Don't Hate Me, All....

[TakeBack]

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?

_________________________________________________________________________________________

Thanks for your feedback here.......

[dgenthusiast]

Is dgenthusiast even a medical student?

From his writing style, he writes like one of the pre-med student member who constantly bashes NP in the doctor forum.

If you want to think that what I have said so far is constant bashing of NPs, that's your choice. However, I have not said anything unreasonable and have presented valid concerns that more and more people are expressing, including those in the nursing profession itself. These concerns include the inadequate training, the pursuit of independent practice and equal reimbursement to physicians, etc.

The problem with this forum is that whenever someone questions something regarding the nursing profession, there's an immediate cry that the person is a nurse hater who idealizes physicians as gods. I normally wouldn't expect that kind of knee-jerk reflex at what are supposed to be "professional" message boards; however, it seems pretty common here along with the anecdotal evidence > scientific studies mentality.

I am getting a little tired of this now though. I doubt any of you will truly understand what I'm saying because of the defensive mode you automatically get into when facing criticism. I have presented evidence in several threads regarding the inadequacies of NP/DNP training, etc; no one arguing for the NPs has presented any links/facts other than flawed studies (which they refuse to admit are severely flawed). I still stand firmly behind what I have said and I will continue to do so. I can only hope that at least some will see the truth behind the nursing propaganda machine and realize what the NP/DNP truly is.

[JDCitizen]

If you want to think that what I have said so far is constant bashing of NPs, that's your choice. However, I have not said anything unreasonable and have presented valid concerns that more and more people are expressing, including those in the nursing profession itself. These concerns include the inadequate training, the pursuit of independent practice and equal reimbursement to physicians, etc.

The problem with this forum is that whenever someone questions something regarding the nursing profession, there's an immediate cry that the person is a nurse hater who idealizes physicians as gods. I normally wouldn't expect that kind of knee-jerk reflex at what are supposed to be "professional" message boards; however, it seems pretty common here along with the anecdotal evidence > scientific studies mentality.

I am getting a little tired of this now though. I doubt any of you will truly understand what I'm saying because of the defensive mode you automatically get into when facing criticism. I have presented evidence in several threads regarding the inadequacies of NP/DNP training, etc; no one arguing for the NPs has presented any links/facts other than flawed studies (which they refuse to admit are severely flawed). I still stand firmly behind what I have said and I will continue to do so. I can only hope that at least some will see the truth behind the nursing propaganda machine and realize what the NP/DNP truly is.

What?

[mbreaz1]

If you want to think that what I have said so far is constant bashing of NPs, that's your choice. However, I have not said anything unreasonable and have presented valid concerns that more and more people are expressing, including those in the nursing profession itself. These concerns include the inadequate training, the pursuit of independent practice and equal reimbursement to physicians, etc.

The problem with this forum is that whenever someone questions something regarding the nursing profession, there's an immediate cry that the person is a nurse hater who idealizes physicians as gods. I normally wouldn't expect that kind of knee-jerk reflex at what are supposed to be "professional" message boards; however, it seems pretty common here along with the anecdotal evidence > scientific studies mentality.

I am getting a little tired of this now though. I doubt any of you will truly understand what I'm saying because of the defensive mode you automatically get into when facing criticism. I have presented evidence in several threads regarding the inadequacies of NP/DNP training, etc; no one arguing for the NPs has presented any links/facts other than flawed studies (which they refuse to admit are severely flawed). I still stand firmly behind what I have said and I will continue to do so. I can only hope that at least some will see the truth behind the nursing propaganda machine and realize what the NP/DNP truly is.

The TRUTH is that you have provided ZERO evidence to support your opinions expressed and your concerns about independent practice for NPs are just that - YOUR concerns. Most people don't share them. While you try to say that the NP profession has something that they have to prove to you, in fact they don't. They have proven themselves to a country and to an army of satisfied patients. Studies have been done to measure outcomes, and however flawed you think they are, they are accepted by everyone, including physicians. The fact that you call a study that physicians accept flawed really brings your credibility into question.

Let's talk about who the defensive one is here. At the beginning of this thread, all that was mentioned was independent practice and DNP programs. YOU are the one that tried to turn this into a superiority argument with all of your knocks on NP education and training and the physician is always better argument. YOU are the one who continues to say that NPs aren't qualified to diagnose and treat patients. YOU are the one who tells NPs that they if they were smart enough they should have just gone ahead and gone to medical school to become a doctor. YOU are the one who acts like a child.

What NPs provide is a potential lower cost solution for millions of Americans to have better access to quality healthcare. Even if it is limited to certain treatments and conditions, this is important for our society. We NEED to have lower cost providers to take care of the simple stuff for us, and we need people who are willing to make things convenient for us too. Primary care physicians simply don't have the ability to do all of that. I'm not interested in discussing the reasons for that or how to make things more advantageous for physicians. The time for that is passed. They have not been proactive in fixing the problems. We need to create a solution that will work for Americans, not for physicians. The patient needs to be the focus of reforms and NPs are patient focused. Physicians as evidenced by the actions of their professional organizations have lost their focus on the patient. It is evident by the actions of the AMA and other physician groups, that they would prefer to lobby governments to keep their monopoly power over the healthcare system, than to focus on what is good for patients. DG, here are a few links and excerpts for your evidence vault to show you what some of these organizations have been doing to keep themselves from having to compete with anyone:

On June 21,1999, the AMA Web site described the organization's concerns about the state by state incursion of NPs, nurse anesthetists, certified nurse midwives, optometrists, psychologists, pharmacists, and others into the clinical practice arenas once the exclusive domain of physicians.

The AMA's concerns seem to be focused on practitioners who move "outside of controlled circumstances" in which they practice "under a competent doctor." The AMA does not cite research or even anecdotal findings that nonphysician prescribers are dangerous, nor does the AMA report patient claims of dissatisfaction or provide evidence that nonphysician providers work outside their area of education. In fact, there do not appear to be data to support these concerns.

The actions of the AMA have aroused concern, specifically from nursing leaders, about future physician-practitioner relationships. Although only about one-third of physicians belong to the AMA, the continued circulation of very restrictive policies about physician practice with nonphysician providers has raised questions even in the minds of some physicians who have been long-time supporters of NPs. These policies have had a negative impact on some physicians who have been NP preceptors or employers. http://findarticles.com/p/articles/mi_qa3958/is_199909/ai_n8853720/

http://www.bcbs.com/news/national/ftc-clinic-rules-not-what-doctor-ordered-medical-group-wants-permits-curbs-on-ads.html

Physicians simply want to maintain the status quo in our healthcare system. They don't want anything to change. They don't want true reform. The truth is that in order to develop a sustainable system, we have to have payment reform, reimbursement cuts, and true cost reduction. Otherwise, nobody is going to be able to afford healthcare. If that means seeing a nurse practitioner instead of a physician, most people don't have a problem with that. You see DG, when it comes down to a simple matter of dollars and cents, and it is the difference between having healthcare or none, your diplomas and years of training don't matter all that much. People are willing to accept one less year of education when it means getting treatment they can afford versus not getting any treatment. That is the choice we are faced with as a society right now. It may not seem like it right now, but with double digit increases every year, it won't be long before that is the reality we have to contend with.

[mrnursing]

If you want to think that what I have said so far is constant bashing of NPs, that's your choice. However, I have not said anything unreasonable and have presented valid concerns that more and more people are expressing, including those in the nursing profession itself. These concerns include the inadequate training, the pursuit of independent practice and equal reimbursement to physicians, etc.

The problem with this forum is that whenever someone questions something regarding the nursing profession, there's an immediate cry that the person is a nurse hater who idealizes physicians as gods. I normally wouldn't expect that kind of knee-jerk reflex at what are supposed to be "professional" message boards; however, it seems pretty common here along with the anecdotal evidence > scientific studies mentality.

I am getting a little tired of this now though. I doubt any of you will truly understand what I'm saying because of the defensive mode you automatically get into when facing criticism. I have presented evidence in several threads regarding the inadequacies of NP/DNP training, etc; no one arguing for the NPs has presented any links/facts other than flawed studies (which they refuse to admit are severely flawed). I still stand firmly behind what I have said and I will continue to do so. I can only hope that at least some will see the truth behind the nursing propaganda machine and realize what the NP/DNP truly is.

Getting a little too emotional are you? :chuckle

If you would post up facts instead of rambling about your NP bashing opinions, some people would take you seriously.

You can stand firm in what you believe in all day if you want. Just don't try to become one of the lemmings who drank too much of the NP hating, insecure physician's koolaid without doing proper due diligence of your own.

[mbreaz1]

DG, here is a bit of "science" for you that was printed in JAMA "PROVING" similar outcomes for NPs and physicians. Can't wait to hear your rebuttal to that.

http://www.ncbi.nlm.nih.gov/pubmed/10632281?dopt=Abstract

[dgenthusiast]

dg, here is a bit of "science" for you that was printed in jama "proving" similar outcomes for nps and physicians. can't wait to hear your rebuttal to that.

http://www.ncbi.nlm.nih.gov/pubmed/10632281?dopt=abstract

look who's the lead author on that paper: mary mundinger. she's one of the main people pushing for equal reimbursement as physicians, dnp equivalence to physicians, etc. a little biased don't you think?

also, one of their main outcome measures was patient satisfaction surveys. like i mentioned previously, satisfaction surveys are a bad way to asses medical competency. just because people are satisfied with me doesn't mean that i provided good medical care. also, why did they measure diastolic value? that makes absolutely no sense. they took a value that is pretty much meaningless and found a statistical significance for it. clearly that's a mark of a scientific study. the fact that they're finding statistical significance in a useless marker does not imply equal outcomes.

this study is actually a perfect example of how not to do a study. it's a pretty poorly designed study and the fact that you posted it thinking it proved equal outcomes shows that you don't understand how studies are designed or interpreted. i recommend that you learn to do this rather than depend on other people to tell you what the results of a study are.

here's another rebuttal for you. even though they say in the paper that they will come back and look in 2 years to find equivalency, they never did. look through all the issues of jama; they never get back to it. instead they publish in the high impact factor, widely read, highly regarded "medical care research and review" (http://mcr.sagepub.com/cgi/content/abstract/61/3/332). they basically didn't have enough follow up to publish a meaningful study.

excellent articles, no? i will say again, there are no well-done studies that show that nps/dnps provide equal care as attending physicians (you know, those who finished training).

waiting for your rebuttal.

[dgenthusiast]

Getting a little too emotional are you? :chuckle

If you would post up facts instead of rambling about your NP bashing opinions, some people would take you seriously.

You can stand firm in what you believe in all day if you want. Just don't try to become one of the lemmings who drank too much of the NP hating, insecure physician's koolaid without doing proper due diligence of your own.

If you search through my posts, you'll find multiple links and analyses pointing out the inadequacies of NP/DNP training. These are not just mere opinions. When you look at an NP/DNP curricula, it looks more suitable for the pursuit of an MPH rather than a clinical degree.

I have stated before and will state again that I do not have anything against midlevels. I think they're a great part of the healthcare system and we'd be worse off without them. I am, however, completely against the idea of letting NPs/DNPs practice independently with the level of training they receive. You can keep ignoring what I say and attributing it to "NP hating" if you want; it seems to be common around here to ignore valid concerns.

[mbreaz1]

look who's the lead author on that paper: mary mundinger. she's one of the main people pushing for equal reimbursement as physicians, dnp equivalence to physicians, etc. a little biased don't you think?

also, one of their main outcome measures was patient satisfaction surveys. like i mentioned previously, satisfaction surveys are a bad way to asses medical competency. just because people are satisfied with me doesn't mean that i provided good medical care. also, why did they measure diastolic value? that makes absolutely no sense. they took a value that is pretty much meaningless and found a statistical significance for it. clearly that's a mark of a scientific study. the fact that they're finding statistical significance in a useless marker does not imply equal outcomes.

this study is actually a perfect example of how not to do a study. it's a pretty poorly designed study and the fact that you posted it thinking it proved equal outcomes shows that you don't understand how studies are designed or interpreted. i recommend that you learn to do this rather than depend on other people to tell you what the results of a study are.

here's another rebuttal for you. even though they say in the paper that they will come back and look in 2 years to find equivalency, they never did. look through all the issues of jama; they never get back to it. instead they publish in the high impact factor, widely read, highly regarded "medical care research and review" (http://mcr.sagepub.com/cgi/content/abstract/61/3/332). they basically didn't have enough follow up to publish a meaningful study.

excellent articles, no? i will say again, there are no well-done studies that show that nps/dnps provide equal care as attending physicians (you know, those who finished training).

waiting for your rebuttal.

at this point i can discount any study you find and you can discount any study i find for any number of reasons that we may choose. the point is this, you can't produce any studies that show that outcomes aren't at least equal. all of the studies show that regardless of their bias. i guess my question to you is, why does jama present the study if all physicians think it is biased? and why do all of the studies show equal outcomes for physicians and nps?

[mbreaz1]

If you search through my posts, you'll find multiple links and analyses pointing out the inadequacies of NP/DNP training. These are not just mere opinions. When you look at an NP/DNP curricula, it looks more suitable for the pursuit of an MPH rather than a clinical degree.

I have stated before and will state again that I do not have anything against midlevels. I think they're a great part of the healthcare system and we'd be worse off without them. I am, however, completely against the idea of letting NPs/DNPs practice independently with the level of training they receive. You can keep ignoring what I say and attributing it to "NP hating" if you want; it seems to be common around here to ignore valid concerns.

Your whole argument is baseless. We have seen multiple testimonies from people who are actually out there practicing to what a rubber stamp physician supervision is. The only thing physician supervision provides is a way for physicians to make a surcharge on the services provided by NPs. It exists in the wording of a law so that physicians can make extra income. This is something that you don't understand because you have never been in practice. You just don't know how it works. NPs basically already function with a level of autonomy that mirrors independent practice and they do so with proven equal outcomes. That is evident in the everyday practice of over 100,000 NPs. It doesn't take a study to prove that, it already happens. Glad you are so "concerned" for patients safety, but you should be more concerned about their access to care.

[dgenthusiast]

what?

yea, it's true. here are a few samples of the kind of stuff that's being spread around about dnps for example (quoted from ranier from another thread in these forums):

http://online.wsj.com/public/article_print/sb120710036831882059.html

more than 200 nursing schools have established or plan to launch doctorate of nursing practice programs to equip graduates with skills the schools say are equivalent to primary-care physicians. the two-year programs, including a one-year residency, create a "hybrid practitioner" with more skills, knowledge and training than a nurse practitioner with a master's degree, says mary mundinger, dean of new york's columbia university school of nursing. she says dnps are being trained to have more focus than doctors on coordinating care among many specialists and health-care settings...

http://www.forbes.com/2007/11/27/nurses-doctors-practice-oped-cx_mom_1128nurses.html

dnps are the ideal candidates to fill the primary-care void and deliver a new, more comprehensive brand of care that starts with but goes well beyond conventional medical practice. in addition to expert diagnosis and treatment, dnp training places an emphasis on preventive care, risk reduction and promoting good health practices. these clinicians are peerless prevention specialists and coordinators of complex care. in other words, as a patient, you get the medical knowledge of a physician, with the added skills of a nursing professional...

...to that end, we are working to enable dnps to take standardized exams similar in content and format to the test that physicians must pass to earn their m.d. degrees. by allowing dnps to take this test, the medical establishment will give patients definitive evidence that these skilled clinicians have the ability to provide comprehensive care indistinguishable from physicians...

peerless prevention specialists? please. knowledge of a physician + nurse? so it's not even saying that dnp = md, it's saying that dnp > md. yea, that makes sense.

here's another recent quote from mundinger (http://www.ama-assn.org/amednews/2009/06/08/prl10608.htm):

"mary o'neil mundinger, drph, rn, dean of columbia university school of nursing in new york, was quoted as saying: "if nurses can show they can pass the same test at the same level of competency, there's no rational argument for reimbursing them at a lower rate or giving them less authority in caring for patients." mundinger, cacc president, declined comment for this article."

this is after the fact that 50% of the test takers failed at taking a very diluted form of the easiest step exam.

if these kinds of statements aren't bs, i don't know what is. it's very easy to look at comments such as these and infer that the np/dnp profession feels like they're better than physicians even though they have lesser training. do you understand what i'm saying now?

[dgenthusiast]

At this point I can discount any study you find and you can discount any study I find for any number of reasons that we may choose. The point is this, you can't produce any studies that show that outcomes aren't at least equal. All of the studies show that regardless of their bias. I guess my question to you is, why does JAMA present the study if all physicians think it is biased? And why do all of the studies show equal outcomes for physicians and NPs?

The burden of proof is on NPs/DNPs to show that they can provide equal outcomes, not on the naysayers. It's like saying the easter bunny exists since you can't prove that he doesn't exist. That's not how it works.

It doesn't matter if all studies show equal outcomes if there are several confounders in each one. That's what invalidates those studies. You can't say that something is wrong with a study and proceed to accept the results as the truth.

[dgenthusiast]

Your whole argument is baseless. We have seen multiple testimonies from people who are actually out there practicing to what a rubber stamp physician supervision is. The only thing physician supervision provides is a way for physicians to make a surcharge on the services provided by NPs. It exists in the wording of a law so that physicians can make extra income. This is something that you don't understand because you have never been in practice. You just don't know how it works. NPs basically already function with a level of autonomy that mirrors independent practice and they do so with proven equal outcomes. That is evident in the everyday practice of over 100,000 NPs. It doesn't take a study to prove that, it already happens. Glad you are so "concerned" for patients safety, but you should be more concerned about their access to care.

Provide evidence. Your word is useless otherwise. Where is this rampant evidence published?

I am concerned for patient safety; I'm glad you understand the reason behind my arguments finally. We should let biology majors treat patients who don't have access. After all, according your argument, any treatment (no matter the quality) is better than no treatment right?