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

Advanced Practice Columnist / Guide · Jul 10, 2008

I do not think so, PA programs are more like medical school why cannot DNP be such if they expect this autonomy? I think its a fair question.

Again, we can argue about which professionals lack what courses and how long the training is for this field and that field. But is there proof that there is a difference in the product of training between a primary care physician, a primary care PA, and a primary care NP? It is easy to assume that a clone of a medical school program will produce a competent clinician in primary care if you apply the standards of medical school education. But isn't advanced practice nursing with its current model of education producing just as competent a clinician in primary care? Prove to me that this is incorrect and not with anecdotal evidence and unconfirmed data.

Not true/pure Autonomy in most states ( like a Physician has) I want to clarify this.

There are currently less than a quarter of all states that allow no physician involvement in NP practice and even less if you factor in prescriptive authority. If that is your definition of autonomy then, you are right. But my idea of the word "autonomy" is not exactly the same. Are family practice physicians truly autonomous? I think not. There are a multitude of disorders and conditions that a family practice physician could not manage on their own, hence, they need to refer their patients to specialists. Some even ask colleagues who are primary care physicians themselves for their opinion. Heck, I don't even think any physician is really independent.

Primary Care NP's, even in those states that require some form of physician involvement, are the sole health care provider in a given rural clinic in some instances. The collaborating physician may be miles away only available by phone. Does the physician get to see the NP's patients? Not unless the NP thinks they need to be seen by a physician. This happens in some states and is completely acceptable as the NP is not breaking any practice act or federal law in this case. Now I know that there are certain states out there where this scenario would never happen because of restrictive practice acts for NP's but in this particular case I described, I WOULD call that autonomous practice.

Advanced Practice Columnist / Guide · Jul 10, 2008

By the way, I am glad I have a string of days off from work to actually find time to express my viewpoint on these issues. By tomorrow, it's bye bye allnurses.com for a while as I will be preoccupied with actual work. Thanks for the opportunity to discuss.

wowza · Jul 10, 2008

But is there proof that there is a difference in the product of training between a primary care physician, a primary care PA, and a primary care NP? It is easy to assume that a clone of a medical school program will produce a competent clinician in primary care if you apply the standards of medical school education. But isn't advanced practice nursing with its current model of education producing just as competent a clinician in primary care?

Is there a study that measures the similarities based on outcomes? B/c if there is I would like to read it. Post the link if possible.

Advanced Practice Columnist / Guide · Jul 10, 2008

Is there a study that measures the similarities based on outcomes? B/c if there is I would like to read it. Post the link if possible.

I am not at work and my home access for my hospital's Ovid Search engine is slower unless I am on-site. However, the American College of Nurse Practitioners have a link to studies on NP's in their website. I can not speak for the quality of these studies as I have not read many of them but I will try to read them myself and will be open to discussion on them if you wish. I am sure many of these studies are imperfect.

http://www.acnpweb.org/i4a/pages/index.cfm?pageid=3321

core0 · Jul 10, 2008

Right on!
Again, you are confusing the DNP degree with other issues such as NP's in primary care. Autonomous practice in primary care already began before the DNP was even made public. And what makes you think NP's do not need CME's or read journals because we do? The next time you attend a medical conference, look around you because you may be sitting next to a NP.

I'm going to separate out this one comment because I think that it goes to the heart of the problem. RN to med school is not the only one that is confusing this issue. The issue became an issue when the dean of on of the nations premier nursing schools declared that the DNP was the answer to the primary care problem. This same person also declared that the DNP was the equivalent of physician practice and that it obligated independent practice.

While NP organizations issued denials and stated that this was not their policy, these were press releases not the New York Time or Forbes. You have to ask yourself how did this happen? The answer goes to the nature of the NP profession. Who speaks for the NPs? Is it AANP? ACNP? NONPF? ANA? There is no unified voice. Instead this leaves the entire profession open to be hijacked by parties with their own agenda. It leaves the profession open to other parties determining which way the profession is going to go.

Part of the problem is that you can't have it both ways. The quote was that nursing was the most trusted profession. As nurses NPs are a subset of this group, but how much do NPs really have in common with organized nursing. If you look at the ACNPs public policy agenda it shows this:

Provide full reimbursement and empanelment for all nurse practitioners in all settings;
Include provider-neutral language in all federal legislation, regulation, and other policies;
Recognize nurse practitioner's authority to order home health and hospice services and to admit patients to skilled nursing facilities;
Develop and sustain a national nurse practitioner database and tracking mechanism;
Support policies that recognize nurse practitioners as primary care providers;
Appropriate increased funding for nursing faculty, advanced practice nursing and basic nursing education and research; and
Enact global malpractice reform that includes nurse practitioners.

On the other hand the ANAs agenda revolves around increasing money for nursing education, staffing ratios, workplace safety issues and unionization.

While some of these issues may indirectly benefit NPs, they do little to directly advance the NP cause. So you end up back with the same issue. Its been stated here that the majority of the practicing NPs do not support the DNP. I generally believe that. However, where is the power to enforce that wish. Instead you have a non nurse practitioner using her own agenda to not only propogate a vision of the profession that is (in my opinion) at odds with the majority of those who work in the profession, but also establish an "independent testing agency" that will certify these DNPs.

In the end the NP profession has no one to blame but themselves. Unless they stand up and take charge of the profession independent of organized nursing, the profession will continue to be defined by those who are not NPs and those wishing to push their own agenda.

The other issue that the whole DNP debate (at least as advanced by Mundinger) is that most NPs don't work in primary care and if the statistics can be believed are moving away from primary care. It ill serves the profession to state that the DNP is the answer to primary care when NPs are saying that they are not interested in primary care (at least by certification and job selection).

David Carpenter, PA-C

JDCitizen · Jul 10, 2008

No matter how one looks at it Advanced Practice Nurses are making inroads more and more into what used to be a medical doctors only domain...

Like candles progressed to light bulbs

Like horses progressed to cars

Like male dominated medicine had to open up...

Like direct observation to indirect observation to phone consultation to chart reviews to "oh my" nurses have who working for them :-)

Times be a changing!

The captain gave up/out too many responsibilities and in more and more cases the team and the audience found out that they are doing quite fine.

But the :argue: will continue.........

PS: More education if it brings better patient care. I don't have to have doctor to do that I can get another masters or post masters degree... A title can sometimes only be a hoax.

wowza · Jul 10, 2008

For this article: Nurse practitioners and physicians’ care activities and clinical outcomes with an inpatient geriatric population

The problems i have with the article: sample size is only 100, uses NP vs interns, no mention of controls, how standardized, types and comparability of patients and how bias was controlled. It even goes on to say that the interns/residents and the NPs cared for a different type of patient. That alone makes the study invalid.

Finally their measured outcomes were pretty inane:

Who spent more time- Spending more time doesnt equate with better care. As a medical student I have to spend about 10x the amt of time with a pt to get the same history and physical as the attending.

who discussed advanced directives more- may have more to do with which patients a given provider had. Also, who cares.

Who was more attentive to functional status

Who did more literature review

Who had more referrals to PT/OTs

Overall a poorly designed study. Moving on.

wowza · Jul 10, 2008

Primary care outcomes in patients treated by nurse practitioners or physicians: two-year follow-up.

I cant get the full text but from the abstract you can tell that at least it has better parameters, more patients and better measure of outcomes. That said, I cannot look at its methods b/c I dont have the full text and the abstract is not adequate for that.

wowza · Jul 10, 2008

I do find it disconcerting that these publications that look at outcomes of DNP/NP vs Physician are almost universally written by the same person, apparently named Mundinger.

wowza · Jul 10, 2008

I'm going to give up my journal review for the time being b/c I cant access the full text of these articles, only the abstracts.

Some of the later ones do seem compelling and seem to have solid design but I just cant really tell w/o the full text.

core0 · Jul 10, 2008

Primary care outcomes in patients treated by nurse practitioners or physicians: two-year follow-up.
I cant get the full text but from the abstract you can tell that at least it has better parameters, more patients and better measure of outcomes. That said, I cannot look at its methods b/c I dont have the full text and the abstract is not adequate for that.

There are two articles here:

The first was published in JAMA:

http://jama.ama-assn.org/cgi/content/full/283/1/59

At six months the measured attributes were essentially the same.

The follow up is here:

http://www.rwjf.org/pr/product.jsp?id=14785 (review)

Essentially there was no difference but there were so many patients lost to follow up that it was impossible to make any inferences.

That is the sum total of comparisons. There are a number of decent studies that look at care by the NP/Physician team and a number that compare NPs with residents. These are generally either equivalent or favorable. In the context of the NP/Physician team there is probably sufficient evidence to say the care is equivalent. There are no studies that say the care is equivalent in an independent practice environment outside the Mundinger studies. I will also point out that at the time of the study NPs in New York were required to have collaborating physicians with chart review.

David Carpenter, PA-C

wowza · Jul 10, 2008

Took a look at the first one. Thank you for the link.

N was sufficient, there were clear goals and clear outcomes to be measured and the patients were randomized but there were some pretty significant flaws in the study.

First and foremost much of the health outcomes were measured by a questionaire. Questionaires are notoriously subjective and unreliable. This is a pretty large flaw in the methods.

They also used questionaires for satisfaction ratings, but really there is pretty much no way to assess satisfaction without asking the person, so not really a strike against them for that.

They also did not blind the patients to what kind of provider was giving them care. So each patient knew if the person in front of them was a doctor or NP. Since they used questionaires after this information was known, it further weakens the assertions of the article and the validity of the data garnered by questionaire. For this kind of study, double blinding is a must and in reality they probably should have used triple blinding.

Next the study only lasted 6 months yet lost 1/3 of its patients to follow up. That is a pretty big attrition rate. It partially invalidates the study. Furthermore, in my opinion, 6 months is hardly enough time to have adequate physiological changes in chronic disease and assess the benefits of the chronic disease management. It really needs to be a longitudinal study over the course of several years. FEV/FVC readings for an asthmatic arent going to change in 6 months unless he/she is having an asthma attack during one of the spirometry readings. So the data (which is invalid for reasons you will see later) has more to do with compliance on medication and time since the patient took the meds than with heath outcomes like the study purports.

Next, and this is a biggie, they took physiological measures after 6 months but took no measurements in the beginning to provide a baseline to compare to. This is an enormous flaw. It totally invalidates all of the physiological measures. Furthermore, the changes in BP, could be due more to the type of anti-hypertensive used. For instance, lower diastolic pressures probably mean a vasodilator like nitroprusside was used or ACEi as compared to a BB. But this wasnt addressed in the article at all. They also didnt provide the data for the physiological measures which is a big no-no.

Finally the population used is not generalizable at all: 90% hispanic in a single geographic location.

It blows my mind that the JAMA editors didnt ask for these things to be addressed.