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?
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.
" 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....."
I fully understand not representing myself as a PHYSICIAN to a patient. If I introduce myself as Dr. Idaho4me, the patient would naturally presume I was a PHYSICIAN only because, up till now, that is the DR. a patient would expect to come into contact with. As a PA you are expected to clarify the distinction for two reasons 1) you don't have a doctorate degree 2) you are not a physician. If you had either 1 or 2, why would you deny the Dr. honor simply because your physician buddies didn't like it. Kinda like a group of English professors getting bent out of shape by physicians calling themselves doctors on a college campus.
If you had your DHSc, it would not improve your care by insisting on being called a Dr. at the bedside. Your job performance is improved by the additional training that earned you the DHSc. If you chose not to use the term Dr., that should be your choice , not dictated by another profession. Personally, if I were to obtain a DNP I would not use the term Dr. clinically. Simply too confusing and too much time explaining the differences. But that is my choice, not imposed by the ruling party.
I also agree we are a long way off from primary care nirvana. NP and PAs have been around 40+ years and still struggle for acceptance within the healthcare community and the public. This may accelerate now that primary care is being vacated by physicians and looming universal healthcare. Who is going to take care of these people?
Also, you post hints at a subtle difference in the psyche (for lack of a better term) of a PA vs. NP. The PA profession entered the world essentially "fully formed". Nursing on the other hand, started at the lowest, least respected position a woman could hold in the mid 1800's. It has grown to the profession it is today by the individuals that have worked it, not endowed into being by the AMA. So if the next step is DNP, so be it. It took 150 years to get this far, another 40-50 years to fully accept a DNP is nothing.
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.
It doesn't make it the same, just because physicians think of it as their turf. If it is delivered differently, then it can be inherently different. Treating patients independently doesn't necessarily require equivalent knowledge base. Monopoly on the provision of services is clearly evident by the lack of independent practice for anyone aside from physicians. You don't have to be able to perform all of the tasks. If you can perform some of them cheaper within your scope of practice, that is enough. There are other professions that exhibit this quite clearly and provide more efficient and cheaper service to customers. Take accounting for example. Bookkeepers are allowed to hang out a shingle and provide bookkeeping services. Certified public accountants may provide the same service in their offices, however, the prices for bookkeeping services are held down by the fact that a lesser educated professional is willing to provide the same services at a competitive price. The bookkeeper may not have all of the knowledge necessary for every client in every situation. Some services that are more complex may require a referral to a CPA, but this requires the CPA to be competitive on price for the run of the mill services. Refer out when necessary is perfectly adequate in all circumstances whether it is an NP or a physician doing the referring. This argument is silly. I don't know where physicians get the idea that NPs make unnecessary referrals and physicians don't. You have no stats to support that one. I think the exclusionary attitude you are referring to must definitely be the physician attitude.
It doesn't make it the same, just because physicians think of it as their turf. If it is delivered differently, then it can be inherently different. Treating patients independently doesn't necessarily require equivalent knowledge base. Monopoly on the provision of services is clearly evident by the lack of independent practice for anyone aside from physicians. You don't have to be able to perform all of the tasks. If you can perform some of them cheaper within your scope of practice, that is enough. There are other professions that exhibit this quite clearly and provide more efficient and cheaper service to customers. Take accounting for example. Bookkeepers are allowed to hang out a shingle and provide bookkeeping services. Certified public accountants may provide the same service in their offices, however, the prices for bookkeeping services are held down by the fact that a lesser educated professional is willing to provide the same services at a competitive price. The bookkeeper may not have all of the knowledge necessary for every client in every situation. Some services that are more complex may require a referral to a CPA, but this requires the CPA to be competitive on price for the run of the mill services. Refer out when necessary is perfectly adequate in all circumstances whether it is an NP or a physician doing the referring. This argument is silly. I don't know where physicians get the idea that NPs make unnecessary referrals and physicians don't. You have no stats to support that one. I think the exclusionary attitude you are referring to must definitely be the physician attitude.
Unfortunately, I don't really think your comparison is appropriate. Treating patients independently DOES require an equivalent knowledge base and equivalent training. Other professions do exhibit this clearly, but last I knew bookkeepers didn't deal with life and death decisions (although that too may be relative). No, cheaper is not always better. Physicians do not hold a monopoly in this, but the simple fact is that unless the training and certification (and scope of practice) are equal, then why would someone assume that they can practice completely independently ?
I am not aware of any statistics showing that NPs make more unnecessary referrals than MDs or DOs. That being said, considering your statement that you don't need equivalent training for practicing medicine (which is what NPs are doing regardless of what others have said...i.e. practicing "advanced nursing"), it would be logical to expect them to refer to other providers more.
Unfortunately, I don't really think your comparison is appropriate. Treating patients independently DOES require an equivalent knowledge base and equivalent training. Other professions do exhibit this clearly, but last I knew bookkeepers didn't deal with life and death decisions (although that too may be relative). No, cheaper is not always better. Physicians do not hold a monopoly in this, but the simple fact is that unless the training and certification (and scope of practice) are equal, then why would someone assume that they can practice completely independently ?
I am not aware of any statistics showing that NPs make more unnecessary referrals than MDs or DOs. That being said, considering your statement that you don't need equivalent training for practicing medicine (which is what NPs are doing regardless of what others have said...i.e. practicing "advanced nursing"), it would be logical to expect them to refer to other providers more.
Actually, my comparison is very appropriate, you just wish that it wasn't. Treating patients requires training and knowledge base that is appropriate to your scope of practice. It is similar to why a family practice physician would be acting inappropriately if they attempted to practice cardiology. They aren't appropriately trained to do so. Furthermore, don't try to discount the comparison with your little "life or death" argument. Last time I checked acne wasn't a "life or death" issue. Physicians often and nurse practitioners often treat things that are not life or death issues. And bookkeepers sometimes deal with issues that are. It doesn't make the comparison any more or less valid. Medicine, nursing, whatever you call it, you are trying to act like there are no scopes of practice for anyone when you know full well that even primary care physicians operate within a scope of practice. That is really the issue, not whether it is medicine or nursing.
Actually, my comparison is very appropriate, you just wish that it wasn't. Treating patients requires training and knowledge base that is appropriate to your scope of practice. It is similar to why a family practice physician would be acting inappropriately if they attempted to practice cardiology. They aren't appropriately trained to do so. Furthermore, don't try to discount the comparison with your little "life or death" argument. Last time I checked acne wasn't a "life or death" issue. Physicians often and nurse practitioners often treat things that are not life or death issues. And bookkeepers sometimes deal with issues that are. It doesn't make the comparison any more or less valid. Medicine, nursing, whatever you call it, you are trying to act like there are no scopes of practice for anyone when you know full well that even primary care physicians operate within a scope of practice. That is really the issue, not whether it is medicine or nursing.
First of all, please define what you mean by practicing cardiology - a family practice physician is more than capable of performing medical management for a cardiovascular compaint or long term issue (i.e. hypertension, anticoagulation, anti-arrhythmic). In fact, all medical students and PA students have a cardiology rotation to expose them to that specialty.
Last I knew, many things which you may not consider "life and death" may be just that. Yes, many conditions may not be, but treatment modalities very well may be life or death - including antibiotics or creams for acne. Last I knew the scope of practice for a physician encompasses medicine. Their scope of practice is not determined by a state medical board but by their individual training. Nursing has a very defined scope of practice based on education. Any physician COULD perform heart surgery. Yes, they probably would not because they are not specifically trained and their malpractice may not like that, but there is nothing saying they can't. Last I checked a NP (even a DNP) can't.
First of all, please define what you mean by practicing cardiology - a family practice physician is more than capable of performing medical management for a cardiovascular compaint or long term issue (i.e. hypertension, anticoagulation, anti-arrhythmic). In fact, all medical students and PA students have a cardiology rotation to expose them to that specialty.
Last I knew, many things which you may not consider "life and death" may be just that. Yes, many conditions may not be, but treatment modalities very well may be life or death - including antibiotics or creams for acne. Last I knew the scope of practice for a physician encompasses medicine. Their scope of practice is not determined by a state medical board but by their individual training. Nursing has a very defined scope of practice based on education. Any physician COULD perform heart surgery. Yes, they probably would not because they are not specifically trained and their malpractice may not like that, but there is nothing saying they can't. Last I checked a NP (even a DNP) can't.
Why do you insist on splitting hairs? Your arguments are making you look ridiculous. A nurse practitioner is also more than capable of performing medical management for a cardiovascular complaint or long term issue. And you are wrong about the life or death issue. Maybe it could be more appropriately described as whether you get better today or stay sick for a few more days, but give me a break, it isn't life or death at every turn in primary care. And spare me the hair splitting on practicing medicine or nursing. This is garbage.
Why do you insist on splitting hairs? Your arguments are making you look ridiculous. A nurse practitioner is also more than capable of performing medical management for a cardiovascular complaint or long term issue. And you are wrong about the life or death issue. Maybe it could be more appropriately described as whether you get better today or stay sick for a few more days, but give me a break, it isn't life or death at every turn in primary care. And spare me the hair splitting on practicing medicine or nursing. This is garbage.
First of all, I am in no way insulting you or the nursing profession (of which DNP, NP are a part). I don't doubt that a nurse practitioner is capable, but not MORE capable than an MD/DO to manage a long term or cardiovascular complaint (I am sorry, but clinically and in terms of education - both pathophysiology and pharmacology the MD/DO is superior). I am by no means saying EVERY issue in primary care is life and death, but often the clinical decisions made by primary care physicians include a broader differential diagnosis which results in a different outcome than a mid-level provider (NP/DO). This affects both the morbidity and mortality and the incidence of hospitalization.
In terms of practicing medicine or nursing - if there is no difference, then why does pretty much everyone on this forum try to differentiate between NPs (DNPs) practicing the nursing model and MD/DO/PAs practicing the medical model ? Further, that implies that medical school is equivalent to a nurse practitioner program which has been demonstrated time and time again on this forum (and thread) to not be true ?
I wonder how often than full descriptive is used by non physician clinical doctors, though....
I and all the other advanced practice nurses I've known in my (lengthy) career are proud of being nurses and find the idea of being mistaken for a physician distasteful. I've always been eager and happy to clarify, if there's any confusion, that I am NOT a physician. I've never been personally aware of a situation where an advanced practice nurse represented her/himself to clients as a physician, or even allowed clients to think that (without promptly correcting the misperception).
There have been threads here in the past about clients who insist on calling you "doc," no matter how many times you've corrected them and explained the difference ... :)
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.
I have had the privilege to work with one of the first female heart surgeons she was (is) great and she had many stories to tell about the male dominated medical world/school. There once was a time when common patient encounters the doctors where all Caucasians, all male... Times change.. Its called evolution. One point though, I believe it is very important, every provider (every employee) needs to identify themselves to the patient/family as well as explaining there purpose for being there.
Not sure what you mean by the preceptor scenario (student?),
Working in two of the largest teaching hospitals in Georgia and also having been a student doing clinicals in those same hospitals there are a lot doctors running around that are not "medical doctors"... Lots of patient/family contact.
but our encounters with patients are meant to serve the patient's interests not our own.
Unfortunately is can't be denied but during training and during research a lot contact with patients/family is in our own interest as much as the patients interest (or a least the next patients interest)... Do we have enough of this procedure or that procedure to go to the next level, do we have enough hours with this clinical set or that clinical set to go to the next clinical level...
Patients deserve to know who is treating them, and the use of the title doctor in the majority of clinical settings implies MD/DO.
The patient deserves to know more than who is treating them they deserve to know why. The statement I am Dr. So and So does not cut it. Multiple disciplines within the realm of medicine handling one patient... I was with an internal medicine/nephrology hospitalist group it was not uncommon to have 4+ doctors involved with our patients: The patient has every right and should not have to ask; who are you, what are you, what are you doing, why are you doing it....
You bring up DO oh how I remember when one hospital I worked at brought the first DO into town... MDs were nice to his face (sort of).
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Because that's not misrepresentation.