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?
Ok....i thought i did - it's no different than my argument all along. If someone does not have the training and education to perform the job then people will die or get suboptimal care.
I have an idea for you to alleviate your "worries". If you think the care will be suboptimal, don't go to see an independent NP for your care.
Experience is NOT the most important factor. If you are practicing independently then you have no one to "train you", something that is the whole idea behind a residency and is especially important if you have very little clinical training and would benefit from physician oversight.
Sounds like what the nursing profession is advocating in BSNs and DNPs - in fact that's exactly what they are looking to do. It's all about the money.
There is plenty of clinical training and experience in the dnp programs. Wouldn't hurt to add a year or two experience requirement for independent practice.
Disposable income is a very simple economic concept. The fact that you don't comprehend it goes further to prove my point that you have absolutely zero business acumen. Everyone requires a certain amount of money to provide for the necessities of life. The amount that is left over is disposable income. Doctors make more money than others and thus have more disposable income. Very simple concept. Just because the education is delivered differently doesn't make it more challenging. Accountants train more on the job than the physician model. And they spend most of their careers working very long hours. The first few years are very tough and there is a lot to learn under supervision before they are really trained to do the job. Numbers on a page can be every bit as complex as the human body. Have you ever tried to interpret a 10-K? Ever even tried to read one? I bet you can't tell me the first thing about it after you do. You simply won't understand it. And I know you can't tell me how you would go about making the complex estimates that go into it. It takes years of experience and professional judgement to do it. Don't try to compare your profession to others and assume you are better smarter or even more challenged than others before you walk a mile in their shoes. This is exactly the attitude that makes physicians poor businesspeople. They don't think that they can take professional advice from someone because they are so much smarter than everyone else. NPs don't seem to have the GOD complex and are certainly more willing to take business advice from an expert instead of thinking that they are their own business expert and can do it exactly the way that they want to and make money at it.
Just because doctors make more money does not mean they have more disposable income.
I am not in any way saying i am better or smarter than any other profession. Nor would I have any idea how to do an accountant's job or vice-versa. What I am saying is that medicine is far more different and the stakes are higher than accounting. In addition, the cost of business is higher in the medical field. It is B.S. to continuously bash physicians as being inferior business people and elevating NPs as superior because you think all physicians have a god complex. Many physicians are getting their MBAs and/or hiring practice managers with business degrees and yes they listen to those people.
I have an idea for you to alleviate your "worries". If you think the care will be suboptimal, don't go to see an independent NP for your care.
I won't be, but the public needs to know the differences in training and realize this can provide for suboptimal care. In addition if they go see a DNP ("doctor") then they need to know that it's not the same as an MD/DO (DOCTOR).
Patient satisfaction is directly correlated to patient outcomes? Wow...
You don't need any evidence to show that NPs provide equivalent care other than patient surveys and the fact that there are 150000 NPs in the workforce? Huh...
I don't really know what to say anymore. I have presented all the facts and yet, they continually get ignored. I just don't know what to say.
There is NOT plenty of clinical training in the NP/DNP curricula. 600-1000 clinical hours?! Hah..that's scary! Physicians get over 17000 clinical hours in training before they're allowed to practice independently. What makes you think that you'd be equal to a physician with 1/17th of that amount of training? Residency is superivised training, not just on-the-job training; you seem to be missing this important point. It takes years of training for a physician to be allowed to practice independently. Why is it okay for NPs/DNPs to take such a HUGE shortcut to practicing independently? If you're smart enough for med school, why don't you just go to med school instead of pretending to be a doctor?
If you'd be so kind, what part of medical education have you streamlined so much that makes you think that your training is equivalent to that of physicians?
Also, how does nursing theory, nurse activism, "DNP Capstone" (***?), etc. help provide better medical care? I'd really like to know.
How are you going to keep a practice going by seeing less patients than PCPs for less money than PCPs? Do you think you'll get a discount on overhead because you're an NP? If PCPs have to see more and more patients in order to make some money, you'd have to see many more patients than PCPs to make similar amounts. Isn't this what you're arguing against? Seeing 50 patients per day? Or is it safer for NPs to see 50 patients per day compared to physicians?
All you've responded with so far has been emotion. You have not provided a shred of evidence supporting your beliefs. I have, on the other hand, provided multiple links, analyzed the various curricula, looked at various studies, etc. before posting. You should try doing the same. If the average NP/DNP thinks the same way as you do, I fear for the safety of patients.
I won't be, but the public needs to know the differences in training and realize this can provide for suboptimal care. In addition if they go see a DNP ("doctor") then they need to know that it's not the same as an MD/DO (DOCTOR).
I agree completely that people should be aware of the credentials that accompany an independent practitioner. People should know what they are getting. I think that the public should know if any professional provides suboptimal care. Maybe what should happen is when doctors provide suboptimal care and lose a malpractice case, they should be required to post that on their door. That would provide some transparency for patients to know who provides suboptimal care.
I agree completely that people should be aware of the credentials that accompany an independent practitioner. People should know what they are getting. I think that the public should know if any professional provides suboptimal care. Maybe what should happen is when doctors provide suboptimal care and lose a malpractice case, they should be required to post that on their door. That would provide some transparency for patients to know who provides suboptimal care.
They already do, most states have doctor profiles that the public can freely access and some insurance companies link to those profiles when people go to the site to find a new pcp.
Patient satisfaction is directly correlated to patient outcomes? Wow...
You don't need any evidence to show that NPs provide equivalent care other than patient surveys and the fact that there are 150000 NPs in the workforce? Huh...
I don't really know what to say anymore. I have presented all the facts and yet, they continually get ignored. I just don't know what to say.
There is NOT plenty of clinical training in the NP/DNP curricula. 600-1000 clinical hours?! Hah..that's scary! Physicians get over 17000 clinical hours in training before they're allowed to practice independently. What makes you think that you'd be equal to a physician with 1/17th of that amount of training? Residency is superivised training, not just on-the-job training; you seem to be missing this important point. It takes years of training for a physician to be allowed to practice independently. Why is it okay for NPs/DNPs to take such a HUGE shortcut to practicing independently? If you're smart enough for med school, why don't you just go to med school instead of pretending to be a doctor?
If you'd be so kind, what part of medical education have you streamlined so much that makes you think that your training is equivalent to that of physicians?
Also, how does nursing theory, nurse activism, "DNP Capstone" (***?), etc. help provide better medical care? I'd really like to know.
How are you going to keep a practice going by seeing less patients than PCPs for less money than PCPs? Do you think you'll get a discount on overhead because you're an NP? If PCPs have to see more and more patients in order to make some money, you'd have to see many more patients than PCPs to make similar amounts. Isn't this what you're arguing against? Seeing 50 patients per day? Or is it safer for NPs to see 50 patients per day compared to physicians?
All you've responded with so far has been emotion. You have not provided a shred of evidence supporting your beliefs. I have, on the other hand, provided multiple links, analyzed the various curricula, looked at various studies, etc. before posting. You should try doing the same. If the average NP/DNP thinks the same way as you do, I fear for the safety of patients.
Look, don't lie to support your opinions. We all know that physicians on average don't get 17,000 clinical hours before practicing independently. Let's try for maybe half that or less. And yet again, there you go with the idea that you have to be smarter to go to medical school than anyone on the planet, and if you didn't go, you aren't as smart as the people who did. That is ludicrous.
The cost of practicing isn't all overhead. Some of it is what you pay yourself. Furthermore, alot of overhead is optional. It depends on what building you want to locate your practice in, how much space you want, how many people you hire, what sort of system you use, and how efficiently you run your business. Most doctors are not good at this, and when they find themselves not making the salary that they want to make, they either try to see more patients or sell their practice to a hospital and guarantee themselves a salary whether the practice makes money or not. If you set the practice up to run efficiently and on a low budget and stick to it, you can lower overhead. It is really very simple math. An NP can run a very low overhead practice and doesn't need to pay themselves as much as the physician thinks they have to. Fewer patients, lower reimbursement and the NP can make the same or more than they make by working for the physician and letting the physician get paid a surcharge on their work.
By the way, I have seen zero links to any evidence in any of your posts.
They already do, most states have doctor profiles that the public can freely access and some insurance companies link to those profiles when people go to the site to find a new pcp.
In the past there have been insurance companies which had direct links to doctor profiles in their provider searches, but the direct links appear to not be there any more (when i went looking again).
Look, don't lie to support your opinions. We all know that physicians on average don't get 17,000 clinical hours before practicing independently. Let's try for maybe half that or less. And yet again, there you go with the idea that you have to be smarter to go to medical school than anyone on the planet, and if you didn't go, you aren't as smart as the people who did. That is ludicrous.
The cost of practicing isn't all overhead. Some of it is what you pay yourself. Furthermore, alot of overhead is optional. It depends on what building you want to locate your practice in, how much space you want, how many people you hire, what sort of system you use, and how efficiently you run your business. Most doctors are not good at this, and when they find themselves not making the salary that they want to make, they either try to see more patients or sell their practice to a hospital and guarantee themselves a salary whether the practice makes money or not. If you set the practice up to run efficiently and on a low budget and stick to it, you can lower overhead. It is really very simple math. An NP can run a very low overhead practice and doesn't need to pay themselves as much as the physician thinks they have to. Fewer patients, lower reimbursement and the NP can make the same or more than they make by working for the physician and letting the physician get paid a surcharge on their work.
By the way, I have seen zero links to any evidence in any of your posts.
I don't know the exact number of clinical hours, but the average is 80 hours a week for residents, resulting in about 4,000 clinical hours in a year (2005 numbers, but i don't think there has been much change - http://www.npr.org/templates/story/story.php?storyId=4512366 ). The shortest residencies are three years resulting in 12,000 clinical hours for residency. Then add in 3rd and 4th year rotations which generally mirror that of residency since students rotate with residents (can't post the article link - subscription service) which would add about 8,000 more - so actually 20,000 hours not including any extra time during 2nd year since some schools add that on.
I would empasize that it doesn't take a smarter person to go to med school, just someone willing to sacrifice many years of their life in training and subsequent debt (personal, financial, social, etc).
In terms of financial management, there is no linking to any proof that what you are saying is anything other than opinion (which is fine, since that's what most of us are posting). Bottom line, anyone can run a practice with lower overhead regardless of NP or MD/DO status. If one is an independent practitioner, they can charge whatever they want and manage their practice any way they want - but the costs will still be there.
I don't know the exact number of clinical hours, but the average is 80 hours a week for residents, resulting in about 4,000 clinical hours in a year (2005 numbers, but i don't think there has been much change - http://www.npr.org/templates/story/story.php?storyId=4512366 ). The shortest residencies are three years resulting in 12,000 clinical hours for residency. Then add in 3rd and 4th year rotations which generally mirror that of residency since students rotate with residents (can't post the article link - subscription service) which would add about 8,000 more - so actually 20,000 hours not including any extra time during 2nd year since some schools add that on.
I would empasize that it doesn't take a smarter person to go to med school, just someone willing to sacrifice many years of their life in training and subsequent debt (personal, financial, social, etc).
In terms of financial management, there is no linking to any proof that what you are saying is anything other than opinion (which is fine, since that's what most of us are posting). Bottom line, anyone can run a practice with lower overhead regardless of NP or MD/DO status. If one is an independent practitioner, they can charge whatever they want and manage their practice any way they want - but the costs will still be there.
My only point to you is that many other people make sacrifices that are just as big for their professions, that isn't limited to physicians.
You are right, there is no linking to any proof and it is my opinion that physicians are poor financial managers. If anyone can run a practice with lower overhead then why will the costs still be there for everyone. You are contradicting yourself. What I really can't explain is, why don't physicians try to lower their overhead. I know for a fact that most of them won't try to, but I don't understand why.
mbreaz1
132 Posts
I have an idea for you to alleviate your "worries". If you think the care will be suboptimal, don't go to see an independent NP for your care.