Don't Hate Me, All....

dgenthusiast · Sep 5, 2009

I argue for equal reimbursement, not increased reimbursement. What you can't stand is that I would advocate physicians having their reimbursement lowered. And yes, nobody really cares about M4s. You are the only one who cares about them because you claim to be one. What I have argued is very consistent. I support an experience requirement for certification for NPs, and I support lowered reimbursement rates for physicians.

I never claimed to be an M4. In fact, if you actually read my posts, you'll see that I mentioned my status in one of them. And it's definitely not M4. Once again, you're making up things and attributing them to me; that doesn't sound fair does it?

Why should physicians have reimbursements lowered more so than they already are? You also do realize that physicians themselves do not set reimbursement rates right?

Why should physicians have same reimbursement rates as NPs when physicians have far greater training? That doesn't make any sense.

dgenthusiast · Sep 5, 2009

I argue for equal reimbursement, not increased reimbursement. What you can't stand is that I would advocate physicians having their reimbursement lowered. And yes, nobody really cares about M4s. You are the only one who cares about them because you claim to be one. What I have argued is very consistent. I support an experience requirement for certification for NPs, and I support lowered reimbursement rates for physicians.

You're also ignoring the fact that M4s have better training in the basic sciences and have far more clinical experience than any NP/DNP curricula even comes close to offering. So you might want to start caring about these M4s since it's very easy to make an argument for independent practice rights for M4s when lesser trained individuals (NPs/DNPs) have independent rights. It logically makes sense.

mbreaz1 · Sep 5, 2009

I never claimed to be an M4. In fact, if you actually read my posts, you'll see that I mentioned my status in one of them. And it's definitely not M4. Once again, you're making up things and attributing them to me; that doesn't sound fair does it?
Why should physicians have reimbursements lowered more so than they already are? You also do realize that physicians themselves do not set reimbursement rates right?
Why should physicians have same reimbursement rates as NPs when physicians have far greater training? That doesn't make any sense.

Simple reason, they perform the same task. People should get paid the same thing for doing the same job. I told you that before and you never responded to it.

dgenthusiast · Sep 5, 2009

Simple reason, they perform the same task. People should get paid the same thing for doing the same job. I told you that before and you never responded to it.

Sure, there are some tasks that are the same between the two, but you can't be saying that NPs have the exact same knowledge base as physicians to handle any possible thing that walks through the door? If you are suggesting this, I want to ask you how you have compressed 7+ years of training into 2-3 years in order to gain that knowledge base.

dgenthusiast · Sep 5, 2009

Simple reason, they perform the same task. People should get paid the same thing for doing the same job. I told you that before and you never responded to it.

Heck, you don't even need an NP degree to do some of the stuff they do. All you need is a high school graduate (maybe not even) trained to do some routine stuff. The problem comes though, when a not-so-routine patient comes in through the door. How do you know the patient is beyond the scope of your training? How do you know you're not missing critical signs for an underlying pathology if you never learnt about it in the first place (since you have spent a far lesser amount of time in training, it's a valid assumption to make that you don't cover every single topic that medical school and residency do)?

So while NPs and MDs do some similar tasks, it's that difference in knowledge base and training that allows MDs to take care of far more complex patients than midlevels. Midlevels just do not have the same knowledge base a full-fledged attending physician. Therein lies the value of a physician; the fact that he/she has more experience with taking care of hugely complex patients and that he/she also has the knowledge base of a huge breadth and depth of pathologies.

mbreaz1 · Sep 5, 2009

Sure, there are some tasks that are the same between the two, but you can't be saying that NPs have the exact same knowledge base as physicians to handle any possible thing that walks through the door? If you are suggesting this, I want to ask you how you have compressed 7+ years of training into 2-3 years in order to gain that knowledge base.

If an NP couldn't handle any possible thing that walked through the door, then why would physicians leave them there to tend the office alone and with no supervision? Of course I am saying they can handle everything that walks through the door, except for the ones that require an ER or specialty referral, which mind you, is handling it appropriately. 7+? I don't think so. Like I told you before you are comparing 4 years of education to 3 years of education, and last time I checked 4 minus 3 equals one year of EDUCATIONAL difference between the two.

mbreaz1 · Sep 5, 2009

Heck, you don't even need an NP degree to do some of the stuff they do. All you need is a high school graduate (maybe not even) trained to do some routine stuff. The problem comes though, when a not-so-routine patient comes in through the door. How do you know the patient is beyond the scope of your training? How do you know you're not missing critical signs for an underlying pathology if you never learnt about it in the first place (since you have spent a far lesser amount of time in training, it's a valid assumption to make that you don't cover every single topic that medical school and residency do)?
So while NPs and MDs do some similar tasks, it's that difference in knowledge base and training that allows MDs to take care of far more complex patients than midlevels. Midlevels just do not have the same knowledge base a full-fledged attending physician. Therein lies the value of a physician; the fact that he/she has more experience with taking care of hugely complex patients and that he/she also has the knowledge base of a huge breadth and depth of pathologies.

Listen, you don't cover every topic in medical school either. Education is going to leave something out. That is why you need experience. And when a not so routine patient comes through the door, the primary care physician is going to have trouble diagnosing them too, and will have to refer them to a specialist, the same way the NP will do. Your arguments about this are silly. NPs are trained well enough to recognize when they need to make a referral. That difference in knowledge is no longer valuable to anyone in primary care because the not so routine patient has their not so routine problem taken care of by a specialist. and there isn't such a huge depth and breadth of difference in knowledge between an NP and a physician. You will never prove that to anyone.

dgenthusiast · Sep 5, 2009

Listen, you don't cover every topic in medical school either. Education is going to leave something out. That is why you need experience. And when a not so routine patient comes through the door, the primary care physician is going to have trouble diagnosing them too, and will have to refer them to a specialist, the same way the NP will do. Your arguments about this are silly. NPs are trained well enough to recognize when they need to make a referral. That difference in knowledge is no longer valuable to anyone in primary care because the not so routine patient has their not so routine problem taken care of by a specialist. and there isn't such a huge depth and breadth of difference in knowledge between an NP and a physician. You will never prove that to anyone.

As you like saying so much, there's no need to provide evidence. The difference in knowledge is evident in everyday practice if you look around. You seem to be in the minority of people who believe that NP training is equivalent to MD/DO training. Primary care is one of the hardest medical specialties because of the breadth of knowledge needed. A good PCP is not just triaging but managing many complicated patients himself/herself.

If the role of primary care providers is to only triage, even NP education is too much. All you need is a high school student sitting at a desk checking vitals and pointing out which specialist to see. So, if that's what you mean when you are discussing PCPs, I have to borrow one of your words again even for NP training: "overtrained."

Regarding the several years difference:

Medical school: 4 years

Residency: 3-5 years

BSN to DNP: 2-3 years

So, medical training is 4 + 3 = 7+ years. NP/DNP training 2-3 max; longer if you do it part-time. It's simple math really. I don't know where you're getting only 1 year of difference. Maybe you don't seem to understand that residency is graduate medical training? It's part of the training that's required before a physician is allowed to practice independently.

dgenthusiast · Sep 5, 2009

Listen, you don't cover every topic in medical school either. Education is going to leave something out. That is why you need experience. And when a not so routine patient comes through the door, the primary care physician is going to have trouble diagnosing them too, and will have to refer them to a specialist, the same way the NP will do. Your arguments about this are silly. NPs are trained well enough to recognize when they need to make a referral. That difference in knowledge is no longer valuable to anyone in primary care because the not so routine patient has their not so routine problem taken care of by a specialist. and there isn't such a huge depth and breadth of difference in knowledge between an NP and a physician. You will never prove that to anyone.

If medical education is guaranteed to leave something out (and it's true that it will), imagine how much more information NP training will leave out in order fit into the 2-3 year schedule. If there's not enough time in medical school and residency to learn everything (which takes a minimum of 7 years), there cannot possibly be any way at all that NP/DNP training can accomplish the same in 2-3 years.

By the time a PCP starts practicing independently, he's been trained for a minimum of 7 years and has seen a wide variety of patients, both complex and uncomplicated. That's a requirement of residency. There's a thing called standardization of medical training that's lacking in NP/DNP training. Medical training provides many checks in place to ensure that nearly everyone who gets trained is pretty competent by the time they're practicing independently. You can't say the same for NP/DNP training.

Once again, you're wrong.

mbreaz1 · Sep 5, 2009

As you like saying so much, there's no need to provide evidence. The difference in knowledge is evident in everyday practice if you look around. You seem to be in the minority of people who believe that NP training is equivalent to MD/DO training. Primary care is one of the hardest medical specialties because of the breadth of knowledge needed. A good PCP is not just triaging but managing many complicated patients himself/herself.
If the role of primary care providers is to only triage, even NP education is too much. All you need is a high school student sitting at a desk checking vitals and pointing out which specialist to see. So, if that's what you mean when you are discussing PCPs, I have to borrow one of your words again even for NP training: "overtrained."
Regarding the several years difference:
Medical school: 4 years
Residency: 3-5 years
BSN to DNP: 2-3 years
So, medical training is 4 + 3 = 7+ years. NP/DNP training 2-3 max; longer if you do it part-time. It's simple math really. I don't know where you're getting only 1 year of difference. Maybe you don't seem to understand that residency is graduate medical training? It's part of the training that's required before a physician is allowed to practice independently.

If primary care is one of the hardest specialties and requires more training, then why do primary care physicians not train as long as their specialist colleagues? You are putting words in my mouth again regarding equivalency. Please read my posts and understand what I am saying before you do that again. If an NP is running the office, they aren't just triaging. They are diagnosing, treating, and referring when necessary. Don't make silly arguments and go to extremes with your patronizing and gratuitous comments. You are belittling all of the nurse practitioners who are out there in practice everyday doing their jobs. You make out like they are all idiots and don't know how to treat anyone because they only went to NP school. However, they are out there everyday acheiving equal outcomes with lesser education. That proves to me that their education must be adquate to fill the job.

When you start working, education in the classroom has stopped and work experience has begun. NPs do the same thing and they are able to learn the same things working in the office that residents learn. It is no different. Furthermore, don't try to count time spent sleeping in the hospital as graduate training. Maybe you don't seem to understand that an NP with several years of experience is every bit as capable as a physician of filling an independtly practicing primary care role.

JDCitizen · Sep 5, 2009

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?

pretty much do...... but mary o'neil mundinger does not represent us all and i bet a big portion of the nps (at least the ones i know). you are seeing the chasm between academia and probably a large chunk of the np population. you are seeing a profession in transition. don't ignore the large group of nps that are pushing for changes in the programs.

to address a problem someone is going to have to fill the void in primary care and do it soon. the baby boomer's are not getting any younger and add to that a public health care option that may come to fruition...

there probably is not enough primary mds to see them all much less enough primary mds to oversee all the mid-level providers necessary to meet the demand.

using your own mentioned article as some rebuttal:

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

...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 columbiauniversityschool of nursing. she says dnps are being trained to have more focus than doctors on coordinating care among many specialists and health-care settings...

"...to establish a national standard for doctors of nursing practice, the non-profit council for the advancement of comprehensive care plans to announce wednesday that the national board of medical examiners has agreed to develop a voluntary dnp certification exam based on the same test physicians take to qualify for a medical license. the board will begin administering the exam this fall. by 2015, the american association of colleges of nursing aims to make the doctoral degree the standard for all new advanced practice nurses, including nurse practitioners"....

i would say somewhere around 2015 when the dnp becomes mandatory the test will be in place not as an option but as a requirement.

"...dr. mundinger, of columbia, says the primary aim of the dnp is not to usurp the role of the physician, but to deal with the fact that there simply won't be enough of them to care for patients with increasingly complex care needs. as doctors face shrinking insurance reimbursements and rising malpractice-insurance costs, more medical students are forsaking primary care for specialty practices with higher incomes and more predictable hours. as a result, there could be a shortfall ranging from 85,000 to 200,000 primary-care physicians by 2020, according to various estimates"....

...a spokeswoman for the medical licensing board, which provides examinations used by licensing authorities for several health professions, says the planned dnp exam will be narrower in scope than the three-step exam that doctors take, including tests on organ systems and a range of medical disciplines. a number of physicians have supported the efforts to advance nursing to the doctorate level through the council for the advancement of comprehensive care....

ANPFNPGNP · Sep 6, 2009

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.......

Why are you even questioning this? Is it because you will ALWAYS have to be supervised by a physician and you will NEVER be able to practice independently? Are you jealous? It's just a matter of time before NP's gain independent practice in every single state. That's something a physician's "assistant" will never achieve.