NP science preparation vs. MD science preparation

allnurses Guide · Apr 21, 2008

If some hospital wants to let NP's become attendings, let them. That will be your study right there. Right now, it's unethical to randomly assign patients to either NP or MD care.
The only studies that has been done to compare MD vs NP care is by Mundinger and there are so many holes in that study it's not even funny. These MD vs NP studies seem to just compare patient satisfaction in pre-diagnosed patients. Sure, Mr. Jones likes the NP who takes care of his HTN because she spends more time with him. Gee, that's surprising. Imagine an NP who has to truly function as an attending and has to treat anything that walks through the door. Any study should look at outcomes with undiagnosed patients.

You really should look somewhere besides the SDN forum before you post such nonsense. Try this link for studies that compare NP outcomes. http://www.aanp.org/NR/rdonlyres/eq4b4j65zxi3u4cz46svq6iutf3rrc6bp7c7aopswoxszcyuxaan36zk2gopktir3mphgad6nzogkdw53hkd57a7aoh/Qual_NPPrac.pdf Hmm...some of them were even reported in JAMA, and no they all don't have to do with spending more time with their patients. All things considered if some physicians spent more time listening to their patients vs. always assuming they knew what was right/best, because of their "superior" education maybe there wouldn't be as many medical errors.

What exactly is your background n_g?

Trauma Columnist · Apr 21, 2008

One must always look to the qualifications of those giving advice. Posters that won't come clean about their background (ng) are not to be taken seriously.

core0 · Apr 21, 2008

You really should look somewhere besides the SDN forum before you post such nonsense. Try this link for studies that compare NP outcomes. http://www.aanp.org/NR/rdonlyres/eq4b4j65zxi3u4cz46svq6iutf3rrc6bp7c7aopswoxszcyuxaan36zk2gopktir3mphgad6nzogkdw53hkd57a7aoh/Qual_NPPrac.pdf Hmm...some of them were even reported in JAMA, and no they all don't have to do with spending more time with their patients. All things considered if some physicians spent more time listening to their patients vs. always assuming they knew what was right/best, because of their "superior" education maybe there wouldn't be as many medical errors.
What exactly is your background n_g?

How is the list of papers provided by the AANP any different from those posted on SDN. If you look at the papers (not the AANP descriptions) you will understand that there have only been three papers that have ever compared practicing physicians to NPs and only two that have compared to "independent" NPs to practicing physicians. While the JAMA article was interesting, you will notice that the follow up article appeared in a third or fourth tier journal.

The problem with conducting studies on this population is that for the most part they are healthy. Therefore you need a very large population to find any difference in provider practice patterns. If you look at the JAMA study that you quoted, they had 806 patients in the NP arm. If I remember correctly they need around 5000 patients according to PASS for them to find the difference they are looking for. The follow up was even more dismal.

You can reasonably state that no study has shown that NPs give worse care than physicians. However, you cannot state that any study has shown that NPs give equivalent or better care than physicians. The data is just not there.

David Carpenter, PA-C

n_g · Apr 21, 2008

There is a reason why there is no study to truly compare NP vs MD care -- because it's unethical. No such study protocol could pass any IRB in this country. How do you design such a study? Randomized double blind study. Any patient with undiagnosed complaint who walks through the door and is randomly assigned to either NP or MD and the patient is not told which one they were assigned to. A panel of experts reviews the care of the provider and rates it. Only later do the researchers determine parameters such as accuracy of diagnosis, following standard of care, patient satisfaction, etc. How can any researcher argue to the IRB that it's ethical to expose patients to possibly inferior care that could lead to injury or death? The first class in the DNP curriculum should be learning how to read scientific literature critically.

allnurses Guide · Apr 22, 2008

How is the list of papers provided by the AANP any different from those posted on SDN. If you look at the papers (not the AANP descriptions) you will understand that there have only been three papers that have ever compared practicing physicians to NPs and only two that have compared to "independent" NPs to practicing physicians. While the JAMA article was interesting, you will notice that the follow up article appeared in a third or fourth tier journal.
The problem with conducting studies on this population is that for the most part they are healthy. Therefore you need a very large population to find any difference in provider practice patterns. If you look at the JAMA study that you quoted, they had 806 patients in the NP arm. If I remember correctly they need around 5000 patients according to PASS for them to find the difference they are looking for. The follow up was even more dismal.
You can reasonably state that no study has shown that NPs give worse care than physicians. However, you cannot state that any study has shown that NPs give equivalent or better care than physicians. The data is just not there.
David Carpenter, PA-C

The point is that there is more than enough evidence to support NPs give equilivent primary care when compared to MDs. Not to mention the BMJ systematic review of literature that looked at 11 clinical trials and 23 observational studies comparing the two. There will never be enough evidence out there for some people no matter if the sample size is 800 or 80,000.

As far as the SDN comment anybody that follows n_g postings know they are nothing more than mimcry of SDN forums, and who can see any value for someone's postings that won't state their qualifications when having a debate. Yours qualifications are clearly identified, and to my knowledge you have always been up front with your perspective. Your input is valuable and provides balance to some of us die hard nurses that are very pro-autonomy for APNs (like me). Don't take that the wrong way, because I mostly disagree with you on APN issues, but one sided debates are boring...lol

We can look at this from another perspective. Where is the research that disproves my assumption that NPs provide equilivent primary to physicians?

n_g · Apr 22, 2008

The lack of solid studies comparing NP vs MD care is not just an academic exercise. Insurance companies and states look at the studies too and hear from both sides, especially the insurance companies. Each patient who needlessly suffers or dies because of an error can cost the insurance company $20 million.

I think that we should just let NP's become attendings. If you allow that, then any NP can become an attending, including ones who did their studies part-time or completely online. Be careful what you wish for. When the morbidities and mortalities start rolling in, then laws will be passed to tighten things up. It just takes a few incompetent people to screw it up for everyone.

core0 · Apr 22, 2008

The point is that there is more than enough evidence to support NPs give equilivent primary care when compared to MDs. Not to mention the BMJ systematic review of literature that looked at 11 clinical trials and 23 observational studies comparing the two. There will never be enough evidence out there for some people no matter if the sample size is 800 or 80,000.
As far as the SDN comment anybody that follows n_g postings know they are nothing more than mimcry of SDN forums, and who can see any value for someone's postings that won't state their qualifications when having a debate. Yours qualifications are clearly identified, and to my knowledge you have always been up front with your perspective. Your input is valuable and provides balance to some of us die hard nurses that are very pro-autonomy for APNs (like me). Don't take that the wrong way, because I mostly disagree with you on APN issues, but one sided debates are boring...lol
We can look at this from another perspective. Where is the research that disproves my assumption that NPs provide equilivent primary to physicians?

From the BMJ study:

"Ambiguity exists over the use of the term "nurse practitioner," with much debate about this role. 22 23 The overlap between nursing roles in the United Kingdom and the introduction of another advanced practice nursing title, nurse consultant, adds to the difficulty in understanding the role definitions in nursing. 1 2 24 Although specific training for nurse practitioners is available, the content of this varies.25 Because of this ambiguity, the definition used in our review was purposefully inclusive. Our review was limited by the quality of the available studies. There were few recent randomised trials, and the larger number of observational studies were generally of poor quality. Because of these problems we based our conclusions primarily on the randomised trials, the more recent of which were of generally high quality, although only one study used patients new to both providers.14"

" Our review lends support to an increased involvement of nurse practitioners in primary care. However, most recent research has been based on nurse practitioners providing care for patients requesting same day appointments predominantly for acute minor illness and working in a team supported by doctors. It cannot be assumed that similar results would be obtained by nurse practitioners working in different settings or with different groups of patients, nor that they could substitute entirely for general practitioners."

When you design a study usually you compare the outcome you are looking for against the so called gold standard. I would posit that for American health care the gold standard for medical treatment is a board certified physician. If you look at the majority of evidence based medicine it compares the practice of one physician or group of physicians against another in terms of patient outcomes. Realistically based on the composition of most non-academic practices what you are really testing is the outcome of one practice which may consist of physicians/PAs/NPs working in a collaborative model.

The use of a collaborative model is an important point. If you look at all of the studies, I would agree that there is a good deal of data that shows that NPs give equivalent care to residents in a collaborative environment. There are good studies in inpatient medicine, neonatology and renal medicine that support this. So from an operations standpoint, you could claim that an NP in a collaborative practice provides equivalent care to a doctor in training in a collaborative practice. If you look at the physician model there is growing evidence that physicians that do not finish a residency have higher malpractice claims and may have higher disciplinary rates. This suggests for the physician model at least, the completion of at least a three year residency is less likely to put a patient at risk than someone who has not completed a residency (although you can argue about the validity of malpractice and disciplinary data).

As the BMJ article point out, it cannot be assumed that the same results can be achieved in independent practice. Given the evidence that non-residency trained physicians should not be practicing independently then there is a natural assumption that other providers with less training should not be practicing independently.

As far as disproving your assumption that NPs provide equivalent care, the lack of negative data is not the same as positive data. The gold standard for independent practice is the board certified physician. Any group that wants to practice in a manner similar to the physician must show equivalence. The issue of osteopathy is a relatively recent development (within the time frame of the NP profession) that shows acceptance of another medical provider with equal independent practice rights. The DOs gained these rights by showing that there training and outcomes were equivalent of MDs. If NPs want independent practice rights they should meet the same high hurdle.

David Carpenter, PA-C

grad*student · Apr 22, 2008

Ok, back to the main topic.

I have undergrad degrees in Biology & Nursing, with a minor in Chemistry. In my NP graduate program, I will be taking the following graduate-level science courses: immunology, bacteriology, virology, parasitology/mycology, two physiology classes, two pharmacology courses, epidemiology, and pathophysiology. Most of these will be taught outside of the nursing school & by PhD's within their respective fields. Many of these are within the school of medicine. My clinicals will be arranged with both MDs and NPs within the community. Though my coursework will not be the equivalent of medical school, since it is specialized for one field (infectious diseases) & includes nursing theory/education in addition to science courses, I feel my schooling will well-prepare me for future work as an NP. My background already includes work in both bench research (molecular work) & clinical/translational research. Clinically, I've worked in med-surg and ICU settings. A lot of nurses enter graduate school with skill sets comparable to med students, and I think there is plenty of room for both disciplines & types of training w/in our healthcare system. Patients only benefit through this type of diversity. Nurses are free to take as many science classes as we wish, just find a program that complements your interests.

allnurses Guide · Apr 22, 2008

Ok, back to the main topic.
I have undergrad degrees in Biology & Nursing, with a minor in Chemistry. In my NP graduate program, I will be taking the following graduate-level science courses: immunology, bacteriology, virology, parasitology/mycology, two physiology classes, two pharmacology courses, epidemiology, and pathophysiology. Most of these will be taught outside of the nursing school & by PhD's within their respective fields. Many of these are within the school of medicine. My clinicals will be arranged with both MDs and NPs within the community. Though my coursework will not be the equivalent of medical school, since it is specialized for one field (infectious diseases) & includes nursing theory/education in addition to science courses, I feel my schooling will well-prepare me for future work as an NP. My background already includes work in both bench research (molecular work) & clinical/translational research. Clinically, I've worked in med-surg and ICU settings. A lot of nurses enter graduate school with skill sets comparable to med students, and I think there is plenty of room for both disciplines & types of training w/in our healthcare system. Patients only benefit through this type of diversity. Nurses are free to take as many science classes as we wish, just find a program that complements your interests.

Wow, that is above and beyond what most NP schools require! Are you taking the courses w/ med students and if so are they for full length of time that med students take them? The one class we took with the med students (medical pharmacology) we took it for one semester vs. the med students two semesters. It was one of three of the pharm classes we had to take for nurse anesthesia school.

Do you mind sharing which school this is?

allnurses Guide · Apr 22, 2008

There is a reason why there is no study to truly compare NP vs MD care -- because it's unethical. No such study protocol could pass any IRB in this country. How do you design such a study? Randomized double blind study. Any patient with undiagnosed complaint who walks through the door and is randomly assigned to either NP or MD and the patient is not told which one they were assigned to. A panel of experts reviews the care of the provider and rates it. Only later do the researchers determine parameters such as accuracy of diagnosis, following standard of care, patient satisfaction, etc. How can any researcher argue to the IRB that it's ethical to expose patients to possibly inferior care that could lead to injury or death? The first class in the DNP curriculum should be learning how to read scientific literature critically.

Again you don't know what you are talking about. There are plenty of totally independent NPs in practice (despite this ongoing debate w/ David to the contrary...lol). All you would have to do is set up a retrospective study looking at whatever your variables of interest are (mortality in similarly diagnosed patients, BP control, Hgb A1C levels, hospital admission rates etc) and compare x amount of years of NP patients with x amount of years of patients from a primary care physician.

And again what exactly are your qualifications? Everyone else has clearly stated their qualifications. I guess now we must assume that you have intergral knowledge of internal review boards all over the country. Nurses don't need their DNP to understand research. Research is introduced on the undergraduate nursing level, and is intergral part of all graduate programs. My graduate programs requires all nursing students to submit for publication, and your publications are?

allnurses Guide · Apr 22, 2008

From the BMJ study:
"Ambiguity exists over the use of the term "nurse practitioner," with much debate about this role. 22 23 The overlap between nursing roles in the United Kingdom and the introduction of another advanced practice nursing title, nurse consultant, adds to the difficulty in understanding the role definitions in nursing. 1 2 24 Although specific training for nurse practitioners is available, the content of this varies.25 Because of this ambiguity, the definition used in our review was purposefully inclusive. Our review was limited by the quality of the available studies. There were few recent randomised trials, and the larger number of observational studies were generally of poor quality. Because of these problems we based our conclusions primarily on the randomised trials, the more recent of which were of generally high quality, although only one study used patients new to both providers.14"
" Our review lends support to an increased involvement of nurse practitioners in primary care. However, most recent research has been based on nurse practitioners providing care for patients requesting same day appointments predominantly for acute minor illness and working in a team supported by doctors. It cannot be assumed that similar results would be obtained by nurse practitioners working in different settings or with different groups of patients, nor that they could substitute entirely for general practitioners."
When you design a study usually you compare the outcome you are looking for against the so called gold standard. I would posit that for American health care the gold standard for medical treatment is a board certified physician. If you look at the majority of evidence based medicine it compares the practice of one physician or group of physicians against another in terms of patient outcomes. Realistically based on the composition of most non-academic practices what you are really testing is the outcome of one practice which may consist of physicians/PAs/NPs working in a collaborative model.
The use of a collaborative model is an important point. If you look at all of the studies, I would agree that there is a good deal of data that shows that NPs give equivalent care to residents in a collaborative environment. There are good studies in inpatient medicine, neonatology and renal medicine that support this. So from an operations standpoint, you could claim that an NP in a collaborative practice provides equivalent care to a doctor in training in a collaborative practice. If you look at the physician model there is growing evidence that physicians that do not finish a residency have higher malpractice claims and may have higher disciplinary rates. This suggests for the physician model at least, the completion of at least a three year residency is less likely to put a patient at risk than someone who has not completed a residency (although you can argue about the validity of malpractice and disciplinary data).
As the BMJ article point out, it cannot be assumed that the same results can be achieved in independent practice. Given the evidence that non-residency trained physicians should not be practicing independently then there is a natural assumption that other providers with less training should not be practicing independently.
As far as disproving your assumption that NPs provide equivalent care, the lack of negative data is not the same as positive data. The gold standard for independent practice is the board certified physician. Any group that wants to practice in a manner similar to the physician must show equivalence. The issue of osteopathy is a relatively recent development (within the time frame of the NP profession) that shows acceptance of another medical provider with equal independent practice rights. The DOs gained these rights by showing that there training and outcomes were equivalent of MDs. If NPs want independent practice rights they should meet the same high hurdle.
David Carpenter, PA-C

1. So basically you are assuming that all of these NPs in all these studies can't make an independent decision w/o being in direct contact w/ MDs.

2. There are all these research studies to prove that NPs provide care is on par with MDs, but you can't provide one valid study that shows NPs do not provide equal care to MDs in primary care.

3. I will stand by my research backed assumption that NPs provide equilivical care to MDs in primary care.

4. Just to be fair, I think there would be similar outcomes for PAs in primary care.

We will just have to agree to disagree unless you want to start a new thread. I have highjacked this thread long enough....

jjjoy, LPN · Apr 22, 2008

In my NP graduate program, I will be taking the following graduate-level science courses: immunology, bacteriology, virology, parasitology/mycology, two physiology classes, two pharmacology courses, epidemiology, and pathophysiology... .Nurses are free to take as many science classes as we wish, just find a program that complements your interests

I'm curious, then, if the coursework you mention is all part of the NP curriculum or if they are courses that you are electing to take. How do you feel about NP programs that don't include that level of instruction or students who don't take extra coursework? Do you feel they are adequately prepared for their role?

A lot of nurses enter graduate school with skill sets comparable to med students, and I think there is plenty of room for both disciplines & types of training w/in our healthcare system. Patients only benefit through this type of diversity. .

You're right that patients only benefit from this type of diversity. And I'm sure there are many nurses who enter graduate school with skill sets comparable to med students. However, such skill sets are not REQUIRED for nursing graduate work... at least not at this point... and nursing graduate work doesn't generally build upon the pre-med skill set... at least MOST programs out there to date don't. I think CRNA is currently the most *consistently* scientifically rigorous nursing coursework - not based on personal experience, though. I imagine, though, there will continue to be changes in NP coursework.

I'm also curious if you have finished an RN program yet? With your strong interest and background in science, I'd be interested to hear your impression of basic nursing education (which I personally found frustratingly shallow in many ways, yet made overly difficult in other ways).