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

PICUPNP · Feb 23, 2010

There are also NPs out here that disagree with you entirely.

mbreaz1 · Feb 23, 2010

There are also NPs out here that disagree with you entirely.

Mostly the ones who would disagree are the NPs who have pigeonholed themselves into specialty practice and will never have the opportunity to practice independently once the laws are changed. Most of the NPs who are in primary care agree with me wholeheartedly.

mbreaz1 · Feb 23, 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.

I'm not exactly sure where you and I got off track. Most of this sounds like something that I would say. I would say the exception being that you think there is a true massive demand for primary care services. I think that the demand for primary care services is artificially created by legislatures that require insurers to cover all of this "preventive care" under the guise that it saves lives and money. Most of it hasn't been proven to do either one. I think we could substantially lower the demand for primary care services by making people pay if they want that stuff, and yes this is my OPINION. Feel free to argue the point if you care to. I know that there are many opinions on both sides of the fence here and that it probably should get down to more specific issues as far as what preventive measures are and are not cost effective, however, I don't see primary care physicians as necessary to monitor someone's weight. If people are too stupid to figure that one out for themselves, maybe they just need to be unhealthy. I'm not a fan of the idea that if someone goes to a physician enough to get reminded about what is healthy, then they will make healthy choices. Why not go to a health coach and pay for it out of your pocket if you need someone to hold your hand for you. We can absolutely have someone who doesn't have all of that training to tell you to exercise, eat right, and you will be healthier. I don't think we need an MD or DO to tell us that. Furthermore, there are a ton of preventive measures in this country that people in other developed nations would laugh at. That should definitely give us some reason to question the massive amount of preventive medicine the physicians in this country would like us to believe is good for us. Also, we should take a look at the person who is giving us the message and ask ourselves "what do they have to gain by telling me that". Think about it. Healthy skepticism will tell you a lot about the current state of our healthcare system.

PICUPNP · Feb 23, 2010

mbreaz, I just happen to be on the other side and don't feel as though nps should have independent practice. As far as pigeonholing myself, I provide both primary and critical care for the pediatric population so don't make statement about that which you don't know. Your rantings are that of an np, I know several, who has convinced themselves that they know as much if not more than doctors...I will call it the Mundinger Syndrome. Nobody with half a mind could look at the differences in education and not see that nps are even close to what doctors know upon exit from school. The nps who push this agenda are the very ones who are going to do great harm when they miss something.

mbreaz1 · Feb 23, 2010

mbreaz, I just happen to be on the other side and don't feel as though nps should have independent practice. As far as pigeonholing myself, I provide both primary and critical care for the pediatric population so don't make statement about that which you don't know. Your rantings are that of an np, I know several, who has convinced themselves that they know as much if not more than doctors...I will call it the Mundinger Syndrome. Nobody with half a mind could look at the differences in education and not see that nps are even close to what doctors know upon exit from school. The nps who push this agenda are the very ones who are going to do great harm when they miss something.

Your first mistake was assuming that I meant you when I mentioned NPs in specialty practice. I never say YOU, now did I? When did I ever say I was an NP? Don't put words in my mouth darling. You are far from right on that one. Also, nobody said they are the same as doctors, just better suited for the primary care role for a large number of reasons, far more than just thte different training. Physicians do great harm when they miss things everyday, so let's not try to compare the two, okay?

prairienp · Feb 23, 2010

prarienp
it is fluff, not for many, it is fluff for anyone. seriously, can you be taught to communicate? i take quite a lot of time explaining my patients conditions to them and making sure they understand all possible treatment outcomes and options, but i didn't need 2 years of "communication and health promotion" classes to do it. if your training focuses on differential diagnosis and treatment that will come naturally unless you don't care about what the average person knows. and if you think the majority of your patients have the slightest idea what they need you are either sorely mistaken or work with a very select group of educated patients. i can tell you after nearly 3 years of working i've never had a patient population greater than 50% that ever truly understood everything i would have liked them to, although i did usually get them to understand enough, they really never grasped the full understanding of their disease. that's why we get paid. don't kid yourself.
that is also why patient satisfaction is retarded. it's based completely on subjective criteria. i've known terrible doctors, whose patients absolutely adored him. why is it used? only by practitioners trying to prove something that isn't true.

i think you may have really helped with the discussion regarding education. in pender's health promotion text the role of the nurse "is to assist clients with health planning rather than control of the process" and clients must be active participants in interpreting assessment data and in planning. maybe this is the key distinction?

PICUPNP · Feb 23, 2010

I can compare the two all I want. I have worked in this field for many years and know the difference. The problem is that NP programs across the country are brainwashing people into thinking just like you, and its actually quite humorous. NPs that think they can function at or near the same level of a physician are only making fools of themselves....darling.

mbreaz1 · Feb 23, 2010

I can compare the two all I want. I have worked in this field for many years and know the difference. The problem is that NP programs across the country are brainwashing people into thinking just like you, and its actually quite humorous. NPs that think they can function at or near the same level of a physician are only making fools of themselves....darling.

If you plan to compare the two then let's not leave out all of the mistakes that physicians make. You act like nurse practitioners are the only people on earth who can make a medical error. I have never been through an NP program and have never been brainwashed into thinking anything by them. I do however have a very deep understanding of monopolists and FTC violations with regard to restraint of trade. The physicians are the ones who are going to look like fools once the public starts to realize that there is no need to deal with the primary care rat race that exists today. People can have greater access to professionals who are far more accomodating, competitive, and willing to provide better customer service. That's what they want and that is what they get with independently practicing NPs in primary care. The brainwashing that occurs is actually on the other side of the coin. The physicians and the healthcare establishment have engaged in it for many years and you appear to be the perfect product of it that they intended.

springing · Feb 23, 2010

If you plan to compare the two then let's not leave out all of the mistakes that physicians make. You act like nurse practitioners are the only people on earth who can make a medical error. I have never been through an NP program and have never been brainwashed into thinking anything by them. I do however have a very deep understanding of monopolists and FTC violations with regard to restraint of trade. The physicians are the ones who are going to look like fools once the public starts to realize that there is no need to deal with the primary care rat race that exists today. People can have greater access to professionals who are far more accomodating, competitive, and willing to provide better customer service. That's what they want and that is what they get with independently practicing NPs in primary care. The brainwashing that occurs is actually on the other side of the coin. The physicians and the healthcare establishment have engaged in it for many years and you appear to be the perfect product of it that they intended.

The problem with this is that no matter how great the customer service is, it doesn't repair your rusty clockwork.

My feelings go like this:

A family medicine physician is preferable to a family nurse practitioner.

A family nurse practitioner is preferable to having NO primary care provider.

I think most people can or SHOULD agree to that. I go a bit further and think it's a waste of a physician to have him/her doing scutwork someone else could be doing. I do think (and numbers bear me out on this) that there is a shortage of PCPs, and thus going to a physician for a well-child exam is not always the best use of that physician's skills. There's a reason many doctors in the real world love and get along with PAs and NPs...they relieve some of the work and some of the stress.

And what that implies by default is that physicians have a superior knowledge base - 2 years plus RN experience is good, but it's not comparable to 7 years. That knowledge base is more important than whether or not the PCP holds your hand and makes you feel all warm-fuzzy inside. I'd rather a patient go to a PCP who recognizes the signs of testicular torsion than a PCP who's nice and chummy and can't see that the pt is about to lose a ball.

We don't need to bring physician mistakes or NP mistakes into the mix. Exceptions DO NOT prove the rule. Of course doctors make mistakes, but you can't in one post claim that malpractice isn't that big of a deal and then in another post start bringing up physician errors. You can't have it both ways.

mbreaz1 · Feb 23, 2010

The problem with this is that no matter how great the customer service is, it doesn't repair your rusty clockwork.
My feelings go like this:
A family medicine physician is preferable to a family nurse practitioner.
A family nurse practitioner is preferable to having NO primary care provider.
I think most people can or SHOULD agree to that. I go a bit further and think it's a waste of a physician to have him/her doing scutwork someone else could be doing. I do think (and numbers bear me out on this) that there is a shortage of PCPs, and thus going to a physician for a well-child exam is not always the best use of that physician's skills. There's a reason many doctors in the real world love and get along with PAs and NPs...they relieve some of the work and some of the stress.
And what that implies by default is that physicians have a superior knowledge base - 2 years plus RN experience is good, but it's not comparable to 7 years. That knowledge base is more important than whether or not the PCP holds your hand and makes you feel all warm-fuzzy inside. I'd rather a patient go to a PCP who recognizes the signs of testicular torsion than a PCP who's nice and chummy and can't see that the pt is about to lose a ball.
We don't need to bring physician mistakes or NP mistakes into the mix. Exceptions DO NOT prove the rule. Of course doctors make mistakes, but you can't in one post claim that malpractice isn't that big of a deal and then in another post start bringing up physician errors. You can't have it both ways.

I fully understand your thinking regarding the hierarchy here and the levels of education that each professional has attained. The problem with your thinking is that you want to project your ideas regarding the capability of providers on everyone else and require them to pay the price for the fact that you think that way. The reality is that someone has to pay for it. In other words, if you require everyone to see a physician, or a nurse practitioner who is required to have a supervising physician, everyone has to basically pay the physician rate. What I can't understand in this whole argument is, if that's the way you feel, then choose for yourself to go see a physician for your own problems and let others choose who they wish to see for their own problems. Why do you insist that you are at liberty to project your own values onto the public?

You say we don't need to bring mistakes into the mix, but you assume here in your post that the NP is going to make a mistake on that torsion issue (ouch!). What is it that makes you think that the NP isn't astute enough to diagnose the problem and make the referral? Why is it that you think the physician is going to do the job correctly just because they aren't chummy? I disagree with you on that, but if you think that NPs aren't smart enough to deal with the problem, just don't go to one. My thought is that I don't get that much additional value for common problems from the additional education that I have to pay for if I go to a physician in most primary care situations.

I can claim that malpractice isn't that big of a deal economically speaking and acknowledge that physicians and nurse practitioners alike make mistakes in the same post. Please explain what you mean by that and how you think it is a contradiction?

bajasauce07 · Feb 23, 2010

My thought is that I don't get that much additional value for common problems from the additional education that I have to pay for if I go to a physician in most primary care situations.

That's the problem, neither you or the patient realize that 99% of "zebras" present as horses, and if you don't recognize it it can behave like a horse all the way till the point that treatment matters no more. That my friends is a game of russian roulette. We can argue all we want that doctors make mistakes just like NP's, PA's, etc. The point is that's why they went to school, if they suck at their jobs, are lazy, or otherwise don't care, the lawyers will take care of that. It's like saying pilots have a monopoly on flying planes. Who says you need to log ten thousand hours of flight time in all weather to fly commercial planes? There are groups out there with about 600 hours of flight time during sunny weather willing to fly you for about 75-85% of the cost!!!! Well they argue, most flying is done during sunny weather, right? but what when the storm hits? everyone on board dies due to inexperience with that type of flying. You can bet you would call that sort of push in such a field irresponsible even if customers are satisfied with the lower prices/personality of the pilot.

as far as my earlier post, I was called out on using the word "retarded" I apologize, I meant using patient satisfaction is a silly thing to measure as a measurable result in any study.

If you'll look closely at my post I say that patient satisfaction is important but irrelevant to medicine.

I stand by my earlier statement that patients do not understand what you think they understand, they may nod their heads but they don't fully comprehend and you have to understand that there is fear there. It may be different as an outpatient we the medicine is not as acute, but I work solely in inpatient medicine.

As far as me finding another profession, I doubt it, there isn't anything else I would get up in the morning for. I love taking care of patients and somehow spreadsheets just don't seem fulfilling. If we want to talk about patient satisfaction my patients LOVE me. I really do take sometimes HOURS to be with family in critical times, I come back after hours if they need to talk, I make sure they understand as MUCH AS POSSIBLE. but like I said, about 50% truly get it if that. and that's probably those with some medical training anyway.

Yes patients ought to be informed decision makers, but you guys are mixing compassion up with good health care. Especially this MBREAZ fellow. Compassion has nothing to do with patient outcomes. it should be part of the entire physician(practitioner)/patient relationship but really and truly I'm surprised that anyone lauds this as some unique feature of the nurse practitioner degree and then many imply that it makes them "better" when that's about as much delusion as I could hope to ask for in any group of people. Much less ones that have as many years of educated profession as NP's.

ALSO, I would LOVE clarification on this statement:

Also, nobody said they are the same as doctors, just better suited for the primary care role for a large number of reasons, far more than just thte different training.

in one breath MBREAZ will tell us he acknowledge that physician and NP training is different, then he'll say that they should get rid of preventative medicine (which I equate to be the "easy" stuff that you reference in the first quote of yours up there that you apparently believe are what NP's are suited for and also what many NP's with your view think they will be handling in their independent practices). While at the same time chiding me that I need to find a new job if I can't make my patients understand, while arguing that most patients are stupid (what do they go to the doctor for if not obesity, smoking, and the complications of such?). Then you ask me to find proof that patient satisfaction is not important in medical outcomes (I said nothing of legal outcomes, which I could care less about as long as I do what's right). If I have to explain that to you I'm very concerned. What do you plan on treating your patients with in your independent Doctor of Nurse Practitioning office? Rainbows and unicorns and happy thoughts? :/

mbreaz1 · Feb 24, 2010

That's the problem, neither you or the patient realize that 99% of "zebras" present as horses, and if you don't recognize it it can behave like a horse all the way till the point that treatment matters no more. That my friends is a game of russian roulette. We can argue all we want that doctors make mistakes just like NP's, PA's, etc. The point is that's why they went to school, if they suck at their jobs, are lazy, or otherwise don't care, the lawyers will take care of that. It's like saying pilots have a monopoly on flying planes. Who says you need to log ten thousand hours of flight time in all weather to fly commercial planes? There are groups out there with about 600 hours of flight time during sunny weather willing to fly you for about 75-85% of the cost!!!! Well they argue, most flying is done during sunny weather, right? but what when the storm hits? everyone on board dies due to inexperience with that type of flying. You can bet you would call that sort of push in such a field irresponsible even if customers are satisfied with the lower prices/personality of the pilot.
Most patients who come in for primary care don't have a zebra, but if they do, they can be referred. That's what is supposed to happen in primary care. Don't make out like nurse practitioners can't recognize the zebra and refer the patient just like a primary care physician can. That's simply not true. It happens everyday already.
as far as my earlier post, I was called out on using the word "retarded" I apologize, I meant using patient satisfaction is a silly thing to measure as a measurable result in any study.
If you'll look closely at my post I say that patient satisfaction is important but irrelevant to medicine.
I stand by my earlier statement that patients do not understand what you think they understand, they may nod their heads but they don't fully comprehend and you have to understand that there is fear there. It may be different as an outpatient we the medicine is not as acute, but I work solely in inpatient medicine.
As far as me finding another profession, I doubt it, there isn't anything else I would get up in the morning for. I love taking care of patients and somehow spreadsheets just don't seem fulfilling. If we want to talk about patient satisfaction my patients LOVE me. I really do take sometimes HOURS to be with family in critical times, I come back after hours if they need to talk, I make sure they understand as MUCH AS POSSIBLE. but like I said, about 50% truly get it if that. and that's probably those with some medical training anyway.
How can patient satisfaction be important, but irrelevant at the same time? If you work solely in inpatient medicine, then why are you trying to act as if your experiences have any relevance in the primary care arena? I have only discussed independent practice for nurse practitioners in the primary care arena.
Yes patients ought to be informed decision makers, but you guys are mixing compassion up with good health care. Especially this MBREAZ fellow. Compassion has nothing to do with patient outcomes. it should be part of the entire physician(practitioner)/patient relationship but really and truly I'm surprised that anyone lauds this as some unique feature of the nurse practitioner degree and then many imply that it makes them "better" when that's about as much delusion as I could hope to ask for in any group of people. Much less ones that have as many years of educated profession as NP's.
I'm not mixing compassion up with anything. What you are missing is that doctors in primary care absolutely refuse to spend the time to even talk to a patient in order to determine what their symptoms are to make a correct diagnosis because they want to keep up with their quotas in order to make the salary that they want to make. It isn't about compassion, it is about being diligent and doing your job. The unique feature of independently practicing nurse practitioners in the states where they are already doing it is that they don't tell their patients to make another appointment if they have multiple problems, they see their patients on time and spend adequate time with them.
ALSO, I would LOVE clarification on this statement:
in one breath MBREAZ will tell us he acknowledge that physician and NP training is different, then he'll say that they should get rid of preventative medicine (which I equate to be the "easy" stuff that you reference in the first quote of yours up there that you apparently believe are what NP's are suited for and also what many NP's with your view think they will be handling in their independent practices). While at the same time chiding me that I need to find a new job if I can't make my patients understand, while arguing that most patients are stupid (what do they go to the doctor for if not obesity, smoking, and the complications of such?). Then you ask me to find proof that patient satisfaction is not important in medical outcomes (I said nothing of legal outcomes, which I could care less about as long as I do what's right). If I have to explain that to you I'm very concerned. What do you plan on treating your patients with in your independent Doctor of Nurse Practitioning office? Rainbows and unicorns and happy thoughts? :/

When did I say get rid of preventative medicine? I never said that. I said stop forcing insurers to pay for it. That doesn't mean stop doing it. It means do it and let the patient pay you for it.

You should find a new job if you can't explain things to your patients. You are incompetent if you don't have the ability to do that. I never argued that all patients were stupid, just that for some reason they listen to stupid advice from doctors. You were the one who said that patient satisfaction was not important to their care. I asked you to show me proof of it. I see you have none.

You really just have a problem with having to face competition from independently practicing nurse practitioners. You try to justify it under the guise of your concern for patients, but physicians are afraid to have to compete with other professionals. That is the bottom line.