discussion regarding education of NP (DNP) and PA compared to MD/DO

menetopali · Feb 23, 2009

I would not be so upset about the switch to DNP programs if it included more in depth specialty education. I would happily spend those two extra years studying psychopharmacology and etc advanced coursework than drowning in nursing leadership theory drivel. Nursing is a different profession than medicine and does follow a different model, however, nurse practicioners working for doctors get pretty close to the medical model. more science less philosophy please! I'm getting worked up =P

Aside from NPs "working for doctors" (many work with physicians in contract relationships, some NPs are doctors ["doctor" is not the same as "physician"], some are employed by group practices, and some are solo practices), I agree completely.

We need to push for more of the clinically relevant material and a federally funded paid apprenticeship [read: residency] would be appropriate (although in my opinion it does not need to be nearly as long as NPs aren't starting from scratch like fresh physicians with just two years of classroom and two years of clinical rotations). I would also point out the need for faculty sharing between medicine, nursing, public health, and pharmacy in part to improve collaboration and understanding of the different professions and in part to weed out some of the theory fluff that is, in my opinion, a waste of time and effort.

silas2642 · Feb 23, 2009

Again, reread. . The MD and DNP degree are both clinical based doctorates.
So does that mean they are not worthy of using the title doctor, or is the title of doctor only reserved for physicians, or perhaps those who physicians indicate they may use the title doctor, such as dentists and podiatrists?
Good work on comparing apples to Buicks. It's not about what is better, what is harder, what is easier or what is more difficult. The basis of your argument against the utility of the title by DNP's, does nothing more than underscore the medical establishments rhetoric for increasing barriers for nurses and their professional development. Fortunately, the rhetoric is falling on deaf ears which is why the terminal degree for NP's for 2015 is the clinical doctorate.
With the DNP being the new terminal degree, you will soon discover that NP's will no longer be referred to as midlevel care providers. Not so much because they are no longer in between a basic nurse and a physician, which they never were in the first place, but because like the physician and unlike the PA, they have a clinical-based doctor in their own discipline and own profession.
Also, if you would prefer not to refer to DNP's as doctors in the clinical setting, I'd suggest booking tickets to hell now, while gas is still cheap. Your lack of respect for earned credentials by advanced practice nurses, however is appreciated.

Look, you can change the name, but the fact of the matter is DNP's are still "mid-levels" with a scope of practice that is similar/equivalent to PA's. Switching the title and adding a few courses in nursing leadership with some research here and there doesn't make their training equivalent or even comparable to physicians and it certainly doesn't make them more qualified than their peer PA's. You have no idea what you don't know. NP's are great and know a lot, but there needs to be someone there to back them up when something goes wrong or when there is a zebra to take care of-- there needs to be a board certified physician there to supervise.

It is absolutely about what is harder and easier-- if I'm sick I want the provider who went through the long, rigorous training with the 4 years of medical school, and minimum of 3 years of residency training, working 80 hours a week. I'd prefer this over to DNP who had courses in nursing theory (what is this, anyway?) and like thousands of training as opposed to tens of thousands.

Dr. Tammy, FNP/GNP-C · Feb 24, 2009

Look, you can change the name, but the fact of the matter is DNP's are still "mid-levels" with a scope of practice that is similar/equivalent to PA's.

Since NP's are not physicians, exactly where do NP's lay in the middle?

Switching the title and adding a few courses in nursing leadership with some research here and there doesn't make their training equivalent or even comparable to physicians and it certainly doesn't make them more qualified than their peer PA's.

Identify one state in the US where a PA may work independent of a physician. Please let me know if you need a list of states where NP's work independent.

You have no idea what you don't know. NP's are great and know a lot, but there needs to be someone there to back them up when something goes wrong or when there is a zebra to take care of-- there needs to be a board certified physician there to supervise.

The same holds true for a physician. And incidentally I hope you are not serious about the "board certification" part for physicians. Most over at our local Kaiser are "board eligible" whereas I don't know any NP's who are not board certified.

It is absolutely about what is harder and easier-- if I'm sick I want the provider who went through the long, rigorous training with the 4 years of medical school, and minimum of 3 years of residency training, working 80 hours a week. I'd prefer this over to DNP who had courses in nursing theory (what is this, anyway?) and like thousands of training as opposed to tens of thousands.

Good for you. Fortunately, the 100 plus patients my preceptor his partner NP and I see each and every day disagree. They would rather be cared for by advance practice nurses. Isn't that nice how every one has a choice?

physasst · Feb 24, 2009

+ 1000 silas.

Lessee.

1.

PA's/MD's- educated in the medical model, no nursing theory BS which is "completely useless drivel"- (from an NP I actually supervise)

NP's- various educational models, with no clear, concise structure

2.

PA's/MD's- take their boards again every so many years to ensure competency

NP's- Not so much, they don't even take a comprehensive national board exam, but rather state based exams that seem to vary considerably.

3.

PA's/MD's- ALL PROGRAMS are accredited by ONE body, with uniform standards....

NP's- NOPE

4.

PA's/MD's- practicing medicine, and therefore licensed BY the board of medicine.

NP's- practicing medicine, under the board of nursing, again....***?

NP's have had a complete chip on their shoulder against the medical establishment for years that is completely comical. THANKFULLY, Minnesota, where I practice does not allow for NP's to practice without a collaborative agreement (Supervision by MD). I think that ANY PA or NP should have some level of supervison, even if only by phone and occasional site visits. NP's, despite some of their members arrogance, are not MD's

AND, the DNP degree is GREAT for PA's, I have had at least five nurses in the last month come up to me asking about PA school. ALL have said that they considered NP school, but with this shift to the DNP, they would rather go to PA school. Good for us.

ALSO, *** is up with online NP schools. YOU HAVE TO BE KIDDING ME. That, quite frankly, is an embarassment to your profession. To have an entry level clinically based degree online is completely irresponsible. Having a postgraduate academic degree would be one thing, but a clinical degree. I heard about this only recently, and I have to tell you, my respect level for NP's which was at least fair before, dropped CONSIDERABLY.

I've had both new NP's and new PA's work for me, and new graduates from either profession scare me a little bit, which is why I am actually pushing for mandatory PA residencies. We have a bunch of them in place now, but they are all optional. I would like to change that for my profession. In fact, I am trying to start a PA Emergency Medicine Residency at my institution. But to be honest, new NP's scare me more. Their education is so varied, and so many of them don't know their way around a level one trauma to save someone's life.

Also, was at one of our institutional committee meetings the other day, and we have passed policies restricting the title of doctor to certain professions. NP's and PA's will not be allowed under any circumstances to call themselves a doctor in the clinical setting. The "Truth and Transparency" legislation looks like it will pass according to our institutional congressional guy, and it will make that a national restriction.

Miss Mab · Feb 24, 2009

Yeah, two weeks was just too long to keep a hold on that thinnest of veils, eh?

Look, attempts to engage ‘the nurses’ to rise up and defend the DNP PROPOSAL or to staunchly present evidence of MD equivalence generally fall flat for a pretty simple reason. Historically the nursing profession has struggled with issues of unity regarding everything from educational preparation to scopes of practice to standardized employment practices and policies. So, not surprisingly there are many licensed nurses who also don’t agree about this thing either. Shocker, I know. It is, however, surprising and somehow oddly reassuring to note those who do choose to respond to the blatant ‘goad game’ with clear and cogent arguments for a terminal practice degree based on needs within the nursing field and without ascribing to some version of MD equality espoused by what so many opponents very well know is only a minority yet stridently vocal wing of nursing academia. There’s no secret that this PROPOSAL has been contentious within our own ranks and presumably before posting one has gauged the community and read at least a sampling of the myriad viewpoints contained in the threads, so why pretend to seek discourse in the guise of ‘understanding’, particularly as you’re ultimately unable to do so without resorting to insult and mockery with the end result being the growing reality that any high-ground once held, and rightfully in my opinion, by the PA community is now quite publicly and decidedly ceding away.

This is the thread to compare and contrast the PA and NP and MD educational models so certainly in that sense your post is spot on. I agree with some of the deficiencies highlighted and while my own shoulders are chip-free, thank you, I do agree there are some background issues of inferiority systemic to nursing though I would more readily call them tragic rather than comical as you would suggest.

Regardless, the irony of your complaints is striking given the trends within the PA profession and the changing profile of students attracted by and accepted within that model. (I agree and have mentioned before that a DNP requirement will likely send many talented prospective RNs and NPs toward PA although I think the end result will actually be a greater gain to the MD applicant pool). It’s ironic because all the old standby knocks on the NP model are now being publicly played out on the PA side. Direct entry NP’s? You know, the anti-christs of midlevels….well, now the idea of zero patient care experience and direct admission straight from undergrad is unquestionably growing at the increasingly popular master’s level PA programs. Oh yeah, and that whole, we don’t need a master’s degree cause we’re competency based? That writing is on the wall and it’s honestly quite disheartening as you can plainly discern the internal conflict and fracture that exists between the ‘old school’ practioners and this new brand of PA student and program gaining ground there. I’m obviously for applicants having HCE in any student arena but that ship has already sailed now for all sides. That military doctorate may perhaps always remain a lone program but realistically the degree creep is a’comin’ and as I’ve reluctantly learned from my own experience, just being adamantly against something on principle isn’t enough to stop it. On the other hand, maybe you’ll be able to successfully fend off the seemingly inevitable if you just ‘wonk’ it hard enough, huh? Time will tell, I suppose

Finally, as much as the online NP program has been for some the Holy Grail of nursing inadequacies, the realization that this card can only still be played to the ignorant is clear. Feigning ignorance to the difference between a didactic (online) and clinical (supervised and onsite) component may be one red herring but claiming that any NP student can be a base ‘entry level’ student is laughable as at least all of them have, if not worked as RN’s and you know, actually held and can use a variety of medical equipment and do know the meanings of different lab values, etc., they’ve at least shown competency in these areas during their pre-licensure training. They don’t need to be taught and waste valuable clinical hours learning the hands on of a physical assessment or even ‘who does what’ in a hospital setting. Compare that to the growing complaints of PA preceptors who say they are wasting many of the vaunted ‘greater number of clinical hours’ of PA school teaching these newbs the most basic of technical tasks like measuring BP, phleb, EKG and just what exactly does RT do again? The old maxim that PA students inherently bring relevant experience is undortunately a lost claim.

I tend to agree, and have always stated, that nursing rightfully deserves some of the stones thrown its way but it appears your time, Mike, might be better spent focusing on the changes negatively affecting the shiny PA glass house over that way rather than here disrespecting the workplace partners in your solely stated goal of providing ‘primary care to the underserved’.

Out of curiosity, that institution policy restricts the doctor title to which certain professions?

physasst · Feb 24, 2009

Miss Mab, thank you for your honest, and well written post. FWIW, I agree with you regarding some of the trends within the PA profession as well. It troubles me, and this is why I say that new graduates from BOTH disciplines scare me a bit. I have complained to our leadership about this, and it is also a primary reason behind my push for MANDATORY residencies, I would like to see a requirement for all PA's to complete an 18 month residency in the specialty of their choice, or at the very least, one in FP/IM. It's not a popular concept.

Look, I do want to work together, and this is the primary purpose of the ACC, I was fairly frustrated last night, and my post reflects that. For that I do apologize. Together, PA's and NP's can accomplish much. My problem lies within the lack of evidence supporting that a DNP can either a.) increase access to care, or b.) increase quality of care that is provided. I don't understand why the NP profession has not chosen to make this degree optional, rather than mandatory.

As far as the institutional policy, it states that only physicians, DPM's, PsyD's, and Optometrists can call themselves doctor here in the clinical setting. This policy does NOT apply to the non clinical setting.

menetopali · Feb 24, 2009

So am I to understand that you support non-physician use of the title "Doctor" as long as it isn't used by a nurse? That seems a bit odd, given the AMA position that such an action leads to the fabled "title confusion" with two of the professions you listed (Psychology & Optometry). You left out one important group that was once decried as a 'cult' and for which it was 'unethical' (according to the AMA) for MDs to consort with - the Osteopaths.

In response to the earlier post -

1. Another group of health care started with a different model of care in 1892 - the osteopathic movement that continues to graduate D.O.s and which is regulated by (in Arizona at least) the Board of Osteopathic Examiners and they continue to sit for, if they choose, a separate licensing exam (it should be noted that the model has shifted significantly over the first century of the D.O. movement). Do some of these arguments sound familiar - 'different training', 'not controlled by the medical establishment', 'patient safety concerns', 'lack of knowledge', 'limited practice', or 'not considered as good as an MD'? They should because they are the exact claims made against the D.O.s throughout the 20th century.

While PAs are educated in the 'medical model' today, they were originally educated in the 'nursing model' according to Eugene Stead (yes that Dr Stead) - it was nursing's (specifically the NLN) failure to recognize the first Advanced Clinical Nurse in 1958 at Duke that lead to the birth of the PA program with medical and nursing faculty in 1965. The 'nursing model' (not theory which is less helpful than it should be given the time dedicated to it by academia) is a solid model of care that is based on the notion that we must treat the entire person not simply their ailment. While medicine claims to use this idea attributed to Hippocrates and first published by Galen (yes that Galen), treating a person instead of a disease (and preventing disease in the first place) has been a standard of nursing education since at least Nightingale. For example - the 'medical home model' that is so new and different was nothing new to nursing or NPs that have been teaching the import of care coordination since the 1920's as part of the 'nursing model'. A case in point was the Frontier Nursing Service which was providing primary and midwifery care to rural Kentucky (and they had significantly better outcomes for infant mortality and maternal mortality than the national average at the time) with a system of referrals to specialists for issues they could not handle internally.

As for nursing 'theory', you will find no argument from me that much of it is 'drivel'.

2. FNP boards are from one of two national organizations (AACN or AANP), do not vary across state lines, and are required for an NP license/certification/endorsement in most, if not all states. It is a bit disingenuous to assert that physicians retake their boards every few years, that only applies to being "board certified", they only take the USMLE steps or COMPLEX once.

3. A totally reasonable criticism and one that is not surprising given the historic discord within nursing in general and the historic lack of support for NPs by the NLN and ANA. That issue is being addressed by NONPF, ANCC, AANP, ANA, and ACNP and a joint statement on the issue was published last summer to move toward standardized curriculum for the DNP.

4. PAs, MDs, and DOs are regulated by three different bodies - the Arizona Regulatry Board of Physician Assistants, the Arizona Medical Board, and the Arizona Board of Osteopathic Examiners - not one. Nurse Practitioners are regulated by the Arizona Board of Nursing as they practice nursing, not medicine or osteopathy. This issue has been decided by the courts in several cases already involving CRNAs, NPs, Dentists, and even Chiropractors - practice is based on who is performing the act and whether or not their regulatory body (ie the state) permits the act by that person (i.e. - Q: is anesthesia the practice of medicine? A: only if provided by a physician, it is the practice of nursing if a nurse does it and the practice of dentistry if a dentist does it).

The chip on the shoulder is squarely within medicine - repeated studies of objections to NP independence have demonstrated that medicine's objection is consist with their economic interests, not patient safety. For example the Henry Street Settlement provide primary care by nurses at the turn of the century to the undeserved right up until the Manhattan physicians sensed an economic threat. The FNS served primary care roles rural Kentucky and FSA nurses served the rural west in the 1920s, 1930s, and 1940s until physicians sensed a post-war economic threat and attempted to clamp down on nurses providing primary care. The real objection from organized medicine has always been economics and perceived prestige - they objected to osteopaths until they were forced to recognize them in the 1960s, they object to non-physician use of the academic title "Doctor" (yes even by optometrists and psychologists), and why they are in the awkward position of saying that NPs are competent professionals with a distinct role capable of operating nurse run clinics for primary and should be included in the 'medical home model' demonstration projects (ACP, 2009) while at the same time asserting that NPs should be 'supervised' by a physician (AAFP 2003). Basically medicine's argument goes like this: NPs are great if physicians make money by employing them or can control the economic threat to primary care physicians by only allowing then to care for the poor or people that medicine chooses not to serve, but if they care for the rich or middle class without paying a physician for the privilege then it becomes a "patient safety" issue.

As for the new NP/PA scaring you, good - you should be scared. Just as I am with a new RNs, PAs, and physician residents (new NPs I've dealt with at least know when a patient is headed south even if they may or may not be able to manage the patient solo and may need to call another provider over for assistance - they recognize the situation, after all they have already had years of experience as a nurse. I can't say the same for new RNs/PAs/residents). In nursing, and I suspect in PA programs, we need to establish a system of mentored and protected in depth clinical experience after graduation [read: residency]. This is happening sporadically already but a systematic approach would be better and it is being pushed by some nursing leaders.

Nursing has a host of internal issues and has a long history of 'never missing an opportunity to miss an opportunity' and the DNP controversy is a product of that maxim. With the advent of anesthesia as a nursing function in the 1860's during the American Civil War and later development of nursing schools dedicated to anesthesia, which were attended by physicians interested in anesthesia, nursing dropped the ball by not insisting that it remain a nursing function or at least continue the cross-disciplinary collaboration with physicians interested in learning anesthesia. When the Flexner Report came out in 1910 medicine transformed from a haphazard apprenticeship based educational system to a standardized post-graduate academically based system. In contrast, when the Goldmark Report came out in 1923 calling for academically based nursing instruction - it was ignored by nursing until 1965. In 1957 with Ingles and Stead nursing again missed an opportunity to develop both an NP program and a systematic post-graduate internship for nurses when NLN withheld accreditation for either program and the ANA self-defined nursing in overly restrictive terms. In the 1960s and 1970s nursing leaders objected to the NP saying that it crossed the line into medicine, and in the 1980's while some thawing occurred, organized nursing continued to miss opportunities in organizing NPs resulting in several NP organization cut along specialty lines. Finally in the 1990s some unity came.

Then the DNP controversy came up in the early 2000s and again nursing has missed an opportunity by not: 1) anticipating objections from medicine and acting proactively to combat it, 2) making the DNP curriculum requirements unduly vague to placate currently practicing NPs- this had the effect of raising the question: what's the point of the DNP if the clinical preparation is substantially is unchanged from the MSN? 3) opening the DNP to all 'practice disciplines' of nursing instead of just the clinical ones - raising the question of - what does the DNP mean if non-clinical nurses [i.e. administrators, educators, and other non-research nurses] are going to use the same credential? and 4) not anticipating and acting to prevent the internal backlash of nursing itself

There are legit issues, like comparative preparation among provider types, need for clinical internship for all providers prior to independent practice, questionable inclusion of 'nursing theory' in a 'practice doctorate', risk of the DNP becoming a PhD-light in the way that the ND, DNS, and DNSc did, access to care, and the need for greater inter-professional dialogue. Thin claims of 'title confusion', 'on-line training' - which in reality only applies to didactic courses, 'patient safety concerns', 'quality of care', and 'it will exacerbate the nursing shortage' have no basis in any research that i have seen to date. if the study has been done, i would like to see it.

I submit that if patient care (and not economics) is truly the motive behind objections to NP independence and the DNP then perhaps medicine should work toward improving the DNP educational experience instead of trying to assert dominance over NPs? They could do that by returning to Dr Stead's & Thelma Ingles' original effort to prepare NPs jointly between nursing and medicine - in the nursing model with additional clinical and procedural education from medical faculty. Perhaps having medical faculty in the College of Nursing and have nursing faculty in the College of Medicine (each reporting to and supervised by that College's Dean as equals). This type of model is exactly what the IOM has called for and the ACP has stated it would support in their white paper on NPs. Now, if NONPF et al will accept similar principles of cross disciplinary training then we can advance the training of physicians and DNPs and move toward a more reasoned dialogue.

Just my two cents though. :twocents:

I_LOVE_TRAUMA, RN · Feb 24, 2009

Thank you for listing so many facts. I was waiting, I really did not have the enegy to speak up on this one. I find it hard to listen to people who are just plain mean and come here to put people down, and to try to appear smarter than others. Your post was wonderfully written and sums up my thoughts exactly, thanks! The DNP concept, I think is harder to grasp for those of us who are in school for our NP at present and are trying to take these changes all in. It is going to affect us (all NPs) more than anyone else, yet everyone else seems to have more problems with it than us.

physasst · Feb 24, 2009

Well, Arizona must have different regulatory bodies. Here in Minnesota, there is the Board of Medical Practice which regulates physicians, PA's, and virtually everyone who isn't a nurse, and then there is the Minnesota Board of Nursing.

I am opposed to the use of the title "Doctor" by non physician personnel whose job closely mimics that of a physicians. Psychologists and Optometrists do not practice almost identically to a primary care physician, unlike NP's and PA's.

Your example of D.O.'s is pertinent, however, they complete medical school, and in order to practice in Minnesota, must take the same board exams the physicians do, and must complete a residency. IF the DNP profession follows that path, (completing a residency, and taking the physician specialty board exams, I would have NO problem with addressing them as "doctor".

Your comments on Dr Stead where poignant, but he also recognized that corpsmen and medics returning from vietnam had incredible medical backgrounds, and with some additional training, could function with some equivalence to a family medicine physician. He noted that physicians were in increasing numbers beginning to practice in urban areas, and in large academic practices, and rural clinics were having an increasingly difficult time finding providers to give care.

At any rate, I appreciate your well reasoned response. As the majority of my time is almost entirely immersed in Health Policy, I simply have concerns about limiting applicant pools, and more importantly, limiting providers who can, and will give care in underserved areas.

menetopali · Feb 24, 2009

couple of points -

first thank you for your kind words.

the title issue is one of the most contentious parts of the entire discussion and i am at a loss as to why medicine seems to believe it holds dominion over an academic title. as for other non-physician doctors - i've worked in an outpt eye surgery clinic where the optometrist and ophthalmologist worked side by side and they were both "Dr" and in the VA system psychiatrists, psychologists, and social workers with doctorate degrees are all addressed as "Dr" and work side by side providing almost identical MH services. the issue only became an issue with nurses. the title war is a turf battle, not a 'patient confusion' issue. I for one think that everyone needs to be aware of who is providing their care, I support uniforming staff by function (ie all my scrubs were navy blue because that was the color for RNs while RT wore tan, radiology wore black, etc), I support disclosure of profession to patients it is physician groups that object to this. instead they falsely claim that "doctor" and "physician" are equivalent terms.

I fully support residency program participation, again medicine is the barrier as they claim lack of funding while 12-15% of family practice slots go unfilled annually. taking physician boards? that is a bit more controversial - i happen the think the CACC has moved nursing toward this but both nursing and medicine have voiced significant opposition to DNPs sitting for medical boards, unfortunately nursing has also failed to develop a clinically based exam for the DNP and is still using the MSN exams (same thing they did with the NCLEX and the ADN / BSN controversy).

My point on D.O.s was that for the better part of a century the course work they completed was not recognized by the medical establishment as "medical school".

Dr Stead recognized the returning military personal after getting soured on nursing as a way to increase providers in rural and under served areas and nursing totally dropped the ball on expanding when the opportunity presented itself in 1958. He, with Ms Ingles, had recognized the potential for nurses to return to providing primary care but the NLN simply could not accept the idea that physicians would teach student nurses (I imagine many physicians would have a great deal of trouble with the notion that nurses could teach medical students as well). You may want to read a piece by Holt, 1998 - "Confusion's Masterpiece: the Physician Assistant".

If you are concerned about improving access in rural and under served areas as a policy issue, I recommend exploring the policy barriers that hinder providers as they try to provide services in those areas. You'll find that medicine is a significant barrier to providing care to the under served through their monopoly on independent practice in many states while nursing is a barrier in their failure to articulate the NP training, education, and qualifications in addition to the historic lack of support for advanced practice.

I'll send you a copy of my dissertation when I finish it (and defend it): "Policy Barriers to Independent Nurse Practitioner Practice in Rural Arizona" where I discuss the policy barriers that effectively limit access to care. (I'm working on my DNP and my minor is rural health policy). One of the things I have found is that because of billing issues, NPs are often forced to enter a practice relationship with a physician (i.e. "hire a name and credentials") to contract with many insurance plans even though they are expressly permitted to practice without a formal collaboration agreement. The reality is, in Arizona you can legally practice solo but it is very difficult economically - 85% reimbursement to start and then you have to employ a physician to satisfy the insurance company - no real decision support or "back-up" just a name to review x% of charts and to put a name on the books as a "collaborating physician" (i spoke with an NP who hadn't ever actually met his "collaborating physician" while he was in Colorado but that physician got a nice cut of the practice earnings every month). The issue is pure economics - if I can't get paid for services out in the boondocks, how can I go out there and open shop? cash payments won't pay the bills as rural Arizona, like most of rural America is notoriously poor. government programs are effectively controlled by the medical lobby to restrict practice of NPs in many places without a "collaborating physician" to take a cut of the practice earning with no risk (NPs have to carry their own insurance as they are independently licensed and the "collaborating physician" is not liable for the actions or in-actions of the NP), minimal time commitment to review charts, no overhead, and somebody else jumps through insurance hoops for you. this is a big headache that many NPs want nothing to do with. their solution is go into the larger urban practices and simply be employed by a group and let somebody else deal with the headache while you get a salary and you have other provider handy to ask questions if you need to get a quick answer (hhmmm - isn't that what a lot of physicians are doing now as well?).

It sounds like access is your biggest concern. Will the DNP increase access - no, it will require policy changes not academic degree changes. Will the DNP decrease access - unlikely in my view as the number of new NPs continues to climb faster than

PAs or physicians. Improving access requires changes to Medicare, Medicaid, and insurance regulators so that NPs can practice without having to "hire a name" and jump through eight million hoops to get paid. If you want to improve access to care in under served areas, increase the number of providers that can practice in those areas, remove restrictions that are not evidence based, and provide incentives to practice in those areas (Arizona has some that are only for physicians and others that applied to all primary care providers).

thanks

silas2642 · Feb 24, 2009

Since NP's are not physicians, exactly where do NP's lay in the middle?
Identify one state in the US where a PA may work independent of a physician. Please let me know if you need a list of states where NP's work independent.
The same holds true for a physician. And incidentally I hope you are not serious about the "board certification" part for physicians. Most over at our local Kaiser are "board eligible" whereas I don't know any NP's who are not board certified.
Good for you. Fortunately, the 100 plus patients my preceptor his partner NP and I see each and every day disagree. They would rather be cared for by advance practice nurses. Isn't that nice how every one has a choice?

You got me; I left out the part where PA's cannot work independently of a physician because they fall under the board of medicine, but in some states NP's can because they have managed to squeak by practicing medicine in the guise of "nursing." Whoops.

It may be true that some physicians are not aware of their scope of practice and are unaware of what they don't know, however, after a minimum of 4 years of undergraduate school, 4 years of medical school, and a minumum of 3 years of residency (12,000 hours of post-med school training-- that's a minimum, btw. Most physicians rack up more than this during residency and/or fellowship), they kind of know more than your average midlevel provider, i.e. PA or NP. They've also managed to prove themselves by passing USMLE steps I, II, and III and their specialty boards-- those physicians at Kaiser who are "board eligible" are more than likely preparing to take their boards because most people don't go through the hell of residency to just say, "I won't become a board certified physician after all so I can avoid a day of sheer terror."

I'm glad you're preceptor and his/her partner are well-liked by their patients. I'm sure that they can diagnose the really difficult and rare diseases that come their door and know exactly what to do during a code. I'm sure that if your mother was going to code on the ground you'd want an NP running the code who had some 1,000 hours of clinical training as opposed to a cardiologist who had tens of thousands of training. Because that makes total sense.

menetopali · Feb 25, 2009

let's try to keep it civil and honest.

four year degree in anything at all, two years class room time and two years of short clinical rotations, followed by a paid apprenticeship that only members of that club can apply to, with some exams in between - yeah i'm not impressed. years in the trenches day in and day out dealing with your specialty and staying within your specialty - that is how you ensure good care.

to answer your question about running a code, i've been in a few and i'd take a fresh NP whose been in the trenches before over a fresh resident; and i'd take an acute care NP with several years experience over an office cardiologist whom i'd have to remind about basic ACLS (yeah, been there). In an ideal world - i'd rather have an ER physician and ER nurses who know their way around a code cart.

NPs provide excellent primary care and have been for several years. would I want an NP performing cardiothoracic surgery? no, but i wouldn't want a cardiothoracic surgeon trying to provide primary care either.