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

ivanh3 · Mar 18, 2009

Wow, lots of great comments. Much to think about. Just a few of mine.

In terms of the OP, I think there is a significant amount of difference. It staggers the mind that some here want to ignore that. Physicians receive not just more training, but more relevant training. Why is that statement considered such a slight to nurses? Nursing has always seemed to me to suffer from an identity problem. We are coming around, but the process seems slow.

People will point to patient outcome studies. These studies indicate to me that NPs are faring well and deservedly so, but that does not mean the training could not be improved. I will say this as far as the DNP goes. I am not really for it right now. I would rather see the masters program beefed up some more. More science classes, more patho classes, more clinical time, and yes, less nursing theory, less about Flo and other theorists. That information is covered quite well in other nursing tracks. Even the research classes seem unnecessary to me. Question. Do physicians receive training in research? Or do they acquire it when they go through dual programs (MD/PhD) or fellowships? I honestly don't know. Again, nursing research is covered quite well in other nursing tracks and culminates in the PhD. If NPs want to pursue research, then they should pursue the extra degree training on their own.

I find it ironic that nurses complain about the political aspect of the AMA and some physician's reluctance to accept NPs. Maybe MDs like the power, maybe in their eyes they are just protecting their "turf". Probably it is both. Well, I think the AMA/MDs are in for a rude awakening. However, how is that any different from what nursing does? As a paramedic I had to listen to nurses proclaim their higher position on the "medical food chain". I hated that. Then when paramedics started to successfully enter hospital practice, nursing went nuts. A paramedic couldn't possibly do a nurses job with their "lesser training". Sound familiar? Where are those studies/facts/figures? I would put any new grad paramedic up with any new grad nurse, and I bet that patient outcomes wouldn't be any different. Revisit those same two people 4, 6, 12 months later and what would we find? I wonder. Be careful nurses, we might just find out one day. My point is this: we are doing the exact same thing. The only difference might be scale, but does scale make it right or wrong?

DNP=clinical. Wrong. DNP=practice. Perhaps the DNP started out as clinical extension of the MSN/NP, but that is now not the case. Even the ANA has clarified that advanced practice doesn't have to be clinical at all. It can be education, clinical, or administrative/leadership based. There are DNP tracts that have NOTHING to do with clinical practice.

Who gets called doctor? WHO CARES! I have to respectfully suggest that if your goal is simply to be referred to as "Dr so and so" then perhaps that is an ego issue. Which is not to say that you won't be an excellent provider. If it is a respect thing, I get it, but is that how you truly define yourself? Not all people with "doctorate" in their degrees are called doctor. Lawyers (JD), pharmacists (pharmD), physical therapist (DPT), etc. I am in my NP clinicals right now. Even after I go into the room and introduce myself as "NP student", I am still referred to as doctor. I don't care. I really just want to help.

Bedside manner. I hear constantly how uncaring doctors are, and that nurses care more. I would really like to see some of those people say that to a doctors face. "I don't think you care as much as I do". This is based on what? You worked with a physician who wasn't pleasant? Have you read some these posts on this board? That includes some of mine. Just how "caring" do we seem here? I have not agreed with much of Wowza's case, but I had to laugh at one of the responses to this person that was brutally snide and sarcastic and then went on to discuss the poor bedside manner of med students. That was very funny.

Bottom line for me is that nurses don't own caring. People do. I find nursing to be one the most hostile professions I have been a part of, and this is coming from a paramedic (Chicago Fire Academy grad), former police officer, and US Army veteran. Article after article has been written about horizontal violence in nursing. For years nursing has proudly proclaimed "We eat our young!" Sometimes we have good reason to be hostile. Sometimes we exemplify caring. That is because we are people. Physicians are no different. Have I come across a butt head doc? Yes. Nurse? Also yes. I know plenty of both, some good, some bad. Nurses and physicians work hard, get tired, cry, get mad, smile, laugh, get sad, and put their pants on one leg at a time.

For me it has been an honor and a privilege to further my education. I look forward to becoming an FNP. I look forward to working with, and yes, sometimes under a physician. That does not demean me as a person. It does not cheapen my intent or lessen my mission, but very likely will improve my ability to help my patients. I see that as a win-win situation.

Ivan

menetopali · Mar 18, 2009

great post Ivan! :yeahthat:

CraigB-RN, MSN, RN · Mar 18, 2009

Hey Ivan you said it well. how quickly we as nurses forget history when it's convinient for us. Look at the CRNA's argualing against teh AA's. They are using almost the exact same arguments that the MD's used against teh CRNA's.

To some point, we have to recognize, good or bad, that wether we mean it to be or not, it is always about ego. Some's we do things because it makes us feel good, and sometimes we get deffensive, because someone or something is stepping into our space.

menetopali · Mar 19, 2009

while there is certainly ego on both sides, the reality is that perceptions matter.

historically it has been medicine trying to dominate others in health care. your CRNA example is a good one in that it demonstrates medicines continued effort to remove any profession' they don't control from the provision of care (the M.A., the failed "Registered Care Technician" to provide bedside care at the direction of a physician, the physician's assistant, and now the A.A.). the strategy of medicine is simple - 'if you don't roll over, we'll replace you with someone who will' and all in the name of "patient safety" while they make a pretty penny from the labors of others (two different policy studies - OTA, 1986, UCSF, 2007 - noted that objections to NPs came from those with an economic interest to protect).

the reality is that medicine will never acknowledge that somebody else can provide independent care. NPs give safe and effective care and every study has shown it to be true with only the "opinions" of physicians saying otherwise. i'd recommend the use of some objective standard to measure the quality of care of all providers, but the AMA will never accept any standard apart from their own failed model and nursing will never accept any standard that a physician was a part of creating.

however, the public cares more about access to safe and effective care than the ego of the AMA.

as for the title issue, part of defining ourselves and our profession includes our academic credentials.

do nurses own caring? no

do physicians own curing? no

does either side own the title "Dr."? no

now try to get both sides to acknowledge these realities...

wowza · Jul 11, 2009

while there is certainly ego on both sides, the reality is that perceptions matter.
historically it has been medicine trying to dominate others in health care. your CRNA example is a good one in that it demonstrates medicines continued effort to remove any profession' they don't control from the provision of care (the M.A., the failed "Registered Care Technician" to provide bedside care at the direction of a physician, the physician's assistant, and now the A.A.). the strategy of medicine is simple - 'if you don't roll over, we'll replace you with someone who will' and all in the name of "patient safety" while they make a pretty penny from the labors of others (two different policy studies - OTA, 1986, UCSF, 2007 - noted that objections to NPs came from those with an economic interest to protect).
the reality is that medicine will never acknowledge that somebody else can provide independent care. NPs give safe and effective care and every study has shown it to be true with only the "opinions" of physicians saying otherwise. i'd recommend the use of some objective standard to measure the quality of care of all providers, but the AMA will never accept any standard apart from their own failed model and nursing will never accept any standard that a physician was a part of creating.
however, the public cares more about access to safe and effective care than the ego of the AMA.
as for the title issue, part of defining ourselves and our profession includes our academic credentials.
do nurses own caring? no
do physicians own curing? no
does either side own the title "Dr."? no
now try to get both sides to acknowledge these realities...

If you want to split hairs, historically it was only medicine alone in health care until others felt they wanted a bigger piece of the pie and started pushing for the allowance to expand their practice rights.

Realistically, each side has an economic interest to protect. To infer only one side is fighting for their economic interest is misleading.

Those studies you are alluding to are very poorly done. They are relatively small, many are based on questionaires and they claim to say that outcomes are the same yet never actually measure outcomes, only the screening tests you would do for the respective diseases. These tests are also very variable based on day. For instance one study measured peak flows in asthmatics.

Furthermore, all of the studies are based on very simple patients- those who first present. Honestly you could have medical students vs NPs vs doctors and you would probably see no statistically significant difference because there are specific guidelines to follow. The difference will be seen with complex patients. For run of the mill patients, yes an NP probably provides similar care but for all people, no. Similarly a 2nd year resident probably provides similar care as the attending yet they are under the attending because the attending not only has more experience but also more expertise. That is why both NPs and residents are not independent.

Medicine is a failed model? I think that is a far cry from reality. While I agree some of medical training can be trimmed (for instance a GI doc could do 2 years IM residency followed by 3 of GI, eliminating 1 year), very little of it is superfluous.

JDCitizen · Jul 11, 2009

if you want to split hairs, historically it was only medicine alone in health care until others felt they wanted a bigger piece of the pie and started pushing for the allowance to expand their practice rights.

historically modern medicine has been developing over thousands of years (ancient egyptians, hippocrates, herbalist, etc.)...

what is now called "medicine" has managed to become organized and has monopolized the business/field..

realistically, each side has an economic interest to protect. to infer only one side is fighting for their economic interest is misleading.

so true...

those studies you are alluding to are very poorly done. they are relatively small, many are based on questionaires and they claim to say that outcomes are the same yet never actually measure outcomes, only the screening tests you would do for the respective diseases. these tests are also very variable based on day. for instance one study measured peak flows in asthmatics.
furthermore, all of the studies are based on very simple patients- those who first present. honestly you could have medical students vs nps vs doctors and you would probably see no statistically significant difference because there are specific guidelines to follow. the difference will be seen with complex patients. for run of the mill patients, yes an np probably provides similar care but for all people, no. similarly a 2nd year resident probably provides similar care as the attending yet they are under the attending because the attending not only has more experience but also more expertise. that is why both nps and residents are not independent.

medicine is a failed model? i think that is a far cry from reality. while i agree some of medical training can be trimmed (for instance a gi doc could do 2 years im residency followed by 3 of gi, eliminating 1 year), very little of it is superfluous.

i myself don't see medicine as a failed model its just a model that needs tweaking (a lot of tweaking)...

Kathleen G · Jul 26, 2009

Dear everyone,

I am also a nurse RN, BSN of 23 years and I too wanted to be a physician. Instead I chose the MSN/NP route as I married a physician and have a 23 year old son applying to medical school presently. Both are excellent but different careers. As I plan to practice primary care with the NP (in about 6 months),

I still do not think it is fair or respectful for anyone to turn this into such a personal, heated debate. Even though both the NP and the MD take care of patients independently, the education and the care is quite different. Where medicine has much greater sophistication in terms of biological sciences, nurses are generally better communicators and have better rapport with patients and families. Both professions have alot to offer the patients. I do feel that as nurses we need to stop all of the back stabbing game playing behavior and concentrate on moving forward together as a profession. I think the MD alluded to that when he/she said I am sick of nursing and glad to be studying to be a MD. I can relate to that statement wholeheartedly. Kathleen G (RN, BSN)

NurseKJ · Jan 24, 2010

This is a great thread, that I come back to to read from time to time. I am currently beginning my first of two graduate level research classes... I hope everyone who is practicing as a nurse, remembers that all "nursing" and "medical" practices are based on evidence and research. understanding how to do and interpret research are vital for evidence based practice- even if you are not the PhD who is actually conducting the research.

I also wanted to add that it gets so frustrating when the health care field compares MDs/DOs/NPs, ect... it's like comparing apples and oranges. Does anyone compare PharmDs/PTs/Resp therapists, ect? Sure some aspects of the professional's scope of practice overlap, but that does not mean one profession is better/trying to "take over" ect.

Thanks for listening... I would love to hear other's thoughts...

-KJ

enoRN · Jan 24, 2010

Thanks for writing this NurseKJ, it is high time we start thinking about improving ourselves as nurses and stop comparing, and if we do this, we can always explain to whoever we meet on the way - our job responsibilities, the more we educate the society, the more they'll understand but we have to get there first and not to sit back and worry.

Kathleen G · Jan 24, 2010

From Kathy G RN BSN

My now 24 year old son has been accepted to 4 allopathic MD programs and 5 Wait List programs. I still say that although alot of degreed nurses (inlcuding myself) wanted to be MD's there is a huge difference between the programs. Also traditional MD programs have become "much more competitive." The number of seats has not changed in 20 years though the US population has doubled. According to my son, when appearing for interviews at the allopathic schools there could be maybe 3 from Harvard, 2 or 3 from Columbia, Duke, Emory or any of the top tier schools. These young adults have degrees in anything from Finance, Biochemistry, Engineering or even Philosophy. The competition for even someone as gifted as my son is tremendous. So I think we go back to the original statement that nurses and MD's are different but complementary. We all need to work together to augment each others gifts.

One thing which makes me really happy is to see "empowerment" for the next generation. We have some wonderful kids coming up. They seem to be moving even higher than alot of us academically. I am proud.

Kathy G RN BSN (presently in NP program)

springing · Jan 30, 2010

I also wanted to add that it gets so frustrating when the health care field compares MDs/DOs/NPs, ect... it's like comparing apples and oranges. Does anyone compare PharmDs/PTs/Resp therapists, ect? Sure some aspects of the professional's scope of practice overlap, but that does not mean one profession is better/trying to "take over" ect.

MDs are justified in their worries that NPs are going to overtake certain MD careers. Of course, they blame the NPs, not the MDs. It's not the fault of any nurse practitioner that so few graduate MDs choose family practice or pediatrics residencies. If MDs choose not to do general primary care, they can't complain that NPs are entering primary care in these numbers. Last time I checked the number of vacancies for family practice physicians grows every single year. You choose an FP residency and you have pretty much a GUARANTEED job, plus loan repayment, at an ever-widening array of locations. But MDs aren't choosing FP and they aren't choosing pediatrics - they are putting their need for money over these fields and then complaining that NPs are seizing the opportunity to provide care to populations that would otherwise be going without.

Any MD who complains about NPs and isn't in primary care only has themselves to blame; it's like people who complain about the president but don't vote.

Now, I don't believe that NPs should go around calling themselves "doctor" any more than physical therapists or physician's assistants should be calling themselves doctor. And I don't believe that NPs and MDs should have the same scope of practice or same model of care. But there is a DESPERATE need in this country for nurse practitioners, and as long as this need exists, it should be filled. I feel that the debate over this has COMPLETELY lost sight of who exactly we're supposed to be serving here. Doctors and nurses are both employed by the same people - the patients. Doctors and nurses both SERVE the same people - the patients. Pushing health care providors out of the field is scorched earth; it's a pyrrhic victory; it's nonsense.

dgenthusiast · Feb 3, 2010

MDs are justified in their worries that NPs are going to overtake certain MD careers. Of course, they blame the NPs, not the MDs. It's not the fault of any nurse practitioner that so few graduate MDs choose family practice or pediatrics residencies. If MDs choose not to do general primary care, they can't complain that NPs are entering primary care in these numbers. Last time I checked the number of vacancies for family practice physicians grows every single year. You choose an FP residency and you have pretty much a GUARANTEED job, plus loan repayment, at an ever-widening array of locations. But MDs aren't choosing FP and they aren't choosing pediatrics - they are putting their need for money over these fields and then complaining that NPs are seizing the opportunity to provide care to populations that would otherwise be going without.
Any MD who complains about NPs and isn't in primary care only has themselves to blame; it's like people who complain about the president but don't vote.
Now, I don't believe that NPs should go around calling themselves "doctor" any more than physical therapists or physician's assistants should be calling themselves doctor. And I don't believe that NPs and MDs should have the same scope of practice or same model of care. But there is a DESPERATE need in this country for nurse practitioners, and as long as this need exists, it should be filled. I feel that the debate over this has COMPLETELY lost sight of who exactly we're supposed to be serving here. Doctors and nurses are both employed by the same people - the patients. Doctors and nurses both SERVE the same people - the patients. Pushing health care providors out of the field is scorched earth; it's a pyrrhic victory; it's nonsense.

You're wrong about physicians choosing specialties rather than primary care out of pure greed. It's kind of hard to work 80hrs a week when you absolutely hate your job; doing something you hate purely for the sake of money is akin to getting in the fast lane towards burnout. Physicians are not choosing primary care because of many reasons, one of which (and not the top reason either) involves reimbursement. Many of the problems include the headaches of administrative duties, haggling with insurers, noncompliance, continually decreasing reimbursement, etc. Many primary care practices are struggling to keep their doors open. Nearly half of the PCPs surveyed by the Physician's Foundation said they would reduce the number of patients they see or close their practices. Of course, that's just because those physicians are so greedy right?

You should really try to understand why physicians are against NP/DNP independent practice before making ignorant comments about greed, how much physicians suck and whine, etc. On a side note, doesn't the nursing community cry just as much regarding LPNs encroaching on nursing territory? A bit hypocritical, no? Physicians, and also many nurses, are arguing that NPs/DNPs do not have adequate training to practice independently without any physician oversight. I can understand why when I constantly see people on this site argue that they're equivalent to physicians...without any of that training, of course. You're not really serving the patients when you practice medicine without proper training. Otherwise, let's just let people with a BS in biology practice medicine after a few hours on the wards. Anything is better than nothing, am I right? That appears to be one of the primary reasons you guys seem to present on this site in favor of greater practice scope for midlevels without making any changes to the training.