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

wowza · Jul 11, 2008

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.

I agree that if you are trying to measure data that is totally subjective (satisfaction and the like), you must use a subjective test. In this case a questionnaire is your best bet. I conceded this point in my initial post on the study.

However, if you are trying to measure very objective data such as physiological outcomes using a questionnaire (like they did in the aforementioned study) that is a massive flaw in the methods.

If I were to have a study on which drug works better to control blood pressure which would produce a more valid and reproducible study?

1) a questionnaire give to all my patients

2) Actually measuring the blood pressure of all my patients

core0 · Jul 11, 2008

snip
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.

I think the point is that the NP world is at what political scientist refer to as a tipping point. As you pointed out the DNP will not changes state nursing practice acts. What the DNP is really about is power. There has been a longstanding goal of the AACN and the NONPF to elevate nursing to a higher academic level. Ie to turn it into a professional field instead of a technical one. Personally I think that nursing is a professional field but it retains many aspects of a technical field ie hourly wages.

There has been a long term effort to move the RN degree to a BSN. This has largely failed since there is no coercive way to make nurses get their BSN. Ie no stick (and really no carrot). A similar situation existed in the NP field in the mid 80's to early 90's. Even though the AACN dictated that NPs should be masters trained nurses the majority of NPs continued to be non-masters. The route they used was to tie Medicare reimbursement to the MSN for all APNs in 1997 through the balanced budget act.

Take the current situation. The ABCC is using the step 3 as the exam for DNPs. The USMLE states, "Step 3 provides a final assessment of physicians assuming independent responsibility for delivering general medical care." Never mind that the ABCC is only using half the test or that no state in the nation will license a physician with only the step 3. The use of the step 3 leads to two scenarios. Neither good for the NP community as a whole.

1. Most of the applicants pass the step 3 with equivalent scores to the physicians. In this case the ABCC can go to Medicare and state that given the DNP with ABCC cert is equivalent to an independently practicing physician this should be the requirement for NPs to receive Medicare billing (presumably at 100%). Hopefully there is a grandfather clause for currently practicing NPs but inherently it leaves open the question whether those NPs are as capable as the ones that pass the ABCC cert.

2. Given that they are taking a test that measures biomedical and clinical knowledge which is gained over four years of medical school and one year of internship the DNPs fail in droves. The failure rate for US grads is less than 5%. The failure rate for IMGs is over 30%. For IMGs there is also a significant winnowing factor since they have to pass step 1 and 2. In this case the ABCC has shown that DNPs are not as capable as physicians. Essentially they are not capable of the same level of independent practice as physicians. This opens the door for medicine to make an organized attack on NP independence in every state in the nation. The ABCC will finally give a metric which compares NPs and physicians. Use of the step 3 also implicitly states that NPs give medical care potentially giving states the rationale to assert BOM authority over NPs.

Ultimately from my point of view the DNP is not about practice or excellence or patient care. Its about power and money. If the DNP was truly about providing better patient care it would have been developed in a way that assessed any deficiencies in patient care and moved to address those. The Canadian NPs went through this several years ago and the identified deficiencies were in pharmacology and clinical experience (the same deficiencies identified by the State BON's in their white paper). They chose to remedy this by expanding the existing NP programs. The NONPF chose the DNP which advances their political goals.

Just my thoughts as a nursing outsider.

David Carpenter, PA-C

Advanced Practice Columnist / Guide · Jul 11, 2008

I think the point is that the NP world is at what political scientist refer to as a tipping point. As you pointed out the DNP will not changes state nursing practice acts. What the DNP is really about is power. There has been a longstanding goal of the AACN and the NONPF to elevate nursing to a higher academic level. Ie to turn it into a professional field instead of a technical one. Personally I think that nursing is a professional field but it retains many aspects of a technical field ie hourly wages.
There has been a long term effort to move the RN degree to a BSN. This has largely failed since there is no coercive way to make nurses get their BSN. Ie no stick (and really no carrot). A similar situation existed in the NP field in the mid 80's to early 90's. Even though the AACN dictated that NPs should be masters trained nurses the majority of NPs continued to be non-masters. The route they used was to tie Medicare reimbursement to the MSN for all APNs in 1997 through the balanced budget act.
Take the current situation. The ABCC is using the step 3 as the exam for DNPs. The USMLE states, "Step 3 provides a final assessment of physicians assuming independent responsibility for delivering general medical care." Never mind that the ABCC is only using half the test or that no state in the nation will license a physician with only the step 3. The use of the step 3 leads to two scenarios. Neither good for the NP community as a whole.
1. Most of the applicants pass the step 3 with equivalent scores to the physicians. In this case the ABCC can go to Medicare and state that given the DNP with ABCC cert is equivalent to an independently practicing physician this should be the requirement for NPs to receive Medicare billing (presumably at 100%). Hopefully there is a grandfather clause for currently practicing NPs but inherently it leaves open the question whether those NPs are as capable as the ones that pass the ABCC cert.
2. Given that they are taking a test that measures biomedical and clinical knowledge which is gained over four years of medical school and one year of internship the DNPs fail in droves. The failure rate for US grads is less than 5%. The failure rate for IMGs is over 30%. For IMGs there is also a significant winnowing factor since they have to pass step 1 and 2. In this case the ABCC has shown that DNPs are not as capable as physicians. Essentially they are not capable of the same level of independent practice as physicians. This opens the door for medicine to make an organized attack on NP independence in every state in the nation. The ABCC will finally give a metric which compares NPs and physicians. Use of the step 3 also implicitly states that NPs give medical care potentially giving states the rationale to assert BOM authority over NPs.
Ultimately from my point of view the DNP is not about practice or excellence or patient care. Its about power and money. If the DNP was truly about providing better patient care it would have been developed in a way that assessed any deficiencies in patient care and moved to address those. The Canadian NPs went through this several years ago and the identified deficiencies were in pharmacology and clinical experience (the same deficiencies identified by the State BON's in their white paper). They chose to remedy this by expanding the existing NP programs. The NONPF chose the DNP which advances their political goals.
Just my thoughts as a nursing outsider.
David Carpenter, PA-C

Totally agree, I think somebody else already posted that gone are the days when nurses were considered handmaidens. The sisterhood is coming to an end and nurses, more than ever, are wielding their power. Bedside nurses are unionizing and clamoring for rights to safe staffing ratios and advanced practice nurses are pushing the buttons for equality with physicians, the same folks nurses we're once subservient to. Good times!

JDCitizen · Jul 11, 2008

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.

If it is set up right? So I guess the doctor gets to make the decision if the set up right? When the doctor is not in the room with the patient at the time the diagnosis is made and treatment is rendered that is something he/she has surrendered to another provider. Protocols, phone calls or anything else it is a surrendered duty. You are teaching to the choir there is more than a few providers on either side of the profession affected by that statement.

At any given time when protocols are in effect:

1)Doctor trusts that I am following them

2)Doctor trusts I am interpreting properly

3)Doctor trusts I am treating properly

4)Doctor trusts I will refer appropriately

5)The doctor is leaving the patient to trust that I am following them

6)The doctor is leaving the patient to trust I am interpreting properly

7)The doctor is leaving the patient to trust I am treating properly

8)The doctor is leaving the patient to trust I will refer appropriately

A review of charts after the fact may catch errors but that’s like checking for failed breaks after the wreck.

Would you use a PA or a NP (or would you see the doctor)? Would you allow your spouse or child? Did you hesitate for even a second with your decision?

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.

BULL for two reasons! 1) So when the lay people set up laws covering the practice medicine can I infer they may have gotton it wrong? 2)Do you think a lot of procedures that nurses do just came out of the blue? Just to name some of the larger known ones: Protocols, standing orders, blank signed prescriptions and ACLS for that matter. If your argument rings true it would be CPR until the doctor gets in... Oh you are going to argue is has the doctors input... Please give me a break the doctor is trusting that I or any other nurse knows what that squiggly line on the monitor is that I am going to grab and give the right drug.

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.

Hmmm does the doctor? Yep I sure have also and a matter of fact have I caught plenty in my time as an RN as well as those pesky medication errors.

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?

;-) I somewhat concur with this but that is a two way road.

One also has to admit quantity is not necessarily a quality. If any one group of doctors knew all and could do all natural selection would have taken care of the rest. I bet all those specialties didn’t form overnight? Medicine evolved? Did it evolve because the disease process needed specialty care or because of substandard care or both?

I am also will add: When its a doctor or a nurse and in either case that person is too stupid or proud to confer / refer when needed it does not matter how many years or school or letters behind the name.

If you don't know: I like my NP / provider setup. I don’t know it all and the doctors I work with don’t know it all and maybe with us all working together the patient stays alive and unharmed.

All my years of nursing still I have one thing that has been linked more to nursing than medicine: Patient advocate. Any nurse in his/her career that has stood up for the patient has faced the wrath from medicine and/or administration...

DMURSE1 · Jul 21, 2008

Wow. There are some frustrated individuals on this forum. There wasn't much said about residency and cliincal experience. I'll have to admit being a critical care nurse for 3 years 99.9 percent of my knowledge is from working in the field. Very little was learned from nursing school and after speaking with residents that appears to be the same. So regardless whether you are a PA, NP, DO or MD, where and how long you have worked in your specialty is of most importance. If you had to get an epidural placed, would you rather have a CRNA that has placed 1000 epidurals or an MDA that just finished a residency who has placed 200 epidurals. The same goes in all clinical settings. When **** hits the fan Letters do not mean a thing. AEB poor physicians, PA's, NP's, RN's, DO, MD's etc...

silas2642 · Jul 21, 2008

Wow. There are some frustrated individuals on this forum. There wasn't much said about residency and cliincal experience. I'll have to admit being a critical care nurse for 3 years 99.9 percent of my knowledge is from working in the field. Very little was learned from nursing school and after speaking with residents that appears to be the same. So regardless whether you are a PA, NP, DO or MD, where and how long you have worked in your specialty is of most importance. If you had to get an epidural placed, would you rather have a CRNA that has placed 1000 epidurals or an MDA that just finished a residency who has placed 200 epidurals. The same goes in all clinical settings. When **** hits the fan Letters do not mean a thing. AEB poor physicians, PA's, NP's, RN's, DO, MD's etc...

I'm sorry, but when the crap hits the fan, I want an attending physician to be in charge-- not an RN, PA, or an NP/DNP. The training that a fully trained physician receives is unparallel-- btw, you think that an anesthesiologist who has just finished his residency would only have completed 200 epidurals during his training? That seems a little low to me.

If my grandmother is going do crash, I want the person who went to medical school, took intensive courses in anatomy, physiology, pathology, pharmacology, etc. I want him/her to know what to do and why they are doing it. But I also want him/her to be backed up by a team of PAs, NP's, RN's and other physicians because that person cannot do it alone. Medicine is a team job, but that team is going to work best if the head of the team received the most intensive training as possible.

JDCitizen · Jul 21, 2008

I'm sorry,

never should feel sorry for your views

but when the crap hits the fan, I want an attending physician to be in charge-- not an RN, PA, or an NP/DNP.

OK... 100% fall under a patients rights.

The training that a fully trained physician receives is unparallel

To a degree but not enough for me to disagree

-- btw, you think that an anesthesiologist who has just finished his residency would only have completed 200 epidurals during his training? That seems a little low to me.

No comment...

When the crap hits the fan I want the most qualified people...

If that is a PA, NP I'll take them it is the MD great also.

If my grandmother is going do crash, I want the person who went to medical school, took intensive courses in anatomy, physiology, pathology, pharmacology, etc. I want him/her to know what to do and why they are doing it. But I also want him/her to be backed up by a team of PAs, NP's, RN's and other physicians because that person cannot do it alone.

True it can't be done alone....

Medicine is a team job, but that team is going to work best if the head of the team received the most intensive training as possible.

I have seen ERs use dermatologist, etc.... Next to a trauma trained PA...

JDCitizen · Jul 21, 2008

never should feel sorry for your views
OK... 100% fall under a patients rights.
To a degree but not enough for me to disagree
No comment...
If that is a PA, NP I'll take them it is the MD great also.
True it can't be done alone....
I have seen ERs use dermatologist, etc.... Next to a trauma trained PA...

Hmmm went back and read your post my post and since the 5 minute correction limit has passed........

Anyway 99% agree with you.

DMURSE1 · Jul 21, 2008

btw, you think that an anesthesiologist who has just finished his residency would only have completed 200 epidurals during his training? That seems a little low to me.

Multifactorial, Ie: Community Hospital versus Teaching Hospital Fellowship and in what specialty.

If my grandmother is going do crash, I want the person who went to medical school, took intensive courses in anatomy, physiology, pathology, pharmacology, etc. I want him/her to know what to do and why they are doing it. But I also want him/her to be backed up by a team of PAs, NP's, RN's and other physicians because that person cannot do it alone

True no one can do it alone. However a logical explanation, as taught in textbooks does not compare with working one on one with a specific patient population and having clinical evidence stored in your noodle to guide practice. For example physiological effects of cardio pulmonary bypass post OH surgery often requires an RN to make split second bedside decisions that a General Intensivist or Attending cannot comprehend.

When it does really hit the fan I want an attending that has SPECIALTY, EXPERIENCE present. An ER attending that has no experience with fresh post op Heart transplants on ECMO are useless in that setting, regardless of all of the logical sciences taken.

The same goes with all specialties regardless of Name Suffixes.

RNPATL, DNP, RN · Jul 22, 2008

Wow - very interesting thread. Have been lurking for the past couple of days just reading the responses and posts. As a nurse that will have an MSN shortly, I am slowly making a decision whether to go for the PhD or for the DNP.

For me - earning a doctoral degree in nursing (DNP or PhD) is not so I can be equal to physicians, it is so I can lend credibility to the science of nursing at the highest level possible. I respect and apprecaite the art and science of nursing. If I held the same respect for medicine, I would have gone to become a physician. For me, nursing offers a unique blend of compassion, nurturing and spirit that I am afraid that medicine lacks. Read the studies - Advance Practice Nurses hold a wonderful lead when it comes to bedside manner and impression that the patient received wonderful care.

I believe health care is changing and the role of the advanced doctoral prepared nurse is changing along with it. It is about time in my opinion. Physicians, DNP nurses and other health care disciplines are all a part of the great collective called a team. Each member serves a wonderful and enlightened role as care is rendered and provided. I truly believe that nursing and medicine must have a collaborative and collegial relationship as educational standards for nurses change. How can anyone look at a doctoral prepared nurse and tell them they are not qualified or that they do not possess the education to stand hand to hand and toe to toe with physicians? Perhaps course content may be different and the philosophy of the degrees may have a different framework, but the rigours of the course content and the scholarly nature of the degree remains the same and consistent. Clearly there are differences, but physicians have no more right to degrade the DNP - RN than the DNP has to degrade the MD or DO.

For me - whether it is your choice to be a medical doctor or a nursing doctor, there is a place for both in this crazy and rapidly changing health care system. Respect and appreicate the contribution that each can bring to providing care to the patient.

kellyjoeds · Jul 23, 2008

OMG,

The pressures and demands in all healthcare professions, and the general tendency of nurses and other healthcare professionals to eat their own young, are enough to frustrate and depress new nurses like me! You may all be well educated, experienced, superior beings; but your people and communication skills are seriously lacking! If everyone forgot for one second that they knew it all, we might be able to benefit or learn from one another's perspectives! :argue:

JDCitizen · Jul 23, 2008

I went back and read some of the postings here...

Ultimately from my point of view the DNP is not about practice or excellence or patient care. Its about power and money.

Yes but I think it is also something more and somewhat darker. I think nursing has a inferiority problem. I think it's reflected in the teaching methods. In my MSN program we spent one of our two years not on patient care but for all practical purposes on nursing. No not nursing as in helping folks but as in them stuffing down our throats proving that nursing was not just a job but a science. To this day I don't care and I sure don't think my patients care what theorist my nursing skills most reflect. I guess it might go back to the submissive or handmaiden days I don't know. I really believe and most of the others in my class believe that a large part of the curriculum of the nursing program is/was based on this inferiority complex........

If the DNP was truly about providing better patient care it would have been developed in a way that assessed any deficiencies in patient care and moved to address those.

I have to agree. APRNs that are not going to be teaching in a school the main focus of the program should be patient care focused.

The Canadian NPs went through this several years ago and the identified deficiencies were in pharmacology and clinical experience (the same deficiencies identified by the State BON's in their white paper). They chose to remedy this by expanding the existing NP programs.

I don't know about those folk in Canada...

100% of my class noted deficiencies in pharmacology and clinical experience on our exit prgram evaluations...

The NONPF chose the DNP which advances their political goals.

??????

DNP until there is greater consistancy in program structure not only within each state but from state to state (as I said in other postings): It will be a joke. Heck there isn't even any consisency form state to state rules and regulations for APRNs. We may not only letting ourseves down but the very patients/people we are supposed to care and be advocates for. In case we forget: There are people/professions out there that are more than happy to let us hang ourselves.

Just my thoughts as a nursing insider............

Flame away.....