Misconceptions in NP/PA/MD education: experiential requirements, online, and for-profits

allnurses Guide · Aug 30, 2017

The board exams are an imperfect sieve, thus it should not be the only filter in the NP pipeline.

What is your concern about the board exams? Minimum competency national board exams have a fairly decent track record...

SummitRN, BSN, RN · Aug 30, 2017

There are also Associate Degree PA programs and online ADN to FNP programs. Is there actually a baseline educational limit? Or is a race to the shortest?

Associate Degree PA programs have very similar curricula and standards to BS/MS programs.

ADN to FNP includes the BSN curriculum and degree before the FNP program that ends with a MSN or DNP degree. This model, on its face, is should not be an issue.

KatieMI, BSN, MSN, RN · Aug 30, 2017

I am playing a bit of devil's advocate here for the purpose of the discussion, but why (having made a statement that NPs are taught well enough in school) do you think there needs to be an excessive "purge" on NP education?

Because we deal with students who have deficit of basic knowledge (the aforementioned biochem, etc) and many of them already spent years from school in atmosphere which, as a general rule, is anti-intellectual and doesn't promote active education. We have to make them providers who will be a backbone of modern American primary care, and we only have 2.5 to 3 years to do so (moving MSN to 4 years full time won't be practical or affordable for the majority, and I do not think that the DNP initiative will ground well in clinical advanced practice nursung unless it becomes fully clinical-oriented, aka medical residency).

For that, some things must be sliced off because each of subjects I mentioned above adds about 4 credits, or 5 to 10 study hours/week:

- nurses need to evaluate evidence and research pertinent problems when they do bedside care with their ADN/BSN. Therefore, all that stuff can be totally incorporated into undergrad level and not repeated further in MSN/DNP programs

- Masters programs typically do not incorporate full- blown transitional research project. Therefore, everything pertaining to it might safely go as well

- instead, more time should be devoted to teaching students how to seek and evaluate existing evidence

- "role development" and "nursing theories" do not add anything to one's clinical knowledge. This time can be used for studying legal and administrative business (which is not taught enough in many programs)

- courses like "health promotion" should be converted to entirely clinical time spent teaching students how to educate patients (which would be one of their prime responsibilities)

- every other part of education which hinders clinical learning and slows down development of clinical critical thinking, cooperation, communication and teaching skills must go. Yes, I speak about APA style too. It is getting freaking ridiculous.

Yes, NPs seem to fare well right now. What has to be done is to make them even better so the talks about "settle for the NP instead of a doctor" won't exist anymore. Knowledge of a physician, heart of a nurse, skills of both of them.

Those who truly like the papers, independent research and other stuff and fluff should be welcome any time in DNP and non-directly clinical MSN programs.

DizzyJ DHSc PA-C · Aug 30, 2017

Then that someone would be just as guilty as you of not reading the opening of my post where I said:

I'm not an expert either....I was capable of spending 10 minutes to look at a few websites and verify the accuracy of your information. So, why couldn't you have taken that 10 minutes to do the same before posting blanket statements that are not really accurate.

DizzyJ DHSc PA-C · Aug 30, 2017

There are also Associate Degree PA programs and online ADN to FNP programs. Is there actually a baseline educational limit? Or is a race to the shortest?
QUOTE]
Associate degree programs must follow the same standards as BS and master's programs. Red Rock and Tri-C programs both require bachelors degree for their associates programs. And both give the option to obtain a master's degree with the PA program.

SummitRN, BSN, RN · Aug 30, 2017

I'm not an expert either....I was capable of spending 10 minutes to look at a few websites and verify the accuracy of your information. So, why couldn't you have taken that 10 minutes to do the same before posting blanket statements that are not really accurate.

You are an expert at assumption... that I did no research. Apart from the knowledge I already had, I spent about 2 hours researching and writing that post. I declared myself a non-expert because I didn't take the time to research every corner. If I wanted to put 4 hours into it, I'd have made it an article with citations... which I went back into my browser history to fetch...

Here are few sources that I used:

Physician Assistant Programs Offering Part-Time Options | The Physician Assistant Life -this PA hopes there will be more p/t PA programs to accommodate those with families
U Wisc Distance
Part Time Option Available Archives | PA School Finder | FREE Physician Assistant Program Directory
PA PT Programs
PA Distance Programs
UND PA Program | Physician Assistant | School of Medicine & Health Sciences | UND: University of North Dakota - (they operate a DL NP program too)
Online Physician Assistant Programs | Yale School of Medicine
Dangers of For-Profit Education: More Than Just Words | The Journal of the American Osteopathic Association
New for-profit medical schools springing up across U.S. - Chicago Tribune
Prices High For Profit | AAUP

You chose to expound at length on two nitpicks, one of them was merely a typo on my part, (I wrote distance learning when I meant televisual learning (telepresence classes)).

Clearly you also didn't bother to understand similar NP programs to which I later compared (ie Vanderbilt). Why didn't you take the 10 minutes to research this? (Pedantry can flow both ways, see?)

Please dial your burner down to simmer, and stick adding substance, like your last post above.

Bob Loblaw · Sep 4, 2017

Best Jobs for the Future 2

TicTok411 · Sep 4, 2017

There are good and bad with each group. For the most part new interns are dangerous and need to be watched closely, but they grow and learn and many of them turn out very good. Same can be said for NPs, but I do believe experience, quality of program and clinical experiences play a role in the quality of NP that is released to patients. I have seen good ones and those who struggle and if you dig into the background it becomes glaring where their shortfalls are.

PAs, sorry but I do not have much of a good record among that group. I have worked along or with 100-200 and can honestly 3 have impressed me. the rest range from functional, modestly competent to what the heck are you doing. Granted that was just my experience in 10 different states, but I am sure there are some great ones out there or at least I hope there are.

shibaowner, MSN, RN, NP · Sep 4, 2017

Oh My Goodness...med school students, in most situations, go straight from college to med school. They do have certain work/volunteer experience in health care. Not certain what you mean by an analogy to NPs or PAs. Please explain.

I'm not sure what you are asking me. Most medical students go straight from college to med school. They do not work as RNs or PAs or CNAs before starting med school. I think that is pretty clear. I went to Yale with a bunch of premeds in undergrad and NONE of them had any healthcare experience and they graduated from Yale and went straight to med school at places like Yale, Harvard, Stanford, etc.

globoid · Sep 5, 2017

wow has anybody here actually gone through medical school or are they just regurgitating what his or her nursing professors say to them?

We have FNP and acute care NP students where I just started my final year of internal medicine residency, most of them know nothing. I wont give the exact name of the school but it is a top 20 residency program on the eastern side of the USA. Whatever has been said of medical school above is simply wrong, dumb, stupid, and stupid.

globoid · Sep 5, 2017

I also cannot remember who was touting some sort of studies showing NPS= MD in regard to primary care, but considering this has been discussed thoroughly at our institution (since the dean of the nursing school was trying to get APRNs to be able to manage patients without physician collaboration at our facility (mind you it was shot down day one since it was laughable) and these studies were brought up.

1. They are funded by nursing organizations that are heavily biased. It has been found in our deep archives that there were plenty of studies done that showed NPs ordered MORE worthless tests, had MORE referrals for silly things, and wasted MORE tax payer dollars than their physician counterparts. These studies were done at OUR institution by the nursing department but WERE NEVER PUBLISHED for obvious reasons. Sort of like the pharmaceutical companies perform study after study (there is no real limit) until one SHOWS that their drug does better than XYZ previous treatment. They all just sit in the bottom of somewhat hidden servers for nobody to ever see outside our network.

2. The studies that have been published (most of them) have been MLP (mid level provider) + physician care Verses physician only care. Very few of these studies actually have autonomous NP vs autonomous physician care being used as metrics.

3. The studies that were actually autonomous NP vs autonomous physician care only measured simple metrics (HTN, DM, HLD) over a period of SIX MONTHS. How much do you think can change in six months??? if I sat a high school kid in front of a patient vs a physician, especially in regard to non compliant patients, do you really think it would make much difference in lipid levels in six months? These illnesses are mostly treated with set guidelines anyway, not hard to manage (hence why we let our NPs in outside university ran clinics manage much of these with oversight).

4. How do they really measure complexity of patients? If a study simply states "the patients of the NP team were of same complexity of that of the physician team" with no supporting evidence, who in their right mind would take that as a blunt fact? Are they really? or did the author just toss that in for good looks.

5. Many of the NPs were trained by physicians for much of their career prior to having these studies conducted. So how does that automatically make NPs the physician equal if they do not often even train their own??

6. I have many more but will toss out the biggest one. The AMA (for which I am active on the local board of) will not publish or dig out previous findings of averse NP outcomes since more than 95% of NPs work with directly or are still supervised by physicians. Why would we want to take out the 5% when we have 95% working for us. No need to scare patients away from MLP level care when they are happy with it, which they should be, as long as there is a physician having oversight.

In regard to NP getting full authority it is not a concern though, most will continue to work for docs anyway. its not going to hit our paychecks. Most hospitals will not give APRN full individual patient care rights no matter what the states say, so big deal, give it to them.

If there ever is a flood of NPs providing patient care without oversight to any great extent the lawyers will clean up that mess with a large influx of lawsuits anyway.

In retrospect, I have met some great MLPs who know their limits, consult as needed, and are great with the patients (we all have limits), but to compare their knowledge base and ability to perform complex diagnostic methods to the same level of a well trained physician (especially an american trained physician) is absurd.

If LPNs started procuring studies from their nether regions showing they are equal to RNs just imagine the outrage.

I do apologize for stepping on toes, but please use common sense. Physicians are the basis of medicine, nurses are the basis of patient care and communication between physician and patient/nursing, both are equally important, but please do not blur the lines between them.

The best,

Globoid

allnurses Guide · Sep 5, 2017

I also cannot remember who was touting some sort of studies showing NPS= MD in regard to primary care, but considering this has been discussed thoroughly at our institution (since the dean of the nursing school was trying to get APRNs to be able to manage patients without physician collaboration at our facility (mind you it was shot down day one since it was laughable) and these studies were brought up.

All patient care is done in collaboration no matter what your degree or job title is (unless you are Dr House's team). In modern medicine, all providers are dependent on collaboration with other members of the healthcare team from pharmacy to PT/OT to case management to nursing to physician specialty practice. In the final year of your internal medicine residency I would think this would be readily apparent.

In this collaborative provider practice, why then is it laughable to have NPs practice without direct supervision in the hospital setting? And why was it shot down? Because of good data or because the physicians did not want to lose control?

1. They are funded by nursing organizations that are heavily biased. It has been found in our deep archives that there were plenty of studies done that showed NPs ordered MORE worthless tests, had MORE referrals for silly things, and wasted MORE tax payer dollars than their physician counterparts. These studies were done at OUR institution by the nursing department but WERE NEVER PUBLISHED for obvious reasons. Sort of like the pharmaceutical companies perform study after study (there is no real limit) until one SHOWS that their drug does better than XYZ previous treatment. They all just sit in the bottom of somewhat hidden servers for nobody to ever see outside our network.

Cite your sources and we can discuss the studies and their "bias". Speaking of laughable, do your physician colleagues snicker when you talk about the myriad of secret studies stored on hidden servers being more important then a large body of extant peer reviewed publications?

2. The studies that have been published (most of them) have been MLP (mid level provider) + physician care Verses physician only care. Very few of these studies actually have autonomous NP vs autonomous physician care being used as metrics.

For a large scale study it is/was difficult to evaluate NP solo practice because most NPs bill incident-to for reimbursement and at the time these studies were done there were few independent practice states.

I have seen this argument made many times and I can understand it superficially I guess, but I am not sure that it really means much. The data is pretty consistent across both independent and collab studies. As a PGY3 IM resident do you feel your outcomes reflect your practice or the practice of your attending?

3. The studies that were actually autonomous NP vs autonomous physician care only measured simple metrics (HTN, DM, HLD) over a period of SIX MONTHS. How much do you think can change in six months??? if I sat a high school kid in front of a patient vs a physician, especially in regard to non compliant patients, do you really think it would make much difference in lipid levels in six months? These illnesses are mostly treated with set guidelines anyway, not hard to manage (hence why we let our NPs in outside university ran clinics manage much of these with oversight.

What percentage of morbidity and mortality in the USA is related to HTN, DM, HLD? How many healthcare dollars are spent on these illnesses or their sequlae? If this is so easy to manage with set guidelines then why aren't physicians better at it? The truth is, as I hope we all know, is that is it not easy and it is not black and white treating these patients. Perhaps NPs do better in management of these issues because, as you put it, they are focused on patient care.

4. How do they really measure complexity of patients? If a study simply states "the patients of the NP team were of same complexity of that of the physician team" with no supporting evidence, who in their right mind would take that as a blunt fact? Are they really? or did the author just toss that in for good looks.

This is pretty simple research methods. Please, cite a study and we can discuss the specifics.

5. Many of the NPs were trained by physicians for much of their career prior to having these studies conducted. So how does that automatically make NPs the physician equal if they do not often even train their own??

How does a resident become an attending's equal? I don't see why novice NPs practicing with an experienced physician is a bad thing: it is good continuing education for the NP and it is a revenue generator for the physician.

6. I have many more but will toss out the biggest one. The AMA (for which I am active on the local board of) will not publish or dig out previous findings of averse NP outcomes since more than 95% of NPs work with directly or are still supervised by physicians. Why would we want to take out the 5% when we have 95% working for us. No need to scare patients away from MLP level care when they are happy with it, which they should be, as long as there is a physician having oversight.

I am going to contact the AMA and ask directly about this. Actually I think the news media would be interested in this if it were true as well as it would be unethical if true, especially since one of the major studies was published in JAMA.

It does highlight the major issue in this debate: physician revenue.

(will get to the rest in a separate post)