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:

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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?

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

[ANPFNPGNP]

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.

What do you mean, NP/DNP training in 2-3 years?? It took me 6 years of college to get a Master's degree and if I wanted to get my DNP, it would take AT LEAST 2 years of fulltime training to get it. Do you really think DNP education is equivalent to a CERTIFICATE from a JUNIOR COLLEGE for a PA?

[pianoman511]

What do you mean, NP/DNP training in 2-3 years?? It took me 6 years of college to get a Master's degree and if I wanted to get my DNP, it would take AT LEAST 2 years of fulltime training to get it. Do you really think DNP education is equivalent to a CERTIFICATE from a JUNIOR COLLEGE for a PA?

Almost all PA programs at this point (except around 3 - maybe less at this point) are masters programs (two years) which requires both a bachelors and health care experience which within itself is more clinical hours than what is in the ENTIRE DNP program (since it's not a clinical doctorate, but a NURSING practice doctorate).

And why would you get a DNP if it afforded the same practice rights as a tmasters program ? (and many are online...)

[pianoman511]

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.

Specialists require an internal medicine residency before their specialty training which does require the same amount (more in the case of family practice) than a PCP. No doubt NPs are doing a SIMILAR job than their PCP colleagues but it's not the SAME job. When a physician starts working they have completed many years of post graduate training where they are supervised (residency). And no, they aren't sleeping most of the time. Also, the experience during residency is completely different than on the job experience as an NP. If independent practice comes for all states, then NPs will have practice rights immediately after school ends, so the experience argument is null.

[pianoman511]

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.

And what's the problem with practicing with physician oversight ? PAs are not advocating for independent practice rights since the degree (just as NP) was conceived with the idea that they would be mid-level practitioners with enough education and training to handle most (but not all) of the tasks a physician would perform. We have heard from many providers thus far that the physician oversight they receive serves more as a resource for care and not a hindrance to care.

[ANPFNPGNP]

And what's the problem with practicing with physician oversight ? PAs are not advocating for independent practice rights since the degree (just as NP) was conceived with the idea that they would be mid-level practitioners with enough education and training to handle most (but not all) of the tasks a physician would perform. We have heard from many providers thus far that the physician oversight they receive serves more as a resource for care and not a hindrance to care.

It makes a big difference. I have a PA friend who lost her contract with a huge IM group b/c she couldn't bill Medicare directly, as the NP's are able to do (they were all seeing the nursing home patients). When a NP practices "independently," the doctor doesn't have the liability as they would with a PA.

Once again, the physician's assistants will NEVER be able to advocate for independent practice, because they HAVE to have physician oversight in every single state. They are an ASSISTANT and NOT A PRACTITIONER!

[ANPFNPGNP]

Almost all PA programs at this point (except around 3 - maybe less at this point) are masters programs (two years) which requires both a bachelors and health care experience which within itself is more clinical hours than what is in the ENTIRE DNP program (since it's not a clinical doctorate, but a NURSING practice doctorate).

And why would you get a DNP if it afforded the same practice rights as a tmasters program ? (and many are online...)

You are totally wrong. I can already think of 4 programs right off the top of my head that don't require a Master's degree! There's Miami Dade Community College, some school in South Dakota, Texas Tech and a TX A&M extension in South Texas - NONE of them have Master's programs. Hey, I'm not even searching the internet and I came up with those!:chuckle I have PA friends who graduated from the schools I just listed. Of all the PA's I know (I would say about 14), only TWO have a Master's degree!

[dgenthusiast]

What do you mean, NP/DNP training in 2-3 years?? It took me 6 years of college to get a Master's degree and if I wanted to get my DNP, it would take AT LEAST 2 years of fulltime training to get it. Do you really think DNP education is equivalent to a CERTIFICATE from a JUNIOR COLLEGE for a PA?

There are many BSN to DNP programs that are 2-3 years in length full time. Look at previous posts of mine where I provided a detailed comparison of a BSN to DNP program with an MD program.

If you want to include college in the years of training as well, then 4 years of college + 4 years of medical school + minimum of 3 years in residency = 11+ years of training for physicians. Either way you look at it, it's still a lot more than NP/DNP training.

The DNP curricula is somewhat of a joke. It's not only me who thinks that but there have been many who've raised that concern, even on these forums; so you can't really discount that as "just my opinion." All they've pretty much added is a bunch of MPH courses with no real value in clinical medicine and made it a doctorate. The DNP degree is pretty much a slap in the face to every other doctorate-level degree out there; I can't think of any other degree that provides you with a doctorate for such little furthering of education (you only need around 80 credits in most programs to go from a BSN to a DNP). It just looks like a push towards wanting to be called a doctor without putting in the effort.

[dgenthusiast]

It makes a big difference. I have a PA friend who lost her contract with a huge IM group b/c she couldn't bill Medicare directly, as the NP's are able to do (they were all seeing the nursing home patients). When a NP practices "independently," the doctor doesn't have the liability as they would with a PA.

Once again, the physician's assistants will NEVER be able to advocate for independent practice, because they HAVE to have physician oversight in every single state. They are an ASSISTANT and NOT A PRACTITIONER!

But PA's have better medical training than any NP/DNP program offers. Maybe that's why people might choose to go the PA route rather than the NP?

The PA programs are modeled after medical programs. The NP/DNP programs are not even close. This is fact, not opinion, by the way.

[dgenthusiast]

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.

But there's no proof of that though! How many times must it be reiterated that there are no properly done studies that show NP outcomes are equivalent to those of attendings. Design and conduct a study first before making blanket statements with no evidence behind it; just because you saw something in the office once doesn't mean it's true for everyone.

And I've never attacked the intelligence of NPs/DNPs. I have, however, repeatedly said that their knowledge base is NOT the same as that of physicians because they receive a much lesser amount of training. That is a true statement; it's not a personal insult. You've been taking every concern I've raised and written it off as a personal slap to the NP profession; you've repeatedly misinterpreted me even after I've clarified my position several times.

You're right that real life experience is an important part of it. But you're severely downplaying the importance of in-class education. You need a solid foundation before you start clinical practice. There's a reason that medical training is such a long and arduous process; it's there to ensure that nearly everyone who goes through it is competent enough to practice without supervision. Physicians also get a LOT more "on-the-job training" with supervision that NPs/DNPs do; it's called residency. So by the time physicians are practicing independently, they've had a significant amount of basic science training (for that solid foundation to understand physio/pathophys) and have had more than 17000 hours in clinical training, what you'd call "on-the-job training."

Not only that, there are many checks along the way to ensure competency and standardization of education. There are many NBME exams during basic science and clinical years, four Step exams to take (since Step 2 is two parts), board certification, and so on. None of these types of checks exist for NP/DNP training. The competency of a graduate from one program may be completely different from the competency of a graduate from another program; this is especially seen when you look at the NP/DNP curricula and see how diverse and varied they are from one another.

[ANPFNPGNP]

But PA's have better medical training than any NP/DNP program offers. Maybe that's why people might choose to go the PA route rather than the NP?

The PA programs are modeled after medical programs. The NP/DNP programs are not even close. This is fact, not opinion, by the way.

Are you kidding me - EVERY PA program is BETTER than EVERY NP program? GIVE ME A BREAK! I spent 1,800 clinical hours in grad/post grad school and I can run rings around any PA I know in internal medicine/primary care! I do it every day WITHOUT SUPERVISION! One of the PA's I know in urgent care calls ME to discuss patient labs, so don't think that PA education is superior, because it's not.

Since when are people choosing the PA route more often, when there are far more NP's than PA's in the USA? Where do you get your information?

[dgenthusiast]

Are you kidding me - EVERY PA program is BETTER than EVERY NP program? GIVE ME A BREAK! I spent 1,800 clinical hours in grad/post grad school and I can run rings around any PA I know in internal medicine/primary care! I do it every day WITHOUT SUPERVISION! One of the PA's I know in urgent care calls ME to discuss patient labs, so don't think that PA education is superior, because it's not.

Since when are people choosing the PA route more often, when there are far more NP's than PA's in the USA? Where do you get your information?

Compare the PA and NP curricula yourself. PAs don't have a bunch of nurse activism, nursing theory, multiple statistics courses, etc. to take. The PA curricula provides better basic science training and more clinical hours. I said the PA program is modeled after the medical program and provides better medical training than the NP curricula does and if you assess the differences in training, it seems like a true statement to make. I probably shouldn't have used the word "any" though since I can't say I've looked at every single NP curricula (although I've looked at quite a few); I do apologize for that slip up.

Once again, your experience doesn't really matter since it's anecdotal. What you've experienced is different from what I've experienced but who's right, you or me? We can't base decisions on anecdotal experience. As I've asked repeatedly, design and conduct a proper study to show that your education is good enough to practice independently.

Edit: The amount of clinical training you've received is not the norm for nearly all of the NP/DNP programs I've looked at (and I've looked at a lot). Most require between 600-1000 hours.

[ANPFNPGNP]

But there's no proof of that though! How many times must it be reiterated that there are no properly done studies that show NP outcomes are equivalent to those of attendings. .

What??? Why don't you go to "Pub-Med" and pull up all the studies that have appeared in JAMA that compare NP/physician patient outcomes. Are you saying that not ONE study out of all those studies are valid?

Sounds to me like someone wishes they had chosen the NP route!