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

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Doctor of Nursing Practice

Sample Plan of Full-time Study

The program requires a minimum of 38 credits comprised of 19 credits of core courses, 15 credits of specialty electives, and 4 credits for a capstone project. Full-time or part-time options are available.

First Semester (Fall) Course Title Credits NDNP 802 Methods for Evidence-Based Practice 3 NDNP 804 Theoretical and Philosophical Foundations

of Nursing Practice 3 NDNP xxx Specialty Elective 3 NDNP 810 Capstone Project Identification 1 Total 10 Second Semester (Spring) Course Title Credits NDNP 805 Design and Analysis for Evidence-Based Practice 4 NDNP 807 Information Systems and Technology for the

Improvement and Transformation of Health Care 3 NDNP xxx Specialty Elective 3 NDNP 811 Capstone II Project Development 1 Total 11 Third Semester (Summer) Course Title Credits NDNP xxx Specialty Elective 1 NDNP 809 Complex Healthcare Systems 3 NDNP 812 Capstone III Project Implementation 1 Total 5 Fourth Semester (Fall) Course Title Credits NDNP 815 Leadership and Interprofessional Collaboration 3 NDNP xxx Specialty Elective 8 NDNP 813 Capstone IV Project Evaluation & Dissemination 1 Total 12 Total Credits Total Credits Total Credits 38

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2 years

MD program University of MD

Curriculum at a Glance

Year I

37 weeks

I ORIENTATION

(9 days)
Informatics, Introduction to Clinical Medicine

II STRUCTURE AND DEVELOPMENT

(49 days)

Participating departments/divisions: Anatomy and Neurobiology, Surgery, Diagnostic Radiology

Areas of study: Human gross anatomy, embryology and histology

III CELL AND MOLECULAR BIOLOGY

(44 days)

Participating departments/divisions: Biochemistry and Molecular Biology, Medicine, Human Genetics, Anatomy and Neurobiology, Pharmacology and Experimental Therapeutics, Cancer Center

Areas of Study: Protein structure and function, cellular metabolic pathways, cell signal transduction, cell microanatomy, human genetics, molecular biology

IV FUNCTIONAL SYSTEMS

(49 days)

Participating departments/divisions: Anesthesiology, Internal Medicine, Neurology, Obstetrics, Gynecology and Reproductive Sciences, Pediatrics, Physiology, Surgery

Areas of study: Cell, cardiovascular, endocrine, gastrointestinal, renal, respiratory and integrative function

V NEUROSCIENCES

(29 days)

Participating departments/divisions: Anatomy and Neurobiology, Biochemistry and Molecular Biology, Neurology, Physiology, Surgery

Areas of Study: Development, structure and function of nervous tissues, anatomical organization of CNS, sensory and motor systems, higher functions, concepts in clinical neurology

ICP INTRODUCTION TO CLINICAL MEDICINE

(1/2 day per week and selected full days throughout the year)

Participating departments/divisions: Family Medicine, Pediatrics, Psychiatry, Internal Medicine, Surgery, Neurology, Surgery, Obstetrics/Gynecology, Emergency Medicine

Areas of study: Ethics, nutrition, intimate human behavior, interviewing and physical diagnosis issues, topics relevant to delivery of primary care, doctor-patient relationship

Year II

I HOST DEFENSES AND INFECTIOUS DISEASES

(52 days)

Participating departments/divisions: Epidemiology and Preventive Medicine, Medicine, Microbiology and Immunology, Pathology, Pediatrics, Pharmacology and Experimental Therapeutics

Areas of Study: Immunology, bacteriology, virology, parasitology, mycology

II PATHOPHYSIOLOGY AND THERAPEUTICS I and II

(108 days)

Participating departments/divisions: Anesthesiology, Cancer Center, Dermatology, Diagnostic Radiology, Epidemiology and Preventive Medicine, Medicine, Neurology, Obstetrics, Gynecology and Reproductive Sciences, Pathology, Pediatrics, Pharmacology and Experimental Therapeutics, Psychiatry, Surgery

Areas of study: Bone, cardiovascular, dermatology, endocrine, gastroenterology, hematology, nervous, pulmonary, renal and reproductive systems

INTRODUCTION TO CLINICAL MEDICINE

(1/2 day per week and selected full days throughout the year)

Participating departments/divisions: Medicine, Family Medicine, Pediatrics, Psychiatry, Neurology, Ophthalmology, Obstetrics, Gynecology and Reproductive Sciences

Areas of Study: Fundamental aspects of history-taking and physical examination, medical ethics, medical economics

Year III

48 weeks

TIME
COURSE TITLE
12 weeks Internal Medicine 12 weeks Surgery/Surgical Subspecialty 4 weeks Family Medicine Clerkship 6 weeks OB/GYN Clerkship 6 weeks Pediatrics Clerkship 4 weeks Psychiatry Clerkship 4 weeks Neurology Clerkship

Year IV

32 weeks (tentative schedule)

APPROXIMATE TIME
COURSE TITLE
8 weeks AHEC 8 weeks Sub-Internship 16 weeks Electives

I do not see how they are the same?

My basic assumption is that more training means a better prepared provider. That is false?

You are still skirting my question- do you feel the 3 years- one of those being nursing theory- that an NP receives is equivalent to the 6 years of training a family physician receives?

Unless you say yes you have to agree with my point.

A short cut is just that- something that cuts out something important- like 4 years of training. Studies with poor sensitivity and design are not going to show small but significant differences in care- especially ones that have created artificially easy patients- like taking pts out who have comorbidities and not using actual outcomes to measure outcomes. The sad thing is that most NPs aren't even aware of what they dont know. And that is scary.

This push for autonomy is purely ego driven. Hiding behind poorly designed studies you can claim all you want to, but in your heart, i am sure you know there is a difference in knowledge that eventually will come out in care.

If your lack of knowledge hurts even one more patient- is that too much? Where is the line?

my basic assumption is that more training means a better prepared provider. that is false?

you are still skirting my question- do you feel the 3 years- one of those being nursing theory- that an np receives is equivalent to the 6 years of training a family physician receives?

unless you say yes you have to agree with my point.

a short cut is just that- something that cuts out something important- like 4 years of training. studies with poor sensitivity and design are not going to show small but significant differences in care- especially ones that have created artificially easy patients- like taking pts out who have comorbidities and not using actual outcomes to measure outcomes. the sad thing is that most nps aren't even aware of what they dont know. and that is scary.

this push for autonomy is purely ego driven. hiding behind poorly designed studies you can claim all you want to, but in your heart, i am sure you know there is a difference in knowledge that eventually will come out in care.

if your lack of knowledge hurts even one more patient- is that too much? where is the line?

please tell us what dnp program has a year of nursing theory, in fact, most dnp programs have 1-2 courses (3-6 credits) in nursing theory out of 80-90 in the program of study. do you think it is possible that most mds are not aware of what they do not know?

be careful what you wish for in outcome studies. the ota studies on the 80s indicated very favorable outcomes for pas and nps in comparison to mds. just think, this was when pas and nps had one entire year of education as compared to the 3 years expected for the dnp now. therefore, nps have incorporated more time/education into their programs of studies to reflect the ever more complex issues in health care.

most importantly, quit generalizing to the entire np community, do you really think the entire dnp push is ego driven. studies are ongoing, not all studies are poorly designed, dnp programs are emphasizing practice improvement projects, time will tell.

Specializes in ED, Tele, Psych.
My basic assumption is that more training means a better prepared provider. That is false?

You are still skirting my question- do you feel the 3 years- one of those being nursing theory- that an NP receives is equivalent to the 6 years of training a family physician receives?

Unless you say yes you have to agree with my point.

A short cut is just that- something that cuts out something important- like 4 years of training. Studies with poor sensitivity and design are not going to show small but significant differences in care- especially ones that have created artificially easy patients- like taking pts out who have comorbidities and not using actual outcomes to measure outcomes. The sad thing is that most NPs aren't even aware of what they dont know. And that is scary.

This push for autonomy is purely ego driven. Hiding behind poorly designed studies you can claim all you want to, but in your heart, i am sure you know there is a difference in knowledge that eventually will come out in care.

If your lack of knowledge hurts even one more patient- is that too much? Where is the line?

back to the "poorly designed study" claim are we? there is no study that i have seen (from nursing, medicine, public health, or public policy or any other field - international or domestic), has shown NP care harms patients - that would be zero, zip, nada and there are many that show increased access to care, comparable outcomes, higher satisfaction with care, comparable utilization of diagnostic tests, more time spent by NPs, fewer prescriptions by NPs, etc. the issue has been studied for more than 40 years with the same result every time - NPs provide safe and effective care. in 22 states NPs practice independently from physicians - they open their own offices, write prescriptions, order and interpret labs & imaging studies, and refer to specialists and yet there has been no uptick in mortality or morbidity in those states (in fact both have gone down with improved access to care).

as for the "most NPs don't know what they don't know" show me the evidence for such a claim. it is true that nobody can use knowledge they don't have - the same can be said for pharmacists, engineers, policy makers, military planners, or any other profession - including physicians. having a degree or a title does not mean you are all knowing in your field - in fact i would argue that the more education you get, the more you realize what you don't know. it is those who fail to recognize this concept who are particularly dangerous and who kill thousands of people every year through errors and omissions - medical error is the eighth leading cause of death in the United States. from my interactions with many physicians over the years, i have found the "all-knowing" or "i went to med school so i'm smarter than you" ones to be the most dangerous of all because they don't know what they don't know and refuse to acknowledge that they may not have all the answers (no, i haven't hunted the study on this phenomenon so it is anecdotal and should be taken as such). to date i have never met an NP with such an ego problem as that, on the contrary - the NPs i've met are much more likely to say "hmm, i'm not sure about that..." or "i don't have an answer for that, let me look into it" (again this is admittedly anecdotal).

now let's try to keep it honest (these are general requirements and there may be outliers):

require an undergrad degree to enter?

DNP/EdD/PharmD/PhD/DDS/DPT/AudD/DVM/DMD/PsyD - yes

MD/DO/DC/DPM - no

higher GPA than the average student?

DNP/MD/DO/EdD/PharmD/PhD/DDS/DPT/AudD/DVM/DMD/DC/DPM/PsyD - yes

require clinical time before conferring degree?

DNP/MD/DO/PharmD/DDS/DPT/AudD/DVM/DMD/DC/DPM/PsyD - yes

require dissertation or other scholarly work with defense?

DNP/PhD/EdD - yes

MD/DO - no

receive federal funds for paid apprenticeship during the first year or more of practice?

MD/DO/DDS/DMD/PharmD - yes

DNP/DC/PsyD/DVM/AudD/DPT - no

lets keep the comparison as apples to apples - counting federally funded and paid apprenticeships (that include time spent sleeping, studying, or otherwise not in contact with the patient) as part of the education of an MD/DO after they have received their degree while only counting time before completion of a degree for the DNP is artificially tilting the discussion and is intellectually dishonest.

is the DNP degree the same as a MD/DO? no, but neither is a DDS, DVM, PsyD, PharmD, DPM, DC

let's play a matching game -

would i go to a dentist for heart surgery? no, i'd go there for a tooth extraction

would i go to a cardiothoracic surgeon for mental health? no, i'd go there for heart surgery

would i go to a pharmacist for physical therapy? no, i'd go there for information about medications

would i go to a podiatrist for primary care? no, i'd go there for foot care

would i go to a DNP (NP) for tooth extraction? no, i'd go there for primary care

would i go to a dentist for foot care? no i'd go there for a tooth extraction

would i go to a physical therapist for medication information? no, i'd go there for physical therapy

each doctor is prepared to provide a different type of care and each of us in healthcare need to recognize the strengths and weaknesses of other members of the healthcare team. the DNP provides a unique, and complimentary, approach to primary care as well as the capability to provide access to care for 600 million patients annually (American College of Physicians, 2009).

you may have a beef with NPs and the DNP, but be honest about it. the ego problem is from the minor deity (MD) community and is tied to those with an economic interest in preventing NPs from practicing independently - specifically the AMA and AAFP. it isn't about patient safety - that is a repeatedly disproved urban legend that keeps re-surfacing.

Specializes in ER; CCT.
My basic assumption is that more training means a better prepared provider. That is false?

You are still skirting my question- do you feel the 3 years- one of those being nursing theory- that an NP receives is equivalent to the 6 years of training a family physician receives?

Talk about faulty logic. What you fail to mention is that by entering DNP training students are already licensed RN's with a practice-oriented and patient-centered undergraduate degree. Unlike medical students, who bring nothing to the table from day one, the average exp. of patient care in my particular class is 17 years of direct patient care practice, with the range topping 35 years. Also, the vast majority of those within the DNP program are continuing to provide direct patient care as RN's or as APN's with their masters degree in the interim. Where does that figure in your 3 year schema?

Oh, also, as I understand the first two years of medical school consist of basic scicences such as a full year of anatomy, histology, embryology, and the last two years are supervised clerkships. And its a good thing, too, because most physicians with whom I talk that actually practice medicine for a living tell me they remember less than 10% of basic science material anyway and nearly nothing of the organic chemistry, physics and calculus, which was required to get into medical school in the first place, as these courses have little to do with patient care anyway. Curiious enough, if you use the 10% mark, it is far less than the coursework in same areas that basic nursing students need to get into nursing school in the first place.

So, as I understand by the time someone graduates from medical school with 8 years of educaation they have roughly two years of supervised clinical experience (4 years undergraduate and 4 years of graduate work) where as the DNP will have at least 3 years of undergrad supervised clinical experience, 4 years of practice experience working as an RN with 2 of those years of APN work and two years of supervised clinical experience in the first two years (not last 2 years) of their MSN or beginning of their DNP program. Again, where does that figure in your 3 year schema?

Come to think of it, you are right, there is really no comparison between the MD and DNP. Could you remind me again of what entitles physicians to use the title "doctor" in the clinical setting?

Also, did they increase the length of medical school? I thought it was 4 years and not six. Perhaps you wern't in that "general population" of which you spoke related to the "brightness" when it comes to math. That's OK, because we nurses welcome you among the ranks of the not-so-bright.

Specializes in Critical Care, Emergency, Education, Informatics.

Hey there menetopali,

I think you hit a number of things on the head. The one addition i'd like to add is that the ego's aren't only on the MD side of things.

I think that our ego, and that is a collective ego and not a individual ego, get's in our way also. We're tilting at the wrong windmills. The past 30+ years have proven that midlevel (yes I know people hate that term) can do the job. Their job, not the cardiologist or the surgions job, but their job. THe data is in and it is so overwhelming that their is not need to any published studies.

Our problem is how we try to sell things, In this case, and it's just my opinion for what ever it's worth, is that we chose to fight the battler of who gets to be called doctor, instead of the battle of who can provide the approprate level of care for the pateint sitting in front of us. We get bogged down in the percieved or real differences in teh nursing model vs the medical model.

Comments have been made about how the AMA is just sitting back an enjoying our internal discourses. I think that the fact that nurses are having this discourse, is an indicated that the DNP isn't addressing the true need.

Were do we start and how do we identify what needs to be addresses and only then can we address how to correct the needs. I"m sitting here tinking about my PhD disertation and wondering if that is something I'm capable of attacking.

DNP, great, I"m all for it as an option. A way to specialize, and advance both patient care and the delivery of care. But I'm a cynic and think this is putting the cart in front of the horse. And making it the end point for APRN's, I'm not sure. What do we do after that, and find that we aren't considered equals by anyone? Were to we go, we've already taken the final step. Do we develop a degree higher than the DNP? Anecdotally I've heard many comments over the years,and it's not about the nrsing theory in the NP education, it's about the clinical. Providers who have both PA and NP students, can't help but make comparasons. PA students are there 8-10 horus a day 5 days a week. NP students are there 1 day a week. The providers see the time, they don't see the fact the NP student is working in a busy high accuity ER and is getting 36-40+ hours a week of unoficial clinical. The provider then goes and sits at a Pri-Med or other pharmcy sponsored CME and the topic comes up in discusion. Now it's about NP's in general and they dicide that their practive needs PA's and not NP's because they understand the PA's better. This is a real discusion that happened around the table at a Pri-Med CME conference here in Atlanta last summer. The table had an OB Doc, a Familyi Practice, a pulmonogist and a Gi doc, as well as 2 PA's, yes one was my wife, and myself and another RN/NP student.

Perception is important,and in some cases more important than reality, it's not right, but that is the fact.

In the case of the DNP, we as a corperate body called nursing, let some academics tell us what needed to change. It didn't come from the grass roots nurses. Nurses have an inherant distrust of those nuses in the ivory towers, because they are always percieved as being out of touch. It may be to late now, the barn dor is open already and the horse is gone, but maybe it's time for US as nurses to have a true dialoge and tell the powers that be, what we want and need.

Ok I'm off my soap box and I've put on my asbestos underwear.

Specializes in ED, Tele, Psych.

hey Craig - i'm putting off my Scholarly Inquiry Project right now for the DNP (the PhD-light version of a dissertation that looks an awful lot like a dissertation in form, length, format, and content)

i agree that there are definitely egos in nursing and frankly you are absolutely right-on with the failures of nursing to manage perception. i will disagree on the title issue though - to move perceptions we need people on the front lines who make it clear that they are doctors (ie doctoral prepared) and that we bring in a different approach to health care. if we wait for the perception to change without working to influence that perception then we will never get anywhere, or worse we will allow others to frame the issue to their own advantage. it is unfortunate that nursing "leaders" failed to see the political ramifications of the DNP and act to overcome them in a more timely manner, but that is the reality we are faced with.

we have already demonstrated that we can provide safe and effective care so that "windmill" has fallen. we should fight the fight of title and independence instead of continuing to be invisible providers who pay kick-backs to physicians for nothing more than a name on a form that we pay for - no support, no back-up, no shared risk, no benefit to the NP what-so-ever outside of prostituting ourselves like some "ghost writer" who does all the work, takes the risk, and then is treated as if they didn't exist in the billing audits and quality measures.

unfortunately the nursing "leaders" failed in selling the DNP to their constituents, the public, or policy makers and tried to take a middle ground instead of committing to a course of action, they lacked decisiveness. this failure has cost us dearly in the PR battle that rages on within and outside of nursing.

Specializes in Family Practice, Primary Care.

Let's take a look at a DNP program, shall we wowza? This is the one I plan on enrolling in:

University of Pittsburgh, BSN-DNP program for FNP; prereq- at least 1 year FT nursing experience

Fall term 1:

Applied Statistics for Evidence Based Practice

Pathophysiology across the Lifespan

Health Promotion and Disease Prevention in Culturally Diverse Populations

Role Seminar 1

Translating Knowledge into Action: Basic Science of Care

Spring 1:

Research for Evidence Based Practice 1

Advanced Pharmacology

Family Theory for Nurse Practitioners: Principles, Implications, and Application Across the Lifespan

Intro to Genetic and Molecular Therapeutics

Summer 1:

Research for Evidence Based Practice 2

Diagnostic Physical Exam Across Lifespan

Leadership Development

Fall 2:

Differential Diagnosis Theory Across Lifespan

Differential Diagnosis Clinical

Ethics, Public Policy, Finance, and Healthcare Orgs

Management of Women's Health

Spring 2:

Morificecript Development

Pediatric Well Child Care

Management of Adult Acute/Chronic Illness Theory

Management of Adolescent Health

Management of Adults Clinical 1

Management of Adults Clinical 2

Summer 2:

Diagnosis and Management of Psychiatric Illness in Primary Care

Management of Geriatric Health

Grant Writing

Capstone Project (aka research and clinical)

Fall 3:

Management of Pediatric Health Theory

Management of Pediatric Health clinical

Organizational and Management Theory

Intro to Health Informatics

Spring 3:

Capstone Clinical

DNP NP Role Seminar (aka residency)

Summer 3:

Role Seminar 2

DNP NP Role Seminar (aka residency)

Clinical Diagnostics

Comprehensive Exam

The only difference from the traditional MSN program is the addition of a residency, the management theory course, the health informatics course, grant writing, a capstone project, morificecript development, the translating knowledge into action course, and the genetic and molecular therapeutics course.

The residency, capstone project and genetics class all sound pretty clinical/sciency to me. So is your argument that NPs shouldn't exist at all, or what?

The residency, capstone project and genetics class all sound pretty clinical/sciency to me. So is your argument that NPs shouldn't exist at all, or what?

No i think NPs fill a vital role esp since there are not enough FPs. The push for complete autonomy is misplaced though.

The issue I have is that the difference between the masters and the "doctorate" is not enough to call the doctorate a doctorate. It should still be a masters. Just as medical school doubled their average duration, there is no reason you have to create a new degree because you feel you need to lengthen training.

I'll respond to everyone else a bit later. I have to go to dinner.

Specializes in ED, Tele, Psych.
No i think NPs fill a vital role esp since there are not enough FPs. The push for complete autonomy is misplaced though.

The issue I have is that the difference between the masters and the "doctorate" is not enough to call the doctorate a doctorate. It should still be a masters. Just as medical school doubled their average duration, there is no reason you have to create a new degree because you feel you need to lengthen training.

I'll respond to everyone else a bit later. I have to go to dinner.

hope you enjoyed dinner but most doctorates are four years in length. post-grad residency is not part of the doctorate but is part of the training evolution for physicians. now, if you would like to join the call for a federally funded and standardized post-grad residency for DNPs (or any new NP for that matter) I would welcome it. unfortunately organized medicine is against such programs crying "poor" while 12% of the family practice slots go empty every year.

Specializes in CT ICU, OR, Orthopedic.

Do the anti DNP people only have a problem with FNP and primary NPs getting a doctorate? Or all NPs?!

Specializes in ED, Tele, Psych.

they have an objection to anyone using the term "Dr" without their permission and any NP practicing without paying a kick-back to a physician (AMA, House of Delegates H35.000). while they call it "collaboration" or "supervising" but it is neither in reality as many NPs practice without them and only hire them for billing (ANA, 2002). some probably believe the propaganda of the AMA that it is a "patient safety issue" but with no evidence to back the claim from any reputable source it is a thin claim indeed.

Miss Mab, I'd just like to say I enjoyed your writing style. It was entertaining, yet very effective. Great work!

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