So this was posted on another message board. I want to get your thoughts on this
Read thru
Family Physician and Nurse Practitioner Training published by AAFP, 2008....look at what they list as the educational training for NPs and other comments. I'm insulted. Someone needs to have a chat with the folks at the American Academy of Family Physicians.....
It went on to say this:
High-quality care is the goal for family physicians and nurse practitioners.
TRUE
Family physicians complete training for complex, differential diagnoses and medical treatments.
TRUE
Nurse practitioners complete training for common diagnoses and treatments
TRUE, this goes on to say allot of BS
You know what you're getting with a physician.
TRUE, though there are many bad doctors, at least the education is standardized. WAY more than we can say for NP programs
Nurse practitioner certification can mean various levels of training.
See previous section
Clinical care is only one-third of nurse practitioner training.
It is embarrassing how little clinic training we have as NPs.
Why spend our energy on whining about what other are saying (when much is true anyway). Why don't we spend our energy making our profession better.
We need standardization in our education ... we need Recertification board exams ... we need more clinical training ... we need residencies for every NP.
We need to STOP saying "was an RN for blah blah years" - it's not the same.
Multiple research studies have found no difference between NP and MD patient outcomes. If you're willing to wait weeks for an MD, that's fine. It seems silly to me, but to each their own.
When I call for a sick appointment with my doctor, and the receptionist tells me the only appointment available is with the NP, I feel like I am being take advantage of. The education of the NP is nowhere near that of the MD. And, the price of the appointment isn't being reduced related to the decreased amount of education of the NP. I wait to see the doctor on the off chance my condition will require that added expertise of an MD education. Sure, there are bad doctors, but the facts are the NP doesn't have the same credentials. Additionally, doesn't the NP have to operate under the license of an MD inorder to be able to write Rx's and can only write certain types of Rx's?I guess that means there are checks and balances on the NP, but that's only because of their reduced education. And why pay for the middle man when I can get the main man for the same price? I bring all this up because I'm an RN looking into my next step in education- MSN to teach, NP to go into clinical practice. When I looked into the curriculum of the PA's, it was much more science based than either. I am more comfortable seeing a PA than an NP for my medical concerns because of this education gap. So, I see the point of the article in question.
Oh dear! You do realize you posted this in a NP forum, right? And you're a NURSE who's thinking about becoming a (gasp) lowly NP? Yikes. I'm trying hard not to take offense to this post. Maybe some more education on the scope of practice of NP's is in order for you. And I will keep all other comments to myself (biting my tongue so hard it bleeds)
Haven't had to wait for the MD when I was firm about who I expected to see for my appointment. If there is not difference in outcomes between MD and NP, then why do physicians need all that education? I would question those studies, except on the most basic conditions. When I did give in and see a NP one day, and told her I was allergic to erythromycin...that was the antibiotic she Rx's for me anyway!! Not all NP are well trained.
When I looked into the curriculum of the PA's, it was much more science based than either. I am more comfortable seeing a PA than an NP for my medical concerns because of this education gap. So, I see the point of the article in question.
Agreed. That's a huge reason why many of us in medicine have also preferred to hire PAs rather than NPs. Their curriculum is pretty solid! Plus, it's standardized! So we have a pretty good idea of what we're getting when we hire a PA.
Full disclosure, in case people are confused -- I'm a PGY-2. My opinions, for the most part, are based on my own experiences (which is pretty extensive --- approx. 10,000 hours of clinical training already, if not more) and my talks with other colleagues (residents and attendings).
I do exactly what my MD colleagues do. I work the same job...
I find this an interesting, but common, assumption amongst nursing midlevels. You actually don't do the same thing that I do. For any given set of symptoms that a patient comes in with, I (and physicians in general) can develop a much, much larger (and stronger) differential diagnosis. So, while we may often reach the same conclusion, as a physician, I'm ruling out a lot more problems than you are. As someone essentially practicing medicine, I'm sure you're aware of how important it is to rule out conditions - it's just as important as figuring out what the actual problem is. I'll give you a couple of examples in a later paragraph, but not developing a large enough differential to rule out subtle, but important, conditions can lead to devastating consequences for the patient (ex. missing cancer diagnoses because the symptoms were too subtle/"common").
You do your job. And I do mine. But, it's insulting to say that you do the exact same thing I do. That is not true. I've spent years in training and sacrificed a good chunk of my 20s studying so I can develop into this "differential diagnosis generating machine" (and I still have a long way to go).
PAs in many states have much more restrictions to their practice (they cannot practice independently), which they are rightfully working to change. They seem to have more freedom, but that is because they have for the most part remained good little soldiers and stay obedient to their MD masters.
They have more freedom in the hospital systems I've worked in not because they're "good little soldiers and stay obedient to their MD masters" but because they receive much better training than our NPs do. In fact, our PAs tend to challenge our residents' plan of action, etc, a lot more than our NPs do. Our PAs' fund of knowledge regarding pathophysiology and clinical decision-making has been much better than the NPs', time and time again. This is just my anecdotal evidence and I don't know if any comparison between NPs and PAs exists in the literature (doubt it). However, looking through both midlevels' curricula, it's easy to see why PAs get more freedom -- their curriculum focuses on developing them as clinicians whereas the NP/DNP curriculum focuses on producing people with business and health policy smarts rather than pure clinical training. It's just the safer route for physicians to prefer PAs. We know a lot less about the training nursing midlevels get and many are unwilling to take that risk.
You have the option to see the MD or NP, you are correct, but you may be doing yourself a disservice by waiting to see the MD. Sure, the cost isn't any different, but you may find the level of service is much better...
If the cost isn't different, you want higher quality. Not service. It doesn't matter if you spend an extra hour with the patient if your training hasn't prepared you to develop an extensive enough differential to figure out what's going on with them. With that being said, the vast majority of patients ultimately do just fine seeing midlevels, so I agree with you (in a sense) there.
A bad NP will have a "know it all" attitude and try to keep the patient in-house, rather than refer them out.
Wow...that sounds like a whole lot like what some doctors do.
Actually, that sounds more like what nurses and other ancillary staff tend to do, rather than doctors. These people go out of their way to "put doctors in their places" and try to show that they know more than the doctor, so this attitude has definitely been more prevalent in the non-physician community. I've seen everything from NPs who've been awesome at referring out patients when they realize it's beyond their scope to NPs who've refused to think that the underlying issue is something pretty bad - over the last year, we've had 2 patients come in with advanced stage cancer because their primary care providers (one was an NP and the other was a DNP) thought all their symptoms were something common. This type of thing is much less common in physicians, because of the way we form differentials. As physicians, we're taught right from the first day of school how little we actually know. It's engrained in our heads that we don't know everything and the length of our training makes that even clearer.
It also makes a big difference on what that NP did before they became an NP. I'll trust an NP's opinion that was a cardiac nurse for several years before she became an FNP before I'll listen to ONE THING a general practice physician says that just did one or two cardiac rotations and during that time, 90% of his job rested around probably asking the nurses what so-and-so doctor normally did....if, for example, I had to see my primary care physician in order to get a referal to a cardiologist.
I thought there was some recent survey showing that prior nursing experience did not translate over to producing better NPs?
I would trust the opinion of the physician. I haven't come across many nurses that understood the subtleties of cardiac conditions and were able to thoroughly explain things like etiology, pathophysiology, pathogenesis, which choice of pressor, etc. Cardiovascular path is a HUGE part of medical training, whether you go into cardiology or not, because of how prevalent CV disease has been. So, a LOT of focus is placed on CV disease - unless you're super, super subspecializing, you have to know this. The general practice/internist physicians are probably second in line, after cardiologists, in terms of cardiology knowledge. The reason we see a lot more referrals to cardiologists rather than FP physicians taking care of it on their own is because of CYA medicine, not because of a lack of knowledge.
And I find it incredibly insulting that you think we did "one or two cardiac rotations and during that time, 90% of [the] job rested around probably asking the nurses what so-and-so doctor normally did." No. It's clear that you don't understand how medical training works and even what it entails. By the time we're done with medical school (not even residency), we've already had multiple rotations where cardiology plays a significant role. And while we occasionally do ask nurses about what a particular attending might prefer, we don't blindly just go with what they suggest. We ask what the attending prefers because if their treatment plan and ours doesn't differ significantly, we might as well go with their plan since they're more used to it (ex. my choice of medications vs. the attending). If I feel that my choice is better, chances are I can reasonably explain it to my attending and get him/her to follow my plan instead. Physicians don't get their primary learning (which includes patient management) from nurses. We get that from residents who are above us in training and our attendings. We would be ripped apart if we blindly followed a plan that a non-physician, no matter what profession, suggested. ACGME requires that we be taught by physicians.
Here is another fact for you: PA's are NEVER allowed to practice independently in any state, while NP's are in many states.
That has a lot to do with how incredibly powerful the nursing lobby is. I can only wish that the medicine lobbies and PACs were even half as well-organized as the nursing lobbies are. So, kudos to your profession on mastering the art of lobbying politicians.
There was also an article posted on here awhile back that stated statistically, ACNP's diagnosed disorders more accurately in an emergency room setting than the ER doc.
Maybe it's because nurses have spent far more time with patients vs a 10 minute fly by.
I think I know what ED study you're talking about. And the conclusions you're drawing are not accurate. The emergency NPs had more thandouble the rate of missed injuries and/or inappropriate management - the only reason this did not come out of be statistically significant was because of how severely underpowered the study was. Not only that, it was the doctors who actually spent more time with patients, rather than the emergency NPs. And that was statistically significant (not that it means anything, considering how underpowered the study was).
This is just from my memory, so feel free to look up the study. I remember going down to the ED for a consult last year and having this discussion with the ED attending and 2 of the ACNPs there. They were having a good chuckle at how easy it was to publish poorly-done studies. Both of those ACNPs also thought the study was essentially worthless.
Multiple research studies have found no difference between NP and MD patient outcomes. If you're willing to wait weeks for an MD, that's fine. It seems silly to me, but to each their own.
These multiple studies have pretty poor methodology (much more so than the avg. study does) or are severely underpowered to draw any meaningful conclusions from. Bad evidence is worse than no evidence (refer to the Wakefield study and the impact it has had, if you want an example). What these same studies also suggest is that nursing midlevels waste more money than physicians (by ordering more tests and referring patients out more) while taking a lot longer to reach the same diagnosis as a physician. Again, neither of those matter either, since the studies were badly designed and we can't make those absolute statements based on bad evidence.
In conclusion, I'm sure there are excellent NPs (I work with a few of them!) and bad NPs just as there are excellent physicians and bad physicians. However, to state that you do exactly the same job that myself and my physician colleagues do is extremely, extremely insulting and completely inaccurate. Know your scope, practice within it, realize there's still a heck of a lot that you (and I) don't know, and you won't have any issues with physicians.
oh dear "whatdoidonow?", If I could tell you how abused our poor NP's were at my work. They do the call, do all of the clinic PE's, routine med orders, take care of all of the difficult mucisitis, hemoturia, unstable BP's, anemia, malnutrition, dehydration, pain, extracurricular social outpatient needs, and all of the other small organ dysfunctions/failures that come from mega-chemo doses. The MD's are brilliant and write the protocols, clinical trials etc, but good lord please don't let 'em show up during a true crisis. Let it be the Critical care doc, a fellow or a nurse practitioner if we want the patient to recover quickly or survive at all. I have to say even our staff RN's are above average in a lot of knowledge and skill if they've been there longer than 2 yrs, but from the day the NP's walk through the door they are assigned to a physician and specialty clinic and are busting their butt's. Monitoring electrolytes, cardiac and endocrine systems that have been permanently impaired, and managing crisis after crisis. I have no desire to do that job.
I'm proud of what I've done at the bedside, burned out and had to quit that one after over 20 yrs, gone to a different job were the NP does the same thing alone, but receives little respect and it is really upsetting me. I'm about to let the other RN have it because there is no way he can do her job at all, and he's mad because she doesn't do his. Idiot! Oh well, maybe not yet, soon enough, but I see dumb people. She is wearing 3 hats right now quite well. It's interesting being an outside observer to an area. It's very busy but not difficult in relation to my old job. I'll keep my mouth shut for a while, and help her as much as I can. Him too, but I see how he creates extra on occasion, lack of organization. Not always one of my better attributes either, but having done the "nurse thang" for 30 yrs. I definitely have some powers of observation.
I love the NP at my MD's office, she knows me better than he does, and I can get straight to the point without repeating my whole hx. She remembers it somehow and easily takes up where we left off with a brief peek at her last note. I trust her as much as my Doc, love her as much too. Long term relationship with both, she is a replacement picked by the previous NP who I really miss, but I grew to trust her quickly, she's good, just cares in a different way than my old NP. (I'm very loyal when I like someone, so I was a bit "testy" at first, but I'm not exactly a spring chicken anymore either.) So please don't consider yourself short-changed at all seeing the NP. You may actually be getting a little more quality time in the long run.
You need to sniff around and see how things work. Who makes the decisions for most of you guys? Administration. When you get out of your cloistered world there and enter the big world, you will get no sympathy for your tuition and years spent in school. Nobody does. It's only about money and you are a drain on somebody else's take. So much to learn and catch up on in the real world for MDs once they get pushed out of the nest. Gonna be a shocker, but I'm pull'in for ya.
If the cost isn't different, you want higher quality. Not service. It doesn't matter if you spend an extra hour with the patient if your training hasn't prepared you to develop an extensive enough differential to figure out what's going on with them. With that being said, the vast majority of patients ultimately do just fine seeing midlevels, so I agree with you (in a sense) there.
Exactly. This is not a personal attack. I'm sure the NP's are hardworking, caring people. Still can't get around the education issue. The fact that I'm an RN is really irrelevant. I'm also a patient. As such, I want the best care for myself and my family. I want the expert, not the stand in. And, after being educated in my program by a few NP's, I can honestly say I was not impressed with the depth of their knowledge. Often they could not answer my questions. At the free clinic where I volunteer and have access to physicians who also volunteer, I can tell you how quickly they can answer my questions. Critical thinking through medical pathophysiology is second nature to them, its automatic, thanks to those many years of training.
Oh dear! You do realize you posted this in a NP forum, right? And you're a NURSE who's thinking about becoming a (gasp) lowly NP? Yikes. I'm trying hard not to take offense to this post. Maybe some more education on the scope of practice of NP's is in order for you. And I will keep all other comments to myself (biting my tongue so hard it bleeds)
Yes, I do. And, that's the wonderful thing about forums- free speech. As for my future in nursing, I said I was looking into my next step, I didn't say I wanted to take the NP option. I compared NP to PA education. Honestly, if I were younger, I would pursue the PA option. But, alas, not really an option for me. My view on the NP as a profession is based on my shock when I realized that these professionals my docs office offered me had so little training. I couldn't believe it!
Sorry your tongue hurts. I thought we nurses were supposed to have thick skins and not take every opinion as a personal attack.
As for the scope of practice of NP, having the legal right to do certain procedures does not equal the same expertise as an MD at doing these procedures.
You need to sniff around and see how things work. Who makes the decisions for most of you guys? Administration. When you get out of your cloistered world there and enter the big world, you will get no sympathy for your tuition and years spent in school. Nobody does. It's only about money and you are a drain on somebody else's take. So much to learn and catch up on in the real world for MDs once they get pushed out of the nest. Gonna be a shocker, but I'm pull'in for ya.
Thanks for the concern, netglow. I appreciate it. I'm not asking for sympathy or anything. However, I'm not worried about the future either. No matter what, I'll always be able to find a job. Pretty easily. The worst thing that'll happen to me, as a physician, is that reimbursements will continue to plummet (and they will), so I'll definitely make less than physicians in the past have and will have to adjust loan-repayments, house mortgages, etc, based on that. There will still be plenty of places looking to hire physicians though, so I'm not worried. All of our graduating residents last year got their top choice jobs in the salary range they were looking for, including in some very awesome big cities, and the current crop of senior residents are already getting offers from great places with the salary range we expect. The only medical specialty that currently is experiencing some issues with saturation and some trouble with finding jobs without a fellowship is pathology. And I'm not a pathologist! Phew. :)
Exactly. This is not a personal attack. I'm sure the NP's are hardworking, caring people. Still can't get around the education issue. The fact that I'm an RN is really irrelevant. I'm also a patient. As such, I want the best care for myself and my family. I want the expert, not the stand in. And, after being educated in my program by a few NP's, I can honestly say I was not impressed with the depth of their knowledge. Often they could not answer my questions. At the free clinic where I volunteer and have access to physicians who also volunteer, I can tell you how quickly they can answer my questions. Critical thinking through medical pathophysiology is second nature to them, its automatic, thanks to those many years of training.
Thanks for the kind words! :)
Don't get me wrong though, I LOVE working with midlevels. As a resident, they free me up for teaching opportunities, didactics, etc, and I'd imagine they'd make running a service a lot smoother. They do have more knowledge of pathophys and clinical management of patients compared to the regular nurses, so if that's a path you want to go down, that's great. I don't really see them as "stand-ins" -- rather, I like to think that they improve the flow of patient care and help make things in the department run more smoothly by freeing up residents and attendings so they can focus on more complicated patients. At least, that's been my experience. My personal opinion is that, regardless of what healthcare profession you go into, a significant portion of how much you learn and how large your knowledge base is is dependent on you. You don't have to only learn what a professor teaches you. It's easy to go beyond and get a more in-depth understanding of something. You just have to be willing to put in the effort to achieve that.
Best of luck in whatever path you choose to pursue!
It's a 4 year old badly written, wholly inaccurate piece. I'm not going to get upset about it. A lot of things were probably published in 2008 that were written poorly and had the facts wrong, lol. What else is new under the sun?
I've got my own INDEPENDENT practice, I love what I do, I love most of my patients, and for over a month now I've been paid equally to my physician colleagues; I couldn't care less how the studentdr(s) or the fool who wrote that yellow journalism op-ed feel about any of it. I'm happy, healthy and professionally fulfilled. I sincerely hope they are/will be as well. :)
meh, a few years out NPs and PAs are pretty much equivalent and considered interchangeable. All this huffing and puffing over the different models of education - for what?
I'll be honest...it is very evident that you have a bare minimal knowledge of how doctors are trained. A little research would go a long way in order to bring a shred of truth into anything you posted, along with very careful reading of what has been posted.
I worked with residents in the hospital EVERY SHIFT. It didn't matter if they were first year, second year, third year, etc. As RN's, we always had to deliver a ton of corrections and almost DAILY I had one that asked, "Well, what do you guys usually do?".
So my dear, I am speaking from experience.
As far as what an NP did prior to becoming an NP...if you want to be a doctor, you need to learn to read more carefully. While it is true that how long someone was a nurse has no bearing on the quality of their practice when they become an NP, I can assure you that you are 100% incorrect that if the NP works in the area of practice he/she did when they were an RN, that is going to translate to a higher quality care than what you would get from a general practice physician...any way you slice it.
Example: An RN that spends 15 years as a L&D nurse and decides to get her FNP and work in an urgent care clinic...nope, those 15 years of experience isn't going to help her.
Example: An RN that spends 10 years as an ER nurse and then gets her ACNP and works in an Emergency Room? I'm going to want to see her before I see the ER doc...she'll actually know what to do.
PS: I am curious, however, how someone who claims to be a resident has "studentdrtobe" as a screen name when you have the option to change it once you have the proper credentials.
oh dear "whatdoidonow?", If I could tell you how abused our poor NP's were at my work. They do the call, do all of the clinic PE's, routine med orders, take care of all of the difficult mucisitis, hemoturia, unstable BP's, anemia, malnutrition, dehydration, pain, extracurricular social outpatient needs, and all of the other small organ dysfunctions/failures that come from mega-chemo doses. The MD's are brilliant and write the protocols, clinical trials etc, but good lord please don't let 'em show up during a true crisis. Let it be the Critical care doc, a fellow or a nurse practitioner if we want the patient to recover quickly or survive at all. I have to say even our staff RN's are above average in a lot of knowledge and skill if they've been there longer than 2 yrs, but from the day the NP's walk through the door they are assigned to a physician and specialty clinic and are busting their butt's. Monitoring electrolytes, cardiac and endocrine systems that have been permanently impaired, and managing crisis after crisis. I have no desire to do that job.
I'm proud of what I've done at the bedside, burned out and had to quit that one after over 20 yrs, gone to a different job were the NP does the same thing alone, but receives little respect and it is really upsetting me. I'm about to let the other RN have it because there is no way he can do her job at all, and he's mad because she doesn't do his. Idiot! Oh well, maybe not yet, soon enough, but I see dumb people. She is wearing 3 hats right now quite well. It's interesting being an outside observer to an area. It's very busy but not difficult in relation to my old job. I'll keep my mouth shut for a while, and help her as much as I can. Him too, but I see how he creates extra on occasion, lack of organization. Not always one of my better attributes either, but having done the "nurse thang" for 30 yrs. I definitely have some powers of observation.
I love the NP at my MD's office, she knows me better than he does, and I can get straight to the point without repeating my whole hx. She remembers it somehow and easily takes up where we left off with a brief peek at her last note. I trust her as much as my Doc, love her as much too. Long term relationship with both, she is a replacement picked by the previous NP who I really miss, but I grew to trust her quickly, she's good, just cares in a different way than my old NP. (I'm very loyal when I like someone, so I was a bit "testy" at first, but I'm not exactly a spring chicken anymore either.) So please don't consider yourself short-changed at all seeing the NP. You may actually be getting a little more quality time in the long run.
and for over a month now I've been paid 
myelin
695 Posts
Multiple research studies have found no difference between NP and MD patient outcomes. If you're willing to wait weeks for an MD, that's fine. It seems silly to me, but to each their own.