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 distinction between practicing nursing and practicing medicine may be trivial until lawyers and courts get involved. If a board of nursing oversees all things nurse, they can't very well allow nurses (NP) to practice medicine. If they did, well then a state's medical board may have some interest in said practice and we can't have that. The treatment course for a sore throat is identical whether administered by MD,PA, or NP. The NP is still practicing advanced nursing to remain under the auspices of the board of nursing.
Splitting hairs? yep. Lawyers eat that up!! Who can remember the famous lawyer who said, "That depends on what the meaning of 'is' is."
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).
A lot of the time probably; but not all the time.
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).
Did you mean NP/PA?
This affects both the morbidity and mortality and the incidence of hospitalization.
So, so many factors to this.... Training (or lack of), pride (too much), greed....
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 am a NP working in the field of medicine I would be nuts not to admit that but I am also working in the field of nursing. I myself have not said my training is equivalent (or better) to anyone else's, I do practice with my own individual style that is probably different than anyone else on this site. But I practice, I improve, I continue training, I use science, I use consultation, etc. etc.. to help my patients. I have had harsh words with the doctors I work with and they have had harsh words with me (sometimes our diagnostic approaches conflict ).. We don't do it to be wise butts we do it to improve patient care. Does our pride get hurt on occasion;sure it does.
Once one works long enough they meet or work with a person (or persons) who has the attitude "the buck stops with me" and all too often it shouldn't have... Health care is that way that why there are so many specialist.
The distinction between practicing nursing and practicing medicine may be trivial until lawyers and courts get involved. If a board of nursing oversees all things nurse, they can't very well allow nurses (NP) to practice medicine. If they did, well then a state's medical board may have some interest in said practice and we can't have that. The treatment course for a sore throat is identical whether administered by MD,PA, or NP. The NP is still practicing advanced nursing to remain under the auspices of the board of nursing.
Splitting hairs? yep. Lawyers eat that up!! Who can remember the famous lawyer who said, "That depends on what the meaning of 'is' is."
And then there is Georgia where there are circumstances where the BOM has much input....
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 ?
You assume that education is the only key to being able to do the job, and there you are dead wrong. Experience matters more. To say that education makes one superior is about as short sited as it gets. You use a key word "often", which is very relative. I would argue that in primary care, "often" situations don't require the broader differential diagnosis that would result in a different outcome that would affect anything. You are talking about a minority of situations that are seen in primary care. The medical establishment (mostly physicians) are very guilty of arguing that more money needs to be spent for isolated incedences. Most primary care visits are very uncomplicated. Why does someone need to pay for the firepower of elaborate and expensive physician education, when 99.9% of the time a nurse practitioner would do just fine. Most of these elaborate differential diagnoses take more than one physician visits and a referral to a specialist to make anyway. Let's not pretend like the primary physician is able to do this of their own accord because they have a far more extensive education than a nurse practitioner.
Nobody is saying that a nurse practitioner program needs to be equivalent to that of an MD program, that is far from what anyone is saying. Nurse practitioners can perform the job just as well with their education and training and some experience. It doesn't take the MD education to do the job. That is what is being said. If physicians really think that their education makes your service so superior, then why are physicians afraid of opening themselves up to the competition of independently practicing nurse practitioners. If you provide superior value, shouldn't you win out in a competitive environment?
." 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."
This statement is simply false. Study after study after study directly disputes this assertion. Show me your supporting evidence to back up your claim. False arguments like this keep being made on this board without any substance. For every statement like " I knew this NP who did this wrong blah, blah blah", is countered by some other's story of " I knew a doctor ..." or "I worked with a PA ....".
NPs have similar outcomes to other primary care providers. Studies DO prove this to be true.
Now, if you were to start again with, "In my opinion, narrowed by my rather limited contact with a less than representative number of NPs, aka a handful, a broader differential diagnosis which results in a different outcome...blah,blah,blah". That's different. Its your opinion. And you're still wrong.
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 ... :)
Patients call me doc all the time, despite the introduction, and the name tag, and the embroidered title on my coat. Same story.
I don't doubt your personal experience but I can't say that the use of the term doctor by a nonphysician cannnot lead to misinterpetation, and at worst, misrepresentation.
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.
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.
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...
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).
I'm not arguing really any of what you mention here; of course all pts deserve to know all members of their care team and what their tx is, possible pos/neg outcomes etc.
When I say our own interest I mean our own interest in displaying our credentials. I'm Joe Smith, a nurse practitioner here....sounds fine.
There is much contention on the PA side about our title. I've seen folks here who post about PAs- that we "assist physicians", "doctor assistant"..... which is not even remotely the case. Does making us PA-S, Master of Science or PA-C, Doctor of Health Science or Physician Associate or whatever the latest rage is....make us different/better? No, our work stands on its own merits.
I have posted extensively on the PA forum that I think there is a place for a new type of provider, primary care provider, which does not have traditional physician 4+4+3+??? training, that a PCP can be trained in far less time and function independently and within the framework of the current system, alongside traditional docs. Like PAs or NPs but with a little more oomph, but not the full MD program. I like the idea that NPs are pushing this, but it bothers me that they are doing it with, frankly, such a streak of arrogance. "Physicians just need to mind their own business, open up competition, and get out of our way"...a few nuggets I've read here recently.
There is so much more that can be accomplished, especially w/ your lobby power, without all the acrimony (and a smidgen of self righteousness). PAs use the slogan "Partners in medicine", a take home message for sure.
Not trying to pick fights, just rocking the boat a bit......
You assume that education is the only key to being able to do the job, and there you are dead wrong. Experience matters more. To say that education makes one superior is about as short sited as it gets. You use a key word "often", which is very relative. I would argue that in primary care, "often" situations don't require the broader differential diagnosis that would result in a different outcome that would affect anything. You are talking about a minority of situations that are seen in primary care. The medical establishment (mostly physicians) are very guilty of arguing that more money needs to be spent for isolated incedences. Most primary care visits are very uncomplicated. Why does someone need to pay for the firepower of elaborate and expensive physician education, when 99.9% of the time a nurse practitioner would do just fine. Most of these elaborate differential diagnoses take more than one physician visits and a referral to a specialist to make anyway. Let's not pretend like the primary physician is able to do this of their own accord because they have a far more extensive education than a nurse practitioner.
Nobody is saying that a nurse practitioner program needs to be equivalent to that of an MD program, that is far from what anyone is saying. Nurse practitioners can perform the job just as well with their education and training and some experience. It doesn't take the MD education to do the job. That is what is being said. If physicians really think that their education makes your service so superior, then why are physicians afraid of opening themselves up to the competition of independently practicing nurse practitioners. If you provide superior value, shouldn't you win out in a competitive environment?
Education does make a superior provider, that is what the nursing establishment is saying. Why else would there be advocating for a DNP to receive the same practice rights as an MD/DO when currently NPs do not ? Unfortunately, while experience does impart a great deal to practicing medicine or nursing, there is a great amount of variety in NP programs as far as education and experience requirements go (that includes direct entry NP programs where the participants have NO prior experience). I agree that often is a relative term, that's why I used it. I don't have any studies to back that statement up - however, if someone is exposed to a broader range of illnesses (i.e. education) then it would be logical that their list of differential diagnoses would be broader as well. I don't know the exact number of times this would be advantageous to a patient, but it is prudent to believe it is of some importance. It may take more than one PCP visit or referral, but it's the recognition of a more involved problem that is the important part.
Physicians are not afraid to open themselves up to competition to independently practicing nurse practitioners because they think the money flow will decrease. There is an overwhelming concern that the inconsistency among programs (in terms of classes, educational requirements, experience required, clinical hours) leads to inconsistency with practice and may lead to worse outcomes than medical education which is standardized (MD/DO/PA). In addition, while patient should be given the choice of a lower cost provider, but I think that if/when nurse practitioners get independent practice rights they will inevitably have a cost similar to that of physicians (with the lobbying for the same reimbursement and the again inevitable increase in malpractice to match that of physicians).
." 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."
This statement is simply false. Study after study after study directly disputes this assertion. Show me your supporting evidence to back up your claim. False arguments like this keep being made on this board without any substance. For every statement like " I knew this NP who did this wrong blah, blah blah", is countered by some other's story of " I knew a doctor ..." or "I worked with a PA ....".
NPs have similar outcomes to other primary care providers. Studies DO prove this to be true.
Now, if you were to start again with, "In my opinion, narrowed by my rather limited contact with a less than representative number of NPs, aka a handful, a broader differential diagnosis which results in a different outcome...blah,blah,blah". That's different. Its your opinion. And you're still wrong.
Actually I could not find a study to support either assertion. Yes, arguments are made on this board for both sides without any substance. As I stated in my previous post, it is logical to assume that with an increased amount of education (in terms of increased pathology, pathophys, varied clinical rotations) and therefore a greater exposure to diseases/conditions, there would be a longer and more diverse differential diagnosis generated for a given condition. This is not the case for EVERY patient, again I am not saying every patient has the zebra not the horse. But, that doesn't mean that zebras don't exist.
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).
My NP who does my year exams at the gyn office did attempt to misrepresent herself as a doctor. She introduced herself as Dr. XxxX and nothing else. When I asked her where she went to medical school, she stated a school. I then asked where she did her residency and she replied with, "well, I didn't exactly do one" to which I was really confused and asked her to clarify. She then told me she was actually a nurse with a doctorate degree.
Yeah, that DNP needs some work on her introduction for sure. She's qualified to do the exam. She has a doctorate. But by your description, she does leave a lingering cloud of confusion/deception in the air. I would have taken this a an opportunity to explain the DNP role. That may become drag to do this with every patient everyday but that's just what it takes. If a patient expects/assumes a physician, it falls on the provider to clarify.
I don't see what is so hard or wrong with saying "I'm Dr. So and So, and I'm your nurse practitioner on the transplant/cardiac/nephrology/primary care team."
).. We don't do it to be wise butts we do it to improve patient care. Does our pride get hurt on occasion;sure it does. 
Idaho4me
32 Posts
The distinction between practicing nursing and practicing medicine may be trivial until lawyers and courts get involved. If a board of nursing oversees all things nurse, they can't very well allow nurses (NP) to practice medicine. If they did, well then a state's medical board may have some interest in said practice and we can't have that. The treatment course for a sore throat is identical whether administered by MD,PA, or NP. The NP is still practicing advanced nursing to remain under the auspices of the board of nursing.
Splitting hairs? yep. Lawyers eat that up!! Who can remember the famous lawyer who said, "That depends on what the meaning of 'is' is."