Two Year Degree and the "Doctor Nurse"

[MedicineDoc]

To be paid by Medicare at 85% of physician level and 95% in rural areas. 200 Doctor Nurse Programs already established. The AMA is doing absolutely nothing from what I have read. I am starting to believe that physicians especially primary care physicians need to unionize.

http://blogs.wsj.com/health/2008/04/02/say-hello-to-dr-nurse/?mod=WSJBlog



Take a look at the incredibly weak course schedule.

DNP Family Nurse Practitioner Schedule
YEAR 1
FALL
NSG 911 Philosophy of Science 3(3-0)
BIOE 712 Principles of Epidemiology 3(3-0)
NSG 814 Biostatistics3(3-0) TOTAL9(9-0)

SPRING
NSG 916 Concept & Theory Analysis 3(3-0)
HSA 851Leadership and Health Policy 3(3-0)
Nursing Advanced Practice Selective 4(2-2) or required specialty equivalent

TOTAL10(8-2)

YEAR 2
FALL
HSA 877 Health Care Economics 3(3-0)
NSG 819Evaluation of Practice 4(4-0)
NAPS Nursing Advanced Practice Selective 4(2-2) or required specialty equivalent

TOTAL11(9-2)

SPRING
NSG 926 Resident Practicum 6(0-6)
NSG 946 Residency Project3(3-0) TOTAL9(3-6)


TOTAL NUMBER OF HOURS FOR THIS OPTION
39(29-10)


Say Hello to ‘Dr. Nurse'

Posted by Joe Mantone
Nursing schools are making a push to award doctor of nursing degrees, a move that has some physicians and nurses worried, the WSJ's Laura Landro reports.

Dawn Bucher, a DNP, treats a child patient at Ivanhoe Clinic in Ivanhoe, Minn. Will this confuse the child?More than 200 schools have started or are readying programs, and the National Board of Medical Examiners has agreed to develop a voluntary certification exam to establish a national standard for doctors of nursing practice.
A fresh supply of well-trained primary care practitioners could help counter a physician shortage.
The goal is to create "hybrid practitioner" who will have more skills and training than a nurse practitioner with a master's degree, Mary Mundinger, dean of New York's Columbia University School of Nursing, tells Landro. She adds that these students are being trained to have more focus than doctors on coordinating care among specialists and health-care settings.
But wait, nurse advocates say, there's a nursing shortage too.
These advocates fear that nurses will be enticed by the higher pay and prestige that comes with advanced degrees and this will make it even harder to find nurses to provide daily bedside care. Some say the doctoral programs are unnecessary.
"Nurse practitioners with master's degrees are already filling the primary care shortages and providing quality, cost-effective care, many times in places that physicians are unwilling to practice," says Wendy Vogel, a nurse practitioner specializing in oncology at Blue Ridge Medical Specialists in Bristol, Tenn.
Also, since these nurses with a doctorate can use "Dr." some physicians worry that patients could become confused. "Nurses with an advanced degree are not the same as doctors who have been to medical school," says Roger Moore, incoming president of the American Society of Anesthesiologists.

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Members don't see this ad.

 

[Leukocyte]

http://encarta.msn.com/encnet/Departments/eLearning/?article=MakeRoomDrNurse&GT1=27001

Making Room For "Dr. Nurse"
By Laura Landro


As the shortage of primary-care physicians mounts, the nursing profession is offering a possible solution: the "doctor nurse."
More than 200 nursing schools have established or plan to launch doctorate of nursing practice programs to equip graduates with skills the schools say are equivalent to primary-care physicians.

The two-year programs, including a one-year residency, create a "hybrid practitioner" with more skills, knowledge and training than a nurse practitioner with a master's degree, says Mary Mundinger, dean of New York's Columbia University School of Nursing. She says DNPs are being trained to have more focus than doctors on coordinating care among many specialists and health-care settings.

To establish a national standard for doctors of nursing practice, the non-profit Council for the Advancement of Comprehensive Care announced in April 2008 that the National Board of Medical Examiners has agreed to develop a voluntary DNP certification exam based on the same test physicians take to qualify for a medical license.
The board will begin administering the exam this fall. By 2015, the American Association of Colleges of Nursing aims to make the doctoral degree the standard for all new advanced practice nurses, including nurse practitioners.
But some physician groups warn that blurring the line between doctors and nurses will confuse patients and jeopardize care. Nurses with doctorates use DrNP after their name, and can also use the designation Dr. as a title.

Physician groups want DNPs to be required to clearly state to patients and prospective students that they are not medical doctors. "Nurses with an advanced degree are not the same as doctors who have been to medical school," says Roger Moore, incoming president of the American Society of Anesthesiologists.

"With four years of medical school and three years of residency training, physicians' understanding of complex medical issues and clinical expertise is unequaled," adds James King, president of the American Academy of Family Physicians.

While nurses with advanced degrees play an important role in delivering care, Dr. King says they should work as part of a physician-directed team.
Although there are no precise statistics on the number of nurses with doctorates because the programs are relatively new, there are about 1,874 DNP students currently enrolled in programs nationwide, up from 862 students in 2006, according to the American Association of Colleges of Nursing.

Nurses have increasingly been moving into more specialized and advanced roles over the past few decades. Advanced-practice nurses include specialists in fields such as nurse midwives and nurse anesthetists, and there are now more than 125,000 nurse practitioners in the U.S. Nurse practitioners in some states are required to work with or be supervised by physicians, but often have independent practices in family medicine, adult care, pediatrics and oncology.

A study led by Columbia's Dr. Mundinger and published in the Journal of the American Medical Association in 2000 showed comparable patient outcomes in patients randomly assigned to nurse practitioners and primary-care physicians.
Nurse practitioners fear the doctoral programs might be raising the bar too high for their profession. The American Academy of Nurse Practitioners says it supports access to a higher educational degree for nurses, but wants to ensure that members won't be marginalized or required to go back to school for a costly advanced degree. Nurse practitioners can write prescriptions, are eligible for Medicare and Medicaid reimbursement, and often act as the primary health-care provider for their patients.

"Nurse practitioners with master's degrees are already filling the primary-care shortages and providing quality, cost-effective care, many times in places that physicians are unwilling to practice," says Wendy Vogel, a nurse practitioner specializing in oncology at Blue Ridge Medical Specialists in Bristol, Tenn. There are "as yet no data to support the need for increasing the amount of education required to practice in this role," she says.

With an acute shortage of nurses, some medical professionals worry that the doctoral programs, with promises of higher-paying jobs and prestige, will lure more nurses away from the critical tasks of day-to-day bedside care.


thumbdown

 

[Doowai]

She says DNPs are being trained to have more focus than doctors on coordinating care among many specialists and health-care settings.

To establish a national standard for doctors of nursing practice, the non-profit Council for the Advancement of Comprehensive Care announced in April 2008 that the National Board of Medical Examiners has agreed to develop a voluntary DNP certification exam based on the same test physicians take to qualify for a medical license.

Trained to have more focus than doctors?????

A voluntary certification exam issued by the NBME?

Wow,

 

[andwhat]

.

 

[nebrfan]

there is no way in hell that a nurse can pass any qualifying examinations, such as USMLE any step, let alone any medical school coursework.
This is a scam, and American Medical Association should be ashamed and humiliated by not stepping in and doing anything about it.
Instead of compensating primary care docs better, they are adding nurse doctors. That is not only unethical, it is just simply shameful.
Are they going to rig the examinations so that nurses can pass, and start working, it is all about MONEY and hiring CHEAPER LABOR. Just like the Lipid clinics from Cardiologists.
Primary Care is going downhill, and nobody is doing anything about it, it is just going to get worse and worse.
Good for the med students smart enough to choose specialties.

I agree - NP/DNP schedules would never prepare them to pass the USMLE - which is why the NBME is creating a special, modified version for DNPs based off of primarily Step 3. It will be a dumbed down version, but gives DNPs the ability to say "we passed a test with similar questions as MDs." (Hell, Pathologists have to pass Step 3, but I sure as hell wouldn't want one as my PCP). So, while the NBME is increasing the score required to pass the USMLE (increasing retakes, increasing $$) they are making a short-cut for non-MDs. I'm not sure if I'm more upset at this, or the $1000 English proficiency test they recently added as a requirement.

 

[secretwave101]

Doctor. Nurse. This would not be an oxymoron because the term is reserved for contradictions that are nevertheless true. For now, it's still just a basic contradiction. Like bike and car. Eventually, they'll get "licensure" and then will be professional oxymorons. Effectively, they'll become bikes with engines in them. Near-cars. Mopeds.

You can't argue with money, people. It's flat-out CHEAPER to train a doctor-nurse and thus cheaper to pay them. Maybe they aren't quite as good...but they'll be close. Say they "know" 20% less than an FP, but they cost around 40% less to do their job. I'm not a businessman, but I can see that the numbers are not in my favor.

It sounds like it's too late to fight 'em. So, we might as well join 'em and just do our jobs as well as we can. GO MOPEDS!

 

[MedicineDoc]

Doctor. Nurse. This would not be an oxymoron because the term is reserved for contradictions that are nevertheless true. For now, it's still just a basic contradiction. Like bike and car. Eventually, they'll get "licensure" and then will be professional oxymorons. Effectively, they'll become bikes with engines in them. Near-cars. Mopeds.

You can't argue with money, people. It's flat-out CHEAPER to train a doctor-nurse and thus cheaper to pay them. Maybe they aren't quite as good...but they'll be close. Say they "know" 20% less than an FP, but they cost around 40% less to do their job. I'm not a businessman, but I can see that the numbers are not in my favor.

It sounds like it's too late to fight 'em. So, we might as well join 'em and just do our jobs as well as we can. GO MOPEDS!

How do you figure that they will know "20% less than FPs" given the weak schedule, weak admissions requirements beginning with in most cases a community college nursing program and the types of classes as seen above. It seems to me you are kind of "talking out of your ass" if you'll forgive the vulgarity. If they were good enough to be doctors why didn't they just go to medical school? If the courses above were adequate to train physicians then why aren't we taking 39 hour weak ass masters program with the "philosophy of science". Why don't we just get a bunch of philosophy PhDs at least they will probably have higher IQs. The types of people I see go into nursing are usually more concerned with sitting on the curb smoking cigarettes than studying science and the treatment of disease. Maybe that's why they only need to know some philosophy of science so they can talk the talk after all grandpa with Alzheimer's isn't going to know the difference and if he dies sooner then it will decrease the cost of health care right?

 

[secretwave101]

Ok. 30%. Whatever.

Of course I'm talking out of my rear-end. My point is that - from the payor perspective - they're cheaper and almost as good as FP's. It's tough to argue against the money.

 

[MedicineDoc]

Ok. 30%. Whatever.

Of course I'm talking out of my rear-end. My point is that - from the payor perspective - they're cheaper and almost as good as FP's. It's tough to argue against the money.

How could they possibly be "almost as good as MDs"? When I took the EMT basic course I was the most stellar student they had ever had. Of course that all changed when I went to medical school. It's a ridiculous assertion. The nurses I have seen in action are no where near "almost as good as MDs". I guess it won't matter if they "almost kill" the patient or in this crazy almost world of okayness. We can give them some points for "almost" not killing the patient. They can almost be good students if we are going by community college standards. Patients are people. We are talking about mom, dad, brother and sister not livestock. Even livestock and research animals get a Veterinarian and not a nurse trained in the "philosophy of science".

 

[zenman]

Even livestock and research animals get a Veterinarian and not a nurse trained in the "philosophy of science".

Man, you're knocking liberal arts. A liberal arts doctorate would run circles around you.

http://www.virtualsalt.com/libarted.htm


On the Purpose of a Liberal Arts Education
Robert Harris
Version Date: March 14, 1991

When they first arrive at college, many students are surprised at the general education classes they must take in order to graduate. They wonder why someone who wants to be an accountant or psychologist or television producer should study subjects that have nothing directly to do with those fields. And that is a reasonable question--Why should you study history, literature, philosophy, music, art, or any other subject outside of your major? Why should you study any subject that does not help to train you for a job? Why should you study computer programming when you will never write a program? Why study logic when all you want to do is teach first grade or be a church organist?

In answer to this question, let's look at some of the benefits a liberal arts education and its accompanying widespread knowledge will give you.

 

[iatrosB]

Man, you're knocking liberal arts. A liberal arts doctorate would run circles around you.

http://www.virtualsalt.com/libarted.htm


On the Purpose of a Liberal Arts Education
Robert Harris
Version Date: March 14, 1991

When they first arrive at college, many students are surprised at the general education classes they must take in order to graduate. They wonder why someone who wants to be an accountant or psychologist or television producer should study subjects that have nothing directly to do with those fields. And that is a reasonable question--Why should you study history, literature, philosophy, music, art, or any other subject outside of your major? Why should you study any subject that does not help to train you for a job? Why should you study computer programming when you will never write a program? Why study logic when all you want to do is teach first grade or be a church organist?

In answer to this question, let's look at some of the benefits a liberal arts education and its accompanying widespread knowledge will give you.

Point is: liberal arts does not equal MD.


I don't give a rat's arse how broad your knowlegde is...if you don't have an MD/DO...don't pretend to know how to treat my ailments.

 

[secretwave101]

How could they possibly be "almost as good as MDs"?

Work that angle as long and loud as you want, it won't sway the accountants at Wal Mart or the bean counters in the Fed. I work with ARNP's - ostensibly less-trained than the upcoming doctor-nurse - and they do a good job. They know their stuff. No, they don't have the experience our MD's do, and they often consult even us residents occasionally, but they're good in general.

I do agree with you, Medicine. Doctors are better-trained and, on average, provide safer and better care. I'm just saying that given the cost of MD/DO training, the quality argument is tough to win with big payers, especially in primary care.

 

[Spleen]

Work that angle as long and loud as you want, it won't sway the accountants at Wal Mart or the bean counters in the Fed. I work with ARNP's - ostensibly less-trained than the upcoming doctor-nurse - and they do a good job. They know their stuff. No, they don't have the experience our MD's do, and they often consult even us residents occasionally, but they're good in general.

I do agree with you, Medicine. Doctors are better-trained and, on average, provide safer and better care. I'm just saying that given the cost of MD/DO training, the quality argument is tough to win with big payers, especially in primary care.

Precisely! You hit the nail on the head. Medicine is controlled by the government through CMS, and enforced by the 'insurance mafia' following suit for payment levels. As long as they control healthcare the patients and us will be subject to their business motives supplanting true health objectives. The solution is plain as day. Do not try to save medicare reimbursements. Let it collapse and maybe the government will leave healthcare. You can bet, that once patients start paying for medical (at the very least primary care-can't get rid of insurance entirely) care you bet that standards will once again mean something.

As long as accountants are running medicine we are on the fast track to extinction. These people will support the reduction of medicine to nothing more than cookbook checklists. And any monkey can follow those. Lord help those who dare to be sickly unique so as not to comply with the checklist. We as physicians (or in training) are too expensive in their eyes.

The natural progression with government run healthcare as it is now, is to eliminate us, and the high quality we insure.

 

[andwhat]

.

 

[Jack Daniel]

I think the ire some have against advanced practice nurses is unfair and is nothing more than turf protection.

Some say nurses can't possibly provide the care doctors can provide. Certainly, nurses won't match the technical training of a physician, but I think they can be trained to treat and manage many types of primary care problems.

There will always be the need for highly-trained physicians. But maybe physicians, with all the training they receive, need to free up their schedules for the difficult patients and let others with less training make the cookbook diagnoses, spend 45 minutes educating patients on their chronic disease and spend 30 minutes on the phone trying to co-ordinate specialist patient care. Is that really what a physician who has trained in surgery, obstetrics, internal medicine and pediatrics needs to be doing?

I think physicians (and those to be like me) need to start thinking more about patients. Nobody wants to pay $75+ for 15 minutes when all they need is an antibiotics script. Physicians can't afford to charge less. If an advanced practice nurse can, then I'm going there.

I think SW101 nailed it. It's about money. Physicians are smart enough to realize that $30 medicare reimbursements won't easily pay the interest on their $40,000+/year med school loans and most feel they didn't study 7 years+ of serious medicine to spend time coordinating ancillary medical care on a phone for their medicare patients. I think physicians are forced to cede primary care to others because they can't afford not to. Those others will step up and carve a niche for themselves. Those others are the nurses.

 

[MedicineDoc]

I think the ire some have against advanced practice nurses is unfair and is nothing more than turf protection.

Some say nurses can't possibly provide the care doctors can provide. Certainly, nurses won't match the technical training of a physician, but I think they can be trained to treat and manage many types of primary care problems.

There will always be the need for highly-trained physicians. But maybe physicians, with all the training they receive, need to free up their schedules for the difficult patients and let others with less training make the cookbook diagnoses, spend 45 minutes educating patients on their chronic disease and spend 30 minutes on the phone trying to co-ordinate specialist patient care. Is that really what a physician who has trained in surgery, obstetrics, internal medicine and pediatrics needs to be doing?

I think physicians (and those to be like me) need to start thinking more about patients. Nobody wants to pay $75+ for 15 minutes when all they need is an antibiotics script. Physicians can't afford to charge less. If an advanced practice nurse can, then I'm going there.

I think SW101 nailed it. It's about money. Physicians are smart enough to realize that $30 medicare reimbursements won't easily pay the interest on their $40,000+/year med school loans and most feel they didn't study 7 years+ of serious medicine to spend time coordinating ancillary medical care on a phone for their medicare patients. I think physicians are forced to cede primary care to others because they can't afford not to. Those others will step up and carve a niche for themselves. Those others are the nurses.

I'm just curious as medicnal student does it seem to you that the subjects of internal medicine and pediatrics are so simple that they don't really require an expert who has trained in these areas? Is it just the fact that they get paid less that makes you think that yeah anybody can do it? Why don't you wait until you actually find out what it entails to be a good primary care doctor before you go making your position statements. As I have read these boards I find that it is mostly premeds and clueless med students that seem to think that these are subjects easily mastered. In fact you are speaking of the core of medicine that takes many years and dedication to master. I'm sorry but it takes more than a community college degree despite your misconceptions of what we are really talking about here. Why don't you wait until you know more about what you speak of before you bestown your weighty opinion on us?

 

[Jack Daniel]

I'm just curious as medicnal student does it seem to you that the subjects of internal medicine and pediatrics are so simple that they don't really require an expert who has trained in these areas? Is it just the fact that they get paid less that makes you think that yeah anybody can do it? Why don't you wait until you actually find out what it entails to be a good primary care doctor before you go making your position statements. As I have read these boards I find that it is mostly premeds and clueless med students that seem to think that these are subjects easily mastered. In fact you are speaking of the core of medicine that takes many years and dedication to master. I'm sorry but it takes more than a community college degree despite your misconceptions of what we are really talking about here. Why don't you wait until you know more about what you speak of before you bestown your weighty opinion on us?

I noticed you posted at 6:16 this morning. Why don't you give yourself time to wake up, have a cup of coffee and READ my post before you comment on it.

 

[MOHS_01]

Jack,

First off -- you picked a piss poor excuse of a bourbon for a namesake...

Secondly -- MedicineDoc has probably been up for a while due to habit and requisite of private practice. Private practice, for those motivated to be above par, is much harder (and more time consuming) than residency any day of the week... compensation is generally better though (for now). Don't throw rocks.... That said, MD does sometimes come across as having a chip on his shoulder, justified as it is. I think that he is where I was at about six months ago, and his anger with the system (as well as the opinions of those who often do not have the experience necessary to form meaningful opinions) is justified to a large degree.

Lastly -- I agree with your opinion regarding the appropriate utility of mid level providers. There is no need to see a MD for many routine follow-ups, high risk medication monitoring, etc. Everyone needs to prepare for the changes that the market is preparing to force upon us -- primary care will be the first to feel the brunt of change, but others will follow.

 

[MOHS_01]

I think physicians (and those to be like me) need to start thinking more about patients. Nobody wants to pay $75+ for 15 minutes when all they need is an antibiotics script. Physicians can't afford to charge less. If an advanced practice nurse can, then I'm going there.

Don't sell the value of your hard earned, overly expensive (relative to current ROI) diagnostic skills short. Often a patient "just needs an antibiotic" when they really do not need an antibiotic at all. It is easier to just give them the Rx than to make a proper Dx and explain to them that they really don't need an antibiotic (thus pissing them off and increasing your likelihood for bad debt). We've been down this road before (remember that pesky thing called resistance).

$75 is cheap for the physician time, training, etc....

 

[Jack Daniel]

Thanks for your comments.
My position is that to bash the advance practice nurses comes across as petty and insecure.

Nobody in their right minds thinks that nurses are better trained in the art and science in medicine. If people like nurses as their PCP, it's because of other strengths. The reports I've read indicate patients prefer their ability to spend time with them and their willingness to explain things to them. It doesn't matter if this is accurate or not. Since this is the perception of many people, maybe we should take more care in this matter.

To bash the APNs for expanding their profession is misdirected anger. Nurse practitioners are filling a hole. I think we should directed our ire at what dug out the hole in the first place. It wasn't the nurses.

 

[andwhat]

.

 

[zenman]

Point is: liberal arts does not equal MD.


I don't give a rat's arse how broad your knowlegde is...if you don't have an MD/DO...don't pretend to know how to treat my ailments.

Point is some bitch about those liberal arts courses when they should be glad to have even more of them.

 

[Jack Daniel]

Do you actually think and believe that a nurse sitting down can converse as well as a physician for chronic disease management or even common ailments?

Pretty much, yep. They do it all the time. Some probably even converse standing up. Usually in large and busy physician practices, it's not even a NP, but someone with less training who spends the time to help patients understand just what diabetes is. Or chronic hepatitis. Or asthma. Or prenatal. Or.... People, this stuff is in books. Nurses can read.

Why should a nurse have the privelages of seeing patients independently?

Fascinating. Really. You can ask this question of any provider. The law gives this privilege and it is this reason ONLY that has given physicians their free run of the healthcare marketplace since the 19th century. Physicians have feared competition from the homeopaths, the chiropractors, the osteopaths, the naturalists, the herbalists, the quacks...choosing to ban them from competition and the marketplace by state licensure instead of having some trust in the training of a physician to out-compete them.

The law giveth and the law taketh away. Now, legislatures are choosing to offer other groups the privilege of practicing medicine. Physicians will actually need to compete.

But, hey, why worry. Right? Physicians are trained longer and better and more intense, right? Surely physicians will come out on top, right? Maybe, unless people are willing to sacrifice a little expertise in some areas to save money. Or get a little more face time with their provider. Or whatever their reason. What's certain is that physicians are no longer the only game in town.

That is what health care is all about, making money and saving it. Simply ridiculous.

I'm pretty sure patient care is in there somewhere.

Look, I'm not slamming physicians, and I'm certainly not slamming primary care. I just see griping about NP or DNP clinicians as pointless. I don't see nurses as the cause of the problem. I see them expanding their profession to take advantage of an opportunity, one that I think physicians helped to create.

 

[Jack Daniel]

A cardiologist can make $20,000 a week putting in stents and doing angiograms. Guess what folks? This is what a Primary Care doctor would get paid IN A WHOLE YEAR to run a nursing home with hundreds of patients, including fielding calls at all hours of the day and night. This is the sad and ridiculous state of health care.

I completely agree.

Procedures always win, hands down. That is where the money is. This isn't going to change, as there are Specialist M.D.s that are running health care where it matters. They certainly are not going to change compensation for subspecialties, and knock down the prices that procedures run.

Perhaps this is a good example to support my opinion that physicians (or at least a group of them) have created much of the problem.

 

[UCFMOP]

Jack Daniel = Mrs. Mundinger

 

[Jack Daniel]

Jack Daniel = Mrs. Mundinger

 

[The Janitor]

Nurse practitioners are filling a hole.

OK, I couldn't resist...

Q: What do you call 100 DNPs buried up to their necks in the sand?

A: Not enough sand.

 

[andwhat]

.

 

[Miami_med]

Point is some bitch about those liberal arts courses when they should be glad to have even more of them.

You know,

My bachelors degree was in a liberal arts discipline. I was valedictorian of my class at one of the top ten programs in the country in my discipline. I wrote a thesis which earned me high honors, and because of a transfer, I accumulated more than 140 credit hours in numerous disciplines from computer programming, to chemistry, to political science, to anthropology. I am not bragging but am rather proving a point.

With all of these credentials, I entered medical school and instantly shot to the middle of my class, where I have been trapped since first semester. I am an average medical student. All of that liberal arts training has made me a supremely better person, but it has probably done very little to advance my capacity to diagnose and treat disease. At the very least, any benefit is only possible because I also studied path, pharm, phys, etc....

As an aside to Jack Daniel:

Sometimes those antibiotic visits are not just about antibiotics, and that is why you have to visit the doctor to get them. We make it sound like these are all easy, but the art is not saying URI=antibiotic. I have seen a "simple URI" turn out to be atypical asthma, lung ca, tracheal ca, and chronic sinusitis requiring surgical intervention. I have also seen it be viral and allergic, not requiring antibiotics at all. If it was this simple, lets just bypass the NP and put a Z-pack/Augmentin dispenser at the front of CVS.

Patients have come in looking for antibiotics, and those that I have worked with have sent them out with everything from albuterol to an oncology referral. As most of my rotations have been inpatient, and I am just finishing my CC-3 year, I suspect that the frequency of these "zebras" must not be all that uncommon, because I've seen a lot in not a lot of time.

 

[Jack Daniel]

hands down absolutely and completely pathetic.
The naivity and one sidedness of this, shows where health care may be headed.
I am sure that patient care is not at all buried in this.
Another way that the specialist can make more money spending more time doing procedures.
Why waste time and counsel patients, when money is to be made out there, that is what it is all about.
I honestly believe that you are a nursing student yourself, or a chiro student.
Nobody in the medical field M.D. or D.O. would support your preposterous beliefs.
Nobody in their right mind that is.

Well, I see this is the only strategy you have left: attack the person.
It's a pretty good one, politicians use it all the time and it works for them. Maybe it will work for the medical profession, too.

You haven't responded to any of my comments. You only wave your hand and dismiss me as someone with nothing sane to say.

Everything I've said is the epitome of sanity:

• Nurses aren't to blame for the opportunity to expand their profession.
• Physicians have lobbied against competition. The profession has used the law to secure our own protected practice and now, based on the rhetoric of some posters, apparently we're worried that we're not going to be able to compete against nurses.

 

[Jack Daniel]

As an aside to Jack Daniel:

Sometimes those antibiotic visits are not just about antibiotics, and that is why you have to visit the doctor to get them. We make it sound like these are all easy, but the art is not saying URI=antibiotic. I have seen a "simple URI" turn out to be atypical asthma, lung ca, tracheal ca, and chronic sinusitis requiring surgical intervention. I have also seen it be viral and allergic, not requiring antibiotics at all. If it was this simple, lets just bypass the NP and put a Z-pack/Augmentin dispenser at the front of CVS.

Patients have come in looking for antibiotics, and those that I have worked with have sent them out with everything from albuterol to an oncology referral. As most of my rotations have been inpatient, and I am just finishing my CC-3 year, I suspect that the frequency of these "zebras" must not be all that uncommon, because I've seen a lot in not a lot of time.

Hi Miami,
Thanks for your comment. I've enjoyed this and your previous posts on various topics.

I absolutely agree with your post, I only mentioned antibiotics as an example. Maybe this is an area that the entire system is willing to compromise with--sort of a cost-benefit of having NPs, who are cheaper trained and cost less to see, but willing to give up a little clinical and technical acumen.

My point is that there has to be common things in medicine that can be safely done by APNs -- which can lower the cost of medicine for the rank and file person. Everything isn't brain surgery.

It seems that some folks get "independent practice" confused with a license to practice full-scope medicine. When a nurse practitioner has done all she/he can, then it's time to send the patient to a more trained physician. Isn't this what happens if the first entry is to a physician? Initial workup, treat what you can, then referral if needed.

 

[andwhat]

.

 

[Jack Daniel]

Before:

hands down absolutely and completely pathetic.
The naivity and one sidedness of this, shows where health care may be headed. ...I honestly believe that you are a nursing student yourself, or a chiro student. Nobody in the medical field M.D. or D.O. would support your preposterous beliefs. Nobody in their right mind that is.

After:

I am not attacking anyone, and you are clearly trying to instigate some sort of negative response from me.

Oooookay, moving right along.

I would say that your comments are borderline harassment.

My point is, that nurses should not be able to see patients independently, and make diagnoses and treatment decisions. ... So what exactly is my argument? My argument is that it is not at all safe for patient care. ...

Gotcha. Listen, it's been interesting reading your posts. I understand your concern about patient safety. It will be interesting to see how the NPs work out over time in the handful of states where they have the most liberal practice laws. Perhaps some future studies reviewing their long-term track record will either calm your worries or vindicate your concern.

JD

 

[zenman]

You know,

My bachelors degree was in a liberal arts discipline. I was valedictorian of my class at one of the top ten programs in the country in my discipline. I wrote a thesis which earned me high honors, and because of a transfer, I accumulated more than 140 credit hours in numerous disciplines from computer programming, to chemistry, to political science, to anthropology. I am not bragging but am rather proving a point.

With all of these credentials, I entered medical school and instantly shot to the middle of my class, where I have been trapped since first semester. I am an average medical student. All of that liberal arts training has made me a supremely better person, but it has probably done very little to advance my capacity to diagnose and treat disease. At the very least, any benefit is only possible because I also studied path, pharm, phys, etc....

.

My point is not that you will be at the top of your medical school class, but a much more rounded "educated" person. However, you might make better and more informed medical decisions based on your increased knowledge. A retired surgeon was in one of my business school classes and he said he was ignorant about anything happening outside the OR and was useless at parties.

 

[racerx]

I have an example of the difference between NP vs. MD diagnostic acumen that I have been reluctant to share, as the patient is my wife. However anecdotal it may be, with n=1, it has still colored my entire family's view of the NP ability to either appropriately diagnose or properly recognize when they are in above their head.

My wife had a red, raw sore throat and fever for 5 days. The fever had reached 104 deg. F every evening before she went to the doctor's office. Unfortunately, our regular FM doc was at a conference, so his NP insisted that she could see my wife and would be able to help her out.

By this time, my wife had developed a bright red diffusely macular rash and swolled wrists that seemed to be worse as her fevers would increase. The NP saw her and said, "I think it's a virus, but I'll do a rapid strep test." Well, the rapid strep was negative, so it was declared a virus and my wife was sent home. 3 days later, there was no improvement (8 days on), and the evanescent fever and rash had actually gotten worse and her cervical lymph nodes had grown huge!

By then, our FM doc had returned and called to see how my wife was doing. He had us come in immediately and saw my wife. After taking one look at her, he thought she should get some bloodwork. Her WBC was 45,000, serum ferritin was >4000, AST >1000, etc. He new that something serious was going onand that it may be beyond his expertise, so he referred my wife to a university hospital about 2 hours away.

Turns out it was Still's disease with a complication of pericarditis and liver damage, not a virus. The NP had missed it and was so sure it was a virus she didn't order any testing beyond the rapid strep. At least the FM doc was more dogged in finding the laboratory abnormalities and was willing to refer when it may be above his abilities.

Good thing my FM doc followed up on all the patients the NP had seen in his absence. May have saved my wife's life.

 

[Frijolero]

Well, I see this is the only strategy you have left: attack the person.
It's a pretty good one, politicians use it all the time and it works for them. Maybe it will work for the medical profession, too.

You haven't responded to any of my comments. You only wave your hand and dismiss me as someone with nothing sane to say.

Everything I've said is the epitome of sanity:

• Nurses aren't to blame for the opportunity to expand their profession.
• Physicians have lobbied against competition. The profession has used the law to secure our own protected practice and now, based on the rhetoric of some posters, apparently we're worried that we're not going to be able to compete against nurses.

Standards exist for other reasons than just power and money for those who set them, you know. Some things just aren't safe in the hands of the untrained. Why do we have pilot's licenses, the bar, etc.? "APNs" are attempting to grow their field into a place they are inadequately trained to fill, and on their side, it is certainly about the money. Nurses ARE to blame, as they are the ones pushing to practice beyond their safe limits. So are physicians in their complicity over the years. As you alluded to in your last post, we shall see if outcomes differ between the DNP and PCP. I'm betting 3 more years of my life that they will. It's naive to assume that everyone opposed to expanding nursing scope is motivated by insecurity and greed.

Additionally, I don't think health care is a safe place for a completely free market, at least when it comes to who we allow to deliver health care. Yeah, competition is good to a point, but we can't allow people to choose substandard care which ends up costing more with worse outcomes. It makes sense to protect people from themselves, at least a bit. Hell, it's the whole reason we have social security.

 

[andwhat]

.

 

[sophiejane]

Keep this cordial and avoid making things personal, please.

Thank you.

Carry on.

 

[sophiejane]

Two questions, and my apologies if they have been discussed already, I'm too ADD to read the whole thread

1. If a DNP opens shop by him or herself, who pays the malpractice? Is there any recourse at all for malpractice? If not, should the patient not be informed that they have no leg to stand on if the DNP makes a medical error that causes harm to a patient?

2. If malpractice is not required, how is it ethical for them to have a DEA license and be prescribing controlled substances?

Okay, three questions: Is it not a misrepresentation for a nurse to introduce themselves to a patient as "Dr" without an explanation that it does not mean doctor of medicine? That seems very shaky legal ground, to be honest.

I think this will take care of itself when patients start being harmed by solo DNPs making mistakes, and their horror when they realize there is no legal recourse for those errors.

We keep talking about the AMA, but my guess is that the insurance lobby is behind this in a very big way. Why wouldn't they be? Less money out is more to line their fat greasy pockets.

 

[racerx]

We keep talking about the AMA, but my guess is that the insurance lobby is behind this in a very big way. Why wouldn't they be? Less money out is more to line their fat greasy pockets.

I had the same thought regarding the insurance lobby. In a way, that makes it an even darker future, as they have a long record of getting exactly what they want.

 

[deleted87716]

If a DNP opens shop by him or herself, who pays the malpractice?

An independently-practicing DNP would have to carry their own malpractice policy, according to the laws in their particular state and the credentialing requirements of their local facilities.

Is it not a misrepresentation for a nurse to introduce themselves to a patient as "Dr" without an explanation that it does not mean doctor of medicine?

IMO, yes...in the clinical setting, "doctor" implies "doctor of medicine."

I think this will take care of itself when patients start being harmed by solo DNPs making mistakes

I suspect you're right.

my guess is that the insurance lobby is behind this in a very big way.

Not so much. It's pretty much a nursing lobby bandwagon.

 

[Miami_med]

My point is not that you will be at the top of your medical school class, but a much more rounded "educated" person. However, you might make better and more informed medical decisions based on your increased knowledge. A retired surgeon was in one of my business school classes and he said he was ignorant about anything happening outside the OR and was useless at parties.

I am good at parties

 

[jklm]

How do you figure that they will know "20% less than FPs" given the weak schedule, weak admissions requirements beginning with in most cases a community college nursing program and the types of classes as seen above. .......The types of people I see go into nursing are usually more concerned with sitting on the curb smoking cigarettes than studying science and the treatment of disease.


Have you double checked the initials on the namebadge of these "nurses" you are speaking of? Community colleges do not offer a BSN - they do however churn out plenty of CNAs and LPNs. Nursing schools are very hard to get into. Just for reference, there were over 300 applicants for 60 spots at our University. Maybe not the same ratio as your medical school, but hardly considered weakly competitive. For the most part, BSN programs are very heavy in the pharmacology, A and P, microbiology and etiology of diseases. To say that nurses are usually more concerned with sitting on the curb smoking sigarettes than studying science and the treatment of disease.. would be like categorizing all doctors as "pill-popping ego-maniacs." A term I would not label many of the physicians I know. And they would never categorize their nurses in that way.

Nurses and doctors are two different fields. Nurses are not people that didn't make it in medical school. They are serving a different purpose than the doctor. As far as the DNPs? I have not reviewed the requirements - so, I'm not here to argue that point. Just from my initial thoughts - no - a nurse is a nurse and a doctor a doctor.

 

[zenman]

She screwed up several of my patients, and has a horrible attitude towards them, acting arrogantly as if she is truly a physician.

I thought that the rule was to "do no harm"

That was a long time ago

Now we have to figure out a way to extinguish these horrible NPs making so many medical mistakes.

But, what about all the medical mistakes not made by NPs? Just keeping them honest!

 

[Jack Daniel]

I know, I know. I 'bout choked on the irony.

 

[persia]

I have posted somewhere else about the mistakes I have seen or heard about from friends, that were made by PA's and NP's in instacare situations. They are about like Racerx's wife's example.

I was reading this thread and I kept thinking: when is the AMA and anyone else going to acknowledge that having a doctorate of nursing is not going to work? Even if some financial types feel that this will "save" money, how is that going to work out when the lawsuits start coming in? and they certainly will.

Misdiagnosing serious cases will cost beaucoup bucks. Quality is cheap at the price, is my motto.

Ok, most recent example from our frontline ER PA: pt with acute RUQ pain, fhx of gallstones; young female. Pain is >> after meals, particularly fatty fast food meals. Three days duration, but second attack in three months. PA told her she had a 'lung infection,' (no cough, fever, etc) and was sent home with some antibiotic. No radiology done, that means no CXR, no RUQ u/s. I think that what's concerning most is that this PA is not (apparently) supervised by a physician and no physician came to ever see the patient. Did someone sign off on this case?

This is very scary medicine. And this could be your sister/friend/wife/daughter. It makes me very angry to think about it. Surely common sense will dictate that this cannot work?

 

[MedicineDoc]

I know, I know. I 'bout choked on the irony.

Tell us the truth are you married to a nurse "practicioner".

 

[Jack Daniel]

Tell us the truth are you married to a nurse "practicioner".

I'm married, but not to a NP. She's a biomedical scientist. I'm not related to any NP and don't know of any in my circle of friends.

I'm a med student with every intention of training in FM. Maybe general IM. Most definitely primary care.

If NPs are shown to adversely affect patients, then I'll immediately shift my support. And by this comment, I'm not trying to diminish those who have posted with first-hand experience of a NP blunder. It's just that everyone can probably come up with anecdotal evidence of a clinician (MD included) missing something.

I'm also not trying to diminish the opinions of those with more clinical experience and training. I understand that many folks here are concerned that independent NPs are dangerous to patients. To me, it doesn't seem that dire. Independent NPs already exist in many states and their malpractice reports don't seem any higher than physicians. So, if we're putting our patients first, it seems to me that some medical care is better than no medical care. Maybe some people are doing well just to get to a clinic staffed by a NP.

 

[Old_Mil]

THE BABOON WHO RAN THE RAILROAD

When James Wide lost both his legs in an accident on the Port Elizabeth main line in Africa in 1877, he thought his life as a railroad man was over. However, the railroad took care of its own and gave him a job as a signalman at the Uitenhage Tower. He lived there in a wooden shack with a garden, with his only companion--a chacma baboon he called Jack.

Jack was general housekeeper for Wide. He pumped water from the well, cleaned the house, and took care of the garden. However, it was in helping Wide run the signal tower that he was most indispensable.

In the morning, Jack would lock up the house and push Wide to work in a trolley that Wide had constructed to run on rails. For a while the baboon had help from Wide's dog, but the dog was killed by a train. After that, Jack had to do the job himself.

At the signal tower, Jack operated the levers that set signals and the tower controls that opened or closed switches on a siding as well as a human being could. In the 9 years Jack worked for the railroad and his legless master, he never made one mistake that resulted in an accident.

If Jack can run a railroad, DNPs can practice family medicine.

 

[MedicineDoc]

I'm married, but not to a NP. She's a biomedical scientist. I'm not related to any NP and don't know of any in my circle of friends.

I'm a med student with every intention of training in FM. Maybe general IM. Most definitely primary care.

If NPs are shown to adversely affect patients, then I'll immediately shift my support. And by this comment, I'm not trying to diminish those who have posted with first-hand experience of a NP blunder. It's just that everyone can probably come up with anecdotal evidence of a clinician (MD included) missing something.

I'm also not trying to diminish the opinions of those with more clinical experience and training. I understand that many folks here are concerned that independent NPs are dangerous to patients. To me, it doesn't seem that dire. Independent NPs already exist in many states and their malpractice reports don't seem any higher than physicians. So, if we're putting our patients first, it seems to me that some medical care is better than no medical care. Maybe some people are doing well just to get to a clinic staffed by a NP.

Can you produce your study, the statistics and methods, who funded the study, where it was published? I spent 4 years doing medical research prior to medical school and I can tell you that oftentimes for every study there is another one saying exactly the opposite. I have seen firsthand how agendas play into interpretation of data, how unwanted results can be played down or repeated and how conclusions often are not justified by data. From my experience in the type of thing we are talking about here the does it smell like a fish test is probably much more reliable. For instance let's suppose that you actually have a study that was performed by a disinterested party with good methods. How do you account for other variables that may exist such as likelihood of malpractice attorneys to pursue nurse practitioners, how good is the nurse practitioner's malpractice insurance, the number of malpractice attorneys in areas where NPs are likely to practice, what types of patients NPs are seeing, how complicated is it to sue a NP if someone is supposedly overseeing their work, how educated are the patients of NPs in being able to determine that they actually suffered from malpractice?

Even the HMO lobby has pointed out the difficulty in pursuing malpractice cases against NP's such as:

"The difficulties with a nurse practitioner malpractice will be these:​

• Lack of clear standards to set duty guides is often seen.

• Often there is no malpractice insurance on the nurse.​

• Plaintiff may look to nurse's employer/supervisor as [FONT=TimesNewRoman,Italic]deep pockets ​

where nurse has no liability coverage.​

• As nurses have become more trained, more aggressive in duties, the courts have been holding them to higher standards as regards to duties."​

http://www.ifebp.org/pdf/harker/Nurse_Practitioners.pdf​

What it comes down to is does common sense actually allow that much less medical education and less academically successful students with much less aptitude actually give you anywhere near the same product. If I was going to teach students how to be pool sharks would it not matter what kind of aptitude they had or how many hours they were required to practice? Do you really need some BS study to give you that answer? How far along are you in your medical training? Truthfully, I am beginning to think you're just one of those types of people that enjoy "tweaking" other people by taking contrary positions. Hence the multiple smiley emoticons. It's not like we all haven't seen a ton of those types in medical school. .​