Doctoral degree to become an NP???

texas-rn-fnp · Jul 12, 2006

It appears the doctors are uncomfortable with the new NP degrees because it may infringe more on their turf. Are they worried that the NP will take all their business away and the poor doctors will not have any work and not be able to feed their families? (ok, I am being a little sarcastic) Every place I have been that was in civilization has had a large demand for appointments and bed space. I have never found a civilian provider that I could get an appointment in less than a month. That goes for both primary care and specialty. Most places don't have bed space either. If someone needs to get admitted, they have to wait for someone else to get discharged.

There is enough work to go around for everyone. There is also an appropriate niche for NP.

NP is not the same as a doctor, but an NP can do a darn good job at taking care of 60-80% of the work the doctor does. The doctors should be happy to have NPs to take care of the routine patients, so the doctors can focus their time and special skills on patients that truly need to be seen only by a doctor. I would think it would be boring for a doctor to not be doing exciting things everyday. Does a doctor really need to or want to see a well baby, well woman exam or every cold, rash ,etc? No. Unless they live in the middle of nowhere with only them and the cows, then there is more work then they will ever be able to take care of. We are all on the healthcare team. It should not be us versus them. It should be how can we all work together as a team so that we can give the best care to the patient. The NPs are a vital part of that team with an expanding role.

fuegorama · Jul 13, 2006

All opinions are equally welcome.
However, to come to the boards and simply make comments that only serve to be divisive is not necessary.
We ALL, the physician and the NP/CNS/PA, serve the public. Please, let's work together. After all, we are all professionals in the name of healthcare.

I'm not the prettiest ham around, but I think this may be directed at me.

I did not come to the boards to be "divisive". I post here in an attempt to give what I believe is a fairly unique perspective. RN turned DO.

I am a fan, cheerleader, patient and pupil of NPs. However, I believe the AACN's unwavering thrust to create a stand alone role for the midlevel provider is a terrible mistake. This is crummy for the profession and frankly dangerous for our patients.

The DNP is a farcical effigy of the doctoral training and accumen of America's physician workforce. Nursing as one pillar of patient advocacy in this country MUST stand up to its purported leadership and demand a return to common sense.

fuegorama · Jul 13, 2006

It appears the doctors are uncomfortable with the new NP degrees because it may infringe more on their turf. Are they worried that the NP will take all their business away and the poor doctors will not have any work and not be able to feed their families? (ok, I am being a little sarcastic) Every place I have been that was in civilization has had a large demand for appointments and bed space. I have never found a civilian provider that I could get an appointment in less than a month. That goes for both primary care and specialty. Most places don't have bed space either. If someone needs to get admitted, they have to wait for someone else to get discharged.
There is enough work to go around for everyone. There is also an appropriate niche for NP.
NP is not the same as a doctor, but an NP can do a darn good job at taking care of 60-80% of the work the doctor does. The doctors should be happy to have NPs to take care of the routine patients, so the doctors can focus their time and special skills on patients that truly need to be seen only by a doctor. I would think it would be boring for a doctor to not be doing exciting things everyday. Does a doctor really need to or want to see a well baby, well woman exam or every cold, rash ,etc? No. Unless they live in the middle of nowhere with only them and the cows, then there is more work then they will ever be able to take care of. We are all on the healthcare team. It should not be us versus them. It should be how can we all work together as a team so that we can give the best care to the patient. The NPs are a vital part of that team with an expanding role.

Great post. I agree with about 85% of what you are saying...except:

1.physician salaries are plummeting at the same time our school debts are skyrocketing

2.the provider shortage is a myth

These are both topics that could lead to another couple of 11 page threads.

Now a question. Regarding your last line. What are the boundaries on the NP's "expanding role"? Where are the limitations on midlevel providers spelled out?

After posting here I took a few minutes in the library today to pick up the NP magazine. It was ~80 pages dedicated to expanding the role of the NP. There were no clinical discussions. Each article was dedicated to state legislative initiatives on how to expand the role of the NP. Some were semantic silliness "change supervise to collaborate". Most were "will secure 'fill in the blank' expansion of privilege".

Where does it end?

brownrice · Jul 13, 2006

So Fuegorama, you think nurses (one of the pillars of healthcare), should stand up and rebel against the DNP? Well, hate to tell ya, but you've got a much bigger fight on your hands than trying to rally up the nurses...

EMEDPA (from the Northwest US), a moderator on the PA forum is quoted below, under the nurse practitioner thread--from which he wrote:

"2 new in your face np things I found out today.....

1. my hospital just donated a CRAPLOAD of money to the local nursing school to help them develop a DNP program( not 1 cent to the pa program that has provided more than 20 pa's to the hospital over the yrs). wonder who controls the pursestrings on that one.....

2. 2 new local np only clinics have opened up that give out bumperstickers to all of their clients; MY DOCTOR IS A NURSE PRACTITIONER

Hmmmm...looks like these dnp programs are popping up everywhere. First initiated by Columbia University, of course. Many universities now have in place the year in which they plan to institute the new DNP degree.

I think it's a little late now!

fuegorama · Jul 14, 2006

Hmmmm...looks like these DNP programs are popping up everywhere. First initiated by Columbia University, of course. Many universities now have in place the year in which they plan to institute the new DNP degree.
I think it's a little late now!

Brownrice-Don't give up!! We can still save her.

As a student doctor I own my mistakes. Now recognizing the sinister potential of this neoplasm I readily admit we should have started with a massive debulking. This was an error. It is my responsibility to try and inform the family (public) about this mistake and attempt to maintain their trust.

We of course can now all see that this is stage IV disease.

The central lesion has crossed the midline and now is evident in distant sites of metastasis. There are multiple nodes involved and constitutional signs of tumor secreted hormones.

Yes she has a beard and hyposmotic urine, but these are not reasons to give up on novel modalities.

We will return with surgical intervention. (see the AMA initiative above) Chemo will begin in earnest. (must liquor up state legislatures) Most importantly, we must maintain a sense of hope. As an osteopath I have tremendous trust in a body's ability to heal itself with proper guidance.

Call/write/petition the AACN and purge this evil from the body.

I am always here for a consult.

Home Health Columnist / Guide · Jul 14, 2006

adding some content to the discussion:

primary care outcomes in patients treated by nurse practitioners or physicians: a randomized trial.

jama. 2000 jan 5;283(1):59-68.

mundinger mo, kane rl, lenz er, totten am, tsai wy, cleary pd, friedewald wt, siu al, shelanski ml.

school of nursing, columbia university, new york, ny 10032, usa. [email protected]

context: studies have suggested that the quality of primary care delivered by nurse practitioners is equal to that of physicians. however, these studies did not measure nurse practitioner practices that had the same degree of independence as the comparison physician practices, nor did previous studies provide direct comparison of outcomes for patients with nurse practitioner or physician providers. objective: to compare outcomes for patients randomly assigned to nurse practitioners or physicians for primary care follow-up and ongoing care after an emergency department or urgent care visit. design: randomized trial conducted between august 1995 and october 1997, with patient interviews at 6 months after initial appointment and health services utilization data recorded at 6 months and 1 year after initial appointment. setting: four community-based primary care clinics (17 physicians) and 1 primary care clinic (7 nurse practitioners) at an urban academic medical center. patients: of 3397 adults originally screened, 1316 patients (mean age, 45.9 years; 76.8% female; 90.3% hispanic) who had no regular source of care and kept their initial primary care appointment were enrolled and randomized with either a nurse practitioner (n = 806) or physician (n = 510). main outcome measures: patient satisfaction after initial appointment (based on 15-item questionnaire); health status (medical outcomes study short-form 36), satisfaction, and physiologic test results 6 months later; and service utilization (obtained from computer records) for 1 year after initial appointment, compared by type of provider. results: no significant differences were found in patients' health status (nurse practitioners vs physicians) at 6 months (p = .92). physiologic test results for patients with diabetes (p = .82) or asthma (p = .77) were not different. for patients with hypertension, the diastolic value was statistically significantly lower for nurse practitioner patients (82 vs 85 mm hg; p = .04). no significant differences were found in health services utilization after either 6 months or 1 year. there were no differences in satisfaction ratings following the initial appointment (p = .88 for overall satisfaction). satisfaction ratings at 6 months differed for 1 of 4 dimensions measured (provider attributes), with physicians rated higher (4.2 vs 4.1 on a scale where 5 = excellent; p = .05). conclusions: in an ambulatory care situation in which patients were randomly assigned to either nurse practitioners or physicians, and where nurse practitioners had the same authority, responsibilities, productivity and administrative requirements, and patient population as primary care physicians, patients' outcomes were comparable.

systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors

sue horrocks, research associate a, elizabeth anderson, senior lecturer b, chris salisbury, consultant senior lecturer a. a division of primary health care, university of bristol, bristol bs6 6jl, b faculty of health and social care, university of west of england, bristol bs16 1dd

[color=#63ceff]abstract

objective: to determine whether nurse practitioners can provide care at first point of contact equivalent to doctors in a primary care setting.

design: systematic review of randomised controlled trials and prospective observational studies.

data sources: cochrane controlled trials register, specialist register of trials maintained by cochrane effective practice and organisation of care group, medline, embase, cinahl, science citation index, database of abstracts of reviews of effectiveness, national research register, hand searches, and published bibliographies.

included studies: randomised controlled trials and prospective observational studies comparing nurse practitioners and doctors providing care at first point of contact for patients with undifferentiated health problems in a primary care setting and providing data on one or more of the following outcomes: patient satisfaction, health status, costs, and process of care.

results: 11 trials and 23 observational studies met all the inclusion criteria. patients were more satisfied with care by a nurse practitioner (standardised mean difference 0.27, 95% confidence interval 0.07 to 0.47). no differences in health status were found. nurse practitioners had longer consultations (weighted mean difference 3.67 minutes, 2.05 to 5.29) and made more investigations (odds ratio 1.22, 1.02 to 1.46) than did doctors. no differences were found in prescriptions, return consultations, or referrals. quality of care was in some ways better for nurse practitioner consultations. bike.f1.gif

conclusion: increasing availability of nurse practitioners in primary care is likely to lead to high levels of patient satisfaction and high quality care.

several studies listed at center for nursing advocacy:

do physicians deliver better care than advanced practice nurses?

outcomes of care managed by an acute care nurse practitioner/attending physician team in a subacute medical intensive care unit

by leslie a. hoffman, rn, phd, frederick j. tasota, rn, msn, thomas g. zullo, phd, carmella scharfenberg, rn, msn and michael p. donahoe, md. from schools of nursing (lah, fjt, tgz, cs) and medicine, division of pulmonary, allergy and critical care medicine (mpd), university of pittsburgh, pittsburgh, pa.

abstract :

• background many academic medical centers employ nurse practitioners as substitutes to provide care normally supplied by house staff.

• objective to compare outcomes in a subacute medical intensive care unit of patients managed by a team consisting of either an acute care nurse practitioner and an attending physician or an attending physician and critical care/pulmonary fellows.

• methods during a 31-month period, in 7-month blocks of time, 526 consecutive patients admitted to the unit for more than 24 hours were managed by one or the other of the teams. patients managed by the 2 teams were compared for a variety of outcomes.

• results patients managed by the 2 teams did not differ significantly for any workload, demographic, or medical condition variable. the patients also did not differ in readmission to the high acuity unit (p = .25) or subacute unit (p = .44) within 72 hours of discharge or in mortality with (p = .25) or without (p = .89) treatment limitations. among patients who had multiple weaning trials, patients managed by the 2 teams did not differ in length of stay in the subacute unit (p = .42), duration of mechanical ventilation (p = .18), weaning status at time of discharge from the unit (p = .80), or disposition (p = .28). acute physiology scores were significantly different over time (p = .046). patients managed by the fellows had more reintubations (p=.02). • conclusions in a subacute intensive care unit, management by the 2 teams produced equivalent outcomes.

a comparison of changes in the professional practice of nurse practitioners, physician assistants, and certified nurse midwives: 1992 and 2000

...despite anecdotes about tensions between physicians and the three professions, significant positive correlations between practitioner per capita ratios for nps, pas, cnms, and physicians indicate that states with more physicians per capita also have more nps, pas, and cnms per capita. this is an indication that the three professions supplement or support physicians rather than substitute for or supplant them. ...

physician assistants and nurse practitioners: the united states experience

graph of pa, np and med school enrollment:

http://www.mja.com.au/public/issues/185_01_030706/hoo10101_fm.html

nursing facts - advanced practice nursing: a new age in health care (ana)

nursingworld | ojin: nurse-physician workplace collaboration

SharonH, RN · Jul 14, 2006

Adding some CONTENT to the discussion:

Thank you Karen. Your contribution is appreciated as always.

fuegorama · Jul 14, 2006

[edit at 1109 7/15/06 est per request of mod. i have kept the citations intact in hopes that some readers will take the time to look at these articles. if this is inadequate or continues to violate the tos i would appreciate being informed. thank you.]

ok. we are pretty far afield of the thread title and thrust of my position, but here goes.

adding some content to the discussion:
primary care outcomes in patients treated by nurse practitioners or physicians: a randomized trial.
jama. 2000 jan 5;283(1):59-68
mundinger mo, kane rl, lenz er, totten am, tsai wy, cleary pd, friedewald wt, siu al, shelanski ml.
school of nursing, columbia university, new york, ny 10032, usa. [email protected]
context: studies have suggested that the quality of primary care delivered by nurse practitioners is equal to that of physicians. however, these studies did not measure nurse practitioner practices that had the same degree of independence as the comparison physician practices, nor did previous studies provide direct comparison of outcomes for patients with nurse practitioner or physician providers. objective: to compare outcomes for patients randomly assigned to nurse practitioners or physicians for primary care follow-up and ongoing care after an emergency department or urgent care visit. design: randomized trial conducted between august 1995 and october 1997, with patient interviews at 6 months after initial appointment and health services utilization data recorded at 6 months and 1 year after initial appointment. setting: four community-based primary care clinics (17 physicians) and 1 primary care clinic (7 nurse practitioners) at an urban academic medical center. patients: of 3397 adults originally screened, 1316 patients (mean age, 45.9 years; 76.8% female; 90.3% hispanic) who had no regular source of care and kept their initial primary care appointment were enrolled and randomized with either a nurse practitioner (n = 806) or physician (n = 510). main outcome measures: patient satisfaction after initial appointment (based on 15-item questionnaire); health status (medical outcomes study short-form 36), satisfaction, and physiologic test results 6 months later; and service utilization (obtained from computer records) for 1 year after initial appointment, compared by type of provider. results: no significant differences were found in patients' health status (nurse practitioners vs physicians) at 6 months (p = .92). physiologic test results for patients with diabetes (p = .82) or asthma (p = .77) were not different. for patients with hypertension, the diastolic value was statistically significantly lower for nurse practitioner patients (82 vs 85 mm hg; p = .04). no significant differences were found in health services utilization after either 6 months or 1 year. there were no differences in satisfaction ratings following the initial appointment (p = .88 for overall satisfaction). satisfaction ratings at 6 months differed for 1 of 4 dimensions measured (provider attributes), with physicians rated higher (4.2 vs 4.1 on a scale where 5 = excellent; p = .05). conclusions: in an ambulatory care situation in which patients were randomly assigned to either nurse practitioners or physicians, and where nurse practitioners had the same authority, responsibilities, productivity and administrative requirements, and patient population as primary care physicians, patients' outcomes were comparable..

this study has been cited so many times on this and evry other nursing site it now is in real time syndication right after golden girls at 11.

that said, it was an eye opener...at the time. this article opened a needed door into a the world of more efficient practice management utilizing a great resource, the np.

welcomed by many docs, it ran fairly roughshod over many issues in the debate. let's first look at the disparity in n. the np arm was significantly larger. with greater power, one could assume this would skew the data.

this study was performed in an arena of physician oversight. these nps could default at any time if patient needs fell out of their expertise. this is mightily different from the proposals we see today.

let us also note that these were the old school of nps. these are the folks who made the possibility of today's profession. multiple years of clinical experience preceding their graduate programs. they were not five semester widgets churned out after their arduous training in english comp, medieval studies or theology. (btw-two of those degrees are held by the s.o. of the best man at my wedding. she is an np)

beyond design/reporting flaws, it was written in a different time for a different audience. the study took place 1995-1997. how many of us considered a future where the promotion of the np would lead to an attempted physician equivalence. noting the authors and their institution i think we can recognize a few who saw a zany and scary future.

systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors
sue horrocks, research associate a, elizabeth anderson, senior lecturer b, chris salisbury, consultant senior lecturer a. a division of primary health care, university of bristol, bristol bs6 6jl, b faculty of health and social care, university of west of england, bristol bs16 1dd
[color=#63ceff]abstract
objective: to determine whether nurse practitioners can provide care at first point of contact equivalent to doctors in a primary care setting.
design: systematic review of randomised controlled trials and prospective observational studies.
data sources: cochrane controlled trials register, specialist register of trials maintained by cochrane effective practice and organisation of care group, medline, embase, cinahl, science citation index, database of abstracts of reviews of effectiveness, national research register, hand searches, and published bibliographies.
included studies: randomised controlled trials and prospective observational studies comparing nurse practitioners and doctors providing care at first point of contact for patients with undifferentiated health problems in a primary care setting and providing data on one or more of the following outcomes: patient satisfaction, health status, costs, and process of care.
results: 11 trials and 23 observational studies met all the inclusion criteria. patients were more satisfied with care by a nurse practitioner (standardised mean difference 0.27, 95% confidence interval 0.07 to 0.47). no differences in health status were found. nurse practitioners had longer consultations (weighted mean difference 3.67 minutes, 2.05 to 5.29) and made more investigations (odds ratio 1.22, 1.02 to 1.46) than did doctors. no differences were found in prescriptions, return consultations, or referrals. quality of care was in some ways better for nurse practitioner consultations.
conclusion: increasing availability of nurse practitioners in primary care is likely to lead to high levels of patient satisfaction and high quality care.

see study below and my bold face above

several studies listed at center for nursing advocacy:
do physicians deliver better care than advanced practice nurses?

i cannot respond to anything posted from cna. it is a rabidly anti physician site. its position statements are so far outside the sane nursing realm that it defines the lunacy of the dnp debate.

a comparison of changes in the professional practice of nurse practitioners, physician assistants, and certified nurse midwives: 1992 and 2000

...despite anecdotes about tensions between physicians and the three professions, significant positive correlations between practitioner per capita ratios for nps, pas, cnms, and physicians indicate that states with more physicians per capita also have more nps, pas, and cnms per capita. this is an indication that the three professions supplement or support physicians rather than substitute for or supplant them. ...

1. this position is one of support for the rational model of midlevel with physician supervision. yay.

2. it is from 1992. once again, today the aacn has attempted to remake the world in its image.

------------------------------------------------------------------------

so here are a few of my own. i sincerely apologize for the c&p but my school's portal doesn't allow external links. i alaso happen to be weary and lazy.

apology #2-a large number of articles regarding the np debate are from the uk. who knew?

the evolution of the nursepractitioner

paula mclaren

senior lecturer, school of nursing and midwifery, university of hertfordshire, uk

pii s1744-2249(05)00106-3

evidence-based healthcare management

nursepractitioners do not reduce general practitioners’ workload

brenda leese, bsc (hons) dphil, commentary author

reader in primary care research, centre for research in primary care, university of leeds, leedsuk.

☆ abstracted from: laurant mgh, hermens rpmg, braspenning jcc, et al. impact of nursepractitioners on workload of general practitioners: randomised controlled trial. bmj 2004; 328: 927–930.

pii s1744-2249(04)00174-3

now some real evidence.

as nurses we see the effects of overprescription of antibiotics. the consequences of non-indicated/overprescription of these agents is heavily documented. further, if you have worked in a hospital in the last 5 years you know what c. diff. colitis smell/sounds/tastes? like. 'nuf said.

wouldn't you expect the well trained, holistic practitioner to not fall into the script trap?

read.

differences in antibiotic prescribing among physicians, residents, and nonphysician clinicians.

roumie cl - am j med - 01-jun-2005; 118(6): 641-8

from nih/nlm medline

nlm citation id:

15922696 (pubmed)

comment:

am j med. 2006 may;119(5):e21-2; author reply e23-4
pubmed id: 16651040

Home Health Columnist / Guide · Jul 14, 2006

cna = california nurses association, nursing union

center for nursing advocacy is seperate organization who's mission isto promote image of nursing. articles posted on this topic come from various sources.

re this article: differences in antibiotic prescribing among physicians, residents, and nonphysician clinicians.

had come across this commentary in my internet wanderings...concur with these points in ann hart 's response:

response to differences in antibiotic prescribing

ann marie hart, phd, fnp

am j med. 2006 may;119(5):e21-2; author reply e23-4.

a. recall that the study examined antibiotic prescribing during the period of 1995 to 2000. during this time frame, most educational campaigns regarding appropriate antibiotic use were not under way or were just beginning

b. ...concern relates to the fact that the authors combined nps and physician assistants (pas) into one nonphysician category. this is problematic for several reasons. nps and pas receive very different educational preparation, and their individual practices are based on unique philosophies. furthermore, there are no data to indicate that nps and pas practice similarly.

i see apples, you see oranges. the explosion of np's in collaberative practice in the philadelphia area has been phenominal in the past 2 years. best practice suggest that hospitals would not be employing np's in er's, critical care units and physician's having them as partner's if care wasn't safe and effective, similar to own practice standards. we'll just have to agree to disagree.

caldje · Jul 14, 2006

b. ...concern relates to the fact that the authors combined nps and physician assistants (pas) into one nonphysician category. this is problematic for several reasons. nps and pas receive very different educational preparation, and their individual practices are based on unique philosophies. furthermore, there are no data to indicate that nps and pas practice similarly.

j am acad nurse pract. 2006 jun;18(6):291-6.[color=#336699]related articles, [color=#336699]links

prescribing trends by nurse practitioners and physician assistants in the united states.

cipher dj, hooker rs, guerra p.

department of psychiatry, university of north texas health science center, fort worth, 76107, usa. [email protected]

purpose: as an important step in analyzing the role of nurse practitioners (nps) and physician assistants (pas), we examined their prescribing behavior. the intent is to study the characteristics of providers and patients, and the type of prescriptions written by nps and pas in primary care and to compare these activities to physicians. data sources: the national ambulatory medical care survey (namcs) database was examined for prescriptions written by primary care clinicians (family and general medicine, internal medicine, and general pediatrics). a representative sample of 88,346 primary care visits over a 6-year period (1997-2002) was analyzed in which a prescription was written by an np, a pa, or a physician in an urban or rural setting. conclusions: the characteristics of all the patients seen were similar for geographical region of visit, age, and gender, but differed by ethnicity and race. an np or a pa was the provider of record for 5% of the primary care visits in the namcs database. the three clinician types were likely to write at least one prescription for 70% of all visits, and the mean number of prescriptions was 1.3-1.5 per visit (range 0-5) depending on the provider. pas were more likely to prescribe a controlled substance for a visit than a physician or an np (19.5%, 12.4%, 10.9%, respectively). only in nonmetropolitan settings did differences emerge. in rural areas, nps wrote significantly more prescriptions than physicians and pas. implications for practice: we suggest that nps and pas may provide a role that is similar to that of physicians in primary care based on prescribing behavior. the prescribing behavior of pas and nps parallels that of physicians by the number of medications per visit, the types of therapeutic classes, and the type of patient. however, in nonmetropolitan areas, prescribing differences emerge between the three types of providers that bear further exploration.

caldje · Jul 14, 2006

I dont want my above post to confuse anyone as to give my position so I'll give my take on the issue.

NPs can have independence. Their scope of practice should be CLEARLY defined and CONFINED to primarily preventative efforts though. As a healthy person I would much rather see an NP and as a sick person I would much rather see a doc. I think midlevels do have an independent role in healthcare and should be afforded the opportunity to break the monopoly physicians have on healthcare. I think it would be VERY beneficial to the health of our society to encourage independent practice of preventative health practitioners who treat minor ailments and screen for major ones and then refer them to their counterparts more trained in that area. Why is that such a stretch?

Keep PAs with physician collaboration as dependent providers and let them take over the current midlevel position thata works collectively and cooperatively with physicians. (we're happy with that and also have a more similar training to physicians with stronger science background needed to collaborate on the more serious health concerns and critical care and surgical cases) Then, let the NPs create their own niche as long as it is clearly defined. It makes sense to me and people might be better off for it?

fuegorama · Jul 14, 2006

We each have our opinions on CNA (my abbreviation). This is one place where we will just disagree.

a. Recall that the study examined antibiotic prescribing during the period of 1995 to 2000. During this time frame, most educational campaigns regarding appropriate antibiotic use were not under way or were just beginning.

This beautifully illustrates the trickle down aspect of medical education. Research and best practice patterns flow majoritively from physician led organizations/projects. Good practice eventually migrates to midlevels who can parrot what doctors perform. The medical community recognized the dangers of overprescription in the 80s. Implementation of these discoveries to practice followed fairly slowly.

Educational campaigns to midlevels and the lay public followed.

What is missed in the commentary is the use of the script pad for NPs in the first place. Why were so many kids with the sniffles being hit with Amoxicillin? Could it be that when your only tool is a hammer, every problem .....

I see apples, you see oranges. The explosion of NP's in collaberative practice in the Philadelphia area has been phenominal in the past 2 years. Best practice suggest that hospitals would NOT be employing NP's in ER's, Critical Care Units and physician's having them as partner's if care wasn't safe and effective, similar to own practice standards. We'll just have to agree to disagree.

Are you saying that NPs working in environments where physician oversight is required enjoy professional privileges? If so then we can both make some OJ.

If by "collaboration" you mean that NPs in stand alone professional niches are physician equivalents, then I will invite you to share this apple tart I'm fixing.