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

Miss Mab · Feb 27, 2009

PR, by definition, is not reliant on facts. My interest in this discussion relates to perception.

Having multiple HC related websites can be good and bad but nah, I'm confident my opinions don't really change based on which board I happen to be frequenting at the time. I'd agree it is hard to take one seriously when their views, while congenial in one community, sway to the divisive and insulting in another. That is irritating.

As all postings contain one's opinions(and clearly phrased as such) perhaps a reminder to all that there is a PM function if it's felt necessary to repeatedly porifice other posts, particularly when there is no incorrect or inflammatory information contained therein.

Otherwise, it's a bit the equivalent of verbal diarrhea and not at all helpful to the continuity of the thread. Ah, dare to dream.

inthesky · Feb 27, 2009

I think one of the big problems of health care teams in general as it seems like everyone has some type of chip on their shoulders.

disclaimer: stream of consciousness

MD: don't second guess me, I'm the doctor

NP: a nurse? a 'mini-doctor'? medical model? nursing model? a mix of both? varied education.. 'what is my place?'

PA: interesting that PAs and NPs have such different educations, but work the same jobs.

RN: so and so is a horrible coworker for (list trivial reasons), problems with autonomy..changing nurses roles.. too much quality of patient care theories and not enough science and group unity

tech: I work just as hard as the nurse and get paid so much less

lots of not-well thought generalizations, but you get the drift.

:twocents: :deadhorse

wowza · Feb 28, 2009

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')

Perhaps I have not been reading the same articles but all the articles comparing NPs and Physicians have suffered from pretty severe biases, poor sample size and strange end points measured. Poor blinding plague these studies. Patient satisfaction is a very strange end point to measure when we are talking about quality of care. While satisfaction is very important, this study in particular has been championed as proof that NPs are equivalent or better (mundinger) than physicians when we are not measuring the right endpoint and dont have a sample size or an objective measure to come to significant conclusions. It ended up being around 100 patients in each group that followed up.

For the physiological endpoints, baselines were not taken for physiological measurements. Acute events were not measured but rather they used screening tests: peak flows, blood pressure and A1C values. Instead, asthmatic complications, strokes, MI and diabetic complications should be measured to give a better estimate of outcomes. So clearly the studies need to go on longer to capture these endpoints.

While the study is compelling, it falls significantly short of evidence or proof of anything, really. The real measure shouldnt be whether a provider can take care of an uncomplicated patient. A drunken monkey can reflexively prescribe HCTZ when hypertension is first diagnosed or metformin when diabetes first pops up. I could design a study and I gaurantee you a 3rd year medical student could do this just as well as a doctor would. A 3rd year is not a doctor as one member of this board has commented. This is because this study just looks at cookie cutter medicine. The difference would be seen in complex patients where there are multiple comorbidities to deal with. These pts were excluded from the study. Until a more inclusive study that actually mimics the complexities of primary care comes out and has proper endpoints there remains no good studies on the differences, if any, between GPs and NPs.

menetopali · Mar 3, 2009

and one more study to add to the pile - this one out of the Netherlands shows that NPs and GPs give comparable care...

Nurse practitioners substituting for general practitioners: randomized controlled trial.

Dierick-van Daele AT; Metsemakers JF; Derckx EW; Spreeuwenberg C; Vrijhoef HJ

Journal of Advanced Nursing (J ADV NURS), 2009 Feb; 65(2): 391-401 (25 ref)

again, show me the study that supports the claim that NPs provide inferior care.

silas2642 · Mar 3, 2009

and one more study to add to the pile - this one out of the Netherlands shows that NPs and GPs give comparable care...
Nurse practitioners substituting for general practitioners: randomized controlled trial.
Dierick-van Daele AT; Metsemakers JF; Derckx EW; Spreeuwenberg C; Vrijhoef HJ
Journal of Advanced Nursing (J ADV NURS), 2009 Feb; 65(2): 391-401 (25 ref)
again, show me the study that supports the claim that NPs provide inferior care.

Again, the studies that have been done have been extremely biased and poorly done. Secondly, it's not up to anyone to prove that NP's, when completely autonomous treating pts with complicated illnesses, when they are compared to attending internists/family physicians, are their outcomes are the statistically the same? Your group bears the standard of proof here and all you've done is throw fluff studies with with kind of pointless endpoints (patient satisfaction is important, but I'm more interested in whether or not more pts are having more MI's if they're seeing NP's, are they on more unnecessary medications, are they being misdiagnosed more often, etc.)

wowza · Mar 3, 2009

and one more study to add to the pile - this one out of the Netherlands shows that NPs and GPs give comparable care...
Nurse practitioners substituting for general practitioners: randomized controlled trial.
Dierick-van Daele AT; Metsemakers JF; Derckx EW; Spreeuwenberg C; Vrijhoef HJ
Journal of Advanced Nursing (J ADV NURS), 2009 Feb; 65(2): 391-401 (25 ref)
again, show me the study that supports the claim that NPs provide inferior care.

This study is just as bad as the last one. Again, the endpoints measured are essentially meaningless. This rehashes the exact same stuff as the other study but in the Netherlands.

When we are interested in whether a group is qualified to have autonomy, why are we not measuring health outcomes in complex patients? Instead we are measuring if patients "appreciate the quality of care" as this most recent article did. I guarantee you I can keep a patient happy and loving their care as they die from acute renal failure because of poor medical care. That they like me has nothing to do with whether I am good or not. The perception of care is in no way equivalent to the quality of care. The inclusion of this useless metric, especially as a cornerstone of a scientific paper, is laughable.

A rhetorical questions: would you rather a callous man cure you or a pleasant man hold your hand as his incompetence kills you? You dont need to answer. It just illustrates how worthless this metric is.

The other thing this paper did was to compare compliance to practice guidelines. Again, anyone can blindly follow practice guidelines. I bet we could get the average LPNs (not trying to insult LPNs) to follow practice guidelines with a month of training. Should LPNs have the same autonomy as NPs do?

Finally, as to the request for articles that show NPs provide inferior care... The issue is that there are no adequate studies saying one way or another. As it stands now, only the nursing community is putting out articles which means there are not a lot of articles out there and those that are out there have some design flaws and biases that need to be addressed. Do NPs provide inferior care in the uncomplicated general patient- i doubt it. Is the care the same between NPs and GPs for complex patients- probably not.

prairienp · Mar 4, 2009

again, the studies that have been done have been extremely biased and poorly done. secondly, it's not up to anyone to prove that np's, when completely autonomous treating pts with complicated illnesses, when they are compared to attending internists/family physicians, are their outcomes are the statistically the same? your group bears the standard of proof here and all you've done is throw fluff studies with with kind of pointless endpoints (patient satisfaction is important, but i'm more interested in whether or not more pts are having more mi's if they're seeing np's, are they on more unnecessary medications, are they being misdiagnosed more often, etc.)

there is a study by everrt (a md)i believe, it has been awhile since i read the article, that evaluated md vs np assessment and treatment of insomnia ( i know simple). yet the results are clear. mds asked fewer questions and rx more sleep medications. nps asked more questions about why (diet, stress other logical inquiry) and rx fewer medications. another thought for study, compare the hands on care of a md compared to a np. compare your friends who have had a recent pe with a np vs a md. what you will find is that the np not only spent more time, but actually examined the patient.

silas2642 · Mar 5, 2009

there is a study by everrt (a md)i believe, it has been awhile since i read the article, that evaluated md vs np assessment and treatment of insomnia ( i know simple). yet the results are clear. mds asked fewer questions and rx more sleep medications. nps asked more questions about why (diet, stress other logical inquiry) and rx fewer medications. another thought for study, compare the hands on care of a md compared to a np. compare your friends who have had a recent pe with a np vs a md. what you will find is that the np not only spent more time, but actually examined the patient.

okay, to imply that md's don't examine patients and neglect them and that np's do is just unfair. i'm going to go out on a limb here and say that md's tend to carry a heavier load of pts. while it's nice that nurse nightangale had time to sit and chat with her patients, i think it's also really, really important that she didn't miss the diagnosis or anything else, which she may very well have considering that she's lacking some training compared to the md. she can sit there all she wants to and chat it up with the pt and feel for this and that, but if she doesn't know what she's looking for, if she hasn't seen the pathology before or doesn't understand the pathophysiology-- well that could be too bad for the pt.

i know plenty of md's who spend plenty of time with their pts and plenty of np's with who don't. my aunt had a hypertensive episode secondary to her medication, pristiq, called up her pcp (an np), who told her to that she would just prescribe her some antihypertensives. didn't even want to see her; assumed it was essential htn. great job there-- way to r/o possible causes. the np didn't even know that pristiq, the medication that she put her on, could cause htn., i had to tell my aunt, who had to tell the np, who still didn't believe her. her "collaborating physician" had to help her come up with a plan to help her treat her depression while simultaneously addressing this htn (200 systolic is a little excessive, don't you think?).

menetopali · Mar 6, 2009

ahhh yes....

the anecdotes come out...

"I heard an NP did this..."

"I saw a physician do that..."

anecdotes make really bad policy, that's why we do research. unfortunately, if the research disagrees with your pre-conceived notions (or economic interests) then the research must be inherently flawed, right?

1) you don't like the results of studies so you call them "inadequate" even when Cochrane Reviews has already done the legwork and evaluated the ones that do compare outcomes (be honest - no study by a PI with "RN" will ever be "adequate" to you will it?, or any study that counters you economic or political position?).

2) you say the studies are biased and only from nursing, yet medicine doesn't do any at all (clearly zero is more adequate than thirty or more total and a half dozen that compare head to head outcomes. just like how no provider in a rural area is better than a NP that doesn't 'hire a name' to provide a kick-back to a physician?).

3) not all the studies or reviews are from nursing - the University of San Francisco - Center for Health Professions noted "Those who oppose expanded NP scopes of practice out of concern for public protection, however, are also motivated by hidden competitive self-interests." (p. 5, 2007) and as early as 1986 the Office of Technology Assessment, U.S. Congress recognized NP care as safe and effective in primary care. Even the American College of Physicians recognizes that NPs provide primary care independently and recomends inclusion of NPs in the Medical Home Demonstration - a nursing model that medicine finally caught on to (clearly the ACP, University of San Francisco, and U.S. Congress [in the 1980s no less] are biased in favor of the NPs).

4) Study after study has shown that physicians don't spend enough time with patients (the average is about six minutes if memory serves). The accept higher caseloads - charge on a piecemeal basis and so get more money for care that may or may not be adequate for each patient while charging a higher rate for those patients (IOM, 2000).

5) you don't like guidelines (i.e. recommendations that have actually been researched and evaluated) when it comes to measuring outcomes? Guidelines and targeted outcomes provide a mechanism to gauge performance. Perhaps we should return to the age before Flexner where the only standard in health care was the ability to write your name to hang out a shingle. Or maybe the days before the pesky nursing studies showed that hospital hygiene improved patient outcomes (a decade before Lister)? Or that Nurse Midwives who attended home births had significantly better outcomes in the backwoods than their physician counterparts in hospitals by providing pre-natal care (Fronteir Nursing Service)? Or the myriad of studies that show patient education and counseling reduces hospital admissions, improves medication compliance, and reduces complications of diabetes, hypertension, obesity, copd, etc? these are all standards of practice in healthcare that came out of nursing studies.

NPs have met their burden to demonstrate safe and effective primary care for anyone who doesn't have an economic or political interest in preventing NP independence over the past 40+ years. medicine has provided no evidence to the contrary, only rhetoric, misleading or false statements, and hoops they want NPs to jump through only to prevent the NPs from being permitted to jump through them.

for example federally funded residency programs - medicine says NPs aren't qualified to provide primary care because they don't go through residencies of 80hrs a week (never mind that most physicians didn't go through them either until the 1960s - some of which are still practicing). NPs say - ok 12% of FP slots go empty, we'll take those to show we are capable. Medicine's reply - no we'll fill them with FMGs or people who don't actually want primary care but are at the bottom of the match barrel. NPs say then let us compete for funds and medicine cries poor. NPs say we'll fund a few of our own, and medicine says "they aren't residencies". in other words, medicine sets a condition and then prevents the condition from being tested. that's not science, that's not patient safety, that's pure politics being played by AAFP & AMA..

the issue of medicine's resistance to NPs has been economic. they are content to have an NP provide care to the underserved, the indigent, and anyone who can't pay for care as long as (a) the NP 'hires a name' and pays a kick-back to a physician for the privilege of being an invisible provider. the NP is held to the same standard of care as that physician who is getting paid to "supervise" - who may or may not have ever met the NP or the patient, incurs no risk, has no overhead, and collects a paycheck to review maybe 1% of charts generated by the NP. patient safety, like title confusion, is a canard and that fact has been pointed out by nursing and health policy groups - the AMA and AAFP just don't get it. well they can keep believing the earth is flat too, but just because they say it...that doesn't make it so.

if we want to discuss outcomes, bring evidence

if we are going to talk quality, bring evidence

if we talk about patient satisfaction, bring evidence

i prefer to talk about how we can improve collaboration between two "distinct and complimentary professions" (ACP, 2009) and continue to improve the DNP model.

wowza · Mar 6, 2009

there is a study by everrt (a md)i believe, it has been awhile since i read the article, that evaluated md vs np assessment and treatment of insomnia ( i know simple). yet the results are clear. mds asked fewer questions and rx more sleep medications. nps asked more questions about why (diet, stress other logical inquiry) and rx fewer medications. another thought for study, compare the hands on care of a md compared to a np. compare your friends who have had a recent pe with a np vs a md. what you will find is that the np not only spent more time, but actually examined the patient.

i looked for this study and couldn't find it. if you can find it i would be interested to read it.

again though, are outcomes different or just approaches different?

prairienp · Mar 6, 2009

okay, to imply that md's don't examine patients and neglect them and that np's do is just unfair. i'm going to go out on a limb here and say that md's tend to carry a heavier load of pts. while it's nice that nurse nightangale had time to sit and chat with her patients, i think it's also really, really important that she didn't miss the diagnosis or anything else, which she may very well have considering that she's lacking some training compared to the md. she can sit there all she wants to and chat it up with the pt and feel for this and that, but if she doesn't know what she's looking for, if she hasn't seen the pathology before or doesn't understand the pathophysiology-- well that could be too bad for the pt.
i know plenty of md's who spend plenty of time with their pts and plenty of np's with who don't. my aunt had a hypertensive episode secondary to her medication, pristiq, called up her pcp (an np), who told her to that she would just prescribe her some antihypertensives. didn't even want to see her; assumed it was essential htn. great job there-- way to r/o possible causes. the np didn't even know that pristiq, the medication that she put her on, could cause htn., i had to tell my aunt, who had to tell the np, who still didn't believe her. her "collaborating physician" had to help her come up with a plan to help her treat her depression while simultaneously addressing this htn (200 systolic is a little excessive, don't you think?).

i am confused (again), your profile has you in nursing education. to be honest, your post sounds more like a pa or md versus a nurse. are you suggesting "chat" is only worthwhile when done by a md? the implications were that the np knew what she was "chatting" about. as the study dealt with one dx and how the provider assessed and treated insomnia. isn't the possibility of missing a dx occur when you seek less information as compared to more? i am not going to generalize and say all nps ask more questions than mds. i am saying in this "one" study nps did ask more questions about insomnia and used less medications to treat insomnia.

i am also confused what in the earth your comment about pristiq and htn have to do with this conversation. we are talking about education and process leading to outcomes not isolated incidents in your family life.

prairienp · Mar 6, 2009

i looked for this study and couldn't find it. if you can find it i would be interested to read it.
again though, are outcomes different or just approaches different?

i will take a look, i used the article in the mid 90s when writing a theory paper on intuition. in fact, i think he and others wrote a series of articles comparing assessment of several diseases. i can only recall the insomnia article