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?
It really is dependent. I've seen great NPs and great PAs and I've seen bad in both. When I was told I have precancerous cells, the women's health NP just broke the news, told me to make an appointment at the front desk to come back to talk about it with the doctor, and walked out of the room. Didn't even give me a chance to ask questions, didn't explain what that meant, or what the future steps were. I walked out of there extremely lost and confused.
On the other hand, I've seen some great NPs at a family practice who really took the time to talk to me, explain things, and make sure all my questions were answered.
I don't think that NPs and PAs are better or worse than each other in practice... just different.
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.
listen, your arguments about the education differences just don't hold water, but let's put that aside for a minute. you try to argue that nurse practitioners want equivalency to physicians. that isn't true at all. what they want is to be able to practice nursing without physician interference. physicians just can't let go of that monopoly they have on the provision of healthcare services. it won't be long before you realize that anti-competitive practices will only work for so long. sooner or later the ftc will crack down on the illegal lobbying that the ama and other physician groups are doing. they have already stepped in on the side of nurse practitioners in illinois when physicians attempted to block retail clinics from advertising their prices. you need to face it, nurse practitioners are perfectly capable of performing a great deal of the same tasks that physicians do, and they do not need interference from physicians in doing so. what society needs is for physicians to butt out, lawmakers to do their job and vote for indendent np practice, and the public to reap the benefit of cheaper outpatient services. all lawmakers need to do is open these things up for competition, lower the reimbursement rate paid to all providers for the services that nps provide, and this will all work itself out. dg, if someone does the same task, it deserves equal reimbursement. the problem now is that rate is too high and it needs to be lowered for everyone performing the task.
Listen, your arguments about the education differences just don't hold water, but let's put that aside for a minute. You try to argue that nurse practitioners want equivalency to physicians. That isn't true at all. What they want is to be able to practice nursing without physician interference. Physicians just can't let go of that monopoly they have on the provision of healthcare services. It won't be long before you realize that anti-competitive practices will only work for so long. Sooner or later the FTC will crack down on the illegal lobbying that the AMA and other physician groups are doing. They have already stepped in on the side of nurse practitioners in Illinois when physicians attempted to block retail clinics from advertising their prices. You need to face it, nurse practitioners are perfectly capable of performing a great deal of the same tasks that physicians do, and they do not need interference from physicians in doing so. What society needs is for physicians to butt out, lawmakers to do their job and vote for indendent NP practice, and the public to reap the benefit of cheaper outpatient services. All lawmakers need to do is open these things up for competition, lower the reimbursement rate paid to all providers for the services that NPs provide, and this will all work itself out. DG, if someone does the same task, it deserves equal reimbursement. The problem now is that rate is too high and it needs to be lowered for everyone performing the task.
The DNP is not making it seem this way. This may be more semantics like practicing "nursing" instead of "medicine", but wanting to be a primary care provider, with independent practice, billing at the physician fee schedule....how is that different than wanting equivalency? You can make a philosophical argument that NPs are providing their own brand of health care (kinda the point of my original post here) but again, evaluation and mangement services look identical whether you call it medicine or nursing.
Arguing that physicians should "butt out" implies that NPs HAVE the equivalent knowledge base and skill set to treat these patients indendently. Yet in the same breath you argue "nurse practitioners are perfectly capable of performing a great deal (not ALL) of the same tasks that physicians do". If you can't perform all the tasks how can you claim monopoly on the provision of services? And saying refer out when necessary is not an adequate out unless you claim that independent NPs will refer out at the same rate that MD/DO PCPs do. If the referral rate is increased, then the cost savings diminish as well as the perceived level of independence.
I think NPs and PAs are a critical component of the future of primary health, but this exclusionist attitude doesn't help anyone- NPs OR patients.
Understand the training and role for clinical doctorate PAs is limited- so much so that it seems unlikely that it will expand to all PAs. Most of these PAs (DHSc) are going into leadership, education, admin roles. Nonclinical doctorates are a separate issue and are useful in all professions.
PAs will not be using the title "Doctor" in the clinical setting.
Curious what is the clinical sitting? Provider to patient: On site where ever that may be? So if a person is on a clinical site with a patient and the preceptor comes into the room in that situation is that not Dr. so and so? How about research facilities/hospitals where the researchers who may doing/helping the with research are not MDs but are PhDs but have access to patients...
If I earned any doctorate degree, by I am referred to as Dr. Idaho4me. I understand that in healthcare physicians are traditionally the only ones referred to as Dr. Blah Blah. This is despite other professions in healthcare with doctorate degrees, ie pharmacists, and they tend to defer their doctor reference. There are others like podiatrists and optometrists that use "Dr", but they don't meet with objection because they practice outside the acute hospital setting. It appears to me that a physician claims the only Dr. title strictly out of tradition, not some unique right. If another provider were to earn a doctorate degree, either PA or NP, why should that individual not be allowed that honor? If the argument is that the patient would be confused, then the response is to educate the patient!!! This reflects new ground in healthcare, I understand that. Certain parties may feel even more threatened. Mid level providers already have to frequently explain their role and training to patients. Why should this be any different or more difficult?
Let me be clear, I am not saying these professions reflect equal training. They do reflect equal degrees. A doctor of pharmacy does not have the same training as a doctor of medicine. For that matter a Doctor of English has the same degree but obviously different training. A DNP is new, not wrong. A Dsc PA is new, not wrong. The only group this threatens are physicians and quite frankly, maybe they just need to make a little room. There obviously will always be a need for the MD. Even the most militant NP will readily admit that. Granted there are considerable bumps to smooth out and I am curious to watch how it all plays out.
I've worked in two PM&R units. Both had psychologists who introduced themselves as "I'm Dr. XXXXX, I'm a psychologist....." No one, patients or physicians, ever had a trouble with this.
I've worked in two PM&R units. Both had psychologists who introduced themselves as "I'm Dr. XXXXX, I'm a psychologist....." No one, patients or physicians, ever had a trouble with this.
Curious what is the clinical sitting? Provider to patient: On site where ever that may be? So if a person is on a clinical site with a patient and the preceptor comes into the room in that situation is that not Dr. so and so? How about research facilities/hospitals where the researchers who may doing/helping the with research are not MDs but are PhDs but have access to patients...
It is the stance of PAs, and is written in our state regs, that PAs may not misrepresent themselves as a physician. As a bedside provider introducing yourself as Dr Smith, the average patient would interpret that as an MD/DO. Since we're talking about the majority of common patient encounters (which are not between PhDs and patients), it would be prudent for PAs to not go down this road.
Not sure what you mean by the preceptor scenario (student?), but our encounters with patients are meant to serve the patient's interests not our own. Patients deserve to know who is treating them, and the use of the title doctor in the majority of clinical settings implies MD/DO.
If I earned any doctorate degree, by I am referred to as Dr. Idaho4me. I understand that in healthcare physicians are traditionally the only ones referred to as Dr. Blah Blah. This is despite other professions in healthcare with doctorate degrees, ie pharmacists, and they tend to defer their doctor reference. There are others like podiatrists and optometrists that use "Dr", but they don't meet with objection because they practice outside the acute hospital setting. It appears to me that a physician claims the only Dr. title strictly out of tradition, not some unique right. If another provider were to earn a doctorate degree, either PA or NP, why should that individual not be allowed that honor? If the argument is that the patient would be confused, then the response is to educate the patient!!! This reflects new ground in healthcare, I understand that. Certain parties may feel even more threatened. Mid level providers already have to frequently explain their role and training to patients. Why should this be any different or more difficult?
Let me be clear, I am not saying these professions reflect equal training. They do reflect equal degrees. A doctor of pharmacy does not have the same training as a doctor of medicine. For that matter a Doctor of English has the same degree but obviously different training. A DNP is new, not wrong. A Dsc PA is new, not wrong. The only group this threatens are physicians and quite frankly, maybe they just need to make a little room. There obviously will always be a need for the MD. Even the most militant NP will readily admit that. Granted there are considerable bumps to smooth out and I am curious to watch how it all plays out.
To me there seems to be some subtlety to it that deserves notice. I respect wanting to push the envelope professionally, but that must be done in the context of what times we are practicing in. Physicians are opposed to the DNP for various reasons, whether it's concern for patient care, turf issues, etc...regardless, these are YOURs and MY colleagues in patient care. I don't see what is to gain by stoking an inflammatory issue when much more can be accomplished with godd care.
There's no one easy side to the issue. I don;t see what's to gain by insisting on the title. If I had my DHSc, how does it improve care if I insist on being called Dr at the bedside? Then the argument is does it serve the profession. I think we are SO far away from the sea change you are alluding to- primary care providers being docs, PAs, NPs all on some sort of elevel ground in terms of autonomy- or better yet creating a new level of provider for primary care- that jumping into this thing guns blazing will make you more enemies than friends......in a health care climate where you need all the friends you can get.....
TakeBack
203 Posts
Noted...
You can tell us better than others how far this is carried by AAPA/ARCPA....
Already on the APPAP email chain, the first two are well agreeg upon (from the membership at least).....