigorous and close to that of medical school - a few courses and different clinical rotation focus. The same cannot be said for nursing programs that are designed to train individuals to practice nursing.

Additionally, you are saying that NPs aren't regulated, hmmm interesting... Wonder why my NP has a license to practice?? Some one must be regulating her practice; she didn't get it from a cracker jack box!

I'll bet you a grand that no where on that license will you see the word 'Medicine.' Of course she has a license ... everyone has a license to do what they do. However, she has a NURSING license regulated by a NURSING board, NOT the board of medicine. However, her intent is to practice independent medicine, which is why I state that it's unregulated with regard to medical practice.

The same can't be said for PAs who are underneath the medical board (like physicians) and also practice in conjunction with a physician's license. This is medical licensing for practicing medicine.

For the record, I will say outright, I have met more PAs I didn't like as caregivers than NPs. I have yet to meet an NP that was snippy etc... however, I routinely meet PAs that I'd like to bitch slap for being snotty/pissy/etc...

Cool. I've interacted with both and found the exact opposite.

Edit: to the above poster... that's ONE NP, and I can say the same thing about several doctors. I could have my sister-in-law tell you about her doctor that accused her, to her face, of being a drug addict... Accused because the MD REFUSED to do an ultrasound on her abdomen when she was complaining of abdominal pain FOR A YEAR, and kept telling her she had gas pain. She was accused of being 'drug seeking' because she came in again for pain, but the doc failed to notice a key point. The RX for the pain meds was over a year old, and had never been refilled. My SIL filed a complaint with the clinic in regards to this. I told her to try an NP, she did, the NP DID the ultrasound and confirmed MY (NOT EVEN A MED STUDENT'S) suspicion of gallstones... Gee... we can go round and round and round about bad providers, they live in both camps

Edit: To the above poster ... that was one doctor, and I can say the same thing about several NPs.

This is why anecdotal evidence isn't worth the paper it's printed on.

 

[JaggerPlate]

I think JaggerPlate needs a vacation

"Nonsense, I have not yet begun to defile myself ..."


Gold star for whoever IDs it.

 

[DbDan]

I'm so happy that you've decided to go into medicine in order to make the world a better place. I trust that as you go through your life and your career, you will continue to grow and mature in ways beyond what you yourself can even imagine at this juncture in your life. I look back on my own life, prior to completing my education, prior to having a "real job", prior to mothering 3 children, and I realize how naive and inexperienced I was in the ways of how the real world works, and yet I was so convinced that I "had it all figured out". Age and life experience teach you that restraint is sometimes the better part of valour, and I know you will figure this out as well in your discussions with your peers. As you grow and mature, you will learn how MD's and APRN's work together to provide the best health care possible to all of our citizens here in the US. It is a team effort, a truly mutualistic relationship. It really is a beautiful thing when providers can work together with mutual respect, casting aside their egos, for the betterment of patient care. Throughout the completion of your studies and training, I hope that you will keep an open mind and that you will truly strive towards what is best for patient care, not merely what is best for MickJagger. The world is a political place, MickJagger. Life is political. My job and your (future) job are also political. Try not to let it make you so angry. No one is out to get "your job". There is room for both MD's and APRN's, and you will see this once you get out into practice. There are plenty of patients to go around. 🙂 Good luck to you.

I had a really long response typed up but chose to not post it... We'll just say working together is great. NPs working under the supervision of physicians is just fine by me. Pushing to take the responsibilities of MDs/DOs in even the most specialized and competitive of fields with FAR less training is not. Do you have any idea how many times I've heard "you shouldn't have even bothered with med school, just go be a CRNA, its SO much easier" thats great... but I'd prefer to actually have in-depth knowledge in what I'm doing in case something goes wrong. Like I said, working together is exactly the way the system is supposed to be, but that is not the leaders of your profession are pushing for, they are pushing to replace the responsibilites without the liability and with equal re-imbursement.

Secondly, there isn't "enough patients to go around". The office I worked at lost money on days where we saw a large number of complex cases that took a long time. Those easy patients you want to take are what keeps practice afloat, which you keep avoiding. Furthermore, what happens when your easy case is actually underlying more difficult, it goes unnoticed and by the time it gets to a DO/MD its too late? Is that an improvement of patient care?

 

[JaggerPlate]

I'm so happy that you've decided to go into medicine in order to make the world a better place. I trust that as you go through your life and your career, you will continue to grow and mature in ways beyond what you yourself can even imagine at this juncture in your life. I look back on my own life, prior to completing my education, prior to having a "real job", prior to mothering 3 children, and I realize how naive and inexperienced I was in the ways of how the real world works, and yet I was so convinced that I "had it all figured out". Age and life experience teach you that restraint is sometimes the better part of valour, and I know you will figure this out as well in your discussions with your peers. As you grow and mature, you will learn how MD's and APRN's work together to provide the best health care possible to all of our citizens here in the US. It is a team effort, a truly mutualistic relationship. It really is a beautiful thing when providers can work together with mutual respect, casting aside their egos, for the betterment of patient care. Throughout the completion of your studies and training, I hope that you will keep an open mind and that you will truly strive towards what is best for patient care, not merely what is best for MickJagger. The world is a political place, MickJagger. Life is political. My job and your (future) job are also political. Try not to let it make you so angry. No one is out to get "your job". There is room for both MD's and APRN's, and you will see this once you get out into practice. There are plenty of patients to go around. 🙂 Good luck to you.

ETA: PS- Did want to add that the president of ACOG, Dr. Waldman, he's married to a CNM. I heard him speak at the last ACNM annual meeting- phenomenal guy. If you ever have the chance to hear him speak, pay attention. That's a man with great respect for CNM's and the work that we do. 👍

Thank you for remaining so civil, but I think we'll just have to agree to disagree with a lot of the points concerning this issue. Best of luck!

PS: Just for clarification sake, I wanted to state that my SDN name has nothing to do with Mick Jagger - I was always more of a Beatles fan, and far more of a Richards than a Jagger fan (though my life both makes them look like 'droopy-eyed, armless children' - a second gold star for that ID)

 

[JaggerPlate]

I had a really long response typed up but chose to not post it... We'll just say working together is great. NPs working under the supervision of physicians is just fine by me. Pushing to take the responsibilities of MDs/DOs in even the most specialized and competitive of fields with FAR less training is not. Do you have any idea how many times I've heard "you shouldn't have even bothered with med school, just go be a CRNA, its SO much easier" thats great... but I'd prefer to actually have in-depth knowledge in what I'm doing in case something goes wrong. Like I said, working together is exactly the way the system is supposed to be, but that is not the leaders of your profession are pushing for, they are pushing to replace the responsibilites without the liability and with equal re-imbursement.

Secondly, there isn't "enough patients to go around". The office I worked at lost money on days where we saw a large number of complex cases that took a long time. Those easy patients you want to take are what keeps practice afloat, which you keep avoiding. Furthermore, what happens when your easy case is actually underlying more difficult, it goes unnoticed and by the time it gets to a DO/MD its too late? Is that an improvement of patient care?

👍 👍 👍

 

[Sinfest]

Jagger, you're one of the people I respect the most on SDN.

Keep fighting the good fight 👍

 

[Sinfest]

I had a really long response typed up but chose to not post it... We'll just say working together is great. NPs working under the supervision of physicians is just fine by me. Pushing to take the responsibilities of MDs/DOs in even the most specialized and competitive of fields with FAR less training is not. Do you have any idea how many times I've heard "you shouldn't have even bothered with med school, just go be a CRNA, its SO much easier" thats great... but I'd prefer to actually have in-depth knowledge in what I'm doing in case something goes wrong. Like I said, working together is exactly the way the system is supposed to be, but that is not the leaders of your profession are pushing for, they are pushing to replace the responsibilites without the liability and with equal re-imbursement.

Secondly, there isn't "enough patients to go around". The office I worked at lost money on days where we saw a large number of complex cases that took a long time. Those easy patients you want to take are what keeps practice afloat, which you keep avoiding. Furthermore, what happens when your easy case is actually underlying more difficult, it goes unnoticed and by the time it gets to a DO/MD its too late? Is that an improvement of patient care?

Exactly what I wanted to say 👍

 

[DbDan]

though my life both makes them look like 'droopy-eyed, armless children' - a second gold star for that ID)

You must have adonis DNA and Tiger Blood

"Nonsense, I have not yet begun to defile myself ..."


Gold star for whoever IDs it.

I'm your huckleberry....

 

[JaggerPlate]

You must have adonis DNA and Tiger Blood



I'm your huckleberry....

Winning (duh) ...

Nicely done. 👍

 

[DbDan]

Interesting that this same thread is ongoing in the allo student forum as well (not pre-allo). Someone over there brought up an old Chinese solution for healthcare shortage of Barefoot doctors. Essentially, they found that while theere were overall improvements in health the results were widely varied. Eventually the government encouraged them to attend medical school or go through the same licensing as physicians to continue practicing as physicians. If they passed they became village doctors, if not they became village aides.

Now the question is, what would the response be of DNPs if the state boards required them to sit for USMLE/COMLEX 1, 2, 3? How many would realistically have any shot of passing? If they really want to claim equality shouldn't they have to at minimum pass the same exams? I remember reading that 50% of NPs failed a simplified version of 3...

 

[Prncssbuttercup]

My physician friend and my NP friend both told me not to become a PA because they get **** on by doctors. This is why NPs will fight any regulation that puts them under sole control of Drs... PAs do 90% of the work of an MD/DO, went to school for 50% of the time, and get paid 25%. No thanks... Additionally, I have looked at the NP programs in my state, and what was quoted before doesn't match. All the schools require 2 years of nursing experience. There used to be programs to go straight from a BS in xyz to an NP, I haven't found one in 6+ years in my area (I think there are still ~2-5 in the country), you can do an accelerated BSN program if you have a BS/BA in xyz, but not NP. DNP programs, as I and The Runners Wife have stated, are 100% non-clinical, so they aren't really a place to compare clinical hours. They are pointless, and most NPs don't want to get them as it will just cost them more $$ for no gain.


Either way, jagger, you clearly want to see the profession removed, so you should go to DC and lobby congress to push three things 1: med schools need to enlarge their class sizes to bring in more physicians, 2: the residency slots need to be expanded to meet the demand, 3: the PAs schools must do the same. If not, you will have a system that will not be able to keep up with patient demand. There is already a shortage in most areas of primary care practitioners, and to remove NPs from the game will only hurt the system. You clearly think they are ALL inept, so don't give me "its fine if they work under drs" no, to you they should be abolished, you just aren't willing to say so. You have stated repeatedly that they are ALL incompetent, don't have enough training to do what they do, and shouldn't be allowed to do it... So, take your ambitions and go do something about it. Be the lobbyist, you seem to have a knack for it...

 

[DbDan]

SBB you are clearly taking it to the extreme. Jagger is stating that NPs should not be allowed independent practice rights; not that they are all incompetant and should be done away with. He is supporting hiring PAs over NPs because unlike NPs, PAs are not fighting to encroach upon the duties of physicians. Furthermore, PAs take the brunt of the bitchwork because they are working direclty under a physicians license. They get paid less than NPs because they assume no responsibility, if they mess up the lawsuit goes toward the physician's malpractice.

IMO, the current model of NPs is perfectly fine, working alongside albeit under the supervision of doctors. When I go to the doctor I expect to see an MD/DO, not an NP in a white coat parading as one. I think that Jagger as well as any other future physician has every right to take offense when someone who has had less schooling and less training in a field attempts to undercut them in the job they were trained to do and claims they are better at it with studies funded by their own organization.

 

[SoDakMLS]

I needed labs for residency employment.... she said that I couldn't have my Hep B titer and BMP checked at the same time (residency employment documents) because if I had Hep B then that would throw off my LFT's - so I should get the Hep B titer first and then based on those results do my LFT's, and strongly warning me that if I was Hep B positive that I should not be drinking even a single glass of alcohol. HUH??? When I asked for Hep C antibody (for work), she told me that it was a really rare and complicated test (it's an elisa) and that I don't need it because I probably don't have Hep C.

From my dealings as a Medical Technologist with nurses over the past 3 years, I've noticed that they really have more trouble than you'd think with labs:

Me: Hi, I'm calling on patient X. I'm reading a glucose of >600 and a K+ >7.0--these need to be redrawn as they are contaminated.
Critical Care Nurse (completely "forgetting" they have dextrose and KCl infusing through the line they drew out of) : What do you mean, CONTAMINATED?!?!
Me: 😕

I also hate having to call and ask about sudden changes in lab values that I can't find explanations for in their computer chart (i.e. surgery, large boluses, drug doses, etc.). They can't always come up with a reason but would rather have a questioned result charted than have blood redrawn. Then if I don't MAKE them redraw, they call me back 15 minutes later after the doc's seen it and say they're going to redraw the specimen.

It's very unfortunate if this is spilling over into some of the NP's as well, although the NP's that are utilized on the night shift at our hospital NICU seem alright (they're actually interested in accurate, quality results instead of complaining about how hard it is to get blood from babies).

Back to the quoted NP story--a Hep B Surface Ab test for immunity is completely different from the test for active Hep B infection, which is a HB surface ANTIGEN test. Anti-HCVs are definitely common and completely automated (read: NOT complicated). And I'm not even gonna touch confusing Hepatitis B immunization (which contains NO virus whatsoever) with contracting HBV.