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

wowza · Mar 6, 2009

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).
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.
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.

i assume that this comment was directed at me so i will respond.

1) first i dont have time to search for the specific cochrane review so hyperlink it for me. second, i like to interpret articles myself. as soon as you stop thinking for yourself and letting another group do the thinking for you, you are one step removed from understanding the information and it's implication.

2) take any article, written by a group that has a clear agenda (mary mundinger) with a grain of salt. a good example of this are trials funded by drug companies. they have something to sell. an article with something to sell is not a reliable article. this is especially true when they clearly pick outcomes and circumstances that will show a good outcome. the last two articles that were discussed were rife with this bias.

4) the time issue is one of pt satisfaction rather than clinical outcomes. again, while important, this issue is not paramount.

5) nope, guidelines are just dandy. the issue is that measuring adherence to guidelines in a clinical trial is not measuring outcomes. guidelines are not outcomes. you cannot claim any impact on outcomes without actually measuring outcomes. poorly done studies are poorly done studies.

3 & 6) i will acquiesce that i do have a minor competitive self interest as a secondary motivation. it is only minor since i am not going into a field that will see any competition from nps or dnps. my major motivation is that i just do not think that the dnp education is adequate to properly train a primary care physician/provider. medical school has drastically more clinical and pre-clinical hours and that is followed by residency. it is not as if this time is wasted. what i take insult to is that insinuations that there is waste throughout medical school and that you can have an adequately trained pcp in fewer years. the aafp relatively recently felt more education was needed to adequately train a pcp. so they added residencies. now nps want to say that less than even medical school is needed... seems like cutting corners to me.

np or dnp school should not be a shortcut through medical school. instead of focusing on pathophys, the dnp degree is full of nursing theory and non-clinical electives. this has been an ongoing critique of higher nursing education that has as of late, not been fixed. further more, some dnp programs can be done almost exclusively online and the type of clincal experience is very variable. many only requie 1000 clinical hours. i reached over 1000 clinical hours 4 months into my 3rd year. i will triple that by the end of third year. then i have all of 4th year. oh and then all of residency. the educations are just not the same.

the lcme recognizes this. as soon as nursing programs fall under the lcme, they will be allowed to enter residencies. unfortunately that would uncover some of the smoke and mirrors that make up nursing education and convert them more to hard sciences instead of fillers like nursing history or nursing theory. ask any np who has gone through medical school as well... there are some on this board. they all say the same thing. medical school and nursing school are two different worlds.

medicine has not put out articles about nps vs doctors because frankly they just dont care. the interest is in moving medical care forward not who gives that care. it they really wanted to quash the whole np movement they would design a study using complex pts, say, in the icu. the issue is that would never get approved by an irb.

wowza · Mar 6, 2009

I looked up some RN to DNP curriculum. This one is from MGH.

http://www.mghihp.edu/nursing/postprofessional/dnp/curriculum-overview/RN-to-DNP-Curriculum.html?cw=1

In it's core courses it has 5 credit hours TOTAL for pathophysiology and pharmacology. These are the cornerstones of medical knowledge and a not even half a semester is spent on these... really?

Instead what is included is 32 hours of courses that have little to no impact on pt care: Nursing theory, nursing education, biostats, epidemiology, heathcare economics and informatics. That is over 1/3 of the course hours that are just fluff.

Really the whole autonomy for NPs is a political charade. Were they really worried about pt care and improving knowledge- instead of forcing their agenda- the courses would be drastically different; there would be a focus on pathology, physiology and pharmacology and more clinical time rather than such a focus on nursing leadership, nursing theory and nursing education. As I have gone through medical education I have realized how hard proper primary care is to do. The more I know, the more i realize I dont know. It makes me realize that these Family Practice residencies are necessary to be adequately trained- as is the rest of medical school. Can most of primary care be done by NPs or even medical students... sure. It is that 1% that the PCP's extra training is needed for. Let's not dumb down primary care. If DNPs really want a piece of the pie and the coveted autonomy, they need to have training that shows their commitment to pt care and medical knowledge.

And if anyone didnt already know, MGH is Harvard's hospital so this example was not from some podunk community college offering a DNP program.

wowza · Mar 7, 2009

Well the results of the first administration of the DNP exam are in. 50% failed.

The sample size was small but that is a pretty severe fail rate for a watered down version of step 3.

http://www.abcc.dnpcert.org/exam_performance.shtml

silas2642 · Mar 7, 2009

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.

you're right, i used an anecdote instead of quoting a nursing study measuring patient satisfaction rates over a short period of time comparing np's vs. residents treating patients in an oupatient setting over a short period of time-- i've seen tons of other anecdotes on allnurses, so i thought i'd go with the theme for once. i guess it backfired.

my point is that np's don't always know what they don't know don't always appreciate some of the underlying pharm and pathophys that physicians learn in med school and more importantly, a rigorous residency. they can miss important findings because their training is insufficient-- there needs to be somewhere there to help them if they need it like in the example that i gave. (again, sorry, next time i won't use an anecdote)

you can spend all the time you want with patients and ask all the questions you want but if you don't understand the pathophysiology and why you are asking the questions then they're pretty pointless and you can easily miss something. it may be that physicians don't spend as much time with patients as nurse practitioners, but it may also be that they are more efficient-- it may be that they are more targeted in their h&p's and more experienced-- they know what they're looking for a little bit better than the dnp who went through the less rigorous training and didn't do the minimum of 12,000 hours of post-med school training.

you're right, i'm not a nursing student, i'm a med student. you caught me. i don't know why it says that i'm a nursing student on my profile, it was an accident.

silas2642 · Mar 7, 2009

Well the results of the first administration of the DNP exam are in. 50% failed.
The sample size was small but that is a pretty severe fail rate for a watered down version of step 3.
http://www.abcc.dnpcert.org/exam_performance.shtml

Kind of backfired on Ms. Mundinger there, didn't it?

wowza · Mar 7, 2009

I found this quote from a member on another forum. He went to both NP school and MD school. Here is his take:

"I have a unique perspective on this. I am a physician (i.e. I actually went to medical school). I was also a nurse and took NP classes.

There is absolutely NO comparison between the two. ZERO. Most NP programs contain less actual "medical" classes than you get in one semester of real medical school. Mine was 15 credit hours. The rest is nursing theory, research, nurse political activism and such. It is so unbelievably different, you can't compare the two. The truly scary thing is that they don't how much they don't know.

NPs, DNPs have absolutely NO right to independent practice. I think there is a role for them such as running coumadin clinics, helping with post-op evals, vaccinations and other such limited practice.

They simply do not have a fraction of the knowledge that the worst FM physician has. Not even close.

Imagine this. Would you let a fourth year medical student open up a clinic and do primary care? H@(( no! And the fourth year medical student already has VAST more medical education than an NP or DNP.

If this does not bother you, it should."

macguyver4u · Mar 13, 2009

To the MD on this thread ummm why are you even on a nursing forum in the first place its very atypical. No offense meant. You also mentioned that you took NP courses the question becomes when and where. Things have changed a great deal and not all NP schools are equal.

I would like to point a few things to both sides of the debate.

1. ARGUMENT NURSES NEED MORE CORE SCIENCE CLASSES ORGANIC, CHEMISTRY, PHYSICS , CAL ETC...

How much of that does the Average doctor recall using in his or her medical practice, better yet how much of that does he or she recall? I'm not saying those courses aren't important, what I'm asking is are they nice to have or must have.

2. Is the average nurse more prepared for the med school than the average b.s. student. In many cases more so, nurses have gone through the basics they have survived A&P, and micro which is often one of the most difficult courses students will have to pass in any academic setting. It can be argued that the average nursing student has a leg up on incoming med student.

3. MD looked down on DO and fought against them for a long time and made peace with them. I believe DO are now allowed to either take MD boards or DO boards or both. If they past the MD boards they will be cert as MD.

UCI medical school was initially a DO school Didn't PA get grandfathered to MD in state of california back in the 70's or 60's?

4. During course work how much of the info that was shoved down your throat do you remember? This question goes for both nursing school and MD school . The breath of knowledge is intense its essentially like drinking water out of a firehose. People often forget to realize that not all the 4 year of class work that a MD goes through, is not all about disease etc... I suspect that if we are honest to ourselves not all of us read every word in every book , but we were able to obtain the highlights.

5. From what I have been able to gather most of what the MD learns is during intense rotation not necessarily classroom. Thats where the huge difference come into play. Lets say if you have been an ER nurse for 5 years and a doctor who going through his rotation. Who would you want to save your life? People forget that the medical field is highly specialize now, so if you do something long enough you know all the tricks and what to expect.

6. If we are talking about primary care realistically it all comes down to the practioner. Most physicals I've gone to by MD were a joke. If a NP did a physical the way they were suppose to, it would put shame to 99.9 % of the doctors out there. With that being said how many of them do?

I wouldn't want a NP to be doing open heart surgery on me or any type of surgery, because that is truly beyond the breath of their knowledge. I have no problem with having a NP as my primary care provider.

P.S.

can anyone explain to me why NP are prevented from prescribing controlled substances?

CraigB-RN, MSN, RN · Mar 13, 2009

Well first off all, the NP's were I spent a lot of my time could.

This is one of the problems in the NP vs PA School debate. We are controlled by the Board of Nursing, which are not exactly known for doing what's best for our proffesion at any level. You see it's a state level thing. Untill there is some continuity between states and not 50 separate nurse practice acts with 50 different interpretations of what a nurse can do. It's something your going to have to live with.

In the case of the controlled substances, well it's your legeslators that are keeping you from that. They are believing whatever someone other than the NP's are telling them. We need a better lobby.

wowza · Mar 14, 2009

To the MD on this thread ummm why are you even on a nursing forum in the first place its very atypical. No offense meant. You also mentioned that you took NP courses the question becomes when and where. Things have changed a great deal and not all NP schools are equal.
I would like to point a few things to both sides of the debate.
1. ARGUMENT NURSES NEED MORE CORE SCIENCE CLASSES ORGANIC, CHEMISTRY, PHYSICS , CAL ETC...
How much of that does the Average doctor recall using in his or her medical practice, better yet how much of that does he or she recall? I'm not saying those courses aren't important, what I'm asking is are they nice to have or must have.
2. Is the average nurse more prepared for the med school than the average b.s. student. In many cases more so, nurses have gone through the basics they have survived A&P, and micro which is often one of the most difficult courses students will have to pass in any academic setting. It can be argued that the average nursing student has a leg up on incoming med student.
3. MD looked down on DO and fought against them for a long time and made peace with them. I believe DO are now allowed to either take MD boards or DO boards or both. If they past the MD boards they will be cert as MD.
UCI medical school was initially a DO school Didn't PA get grandfathered to MD in state of california back in the 70's or 60's?
4. During course work how much of the info that was shoved down your throat do you remember? This question goes for both nursing school and MD school . The breath of knowledge is intense its essentially like drinking water out of a firehose. People often forget to realize that not all the 4 year of class work that a MD goes through, is not all about disease etc... I suspect that if we are honest to ourselves not all of us read every word in every book , but we were able to obtain the highlights.
5. From what I have been able to gather most of what the MD learns is during intense rotation not necessarily classroom. Thats where the huge difference come into play. Lets say if you have been an ER nurse for 5 years and a doctor who going through his rotation. Who would you want to save your life? People forget that the medical field is highly specialize now, so if you do something long enough you know all the tricks and what to expect.
6. If we are talking about primary care realistically it all comes down to the practioner. Most physicals I've gone to by MD were a joke. If a NP did a physical the way they were suppose to, it would put shame to 99.9 % of the doctors out there. With that being said how many of them do?
I wouldn't want a NP to be doing open heart surgery on me or any type of surgery, because that is truly beyond the breath of their knowledge. I have no problem with having a NP as my primary care provider.
P.S.
can anyone explain to me why NP are prevented from prescribing controlled substances?

My last post was a quote from another board from another person. I left out that person's screen name. I am not that person. I am not an NP.

1) I think the debate is less about the pre-requisites for medical school (organic chem/bio/physics/calc/etc), and more about more core sciences in the actual training. This is especially applicable to advanced nursing degrees that are looking for expanded practice rights but have substituted applicable medical knowledge for nursing theory /nursing education/nursing advocacy classes. What the pre-requisites help with for medical education is that they help weed out those not fit for medical school and it is also useful for pharmacology, genetics, physiology and biochemistry. Without a proper background these classes in medical school would be near impossible to weather.

2) Clinically, nurses have a leg up undoubtably. First, second and beginning third year students are incredibly awkward around pts mainly because they do not have the experience. But that is what medical school is for. For most, you see a clear change over the course of 3rd year. Some medical students are just beyond help. I am sure you all know what i am talking about- the creep-tastic med students that just wont ever get it.

Academically this is not the case. Just speaking from personal experience, the nursing courses were not anywhere near as rigorous as a normal BS in biochemistry, biology or chemistry at my undergrad. I went to a very well known undergrad so we had very capable students in the nursing program. These students at my undergrad were probably a level above those who take the nursing classes online or at community college.

I have a bunch of friends that completed nursing school and are current nurses. There definitely are some very bright ones but on the whole, they are not the same caliber as an average medical student. Academically, can you really say you think the average nurse is on par with the average medical school matriculant? Most of my medical school class was at the top of their graduating undergrad class. Most graduated from top 50 universities.

I am not saying that nurses cant be doctors at all. We have quite a few former nurses in my class who are great students. But there is a pretty heavy weed out process to get into medical school

3) Both MD and DOs are physicians. While a DO can take the MD boards they will never become an MD. The degree is conferred by the school. The right to practice is conferred by the state. DOs have full practice rights after they finish the DO boards. Taking the MD boards basically allows them to apply for MD residencies. It is a convoluted situation. If you want more info PM me but i dont want to derail the thread.

The reason MDs made peace with DOs is that DOs largely dropped the unproven theories and changed from an esoteric field to a medical field. DO and MD curriculum are identical. DNP and DO/MD curriculum are not even comparable.

4) You generally remember one level more basic from what you were taught. In depth training allows you to forget some of the superfluous knowledge yet still have a sufficient knowledge base to be functional. In theory, only teaching the highlights seem practical but you just dont retain all that knowledge so you lose impt stuff. If you naturally forget 50% of what you were taught and what you were taught only scrapes the surface, where do you stand?

5) In med school, much of the medical knowledge base is learned during the first 2 years. Rotations during 3rd and 4th year expand that knowledge base and teach you how to apply that knowledge clinically. During rotations, you are still a medical student not an MD. I would definitely rather an ED nurse with 5 years experience take care of me than a 3rd or 4th year medical student. I would rather a 3rd year emergency medicine resident (MD) take care of me than a 5th year ED nurse.

6) Most physicals are too brief. That said, a full physical is rarely needed. Do you really need the check PT and DP pulses in the feet if the pt is a healthy 20 something. NO. A more detailed physical in that area is needed when there are irregularities with the brief part. This for the most part is done.

FWIW I would not go to a family medicine doctor for my primary care. I just dont feel they have sufficient training. I would only go to an internal medicine doctor or for my kids, a pediatrician. Perhaps that will give you some insight on why I really do not trust the new DNP degree- If 4 years of medical school and 2+ years of residency are not good enough, how is 3 years total (with worthless courses taking up over a year of that 3) going to be enough?

Dr. Tammy, FNP/GNP-C · Mar 14, 2009

I have a bunch of friends that completed nursing school and are current nurses. There definitely are some very bright ones but on the whole, they are not the same caliber as an average medical student.

Really? I often have the same thoughts of medical students and physicians.

wowza · Mar 14, 2009

Really? I often have the same thoughts of medical students and physicians.

Perhaps I should clarify my point:

Nursing students have finished a bachelors degree. Medical students have also finished a bachelors degree but were selected to enter medical school out of the group of college educated people based on high grades (average of 3.6 nationally), scores and recommendations.

My comments would also fit for the average college student- non-medically related. Since medical students have been selected out of that pool of college students, it fits that they on average would be brighter than the average college student.

My comment was directed at the comment that nursing students were more prepared for medical school. Not everything said is meant to be a personal attack.

wowza · Mar 14, 2009

My comments on this board are also not meant to be attacks on nursing, just that those who created the DNP degree do not have patient care on their mind.

I feel that every effort needs to be made to show the public that the new degree does not offer the same education as an MD/DO.

If the education and the licensing requirements were the same i would withdraw absolutely all of my objections. My issue is not that this is going to over crowd the market with providers or that it is going to influence my job- i am going into a field that is largely free from encroachment; my issue is that the lack of education will lead to improperly trained providers.

Years ago, the family practitioners realized that medical school alone was not adequate enough training for the expanding medical knowledge for a primary care physician so they created a 2 year residency.The DNPs have not found some efficient way to train their providers, especially not with a years worth of nursing theory/epidemiology. They are just cutting corners. Someone will get hurt. People need to put down the ambitions and start being patient advocates again.

If anyone actually feels that the training and knowledge base are the same between the two, please speak up. Otherwise you have an ethical imperative to help prevent improperly trained providers from practicing unrestricted and hurting someone.