What Is the Difference Between "Nursing" and the Rest of Medicine?

[sat0ri]

How much can a RN, NP, or PA specialize? I mean relatively, as compared to a physicians' latitude in specializing.

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[sarjasy]

That's not quite accurate. Dr. Stead wanted to take the most experienced non-physician (ie: the nurse), and give them two years of training in MEDICINE, so that they could then practice MEDICINE under the supervision of a physician. He got the concept approved at Duke, but the ANA (aka the "nursing mafia") refused to let him use nurses because, in their domain, nurses practice nursing and doctors practice medicine. THAT is when he went to plan B and started the PA profession using military medics. Meanwhile the nursing mafia (the ANA and nursing academia) decided they liked the idea, but they weren't going to give up the political control of the nurse, so they created the Nurse Practitioner program in Colorado and labeled it "advanced nursing".

Not sure that we are really disagreeing here. BTW, my long quote with bolding is from Ingles herself in how the role was envisioned to be that of taking a nurse and giving the nurse medical training, which would then become part of his/her role as a nurse hence Ingle's reference to these functions traditionally not being considered "part of her role [as a nurse]" and that patients would then "be told to come in and see the nurse." It was not envisioned as an obliteration of the nurses role, but an extension and expansion of the nurses role. And yes, the training was in MEDICINE as you point out, but it was envisioned as taking a nurse and making basic medical practice as part of the nurses scope of practice (as had happened with taking blood pressures, and temperatures).

And yes, the ANA stood in they way (you should thank them for that! ), and yes the University of Colorado got the first nurse practitioner program approved (in pediatrics). Not really that relevant though. And, my point is only to show how the concept of "advanced nursing practice" came about.

 

[Boatswain2PA]

We are disagreeing about the original goal of the envisioned "mid-level". Dr. Stead is the one who came up with the idea, and he wanted to teach MEDICINE to experienced nurses so that they could practice medicine. These would no longer be "just" nurses, but "more than a nurse, but less than a doctor." While they would retain their ability to be a nurse, they would also practice medicine.

The concept of "advanced nursing practice" came about when the nursing mafia refused to let physicians teach nurses medicine. Instead they (the nursing mafia) insisted that nurses not be allowed to transition to medicine, but instead started a political push to create the "advanced nursing" idea. This political pushing continues to this day as the nursing mafias continue expanding the scope of "advanced nursing" into clearly medical related fields....which leads us to the OPs original question.

The AMA and other physician groups have, of course, failed to stem this tide by clearly defining what the definition of "practicing medicine" is.

 

[Boatswain2PA]

And NO, I am not going to thank the ANA for that. They prevented the creation of the best model of mid-level education/production (teaching medicine to experienced nurses) and created a watered down "advanced nursing" education concept. This has led to the inferior two-pronged mid-level system we have now. PA education, which can take a 22 yo history major who has never touched a patient before but pushes them through a rigorous didactic and clinical education, and NP education which takes (or, rather should take) an experienced nurse but only provides a fraction of the medical education.

 

[sarjasy]

We are disagreeing about the original goal of the envisioned "mid-level". Dr. Stead is the one who came up with the idea, and he wanted to teach MEDICINE to experienced nurses so that they could practice medicine. These would no longer be "just" nurses, but "more than a nurse, but less than a doctor." While they would retain their ability to be a nurse, they would also practice medicine.

Not based on what Ingles said. To her, it was expanding the scope of nursing. I reference the above quotes once again. She was there, and the first "nurse practitioner," so I'll take her word for it.

The concept of "advanced nursing practice" came about when the nursing mafia refused to let physicians teach nurses medicine.

It is not simply that Ingles, et al. created the term "advanced practice nursing" to appease the ANA. It is crystal clear from Ingle's statement -- made long before ANA involvement -- that she envisioned the role as an expanded nursing scope of practice, even if the term had not yet been coined.

Furthermore, I really don't care what the ANA thought 60 years ago. Stead, Ingles, NP programs today, and even the ANA, don't agree with how the ANA acted at the time. Physicians teach in nurse practitioner programs, such as mine, and 80% of my rotations have been with physicians. The only thing relevant from a historical perspective of this discussion is what Stead and Ingles envisioned, which I have already detailed.

The AMA and other physician groups have, of course, failed to stem this tide by clearly defining what the definition of "practicing medicine" is.

It is not for them to decide. Legislatures decide what the practice of medicine is, as such terms must be legally codified. Scopes of all health care professions have been expanded including nursing, pharmacy, optometry, physical and occupational therapy, MA's, CNA's, etc. and all of them will continue to expand and "encroach" on one another's areas. By definition, many others professions are "new" by comparison and their very creation stepped in and took over things once performed only by "medicine." The fact is, "advanced practice nursing" is not a political definition, but a LEGAL definition backed by a historical definition that I have already explained. Prescription of drugs was once legally considered to be only the domain of medicine. Now, depending on the state, it is also considered within the realm of practice of nurses, pharmacists, and optometrists, and as such is no longer considered the practice of medicine only, just as taking blood pressures and temperatures is not longer considered the practice of medicine only.

Whether you think that is OK or not is not germane to this discussion, which is about the definition of "advance practice nursing" and what it really means. Your dislike of the term and insistence that is nothing more than a political tool is fine. I am well aware of similar arguments from some of the bitter, hand-wringing, dissatisfied PA's who are fortunately a small percentage of an otherwise excellent profession. And, no, I am not saying your are one of those.

My point is simply to show that advanced practice nursing is a historical concept whose intent is to reflect the original vision of Ingles (and Stead) of expanding the nurses role to include an element of medical practice. A concept which is now codified into the laws of 50 states.

As a side note, it is ironic that many PA's dislike their own title because it has the word "assistant" in it - is that not political?

 

[Boatswain2PA]

Not based on what Ingles said. To her, it was expanding the scope of nursing. I reference the above quotes once again. She was there, and the first "nurse practitioner," so I'll take her word for it.

It is not simply that Ingles, et al. created the term "advanced practice nursing" to appease the ANA. It is crystal clear from Ingle's statement -- made long before ANA involvement -- that she envisioned the role as an expanded nursing scope of practice, even if the term had not yet been coined.

Furthermore, I really don't care what the ANA thought 60 years ago. Stead, Ingles, NP programs today, and even the ANA, don't agree with how the ANA acted at the time. Physicians teach in nurse practitioner programs, such as mine, and 80% of my rotations have been with physicians. The only thing relevant from a historical perspective of this discussion is what Stead and Ingles envisioned, which I have already detailed.

I'm not doubting Ingles said that, however it was not the original premise for the mid-level provider. The original premise, envisioned by Dr. Stead (long before Ingles went to Colorado), was to teach nurses how to practice medicine. Since nurses would already have extensive experience of administering medicine/treatments/etc, they should be able to learn the science/medicine aspect much quicker than a prototypical medical student. It was years later, AFTER the ANA shot this idea down (because, as they argued, nurses couldn't "practice medicine"....they could only "practice nursing").

It is not for them to decide. Legislatures decide what the practice of medicine is, as such terms must be legally codified. Scopes of all health care professions have been expanded including nursing, pharmacy, optometry, physical and occupational therapy, MA's, CNA's, etc. and all of them will continue to expand and "encroach" on one another's areas. By definition, many others professions are "new" by comparison and their very creation stepped in and took over things once performed only by "medicine." The fact is, "advanced practice nursing" is not a political definition, but a LEGAL definition backed by a historical definition that I have already explained. Prescription of drugs was once legally considered to be only the domain of medicine. Now, depending on the state, it is also considered within the realm of practice of nurses, pharmacists, and optometrists, and as such is no longer considered the practice of medicine only, just as taking blood pressures and temperatures is not longer considered the practice of medicine only.

My point was that the AMA and other physician groups failed to use their political leverage to maintain the definition of "practicing medicine", and therefore the various boards of nursing can just add whatever they want to their definition of "practicing advanced nursing". Had they done this, then NPs would have been forced to be licensed by the boards of medicine, and this semantic argument would have been moot.

.... Your dislike of the term and insistence that is nothing more than a political tool is fine. ....My point is simply to show that advanced practice nursing is a historical concept whose intent is to reflect the original vision of Ingles (and Stead) of expanding the nurses role to include an element of medical practice....

As a side note, it is ironic that many PA's dislike their own title because it has the word "assistant" in it - is that not political?

Who said I disliked the term?

But here is where your point is wrong. The "advanced practice nursing concept" has nothing to do with Stead's original concept of a mid-level provider. He wanted to take nurses and teach them medicine so that they could practice medicine. The ANA stopped that because, in their purview, nurses couldn't practice medicine, so therefore they came up with the term "advanced nursing." THAT is where the semantic divide was created, and thus when I put in a chest tube it is considered practicing medicine, but when you put in a chest tube it is considered practicing "advanced nursing".

And yes, the whole "assistant" thing is political, and while I understand why some people get upset by this, I think it's all silly because we are, indeed, assistants.

 

[2Pints]

How much can a RN, NP, or PA specialize? I mean relatively, as compared to a physicians' latitude in specializing.

There are actually several routes you can take as an NP. http://www.nursecredentialing.org/Certification.aspx

Currently, as an RN I work in the ICU but I could apply for a position in the OR or ED or Peds or whatever my heart desired and have a shot at a position. there's a certification exam I can take for critical care nurses. To maintain that certification I'd have to complete quite a few CEUs every 3 years on top of CEUs to retain my RN. Having that certification doesn't keep me boxed in. It just boosts my hourly rate. 50 cents an hour OMG...I also have an extra 50 cents/hr for my BSN. Needless to say, I'm just rolling in the money.

Some RNs choose to work at an office or outpatient surgery. Some RNs only insert PICC lines at my hospital and IVs when a patient is a really difficult stick. They would probably struggle getting a typical bedside hospital position if they stayed there too long more because some managers would be hesitant to hire somebody so far removed from certain skills. Legally though, there aren't any restrictions.

 

[fab4fan]

That's not quite accurate. Dr. Stead wanted to take the most experienced non-physician (ie: the nurse), and give them two years of training in MEDICINE, so that they could then practice MEDICINE under the supervision of a physician. He got the concept approved at Duke, but the ANA (aka the "nursing mafia") refused to let him use nurses because, in their domain, nurses practice nursing and doctors practice medicine. THAT is when he went to plan B and started the PA profession using military medics. Meanwhile the nursing mafia (the ANA and nursing academia) decided they liked the idea, but they weren't going to give up the political control of the nurse, so they created the Nurse Practitioner program in Colorado and labeled it "advanced nursing".

Because no one should teach nurses other than nurses, right?

 

[2Pints]

Because no one should teach nurses other than nurses, right?

Oh no you didn't.

 

[Boatswain2PA]

Because no one should teach nurses other than nurses, right?

Its not a matter of WHO is being taught, but rather WHAT is being taught.

 

[AnnoyedByFreud]

Because no one should teach nurses other than nurses, right?

Hmm. That's not how it works in my program.

 

[fab4fan]

Hmm. That's not how it works in my program.

I was being sarcastic.

 

[AnnoyedByFreud]

I was being sarcastic.

I assumed so.

 

[matthewandrew]

There is distinction and overlap in both medicine and nursing. To claim ownership in one aspect within the overlap is just silly. As healthcare professionals, we use knowledge and skills found in every discipline.

Whenever I see this happening, I imagine a chemist and a biologist arguing with each other who knows more about genetics.


UCLA FNP Class of 2016

 

[sarjasy]

I'm not doubting Ingles said that, however it was not the original premise for the mid-level provider. The original premise, envisioned by Dr. Stead (long before Ingles went to Colorado), was to teach nurses how to practice medicine.

If this is true, then Ingles and Stead, despite working together to create the role, disagreed on the role. Ingles clearly saw it as bringing certain aspects of medicine into the scope of practice of nursing. Maybe you have access to historical information that I don't have. (BTW, Ingles never went to Colorado. The University of Colorado PNP program was developed independently).

...when I put in a chest tube it is considered practicing medicine, but when you put in a chest tube it is considered practicing "advanced nursing".

Call it semantics if you wish, but if you or a physician takes a blood pressure or a temperature, or administers a medication or a treatment, or draws blood, or starts an IV, you are practicing medicine. If a nurse does any of these, he/she is practicing nursing.

 

[Boatswain2PA]

It is semantics NOW, because of the encroachment....but it doesn't mean it SHOULD be that way.

Think about it this way. What if the state medical board started allowing basic EMTs to start doing some of the tasks currently limited to nurses (drug calculations and administration, monitoring, IV, caths, etc). And over 20 years this trend kept growing and moved toward other states.

At the end of the twenty years, the difference between what that basic EMT does and a nurse does could be considered just "semantics", right? Doesn't matter that the basic EMT just went to school for 6 weeks while the RN went for four years, it would all just be "semantics", right?

 

[pamac]

It is semantics NOW, because of the encroachment....but it doesn't mean it SHOULD be that way.

Think about it this way. What if the state medical board started allowing basic EMTs to start doing some of the tasks currently limited to nurses (drug calculations and administration, monitoring, IV, caths, etc). And over 20 years this trend kept growing and moved toward other states.

At the end of the twenty years, the difference between what that basic EMT does and a nurse does could be considered just "semantics", right? Doesn't matter that the basic EMT just went to school for 6 weeks while the RN went for four years, it would all just be "semantics", right?

That actually could happen, and there could be aspects of that that could prove to be beneficial. Look at AAs. That's a field created out of thin air to fulfill a need that wasn't there, as CRNAs have been very successful in their own right, having had less supervision and great results over many years.

 

[marijea]

Imagine if you will a board of archery and a board of firearms. both can accomplish simple things like shoot that deer at 20yrds. But, by the time you are shooting a rabbit at 100yrds, a board of firearms trained hunter is all but required. now imagine a few archers realized there wasn't always a board of firearms hunter around when they needed one, so they buy a few rifles and try to teach themselves how to use them. eventually they say they are just as good at shooting that rabbit at 100yrds and they want to do so, they call themselves advanced practice archers or archer practitioners. The board of firearms gets upset and says you don't have the approved training from the board of firearms. The archer practitioners (with gunpowder residue on their fingers) says they aren't under the board of firearms because they are archers. They just practice "advanced archery".

I don't care how advanced your archery is, if you are using a .30.06 rifle.....you are in board of firearms territory.

You definitely captured my attention....thanks for the truthful humor!

 

[Zenman1]

Imagine if you will a board of archery and a board of firearms. both can accomplish simple things like shoot that deer at 20yrds. But, by the time you are shooting a rabbit at 100yrds, a board of firearms trained hunter is all but required. now imagine a few archers realized there wasn't always a board of firearms hunter around when they needed one, so they buy a few rifles and try to teach themselves how to use them. eventually they say they are just as good at shooting that rabbit at 100yrds and they want to do so, they call themselves advanced practice archers or archer practitioners. The board of firearms gets upset and says you don't have the approved training from the board of firearms. The archer practitioners (with gunpowder residue on their fingers) says they aren't under the board of firearms because they are archers. They just practice "advanced archery".

I don't care how advanced your archery is, if you are using a .30.06 rifle.....you are in board of firearms territory.

You might be in their territory but there's not a lot the firearms board can do. Getting close to a target and hitting it with an arrow also requires great skill.

 

[deleted480308]

You might be in their territory but there's not a lot the firearms board can do. Getting close to a target and hitting it with an arrow also requires great skill.

an archer can buy a gun and spray bullets at the tree line all day, doesn't make them a sniper

 

[Boatswain2PA]

But its so much easier to go to online archery school where you learn feather theory, and practice hitting virtual targets. Then, if you want to reach the pinnacle of archery and become a Zen-archer, you can study the flight patterns of the birds whom the fletching feathers come from. As a true zen-archer-master, you can then look down with disdain at those silly barbarians who limit themselves to simple firearms.

 

[Zenman1]

But its so much easier to go to online archery school where you learn feather theory, and practice hitting virtual targets. Then, if you want to reach the pinnacle of archery and become a Zen-archer, you can study the flight patterns of the birds whom the fletching feathers come from. As a true zen-archer-master, you can then look down with disdain at those silly barbarians who limit themselves to simple firearms.

While I developed my Zen mind purposely at the higher end of the continuum, you were born with an empty mind at the lower end. (I also did Kyudo at one point.) That is why I'd like to start a collection for psych testing for you as I'm sure the result would be enlightening. All professions are theory driven except possibly the one you are in. Studies show actually doing something (hitting virtual targets) or imaging you are doing it is basically the same as the brain doesn't know the difference. Yours, I'm afraid, rarely even knows it exists. Please have someone wake it up.

 

[sarjasy]

But its so much easier to go to online archery school where you learn feather theory, and practice hitting virtual targets.

News flash. Many on this board consider you an "advanced archer" too.

 

[Boatswain2PA]

While I developed my Zen mind purposely at the higher end of the continuum, you were born with an empty mind at the lower end. (I also did Kyudo at one point.) That is why I'd like to start a collection for psych testing for you as I'm sure the result would be enlightening. All professions are theory driven except possibly the one you are in. Studies show actually doing something (hitting virtual targets) or imaging you are doing it is basically the same as the brain doesn't know the difference. Yours, I'm afraid, rarely even knows it exists. Please have someone wake it up.

I'm trying Zenman. Maybe, just maybe, some day I will be able to fill my empty brain with a small fraction of your immense Zen-like knowledge.

With all of that Zen in your head, how do you make room for science?

Oh...wait....never mind.

 

[Boatswain2PA]

News flash. Many on this board consider you an "advanced archer" too.

Everyone is entitled to their opinion.

I certainly don't consider myself to be "advanced" anything as I am humbled on every shift with the things that I DON'T know. That list is simply too long for me to be "advanced", and certainly not a Zen-archer!

However, I am in the woods a lot, and I hunt with a rifle!

 

[Zenman1]

I'm trying Zenman. Maybe, just maybe, some day I will be able to fill my empty brain with a small fraction of your immense Zen-like knowledge.

With all of that Zen in your head, how do you make room for science?

Oh...wait....never mind.

I consider myself to have only a smidgin of knowledge so if you want a small fraction of what I know you're in trouble.

 

[4nursepractitioners]

Let me start off by saying that you are not making war. Your thoughts represent the elephant in the room of medicine today. The idea of the Nurse practitioner started off with the pediatric CNS going to rural areas to help families with education and immunizations. NPs are now faced with the question of what is so different about you? As a mental health NP I am asked daily "Why am I not seeing a real doctor". My response is what kind of care do you seek? Tell me your goals of treatment. If they just want drugs and nothing more, maybe a DR is better. Nursing is known for communication, education and holistic care. That is what makes us different from Doctors and PAs for that matter. Let me ask medical students or residents this: What do you learn in school? I see residents and they focus on the part of the body that has a problem. Notice I said, a part of the body that is ill not the patient that is ill. It takes doctors many years to learn how to treat a patient and not a body part. Now, I am not being negative or slamming residents or doctors. I have learned a lot from each regarding those sick body parts. Nurses and nurse practitioners just see that sick body part differently. Our mantra is "the whole person" that is our goal. To treat mind body and spirit. It is just different. We all have the same goal and that is to help the patient get better. So you ask what is different about being a nurse practitioner? We just see the patient different due to our training. Nurse practitioners have a lot to offer medicine. I really wish doctors and other health professionals would just accept us as another part of the team. We are here to help the patient just like you are.
Thank you for the opportunity to speak.

 

[4nursepractitioners]

I’ll give you my perspective but it’s colored by my other training. I’m a Psych NP and I sit in my office treating Soldiers just like the psychiatrists around me. I do initial evals and make diagnoses, order meds, therapy, do follow-ups with med management and therapy, and order necessary labs, a rare CT or MRI, sleep studies, and occasional other consults to primary care, urology, neuro, etc.. What is different is that I can use any one of a number of theories to view a patient. These are the theories that many nursing students call “fluff courses” and want to spend as little time as possible on them. This may be because their teachers don’t explain the purpose of a theory, how to use them, or that all professions are theory-driven, otherwise you’re known as a trade school graduate. I think in nursing school you learn concepts while in medical school you memorize a wad of material and try to fit a patient into a diagnostic category. Physicians, for the most part I think, stick hard and fast to the science bible, in spite of the fact that most peer-reviewed studies are hardly worth the paper they are written on. There are plenty of comments on this even from journal editors themselves. I didn’t become a fanatic of the science-based approach and actually trained in other approaches just so I would have the experience rather than a belief for or against them. I studied Chinese medicine philosophy, Tai chi (which has quite a few studies behind it) for healing plus it’s fun to beat people up with it also, the Korean martial art of HapKiDo, Reiki, Japanese Zen shiatsu, Chinese medical and martial qigong, studied with Q’ero Indians in Peru and Shipibo medicine people in the Amazon. I think that’s everything.

So, I have a big toolbox to choose from. The other day I saw a young lady who had miscarried and was having dreams of the baby progressing from an infant to 5 years of age and asking for a name. So how would you treat this young lady?

While I don’t see auras I understand it’s easy to learn how to do so. If you don’t believe in energy fields you might want to wake up Einstein and have a chat with him. Everything is energy so what you’re basically saying is that you have a lack of knowledge on the subject. I teach medical qigong (basically energy medicine) to Soldiers in a functional restoration program (I’m credentialed by the hospital) to help them deal with chronic pain, which has not been successfully “fixed” by Western medicine. I won’t go into what all I teach them but I’m sure some will be glad to take your money if you ever want to place a bet with them that it doesn’t help them.

Here Here!!! I am with you. I think maybe there is jealousy and territorial BS going on?

 

[W19]

Let me start off by saying that you are not making war. Your thoughts represent the elephant in the room of medicine today. The idea of the Nurse practitioner started off with the pediatric CNS going to rural areas to help families with education and immunizations. NPs are now faced with the question of what is so different about you? As a mental health NP I am asked daily "Why am I not seeing a real doctor". My response is what kind of care do you seek? Tell me your goals of treatment. If they just want drugs and nothing more, maybe a DR is better. Nursing is known for communication, education and holistic care. That is what makes us different from Doctors and PAs for that matter. Let me ask medical students or residents this: What do you learn in school? I see residents and they focus on the part of the body that has a problem. Notice I said, a part of the body that is ill not the patient that is ill. It takes doctors many years to learn how to treat a patient and not a body part. Now, I am not being negative or slamming residents or doctors. I have learned a lot from each regarding those sick body parts. Nurses and nurse practitioners just see that sick body part differently. Our mantra is "the whole person" that is our goal. To treat mind body and spirit. It is just different. We all have the same goal and that is to help the patient get better. So you ask what is different about being a nurse practitioner? We just see the patient different due to our training. Nurse practitioners have a lot to offer medicine. I really wish doctors and other health professionals would just accept us as another part of the team. We are here to help the patient just like you are.
Thank you for the opportunity to speak.

 

[KSBaylor]

It is semantics NOW, because of the encroachment....but it doesn't mean it SHOULD be that way.

Think about it this way. What if the state medical board started allowing basic EMTs to start doing some of the tasks currently limited to nurses (drug calculations and administration, monitoring, IV, caths, etc). And over 20 years this trend kept growing and moved toward other states.

At the end of the twenty years, the difference between what that basic EMT does and a nurse does could be considered just "semantics", right? Doesn't matter that the basic EMT just went to school for 6 weeks while the RN went for four years, it would all just be "semantics", right?

EMT-P's (paramedics who go to school for 2 years) have been able to administer drugs, monitor, IV's, chest tubes, intubations, etc, etc for years. Nurses have been the worst when it comes to trying to claim ownership over who can really perform those tasks. It's actually pretty comical to watch nurses flip their lids because a CT tech can administer contrast or a paramedic putting in a foley.
I say all of this as a nurse, but I don't come from the stance of ignorance in thinking nurses are always the best person for the "job". It is this manner of thinking, in my opinion, on why there are so many issues with the nursing model and nursing theory. All of the nursing diagnoses and theories fly right out the window when you are dealing with 5-6 patients in a shift and barely have time to get med passes done on time and charting. The typical nursing programs don't come anywhere near preparing nurses what they need to know in basic practice which is why so many feel so burnt out as early as their first nursing job. Nursing administrations are a joke. I can't believe more nursing programs aren't more focused on patho, pharmacology, etc...The 15+ hours in BSN programs teaching nursing theories could be much better spent focused on hard science. It's amazing how many nurses scoff at the idea of teaching a science-based nursing program. Don't get me started on DNP programs. I'm obviously looking for another career LOL

 

[Zenman1]

As a mental health NP I am asked daily "Why am I not seeing a real doctor".

I have never in my life been asked this question…just saying.

 

[deleted6669]

I have never in my life been asked this question…just saying.

That's because you look "mature". I get asked that question a lot less now than 15-20 years ago. amazing what a beard and a wedding ring does for you.

 

[sarjasy]

amazing what a beard and a wedding ring does for you.

Works great for us men. Not so much for the ladies.

 

[BruceWilly]

Let me start off by saying that you are not making war. Your thoughts represent the elephant in the room of medicine today. The idea of the Nurse practitioner started off with the pediatric CNS going to rural areas to help families with education and immunizations. NPs are now faced with the question of what is so different about you? As a mental health NP I am asked daily "Why am I not seeing a real doctor". My response is what kind of care do you seek? Tell me your goals of treatment. If they just want drugs and nothing more, maybe a DR is better. Nursing is known for communication, education and holistic care. That is what makes us different from Doctors and PAs for that matter. Let me ask medical students or residents this: What do you learn in school? I see residents and they focus on the part of the body that has a problem. Notice I said, a part of the body that is ill not the patient that is ill. It takes doctors many years to learn how to treat a patient and not a body part. Now, I am not being negative or slamming residents or doctors. I have learned a lot from each regarding those sick body parts. Nurses and nurse practitioners just see that sick body part differently. Our mantra is "the whole person" that is our goal. To treat mind body and spirit. Tis just different. We all have the same goal and that is to help the patient get better. So you ask what is different about being a nurse practitioner? We just see the patient different due to our training. Nurse practitioners have a lot to offer medicine. I really wish doctors and other health professionals would just accept us as another part of the team. We are here to help the patient just like you are.
Thank you for the opportunity to speak.

I completely agree. I was in the ED the other day for a drug overdose, and the doctor just prescribed a few meds. I left after making a full recovery, but I just couldn't stop wondering... No yoga? Why didn't the doctor and I do some yoga? The audacity...

 

[Zenman1]

I completely agree. I was in the ED the other day for a drug overdose, and the doctor just prescribed a few meds. I left after making a full recovery, but I just couldn't stop wondering... No yoga? Why didn't the doctor and I do some yoga? The audacity...

Yoga not appropriate for the ED but tends, for some, to help with PTSD.

 

[mj1988]

Let me start off by saying that you are not making war. Your thoughts represent the elephant in the room of medicine today. The idea of the Nurse practitioner started off with the pediatric CNS going to rural areas to help families with education and immunizations. NPs are now faced with the question of what is so different about you? As a mental health NP I am asked daily "Why am I not seeing a real doctor". My response is what kind of care do you seek? Tell me your goals of treatment. If they just want drugs and nothing more, maybe a DR is better. Nursing is known for communication, education and holistic care. That is what makes us different from Doctors and PAs for that matter. Let me ask medical students or residents this: What do you learn in school? I see residents and they focus on the part of the body that has a problem. Notice I said, a part of the body that is ill not the patient that is ill. It takes doctors many years to learn how to treat a patient and not a body part. Now, I am not being negative or slamming residents or doctors. I have learned a lot from each regarding those sick body parts. Nurses and nurse practitioners just see that sick body part differently. Our mantra is "the whole person" that is our goal. To treat mind body and spirit. It is just different. We all have the same goal and that is to help the patient get better. So you ask what is different about being a nurse practitioner? We just see the patient different due to our training. Nurse practitioners have a lot to offer medicine. I really wish doctors and other health professionals would just accept us as another part of the team. We are here to help the patient just like you are.
Thank you for the opportunity to speak.

Not completely disagreeing just elaborating. I'll preface by saying that I work in clinical quality outcomes administration and direct report to physicians but collaborate quite a bit with nursing mostly NPs (at my previous job the RNs I worked with were chummy enough to invite me out to happy hour with them every week but as I was supposed to be evaluating the processes they do declined to keep things professional - watched/observed them in rounds and on the floor units and got as much input from them about the strengths and weaknesses of the team (siloing of pharm, nursing, doctors, case mgmt, and social work - it was a childrens hospital in a urban impoverished area). I also was/still is considering a career in medicine for many years now. Yes, the elephant in the room is the blurred lines of medicine and nursing. However, while many younger or more highly specialized physicians/residents with some exceptions are more narrowly focused on a specific localized area of disease/body part/organ this is not entirely the case. The whole person approach is very highly regarded in DOs, part of the reason why the MD/DO split for philosophy the other is OMM unless the MD specializes in neuromuscular skeletal medicine or kinesthesiology. There is also a stronger push from medical schools both MD and DO to keep in mind the patient as a whole person and take into account their unique circumstances and values and their emotional and social issues when treating a patient's well being. This is really important and duly noted by many physicians but as always changing the herd takes time. This is where nursing has a slight advantage in care coordination and continuation. The knowledge base of the physician will most likely be greater overall on disease etiology (but the experienced and specialized nurse has the edge on newly graduated docs). Physician knowledge about the human body is good but the application is also very important (thus the experienced/specialized nurse over residents/fellows) - the booksmart vs. streetsmart analogy.

Historically however, healing and rise of physician-healer came from a whole person approach - think ancient times (I've studied and researched the history of greek and roman medicine which though primitive is the basis for medical philosophy - hippocrates and aesclepius and emphasis on diet, exercise, mental health and the effects of religion and culture on health with the exception of military medicine, surgery, and gynecology obstetrics) and know a little about chinese traditional medicine - not saying these people followed scientific/evidence based medicine thousands of yrs ago or weren't influenced by cultural religious beliefs/cults or have been known to use different methods for medicine some now proven to work (many medicinal herbs/plants used to heal have medicinal properties and have been used to derive useful medicines for the present day while others more hoax) but for the most part they thought of the patient as a whole. Only within the last 200 yrs has this whole person approach been edged out by the need for physicians to specialize and to learn/ keep up with advances in medicine and the medical field has expanded and become more technical/pharmacological. The way I see it the paradigm shift back towards whole person medicine today came about because of both advances in personalized medicine/molecular genetics and the diversity of cultures/SES and globalization. Without holistic healing medicine is at a disadvantage in treating patients of various backgrounds. Medicine is ever evolving and physicians need to realize the need for whole person healing. I think physicians know this and medical schools (DO and now increasingly MD as the AMA is making changes) are seeking out and graduating people more and more aware of the patient over the body part. Thus changes in premed and medical school curriculum and the mcat to ensure more compassionate doctors. And I highly respect nurses and NPs and PAs (yes I know they are not the same as nurses) because of the crap they have to put up with from some of the more narrow minded physicians. But I work at a cancer center that sees thousands of patients a year (hundreds each day) we've 40 physicians on staff (diagnose and prescribe initial Tx) and at least half a dozen NPs and a few PAs (treat chronic issues, follow ups, and ordering prescription refills) and without everyone working together those patients would not be cared for. Unfortunately, as each profession continues to overlap and encroach on each other in terms of title and duties/responsibilities, it will take time for the politics and emotions of each profession to die down/work itself out but the bottom line as you said is: the treatment, health, and well being of the patient

 

[BreathDeep]

Nursing is known for communication, education and holistic care. That is what makes us different from Doctors and PAs for that matter. Let me ask medical students or residents this: What do you learn in school? I see residents and they focus on the part of the body that has a problem. Notice I said, a part of the body that is ill not the patient that is ill. It takes doctors many years to learn how to treat a patient and not a body part. Now, I am not being negative or slamming residents or doctors. I have learned a lot from each regarding those sick body parts. Nurses and nurse practitioners just see that sick body part differently. Our mantra is "the whole person" that is our goal. To treat mind body and spirit. It is just different. We all have the same goal and that is to help the patient get better. So you ask what is different about being a nurse practitioner? We just see the patient different due to our training.

I for one am getting tired of the word "holistic" in general, but especially how it has been twisted in regards to Nursing and Nurse Practitioners. Holistic has two definitions, first being philosophical: "Holistic - adjective - Characterized by comprehension of the parts of something as intimately interconnected and explicable only by reference to the whole." And secondly a special medical definition: "Characterized by the treatment of the whole person, taking into account mental and social factors, rather than just the physical symptoms of a disease."

By both definitions NP's are still second rate. Allow me to explain why.

First, what do physicians learn in school? A quick glance at my old hospitals MD program shows they cover in order: Gross anatomy, physiology, cell & tissue biology, molecular medicine, microbiology, immunology, pharmacology, pathology, endcodrine, nutrition, reproduction, genetics, neurosciences/neurobiology, psychiatry, bioethics, systemic pathology, pharmacology again, musckuoloskeletal, dermatology, pulmonary medicine, cardiology, more pathology again, even more pharmacology, nephrology, gastroenterology, oncology, even more pathology, and even more pharmacology. Then they start their rotations.

I would say doctors learn a good foundation in, well, just about everything. That is the whole point of medical school anyway right? But you are correct, it does take doctors many years to learn how to treat a whole patient. It's called medical school, where they learn about every part of the body and how to treat the entire thing before they head off to residency to hone their craft.

You are also correct that nurses do see a sick body differently. Because compared to a doctor they can't see the whole picture, so of course it's going to look different. Here's a the complete curriculum for my local NP program: Research methods, theoretical foundations for APN's, professional role of the APN, health assessment, physical assessment lab, pathophysiology, family centered nursing, analysis of health policy issues, health protection, promotion, and screening, pharmacology, 90-120 hours clinicals, care of acute conditions, 240 hours clinicals, synthesis project, advocacy for entry to advanced practice, care of chronic conditions, and 240 hours clinicals.

Wow. See the difference? None of those classes are more than 3 units by the way. But yeah, I can totally see how someone with 3 units worth of pharmacology, pathophysiology, physical assessment and 600 clinical hours would see things quite differently. Not to mention the fact that, well, where's the science? If you don't understand the basics of how the body functions, how on earth can you really understand/treat it?

Now circling back to the whole "mind, body, and spirit" thing. I believe there are people out there called Psychiatrists and Psychologists right? As we've established NP's don't have the appropriate knowledge to compete with a psychiatrist in treatment of the brain, I'm gonna go ahead and say that they don't hold a candle to properly trained mental health professionals such as Psychologists either. Or LCSW's, or MFT's, or any other Masters/Doctorate trained therapist. Clinical Social Workers are probably better at handling most social issues too, just a hunch.

Keep in mind, this is coming from a guy who works with some great NP's that I respect very highly. But I don't drink the kool-aid, and don't get caught up in the buzzwords. I examine the facts for what they are, and the answer is simple: Nurse Practitioners lack the appropriate education to have a comprehensive understanding of medicine, therefore they also lack the ability to treat "the whole person" secondary to their shortcomings in knowledge. Lets be real here, the only reason words like "holistic" and "treating the whole patient" and "mind body and spirit" are used is because they are vague and impossible to be measured objectively.

So yeah, NP's do see the patient different due to their training. Definitely. Just not for the reasons you think they do.

 

[AnnoyedByFreud]

I’m not sure why you’re judging all NPs based off of one NP program’s curriculum. Not all NP curricula are the same and that program sounds weak. Also, there are NP programs that specialize in psychiatry.

 

[BreathDeep]

Indeed it is hot garbage, but I've never found a program that's really much better.

So how about this. Find me one single NP program that comes close (I'll even consider 50% "close") to the didactic clinical/scientific education, including depth and comprehensive coverage of material, plus clinical hours of any medical school, and I will admit I was wrong.

 

[Zenman1]

So, yesterday I listened to a patient tell me why he didn't like the provider (psychiatrist) that he had before me, "he never talked to me like you and I are talking." A patient today went on and on about his therapists and psychiatrist he had while stationed in Germany. Yesterday, I emailed the primary care physician of one of my behavioral health patients as she had him on HCTZ and Lisinopril and I wanted to put him on Prazosin since his nightmares were returning and interfering with his sleep. This was a professional courtesy email to the same physician that told one of my patients last week to stop her Venlafaxine, which she was responding well to, so she could start her on Elavil for her joint pain. This physician responding by telling me what doses of Prazosin I could use (WTH?) and that she should be fine…just make sure the HCTZ was given in the am (WTH?). I'm writing her up as soon as my patient returns next week and I see how she is doing. I saw another patient today who had a crush injury to his left arm and hand. This was three weeks ago and he is going to OT twice daily while his ortho doc tries to prevent compartment syndrome and surgery. I asked the guy if they had given him an IV pole to sling his arm up while he slept. He replied that they did. He was returning to the hospital today so I told him to tell his ortho docs that I was a psych guy but had they considered slapping a "fluid pill" in him? Can't wait to hear how this turns out. Sometimes a lot of learning just makes you too dumb to operate in the trenches.

 

[BreathDeep]

Thank goodness in the medical field we test the veracity of something through empirical, not anecdotal, evidence.

 

[deleted480308]

So, yesterday I listened to a patient tell me why he didn't like the provider (psychiatrist) that he had before me, "he never talked to me like you and I are talking." A patient today went on and on about his therapists and psychiatrist he had while stationed in Germany. Yesterday, I emailed the primary care physician of one of my behavioral health patients as she had him on HCTZ and Lisinopril and I wanted to put him on Prazosin since his nightmares were returning and interfering with his sleep. This was a professional courtesy email to the same physician that told one of my patients last week to stop her Venlafaxine, which she was responding well to, so she could start her on Elavil for her joint pain. This physician responding by telling me what doses of Prazosin I could use (WTH?) and that she should be fine…just make sure the HCTZ was given in the am (WTH?). I'm writing her up as soon as my patient returns next week and I see how she is doing. I saw another patient today who had a crush injury to his left arm and hand. This was three weeks ago and he is going to OT twice daily while his ortho doc tries to prevent compartment syndrome and surgery. I asked the guy if they had given him an IV pole to sling his arm up while he slept. He replied that they did. He was returning to the hospital today so I told him to tell his ortho docs that I was a psych guy but had they considered slapping a "fluid pill" in him? Can't wait to hear how this turns out. Sometimes a lot of learning just makes you too dumb to operate in the trenches.

Your theory is that less knowledge makes someone better at health care decisions?

 

[Zenman1]

Thank goodness in the medical field we test the veracity of something through empirical, not anecdotal, evidence.

And there is nothing wrong with that, other than humans are involved, which has lead medical journal editors to report that much of what is written in their journals is hardly worth the paper it is written on. Hope you are learning the "real" stuff.

Research is based on populations so when a patient asks you how long they have to live you tell them "6 months based on the latest data." I ask them how long they want to live.

That "anecdotal" sitting in front of you has their own story and that is all that matters to them and to me. You can of course take their story if interesting and write it up as an interesting case and proceed from there to research if you wish.

 

[Zenman1]

Your theory is that less knowledge makes someone better at health care decisions?

No, but don't think that because you are the top dog that you are the top dog.

 

[deleted480308]

No, but don't think that because you are the top dog that you are the top dog.

This isn't inception...the top dog actually is the top dog.

 

[Zenman1]

Kinda like Obama thinks he is top dog? He actually is but what do we think about him? What my patients think about me is important, read therapeutic relationship, and has a bearing on how well they do.

 

[deleted480308]

Kinda like Obama thinks he is top dog? He actually is but what do we think about him? What my patients think about me is important, read therapeutic relationship, and has a bearing on how well they do.

Sweet lord, you are random. People liking you is irrelevant to who is the top dog.

 

[Zenman1]

Sweet lord, you are random. People liking you is irrelevant to who is the top dog.

At some point you might get it, but most likely not. Your concrete thinking is getting in your way. While you might have a boatload of information stored in your head, you are lacking knowledge.

 

[deleted480308]

At some point you might get it, but most likely not. Your concrete thinking is getting in your way. While you might have a boatload of information stored in your head, you are lacking knowledge.

I get it. You think because you've been spinning the stop sign on the road crew for decades that you know more about building roads than the foreman. It's clear from your postings we'll just have to coexist and disagree.

 

[Zenman1]

I get it. You think because you've been spinning the stop sign on the road crew for decades that you know more about building roads than the foreman. It's clear from your postings we'll just have to coexist and disagree.

Don't think that because you are the top dog means that you are the top dog. Meditate on this for a week or so and get back to me.