Is NP practice truely semi/autonomous?

DaisyRN, ACNP · Apr 17, 2008

i don't mean to rain on your parade, but good luck getting a great bit of response here. this topic has been addressed under several different threads, i.e. pa vs np, differences between np, pa, and md, np ever considered medical school? etc. i would suggest browsing thru some of those type of headings.

nps are adjuncts. we are all in this together. if you want complete autonomy, np is probably not for you. most nps are satisified with their level of autonomy without feeling subordinate or unworthy of respect from physician counterparts. we are not physicians, nor do we try to claim such.

you just have to look at your true goals and what it is you ultimately want to do. i was afraid that i would be unhappy with the level of autonomy as an np, but i am fine with it. granted, i am new... but by the time i am experienced, it will be sufficient and i will not regret my decision. i have yet to regret that decision yet.

good luck with everything!

emtneel · Apr 17, 2008

My background is very similar to yours. I also did Biology pre-med and actually got accepted to medical school.

If you go the NP route, you will NEVER be considered a Doctor. Depending on which state you practice in you have more autonomy than other's.

All fields of medicine should be a collaboration, sometimes it is not.

physicians need nurses whether they admit it or not. Hospitals would not run without us. And most Doctors could not run clinics on their own, without MA's, nurses, and other support staff.

NP's on the other hand could run their own clinic they know how to take BPs, and do all vitals, we know how to get accurate weight and height, we definitely know how to chart all that crap!

I think being an NP is the best of both worlds. YOu have less school and less loans, therefore do have some limitations on what you can treat, but have many options, you can switch between specialities without having to do another residency, you could go to a 3rd world country and do a world of good because your background is geared towards preventative medicine and care, not to mention nurses know how to use resources adequately and improvise!

When I started my NP education I almost quit in the 1-2 semester because I was really having doubts and I don't agree with a lot of the nursing theories because they are not "science" based. You definitly do not get all the science in nursing or NP school, and I am thankful for my scientific background and feel i understand things more deeply because of that.

I am glad for the decision i made now. Doctors seem to spend a lot of time in Med school, then residency, and then most work a LOT of hours.. that's not exactly what i want.

Don't know if that was helpful but thought I could reply.

Advanced Practice Columnist / Guide · Apr 17, 2008

In addition...although provisions for being independent are available by practice acts in specific states, true autonomy by being the sole provider in a clinic setting, for instance, requires a lot of jumping through hoops. There are many barriers to true independent NP practice. My state, for instance, is listed by an NP association as one of those where NP's can independently practice. However, prescriptive authority is still a delegated role in this state. This means that although NP's do write prescriptions on their own, an MD still needs to be identified as the colaborating physician who by virtue of the term "delegated role", delegates the act of prescribing to the NP. Our hospital issues prescription pads to NP's with only the NP's name on them. But this is possible because the delegating physician's name is on record and is available just in case there is an audit.

Another barrier to independent practice is billing. Currently in my state, Medicare, Medicaid, and Blue Cross of Michigan can reimburse NP services. However, private insurances do not. In addition, HMO's usually have very stringent requirement in order to empanel a provider as a PCP. NP's usually are not granted PCP status by HMO's. This greatly affects the NP's ability to have access to patients with various insurance coverage and limits patients seen if the NP wants to run the show on their own.

Hospital priviledging and credentialing can also present a barrier to independent NP practice. Although NP's are credentialed by hospitals to provide services to hospitalized patients, admitting priviledges are usually allowed only under collaboration with a physician. This can basically mean that an NP who wants to be a PCP will not be able admit his/her patients to a hospital and follow the patient on his/her own or without a collaborative physician.

The above can have many implications on individual NP's and what their goals are. I personally have no problem with the current system and the way it works. I am pretty content with the physician-driven practice I am involved in especially because I am in a specialty practice and my education and skills obviously do not compare to the double fellowship training my attending physicians went through. However, I have autonomy to make clinical decisions regarding patient care consistent with the medical plan of care establised for the patient population I am caring for. I have enough support from physicians when the complexity of patient management becomes too overwhelming for my knowledge base.

The way it goes, physicians who hire NP's or have NP's on their service usually have a collegial relationship with the NP. It is based on mutual respect and knowing what the NP's capabilities are and what their limitaitions are as well. I could not imagine an NP staying with a collaborative physician who is disrespectful and who has no trust in the NP's knowledge and skills. Similarly, I could not imagine a physician not terminating an NP's services if he/she does not meet the physician's expectations.

Trauma Columnist · Apr 17, 2008

I so agree with the above posters. From your post, I don't think anything short of a being a medical doctor is going to be fulfilling for you.

As to being disrespected by physicians, well it does happen. However, as an APN, I looked carefully for a practice that empowers their mid-level providers (both APN and PA) and have not been disappointed.

Good luck with your decision.

n_g · Apr 18, 2008

I'm not sure why you keep referring to pharms. Pharms don't compete with physicians. Dentists don't compete with physicians. NP's and DNP's claiming to be equivalent to physicians are in direct competition with physicians. By virtue of your rigorous training, physicians are held to the highest esteem in medicine. A DNP has 1/12 of the hours as a board-certified internist or FP (1000 vs 12k). I don't quite understand why're surprised that you don't have the same level of autonomy or public respect.

westcoastgirl · Apr 18, 2008

most of the physicians I work with are very collegial and nice to work with.

At the end of the day physicians will always remember that you "didn't go to medical school". I've heard the same attitude expressed towards dentists and pharmacists too. It's just a bar by which many MDs seem to measure the rest of the world around them.

it doesn't bother me, I am not a doctor and I am happy in my role as a mid level, never mind that I went to a more prestigious undergraduate university than many of my MD colleagues and did my share of hard sciences back then. I've learned to let go of that, it doesn't matter one iota now. I didn't go to medical school. I will always be a NP. There are certain benefits to being a mid level such as going into different specialties that are much harder to do as a physician.

think long and hard about what you really want........

amzyRN · Apr 18, 2008

I'm not sure why you keep referring to pharms. Pharms don't compete with physicians. Dentists don't compete with physicians. NP's and DNP's claiming to be equivalent to physicians are in direct competition with physicians. By virtue of your rigorous training, physicians are held to the highest esteem in medicine. A DNP has 1/12 of the hours as a board-certified internist or FP (1000 vs 12k). I don't quite understand why're surprised that you don't have the same level of autonomy or public respect.

Do NPs and DNPs compete with physicians or are they trying to help patients? Would physicians prefer to do everything on their own? Maybe everyone should walk out and let physicians do everything and see what would happen to the health care system. Maybe the some training to become a physician is unnecessary and that's why some are angry. I do think physicians should be respected for their commitment to humanity to take the time to train to such an extent. It is a big commitment and one which should be rewarded with great respect. But I don't feel I must or anyone else should have to kiss hiney either. That is not respect. Respect sometimes means challenging the other persons intellect and judgment. If physicians are taught to be cruel, competitive, and vindictive, how is that conducive to helping heal other human beings. To learn for the sake of love for the subject matter, and to dedicate ones efforts to truly helping other people are what I believed was heart of medicine. If all of that training does not evolve the heart and consciousness of the physician, than a big part is missing. Thanks much for your comments.

Trauma Columnist · Apr 18, 2008

jzzy88 - you seem to have had some negative experiences with MDs. As you get further into the world of mid-levels (if you decide to pursue this route), I hope you have some positive experiences. Physicians are just like the rest of us: some are nice, kind and respectful and others are jerks. However, just like in the rest of the community, you can choose who you work for and with. I choose not to work with jerks or if thru circumstances, I must work with jerks, I maintain a professional distance and communicate carefully and keep things to the point.

dhigbee · Apr 18, 2008

With regards to semi-autonomy: MDs are not completely autonomous. Generalists often consult with each other, or refer to specialists. With any profession, one must know one's limits, and when it's time to send the patient on. We can't solve every problem for every one of our patients.

That being said: I work in indigent care, and have much more "autonomy" then if I worked in a standard group practice setting. There is often an MD onsite, but at times I'm the only provider. The responsibility is immense, but the rewards are also immense. My job is stressful at times, but I wouldn't want to be doing anything else.

Dana

n_g · Apr 18, 2008

Do NPs and DNPs compete with physicians or are they trying to help patients? Would physicians prefer to do everything on their own?

When you look for a job, when you are looking at reimbursements, when you're writing scripts, when you're trying to get hospital privileges, the answer will come to you.

amzyRN · Apr 19, 2008

With regards to semi-autonomy: MDs are not completely autonomous. Generalists often consult with each other, or refer to specialists. With any profession, one must know one's limits, and when it's time to send the patient on. We can't solve every problem for every one of our patients.
That being said: I work in indigent care, and have much more "autonomy" then if I worked in a standard group practice setting. There is often an MD onsite, but at times I'm the only provider. The responsibility is immense, but the rewards are also immense. My job is stressful at times, but I wouldn't want to be doing anything else.
Dana

You make and excellent point.