Still not clear about NPs vs. IM

[powermd]

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Having a daughter-in-law who is an OD degree, meaning, Doctorate of Optometry, she has every right to be called Doctor in her professional setting. You seem remarkably uninformed about both Optometrists and DO's

The semantic issue of who is a real "doctor" is soooooooo tedious. Why do non MD/DO "doctors" and their friends get so defensive when confronted with the fact that almost 100% of the time in the mind of the public, doctor = physician. Non-physician doctors may have a right to their title (I say "may" because I'm not sure DCs deserve the title), but they need to accept that 1) publicly "doctor" = physician, and 2) they are not physicians, and should recognize and acknowledge the limits of their profession. Same goes for NPs/PAs/CRNAs.

It's unfortunate so many of the tags that identify the unique skills and education that physician's have are being co-opted by so many non-physicians. There is something to be said for being able to quickly identify the "doctor" who has the skills and willingness to intervene in a medical emergency. Maybe the MD/DO community should start a public education campaign to teach people to refer to them as "physicians." On a recent flight from Boston to Chicago, the flight attendants announced that there was a medical emergency, and if there were any doctors on board, they should press their call button. I pressed my call button, but immediately made it known to the attendant who responded that I was a fourth-year medical student (although technically, I have completed all requirements for the title of "doctor"), and would offer help only if a practicing doctor was unavailable. Fortunately, one was. Should I have proudly asserted "yes, I am a doctor" despite not being at all ready to meet the standard of care that would be expected of a physician? I don't think I should have, and neither should any other non-physician "doctor".

 

[shod0039]

I am an RN, planning on returning to Uni to do my masters and later (after many years of experience) becoming a Nurse Practitioner. I have absolutley no intention whatsoever of usurping the role of the physician. A nurse practitioner is qualified (and authorised by the appropriate registration board) to practice as a nurse, but at an advanced level. Thus, they are given prescriber authority as well as assuming many duties traditionally left for Doctors lower down the food chain.

This does not pose a threat to the medical profession for two reasons:

1) Nurse practitioners, while able to practice with autonomy to a certain extent, recognise there are limitations to their scope of practice. Thus, it is still neccessary to involve a physician in many situations. Additionally, while many studies have proven that patients are satisfied with care received from advanced practice nurses, they still overwhelmingly prefer a physician to lead or manage the team.

2) Nurse practitioners are still nurses, and thus have different goals to physicians. While some duties they perform may overlap with duties once performed by medical staff, they are still employed as nurses to perform nursing work.

There seems to be a repeating theme in many (most) of these forums: that the big bad nurses are out to steal medicine's thunder, thus giving patient's substandard care and bla bla bla. This is simply not true, and the people making these assertions are only demonstrating the extent of their ignorance. Nursing and medicine are co-dependant (you wouldn't send your patients to hospital if they didn't need nursing care), and as soon as everyone realises that such changes will always be a part of healthcare, we're all doomed to read these ignorant and inflammatory remarks.

Lastly, there is a big misunderstanding about how a NP is qualified to diagnose and treat patients. During the 4 year undergraduate degree most RN's undertake, all are taught the same anatomy, physiology, pharmacology, etc, as medical students. The clinical experience they gain over the years following graduation further consolidates this knowledge, and helps the RN to gain many new skills. The masters (and in some cases PhD / DNSc) programs offered to nurse practitioners provide further education and training so that they are able to function safely in advanced practice roles. All up it generally takes at the very least 6 years of university study to become a NP, but often it is more. It is also important not to overlook the knowledge and skills gained from many years of clinical practice. Nurses employ the same evidence based approach to practice as doctors, and to suggest that a patient is receiving inferior care simply by choosing to see a NP for less complex matters is ridiculous.


Regards,

Steve (RN)

PS: I understand that the issue of CRNA's is rubbing many people up the wrong way too: I urge you all to actually do your homework and come up with an informed opinion (rather than one you have formulated reading the vitriolic posts on this forum) before slandering the majority of hard working and dedicated nurses on whom you depend to perform many of your duties.

 

[zenman]

Posted by Leukocyte: I say MDs should run public ads to inform the public about what is going on. Let the patients vote. It's their health anyway.

You guys can't even fight the right battle! LOL! Patients have already voted. They are spending more out of pocket dollars and making more visits to alternative practitioners than they are to physicians. Have you a clue why?

 

[Eidolon6]

MDs will always need to be around...no ground is lost...as MDs have a much larger range of skills and specialization opportunities.

Frankly, I am glad they are there to handle sore throats, VD screening, and outpatient diabetes, etc. I work with one in the ER and she is great. She's got a good handle on differential diagnosis, up to date treatments. The best thing is though...she knows when to ask us MDs a question...in other words, she knows her limits, in the same way that MDs consult other MDs when they have taxed their knowledge. She also knows that they best provider knows when *not* to do something as well as when to do something.

I personally prefer the more complex cases they are not trained to handle or the cases they send my way because things have gotten out of hand.

Once insurance companies and lawyers find a way to cash in on the NP/PA craze, as they strive for more autonomy....we'll start seeing malpractice insurance/lawsuits for these groups...then they may think twice about the depth of their skills earned in only 2 years of training.

 

[powermd]

You guys can't even fight the right battle! LOL! Patients have already voted. They are spending more out of pocket dollars and making more visits to alternative practitioners than they are to physicians. Have you a clue why?

People are *****s and will listen to any snake oil salesman claiming to posess the magic beans that will cure all their ills?

 

[supercut]

I share the concern of the original poster. There are a number of PA and NP who view themselves as physician replacements rather than physician extenders. This is very problematic in the city where I am a resident.

There is a service within the IM department called the NP service. It is just that...several NPs, attendings and NO RESIDENTS. There is no trieage of pts, the NP service takes all comers, sometimes very sick, very complicated pts (from the surgery standpoint we get consults for all the same issues from there service as we do from the residents service). I have seen the NPs write notes after the attending note saying "agree with Dr X recommendation to use medication Y"

Within the surgery department, PA and NP are becoming increasingly aggressive. THey run the floors and generally (with few exceptions) do no tolerate or welcome any input from residents. THey do not come in early and round, however. When we try to run the list with them and go over the mamangement plan, they ignore what we want and do whatever they want. On several services (and increasing gradually) they show up and start d/cing all resident orders and write their own. An increasing number of attendings round with their PA/NP only and and not with the residents (residents round separately...thus you have two separate teams in essesce, seeing the same pts) They have even been scrubbing cases in leiu of junior residents, and I have heard several attendings say they don't care if they have a PA, intern or chief scrub the case with them. It is largely because of this that I am looking for a spot elsewhere. I cannot afford to allow these individuals to jepordize my surgical education.

I know several people who were PA or NP prior to going to med school. THey attest to how different the training is. I have yet to meet a MLP who understands prereanal vs intrinsic renal vs post renal azotemia.

In my state, NP can do nearly everything that MD can do. There is no limits on practice setting, no limits on what Rx they write. Some services have them getting surgical consent (something I believe a surgeon should be doing). THe only thing they can't do is sign a death certificate. (I have been paged on call to an ICU that is totally run by PA/NP with no residents for the sole purpose of pronouncing a pt and doing the death paperwork)

The presence of PA/NP here is a serious threat to resident education. It is only a matter of time before they push to try to take over medicine completely. There are many very good ones who know and keep within their appropriate limits. However, the profession is very organized and very politically active and on a mission. THe AMA and other organizations for MD's are very lax in comparison. It's time to wake up before it's too late.

 

[Andrew_Doan]

The AMA and other organizations for MD's are very lax in comparison. It's time to wake up before it's too late.

I agree! I just paid my AMA membership fee and sent money to the AMA Political Action Committee.

I sent money to OPHTH PAC, but you all can support ophthalmology's fight against optometry's expansion of their scope of practice by sending letters to your congress members. You can use these sites to generate e-mails/letters/FAX:

http://capwiz.com/aao/issues/alert/?alertid=4509636

http://www.vetscoalition.org

Here's an old article about non-physicians pushing for expanded scope of practice:
http://forums.studentdoctor.net/showthread.php?t=124132

 

[cbc]

Yeah people. You should browse the PA forum. The PAs in there are crazy. They bag on nurses, residents, and believe they are as well trained as an certified MDs when they are not, and want to mislead the public into thinking they have all it takes to provide complete care to patients at lower costs. They will end up misleading the public, taking over the physician's role, and reducing the quality of care to patients in our entire society. MDs, let's stand together and fight aggressively on this war against them throughout our entire medical careers!!! Join AMA and fight!!!

I agree! I just paid my AMA membership fee and sent money to the AMA Political Action Committee.

I sent money to OPHTH PAC, but you all can support ophthalmology's fight against optometry's expansion of their scope of practice by sending letters to your congress members. You can use these sites to generate e-mails/letters/FAX:

http://capwiz.com/aao/issues/alert/?alertid=4509636

http://www.vetscoalition.org

Here's an old article about non-physicians pushing for expanded scope of practice:
http://forums.studentdoctor.net/showthread.php?t=124132

 

[sdude]

Lastly, there is a big misunderstanding about how a NP is qualified to diagnose and treat patients. During the 4 year undergraduate degree most RN's undertake, all are taught the same anatomy, physiology, pharmacology, etc, as medical students.

Do you really believe this?

 

[Neuron]

I share the concern of the original poster. There are a number of PA and NP who view themselves as physician replacements rather than physician extenders. This is very problematic in the city where I am a resident.

There is a service within the IM department called the NP service. It is just that...several NPs, attendings and NO RESIDENTS. There is no trieage of pts, the NP service takes all comers, sometimes very sick, very complicated pts (from the surgery standpoint we get consults for all the same issues from there service as we do from the residents service). I have seen the NPs write notes after the attending note saying "agree with Dr X recommendation to use medication Y"

Within the surgery department, PA and NP are becoming increasingly aggressive. THey run the floors and generally (with few exceptions) do no tolerate or welcome any input from residents. THey do not come in early and round, however. When we try to run the list with them and go over the mamangement plan, they ignore what we want and do whatever they want. On several services (and increasing gradually) they show up and start d/cing all resident orders and write their own. An increasing number of attendings round with their PA/NP only and and not with the residents (residents round separately...thus you have two separate teams in essesce, seeing the same pts) They have even been scrubbing cases in leiu of junior residents, and I have heard several attendings say they don't care if they have a PA, intern or chief scrub the case with them. It is largely because of this that I am looking for a spot elsewhere. I cannot afford to allow these individuals to jepordize my surgical education.

I know several people who were PA or NP prior to going to med school. THey attest to how different the training is. I have yet to meet a MLP who understands prereanal vs intrinsic renal vs post renal azotemia.

In my state, NP can do nearly everything that MD can do. There is no limits on practice setting, no limits on what Rx they write. Some services have them getting surgical consent (something I believe a surgeon should be doing). THe only thing they can't do is sign a death certificate. (I have been paged on call to an ICU that is totally run by PA/NP with no residents for the sole purpose of pronouncing a pt and doing the death paperwork)

Sounds like an insane program.

I'm surprised the attendings/administration haven't tried to do something about it - if the services are run exactly as you say, you'd be hard pressed to convince anyone that patients are not dying/getting poorer outcomes from this, but even leaving that out of the picture, wouldn't this duplication of services be economically disadvantageous for the hospital? Wouldn't having a service run the traditional way cost less than having one resident-run IM service + one "NP-run service " ? Cripes, just the thought of it creeps me out. You have an ICU run only by NPs???!!!!!

 

[shod0039]

Regarding several postings discussing the militancy of nursing professional organisations compared with medical organisations: While it is true that nurses are well organised industrially, etc. the majority of their success can be attributed right back to physicians who actually push the NP and PA agenda.

Many private hospital facilities are chaired by physicians, or the attending physicians in the facility have controlling interest in the stock. When they see that employing NP's and PA's can increase their profits +++, why would they stand in the way? And in a nation where health care is seen as a commodity that can be bought and sold rather than a fundamental right of every citizen, it is inevitable that market forces will cause physicians to compete with other providers who provide similar services at a lower cost.

So do we just get a government sponsored system of universal health coverage? It will never happen - MD's in the USA are among the best paid in the world - universal health coverage would limit the profitability of health care and physician pay would decrease. Besides, the hospital corporations would never stand for it. It looks as though NP's and PA's are an inevitability in the current health care climate.

It disturbs me to hear of the unrest in the medical community about NP's. Nurses in general are independant practitioners, regardless of whether they are RN, NP, CRNA, etc. Advanced practice roles simply give nurses the authority to conduct nursing work at a higher level. To suggest that nurses will EVER replace physicians as experts in medicine is ridiculous. We went into nursing because our interest was in that field. Nurses who long to practice medicine generally leave nursing to do just that, not become NP's...

 

[Andrew_Doan]

It disturbs me to hear of the unrest in the medical community about NP's. Nurses in general are independant practitioners, regardless of whether they are RN, NP, CRNA, etc. Advanced practice roles simply give nurses the authority to conduct nursing work at a higher level. To suggest that nurses will EVER replace physicians as experts in medicine is ridiculous. We went into nursing because our interest was in that field. Nurses who long to practice medicine generally leave nursing to do just that, not become NP's...

Good points. My wife is a nurse, and I have some understanding from the nursing perspective.

I think the problem, however, is that organized nursing and non-physician groups want the autonomy of a physician without the MD training or additional schooling. It's amazing that with a stroke of a pen, the legislators have the power to determine overnight who will do surgery or prescribe dangerous systemic medications.

 

[bennyhanna]

I am an RN, planning on returning to Uni to do my masters and later (after many years of experience) becoming a Nurse Practitioner. I have absolutley no intention whatsoever of usurping the role of the physician. A nurse practitioner is qualified (and authorised by the appropriate registration board) to practice as a nurse, but at an advanced level. Thus, they are given prescriber authority as well as assuming many duties traditionally left for Doctors lower down the food chain...



...Lastly, there is a big misunderstanding about how a NP is qualified to diagnose and treat patients. During the 4 year undergraduate degree most RN's undertake, all are taught the same anatomy, physiology, pharmacology, etc, as medical students. The clinical experience they gain over the years following graduation further consolidates this knowledge, and helps the RN to gain many new skills. The masters (and in some cases PhD / DNSc) programs offered to nurse practitioners provide further education and training so that they are able to function safely in advanced practice roles. All up it generally takes at the very least 6 years of university study to become a NP, but often it is more. It is also important not to overlook the knowledge and skills gained from many years of clinical practice. Nurses employ the same evidence based approach to practice as doctors, and to suggest that a patient is receiving inferior care simply by choosing to see a NP for less complex matters is ridiculous.


Regards,

Steve (RN)

.

Are you kidding me? I'm not sure where you went to nursing school, but it must be one hell of a nursing school if you truly beleive that basic college anatomy and physiology is the same as a physician's advanced anatomy/physiology/biochemistry classes.

Lets take a look at the 4 year BSN degree.

2 years are spent satisfying general education requirements, along with the RN requirements... pharmacology, patho-microbiology, biology, SOME college's require an Intro Chemistry class (but many BSN programs do not).

Also, many BSN programs require MATH 1000, problem solving math, below the college algebra/pre-calculus level! This followed by 2 years of nursing class.

I would say, the BSN is more comparable to two Associates degress. One, a 2 year associate of science, and one an associate of applied science with an emphasis in nursing (available at your local community college).

Now, to say that under grad Anatomy &Physiology compares with the integrated advaced A&P (integrated with chemistry, biochemistry, college physicis, and calculus) is a bit far fetched. The gross anatomy, comparative antatomy, and histology a physician takes far excedes that of the typical undergraduate A&P course.

And pharmacology too? Are you serious? The advanced, and again integrated, pharmacology a physician takes in no way compares to an RN's 1 SEMESTER of pharmacology... if it does at your school, then they're graduating physician quality RN's... I am amazed that one would think the two classes comparable.

That said... The BSN degree is more or less a 2 year science program, followed by a 2 year nursing program = BSN. Yes, they do have to have one year of experience as an RN before Masters, but even Masters level RNP is not a comparison to the MD training...

Now, lets look at a TYPICAL physician's education...

4 years in an (generally) undergraduate science degree. (compared to a nurses 2 years of science and 2 years of nursing).

In addition to the degree of choice of the physician, because it does NOT need to be in a science field, but, if it is a non-sci degree, they still must fulfill the pre-reqs, which could make their degree pursuit longer. Here is an example of BASIC pre-reqs from the University of Colorado School of Medicine, which is similar to many med schools nationally. <http://www.uchsc.edu/sm/sm/mddgree.htm>

Prerequisite Course Semester Hours
General biology (with lab) 8
General chemistry (with lab) 8
Organic chemistry (with lab) 8
General physics (with lab) 8
English literature, composition or equivalent 9
Mathematics (college level)* 6

So, RNs, may satisfy the General biology (BIO 101 4 credits, Patho-micro 4 credits), maybe english I and II (at 4 credits a piece), and a few college's that require nurses to be at a college algebra level could meet 3 of the 6 college level mathematics courses. But physician's generally need AT LEAST A CALCULUS LEVEL OF MATH, meaning, college algebra, triginometry, and analytic calculus... Quite different from Math 1000 problem solving math, that wouldn't count as a college level course in many other degrees. In addition, many medical colleges, and certainly the MCAT require a strong college (not general) level of knowledge in physics.

Physicians need to have their FULL four year bachelor's (emphasing the 2 year breaks in the RN degree), need to satisfy similar requirements to those above, and are urged to take a Biochemistry class. Then, they must take the MCAT and score high enough amongst their peers, who also have bachelor's degrees, have met the requirements, and have acceptable gpa's, and hope to get in.

The first two years of medical school are NOT like an RN's undergrad A&P, pharmacology, they are ADVANCED and integrated a/p, pharmacology, biochemistry, followed by 2 years of rotations, followed by a 2-7 (neurosurgeon) year residency. And that compares to a 1 year undergraduate Anatomy class that CNA's and EMT's take?


I would suggest talking with your physicians, or contacting local medical schools to see how advanced their classes really are.

Do you really think that a physician's Doctor-Level course compares to a Freshman's-undergraduate Anatomy/physiology/pharmacology class? If it was as easy as that, we'd all by physicians!

... It seems, everyone thinks that they are a physician. Maybe this is where the problem lies.

~BB

 

[shod0039]

Are you kidding me? I'm not sure where you went to nursing school, but it must be one hell of a nursing school if you truly beleive that basic college anatomy and physiology is the same as a physician's advanced anatomy/physiology/biochemistry classes.

Lets take a look at the 4 year BSN degree.

Do you really think that a physician's Doctor-Level course compares to a Freshman's-undergraduate Anatomy/physiology/pharmacology class? If it was as easy as that, we'd all by physicians!

... It seems, everyone thinks that they are a physician. Maybe this is where the problem lies.

~BB

I think my remarks were taken out of context (although I can see now I did not express myself as clearly as I perhaps ought) - what I meant to say was that nursing is a science based discipline, and thus we are taught anat/phys/etc as are all other health disciplines. I am not suggesting that nurses study these subjects in the same depth that physicians do, nor do I think that a RN is suitably qualified to replace a MD. However, I do firmly believe that with all the advances in medicine, nursing, and healthcare generally, NP's have a legitimate claim to practice at the levels they do (generally very simple diagnosis/treatment such as UTI's, etc) thus freeing up physicians to practice as the real experts in medicine. Find me a NP who seriously asserts they could replace an MD and I'll refer them to the relevant NP disciplinary committee for unethical conduct...

I'm not doubting that physicians are the true experts in medicine/surgery. Not many nurses would dispute that either. But the education, training, and experience of advanced practice nurses makes them more than qualified to take the cases that physicians don't want. Basically, it makes no sense for me to page a physician 6 times a day to get tylenol or replacement fluids charted and re-charted or path. forms signed for routine cultures etc. when I can just get a NP to review the patient and authorise it. As far as family practice goes, I have very little knowledge of that area and can't comment, but I doubt that NP's etc in this area are trying to dethrone physicians either. Relax. Your jobs are safe...

 

[cbc]

I give credit to the nurses posting here in a sense that they express having limits, their recognition of those limits, and that physicians know more. You all should seriously browse the PA forum. The PAs there believe they know 80% of a physician, and that their training or care is basically equaled to a physician.

I think my remarks were taken out of context (although I can see now I did not express myself as clearly as I perhaps ought) - what I meant to say was that nursing is a science based discipline, and thus we are taught anat/phys/etc as are all other health disciplines. I am not suggesting that nurses study these subjects in the same depth that physicians do, nor do I think that a RN is suitably qualified to replace a MD. However, I do firmly believe that with all the advances in medicine, nursing, and healthcare generally, NP's have a legitimate claim to practice at the levels they do (generally very simple diagnosis/treatment such as UTI's, etc) thus freeing up physicians to practice as the real experts in medicine. Find me a NP who seriously asserts they could replace an MD and I'll refer them to the relevant NP disciplinary committee for unethical conduct...

I'm not doubting that physicians are the true experts in medicine/surgery. Not many nurses would dispute that either. But the education, training, and experience of advanced practice nurses makes them more than qualified to take the cases that physicians don't want. Basically, it makes no sense for me to page a physician 6 times a day to get tylenol or replacement fluids charted and re-charted or path. forms signed for routine cultures etc. when I can just get a NP to review the patient and authorise it. As far as family practice goes, I have very little knowledge of that area and can't comment, but I doubt that NP's etc in this area are trying to dethrone physicians either. Relax. Your jobs are safe...