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?
The most important factor in developing a nationwide Advanced Practice Nursing program is standardization, Mundinger said. The nursing profession has never really grasped the notion that a standardized format for educating the students equals quality, she said.
"Nursing programs and regulations vary so much from state to state," Mundinger said. "It's like herding cats when you are trying to get everyone in nursing to do the same thing."
the most important factor in developing a nationwide advanced practice nursing program is standardization, mundinger said. the nursing profession has never really grasped the notion that a standardized format for educating the students equals quality, she said.
"nursing programs and regulations vary so much from state to state," mundinger said. "it's like herding cats when you are trying to get everyone in nursing to do the same thing."
how can you have faith in this educational model?
md/do/pa = all standardized!
queen: i don't think so.............. :-)
"the nursing profession has never really grasped the notion that a standardized format for educating the students equals quality" echoed in multiple postings on this site. i dare say from state to state, school to school its being ignored.. there are too many queens.
"how can you have faith in this educational model"?
do i think my school could have been better? yes i do. am i silent about it no i am not... i push for change i push for improvement.. i am not a silent nurse and several politicians know me well, several nursing leaders know me well. when i was told in school to avoid pas i ignored that; one of my best preceptors and now friend is a pa. i had multiple preceptors mds dos pa and np... i worked my butt off in clinicals and did more than was called for.. i have multiple subscriptions for journals and continuing ceus. i go to conferences with pas, mds, and nps. i don't want to only know what is developing in my field but i look and continue to study within others. i took/take what i had/have and built/build onto it.
someone somewhere has some trust:
in georgia:
number of active licensees as of 8/14/2009
- advanced practice - crna 1,738
- advanced practice - cnm 421
- advanced practice - np 4,151
- advanced practice - cns/pmh 307
- registered professional nurse 102,953
there are many schools that teach/train mds, pas, and nps... some of these schools actually combine some of the early courses...what does that say for educational models?
"how can you have faith in this educational model"?
do i think my school could have been better? yes i do. am i silent about it no i am not... i push for change i push for improvement.. i am not a silent nurse and several politicians know me well, several nursing leaders know me well. when i was told in school to avoid pas i ignored that; one of my best preceptors and now friend is a pa. i had multiple preceptors mds dos pa and np... i worked my butt off in clinicals and did more than was called for.. i have multiple subscriptions for journals and continuing ceus. i go to conferences with pas, mds, and nps. i don't want to only know what is developing in my field but i look and continue to study within others. i took/take what i had/have and built/build onto it.
someone somewhere has some trust:
in georgia:
number of active licensees as of 8/14/2009
- advanced practice - crna 1,738
- advanced practice - cnm 421
- advanced practice - np 4,151
- advanced practice - cns/pmh 307
- registered professional nurse 102,953
there are many schools that teach/train mds, pas, and nps... some of these schools actually combine some of the early courses...what does that say for educational models?
"I'm a member at American College of Clincians and think that there is more to gain from collaboration than division; it's the distinction being drawn, that NPs offer superior care by virtue of a nursing model, compared to MDs/PAs, that pushes us away from any potential collaboration as nonphysician providers. As I'm sure you can imagine, as a PA (or doc, but I hesitate to speak for them), it is frustrating to hear en entire group of clinicians say that PAs are lesser providers, have poor bedside manner, or at worst indicate that we don't look at patients in totality". So does American College of Clinicians not view the distinction that is being drawn that PA's (MD's) offer superior care by virtue of the medical model than that of combining the nursing and medical model that we NPs use?
I can't speak for the ACC, are they making claims that "PA's (MD's) offer superior care by virtue of the medical model than that of combining the nursing and medical model that NPs use"?
I have seen remarks from physician groups maintaining that physician-led care teams should remain the standard, but I honestly haven't heard PAs as their representative groups denigrating NP care. Over on the PA forum there is always comparison about the edcuational content of the 2 programs, as well as the rise of distance education for NPs. Obviously I am biased but I have to agree that a generalist basis (as seen in PA education) is important.
I am interested to hear if PAs are openly slamming NP education.
I can't speak for the ACC, are they making claims that "PA's (MD's) offer superior care by virtue of the medical model than that of combining the nursing and medical model that NPs use"?
I have seen remarks from physician groups maintaining that physician-led care teams should remain the standard, but I honestly haven't heard PAs as their representative groups denigrating NP care. Over on the PA forum there is always comparison about the edcuational content of the 2 programs, as well as the rise of distance education for NPs. Obviously I am biased but I have to agree that a generalist basis (as seen in PA education) is important.
I am interested to hear if PAs are openly slamming NP education.
I don't know I just turned your question/statement around?
You won't hear me bashing PAs as a whole, I won't even bash MDs as a whole. There are some organizations out there that, I believe, do deserve some bashing (and a few of them I don't have to look across the fence)....
Now back to the original posting intent : "...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....."
Me/myself as a nurse, as a family nurse practitioner and without speaking with the powers that be:
- Different; yes
- Better: sometimes yes (No field can claim 100% superiority)
- Worse; sometimes yes (No field will claim 100% inferiority)
- The route I went worked for me and apparently my employers as well.
- Over 25 years of health care service and I still am contemplating more school. Life: lots to learn about, lots to improve.
Do I practice in the world of medicine; yes I do. Medicine over the long term has seen fit to delegate more and more to nurses and more and more many nurses have been happy to expand on that. Everyone happy: Nope. Will there ever be a day that everyone is happy: Nope.
:) Nope I don't hate you... But I will defend my profession.
I can't speak for the ACC, are they making claims that "PA's (MD's) offer superior care by virtue of the medical model than that of combining the nursing and medical model that NPs use"?
I agree that when you combine the practice of "medicine" as we like to define it with the practice of "nursing", we have an ideal model. MD/DO/PA and RN's complete the package. I don't believe NP's are practicing nursing....it was simply a loophole to advance the profession and elude oversight from medical boards. NP's are practicing medicine......please don't forget....as far as I'm concerned the medical practitioners that invented the talking points of holistic and total care...treating the person not the disease rhetoric were the osteopaths....not NP's.
NP's are massaging this like it's something novel and new. It's been around for over 100 years....before NP's existed.
Please don't confuse me with somebody who dislikes nurses. I think RN's are arguably the most important to healthcare...
"my favorite this week: referred as "moderate ankle sprain" patient presented + otowa signs....np never ordered radiograph....so had to back track...called referring np and requested radiograph. np ordered films, but failed to order stress view after i told her i thought it was necessary.....didn't seem to know what it was".
hey that's weird last week i saw a patient. md thought sprain/strain since some swelling and patient could walk on it... the patient was given an ace wrap. next day my exam (by me little old np) yes the patient could walk on it.. swelling for sure... prior to x-ray: rice instructions... splint / ace wrap applied with instructions.. crutches with instructions and use observed. x-rays confirmed fracture at the base of the fibula. difference in care? difference in providers? you did what you should have done to help the patient and guess what so did i.... anyone who has practiced for any length of time has stories they could tell.... - jdcitizen
out of curiosity, why did you decide this individual needed an x-ray?
swelling? the idea of the ottawa ankle rules is to eliminate unnecessary radiographs and referrals.
although md didn't discover the distal fib fx, he might have been following the rules.
just curious....if your not following the rules, your probably ordering more studies and referrals than are needed.
and answer the question if you wish.....how knowledgeable do you feel with nms issues? how knowledgeable do you believe np's are in general in this area when compared to md/do/pa who make a concerted effort in their educational model to learn this material?
and for the record....i would fully support np's if they had more rigorous training and education:
full-time study...no more online set up your own clinical garbage
educational standardization
one governing body
trained in the medical model
oversight by board of medicine for practicing np's...not nursing boards
abandon the "independent" non-team player lobbying efforts
"my favorite this week: referred as "moderate ankle sprain" patient presented + otowa signs....np never ordered radiograph....so had to back track...called referring np and requested radiograph. np ordered films, but failed to order stress view after i told her i thought it was necessary.....didn't seem to know what it was".
hey that's weird last week i saw a patient. md thought sprain/strain since some swelling and patient could walk on it... the patient was given an ace wrap. next day my exam (by me little old np) yes the patient could walk on it.. swelling for sure... prior to x-ray: rice instructions... splint / ace wrap applied with instructions.. crutches with instructions and use observed. x-rays confirmed fracture at the base of the fibula. difference in care? difference in providers? you did what you should have done to help the patient and guess what so did i.... anyone who has practiced for any length of time has stories they could tell.... - jdcitizen
out of curiosity, why did you decide this individual needed an x-ray?
swelling? the idea of the ottawa ankle rules is to eliminate unnecessary radiographs and referrals.
although md didn't discover the distal fib fx, he might have been following the rules.
just curious....if your not following the rules, your probably ordering more studies and referrals than are needed.
and answer the question if you wish.....how knowledgeable do you feel with nms issues? how knowledgeable do you believe np's are in general in this area when compared to md/do/pa who make a concerted effort in their educational model to learn this material? sometimes its true one has to actually touch the patient...
foot was so swollen it was round the toes looked like raisins. actually by first observation i was worried about circulatory compromise (you know part of the abcs of assessment). the fracture was more than suspected by the crepitus felt . his whole foot was tender (from his statement all the way up to the knee). x-ray showed the fracture with fragment. plus since a doctor had already been involved the head doctor came in at my request and was amazed that the guy had been walking on it.
i was a paramedic and one of those things we did was deal with trauma in the field. also i went through np school with a nurse who was being sent to school by his orthopedic employers (learned a lot from him). worked with some orthopedic doctors: by golly learned some stuff from them also.. one of my friends is an orthopedic surgeon. also spent time with some physical therapist and guess what they taught me some stuff also.. over 25 years in the medical industry i have learned a lot and i still am learning.
and for the record....i would fully support np's if they had more rigorous training and education: i doubt it; you would find another item to list...
full-time study...no more online set up your own clinical garbage i didn't go this way so whine some more...
educational standardization true(read some more on this site).
one governing body nope...
trained in the medical model why just the medical model?
oversight by board of medicine for practicing np's...not nursing boards i would like to see it the other way around.
abandon the "independent" non-team player lobbying efforts why so the medical model or the md can have all the say?team playing on what your terms?
this would bring validity to the profession. we have validity you obviously can't accept it.
how can you say that np/dnp training is similar to medical training though? that's what i don't understand. there's people out there lobbying for equivalence to physicians and equal reimbursement as physicians stating that their training is the same. come on, that's such a blatant lie! how can you justify that you care for the patient when you're willing to practice medicine with inadequate training? here's a post i made in a different thread about the differences between np/dnp training and md/do training:
you need 73 credits to go from a college degree to a doctorate. that turns out to be less than 3 years.
now, let's look at the fluff courses that aren't really clinically useful: research methods (3 credits), health services program planning and outcomes analysis (3 credits), applied statistics (2 credits), research utilization in advanced nursing practice (3 credits), data driven health care improvement (4 credits), evidence based practice and applied statistics i & ii (7 credits, since you told me medicine is not evidence based), effective leadership (2 credits), transforming the nation's health (3 credits), dnp capstone (6 credits), health systems transformation (3 credits), financial management & budget planning (3 credits).
here are the clinically useful courses: population-based approach to healthcare (3 credits), clinical pharmacology and interventions for advanced practice nursing (3 credits), managing common acute and chronic health problems i (3 credits), selected topics in advanced pathophysiology (3 credits), diagnostic reasoning & physical assessment in advanced nursing practice (4 credits), common acute and chronic health problems ii (3 credits), sexual and reproductive health (2 credits), nurse practitioner residency: adult primary care (3 credits), electives (12 credits).
so, out of the 73 credits needed to go from bsn to dnp, 37 credits are not clinically useful. in addition, the number of required clinical hours is 612 hours (unless i miscounted something)!! wow! and the np program is designed the same way, with a bunch of fluff courses (11 credits out of 43 required are fluff) and requires 612 hours as well: http://nursing.duke.edu/wysiwyg/down...rriculum_2.pdf
it's kinda scary how inadequate that training is in order to practice medicine independently. you can't really count prior nursing experience as time practicing medicine because you weren't practicing medicine during that time nor were you thinking in a medical manner (ie. the way a physician would). nursing clinical hours might help you transition into medicine but they are not a replacement for medical clinical hours.
fluff courses at baylor school of medicine during m1/m2 years only: patient, physician, and society-1 (4.5 credits), patient, physician, and society-2 (6 credits), bioethics (2.5 credits), integrated problem solving 1 & 2 (10 credits).
useful courses at baylor school of medicine during m1/m2 years only: foundations basic to science of medicine: core concepts (14.5 credits), cardiovascular-renal-resp (11.5 credits), gi-met-nut-endo-reproduction (14 credits), general pathology & general pharmacology (6.5 credits), head & neck anatomy (4.5 credits), immunology (5 credits), behavioral sciences (6.5 credits), infectious disease (13 credits), nervous system (14 credits), cardiology (4.5 credits), respiratory (3.5 credits), renal (4 credits), hematology/oncology (5 credits), hard & soft tissues (3 credits), gastroenterology (4 credits), endocrinology (3.5 credits), gu/gyn (3 credits), genetics (3 credits), age related topics (2.5 credits).
for only the m1/m2 years at baylor, there's 162.5 total credits. out of these 162.5 credits, 23 credits are fluff.
core clerkships during m3 (useful clinical training): medicine (24 credits, 12 weeks), surgery (16 credits, 8 weeks), group a selective (8 credits, 4 weeks), psychiatry (16 credits, 8 weeks), neurology (8 credits, 4 weeks), pediatrics (16 credits, 8 weeks), ob/gyn (16 credits, 8 weeks), family & community medicine (8 credits, 4 weeks), clinical half-day (includes clincal application of radiology, clinical application of pathology, clinical application of nutrition, clinical evidence based medicine, longitudinal ambulatory care experience, and apex -- 23 credits).
so, without even taking into consideration m4 electives and required subinternships (which are usually in medicine and surgery), medical students already have a far superior medical training than nps or dnps. other examples of med school curricula:
you can get a bsn to dnp in about 3 years according to many programs i've looked at. medicine involves 4 years of medical school and a minimum of 3 years of residency before allowing independent practice. here's the math:
bsn to dnp: 2.5 - 3 years of training; longer if courses taken part-time; 600-1000 clinical hours!
bs/ba to md/do: 4 years med school + 3-5 years residency: 7-11 years of training; not possible part-time; clinical hours > 17000
yup, you're right mbreaz1. np/dnp training is very similar to that of medical training. they do deserve to be reimbursed at the same rates because they obviously have the same level of knowledge base and understand physiology/pathophys equally well.
so i gave you evidence that np/dnp training is nowhere close to being similar to that of medical training. i will answer the rest of the questions you had in a little bit and i will provide evidence for them."
the idea that nps/dnps will be cost-effective is wrong; there's an active push towards equal reimbursement rates as physicians. how will this save money?
also, by the time a medical student reaches 4th year, he has had a better basic science training and far more clinical hours in training than and np/dnp does. should we let 4th year medical students practice independently?
as for studies, patient satisfaction studies don't tell you anything about the level of competence. show me studies that are not horribly flawed (like pretty much every single one out there currently), not horribly designed, not conducted by people heavily biased (ie. mundinger), and that don't measure useless markers. try doing studies with inpatient care where the patients are actually complex rather than outpatient care. i haven't found a single study that shows that nps/dnps have equivalent health outcomes in their patients that wasn't really badly designed. with all those statistics courses you guys have to take in np school, i'd think you'd be better at both designing experiments and analyzing studies.
you can go from bsn to dnp within 2-3 years with less than 1000 clinical hours in training!! that's scary! mds/dos have a minimum of 7 years of training and more than 17000 hours of clinical training. i don't see the logic in letting nps/dnps practice independently when both pas and 4th year medical students are better trained.
"How can you say that NP/DNP training is similar to medical training though? That's what I don't understand. There's people out there lobbying for equivalence to physicians and equal reimbursement as physicians stating that their training is the same". And then there are some that are not
How do you go from "how can you say" to "there's people out there lobbying"...
Have you not seen/read that there are people that are pushing / lobbying for more clinical hours as well a restructuring of the curriculum???
You use Duke as an example why not ask Duke? Please be kind enough to share their response...
What is a supervised or what is a independent or what is a semi-independent practice:
1) Doctor in one practice location while the PA or NP is in the other. Signs charts sometime during the week.
2) Doctor in same building who sees his load of patients and then signs the PA's or NP's load at the end of the shift
3) Doctor who can be reached on the phone and his/her presence in the building is once a week to sign the PA's or NP's charts.
Does a signature show review? When does it cross the threshold of really being an unsupervised practice...
We are spending more than any other civalized country on healthcare and we are not as healthy - Other countries are just beginning to look at midlevel providers.....In the US they have been around since the 60's.
Midlevels are 15-20% cheaper reimbursement wise....but that doesn't mean their cheaper! If they are indeed referring more and requiring more visits to achieve favorable outcomes....it's not cheaper...or if they miss a DX....ect.
NP's currently offer nothing to enhance healthcare that RN's don't already do..... it's the bedside nurses that add to the dynamics of healthcare....NP's are trying to practice medicine. I haven't seen a reasonable arguement to that yet. Why the lobbying efforts to be "INDEPENDENT". That isn't exactly a team approach.
If advance practice nurses stuck to bedside nursing....that would improve care. Work to improve bedside nursing....it needs help in the USA. Aside from the practice of defensive medicine by PA's/MD/DO, their doing good work.
I am not NP I am a bedside RN, but you sound like an NP Hater!! Don't hate.
As someone heavily considering NP vs PA route this is exactly what I am talking about and I am going to be an RN in less than a year. I don't want to lack competence when being a mid-level. After looking closely at the hours and curriculum for NP's and PA's there is a HUGE difference between the two in terms of education and clinical base and the amount of fluff courses like the person above so adequately pointed out when comparing curriculums and clinical hours. Why is no one talking about this. All anyone says is yeah we are trying to change that or why don't you ask the program about their curriculum and so forth.
You people are not addressing the blatant gap in clinical and science based curriculum between NP's and PA's, Not opinion, FACT. I am not even talking about MD/DO because that is a whole other level and I can't even believe people are trying to say they are equal to doctor's. NUTS. I think one poster hit the nail on the head. If all nursing curriculum post-bac required the prereq's and classes and clinical hours at the level PA's have you would DEFINITELY have a lot fewer people pursuing advanced degrees in nursing. How do I know this as a FACT? Look at the posts on this site. Everyone and their mom come on at least everyday asking should I go PA or NP route and how they really want to go PA because the curriculum and clinical hours far surpass NP, but they might not get in with their rap GPA or it will take an additional few years to even apply because of the advanced science coures needed even to apply. But, then again it would be so much less time, effort, and energy and a gurantee they would get in to an NP program. SO, then they think ok I will go NP route but then will I worry about being as satisfied going NP vs PA. Then they want all of you to comment and tell them what to do. I admit I am a fprior offender and have done the same thing. In the years I have spent going back and forth between the two professions and gathering my data to make a decision, I have only recently realized with the adoption of the DNP that mid-level nursing programs fall short of training their students at the level PA's are trained when it comes to science curriculum and clinical hours required. DO NP programs even require biochemistry? Oh, they don't because that is usually just a prereq class to apply to a PA program. Come on people it is the same question and story worded differently everyday on these forums. I am not saying one is superior over the other in every clinical situation as evidenced by NP's that caught something the PA missed and vice versa. But, PA's come out with a more solid base in the biological and chemical sciences plus a ton more clinical hours in their programs than NP's and you cannot tell me this does not effect a person's diagnostic and assessment ability. I don't care how compassionate someone is, you don't know what you don't know and I would rather have a provider with the most knowledge they could posses next to a doctor treat me because that is what saves money and lives in healthcare.
On a side note I am shocked at the crap regulation of nursing programs across the board. It is insane that you could have 5-10 nursing programs in one area with different curriculum and requirements. How do I know this. When I was applying to nursing programs (10-15 of them in the same and different areas) every single last one of them had different requirements. I thought I was going to lose my mind trying to keep it all straight. It is ridiculous. No one wonder the one hand doesn't know what the other is doing half the time. And forget trying to transfer nursing programs, cuz you would end up basically repeating half of your education because the programs are so different. I tell ya I haven't even finished nursing school yet and I am already fed up the bureacracy and red tape of this profession. Oh and to answer the original posters question. I will be a bedside nurse for at least a few years before becoming a PA so I guess I will be the best provider ever, trained as a mid-level in the medical model with a heavier science and clinical background plus my superior bedside manner and outstanding compassionate whole-person care :) Yay for me!
atcpt11
6 Posts
Words from the queen of nursing herself:
http://media.www.thelantern.com/media/storage/paper333/news/2002/02/28/Campus/Mundinger.Nursing.Deserves.Doctorate-193700-page2.shtml#5
The most important factor in developing a nationwide Advanced Practice Nursing program is standardization, Mundinger said. The nursing profession has never really grasped the notion that a standardized format for educating the students equals quality, she said.
"Nursing programs and regulations vary so much from state to state," Mundinger said. "It's like herding cats when you are trying to get everyone in nursing to do the same thing."
How can you have faith in this educational model?
MD/DO/PA = all standardized!