I have been following your discussions here on the recent media coverage of the primary gap, and NPs place in it. I posted this on another forum that I moderate, and felt it was only fair to give you all a chance to chime in. I hope it doesn't come across as an attack, but rather a clinician of a different stripe with some real questions about how we market ourselves. The text below is addressed to PAs, so read in that context:
I have been reading the coverage of the recent articles from CNN and Time that we discuss here, in particular the responses on allnurses.
Of course I have to provide my PA disclaimer.....I work with NPs.....about a dozen of them at my institution. I have never had a negative experience with any of them, and have no need to write a "hit piece". We confer, they give medical feedback, I give surgical, etc....collegial and pleasant.
That being said, I have read over and over again about the presumed advantage NPs provide over docs (this is in their words) becuase they offer a "nursing perspective", "treat the patient, not the disease", "look at the patient as a whole", "offer prevention as well as treatment", etc.....
I really don't see this as NP bashing, but I see these comments as somewhat elitist....or at least "leading the argument". The NPs I work with practice the same medicine (!) as the rest of us, PAs, MDs, etc. Their preop cardiac workups look just like any other. And they're good. A clinic NP treating OM...are they really offering that much of an edge over a non-NP due to their nursing background? What does the nursing backgroud teach about listening, empathy, and thinking about interdependent body systems that our medical model education does not?
This all seems like a phoney selling point that is SO subjective that there is no way to argue it, putting NPs in a position which is easy to defend and impossible to refute.
Thoughts?
Do you feel like you treat your patients any less holistically b/c you were trained in the medical model?
Why do you think these studies were even done? Its exactly the questions you raise that produced these studies. Even in the face of hard science, you still want hold you ground? What exactly then would put your mind at ease?
I agree, costs are rising - but most of those costs are related to insurance and the "administrative costs". Malpractice rates are rising not because of all of the "bad apples", but because patients are suing more - be it from legal persuasion (have you seen the number of medical malpractice commercials lately?) or just due to the economy. Regardless, malpractice rates will continue to rise as well.
The problem with the argument that you can provide the same services at a lower rate is not really something that is going to work well in healthcare since again the cost of practice will inevitably be the same for any independent practitioner.
To get back to the idea of this thread - I personally do not understand the concept of having a doctorate in nursing practice. As has been shown previously, there is less clinical education than medical school or PA school and a lot of classes regarding research and nursing theory. If that is going to be the basis of someone practicing independently then how would that prepare someone for advanced medical decision making ? If someone wants to practice medicine (which is what an independent practitioner would practice as stated above) then why not go to medical school or PA school ? Last I knew, someone who wanted to practice nursing would become a nurse.
A DNP degree as described by most of the educational institutions that offer it make it seem like an advanced degree in nursing practice. If there is equivalent scope of practice then why not equivalent training ? With the argument of less training can do the same job the health care industry could easily spiral downward. In fact, that seems to be going in the opposite direction - RNs requiring BSNs, LPNs replaced by RNs, medical assistants replaced by RNs/LPNs. It's not always the case that it's better to have someone who can do ALMOST everything than someone else be a better option than someone who COULD do everything.
You are very misinformed about the cost drivers in healthcare. Also, the cost of practice is different for every independent practitioner. It is all based on the choices you make. I have a quick question for you. You continually lump PA school in with medical school in all of your posts. Are you saying that PA school is equivalent to medical school? That is what you seem to be implying. I just wanted to hear your justification for that one.
With regard to a DNP degree, it is different, but that doesn't mean it might not be equal or better than the PA or MD education. It doesn't have to be equivalent to train someone to do the task equally or better.
I'm not arguing really any of what you mention here; of course all pts deserve to know all members of their care team and what their tx is, possible pos/neg outcomes etc.
When I say our own interest I mean our own interest in displaying our credentials. I'm Joe Smith, a nurse practitioner here....sounds fine.
There is much contention on the PA side about our title. I've seen folks here who post about PAs- that we "assist physicians", "doctor assistant"..... which is not even remotely the case. Does making us PA-S, Master of Science or PA-C, Doctor of Health Science or Physician Associate or whatever the latest rage is....make us different/better? No, our work stands on its own merits.
I have posted extensively on the PA forum that I think there is a place for a new type of provider, primary care provider, which does not have traditional physician 4+4+3+??? training, that a PCP can be trained in far less time and function independently and within the framework of the current system, alongside traditional docs. Like PAs or NPs but with a little more oomph, but not the full MD program. I like the idea that NPs are pushing this, but it bothers me that they are doing it with, frankly, such a streak of arrogance. "Physicians just need to mind their own business, open up competition, and get out of our way"...a few nuggets I've read here recently.
There is so much more that can be accomplished, especially w/ your lobby power, without all the acrimony (and a smidgen of self righteousness). PAs use the slogan "Partners in medicine", a take home message for sure.
Some of us here have been discussing that same thing here... Kind of makes me wonder if there is a growing consensus... I would say about 5 years ago a pretty large group of us (friends / co-workers) were discussing the confusion of "mid-level providers" amongst patient populations. We kind all thought some new type of provider would be coming down the pipeline in the future especially with the rise of the baby boomer's hitting their elder years . The doctors in the group actually concurred.
You know some folks would consider the topic of a hybrid provider blasphemy ("Like PAs or NPs but with a little more oomph")...
Not trying to pick fights, just rocking the boat a bit......
Education DOES make a huge difference in providing care. Like I said in earlier threads, if NPs/DNPs can practice independently, I don't see why 4th year med students can't either. They have more basic science training AND clinical training than nearly all NP/DNP programs. I can guarantee allowing M4s to practice independently will increase the popularity of primary care specialties and thus, we won't have a need of independent midlevels at all!
Also, mbreaz, you keep saying you're sick of physicians not wanting to compete with midlevels. How is that fair however? Midlevels will take all the easier, cookbook cases while pushing all the harder ones to PCPs. Not only are the PCPs stuck with more liability, they would also be getting the same reimbursement rates as an NP/DNP would for seeing a much less complex patient. How is that fair? Before you tell me to quit crying, I hope you realize that this push for midlevel independence with inferior training shows the greed of the nursing profession, not the greed of physicians fighting it.
As for the current studies out there, I have come across none that aren't significantly flawed. You guys take so many statistics courses, etc; I'd think you'd be able to design better studies or at least evaluate studies objectively after all that. I guess I was hoping for too much there.
Lets not forget if M4s were to practice, PAs are out of work also.
PCPs are not lacking patients. There has been a PCP shortage for quite some time. More than enough patients to go around and more to come if universal healthcare comes to be.
Please. Are you kidding me? ALL the studies are significantly flawed? Surely you could find one that shows me that you have some actual PROOF to support your position that the patient outcomes are significantly lower than that of PAs. With the claim of superior training, that should be a slam dunk. Yet all I read is post after post of slander. Apparently, I'm asking too much here, too.
Education DOES make a huge difference in providing care. Like I said in earlier threads, if NPs/DNPs can practice independently, I don't see why 4th year med students can't either. They have more basic science training AND clinical training than nearly all NP/DNP programs. I can guarantee allowing M4s to practice independently will increase the popularity of primary care specialties and thus, we won't have a need of independent midlevels at all!
Also, mbreaz, you keep saying you're sick of physicians not wanting to compete with midlevels. How is that fair however? Midlevels will take all the easier, cookbook cases while pushing all the harder ones to PCPs. Not only are the PCPs stuck with more liability, they would also be getting the same reimbursement rates as an NP/DNP would for seeing a much less complex patient. How is that fair? Before you tell me to quit crying, I hope you realize that this push for midlevel independence with inferior training shows the greed of the nursing profession, not the greed of physicians fighting it.
As for the current studies out there, I have come across none that aren't significantly flawed. You guys take so many statistics courses, etc; I'd think you'd be able to design better studies or at least evaluate studies objectively after all that. I guess I was hoping for too much there.
Two of the things I learned in statistics:
- Statistics tell lies, damned lies (ie. either party can bend the numbers to fit the need)....
- The party that that disagrees with the findings will always claim the study was flawed.
One of the things I was taught about the sciences..
- There is no such thing as a fact: Everything is open for debate and further discovery which may include either support or rebuke..
My physicians are quite happy to have me handle:
- Those nice non-complicated cookbook HIV folks..
- Those nice non-complicated cookbook diabetics..
- Those nice non-complicated cookbook hypertensive folks..
- Those nice non-complicated cookbook end stage renal folks..
- Those nice non-complicated cookbook HIV, diabetic, hypertensive folks..
- Those nice non-complicated cookbook: Colon cancer
Brain cancer
Lung cancer...
- ETC....
My doctors may take the day off or the week off I am in the office by myself (office depending on location is just an office or an office with emergent capabilities) I have no qualms about picking up the phone and calling a specialist and telling them I have a referral or just to ask a question.. Most of the specialist I call know do know that when I call there is a significant problem. But I of course as a NP I guess I am seeing only the nice non-complicated cookbook cases and they know my patients are easy money? I also have no qualms about taking care of my patients on sight...
Education DOES make a huge difference in providing care.... So does experience... So does common sense..
Unfortunately sometimes nothing make a difference....
Education DOES make a huge difference in providing care. Like I said in earlier threads, if NPs/DNPs can practice independently, I don't see why 4th year med students can't either. They have more basic science training AND clinical training than nearly all NP/DNP programs. I can guarantee allowing M4s to practice independently will increase the popularity of primary care specialties and thus, we won't have a need of independent midlevels at all!
Also, mbreaz, you keep saying you're sick of physicians not wanting to compete with midlevels. How is that fair however? Midlevels will take all the easier, cookbook cases while pushing all the harder ones to PCPs. Not only are the PCPs stuck with more liability, they would also be getting the same reimbursement rates as an NP/DNP would for seeing a much less complex patient. How is that fair? Before you tell me to quit crying, I hope you realize that this push for midlevel independence with inferior training shows the greed of the nursing profession, not the greed of physicians fighting it.
As for the current studies out there, I have come across none that aren't significantly flawed. You guys take so many statistics courses, etc; I'd think you'd be able to design better studies or at least evaluate studies objectively after all that. I guess I was hoping for too much there.
I could care less if it is fair to physicians, that isn't my problem or my concern. My concern is what is fair to patients. It isn't fair for patients not to be given a lower cost alternative provider who is willing to make less money and spend more time to do their job the right way when one is available.
I could care less if it is fair to physicians, that isn't my problem or my concern. My concern is what is fair to patients. It isn't fair for patients not to be given a lower cost alternative provider who is willing to make less money and spend more time to do their job the right way when one is available.
I am glad you have such a high opinion of those in the NP profession that if they obtain independent practice rights they will be "willing to make less money". Once they realize that the key to actually making money in practice is seeing more patients in the day, the time spent with each patient will have to go down. That, and inevitably they will demand equal reimbursement.
When working in a physician's practice as a NP with oversight, most NPs are employees paid a salary regardless of patient load while the physician's income (minus overhead, malpractice, etc) is based on the number of patients they see each day - that doesn't mean they don't want to see less patients and take a lot of time with each one - just that they have to maintain x amount of patients each day to remain financially viable.
- Statistics tell lies, damned lies (ie. either party can bend the numbers to fit the need)....
- The party that that disagrees with the findings will always claim the study was flawed.
One of the things I was taught about the sciences..
- There is no such thing as a fact: Everything is open for debate and further discovery which may include either support or rebuke..
My physicians are quite happy to have me handle:
- Those nice non-complicated cookbook HIV folks..
- Those nice non-complicated cookbook diabetics..
- Those nice non-complicated cookbook hypertensive folks..
- Those nice non-complicated cookbook end stage renal folks..
- Those nice non-complicated cookbook HIV, diabetic, hypertensive folks..
- Those nice non-complicated cookbook: Colon cancer
Brain cancer
Lung cancer...
- ETC....
My doctors may take the day off or the week off I am in the office by myself (office depending on location is just an office or an office with emergent capabilities) I have no qualms about picking up the phone and calling a specialist and telling them I have a referral or just to ask a question.. Most of the specialist I call know do know that when I call there is a significant problem. But I of course as a NP I guess I am seeing only the nice non-complicated cookbook cases and they know my patients are easy money? I also have no qualms about taking care of my patients on sight...
Education DOES make a huge difference in providing care.... So does experience... So does common sense..
Unfortunately sometimes nothing make a difference....
I don't doubt that with your education and experience you are able to handle a complex patient. My question to you would be whether or not it helps you to have physician oversight or the option to consult them with a difficult patient ? Also, do you anticipate that anything will change with the way you practice now if NPs were given independent practice rights ?
My question/concern is not that an experienced, competant provider is caring for complex patients, but that with independent practice rights, a new grad with very limited experience who doesn't have the experience and physician oversight is expected to manage the same type of patients. (I know some dnp programs have residencies, but they are not the same in terms of clinical hours and intensity of training as an MD/DO program)
You are very misinformed about the cost drivers in healthcare. Also, the cost of practice is different for every independent practitioner. It is all based on the choices you make. I have a quick question for you. You continually lump PA school in with medical school in all of your posts. Are you saying that PA school is equivalent to medical school? That is what you seem to be implying. I just wanted to hear your justification for that one.
With regard to a DNP degree, it is different, but that doesn't mean it might not be equal or better than the PA or MD education. It doesn't have to be equivalent to train someone to do the task equally or better.
I agree that the cost of practice is different for everyone, but in any case it is still a large factor in determining the number of patients you need to see every day to maintain financial viability.
I lump PA school with medical school not because it is equivalent to medical school, but because it follows the medical model. The PA program has a year of sciences, physiology, pathology, etc. followed by clinical rotations in all specialties. PA programs are standardized and the curriculum is nearly the same across institutions. In addition many require at a minimum a thousand or more clinical hours for entry.
The DNP degree varies greatly across institutions, some requiring no clinical experience for entry (i.e. direct entry programs), varied curriculum, and more nursing theory, statistics, and other courses than clinical or science courses. In that way it is greatly different than either PA or MD/DO school.
You are correct, it does not need to be the same if you are calling the end result something different. A doctor of nursing practice is not a doctor of medicine or doctor of osteopathic medicine. That being said, a doctor of nursing practice is not trained to do the complete job of a medical/osteopathic medical doctor. That is why currently NPs are referred to as mid level providers. The training is NOT equivalent to physicians - that much has been stated multiple times already.
Colleges and universities are not training people to do manual labor or something with a fixed set of variables, medicine involves many factors which are constantly changing. Just following a set of guidelines for treatment without looking at the complete picture and treating a case of strep throat while ignoring the rest of the patient may solve the immediate problem but not the whole problem (or may not be the problem at all).
I could care less if it is fair to physicians, that isn't my problem or my concern. My concern is what is fair to patients. It isn't fair for patients not to be given a lower cost alternative provider who is willing to make less money and spend more time to do their job the right way when one is available.
That's fine that you don't care what's fair to physicians; you're entitled to that opinion. But you're not offering a lower cost alternative for patients. It's not fair to mislead people that independent midlevels will save money when the current push is for equal reimbursement as physicians. How are you saving the system money? Maybe you're an NP who says you don't want equal reimbursement. But the only things out in media that the public will see are articles pushing for that equal level of pay. If you are against what people like Mundinger et al are saying, why don't you speak out in public rather than make posts suggesting that you don't believe in the same things as Mundinger on an anonymous forum? While I'll admit that I haven't been searching extensively, I haven't come across any articles where nurses, NPs, whatever, speak out against this push for equivalency to physicians and equal reimbursements.
So, it's definitely not fair to say that midlevels will save money when the current focus of the nursing organization seems to be to push for independence in all states and equal reimbursements as physicians.
It's also not fair for patients to be treated with someone of lower level of training. Education matters and experience matters. That's why medical training is so long and intense; that's why residencies exist; that's why there are so many rigorous checks for medical competence. Can you say the same for NP/DNP training? No you cannot. The curricula between schools is very different, you can get the degree online, most programs don't have more than a 1000 clinical hours in training (!!), there are no rigourous checks to determine competency, etc.
And no, you haven't "streamlined" medical training; sure, there might be a few things that need changing in med school curricula but the answer is not to remove nearly every basic science course, spend a minimal amount on pathophys, focus on nursing theory/activism, etc. That's not streamlining anymore.
Lets not forget if M4s were to practice, PAs are out of work also.
PCPs are not lacking patients. There has been a PCP shortage for quite some time. More than enough patients to go around and more to come if universal healthcare comes to be.
Please. Are you kidding me? ALL the studies are significantly flawed? Surely you could find one that shows me that you have some actual PROOF to support your position that the patient outcomes are significantly lower than that of PAs. With the claim of superior training, that should be a slam dunk. Yet all I read is post after post of slander. Apparently, I'm asking too much here, too.
The burden of proof is on the midlevels to show that their outcomes are similar. This means designing a valid study, not one that measures random values or one that compares independently practicing midlevels vs. PGY-1 residents or one where rather uncomplicated patients are treated (where the only thing you need is the ability to follow an algorithm), etc.
You have to realize that I'm not against midlevels. They're great, they help out a lot, etc. I just do not support the idea of independent practice. Before just pushing away everything I say as "slander" or "hate" or whatever, take a look at what I actually wrote. I haven't said any rude things or anything like that; I've pointed out, with links, etc. the differences between medical education and NP/DNP education and I've stated that the significant difference between the two doesn't support the idea that NPs/DNPs should be allowed to practice medicine independently. It's unfair for me when you say that all I'm doing is slandering.
Idaho4me
32 Posts
Why do you think these studies were even done? Its exactly the questions you raise that produced these studies. Even in the face of hard science, you still want hold you ground? What exactly then would put your mind at ease?