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?
- 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....
Sorry for the third post in a row. I probably shouldn't have said that about cookbook medicine; my response was showed some of the annoyance I was feeling. I apologize.
That's great that you have had years of experience and that you know what patients you can handle/can't handle. However, you're more of an exception rather than the rule. So you can't say that every NP/DNP acts similar to you.
You're right that experience does matter in addition to education. That's what residency is for; that's why medical training is such a long and intense process: it's there to make sure that competent individuals are being put out before they're allowed to practice independently. During residency, you receive more than 15000 yrs of trained supervision. You can't say the same for NP/DNP training.
It's also not fair for patients to be treated with someone of lower level of training.
It is if that's what they want. Both my parents and my wife prefer their NPs. I think it might also be considered fair to be treated by anyone with less training than a physician if a physician is not available or in the military where you don't want to "waste" a good doctor to enemy fire. Maybe we should have civilian likes of Special Forces and Navy medics in every designated "needy" area. Would that be fair?
Now, nursing has never been able to get it together, not even with the entry level degree. I've been around long enough to remember when we had a Nursing Doctorate and Doctor of Nursing Science in addition to the Ph.D.. If I remember correctly one or both were to provide more clinical training. Where the heck are those degrees now? I don't even try to keep track anymore.
NP training should be set up more like PA training and everyone should have some type of physician oversight. The DNP was created for some reason but I don't really know why. I don't see much in the way of more clinical training. Mundinger was a rebel and the only dean of any DNP school to think her grads could take the Step 3. Now, I'd have no problem with the DNP if I could figure out why the program was created. Is it going to go the way of the other doctorates in nursing?
I'm a psych NP student because...I admit it...it's the easiest thing for me to do since I already have a masters in nursing. I did consider going the PA route many years ago as an ex-Army medic, but fell into nursing instead. And when I graduate I want to make the most money I can make without killing myself. My selfish reason for doing that is so I can offer my shamanism services free or little cost, mainly to Vets with PTSD, since it's so much more effective than anything else out there.
And one more thing. No studies that involve humans is worth much except to provide someone with a job and or the ability to publish a paper.
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.
Equal reimbursement is fine with me as long as it is lower. Physicians are the ones who constantly cry about not making as much as their specialist colleagues. They are also the ones who cry about what a terrible job primary care is and how nobody wants to do it. There are however plenty of NPs who love doing the job, and guess what, they get paid less than half of what a primary care physician does for doing the same job. Why isn't it safe to assume that the NP who is happy to do the job wouldn't be just as happy making about 20% more and without physician interference. That is very easy to do even with reimbursement cuts. You always assume that equal reimbursement means that the reimbursements go up for NPs. I think they should simply go down for physicians.
Financially viable? I think what you mean is they need to see that many patients to make the inflated salary that they want to bring home. It has nothing to do with financial viability. It has to do with shortchanging your patients so that you can make the money that you want to make, and that is WRONG. it is the same thing as cheating or stealing.
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).
So you are saying that PA school is not equivalent then. If so, please refrain from lumping it together. I believe it is different regardless of the model. I also think it is ridiculous to think there is only one way to skin a cat. What you are arguing is equivalent to saying that someone who goes to school at UCLA is more qualified to do their job than someone who goes to USC because they teach a different model there. We are talking about two accredited schools who have had their curriculum reviewed. Like I told you before, the training doesn't have to be the same to produce an equivalent product.
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.
You continue to assume equivalent means that NP reimbursement goes up. I continue to tell you that there is no reason that physician reimbursement can't go down to the current level of NP reimbursement. That is fair and it will save the system plenty of money too.
Being treated by someone with less education doesn't mean lower quality. What does equal lower quality is doctors trying to see 40 - 50 patients a day to try to make more and more money. This means less time talking to or thinking about a patients problems and leads to far worse outcomes. Making accurate diagnosis has far more to do with thinking things through than it does having one extra year of education. If paying for that one extra year means that you don't have more than 5 minutes to spend with each patient, then I think allopaths and osteopaths no longer have any place in primary care.
You continue to assume equivalent means that NP reimbursement goes up. I continue to tell you that there is no reason that physician reimbursement can't go down to the current level of NP reimbursement. That is fair and it will save the system plenty of money too.
Being treated by someone with less education doesn't mean lower quality. What does equal lower quality is doctors trying to see 40 - 50 patients a day to try to make more and more money. This means less time talking to or thinking about a patients problems and leads to far worse outcomes. Making accurate diagnosis has far more to do with thinking things through than it does having one extra year of education. If paying for that one extra year means that you don't have more than 5 minutes to spend with each patient, then I think allopaths and osteopaths no longer have any place in primary care.
Why does PCP reimbursement need to come down to NP levels? That makes absolutely no sense since physicians go through a much longer and much more difficult training. You do understand how compensation works right? Generally, the more training you have, the higher salaries tend to be. Otherwise, what's the point of higher education/training?
PCP reimbursement actually needs to go up. That way these physicians can spend more time with patients. We should do this instead of giving midlevels free rein. It's safer and it makes sense. The burden of proof that NPs don't provide lower quality care is on you, not on those opposing you. You have to design valid studies (ie. without significant flaws) to prove this. Yes, I know that no study can be truly perfect but the ones regarding NP outcomes are very significantly flawed, not just slightly.
If you're so sure that you can provide equal quality care for all patients, then design a proper study and publish it. I understand that you'd like to pretend to be a doctor without putting in the effort, but that's no excuse to endanger unknowing patients. Without the education, how do you know when a patient with morbidities beyond your scope is sitting in front of you?
I've repeatedly provided evidence as to how ridiculous NP/DNP training is but everyone seems to conveniently ignore it. Taking away most science classes and putting in fluff courses doesn't make you equivalent to a physician. And less that 1000 clinical hours?! That's just scary...How can you say that the diverse NP curricula and severe lack of basic science AND clinical training is okay? That's like saying you want to take quantum mechanics when you have only taken high school level algebra beforehand. I'm sure it would feel cool to sit in the class though.
Equal reimbursement is fine with me as long as it is lower. Physicians are the ones who constantly cry about not making as much as their specialist colleagues. They are also the ones who cry about what a terrible job primary care is and how nobody wants to do it. There are however plenty of NPs who love doing the job, and guess what, they get paid less than half of what a primary care physician does for doing the same job. Why isn't it safe to assume that the NP who is happy to do the job wouldn't be just as happy making about 20% more and without physician interference. That is very easy to do even with reimbursement cuts. You always assume that equal reimbursement means that the reimbursements go up for NPs. I think they should simply go down for physicians.
Financially viable? I think what you mean is they need to see that many patients to make the inflated salary that they want to bring home. It has nothing to do with financial viability. It has to do with shortchanging your patients so that you can make the money that you want to make, and that is WRONG. it is the same thing as cheating or stealing.
Physicians are not saying that primary care is terrible, but they simply want more fair reimbursement. The primary care physicians see more varied patients than do specialists and they need a broader base of medical knowledge to care for those patients. Many of them are more upset that they are not able to make a living doing what they love. Their choices are: don't practice because the cost is too high to have the care you want to provide, practice and do your best to maintain your practice still try to maintain the quality of care, or see one patient every 10-15 minutes, minimize patient interaction, but still provide care. Obviously we want to really push physicians towards the latter option by decreasing reimbursement.
But I guess it's ok because we have tons of independently practicing NPs which will gladly do the same job, see less patients in the day (because they take more time with their patients), and get paid less...while maintaining a practice. Many people have insurance and most of the time the insurance is setting reimbursement rates, not the physician, and that rate is way too low to maintain costs. Not to mention the fact that physicians take at least 7-10 years to be in school full time without being able to have much additional income and incurring around a quarter million to half million in debt to be able to practice medicine.
So you are saying that PA school is not equivalent then. If so, please refrain from lumping it together. I believe it is different regardless of the model. I also think it is ridiculous to think there is only one way to skin a cat. What you are arguing is equivalent to saying that someone who goes to school at UCLA is more qualified to do their job than someone who goes to USC because they teach a different model there. We are talking about two accredited schools who have had their curriculum reviewed. Like I told you before, the training doesn't have to be the same to produce an equivalent product.
Regardless of the equivalency between the PA and MD/DO the training is very similar. Definitely more similar than either program to nursing or nurse practitioners. The training for a PA is modeled after that of medical school with half basic sciences and half clinical rotations. I never made the statement that PA school was equivalent to MD/DO school, but PA students make a choice when they start school, regardless of the reason, that they want to be a physician's assistant and assume the role of a midlevel provider with physician oversight. They understand the difference, and if they wanted complete autonomy and independent practice they would go to medical school.
Each school may have minor differences in teaching, but for PA, MD, and DO schools there is a standardized curriculum which dictates the courses that students take to make them competant providers. Yes, there may be differences, but there are standardized, national tests that evaluate students at every step in the process. For medical schools alone there are three (actually four - step 2 for DO and MD are two parts) exams that make sure students are progressing along the way and ensure competancy. The current NBME exam for DNP, from what I understand, is based on retired USMLE Step 3 questions, for which the failure rate was 50% for the first round of students who took it. That exam does tests diagnostics and clinical medicine, but there is no equivalent exam to mirror step 2 which includes complete physican diagnosis and exam (which is even more important). If DNP students and medical students were able to take the same type of exam to evaluate competency then it would be more understandable to mirror the scope of practice (which would be an objective comparison regardless of training).
Like I keep saying, if NPs/DNPs want full independent rights, it follows logically that 4th year medical students should be allowed to practice independently. As I've pointed out in prior posts, by the time a medical student reaches 4th year, he/she has had FAR MORE basic science AND clinical training than any NP/DNP program provides. I can guarantee that this would result in a boost in popularity for primary care specialties since the students will save a year of tuition and will also be able to skip the hellishness of residency; not only that, they can also start paying back loans earlier. What a great deal!
But why are people afraid of being treated by M4s? As mbreaz argues, they can always just learn on-the-job if they're deficient in something, right? This seems like a great solution to the primary care shortage.
PS. I am not actually advocating for independent practice for M4s. I'm just pointing out how an M4, who has much more basic science and clinical training than graduating NPs/DNPs, is not allowed to practice independently but it's okay for someone with lesser training to do so.
Why does PCP reimbursement need to come down to NP levels? That makes absolutely no sense since physicians go through a much longer and much more difficult training. You do understand how compensation works right? Generally, the more training you have, the higher salaries tend to be. Otherwise, what's the point of higher education/training?
PCP reimbursement actually needs to go up. That way these physicians can spend more time with patients. We should do this instead of giving midlevels free rein. It's safer and it makes sense. The burden of proof that NPs don't provide lower quality care is on you, not on those opposing you. You have to design valid studies (ie. without significant flaws) to prove this. Yes, I know that no study can be truly perfect but the ones regarding NP outcomes are very significantly flawed, not just slightly.
If you're so sure that you can provide equal quality care for all patients, then design a proper study and publish it. I understand that you'd like to pretend to be a doctor without putting in the effort, but that's no excuse to endanger unknowing patients. Without the education, how do you know when a patient with morbidities beyond your scope is sitting in front of you?
I've repeatedly provided evidence as to how ridiculous NP/DNP training is but everyone seems to conveniently ignore it. Taking away most science classes and putting in fluff courses doesn't make you equivalent to a physician. And less that 1000 clinical hours?! That's just scary...How can you say that the diverse NP curricula and severe lack of basic science AND clinical training is okay? That's like saying you want to take quantum mechanics when you have only taken high school level algebra beforehand. I'm sure it would feel cool to sit in the class though.
You obviously don't understand how a free market economy works. When you offer your services to the market, you get paid the same as the guy down the street who is offerring the same service. Unless you offer more value. That is the whole point, physicians do not offer good value in primary care. They offer terrible value. And no, you don't need studies that prove NPs are better. All you need to do is ask their patients if they would like to see them in independent practice. Your problem is that you think medicine is all science is all there is to healing people. That is far from the truth.
Physicians are not saying that primary care is terrible, but they simply want more fair reimbursement. The primary care physicians see more varied patients than do specialists and they need a broader base of medical knowledge to care for those patients. Many of them are more upset that they are not able to make a living doing what they love. Their choices are: don't practice because the cost is too high to have the care you want to provide, practice and do your best to maintain your practice still try to maintain the quality of care, or see one patient every 10-15 minutes, minimize patient interaction, but still provide care. Obviously we want to really push physicians towards the latter option by decreasing reimbursement.
But I guess it's ok because we have tons of independently practicing NPs which will gladly do the same job, see less patients in the day (because they take more time with their patients), and get paid less...while maintaining a practice. Many people have insurance and most of the time the insurance is setting reimbursement rates, not the physician, and that rate is way too low to maintain costs. Not to mention the fact that physicians take at least 7-10 years to be in school full time without being able to have much additional income and incurring around a quarter million to half million in debt to be able to practice medicine.
Let's go ahead and quantify what you mean by making a living. If they really love it so much, why wouldn't they be willing to do the job for 100,000 a year as opposed to the 160,000 they are currently making. You say the reimbursements are too low to maintain cost, and that is a lie. There are no physicians going out of business because they can't maintain costs. They do however refuse to cut costs to run their practice in a manner where they spend the time they should with patients. Reimbursement cuts are coming. Best figure out how to cut those costs or the NPs will take over the field.
Regardless of the equivalency between the PA and MD/DO the training is very similar. Definitely more similar than either program to nursing or nurse practitioners. The training for a PA is modeled after that of medical school with half basic sciences and half clinical rotations. I never made the statement that PA school was equivalent to MD/DO school, but PA students make a choice when they start school, regardless of the reason, that they want to be a physician's assistant and assume the role of a midlevel provider with physician oversight. They understand the difference, and if they wanted complete autonomy and independent practice they would go to medical school.
Each school may have minor differences in teaching, but for PA, MD, and DO schools there is a standardized curriculum which dictates the courses that students take to make them competant providers. Yes, there may be differences, but there are standardized, national tests that evaluate students at every step in the process. For medical schools alone there are three (actually four - step 2 for DO and MD are two parts) exams that make sure students are progressing along the way and ensure competancy. The current NBME exam for DNP, from what I understand, is based on retired USMLE Step 3 questions, for which the failure rate was 50% for the first round of students who took it. That exam does tests diagnostics and clinical medicine, but there is no equivalent exam to mirror step 2 which includes complete physican diagnosis and exam (which is even more important). If DNP students and medical students were able to take the same type of exam to evaluate competency then it would be more understandable to mirror the scope of practice (which would be an objective comparison regardless of training).
We never were talking about mirroring the scope of practice. We are simply talking about independent practice. The educational/training/testing model does not have to be the same in order for that to happen. I'm not sure what fantasy land you are living in, but that simply isn't true. Part of the reason that people prefer NPs is because they do have different training.
:redbeathe
dgenthusiast
237 Posts
Sorry for the third post in a row. I probably shouldn't have said that about cookbook medicine; my response was showed some of the annoyance I was feeling. I apologize.
That's great that you have had years of experience and that you know what patients you can handle/can't handle. However, you're more of an exception rather than the rule. So you can't say that every NP/DNP acts similar to you.
You're right that experience does matter in addition to education. That's what residency is for; that's why medical training is such a long and intense process: it's there to make sure that competent individuals are being put out before they're allowed to practice independently. During residency, you receive more than 15000 yrs of trained supervision. You can't say the same for NP/DNP training.