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

prairienp · Feb 3, 2010

you're wrong about physicians choosing specialties rather than primary care out of pure greed. that's a pretty ignorant comment to make. 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?.

need a reality check, $$$$$$$$$ is by far the number reason. look at the % of students entering medical school who "say" they are planning on going into family practice and compare to the number that enter primary care. when considering residency, reality hits, the top students seek the top residencies, which historically have been the highest paying "specialties". are you suggesting those in the specialty areas are not subject to the headaches of administrative duties, haggling with insurers, noncompliance, continually decreasing reimbursement????? here is another revelation, if you polled fnps, they would also prefer to reduce the number of patients they see

dgenthusiast · Feb 4, 2010

need a reality check, $$$$$$$$$ is by far the number reason. look at the % of students entering medical school who "say" they are planning on going into family practice and compare to the number that enter primary care. when considering residency, reality hits, the top students seek the top residencies, which historically have been the highest paying "specialties". are you suggesting those in the specialty areas are not subject to the headaches of administrative duties, haggling with insurers, noncompliance, continually decreasing reimbursement????? here is another revelation, if you polled fnps, they would also prefer to reduce the number of patients they see

and your source regarding med students choosing specialties due to money being the number one reason is? sorry, but i think you're the one who needs a reality check.

what premeds say at interviews regarding specialty interests has very little bearing on what they end up pursuing. the vast majority of premeds will change their minds about specialties no matter if they said they wanted to do primary care or if they said they wanted to go into plastics. as you go through med school and learn more and more about different specialties, your interests will probably change.

you're right that specialists have to deal with similar crap as pcps. however, it's less of a hassle for them when compared to pcps. pcps tend to deal with much more paperwork, haggling with insurers, working long hours to make ends meet, etc when compared to specialists. why do you think pcps are so dissatisfied with their jobs?

that's cool that fnps would say that they would prefer a lower volume of patients. but how many of them are saying that they would be forced to do something like this or even shut down their practices because of decreasing reimbursements? that's what a significant portion of pcps are arguing. that they cannot afford to keep their practices open with current reimbursement rates. they already work pretty long hours in order to make what they did years ago. there are a finite number of hours per day and you can only increase your patient volume so much. now, looking at all this, what smart medical student would willingly jump into such a field where pcps are burning out left and right? where professional dissatisfaction is among the highest of all medical specialties?

ivanh3 · Feb 4, 2010

Truthfully, it doesn't matter why medical students don't want to go into family practice: less money, no glamor, boredom (I have heard this from many residents/medical students), and more paperwork. An old study by UCSF said students complained about "insufficient prestige and low intellectual content". Whatever: they are all personal and therefore valid reasons. Some want to call it greed. I think that is too strong. Why is it wrong to want to make more money? Having said that, it doesn't matter why...it just matters that medical students overwhelmingly don't want to be PCPs (some figures state that only about 15 percent of medical students matched to family practice residency) , and a significant number of PCPs don't want to remain in practice (in fact a significant percentage either transition into a specialty, leave practice or retire early). Again, it doesn't matter why.

I completely agree with a previous poster on this point: If physicians don't want to be PCPs then move the hell out of the way! Even though I am the first to say lets tweak NP training and increase the rigor, I am also the first say that there is NO doubt that NPs can be PCPs. How do I know this? Because NPs are already doing it! Right now...today! It has been suggested that the studies that indicate similar outcomes are flawed. Fine. Then where are the studies to the contrary?

With so many open family practice residencies (around 40 percent by some studies) how about using some of that guv'mint money to fund NP "residencies" in family practice? Imagine the skills a PA or NP could obtain working in a paid residency for several years?

This is the time where physician assistants and nurse practitioners are poised to fill the need of primary care. As more and more spots become available through attrition it seems to me that physicians should either get on board with, and even help during this inevitable transition, or quietly step aside.

Ivan

Dr. Tammy, FNP/GNP-C · Feb 5, 2010

you're wrong about physicians choosing specialties rather than primary care out of pure greed.

"the reasons why fewer students are choosing primary are fairly clear, says dr. marc berliant, chief of the urmc's general medicine division....foremost is salary. primary-care doctors are paid significantly lower salaries than specialists. starting salaries range from $100,000 to $120,000, while more experienced doctors earn between $140,000 and $160,000. it's hard to crack $200,000. but $200,000 is a starting point for some specialists. and depending on their area of expertise, many will go on to earn much more. road (radiology, obstetrics, anesthesiology, and dermatology) has become industry shorthand for big money.

http://www.rochestercitynewspaper.com/news/articles/2009/12/state-of-emergency-the-disappearing-primary-care-doctor/

"one big reason fewer medical students are specializing in primary care is pure and simple economics."

http://www.smartmoney.com/spending/rip-offs/10-things-your-primary-care-physician-wont-tell-you-22190/

"pcps typically earn two to three times less than their counterparts who go into medical subspecialties that are more procedure-based and less oriented around office visits. that's why more medical students choose to hit the road for radiology, orthopedics or ophthalmology, anesthesiology and dermatology."

http://www.marketwatch.com/story/no-easy-cure-for-doctor-shortage-2009-11-19

"general practice: new doctors avoiding most-needed, worst-paid field"

http://www.usatoday.com/news/health/2009-08-17-doctor-gp-shortage_n.htm

"the number of u.s. medical graduates going into family medicine has been falling — by more than 50 percent from 1997 to 2005 — with many young doctors preferring specialties that pay better and offer more control over work hours."

http://www.msnbc.msn.com/id/15020430

"the nation’s shortage of primary care physicians has been linked to a host of poor health outcomes, and a study published in the journal of the american medical association suggests that salary disparities play a major role in the shortage."

http://medicalpartnership.usg.edu/research/collaborations/addressing_the_physician_shortage/

"primary care physician shortage linked to lower income"

http://www.medpagetoday.com/publichealthpolicy/healthpolicy/10850

gee, do you see a central theme? let me know if you need more support, i only had 5 minutes to kill.

ivanh3 · Feb 5, 2010

you're wrong about physicians choosing specialties rather than primary care out of pure greed.

"the reasons why fewer students are choosing primary are fairly clear, says dr. marc berliant, chief of the urmc's general medicine division....foremost is salary.
"one big reason fewer medical students are specializing in primary care is pure and simple economics."
"pcps typically earn two to three times less than their counterparts who go into medical subspecialties that are more procedure-based and less oriented around office visits. that's why more medical students choose to hit the road for radiology, orthopedics or ophthalmology, anesthesiology and dermatology."
"the nation’s shortage of primary care physicians has been linked to a host of poor health outcomes, and a study published in the journal of the american medical association suggests that salary disparities play a major role in the shortage."
gee, do you see a central theme? let me know if you need more support, i only had 5 minutes to kill.

i would not chastise physicians about avoiding a specialty due to money or finances. i just think "greed" is way to strong. i would point out that most professionals, including nurses, make these same types of decisions every day. there are plenty of nurses who have picked one job over another due to money. i bet there are over 1000 posts on this website about nursing wanting better compensation. i don't blame physicians if they feel that primary care is too mundane. i know some icu/er nurses who feel that way about med/surge (an area of nursing where nurses work their tails off but don't get much by way of respect, which is crap). we can't have it both ways. however, neither can the physicians. if they don't want to practice primary care, fine. then they should help nps to take it over.

dgenthusiast · Feb 5, 2010

Truthfully, it doesn't matter why medical students don't want to go into family practice: less money, no glamor, boredom (I have heard this from many residents/medical students), and more paperwork. An old study by UCSF said students complained about "insufficient prestige and low intellectual content". Whatever: they are all personal and therefore valid reasons. Some want to call it greed. I think that is too strong. Why is it wrong to want to make more money? Having said that, it doesn't matter why...it just matters that medical students overwhelmingly don't want to be PCPs (some figures state that only about 15 percent of medical students matched to family practice residency) , and a significant number of PCPs don't want to remain in practice (in fact a significant percentage either transition into a specialty, leave practice or retire early). Again, it doesn't matter why.
I completely agree with a previous poster on this point: If physicians don't want to be PCPs then move the hell out of the way! Even though I am the first to say lets tweak NP training and increase the rigor, I am also the first say that there is NO doubt that NPs can be PCPs. How do I know this? Because NPs are already doing it! Right now...today! It has been suggested that the studies that indicate similar outcomes are flawed. Fine. Then where are the studies to the contrary?
With so many open family practice residencies (around 40 percent by some studies) how about using some of that guv'mint money to fund NP "residencies" in family practice? Imagine the skills a PA or NP could obtain working in a paid residency for several years?
This is the time where physician assistants and nurse practitioners are poised to fill the need of primary care. As more and more spots become available through attrition it seems to me that physicians should either get on board with, and even help during this inevitable transition, or quietly step aside.
Ivan

You're right that the fact of the matter is that med students are less likely to choose primary care. But that doesn't mean you replace physicians with lesser-trained individuals. One could make the argument that primary care is one of the most challenging and intellectual specialties due to both the breadth and depth of knowledge a PCP needs to have. So how can you think it would be a better idea to replace an attending with someone who lacks the basic science and clinical foundation that med school + residency provide? The solution is to make changes that make primary care more enticing to med students.

Also, I thought you guys had a lot of (useless) stats courses during NP/DNP training? You ought to know by now that the burden of proof is in you to provide well-designed studies with complex patients to show that your outcomes are similar to those of attendings. It's not up to others to prove that you're unsafe. You guys make this claim so often but I would think they'd teach at least this basic principle in one of those stats classes. Or are you all conveniently "forgetting" that? I say complex patients because an "easy" patient is, well, pretty easy to treat. You can get a high school student to follow an algorithm and treat an "easy" patient. Where are the studies that show NP/DNP outcomes are similar to those of attendings when treating complex patients? Where are the studies that compare how often midlevels miss zebras in comparison to attendings? There's no way you could've learned the same amount of pathophys as someone who goes through med school and residency does. I've shown this in previous threads where I compared curricula.

And what do you mean by residencies for NPs/DNPs? Something separate from medical residencies? Or do you mean you want to enter a medical residency without going through medical school? If it's the former, is the residency going to as fluffy as the current NP/DNP curriculum is? A few hundred more hours or something like that? Or will it be as rigorous as an actual residency (ie. 80+ hour work-week, strong didactics, regular in-service exams, etc)? If you meant for NPs/DNPs to enter medical residencies, why should you get to skip all of medical school? You wouldn't have the basic science and clinical foundation that a graduating medical student will have to perform well in a medical residency.

I do agree with you on one thing though. There need to be changes made to the current NP/DNP curriculum. Too many nursing theory/activism, research-related, etc courses and not enough phys/pathophys. I would hope the nursing community focuses on this before pushing for even more independence.

dgenthusiast · Feb 5, 2010

"the reasons why fewer students are choosing primary are fairly clear, says dr. marc berliant, chief of the urmc's general medicine division....foremost is salary. primary-care doctors are paid significantly lower salaries than specialists. starting salaries range from $100,000 to $120,000, while more experienced doctors earn between $140,000 and $160,000. it's hard to crack $200,000. but $200,000 is a starting point for some specialists. and depending on their area of expertise, many will go on to earn much more. road (radiology, obstetrics, anesthesiology, and dermatology) has become industry shorthand for big money.
http://www.rochestercitynewspaper.com/news/articles/2009/12/state-of-emergency-the-disappearing-primary-care-doctor/
"one big reason fewer medical students are specializing in primary care is pure and simple economics."
http://www.smartmoney.com/spending/rip-offs/10-things-your-primary-care-physician-wont-tell-you-22190/
"pcps typically earn two to three times less than their counterparts who go into medical subspecialties that are more procedure-based and less oriented around office visits. that's why more medical students choose to hit the road for radiology, orthopedics or ophthalmology, anesthesiology and dermatology."
http://www.marketwatch.com/story/no-easy-cure-for-doctor-shortage-2009-11-19
"general practice: new doctors avoiding most-needed, worst-paid field"
http://www.usatoday.com/news/health/2009-08-17-doctor-gp-shortage_n.htm
"the number of u.s. medical graduates going into family medicine has been falling-by more than 50 percent from 1997 to 2005-with many young doctors preferring specialties that pay better and offer more control over work hours."
http://www.msnbc.msn.com/id/15020430
"the nation's shortage of primary care physicians has been linked to a host of poor health outcomes, and a study published in the journal of the american medical association suggests that salary disparities play a major role in the shortage."
http://medicalpartnership.usg.edu/research/collaborations/addressing_the_physician_shortage/
"primary care physician shortage linked to lower income"
http://www.medpagetoday.com/publichealthpolicy/healthpolicy/10850
gee, do you see a central theme? let me know if you need more support, i only had 5 minutes to kill.

haha, are you really quoting news articles as proof that med students/physicians are greedy? wow, i don't really know what to say.

http://jama.ama-assn.org/cgi/content/full/300/10/1154

"...the items most frequently cited as somewhat or very much pushing students away from im careers were paperwork and charting in im (748, 63.6%), attractiveness of other (non-im) specialties (575, 48.8%), types of patients an internist sees (534, 45.4%), the need to bring work home as an internist (497, 42.2%), and the appeal of being a primary care physician (486, 41.3%). the item on debt, "the loans i have to repay," pushed 26.1% of students (307) away from the field."

this following one is regarding law students and debt, but it was a very well done study and shows how much of a psychological impact debt has in choosing a lower-income field:

http://www.nber.org/papers/w12282

the following is a robert graham center paper regarding what influences med student and resident choices:

http://www.graham-center.org/online/etc/medialib/graham/documents/publications/mongraphs-books/2009/rgcmo-specialty-geographic.par.0001.file.tmp/specialty-geography-compressed.pdf

"growing physician income disparities are a major driver of student behavior. it does so directly, but also

indirectly through messages about prestige, intellectual rigor, need to increase "productivity," and status.

in many academic health centers, primary care is labeled as the revenue "loss leader" rather than as a

core function or even producer of downstream revenue."

you should note that none of these studies (and you can find more if you search through pubmed) says anything about med students rejecting primary care because of greed. there are many factors involved in making this decision. as i've said in a previous post, the administrative headaches, lower prestige, dealing with troublesome patients, etc all play a major role. studies regarding the influence of debt on specialty choice have been a bit inconsistent with some suggesting that debt plays a significant role and others saying it doesn't. however, based on the studies i have read discussing the psychological impact of having a huge debt (i believe that in 2008, 1 in 4 med students graduated with over $200k in debt) it appears that debt does play a very important role in driving students towards higher paying fields. take a look at the law student article i provided, for example. so, yea, nothing about greed. there's a difference between greed (wanting to make money at all costs) and wanting to get rid of the 1000lb gorilla that is med student debt off your back.

bajasauce07 · Feb 7, 2010

"You're right that the fact of the matter is that med students are less likely to choose primary care. But that doesn't mean you replace physicians with lesser-trained individuals. One could make the argument that primary care is one of the most challenging and intellectual specialties due to both the breadth and depth of knowledge a PCP needs to have. So how can you think it would be a better idea to replace an attending with someone who lacks the basic science and clinical foundation that med school + residency provide? The solution is to make changes that make primary care more enticing to med students.
Also, I thought you guys had a lot of (useless) stats courses during NP/DNP training? You ought to know by now that the burden of proof is in you to provide well-designed studies with complex patients to show that your outcomes are similar to those of attendings. It's not up to others to prove that you're unsafe. You guys make this claim so often but I would think they'd teach at least this basic principle in one of those stats classes. Or are you all conveniently "forgetting" that? I say complex patients because an "easy" patient is, well, pretty easy to treat. You can get a high school student to follow an algorithm and treat an "easy" patient. Where are the studies that show NP/DNP outcomes are similar to those of attendings when treating complex patients? Where are the studies that compare how often midlevels miss zebras in comparison to attendings? There's no way you could've learned the same amount of pathophys as someone who goes through med school and residency does. I've shown this in previous threads where I compared curricula.
And what do you mean by residencies for NPs/DNPs? Something separate from medical residencies? Or do you mean you want to enter a medical residency without going through medical school? If it's the former, is the residency going to as fluffy as the current NP/DNP curriculum is? A few hundred more hours or something like that? Or will it be as rigorous as an actual residency (ie. 80+ hour work-week, strong didactics, regular in-service exams, etc)? If you meant for NPs/DNPs to enter medical residencies, why should you get to skip all of medical school? You wouldn't have the basic science and clinical foundation that a graduating medical student will have to perform well in a medical residency.
I do agree with you on one thing though. There need to be changes made to the current NP/DNP curriculum. Too many nursing theory/activism, research-related, etc courses and not enough phys/pathophys. I would hope the nursing community focuses on this before pushing for even more independence"

Very well said, studies on whose diabetic patient has more proteinuria are all well and good, but, how about a study comparing the number of "zebras" missed? or even a basic medical knowledge bowl competition between an NP and an MD? If you want to practice independently you MUST understand and KNOW the pathophysiology and treatment of these diseases, what you don't know in this field will kill someone, nurse practitioners seem all too willing to throw the 1 in 100000 or perhaps even the 1 in 1000 patient with x "zebra" disease under the bus in order to continue their push for independent practice. Our roles as midlevels are to extend the reach of the physician. Each midlevel is highly individual in regards to skill and knowledge base, we truly are as good as we want to be. If you know how to treat colds and diarrhea's and titrate BP meds then excellent for you, you are not a PCP. Our role is to work under the supervision of an MD. My experience is if you have proved yourself as a midlevel then your attending physicians will trust you with more complex patient cases and responsibility, maybe they'll even ask you to operate a satellite clinic for them. But each of these things is individual based on the amount of trust your physician has in your skill set/ knowledge base.

A push by any midlevel (PA/NP) political party to gain a more independent practice than described above is Hubris, irresponsible, and a detriment to patients everywhere as well as to your own profession.

I am a PA with 2-3 years hospitalist experience, I recognize the zebras, I know a lot of medicine, I read harrison's textbook of internal medicine religiously and about 6 uptodate articles per week, for my own learning, not because I'm looking up a patient case, I don't want to miss the rare infection with a JC virus (progressive multifocal leukoencephalopathy) in my AIDS patients,

or the limited scleroderma case, or the odd T. Whippelli infection, perhaps churg-strauss, Takayasu's arteritis, kaplan synrome, DIDMOAD etc.

If you don't have any idea what these diseases are you have no business in independent practice because you WILL kill someone, and you may not ever even know it. and even if you happen to recognize them, a midlevel's training does not prepare them for independent practice, our role is still support of the physician. Because I recognize these things, and more importantly, I recognize when I'm over my head I am allowed an amazing degree of autonomy. I love medicine, but the final degree for independent practice is MEDICAL SCHOOL. Don't fool yourselves into thinking otherwise because you know how to prescribe azithromycin for a viral bronchits. This is a word of warning to BOTH NP's AND PA's, it just happens to be on a nursing thread.

To DGenthusiast: It sounds like you are an MD. I've always wondered what MD's think about PA training. I hear a lot of things from MD's who are upset with the NP's push for independence about their training, but not much about the feelings of MD's for PA's in general. Personally I'm very proud of the PA model of education since it is based off of the medical model, any thoughts?

ivanh3 · Feb 7, 2010

You're right that the fact of the matter is that med students are less likely to choose primary care. But that doesn't mean you replace physicians with lesser-trained individuals. One could make the argument that primary care is one of the most challenging and intellectual specialties due to both the breadth and depth of knowledge a PCP needs to have.

One could argue that, but apparently that is not the consensus of medical students and residents as they consider primary care to be a discipline of "low intellectual content". Here is the deal: it is completely irresponsible to proclaim that only MDs can be PCPs, and then walk away from that specialty as a profession. It is actually beneath contempt.

Also, I thought you guys had a lot of (useless) stats courses during NP/DNP training? You ought to know by now that the burden of proof is in you to provide well-designed studies with complex patients to show that your outcomes are similar to those of attendings. It's not up to others to prove that you're unsafe. You guys make this claim so often but I would think they'd teach at least this basic principle in one of those stats classes. Or are you all conveniently "forgetting" that? I say complex patients because an "easy" patient is, well, pretty easy to treat. You can get a high school student to follow an algorithm and treat an "easy" patient. Where are the studies that show NP/DNP outcomes are similar to those of attendings when treating complex patients? Where are the studies that compare how often midlevels miss zebras in comparison to attendings? There's no way you could've learned the same amount of pathophys as someone who goes through med school and residency does. I've shown this in previous threads where I compared curricula.

I am not forgetting anything, and in one case you are dead wrong. If you are saying that a group of individuals can not perform a certain function then most assuredly you have the responsibility to back that up. Cite it. Plain and simple. You and I have discussed the current studies that indicate comparable outcomes. You don't think they stand close scrutiny. Fine, but the ball is in your court to demonstrate otherwise.

And what do you mean by residencies for NPs/DNPs? Something separate from medical residencies? Or do you mean you want to enter a medical residency without going through medical school? If it's the former, is the residency going to as fluffy as the current NP/DNP curriculum is? A few hundred more hours or something like that? Or will it be as rigorous as an actual residency (ie. 80+ hour work-week, strong didactics, regular in-service exams, etc)? If you meant for NPs/DNPs to enter medical residencies, why should you get to skip all of medical school? You wouldn't have the basic science and clinical foundation that a graduating medical student will have to perform well in a medical residency.

Wow, that is pretty snide, and indicates a lack of breadth of knowledge/experience on your part. First of all, I do mean a separate residency, but essentially they would be very similar. What exact training did you receive that NPs don't that would cause an NP to be unsuccessful? Because, brother, I have worked side by side with both residents and medical students FOR YEARS, and I don't get your point. When I see that med student or resident get that "1000 yard" stare over some of the most basic of concepts, I become puzzled by statements like yours. When I see a med student/resident slip up, I don't slap my head and say, "idiot". I understand that they are bright people who are new, learning their craft, and have much to offer. I just recently had to explain to a resident that the probable reason a certain drug level was toxicly high in a patient was due to a CYP 450 3A4 conflict. Something I learned, you guessed it, in NP training. The resident informed me that, "further research was required". Read: run over and Google it. Again, the resident was not stupid. I know this person to be bright, but there was a learning moment, and we both benefited from it (as did the patient).

Lets be clear: NPs are PCPs. Right now. Today. They are successful. They are competent. They have good patient outcomes, and YES, YES, YES, they manage complex patients. Were they like that right out of school? Newp. And they don't have to be. That is what experience is for. Often the practice is to work under and then with a physician. That is our current "residency". And we do understand the whys and the hows. It is extremely arrogant and snotty to suggest that NPs could only follow algorithms, and that we could not possibly have synthesis of the material at hand. That some how, we have no pathophys, and can only manage AOM and the like.

I do agree with you on one thing though. There need to be changes made to the current NP/DNP curriculum. Too many nursing theory/activism, research-related, etc courses and not enough phys/pathophys. I would hope the nursing community focuses on this before pushing for even more independence.

Changes are being made. This, like most medical fields, are in a constant state of change. But please remember this: before you get all hot n bothered to change the nursing industry, maybe you should take a good look at your own. How much of your course work is relevant to patient care? How much of physician training is based on "tradition" as opposed to evidenced based practice? Algebra based physics? Really? You use that much at the bedside?

To tie this in to the OP, I do believe that all training can be improved. I would like to see some more hard sciences in the classroom for NPs, and that NP training could use a bit more "medical" influence. But having just graduated from NP training I can say this: I do feel prepared to be a novice NP. I know that this is just the beginning of my learning. I will be curious to revisit this topic in a number of years to share my input.

ivanh3 · Feb 7, 2010

Very well said, studies on whose diabetic patient has more proteinuria are all well and good, but, how about a study comparing the number of "zebras" missed? or even a basic medical knowledge bowl competition between an NP and an MD? If you want to practice independently you MUST understand and KNOW the pathophysiology and treatment of these diseases, what you don't know in this field will kill someone, nurse practitioners seem all too willing to throw the 1 in 100000 or perhaps even the 1 in 1000 patient with x "zebra" disease under the bus in order to continue their push for independent practice.

I must have missed the throw the patient under the bus intervention deal at school. What a silly thing to say. I have never met an NP, PA, or MD that was willing to sacrifice a patient for personal gain. Are they out there? Sure, but please don't try to implicate any one profession with something like that. It is an unsubstantiated statement. I don't think anyone thinks an NP learns more in school than an MD. However, there is a question as to whether and NP learns enough in school to begin entry level practice. I say we do. That is not to say I don't want to improve the training.

Our roles as midlevels are to extend the reach of the physician. Each midlevel is highly individual in regards to skill and knowledge base, we truly are as good as we want to be. If you know how to treat colds and diarrhea's and titrate BP meds then excellent for you, you are not a PCP.

You are over simplifying the issue so I won't respond to your diarrhea. However, it is a simple uncontested fact: NPs are PCPs. Where are you getting that they are not? And please don't come back with "Well technically they are..." because that would just be lame. NPs are PCPs. Get over it.

Our role is to work under the supervision of an MD. My experience is if you have proved yourself as a midlevel then your attending physicians will trust you with more complex patient cases and responsibility, maybe they'll even ask you to operate a satellite clinic for them. But each of these things is individual based on the amount of trust your physician has in your skill set/ knowledge base.
A push by any midlevel (PA/NP) political party to gain a more independent practice than described above is Hubris, irresponsible, and a detriment to patients everywhere as well as to your own profession.

How so as long as it is done responsibly? I agree with your scenario: NPs/PAs obtain more trust as they prove themselves. I have no problem with that. I have no problem working under a physician, but don't poo poo the efforts of others to advance your profession because right now you are enjoying some of those advancements in your own practice whether you lifted a finger to help that or not.

I am a PA with 2-3 years hospitalist experience, I recognize the zebras, I know a lot of medicine, I read harrison's textbook of internal medicine religiously and about 6 uptodate articles per week, for my own learning, not because I'm looking up a patient case, I don't want to miss the rare infection with a JC virus (progressive multifocal leukoencephalopathy) in my AIDS patients,
or the limited scleroderma case, or the odd T. Whippelli infection, perhaps churg-strauss, Takayasu's arteritis, kaplan synrome, DIDMOAD etc.
If you don't have any idea what these diseases are you have no business in independent practice because you WILL kill someone, and you may not ever even know it. and even if you happen to recognize them, a midlevel's training does not prepare them for independent practice, our role is still support of the physician.

Nice little way to show what you got. Kudos to you and your accomplishments. Let me ask you this: Do all MDs have mastery over those topics? Let me answer that one for you: NO THEY DO NOT. That is why people specialize. Do you know one of the most important parts of clinical practice? Knowing when to turf out a patient. Here is the irony in your statement. You probably know more than some MDs do about your specialty. Your are part of a team that other physicians, PAs, and NPs send patients to because they don't know as much about it as you do. But those MDs all went to medical school right? Again, they know when to refer.

Because I recognize these things, and more importantly, I recognize when I'm over my head I am allowed an amazing degree of autonomy. I love medicine, but the final degree for independent practice is MEDICAL SCHOOL. Don't fool yourselves into thinking otherwise because you know how to prescribe azithromycin for a viral bronchits. This is a word of warning to BOTH NP's AND PA's, it just happens to be on a nursing thread.

Again, wrong. Like it or not, in some states NPs can practice independently. That's not my rule. That is just how it is. You keep bringing these diarrhea like examples "z-pack for viral bronchitis". Is that just you being funny? Or do you fail to recognize that many NPs manage and treat complex patients? Does that mean NPs don't refer? Newp, cause at some point some patient become too complicated no matter who you are. It sounds like you have some experience under you belt (when you are not running off about diarrhea). Have you spent any time recently around new PAs, NPs, or residents? Didn't you feel like you had something to teach them? Don't you think that means something? Man, I work with some PAs that are sharp. They could definitely school some residents (and NPs). Once again, the question is do NPs receive sufficient training to be entry level providers. I say they do, and let the patient outcomes speak for themselves. I don't want to be a neurosurgeon. I want to be a competent primary care provider. It will take me years to move from novice to expert, but it will happen. I am sure somewhere along the way I will learn about your churg-ey/Takayasu do-hicky.

dgenthusiast · Feb 9, 2010

One could argue that, but apparently that is not the consensus of medical students and residents as they consider primary care to be a discipline of "low intellectual content". Here is the deal: it is completely irresponsible to proclaim that only MDs can be PCPs, and then walk away from that specialty as a profession. It is actually beneath contempt.

Seeing a specialty as unappealing is beneath contempt? What about all the bedside nurses leaving the bedside to pursue advanced practice? Is that beneath contempt as well? The problem is that primary care has been becoming less and less appealing. Did you know that primary care used to be one of the most competitive specialties to get into and that the superstars in med school went into it? Then, continually decreasing reimbursements, increased paperwork, etc hit and slowly smothered it down into a field that most med students don't find appealing. It's completely irresponsible to suggest that because one group doesn't find a challenging specialty appealing, the solution is to replace them with significantly lesser trained individuals. That's not the solution. There need to be more incentives in primary care to get med students to notice it and enter into it. That's how you fix the primary care problem, not by replacing physicians with NPs/DNPs.

I am not forgetting anything, and in one case you are dead wrong. If you are saying that a group of individuals can not perform a certain function then most assuredly you have the responsibility to back that up. Cite it. Plain and simple. You and I have discussed the current studies that indicate comparable outcomes. You don't think they stand close scrutiny. Fine, but the ball is in your court to demonstrate otherwise.

Once again, I'm concerned about what your stats courses are teaching you. The burden of proof is on you (the one making the claim that you are safe) to produce valid data suggesting you are right. Let's say the experimental hypothesis is that NPs/DNPs have similar outcomes as board certified physicians. The null hypothesis would negate this. In this case, the null hypothesis would be that NPs/DNPs do NOT have similar outcomes as physicians. Now, the rules of science dictate that scientists must assume that the null hypothesis holds true until research contradicts it. You already know of my view regarding the studies out there: they're heavily biased (ie. authored by Mundinger et al) or significantly flawed in design. Pretending that the studies with very biased investigators are accurate is just like saying you'd believe a study coming out from a pharmaceutical company praising its newest drug after it spent millions on research and development.

If it helps, here's another example on how the burden of proof is on you, the claimant, to provide valid studies showing that NPs/DNPs provide similar levels of care as BC physicians, manage complex patients just as well, etc:

I say that the Flying Spaghetti Monster, though invisible, rules us all and secretly controls every action we make. I'll provide a flawed study about a dream I had that proves this is true. Now, if you can't prove otherwise (and it's pretty much impossible for you to prove otherwise), I am correct in saying the Flying Spaghetti Monster is real. Does this makes sense to you? No? Well, replace 'Flying Spaghetti Monster' with 'NPs/DNPs' and 'ruling us all' with 'provide similar outcomes as physcians' and you're making that same argument.

Wow, that is pretty snide, and indicates a lack of breadth of knowledge/experience on your part. First of all, I do mean a separate residency, but essentially they would be very similar. What exact training did you receive that NPs don't that would cause an NP to be unsuccessful? Because, brother, I have worked side by side with both residents and medical students FOR YEARS, and I don't get your point. When I see that med student or resident get that "1000 yard" stare over some of the most basic of concepts, I become puzzled by statements like yours. When I see a med student/resident slip up, I don't slap my head and say, "idiot". I understand that they are bright people who are new, learning their craft, and have much to offer. I just recently had to explain to a resident that the probable reason a certain drug level was toxicly high in a patient was due to a CYP 450 3A4 conflict. Something I learned, you guessed it, in NP training. The resident informed me that, "further research was required". Read: run over and Google it. Again, the resident was not stupid. I know this person to be bright, but there was a learning moment, and we both benefited from it (as did the patient).

Why would you need a separate but very similar residency? I hope you realize that you need that basic science foundation learned in medical school to do well in a rigorous residency. And as I've shown multiple times and as I'm sure you realize, the basic science foundation gained from NP/DNP training nowhere close to the same level as what you'd get from med school. How can you expect to do well in a residency equivalent to a medical residency when you don't have that huge knowledge fund to reach into? This is not a snide comment. It's a valid question. The training that physicians receive that NPs/DNPs don't is 2 hard years of solid basic science (including a significant amount of pathophys...not just 5 credits worth), 2 years of clinical training (M3 and M4) where they accumulate thousands of hours of clinical training, and a rigorous residency that's, at a minimum, 3 years long amounting to more than 15000 hours of clinical training. That's what physicians have that NPs/DNPs don't. Hope I answered that question. I'm sure you'll come back at me by saying that you have nursing experience, but I'd like to remind you that nursing experience =/= medical experience.

I also don't get why you provided an example of a resident being confused about a concept; they're still in training, in case you hadn't realized. They're not expected to know as much as attendings. Generally, the medical training model is rigorous enough and has enough checks and balances in place that the vast majority of physicians are very competent at what they do. In addition, going with you example of a confused resident, if the resident with his/her basic science foundation and clinical training couldn't understand something properly, how much more trouble would someone with significantly lesser amount of training have? I'd like to hear your view on this.

Lets be clear: NPs are PCPs. Right now. Today. They are successful. They are competent. They have good patient outcomes, and YES, YES, YES, they manage complex patients.

NPs are PCPs? According to whom? Your view that they have good patient outcomes is based on flawed studies (for example, studies using patient satisfaction, which has nothing to do with medical care but probably everything to do with how "nice" the provider was, as a measure of patient outcomes), so you can't definitely say they're doing a good job. If you can cite any studies looking at midlevels managing complex patients, I'd be happy to look at them since a PubMed search didn't really return any to me (maybe I typed in the wrong keywords?). The only study I came across said that midlevels were significantly less likely than physicians to change BP treatment for diabetic patients with multiple chronic conditions presenting with elevated BP at a single visit. I haven't had a chance to read it beyond the abstract so I can't say whether it is flawed or not, but I'll get to it as soon as I can.

Were they like that right out of school? Newp. And they don't have to be. That is what experience is for. Often the practice is to work under and then with a physician. That is our current "residency". And we do understand the whys and the hows. It is extremely arrogant and snotty to suggest that NPs could only follow algorithms, and that we could not possibly have synthesis of the material at hand. That some how, we have no pathophys, and can only manage AOM and the like.

I don't think it's "extremely arrogant" to suggest that NPs/DNPs don't have the same fund of knowledge as an attending. You guys get a significantly lesser amount of pathophys training than physicians do (look at my previous post history if you want to look at a comparison between NP/DNP and MD/DO curricula). Surely you're not suggesting that you're cramming 162.5 credits worth of pathophys (from UMich med school, for example) into 4 credits (from the University of Arizona, for exampe...also this class is for both physio and pathophys, not even just pathophys)? It's not arrogant to assume that someone with lesser training will have a smaller knowledge fund than the one with the highest authority in the field (ie. attending physicians).

Changes are being made. This, like most medical fields, are in a constant state of change. But please remember this: before you get all hot n bothered to change the nursing industry, maybe you should take a good look at your own. How much of your course work is relevant to patient care? How much of physician training is based on "tradition" as opposed to evidenced based practice? Algebra based physics? Really? You use that much at the bedside?

Uh, what medical school teaches algebra-based physics?! You're confusing prereqs (those things you have to take before med school) with actual med school courses. So no, there's no algebra-based physics class in med school. However, I want to point out that physics is used pretty extensively in medicine: the cardiovascular system can be though of in terms of circuits/E&M, hemodynamics is fluid dynamics (ie. Bernoulli's, etc), respiratory involves gas exchange, etc. So, even as a prereq, alegbra-based physics is pretty damn useful I'd say. In case you plan on attacking chemistry (another prereq) next, acid-base chemistry is pretty extensively used in the clinic and I'm sure one can make the case for kinetics in pharmacology.

I will agree with you that some prereqs for med school are out of date. I, for one, support replacing one semester of orgo with one semester of biochem instead. But comparing med school prereqs with actual NP/DNP courses is kind of silly, because you're comparing apples to oranges. You shouldn't have all that theory/activism/research-oriented courses in what is touted to be a clinical degree.

But you're wrong about how much of medical training (you know, the training that starts after you begin medical school) is only based on tradition and not useful. Some parts of it could be streamlined a bit, but overall, medical education is right on the money about how much it teaches and how rigorous it is.

To tie this in to the OP, I do believe that all training can be improved. I would like to see some more hard sciences in the classroom for NPs, and that NP training could use a bit more "medical" influence. But having just graduated from NP training I can say this: I do feel prepared to be a novice NP. I know that this is just the beginning of my learning. I will be curious to revisit this topic in a number of years to share my input.

This is really the only point of your post I agree with. Improved training would be great! I'd like to see NP/DNP curricula with more pathophys and less nursing theory/activism.

ivanh3 · Feb 9, 2010

Seeing a specialty as unappealing is beneath contempt? What about all the bedside nurses leaving the bedside to pursue advanced practice? Is that beneath contempt as well? The problem is that primary care has been becoming less and less appealing. Did you know that primary care used to be one of the most competitive specialties to get into and that the superstars in med school went into it? Then, continually decreasing reimbursements, increased paperwork, etc hit and slowly smothered it down into a field that most med students don't find appealing. It's completely irresponsible to suggest that because one group doesn't find a challenging specialty appealing, the solution is to replace them with significantly lesser trained individuals. That's not the solution. There need to be more incentives in primary care to get med students to notice it and enter into it. That's how you fix the primary care problem, not by replacing physicians with NPs/DNPs.

I will say that adding incentives to get more primary care residents is a great idea. I think that is part of the solution. We need more primary care physicians. I have never said otherwise meaning I never said replace physicians, but rather augment them: team approach, collaboration, referrals. Just like MDs do all day long.

Once again, I'm concerned about what your stats courses are teaching you. The burden of proof is on you (the one making the claim that you are safe) to produce valid data suggesting you are right. Let's say the experimental hypothesis is that NPs/DNPs have similar outcomes as board certified physicians. The null hypothesis would negate this. In this case, the null hypothesis would be that NPs/DNPs do NOT have similar outcomes as physicians. Now, the rules of science dictate that scientists must assume that the null hypothesis holds true until research contradicts it.

Somebody (maybe me) needs to go back and review what a "null hypothesis" is. A null hypothesis is either rejected or not rejected. A null hypothesis does not prove or disprove anything. I am not sure how to apply a null hypothesis here because a null hypothesis states that two groups are similar/the same until proven otherwise or that no relationship exists. You would then apply significance testing to reject/not reject.

If it helps, here's another example on how the burden of proof is on you, the claimant, to provide valid studies showing that NPs/DNPs provide similar levels of care as BC physicians, manage complex patients just as well, etc:
I say that the Flying Spaghetti Monster, though invisible, rules us all and secretly controls every action we make. I'll provide a flawed study about a dream I had that proves this is true. Now, if you can't prove otherwise (and it's pretty much impossible for you to prove otherwise), I am correct in saying the Flying Spaghetti Monster is real. Does this makes sense to you? No? Well, replace 'Flying Spaghetti Monster' with 'NPs/DNPs' and 'ruling us all' with 'provide similar outcomes as physcians' and you're making that same argument.

Your example is not appropriate because your original premise can not be demonstrated by any reasonable means at all. On the other hand, patient outcomes can be reasonably studied both quantitatively and qualitatively. The results can often be recreated or observed by third parties. If you have problems with a certain study because you think there is bias, then that is one thing, but to compare that study to the "invisible spaghetti monster" just does not hold any water.

Why would you need a separate but very similar residency? I hope you realize that you need that basic science foundation learned in medical school to do well in a rigorous residency. And as I've shown multiple times and as I'm sure you realize, the basic science foundation gained from NP/DNP training nowhere close to the same level as what you'd get from med school. How can you expect to do well in a residency equivalent to a medical residency when you don't have that huge knowledge fund to reach into? This is not a snide comment. It's a valid question. The training that physicians receive that NPs/DNPs don't is 2 hard years of solid basic science (including a significant amount of pathophys...not just 5 credits worth), 2 years of clinical training (M3 and M4) where they accumulate thousands of hours of clinical training, and a rigorous residency that's, at a minimum, 3 years long amounting to more than 15000 hours of clinical training. That's what physicians have that NPs/DNPs don't. Hope I answered that question. I'm sure you'll come back at me by saying that you have nursing experience, but I'd like to remind you that nursing experience =/= medical experience.

Here, I will have to get a little anecdotal on you. I can expect that I could do well in a resident-ish type scenario based on my personal experiences of successfully making it through my NP clinicals. I was able to successfully diagnose/manage/treat a multitude of illnesses across the lifespan. Males and females. Wellness and illness. For some of the more complex patients I sought guidance from my preceptors (an MD, a DNP, and a PNP). I learned and applied that guidance to future patient encounters. In other words there was growth. During my entire clinicals never once was I not allowed to participate in patient care because the patient was deemed too complex. Believe it or not, although I didn't always have mastery over the subject matter, I was able to understand all of the subsequent explanations. Largely, this was because of my training and because I had great preceptors. So apply this over a period of several years either in a formal "residency" or from learning on the job (very likely under the supervision of physician) and it makes perfect sense to me that my skills and patient outcomes would be favorable to those of a physician. Again, through the use of collaboration, referrals, and teamwork. Just like a physician does.

I also don't get why you provided an example of a resident being confused about a concept; they're still in training, in case you hadn't realized. They're not expected to know as much as attendings. Generally, the medical training model is rigorous enough and has enough checks and balances in place that the vast majority of physicians are very competent at what they do. In addition, going with you example of a confused resident, if the resident with his/her basic science foundation and clinical training couldn't understand something properly, how much more trouble would someone with significantly lesser amount of training have? I'd like to hear your view on this.

Maybe you didn't read what I said. On this particular instance the resident didn't know as much as I did, much less the attending. How could that possibly be under your premise? Again, guess what, that resident knows now. Probably knew before (CYP 450 3a4 issues are common), but I (not an attending) pointed that out. I am new (as an NP) so is the resident, but I did know. Are there other areas where I might get spanked? Sure. But how about this scenario: I eventually get 3-4 years full time experience in a learning environment. The PGY-1 shows up, how do you think we would compare?

NPs are PCPs? According to whom?

According to insurance companies, hospitals, clinics, state/federal government, and here is the big one: the patients that go to them. Are you really asking that? NPs own and operate there own practices. They can be and are PCPs. That really is a fact that is not open for debate. It just is a fact. I really don't know how to respond past that.

Your view that they have good patient outcomes is based on flawed studies (for example, studies using patient satisfaction, which has nothing to do with medical care but probably everything to do with how "nice" the provider was, as a measure of patient outcomes), so you can't definitely say they're doing a good job. If you can cite any studies looking at midlevels managing complex patients, I'd be happy to look at them since a PubMed search didn't really return any to me (maybe I typed in the wrong keywords?). The only study I came across said that midlevels were significantly less likely than physicians to change BP treatment for diabetic patients with multiple chronic conditions presenting with elevated BP at a single visit. I haven't had a chance to read it beyond the abstract so I can't say whether it is flawed or not, but I'll get to it as soon as I can.

Now look, you want to say that a study is flawed. I can meet you halfway on that. I, too, would love to see more studies that are well designed, and conducted by both MDs and NPs. Really. But often, where there is smoke there is fire, and I will say this. You have not yet demonstrated that the studies were completely erroneous (you really have not demonstrated that they were even partially erroneous). You have your doubts. I think it is valid to have those doubts which is why I would love for there to be more studies.

I don't think it's "extremely arrogant" to suggest that NPs/DNPs don't have the same fund of knowledge as an attending. You guys get a significantly lesser amount of pathophys training than physicians do (look at my previous post history if you want to look at a comparison between NP/DNP and MD/DO curricula). Surely you're not suggesting that you're cramming 162.5 credits worth of pathophys (from UMich med school, for example) into 4 credits (from the University of Arizona, for exampe...also this class is for both physio and pathophys, not even just pathophys)? It's not arrogant to assume that someone with lesser training will have a smaller knowledge fund than the one with the highest authority in the field (ie. attending physicians).

I have already posted that I think that MDs receive far more training/education than NPs. That is not in question. The question, still, is whether NPs have enough training to perform as PCPs. I say yes, because, again, NPs are PCPs. They manage sick, complex patients in a large variety of settings. As you and I have discussed before, how much of that training do MDs retain outside of their specialty the farther they get from graduation? That is the whole point of specializing. I mean, I hear you about the training, but what matters just as much, if not more, is experience. That is where the rubber hits the road.