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

djc1981 · Jul 10, 2008

No offense, but anyone can find something wrong with a study if the results are not showing favor to your personal agenda. I've seen this happen in a plethora of fields...business, politics, etc. However, had the exact same study with the exact same methods produced results congruent to what a person believes, they'd be hailing them as the Second Coming of empirical evidence. Bottom line, take every study you read with a grain of salt, regardless of supposed outcome. :twocents:

Advanced Practice Columnist / Guide · Jul 10, 2008

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.

Ummm, who said her school is the premier nursing school?

This same person also declared that the DNP was the equivalent of physician practice and that it obligated independent practice.

Again, which nursing organization has backed her up at the current time?

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.

Again, there is a unified statement over at the NONPF website

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.

How do those statements counter the goals of organized nursing?

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

Again, your point doesn't make sense. Doesn't ANA stand for all nurses in general? Nursing is a profession that has one of the greatest diversity in roles. It sounds like ANA is sticking out for the bedside nurse in the issues you mentioned. Why would that be odd?

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.

What made you think Dr. Mundinger is not a NP? just because of her credentials at the Columbia website? Could it be possible that she has a post-master's NP certificate? She was the recipient of the 1998 Nurse Practitioner of the Year Award by the Nurse Practitioner Journal. You don't really know her and you're not a NP to know that information at all.

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.

See answer above.

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).

The majority of NP's are FNP's, I think that means many would like to practice in primary care.

Advanced Practice Columnist / Guide · Jul 10, 2008

No offense, but anyone can find something wrong with a study if the results are not showing favor to your personal agenda. I've seen this happen in a plethora of fields...business, politics, etc. However, had the exact same study with the exact same methods produced results congruent to what a person believes, they'd be hailing them as the Second Coming of empirical evidence. Bottom line, take every study you read with a grain of salt, regardless of supposed outcome.

Exactly! what you need to prove to me is the assumption that NP's have no business doing primary care. Sadly, no study has proven that.

wowza · Jul 10, 2008

No offense, but anyone can find something wrong with a study if the results are not showing favor to your personal agenda.

Sure, with a fine enough comb you can find minor faults with most journal articles but these were egregious. I mean common things like controls or adequate blinding should be caught and fixed before the study even begins. Usually when a study has such major flaws in methods and design it is outright rejected by the reviewers/editors of the journal and never published.

core0 · Jul 11, 2008

ummm, who said her school is the premier nursing school?
sorry that on is supposed to be one as in one of the nations premier nursing schools. usn&w reports puts in the top 20.
again, which nursing organization has backed her up at the current time?
again, there is a unified statement over at the nonpf website
here is the list of directors for the abcc (the group with the dnp certification). it includes the executive director of the ancc as well as a lot of nursing school deans.
http://abcc.dnpcert.org/board.shtml
yes there is a unified statement over at the nonpf website but no plan to counter the dnp certification exam and again press release vs. ny times. the public generally doesn't look at the nonpf websites. the information they get is from the press.
how do those statements counter the goals of organized nursing?
does the average bedside nurse really care about any of those issues. they may generally feel these are a good idea but that is different that supporting and implementing these goals.
again, your point doesn't make sense. doesn't ana stand for all nurses in general? nursing is a profession that has one of the greatest diversity in roles. it sounds like ana is sticking out for the bedside nurse in the issues you mentioned. why would that be odd?
thats exactly the point. the ana is more concerned with bedside nursing than it is with advanced practice nursing. if you remember history, the ana was more than than happy to throw non-masters nps under the bus in 1997 to get what it wanted. if the ama went to the ana and wanted to exchange a 1:4 staffing requirement for required physician supervision of nps are you sure of the outcome? how do you balance the wants of the 2.3 million or so rns vs the needs of the 75,000 or so practicing nps?
what made you think dr. mundinger is not a np? just because of her credentials at the columbia website? could it be possible that she has a post-master's np certificate? she was the recipient of the 1998 nurse practitioner of the year award by the nurse practitioner journal. you don't really know her and you're not a np to know that information at all.
well her cv doesn't list it, new york state doesn't list her license as a np license and the page from her clinic lists here as phd rn founder not one of the providers. at the very least she's not licensed as an np in new york.
the majority of np's are fnp's, i think that means many would like to practice in primary care.

it would seem so. however, if you look at the advance for np listing for practice it shows 40% doing primary care (fp+peds+im). the only way that you could get more than 50% is by assuming that all of the "other" are in primary care. the other point is that while 52% of nps have an fnp only 16% working primary care. i will point out that it is hard to figure out the position (35%fp) vs employment setting (16%). if you look at the advance data and the program data acnp has been increasing over the time and the fp percentage is going down. as a percentage the acnp seems to be gaining favor over the fnp. the fnp does continue to constitute the bulk of the new grad fnps currently. the np world seems to be following the physician and pa world. its really difficult if not impossible to make money in primary care. in a shortage market specialty care can offer more money.

the dnp does not change this. if anything it accelerates the movement. there are a number of studies that show (in medicine at least) that debt level is inversely correlated with the desire to practice primary care.

i think that you and i both agree that the rank and file nps do not support a move to the dnp. however if you look at the abcc board of directors you see a lot of nursing school deans as well as nonpf and aacn members supporting the certification. essentially they have proposed using a test for designed to assess for the unsupervised practice of medicine as the primary certification for advanced practice nursing. never mind that the test primarily tests inpatient medicine skills (at least as explained to me). how does that best serve nps?

david carpenter, pa-c

allnurses Guide · Jul 11, 2008

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.

Actually, questionnaires can be assessed for their validity and reliability and may be the best choice.

RN to Medschool · Jul 11, 2008

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.

You are missing the point, you cannot expect someone not trained as a Physician to replace a Physician. You are arguing that Nursing is training better Primary care providers, How? What is the evidence of this?

How can Nurses train such providers without medical focus?

What you are posting is worrisome and problematic IMHO.

Why do I have to prove that Doctors are trained to practice medicine best? I think it is the NP's that need to prove they can practice just as well.

That is what I'm asking.

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.

Name the states please till then this is anecdotal, name the states I will happily look into the laws and rules and see if that is true then. I would like to know. The study with charts I saw said it was only about 4.

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.

what states? Georgia has NP's in rural settings but they must have physician involvement.

The collaborating physician may be miles away only available by phone.

So? Fax machines and email, phone calls, that Physician can still change the plan of care. So this is not pure autonomy. That is my point and by the way I agree with this level, still a high level but with a check and balance. Why would you appose that?

Does the physician get to see the NP's patients? Not unless the NP thinks they need to be seen by a physician.

This is not correct if there is collaboration, if the Physician who is collaborating wants to see the patient how can this be refused? Why would you? as far as I know it is not lawful.

This happens in some states and is completely acceptable as the NP is not breaking any practice act or federal law in this case.

I'm confused? a Physician requests to see a patient and the NP can refuse? this is normal practice?

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.

sure if this is the case but I doubt it is as clear cut as you post here. I have serious questions as above.

As a physician I would never "Keep my patient" to myself, I would refer and confer with colleges, its scary to see a proposal that a NP may not to be "Autonomous" Taking care of patients is not a way to do this.

Please explain because I think I may have misunderstood the intent here. from what I see you want me to believe these NP's are now alone and not part of the "Team" RURAL practice is different then you think, I'm in the middle of the deep south, times have changed.

Please explain.

wowza · Jul 11, 2008

Actually, questionnaires can be assessed for their validity and reliability and may be the best choice.

Of course questionnaires can be assessed for validity but they cannot correct for a number of biases. That is why they are nearly universally considered a weak way to obtain data when other options are available.

When we are talking about an endpoint that can easily be measured objectively, using questionnaires is not the best way to go about it.

JDCitizen · Jul 11, 2008

It would seem so. However, if you look at the advance for NP listing for practice it shows 40% doing primary care (FP+peds+IM). The only way that you could get more than 50% is by assuming that all of the "other" are in primary care. The other point is that while 52% of NPs have an FNP only 16% working primary care. I will point out that it is hard to figure out the position (35%FP) vs employment setting (16%). If you look at the advance data and the Program data ACNP has been increasing over the time and the FP percentage is going down. As a percentage the ACNP seems to be gaining favor over the FNP. The FNP does continue to constitute the bulk of the new grad FNPs currently. The NP world seems to be following the physician and PA world.

I disagree, a little, I don't think we are following I think to a large degree we are being sucked in if not invited in.

Its really difficult if not impossible to make money in primary care. In a shortage market specialty care can offer more money.

Exactly and that's why groups have so many us running around seeing patients for them. Cost benefit ratio: More seen more money in the bank.

Advancement of nursing education + sicker population + shortage of providers + delegation of authority = Certain providers are losing ground (i.e. money, prestige)

Nurses have been diagnosing, ordering test, intervening well before any of us even existed. Still happens now, tomorrow and the next. Hospital nurses, office nurses doing what needs to be don. Doctors have not only delegated this authority but they have given it away. Now under the guise of patient safety and being better educated they are raising a public outcry even though large majorities are still doing the same thing in private.

Loss of market share does strange things.

The captain of the team theory has gone out the door because necessity opened that door.

I have provided medical care and observed others at many different levels rendering medical care (inside and outside the hospital). Its not all about school.

The DNP does not change this. If anything it accelerates the movement. There are a number of studies that show (in medicine at least) that debt level is inversely correlated with the desire to practice primary care.
I think that you and I both agree that the rank and file NPs do not support a move to the DNP. However if you look at the ABCC board of directors you see a lot of nursing school deans as well as NONPF and AACN members supporting the certification. Essentially they have proposed using a test for designed to assess for the unsupervised practice of medicine as the primary certification for advanced practice nursing. Never mind that the test primarily tests inpatient medicine skills (at least as explained to me). How does that best serve NPs?
David Carpenter, PA-C

Actually I myself could care less for the DNP. Unless the program is at least basically standerized with basic minimal requirements etc.. from state to state it's a hoax.

DO MD PA NP apples to oranges with never in our life time a consensus be. :yawn:

allnurses Guide · Jul 11, 2008

Of course questionnaires can be assessed for validity but they cannot correct for a number of biases. That is why they are nearly universally considered a weak way to obtain data when other options are available

Sorry, totally disagree - it all depends what TYPE of data you're trying to measure as to the best data collection tool. Almost certainly not "universally" considered a "weak" option - again depending on the measure you're looking at.

RN to Medschool · Jul 11, 2008

Its really difficult if not impossible to make money in primary care.
In a shortage market specialty care can offer more money.

Exactly and that’s why groups have so many us running around seeing patients for them. Cost benefit ratio: More seen more money in the bank.

Advancement of nursing education + sicker population + shortage of providers + delegation of authority = Certain providers are losing ground (i.e. money, prestige)

Nurses have been diagnosing, ordering test, intervening well before any of us even existed. Still happens now, tomorrow and the next. Hospital nurses, office nurses doing what needs to be don. Doctors have not only delegated this authority but they have given it away. [

1st off, the concept of having a PA or NP working in primary care with the physician is a sound one if set up right, the physician should be seeing the same patients on a rotation basis. It is not meant and in some states by law, that the PA or NP are the only care givers. Again that this goes on does not mean it is the right thing to do, in some cases it is breaking the law, in states where the law is broken it does not matter if you think it is a bad law, adhering to a law is the civic duty, if you disagree with a state law you lobby for change, open defiance by breaking it is criminal and is prosecuted.

2nd Physicians did not give away anything, its lay people who have been influenced and confused, many lay people think Nurses are "Junior Doctors" after 20 years as an RN this concept was told to me 100's of times, Law makers are not in medicine, they are lay people.

As far as ordering tests, sure did that as a Nurse, but do nurses always know why they order a test? I have already caught mistakes in test ordering in CLinicals.

3rd Diagnosis? What percentage of them are right? That would be the real figure to know, ( probably will not be studied though) One thing to point out its hard to write a diagnosis of something you have no knowledge of, a disease process you have never heard of, limited class time and study time of PA and NP can lead to wrong diagnosis at times, it happens to Physicians with more class and study time, how does less class and study time on Medicine equate to being expert at Diagnosis? The longer residency of MD/DO helps too, residency is learning time, PA's and NP's have an extremely short Clinical time (MD and DO have both Clinicals for 2 years plus any residency so at least 5 years on the wards) PA and NP have only about a year, how does a year become better then 5 years?

Advanced Practice Columnist / Guide · Jul 11, 2008

It would seem so. However, if you look at the advance for NP listing for practice it shows 40% doing primary care (FP+peds+IM). The only way that you could get more than 50% is by assuming that all of the "other" are in primary care. The other point is that while 52% of NPs have an FNP only 16% working primary care. I will point out that it is hard to figure out the position (35%FP) vs employment setting (16%). If you look at the advance data and the Program data ACNP has been increasing over the time and the FP percentage is going down. As a percentage the ACNP seems to be gaining favor over the FNP. The FNP does continue to constitute the bulk of the new grad FNPs currently. The NP world seems to be following the physician and PA world. Its really difficult if not impossible to make money in primary care. In a shortage market specialty care can offer more money.
The DNP does not change this. If anything it accelerates the movement. There are a number of studies that show (in medicine at least) that debt level is inversely correlated with the desire to practice primary care.
I think that you and I both agree that the rank and file NPs do not support a move to the DNP. However if you look at the ABCC board of directors you see a lot of nursing school deans as well as NONPF and AACN members supporting the certification. Essentially they have proposed using a test for designed to assess for the unsupervised practice of medicine as the primary certification for advanced practice nursing. Never mind that the test primarily tests inpatient medicine skills (at least as explained to me). How does that best serve NPs?
David Carpenter, PA-C

I think we have to take Advance data with a grain of salt. How many NP's actually responded to their survey? Currently, there is no authoritative survey of NP's nationally. Even the AANP survey is not as reliable as many NP's are not members of that organization and are not certified through that group. I think much of what NP's choose as their specialization is driven by what the market offers. I wouldn't mind doing primary care myself if I can get a job doing it in my own backyard. The metro area I live in is very urban -- many physicians saturate the market and NP openings are in the specialty fields. That's why I went into ACNP.

Much can be learned from the PA profession about a unified voice. CRNA's and CNM's are very similar in that they are represented by a single organization. However, it is inherent in the NP profession that we come from different specializations. I think of it as something akin to the different specializations in medicine and the different professional associations for each group. The ANA is the national association for all nurses. However, even the ANA has issues. If you don't already know, many state nursing associations have disaffiliated from ANA including the state nursing association in Michigan. That's the nature of nursing -- one profession many roles but definitely very fragmented.

The ABCC is an interesting concept. I tell you that Dr. Mundinger is truly a force to reckon with. Not only does she head one of the top programs in nursing in the nation (and I acknowldge your mistake -- it's not the top but one of the top 20 if you believe in the unreliable rankings from US News). The ABCC is composed of deans and bigwigs in health care both in the fields of medicine and nursing. Two members are from my home state of Michigan. However, the group does not have the word "nursing" anywhere mentioned in their website aside from when they state the degree of DNP. Dr. Mundinger, I assume, has connections with people at the highest level of the business of health care. She was inducted to the Institute of Medicine.

I for one, do not totally disagree with the DNP concept. My biggest problem is how it was implemented and how it has taken off from all different directions. But really, the reason why I am posting in this thread is that my feelings are these:

1. the DNP will not change practice acts for NP's in each state. At least not in the near future so all this hoopla over nurses with DNP's replacing physicians and asking for an expanded scope of practice is baseless.

2. NP's have and will continue to provide primary care whether independent or in collaboration with physicians. Primary care in this country is deeply flawed. Patients show up in acute care hospitals in advanced disease and requiring tertiary level of care. How did this happen? How did we not catch people before their disease got to where it is. I think there is huge issue with access to healthcare. Physicians, I agree, would like to keep primary care under their wings. But is there enough physicians taking the call? Huge student loans are preventing med school grads to pursue low paying fields such as primary care -- at least, that's their excuse. Regardless of what it really is, NP's are answering the call and so are PA's. We are competent to assume first contact care to Americans at less cost to the entire health care system. Will a NP not refer to a physician if need be? of course not.

That's all the time I got for now. I am at work and a sick LVAD patient is coming from the OR. Any other responses to other posts I am going to forego. I said my case and anyone can disagree.