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

physasst · Feb 25, 2009

Yeah, I had an interesting conversation with one of our ER docs today. Was talking about a smaller ER that I moonlight at, that has been the subject of a lot of state and national attention, as there is NO physician on duty. It is staffed and run completely by PA's. We have a Family Medicine physician on backup call, but it may be several minutes before they could respond. He laughed, and said, "To be honest Mike, I'd rather have a PA with years of real Emergency Medicine experience in that ED, than a family practitioner who doesn't know their way around a real trauma or code."

Which, I think, is likely true.

If you'd like to, I'd be interested in reviewing your paper. It sounds very interesting.

core0 · Feb 25, 2009

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

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
the idea that hce is part of the competency based education and certification of pas is a misconception. education of pas without hce began shortly after the expansion beyond the first pa program. competency based education is based instead on the standardized model that developed in the early 1970s after the rejection of the a b and c levels of pa practice. this model was first developed in 1971 and the first exam given in 1973 by the nbme (interestingly 10% of the first group of certified pas were actually nps who were allowed to take the test at that time). the model has evolved over time and now consists of the arc-pa which provides the blueprint for pa programs and the nccpa which develops the pa certfication according to that blueprint with input from the aapa and paea. this competency based model has both internal and external validation. this is what distinguishes competency based pa education not prescence or lack of hce.
pa educational programs have long recognized that all hce is not created equal. they also recognize that within their individual communities and curriculums there are different values placed on any hce. programs continue to exist because they have a measured objective and must meet objective criteria to continue to exist as pa programs. if they find that hce helps them best meet those goals then fine. if they find that hce does not matter for those goals then that is also acceptable. there is more than enough room at the table for all the programs as long as the product they produce meets standards. if you look at the history of pa programs you will find that the programs that were closed were much more likely to require hce than not. is this an indictment of hce? no, instead its a reflection of the necessity to not only be able to impliment the pa curriculum but also to have sufficient resources.
the gap that you claim to exist between "old school" pas and the new brand of pas largely exists on the pa forum. i have never even seen this subject brought up in other venues. i can say with confidence that it has never been discussed in the last eight years in the aapa hod and two my knowledge has never been addressed at all. even in educational meetings there is no divide between the programs that do or do not require hce. even if a group feels their way is better, they acknowledge that the curriculum and the product are what sets schools apart.
the move to the masters has been largely driven by the pa programs. there are a multitude of reasons both valid and invalid for this move. even within the pa community policy is somewhat schizophrenic. there is policy from the aapa that pa education is conducted at the graduate level. however there is also policy that the bachelors degree is the appropriate degree (passed with some teeth nashing) and that the terminal degree is the masters degree. woven within this policy is the concept that the pa profession is a competency based profession and all pas practice equally regardless of the degree. the pa-c is the important thing not the degree.
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?

once again don't confuse the pa forum with what happens in the real world. as i stated above pas schools have long recognized that even if hce brings value, it is impossible to give a standardized value to hce. this is why pa schools almost never give credit in pa programs for prior experience. the pharmacist in the program still has to take pharmacology. the rad tech still has to take radiology. in my class we had a vascular surgeon from another country. he still took all the surgrery courses. the reason for this is not necessarily to teach the student anything. instead its to make sure that the material is covered in sufficient depth to have the required working knowledge as a pa. if pa preceptors are complaining that the students lack basic skills that is a function of the program not whether the student has hce or not.

a couple of other random points. the concept of rural providers in the pa profession is inherently tied to the degree issue. the pa profession has long recognized that the best way to train and keep rural providers is by providing the training to provider in a rural area to providers that are from a rural area. the medex program in washington has been a leader in this for more than 30 years and the programs founder dr. smith did studies to show this in the early years of the program. because of this non-masters pa programs provide a disproportionate share of rural health care providers. if the pa profession wishes to remain relevant in this area they should promote programs that are properly supported in rural areas regardless of the degree given.

the bear no one talks about in the doctoral debate is that there is no need to change pa education at all to produce doctorally educated pa students. in programs that give students credits for all hours earned the students routinely receive more than 120 credits for two years. this amount of post graduate work is sufficient for a doctoral degree in most accrediting agencies. the credits given far exceed credits for other professions that grant doctoral degrees (with the possible exception of the pharmd. and the md).

while the discussion has been interesting, one of the biggest difficulties in discussing the different professions is the misunderstanding of competency based education.

david carpenter, pa-c

silas2642 · 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.

You're right. Becoming a physician is a piece of cake-- what was I thinking? What, four years of clown school with a 1.0 gpa, and that easy breezy mcat, waltzing through the admissions comittees of med schools. Then there's 2 years breezing through the pre-clinical years (most of my time is spent watching tv by the way-- I don't really have to study all that much because physicians don't have to know anything at all since they can always ask the nurses) and then we can waltz onto the wards for 2 short years of clinical years rotating here and then there as we observe this and that and maybe bubbling in a few answer sheets occassionally. Don't have to worry about learning anything, we'll just match into our chosen specialty because it's a "member's only." Residency-- a breeze. Only 80 hour workweeks, if they're enforced. Don't worry, they'll be plenty of time for family and friends. Don't worry about your boards, killing patients, learning what you need to to become a competent physician, it'll all happen on it's own because the experienced nurses are there to back you up and since they know everything it will all be all right. Becoming an MD-- no problemo. I shouldn't have even hesitated when I signed up for this because there is no sacrifice or work involved at all. I would have been much better off being a nurse because I would have had a greater fund of knowledge and would have spent less time in school and known where things in the crash cart were.

Look, physicians respect nurses, they really do. But you have to respect them too. Give them some credit for what they do and what they know. There is something to this med school and medical training thing, and maybe, just maybe they have a point when we say that Mary Mundinger is wrong in her claim that the DNP is the solution to the primary care shortage; that DNP's should be set loose on the community without a qualified physician somewhere to back them up when the crap hits the fan, when the DDx isn't so clear, etc.

menetopali · Feb 25, 2009

first, i'm trying very hard to keep things civil, please do the same.

the point i was making is that the oft cited claims of - 11 years or more of training for an MD/DO compared to two years for an NP mixes apples and oranges. i broke out the training to demonstrate that. the 4 years of "clown school" as you put it - is not training in healthcare, it is an undergraduate degree in anything from Art to Zoology with some defined pre-reqs that look an awful lot like the pre-reqs or co-reqs for a nursing major. as for the 1.0 gpa - newsflash half of applicant to med school go, and 95% of those you go, graduate - not exactly a club reserved for Mensa members, rather it is an exercise in dedication and perseverance. the two years of classroom and two years of clinicals is an accurate description and the MS III and MS IV students i've met look just like the dear in the headlights as the nursing students do during their clinicals two years of clinicals while they are still in school (yes fewer hours per week in clinicals as they do it while taking course work) as undergrads. then med students have a federally funded, paid apprenticeship - that the AMA and AGME reserve for medical students even while family practice slots go empty, NP students have another three years or more out in the world before starting an NP program that includes another 2 years of classroom and clinical time combined - then depending on the DNP program - two more years of classroom and clinical time (or just classroom time in some programs - a fair critisism that i have mentioned elsewhere) with no opportunity for the federally funded paid apprenticeship.

nurses respect what physicians know, unfortunately physicians often have little or no respect for the training that NPs go through and are stuck in the outdated belief that 1) only the physician is competent to care for patients independently (in spite of evidence to the contrary), 2) physician over sight is related to 'patient safety' - (in spite of evidence to the contrary), 3) only the best and brightest go to med school (in spite of evidence to the contrary), 4) the long hours of residency make better providers (in spite of evidence to the contrary), and 5) because NP don't go through residency - because the AMA and AGME won't permit it - NPs aren't as competent (in spite of evidence to the contrary). show me the study that shows worse outcomes in primary care if you are going to claim that NPs provide lower quality.

The ACP has taken a much more reasoned stand, although I disagree with their position - they have noted that NPs operate health clinics and offices solo and that both sides should recognize the others strengths.

silas2642 · Feb 26, 2009

first, i'm trying very hard to keep things civil, please do the same.
the point i was making is that the oft cited claims of - 11 years or more of training for an MD/DO compared to two years for an NP mixes apples and oranges. i broke out the training to demonstrate that. the 4 years of "clown school" as you put it - is not training in healthcare, it is an undergraduate degree in anything from Art to Zoology with some defined pre-reqs that look an awful lot like the pre-reqs or co-reqs for a nursing major. as for the 1.0 gpa - newsflash half of applicant to med school go, and 95% of those you go, graduate - not exactly a club reserved for Mensa members, rather it is an exercise in dedication and perseverance. the two years of classroom and two years of clinicals is an accurate description and the MS III and MS IV students i've met look just like the dear in the headlights as the nursing students do during their clinicals two years of clinicals while they are still in school (yes fewer hours per week in clinicals as they do it while taking course work) as undergrads. then med students have a federally funded, paid apprenticeship - that the AMA and AGME reserve for medical students even while family practice slots go empty, NP students have another three years or more out in the world before starting an NP program that includes another 2 years of classroom and clinical time combined - then depending on the DNP program - two more years of classroom and clinical time (or just classroom time in some programs - a fair critisism that i have mentioned elsewhere) with no opportunity for the federally funded paid apprenticeship.
nurses respect what physicians know, unfortunately physicians often have little or no respect for the training that NPs go through and are stuck in the outdated belief that 1) only the physician is competent to care for patients independently (in spite of evidence to the contrary), 2) physician over sight is related to 'patient safety' - (in spite of evidence to the contrary), 3) only the best and brightest go to med school (in spite of evidence to the contrary), 4) the long hours of residency make better providers (in spite of evidence to the contrary), and 5) because NP don't go through residency - because the AMA and AGME won't permit it - NPs aren't as competent (in spite of evidence to the contrary). show me the study that shows worse outcomes in primary care if you are going to claim that NPs provide lower quality.
The ACP has taken a much more reasoned stand, although I disagree with their position - they have noted that NPs operate health clinics and offices solo and that both sides should recognize the others strengths.

That residency/apprenticeship that you speak of is a joke-- the money you make during that time is laughable. It comes down to like, what, $1.13 per hour? Yeah, we're lucky. As for NP's receiving federal aid for residencies, there's a physician shortage already and they won't expand residencies and there's a nursing shortage, so why would it make sense to start nursing residency?

It is your burden of proof to provide clear and convicing evidence that NP's provide care that is equal to physicans-- you don't assume that NP's competent care until it is clear that they don't. So far there have not been any studies that have shown this-- only a few short term, poorly down nursing studies that show that patients are satisfied with NP care and I believe that that was in an outpatient setting and comparing NP's to residents. You've got to compare NP's to the gold standard-- experienced attending physicians. Prove that with longterm followup studies and outcome studies including morbidity, mortality, cost of followup studies, etc., and you've got my attention.

Dr. Tammy, FNP/GNP-C · Feb 26, 2009

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.

Very well said. Please consider publishing your post. I never knew about the rift and attempts by medicine to quash the osteopaths professional development but it does not surprise me.

Dr. Tammy, FNP/GNP-C · Feb 26, 2009

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.

again, well said.

Miss Mab · Feb 26, 2009

as i stated above pas schools have long recognized that even if hce brings value, it is impossible to give a standardized value to hce.
----
while the discussion has been interesting, one of the biggest difficulties in discussing the different professions is the misunderstanding of competency based education.
interesting background.
clearly i misstated the relevance of the 'competency based' issue in regard to a move to a master's. perhaps it was my fatigue that caused me to insert the mantra. regardless, agree to disagree that, for whatever motive and based on evidenced reasoning or not, pa will end up being a ms requirement but time will have to bear that out. and it will be a shame if the quality cc programs that do exist(particularly in my area) aren't able to form a work-around w/local uni's or however to get that done.
re the hce, again it wasn't really about whether hce is needed, affects later success, etc., but simply illustrative of another area where, to the un-informed, physician assistant education may have seemed the better alternative to nursing's direct entry route. it's my opinion that direct from undergrad admission becoming more widely known is a negative in the pr sense and one less 'pro' for that route. nothing else.
you said:
once again don't confuse the pa forum with what happens in the real world.
david carpenter, pa-c

i'm certain you don't mean to imply that my only awareness of these professional issues is contained within internet forums or that i'm unable to discern real life practice issues from bb grumblings. i appreciate the caution offered but am fairly sure we haven't met. i actually find myself in a relatively unique situation to both participate in and observe these issues on an ongoing basis, to include the hiring of all levels of practitioners(md/do also), as well as discussions of salary, practice placement and benefits. for that reason i tend to chime in only minimally and generally don't make assumptions about others' sphere of understanding. i do enjoy perusing all the boards from time to time, though. especially when i've had a good day and need to be brought down a peg or two based on my currently relevant educational background. lord knows there are plenty of boards for that!:)

Editorial Team / Admin · Feb 26, 2009

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core0 · Feb 27, 2009

interesting background.
clearly i misstated the relevance of the 'competency based' issue in regard to a move to a master's. perhaps it was my fatigue that caused me to insert the mantra. regardless, agree to disagree that, for whatever motive and based on evidenced reasoning or not, pa will end up being a ms requirement but time will have to bear that out. and it will be a shame if the quality cc programs that do exist(particularly in my area) aren't able to form a work-around w/local uni's or however to get that done.
re the hce, again it wasn't really about whether hce is needed, affects later success, etc., but simply illustrative of another area where, to the un-informed, physician assistant education may have seemed the better alternative to nursing's direct entry route. it's my opinion that direct from undergrad admission becoming more widely known is a negative in the pr sense and one less 'pro' for that route. nothing else.

actually as far as i know all of the cc programs have the ability to offer a masters or a bachelors depending on what degree the student has on entering. this is usually done through an affiliation agreement through other programs.

the issue of direct from undergrad is not a new issue. the newest program is 10 years old and some are more than 30 years old. all of these programs except one are concentrated in a relatively small geographic area and the programs are well regarded. i'm relatively familiar with all of the programs except one since i trained in that area. none are exactly a walk in the park for the undergrad program. it usually means three years including summers with required volunteer/paid hce during the undergrad years. the attrition rate is much higher than regular pa programs (around 50% for the undegrad phase). most of the undergrads that i have met are well prepared for the professional phase.

the difference that i see between the two direct entry programs is that pa programs that do not require hce are statistically different than those that do. they are longer and usually require more didactic and clinical time (although the largest amount of clinical hours are actually in some of the cc programs). my supposition is that programs that do not require hce are making up for this lack by longer training in clinical medicine. on the other hand i don't think that nursing has bought in to the mepn concept. i see a number of ads that are looking for np/pa. for the pa part its grad of an accredited program. for the np part its usually 1-2 years of nursing experience plus the appropriate state license.

i'm certain you don't mean to imply that my only awareness of these professional issues is contained within internet forums or that i'm unable to discern real life practice issues from bb grumblings. i appreciate the caution offered but am fairly sure we haven't met. i actually find myself in a relatively unique situation to both participate in and observe these issues on an ongoing basis, to include the hiring of all levels of practitioners(md/do also), as well as discussions of salary, practice placement and benefits. for that reason i tend to chime in only minimally and generally don't make assumptions about others' sphere of understanding. i do enjoy perusing all the boards from time to time, though. especially when i've had a good day and need to be brought down a peg or two based on my currently relevant educational background. lord knows there are plenty of boards for that!:)

i didn't mean to make assumptions. just that your statements sounded a lot like the arguments on another forum:rolleyes:. i've had the opportunity to work on pa policy at a national and state level as well specialty organizations. from that perspective the hce argument is really a non-issue. i also have been involved at hiring in several practices. at the current practice where we have a mixed workforce i see that nps and pas evaluate candidates differently (small n). the nps seem to focus more on previous experience and status of the school, while the pas focus on what their experience was as a pa and pa student. i think that in part its the leveling that occurs in pa school. nobody particularly cares what your background was, only your ability to do the work as a student.

david carpenter, pa-c

menetopali · Feb 27, 2009

Yeah, I had an interesting conversation with one of our ER docs today. Was talking about a smaller ER that I moonlight at, that has been the subject of a lot of state and national attention, as there is NO physician on duty. It is staffed and run completely by PA's. We have a Family Medicine physician on backup call, but it may be several minutes before they could respond. He laughed, and said, "To be honest Mike, I'd rather have a PA with years of real Emergency Medicine experience in that ED, than a family practitioner who doesn't know their way around a real trauma or code."
Which, I think, is likely true.
If you'd like to, I'd be interested in reviewing your paper. It sounds very interesting.

I'd agree with that physician's assessment, and I work in one of those podunk ED's part time while I'm in school. it is a three bed ED in a single room, we have a physician "on-call" 24/7 but we have PAs & NPs during most weekend days (when I'm there) and only the "on-call" physician at night who covers the house. in our case the physician response time is usually a matter of 15 minutes or less because they are somewhere on campus and the vast majority of cases are walk-in/walk-out "why are you here instead of in your PCP's office?" type cases - but when it hits, it is whoever is on site will be running the code until more help arrives. sometimes a PA, sometimes an NP, sometimes a physician, and sometimes an RN.

after it is completed and defended i'll be happy to send you a copy of my paper.

menetopali · Feb 27, 2009

That residency/apprenticeship that you speak of is a joke-- the money you make during that time is laughable. It comes down to like, what, $1.13 per hour? Yeah, we're lucky. As for NP's receiving federal aid for residencies, there's a physician shortage already and they won't expand residencies and there's a nursing shortage, so why would it make sense to start nursing residency?
It is your burden of proof to provide clear and convicing evidence that NP's provide care that is equal to physicans-- you don't assume that NP's competent care until it is clear that they don't. So far there have not been any studies that have shown this-- only a few short term, poorly down nursing studies that show that patients are satisfied with NP care and I believe that that was in an outpatient setting and comparing NP's to residents. You've got to compare NP's to the gold standard-- experienced attending physicians. Prove that with longterm followup studies and outcome studies including morbidity, mortality, cost of followup studies, etc., and you've got my attention.

the studies have been done, repeatedly, and every one has shown equal outcomes (yes with higher pt satisfaction). there is also a Cochrane review of those studies (including those cited by the American College of Physicians and published by JAMA - not exactly fans of NPs). would more studies be helpful to continue to demonstrate that NPs spend more time with pts (yes that does mean fewer pts per day and higher pt satisfaction), NPs provide more pt education (yes that does mean fewer pts per day and higher pt satisfaction), NPs have equal resource utilization and equal outcomes (better in some cases) than primary care providers. I'm sorry if you don't like the evidence, but just because it doesn't agree with your belief, doesn't mean it is wrong.

It sounds like no amount of evidence will dissuade you from the belief that only the almighty physician is capable of providing independent care. If that is the position you wish to take then perhaps you can educate us all on how health is dependent on the humors of the body? (after all, that was a long held belief overthrown with evidence that was ignored or not accepted by the 'medical establishment')