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

wowza · Feb 10, 2010

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.

Sorry I think it is you who needs to go back and review the null hypothesis because DG was right on the money.

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.

First, May his noodly appendage touch you.

Second, He used hyperbole to show how your assertion needs to be proved first, before it can be taken as true. In science you cannot just say something is true and make the opposing side prove it false. Instead, you must show that it is true. That is the entire idea of the null hypothesis and how things are proven in science.

In other words there was growth [During my clinicals]
So apply this over a period of several years either in a formal "residency" or from learning on the job ... and it makes perfect sense to me that my skills and patient outcomes would be favorable to those of a physician.

I don't disagree that experience counts, however, you need the correct foundation to build upon it. Using your argument, an NP with 20 years experience should have the same knowledge base as an attending. That is definitely not the case as I have seen over and over again.

Does an intern know everything... definitely not. And even an experienced NP looks like a superstar next to him in the beginning. Yet, in those 3 years that it takes for the IM intern to become an attending, it becomes obvious who the leader of the team is. Were your premise correct, the experienced NP should not get leapfrogged in clinical acumen like that.

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.

There have been instances during medical school when I have known a tidbit of information and the attending didn't. I am far from an attending and would never assume that those few instances meant that I knew more than the attending. That would show hubris and a lack of maturity.

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 have posted on this before so I will just copy and paste:

With regard to the study in JAMA where patients who first presented with Asthma, Diabetes or HTN went to either an NP or GP:

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

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

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

The study:

Nurse practitioners substituting for general practitioners: randomized controlled trial.

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

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

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

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

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

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

Finally, as to the request for articles that show NPs provide inferior care... The issue is that there are no adequate studies saying one way or another. As it stands now, only the nursing community is putting out articles which means there are not a lot of articles out there and those that are out there have some design flaws and biases that need to be addressed. These 2 things alone make the studies worthless. Do NPs provide inferior care in the uncomplicated general patient- i doubt it. Is the care the same between NPs and GPs for complex patients- probably not.

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.

That NPs are considered competent by the gov't (a function of lobbying) or the insurance companies (a function of lobbying) or by their patients (who do not have enough knowledge to make such a decision) does not mean they are competent.

In terms of retaining information, let's take a Cardiologist for instance. To remain boarded in internal medicine and cardiology they have to not only take the cardiology boards every 10 years but also the internal medicine boards every 10 years. Since internal medicine is EVERYTHING... I would say they retain a good amt.

NurseKJ · Feb 10, 2010

actually, Ivan is right about the null hypothesis. I think you should check a stats or research text...

"One may either reject or not reject the null hypothesis."

dgenthusiast · Feb 10, 2010

actually, Ivan is right about the null hypothesis. I think you should check a stats or research text...
"One may either reject or not reject the null hypothesis."

Yea you either reject or fail to reject the null hypothesis. However, it was Ivan who mentioned something about proving/accepting the null hypothesis, not me. I was absolutely correct in what I said. Look at what I actually wrote before jumping to conclusions about who's right or wrong.

The reason wowza said Ivan was wrong was because Ivan keeps asking for physicians to show that NPs/DNPs are not safe. That's not how the null/experimental hypotheses work. And that's not how science works. This suggests that Ivan doesn't fully understand the concept of experimental/null hypothses. Wowza wasn't pointing out that the definition was wrong. Just knowing the definition of a word is not enough. You need to understand the concept. Hope this clarifies things.

I'll post more later when I get home.

NurseKJ · Feb 10, 2010

DG,

I'm just wondering... are you a physician? Are you pro-nurse practitioners, just not pro- independent practice for nurse practitioners?

-KJ

dgenthusiast · Feb 10, 2010

DG,
I'm just wondering... are you a physician? Are you pro-nurse practitioners, just not pro- independent practice for nurse practitioners?
-KJ

Nope, not a physician. And yea, I'm pro-NP. I'm just against this push for independence.

bajasauce07 · Feb 10, 2010

To Ivan:

You replied to an earlier post of mine and I never got back to you. I won't bother quoting the post, I'll just reply briefly as WOWZA has already stated most of what I would say.

As far as my whether or not NP's are PCP's you are right, I should have specified, all midlevels are PCP's, the question is whether or not NP's are knowledgeable enough to provide SOLO care. you refer to collaboration, but you insinuate this will be done by referrals to MD's, not by immediate physician oversight. This is the crux of the issue. you say that you will learn all these disorders over the years, thing is how many patients are you willing to throw under the bus before you catch one that makes you realize "oh, I should have been referring these types of patients earlier." A physician's training is rigorous enough that they are familiar with most disorders out the door. An NP/PA does not. Hubris and any NP trying to start a solo PCP practice will sacrifice patient outcomes to have the pride of "being the boss". If you want to be the boss in this field, go to med school. Otherwise practice in "collaboration" with MD's, not in place of, with them as referral centers.

As far as whether or not there are midlevels out there that know more than attendings? I doubt it, I will say that there have been more times than I thought there would be where I remembered a differential diagnosis/ syndrome than my attending, however, do I know more? highly unlikely, the depth of training and experience in managing X diagnosis in the presence of "Y" complication requires experience. Yes, all of us "PCP's" will garner experience over the years but as WOWZA said

"I could design a study and I gaurantee you a 3rd year medical student could do this just as well as a doctor would. A 3rd year is not a doctor as one member of this board has commented."

Even if I could never prove to you that an NP with 20 years experience doesn't deserve to be an attending in place of a new grad doctor, I just don't understand the mentality of "oh I have 20 years experience in primary care, I should practice independently"

Not to be too sarcastic but I honestly believe this is the same thing as a secretary at a fortune 500 company with 20 years experience wanting to become CEO. or perhaps a legal clerk saying "I'm going to open my own law firm" just because they've been exposed to the profession, and could MAYBE do the job adequately, doesn't mean they get to be grandfathered into being a lawyer, they still have to go to law school and obtain a license to practice independently, because that is quality control, if you want to practice law, prove you can through the board that is established to control those things. If things weren't this way any hack off the street could become a lawyer, and while a select few may do a good job, the vast majority will screw people over or as I put it earlier "throw their clients under the bus"

I swear, is it only in medicine that this discussion needs to take place?

And yes I was using hyperbole to prove a point with the diarrhea and bronchitis thing, but it's not too far from the truth...

ivanh3 · Feb 11, 2010

Yea you either reject or fail to reject the null hypothesis. However, it was Ivan who mentioned something about proving/accepting the null hypothesis, not me. I was absolutely correct in what I said. Look at what I actually wrote before jumping to conclusions about who's right or wrong.

I only mentioned that I am not sure how to apply a null hypothesis in this scenario because the two groups being compared are unrelated. In other words, I was admitting my occasional lack of prowess with stats. It's not my strong point. Sue me.

The reason wowza said Ivan was wrong was because Ivan keeps asking for physicians to show that NPs/DNPs are not safe. That's not how the null/experimental hypotheses work. And that's not how science works. This suggests that Ivan doesn't fully understand the concept of experimental/null hypothses. Wowza wasn't pointing out that the definition was wrong. Just knowing the definition of a word is not enough. You need to understand the concept. Hope this clarifies things.

No, here is how science works. Hope this clarifies things for you. One makes a claim and presents their case. There are only a small handful of studies of any size that pertain here. You (and and others here) do not think highly of these studies. This is despite the fact that they were performed by a collaboration of NPs, MDs (4 in the case of the 2000 Mundinger et al. study), and various PhDs. The Mundinger et al. study was then peer reviewed and published in a respected journal. Apparently however, this study does not meet or exceed your expectations. In other words you as a medical student (or are you resident now? If so then congrats..really) have deemed that your background gives you the clout to say the study was flawed. Okay, I will meet you there. You and your cohorts here think the Mundinger study was flawed. You may be right. However, I think it is entirely reasonable to think that study was essentially valid for reasons I have mentioned already. Because I (and others) think the study does have merit, we think that the ball is in your court to demonstrate other wise. It is not reasonable to stand there and say that you don't accept the rigor of study so you will wait patiently while somebody puts together a study that will suit you. So my question to you is this: what exactly do you not like about the Mundinger et al. study?

To Ivan:
You replied to an earlier post of mine and I never got back to you. I won't bother quoting the post, I'll just reply briefly as WOWZA has already stated most of what I would say.
As far as my whether or not NP's are PCP's you are right, I should have specified, all midlevels are PCP's, the question is whether or not NP's are knowledgeable enough to provide SOLO care. you refer to collaboration, but you insinuate this will be done by referrals to MD's, not by immediate physician oversight. This is the crux of the issue. you say that you will learn all these disorders over the years, thing is how many patients are you willing to throw under the bus before you catch one that makes you realize "oh, I should have been referring these types of patients earlier." A physician's training is rigorous enough that they are familiar with most disorders out the door. An NP/PA does not. Hubris and any NP trying to start a solo PCP practice will sacrifice patient outcomes to have the pride of "being the boss". If you want to be the boss in this field, go to med school. Otherwise practice in "collaboration" with MD's, not in place of, with them as referral centers.

First, you are wrong yet again. All NPs/PAs are not PCPs. Many work in specialty care. You gotta watch those "all/none" statements. In regards to your query can NPs provide care solo, that is easy. The answer is NO. But then neither can an MD. Again, that is just plain fact. I really don't know how to proceed from here. Everyone needs to refer/collaborate at some point. I see MDs within the same specialty confer with each other all the time. Why should the expectation be any different for NPs? And no, no one provider is familiar with most disorders, uh because there are 1000s of disorders. I won't even agree with you if by "familiar" you mean having heard the name before. I do plan to work in collaboration with an MD. Just like they do.

Not to be too sarcastic but I honestly believe this is the same thing as a secretary at a fortune 500 company with 20 years experience wanting to become CEO. or perhaps a legal clerk saying "I'm going to open my own law firm" just because they've been exposed to the profession, and could MAYBE do the job adequately, doesn't mean they get to be grandfathered into being a lawyer, they still have to go to law school and obtain a license to practice independently, because that is quality control, if you want to practice law, prove you can through the board that is established to control those things. If things weren't this way any hack off the street could become a lawyer, and while a select few may do a good job, the vast majority will screw people over or as I put it earlier "throw their clients under the bus"

That is just a lame comparison, and I would think you could do better. A legal secretary? Weak. Very weak. Nobody is asking to be grandfathered in. NPs are educated, certified and licensed individuals as required by law.

Sorry I think it is you who needs to go back and review the null hypothesis because DG was right on the money.

Please go back and read the quote. Did I not indicate I was not sure? Seriously, you guys need to read the quotes you are responding too. I know some of these can get long, but if you are not going to actively read them then why participate here?

Second, He used hyperbole to show how your assertion needs to be proved first, before it can be taken as true. In science you cannot just say something is true and make the opposing side prove it false. Instead, you must show that it is true. That is the entire idea of the null hypothesis and how things are proven in science.

Well then enough of the hyperbole. If you guys can't bring anymore to this conversation than hyperbole what is the point?

I don't disagree that experience counts, however, you need the correct foundation to build upon it. Using your argument, an NP with 20 years experience should have the same knowledge base as an attending. That is definitely not the case as I have seen over and over again.

I know some NPs with 20 years and there are some practicing MDs out there who couldn't dust their boots. Having said that, what your experience is and my experience is really doesn't matter. That why we do studies.

Does an intern know everything... definitely not. And even an experienced NP looks like a superstar next to him in the beginning. Yet, in those 3 years that it takes for the IM intern to become an attending, it becomes obvious who the leader of the team is. Were your premise correct, the experienced NP should not get leapfrogged in clinical acumen like that.

First, it is not always clear. I have seen RNs step up to lead when the MD would/could not, and second, I agree about the leapfrogging. Is that not the whole point of the discussion?

I have posted on this before so I will just copy and paste:
With regard to the study in JAMA where patients who first presented with Asthma, Diabetes or HTN went to either an NP or GP:
Perhaps I have not been reading the same articles but all the articles comparing NPs and Physicians have suffered from pretty severe biases, poor sample size and strange end points measured. Poor blinding plague these studies. Patient satisfaction is a very strange end point to measure when we are talking about quality of care. While satisfaction is very important, this study in particular has been championed as proof that NPs are equivalent or better (mundinger) than physicians when we are not measuring the right endpoint and dont have a sample size or an objective measure to come to significant conclusions. It ended up being around 100 patients in each group that followed up.
For the physiological endpoints, baselines were not taken for physiological measurements. Acute events were not measured but rather they used screening tests: peak flows, blood pressure and A1C values. Instead, asthmatic complications, strokes, MI and diabetic complications should be measured to give a better estimate of outcomes. So clearly the studies need to go on longer to capture these endpoints.

Agreed. There needs to be more studies. One issue I have with the Mundinger et al. study is that it is based on info that is now 15 years old. NP training has come far since then. It is almost not even the same profession.

While the study is compelling, it falls significantly short of evidence or proof of anything, really. The real measure shouldnt be whether a provider can take care of an uncomplicated patient. A drunken monkey can reflexively prescribe HCTZ when hypertension is first diagnosed or metformin when diabetes first pops up. I could design a study and I gaurantee you a 3rd year medical student could do this just as well as a doctor would. A 3rd year is not a doctor as one member of this board has commented. This is because this study just looks at cookie cutter medicine. The difference would be seen in complex patients where there are multiple comorbidities to deal with.

The inference being that NPs couldn't possibly have the critical thinking skills needed and just simply follow the algorithm. Hubris, what? Okay fine: in your opinion in a primary care scenario. Give us an example of what you deem to be a complex patient. Oh, and by the way, you speaking of proof and referring back to the null hypothesis: don't look for proof, because in stats there is no "proof". Maybe we all need to go back and refresh our stats, eh?

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

You will have to excuse me if I expect someone to be pleasant and competent. They are not mutually exclusive, and if you have read any of my previous quotes, you would know that I think it is ridiculous to suggest that MDs don't care. Shame on nurses who say otherwise.

The other thing this paper did was to compare compliance to practice guidelines. Again, anyone can blindly follow practice guidelines.

I would love to hear you say that in a deposition or in court:"Your honor, anyone can blindly...."

That NPs are considered competent by the gov't (a function of lobbying) or the insurance companies (a function of lobbying) or by their patients (who do not have enough knowledge to make such a decision) does not mean they are competent.

And that is different for MDs how?

PICUPNP · Feb 13, 2010

THis discussion is insane. It is simply the rantings of those NPs who follow in Mundingers footsteps. I've been practicing for years but have no doubts that I am inferior in training to a MD/DO. Its ridiculous for any NP to say that they can perform at the same level as a physician. Their trainig is light years beyond that of the NP.

mbreaz1 · Feb 21, 2010

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.

I have a simple solution for this problem. All we need to do is reduce the amounts that we pay specialists and the disparity ends. Problem solved!

http://www.dallasnews.com/sharedcontent/dws/dn/opinion/viewpoints/stories/DN-cole_17edi.ART.State.Edition1.36a3cc3.html

Take it from the mouth of the horse in the article above. Physicians are the problem in our current sad state of affairs in the healthcare system. Don't kid yourself by thinking that paying primary care physicians more would ever do anything to even begin to solve the problem. We probably need to start by reducing demand for their services, and stopping the gravy train they ride everday. Physicians are like vampires sucking our country dry. Their complete dysfunction in how they operate everyday is robbing our country of the ability to be a competitive economy. We need to break their monopolistic hold on the provision of healthcare services now before they completely bankrupt us as a nation. It is sickening to hear a rant like this that is designed to make us feel sorry for the poor medical student who just graduated with a large student loan debt. Many students in other professions graduate with a far greater proportion of debt related to their starting salaries. We don't really need more primary care physicians. If they won't do the job for a reasonable price, let someone else fill their role. Maybe we could even find someone who doesn't cry about not having enough prestige or not making enough money.

wowza · Feb 21, 2010

I have a simple solution for this problem. All we need to do is reduce the amounts that we pay specialists and the disparity ends. Problem solved!
http://www.dallasnews.com/sharedcontent/dws/dn/opinion/viewpoints/stories/DN-cole_17edi.ART.State.Edition1.36a3cc3.html
Take it from the mouth of the horse in the article above. Physicians are the problem in our current sad state of affairs in the healthcare system. Don't kid yourself by thinking that paying primary care physicians more would ever do anything to even begin to solve the problem.

I am not even sure where to start in this post.

You're mixing up 2 disparate problems as the same:

1) Lack of primary care physicians

2) Increasing heathcare costs

We probably need to start by reducing demand for their services,and stopping the gravy train they ride everday. Physicians are like vampires sucking our country dry. Their complete dysfunction in how they operate everyday is robbing our country of the ability to be a competitive economy. We need to break their monopolistic hold on the provision of healthcare services now before they completely bankrupt us as a nation. It is sickening to hear a rant like this that is designed to make us feel sorry for the poor medical student who just graduated with a large student loan debt. Many students in other professions graduate with a far greater proportion of debt related to their starting salaries. We don't really need more primary care physicians. If they won't do the job for a reasonable price, let someone else fill their role. Maybe we could even find someone who doesn't cry about not having enough prestige or not making enough money.

I think we should break the lawyer's monopolistic hold on the justice system. We should reduce the demand for their services. It is ridiculous that they should make so much money and force their clients to pay for it when the paralegals could do their job just as well despite the complete lack of experience or education. Using a fallicous argument like that other students don't make as much money makes my argument valid.

prairienp · Feb 21, 2010

THis discussion is insane. It is simply the rantings of those NPs who follow in Mundingers footsteps. I've been practicing for years but have no doubts that I am inferior in training to a MD/DO. Its ridiculous for any NP to say that they can perform at the same level as a physician. Their trainig is light years beyond that of the NP.

Any discussion has validity as long as both sides try and see rationale. I have been practicing for 25+ years in a rural clinic. I can tell you that numerous times every month I out perform the MD in the same rural clinic. I see more patients, I refer less, and have far greater levels of patient satisfaction, Most importantly, my DM and CAD patients are doing far better according to the parameters the organization has established. Why?? The MD has far "superior' education. The reason is we are all human, some adapt better than others, some just cant communicate. I am not ranting, I do understand that NPs are capable of providing healthcare in a safe and economical methodology.

PICUPNP · Feb 21, 2010

There is no rationale that will ever show that NPs outperform MD/DO's in clinical ability. It is ridiculous to keep beating a horse that's been dead for a long time.............