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

mbreaz1 · Feb 24, 2010

Unfortunately a hospital is not a hotel. The primary goal of physicians is to make a sick person better, not cater to their every needs in hopes that their customer satisfaction rating is high. And I don't think wowza's the one who sounds like an idiot either.
You fail to understand that satisfaction has nothing to do with outcomes. If you're incredibly nice to the patient, cater to his every need, but do a poor job in actually treating him, he'll still likely think you're the greatest doctor in the world. Just because you listened to him (because you know, all the other docs that don't listen are just meanies). It doesn't matter whether you actually fixed the problem or not.
That's the problem with using patient satisfaction surveys to assess medical competency. They're completely unrelated. Maybe now you finally understand? And maybe now you can finally stop using patient satisfaction as an indication of NP/DNP competency?

So coud you please explain to me how you can satisfy a patient without providing good care?

mbreaz1 · Feb 24, 2010

That is a strawman argument. Service is not directly measured by patient satisfaction!
But yes, you can have happy patients and still deliver terrible care. Conversely, you can deliver excellent care and have your patients hate you because of bedside manner. So patient satisfaction is a terrible metric of quality of care because it is unrelated to quality.
They are neither mutually exclusive nor mutually inclusive.

Huge flaw in this argument - how in the hell can you deliver terrible care and have a satisfied patient. That is complete foolishness. Give it up.

wowza · Feb 24, 2010

Huge flaw in this argument - how in the hell can you deliver terrible care and have a satisfied patient. That is complete foolishness. Give it up.

It is very easy to deliver improper (terrible) care and have your patient happy precisely because patients do not know what the right care is. All you have to do is take extra time with your patient and they will love you for it. It has no effect on the outcome and does not mean you delivered good care. Here's an example:

Let's say a pt from a nursing home with multiple hospitalization comes in with an infected sacral decub. and you take extra time with her and her family explaining her condition. You prescribe her keflex. While the patient and the family loves you for taking the extra time, you prescribed the wrong antibiotic and delivered totally improper care. Your quality was crap but your patient and family satisfaction would b e very high because they would not realize that Keflex was a very, very poor choice.

bajasauce07 · Feb 24, 2010

But WOWZA, if the patient is happy, doesn't that mean I did a good job!??? I don't understand.... You're saying that if I do something wrong, and the patient is happy, I'm still wrong? Are you sure? all my communication classes didn't prepare me to accept this, you must be wrong.... :yeah:

sorry, couldn't resist.

dgenthusiast · Feb 24, 2010

You think physician training is superior, when actually it is just excessive. Nobody in the nursing leadership claims it is the same, only that it is more than adequate and not excessive. What they claim it to be is efficient, something physicians can't seem to comprehend.

I think you're the only person I've ever seen say that physicians are overtrained. When the rest of the medical community is worried that even the current length of training might not be enough. I think it might be you who's failing to comprehend how important those extra years of training are. There's no such thing as overtraining in medicine.

Also, I'd say PA training is better than NP training, not inferior, since PAs don't skimp out on important stuff, like pathophys. Luckily for them, they don't have to take a ton of nursing activism courses.

springing · Feb 24, 2010

You think physician training is superior, when actually it is just excessive. Nobody in the nursing leadership claims it is the same, only that it is more than adequate and not excessive. What they claim it to be is efficient, something physicians can't seem to comprehend.

Physician training is excessive?

Go through the curriculum of medical school and a typical family medicine residency and tell me what you'd remove.

bajasauce07 · Feb 24, 2010

You realize that if NPs get independent practice rights, PAs will get the exact same thing soon after. Baja knows that and apparently knows and respects his/her limitations of training. The most dangerous thing possible in medicine is someone who does not understand just how much they don't know.
Nothing of this sort is true. Won't happen because their training is so far inferior to that of NPs.

Whoah, I missed that the first go around... PA training is inferior? What do you use to claim that? I think you ought to check your curriculum against ours. Now I'll admit, we don't have all those fancy patient satisfaction courses and communications classes and we also don't have 4 years of experience opening tylenol bottles and giving suppositories, but I think we more than make up for that with our extra training in pathology, pharmacology, differential diagnosis, and clinical work measured by thousands not hundreds.

Now don't get me wrong, there are plenty of "adequate" (your words, not mine) NP's, but you've thrown down a gauntlet here. I've reviewed NP curriculum and PA curriculum as well as have chatted with plenty of NP's regarding their training. It doesn't compare. Be prepared to back this up.

As far as PA's not being for independent practice, you're right there are probably a few out there who don't have much common sense but the majority of those go back to med school. I hate to break it to you but yes, if NP's get independence I'm worried it would make it easier for these other PA's to whom you refer to push that through. We are not trained for that.

You seem to think that primary care is just physicals, colds and diarrhea's where, in reality, they are the patients first line of detection and defense against ALL disease, not just the easy stuff. do you know what Churg-Strauss syndrome is, or whipples disease, or of the many different types of ILD? Or maybe the different dermatomyositis syndromes? Or the differences between Multiple myeloma, MGUS, Waldenstroms Macroglobulinemia? perhaps even something as simple as culture negative endocarditis. Perhaps typical histories of patients with histoplasmosis, tularemia, Q-fever, Brucellosis, schistosomiasis, naegleria, the natural vectors of leprosy in the united states, perhaps the geographic distributions of blastomycosis? Perhaps you know what organisms to worry about when someone who is iron overloaded (hemochromatosis/thalassemia) gets an infection after a trip to a salt water beach? I highly doubt it, neither would many of your nursing bretheren/sisters. I bring these up because they are but a few on a long list of diseases which can present insidiously, masquerade as the "Horses" and require a knowledge of, and high index of suspicion when seeing a patient complaining of a "small rash" or a "little" shortness of breath, or trouble combing their hair/shampooing etc. The point is, if you don't know they EXIST, how will you know to test or even refer? Time to diagnosis with these things equates directly to functional lifespan.

You say physician training is excessive because you have NO IDEA how much medicine is out there. The very edges of the chasm that is the knowledge necessary to even be a good midlevel escapes your feeble imagination. Your next argument will be that these disorders don't matter because they are rare (some not as much as you are guessing), so you are willing to throw these under the bus? each of those statistics represents a real person, with a FAMILY, (and with a lawyer if they're smart enough to recognize they need it.)

Next you'll say, oh doctors miss those too, yeah, but ask any of them if they're familiar with the disease. Even if they miss it the answer is yes. It was taught to them at some point, therefore if they miss these with their vastly more extensive fund of experience and knowledge, what makes you think you'll ever even get a shiver up your spine as you prescribe advil for the joint pains of whipples, or reassure the late middle aged woman that her trouble with her hair is due to age? or allow the nice old man with the "viral fever" who was out rabbit hunting last week or working with his cows to treat his fever OTC? Perhaps the rash from the child with the new pet armadillo in new mexico is atopic? as is the middle aged man's new onset asthma and slightly elevated eosinophil count (only slight, no cause for concern), or the young man who was diving in fresh water with the headache? The older african american man's proteinuria is surely due to his diabetes, nevermind his mildly elevated calcium or alk phos levels. oh what's that the alk phos is nothing because his gallbladder checked out? what a relief...

The only reason this argument is allowed by politicians and NP's and YES PA's, is that they are IGNORANT of all that lies out there. The training is insufficient to allow independence. You continually point to satisfaction as a measure of outcome because in your limited breadth of knowledge, all disease is easy to treat, and therefore the only difference between you and the MD will be how "satisfied" the patient feels with your cheaper and "adequate" care.

Don't worry though, it's coming, and then we will see. Though the outcome may be different than we all expect, especially a few years down the line. (Rainbows and unicorns don't work on these disorders sir or madame) and if the consumer is as astute as you think, they won't be satisfied with subpar care or late referrals.

P.S. :and if my inpatient experience of internal medicine has no relevance here, perhaps you'd care to explain who you are? I'm starting to get the feeling based on the sound logic of your arguments that you may not even be a provider of ANY sort, and if so, again, I'm worried. also, are there 2 people on that username? you throw around the term idiot rather freely for someone who got on my case when using retarded as a description of a thing, much less a person...

bajasauce07 · Feb 24, 2010

oh, and quickly, to clarify, when I admit that there are some PA's pushing the same independence agenda as NP's I'm assuming you're right based on statistics and the fact that our profession toyed with the idea of a doctoral degree. I've never actually heard a single PA want independence nor is it the position of the AAPA.

wowza · Feb 24, 2010

Perhaps typical histories of patients with... naegleria?

Let me take a whack at this one...

I'm fine. I'm fine. I'm fine. I'm in a coma. I'm dead?

wowza · Feb 24, 2010

This was posted in another thread by a member of Allnurses who went to NP school and then to medical school. (I posted this earlier in the thread):

"I have a unique perspective on this. I am a physician (i.e. I actually went to medical school). I was also a nurse and took NP classes.

There is absolutely NO comparison between the two. ZERO. Most NP programs contain less actual "medical" classes than you get in one semester of real medical school. Mine was 15 credit hours. The rest is nursing theory, research, nurse political activism and such. It is so unbelievably different, you can't compare the two. The truly scary thing is that they don't how much they don't know.

NPs, DNPs have absolutely NO right to independent practice. I think there is a role for them such as running coumadin clinics, helping with post-op evals, vaccinations and other such limited practice.

They simply do not have a fraction of the knowledge that the worst FM physician has. Not even close.

Imagine this. Would you let a fourth year medical student open up a clinic and do primary care? H@(( no! And the fourth year medical student already has VAST more medical education than an NP or DNP.

If this does not bother you, it should."

Yeah, someone who has experience with both posted that (wasn't me). I will now post the comparison of courses if I can find what I posted in the past.

Trauma Columnist · Feb 24, 2010

It lends credibility to your argument when you state your credentials.

When you call others "darling" it only degrades YOU.

Good debate.

wowza · Feb 24, 2010

This is an RN to DNP curriculum from MGH Adult Primary Care.

http://www.mghihp.edu/academics/nursing/degree-options/rn-to-doctor-of-nursing-practice/curriculum/adult-primary-care.aspx

In it's core courses it has 5 credit hours TOTAL for pathophysiology and pharmacology. These are the cornerstones of medical knowledge and a not even half a semester is spent on these... really? Here is the actual curriculum:

Clinically related coures (35- 33 credits)

2 Credits Advanced Pathophysiology3 Credits Advanced Pharmacology

4 Credits Adv Assess/Diag Reas - Adult

3 Credits Chld/Adol Psych Mental Hlth

5 Credits DNP Residency

3 Credits Nsg Mngmt/Adlt: Prim Care I Th

3 Credits Nsg Mngt Adlt: Prim Care II Th

3 Credits Nsg Mgmt Adlt: PC III Theory

3-6 Credits Nsg Mgt Adlt:Prim Care I Clin

3-6 Credits Nsg Mgt of Adlt:PC II Clinical

3-6 Credits NU Mgmt Adlt: PC III Pract

Non-clinical fluff (33-34 credits)

3 Credits Hlth Care Policy & Politics

3 Credits Leadership for Adv. Nu Pract.

2 Credits Professional Issues

3 Credits Population Health

3 Credits Outcomes measurement3 Credits Survey of Health Care Informatics

2-3 Credits Designing Clin Rsrch

3 Credits Knowledge & Inq Dev for NP

3 Credits NU Research, Analysis & Crit

3 Credits Mentored doctoral practicum

3 Credits Intermediate biostatsitics

2 Credits Capstone project

Really the whole autonomy for NPs is a political charade. Were they really worried about pt care and improving knowledge- instead of forcing their agenda- the courses would be drastically different; there would be a focus on pathology, physiology and pharmacology and more clinical time rather than such a focus on nursing leadership, nursing theory and nursing education. As I have gone through medical education I have realized how hard proper primary care is to do. The more I know, the more i realize I dont know. It makes me realize that these Family Practice residencies are necessary to be adequately trained- as is the rest of medical school. Can most of primary care be done by NPs or even medical students... sure. It is that 5% that the PCP's extra training is needed for. Let's not dumb down primary care. If DNPs really want a piece of the pie and the coveted autonomy, they need to have training that shows their commitment to pt care and medical knowledge.

And if anyone didnt already know, MGH is Harvard's hospital so this example was not from some podunk community college offering a DNP program.

When I have some time I will post my school's currriculum for comparison.