DNP: Mirroring the Path of DO?

AF2BSN · Nov 18, 2020

14 minutes ago, myoglobin said:

No doubt an MD will beat an NP on "medical jeopardy" nine times out of ten. However, "knowing more facts" does not always equate to better outcomes. Actively, bringing into practice evidence based modalities such as diet, exercise, and evidence based CAM approaches can often have profound implications on patient health. Going after the underlying insulin resistance that drives "metabolic syndrome" for example is likely to be far more effective in modifying risk factors such as stroke, heart disease and end target organ damage than is "prescribing more insulin" or the latest greatest diabetes drug(unless it is the only way to achieve glucose regulation, and even then it should be seen as a necessary evil given that it usually increases insulin resistance in Type II diabetes thus worsening the underlying etiology). Many times even as a PMHNP I am able to reduce or eliminate cognitive dulling medications used in my clients with co-occurring seizure disorder through the use of interventions such as a low carb/ketogenic diet and or addition of MCT's. I have had many clients ask their neurologist's about these diets (in the context of seizure disorder) and they often say something to the effect of "yea they work, but they are too hard for us to patients to follow and we just don't have the time.". Well, I can often get my client to implement these approaches at least to a significant degree. In my experience seven times out of ten the NP will do a better job in emphasizing these lifestyle modifications. Thus ,even if they lose "medical jeopardy" their patients will often win in terms of better outcomes.

There are plenty of physicians who use a holistic approach. Why do nurses think they’re the only ones LOL? It’s not the sole domain of nursing, come on. I realize I’m on allnurses, but seriously?

You all win. NPs do the same thing as physicians, but also not the same, but also better. ?

myoglobin, ASN, BSN, MSN · Nov 18, 2020

30 minutes ago, AF2BSN said:

There are plenty of physicians who use a holistic approach. Why do nurses think they’re the only ones LOL? It’s not the sole domain of nursing, come on. I realize I’m on allnurses, but seriously?

You all win. NPs do the same thing as physicians, but also not the same, but also better. ?

In my experience there is an exponentially greater emphasis on holistic approaches among NP’s than MD’s and a relatively lower emphasis on materialism verses a more spiritual approach. Also, yes this is Allnurses I am bias towards nursing. I rather expect that over at studentdoctor.net that I might find and at least equal bias in the other direction.

Ellen NP, MSN, NP · Nov 18, 2020

5 hours ago, myoglobin said:

No doubt an MD will beat an NP on "medical jeopardy" nine times out of ten. However, "knowing more facts" does not always equate to better outcomes. Actively, bringing into practice evidence based modalities such as diet, exercise, and evidence based CAM approaches can often have profound implications on patient health. Going after the underlying insulin resistance that drives "metabolic syndrome" for example is likely to be far more effective in modifying risk factors such as stroke, heart disease and end target organ damage than is "prescribing more insulin" or the latest greatest diabetes drug(unless it is the only way to achieve glucose regulation, and even then it should be seen as a necessary evil given that it usually increases insulin resistance in Type II diabetes thus worsening the underlying etiology). Many times even as a PMHNP I am able to reduce or eliminate cognitive dulling medications used in my clients with co-occurring seizure disorder through the use of interventions such as a low carb/ketogenic diet and or addition of MCT's. I have had many clients ask their neurologist's about these diets (in the context of seizure disorder) and they often say something to the effect of "yea they work, but they are too hard for us to patients to follow and we just don't have the time.". Well, I can often get my client to implement these approaches at least to a significant degree. In my experience seven times out of ten the NP will do a better job in emphasizing these lifestyle modifications. Thus ,even if they lose "medical jeopardy" their patients will often win in terms of better outcomes.

My internist does all of these things and has superior medical training as have my past internists. Current medical training is much more holistic than in the past. Physicians are receiving more holistic training and NPs are having even less standardized clinical training. This is not a winning strategy for our profession.

Ellen NP, MSN, NP · Nov 18, 2020

4 hours ago, myoglobin said:

In my experience there is an exponentially greater emphasis on holistic approaches among NP’s than MD’s and a relatively lower emphasis on materialism verses a more spiritual approach. Also, yes this is Allnurses I am bias towards nursing. I rather expect that over at studentdoctor.net that I might find and at least equal bias in the other direction.

This was my experience 20 years ago but this has changed. Medical education is more holistic and NP education has become less rigorous and less standardized in terms of clinical training.

7 hours ago, BSN2DNPFNP said:

I can’t agree enough with this. There are true benefits to being and NP, and having the background as an RN that you don’t get as an MD. There are advantages to both career paths, but both providers focus on bettering patient outcomes. Same end goal, sometimes different approach.

Too bad that clinical nursing background is no longer required for NP education.

myoglobin, ASN, BSN, MSN · Nov 18, 2020

9 hours ago, Ellen NP said:

My internist does all of these things and has superior medical training as have my past internists. Current medical training is much more holistic than in the past. Physicians are receiving more holistic training and NPs are having even less standardized clinical training. This is not a winning strategy for our profession.

Maybe so but the psychiatrists I trained under barely used holistic approaches in practice and spent about 15 minutes per patient on follow ups and 40 min on intakes. I get up to 2 hours with clients on intakes and 60 min (if I need it ) on follow ups. Thus, even if a psychiatrist had the inclination (and few do in my experience) they would not have the time. I observed a similar pattern with Family practice MD’s 10-15 minutes for appointments. FNP’s (at least those with their own business or 1099) have the ability to see less patients and spend more time with them. My point is rather than bemoaning the short comings of the education it would be preferable to focus on our strengths and focus on CE’s, journals and other avenues where we can enhance our education. In states like Washington, Arizona, Oregon and elsewhere NP’s provide a huge amount of care in an IP scenario and have done so successfully for years. Indeed to some extent we have outcompeted MD’s who often move to states where their incomes are not driven down by the competition. However, even in non IP states like Florida I have found numerous MD’s willing to “supervise” largely in name only for about 10 percent of revenue. Even the W-2 supervised jobs I was offered for about 100k were mostly “in name only” with at most monthly meetings of about 2 hours to discuss cases. MD’s are usually too busy seeing clients of their own to offer meaningful supervision outside of inpatient settings.

Also, don't forget even if educational standards are going to change (and it is a complicated if) it is a process likely to take many years. Thus, the "de facto" situation on the ground is that NP's (of all stripes) have effective IP in essentially every state (so long as they work out an arrangement with a willing MD). Thus, it stands to reason that they should seek out the best possible deal in terms of compensation and time with patients while also seeking to optimize their education, and cognitive acumen across as many domains as possible.

Advanced Practice Columnist / Guide · Nov 19, 2020

Holistic training aside, what I see happening is that as Medicine pushes for more training and specialization among their ranks...the NP field has remained stagnant refusing to keep up with the outdated, oversimplified, and impractical ways we structure our education. We've allowed so much unchecked saturation in our training programs further making standardization and quality control problematic.

Think about this...for example, we have MD's and DO's going from Internal Medicine residency to Cardiology Fellowship to Advanced Heart Failure Fellowship only to have the ability to care for patients with complex cardiomyopathies requiring advanced heart failure therapies. On the other hand, we NP's can't even decide whether an AGACNP or AGNP or FNP is appropriate for a job in Cardiology.

The silver lining is that fellowships are starting to become established and I hope these do gain a lot of traction.

myoglobin, ASN, BSN, MSN · Nov 19, 2020

4 hours ago, juan de la cruz said:

Holistic training aside, what I see happening is that as Medicine pushes for more training and specialization among their ranks...the NP field has remained stagnant refusing to keep up with the outdated, oversimplified, and impractical ways we structure our education. We've allowed so much unchecked saturation in our training programs further making standardization and quality control problematic.

Think about this...for example, we have MD's and DO's going from Internal Medicine residency to Cardiology Fellowship to Advanced Heart Failure Fellowship only to have the ability to care for patients with complex cardiomyopathies requiring advanced heart failure therapies. On the other hand, we NP's can't even decide whether an AGACNP or AGNP or FNP is appropriate for a job in Cardiology.

The silver lining is that fellowships are starting to become established and I hope these do gain a lot of traction.

Yes, but "the problem" with MD's is that the "creep upward" for their educational requirements means that they have to spend ever more years of their lives in training with concurrent increasing costs for their education. We should celebrate the advantages of the reduced requirements and barriers to entry and the opportunities this creates to practice (as an NP) at a younger age and carefully consider the necessity of additional regulatory burdens which will increase the cost/time needed to practice. Thus, if there are to be additional requirements at least make them highly targeted to courses and proficiencies most relevant to practice and make them highly evidence based for outcomes (and as minimal as possible). In no case should they be added to "protect wages" or make things easier for those already practicing (like me). If the market becomes "flooded" and my wages go down to 100k from the 250k that I am now earning then that is overall probably a very good thing for most patients as it means they will have better access to providers (and those like myself will have to find more efficient ways to compete or subsist on less income).

AF2BSN · Nov 23, 2020

On 11/19/2020 at 6:39 PM, myoglobin said:

Yes, but "the problem" with MD's is that the "creep upward" for their educational requirements means that they have to spend ever more years of their lives in training with concurrent increasing costs for their education. We should celebrate the advantages of the reduced requirements and barriers to entry and the opportunities this creates to practice (as an NP) at a younger age and carefully consider the necessity of additional regulatory burdens which will increase the cost/time needed to practice. Thus, if there are to be additional requirements at least make them highly targeted to courses and proficiencies most relevant to practice and make them highly evidence based for outcomes (and as minimal as possible). In no case should they be added to "protect wages" or make things easier for those already practicing (like me). If the market becomes "flooded" and my wages go down to 100k from the 250k that I am now earning then that is overall probably a very good thing for most patients as it means they will have better access to providers (and those like myself will have to find more efficient ways to compete or subsist on less income).

Once a physician graduates they're making a salary as a resident (albeit, a smaller one than most new grad nurses these days), as well as fellows. They're not incurring any cost other than their sanity. If you mean to speak about opportunity cost regarding more training equaling less salary, I can maybe bite on that. However, attending salaries are hardly a poor house affair. Even those who do fellowships end up with lucrative salaries unless the physician decides to pursue academic medicine (which is still a decent six figure salary).

I'm not seeing where we should celebrate people with less training, operating with more autonomy, as bright point for the NP profession. Practicing NPs should be leading the charge for higher standards. I think we have all agreed that the curriculum needs an overhaul and that the material covered should be applicable to assessing, diagnosing, and treating patients. With regards to the market "flood": you can't mass produce quality. I don't see it as a good thing for patients. Just look at the FNP salary market and overall quality of new grads-- it's dismal.

myoglobin, ASN, BSN, MSN · Nov 24, 2020

42 minutes ago, AF2BSN said:

Once a physician graduates they're making a salary as a resident (albeit, a smaller one than most new grad nurses these days), as well as fellows. They're not incurring any cost other than their sanity. If you mean to speak about opportunity cost regarding more training equaling less salary, I can maybe bite on that. However, attending salaries are hardly a poor house affair. Even those who do fellowships end up with lucrative salaries unless the physician decides to pursue academic medicine (which is still a decent six figure salary).

I'm not seeing where we should celebrate people with less training, operating with more autonomy, as bright point for the NP profession. Practicing NPs should be leading the charge for higher standards. I think we have all agreed that the curriculum needs an overhaul and that the material covered should be applicable to assessing, diagnosing, and treating patients. With regards to the market "flood": you can't mass produce quality. I don't see it as a good thing for patients. Just look at the FNP salary market and overall quality of new grads-- it's dismal.

In response I assert the following:

a. Outcomes in primary care for FNP's have been excellent in many cases equal or superior to that of MD's. There is no reason to believe that this will not continue. More education does not automatically equal better application or improved outcomes. NP's often do things differently and inherent in some of those differences (maybe) is the reason for parity in outcomes (like spending more time on average with patients).

b. Pay would be far better and time with patients maximized if "my" approach to "NP owned and managed" groups was more the norm. As I have outlined in other threads this is possible even in non IP states by paying a reasonable fee of around 10% to MD's to act as supervisors/collaborators (the practice can still be owned by the NP's). In this way a much higher percentage of the insurance revenues would be passed on to the FNP's. I had that very offer made to me during my "medical rotation" and both MD's offered me around 80% if insurance if I worked 1099 which they said should be well in excess of 200K even in Florida (salaried positions would have been around 100K for FNP's at the time).

c. I do believe that education can be "enhanced" but do not advocate for "overhaul". Also any such process will be years in the making. Meanwhile, we have effective IP in nearly every state. Hence, the focus should be on maximizing education "now" with the current system by using CE's and other excellent resources available to NP's who have graduated. The same can be said of using approaches (as I have outlined) to increase pay for FNP, PMHNP's and others by working more 1099 and or creating their own independent groups. My interventions/solutions can be immediately enacted by many as of now and are not something that may or may not come to pass years in the future.

AF2BSN · Nov 24, 2020

29 minutes ago, myoglobin said:

In response I assert the following:

a. Outcomes in primary care for FNP's have been excellent in many cases equal or superior to that of MD's. There is no reason to believe that this will not continue. More education does not automatically equal better application or improved outcomes. NP's often do things differently and inherent in some of those differences (maybe) is the reason for parity in outcomes (like spending more time on average with patients).

b. Pay would be far better and time with patients maximized if "my" approach to "NP owned and managed" groups was more the norm. As I have outlined in other threads this is possible even in non IP states by paying a reasonable fee of around 10% to MD's to act as supervisors/collaborators (the practice can still be owned by the NP's). In this way a much higher percentage of the insurance revenues would be passed on to the FNP's. I had that very offer made to me during my "medical rotation" and both MD's offered me around 80% if insurance if I worked 1099 which they said should be well in excess of 200K even in Florida (salaried positions would have been around 100K for FNP's at the time).

c. I do believe that education can be "enhanced" but do not advocate for "overhaul". Also any such process will be years in the making. Meanwhile, we have effective IP in nearly every state. Hence, the focus should be on maximizing education "now" with the current system by using CE's and other excellent resources available to NP's who have graduated. The same can be said of using approaches (as I have outlined) to increase pay for FNP, PMHNP's and others by working more 1099 and or creating their own independent groups. My interventions/solutions can be immediately enacted by many as of now and are not something that may or may not come to pass years in the future.

Cool, except you keep glossing over what a lot of NPs are actually doing: not primary care. I could probably unleash seasoned bedside nurses on a PC population and they could manage 75-85% of the presenting issues. Non-standardized online learning and 500 hours of questionable clinicals later? Sure, have at it. The problem stands that NPs are not rushing to rural PC as was envisioned. They're specializing. They don't have bedside experience. They don't have a deep science foundation. They start off in a new job scared and scrambling. It's not all coughs and boo-boos. It's not cutting it in the CVICU, ED, surgical setting, etc.

You keep talking around my points here. Most physicians are not comfortable renting out their licenses, to be frank. It's a lot of risk for not a lot of reward. Take a stroll through any "white coat" financial group, or just listen to how they refer to APPs in general. Sure, there are some willing to rent their license. Should they? I can't say that I would to a new grad FNP from whatever online school they came from. You're dreaming if you think that's feasible overall.

Who cares if it takes some time? Do we not have a duty to produce the best and brightest? Are we not in the business of providing the best care and outcomes for our patients? I get that you're viewing this all from a new grad PMHNP lens, but step outside from it for a bit. This isn't about maximizing salaries via the "Elite NP" methodology of every NP owning their own practice/side hustle, or negotiating a 1099 position (where a lot of acute care folks in the hospital just can't do). It's about NPs taking control of the their profession, setting standards, and enforcing them before the bar is too low to salvage it.

myoglobin, ASN, BSN, MSN · Nov 24, 2020

22 minutes ago, AF2BSN said:

Cool, except you keep glossing over what a lot of NPs are actually doing: not primary care. I could probably unleash seasoned bedside nurses on a PC population and they could manage 75-85% of the presenting issues. Non-standardized online learning and 500 hours of questionable clinicals later? Sure, have at it. The problem stands that NPs are not rushing to rural PC as was envisioned. They're specializing. They don't have bedside experience. They don't have a deep science foundation. They start off in a new job scared and scrambling. It's not all coughs and boo-boos. It's not cutting it in the CVICU, ED, surgical setting, etc.

You keep talking around my points here. Most physicians are not comfortable renting out their licenses, to be frank. It's a lot of risk for not a lot of reward. Take a stroll through any "white coat" financial group, or just listen to how they refer to APPs in general. Sure, there are some willing to rent their license. Should they? I can't say that I would to a new grad FNP from whatever online school they came from. You're dreaming if you think that's feasible overall.

Who cares if it takes some time? Do we not have a duty to produce the best and brightest? Are we not in the business of providing the best care and outcomes for our patients? I get that you're viewing this all from a new grad PMHNP lens, but step outside from it for a bit. This isn't about maximizing salaries via the "Elite NP" methodology of every NP owning their own practice/side hustle, or negotiating a 1099 position (where a lot of acute care folks in the hospital just can't do). It's about NPs taking control of the their profession, setting standards, and enforcing them before the bar is too low to salvage it.

Again, one of our intrinsic assets is our relative lower cost to educate. We should not diminish that attribute without very good cause, and then only so much as necessary and which is supported by good clinical data to improve outcomes. In general I feel that "education creep" has greatly increased the cost of physician costs in the United States and is one of the reasons that we have the most expensive healthcare system (not to mention stressed out MD career paths). Also, I found no less than six or seven MD's in Florida (2 if I chose to become an FNP) and four for PMHNP willing to "rent their licenses and I wasn't even trying (just in the course of looking for a W-2 job). I am in favor of the best "cost effective" care that also increases access. As someone who does not have medical insurance I am very happy to have access to an primary care clinic staffed by a PA and NP where I can get seen for a "cash price" of about $100.00 (for a 20 minute appointment). I called about five MD practices and none would even see me without insurance (despite that fact that I can pay cash at time of services). The approach of NP owned/managed clinics can work for FNP's as well as PMHNP's. Acute care NP's have a harder road in this matter and here (for this specialty) I do not believe that it is unreasonable to require a year or two of ICU experience before applying to those programs. However, at the same time there is almost always greater oversight for Acute care NP's. The system "isn't broke" but could well be better. However, my point is that the focus should be on personal excellence and what can be done within the context of the current situation in order to provide better job environments and elevate educational opportunities.

AF2BSN · Nov 24, 2020

It would seem there is growing concern.

https://www.live5news.com/2020/11/04/nurse-practitioner-field-grapples-with-question-whether-standardize-curriculum-nationwide/