NP vs MD Scope of practice

dissent · Aug 18, 2011

Hello all,
Right now, I am in the BSN portion of Columbia's accelerated ETP to MSN/DNP program. When I entered the program, my plan was to go into a PMHNP and do pediatric psych. However, now that I am in the throes of the program, I am realizing how much I LOVE working in the hospital, how fascinated I am by the mechanism of illness, and how deeply I want to get into this. After thinking about it fairly extensively and learning more about it, I've become increasingly interested in pediatric ICU or pediatric oncology. However, before I entered the program I had only looked into the scope of practice of a PMHNP because that was my field. Now I'm at the point where I'm strongly considering switching to a postbac and medical school (I'm turning 24 in a few days). However, I don't know if it's worth it for me to switch over or if the difference in NP vs MD is big enough that it will make a difference. Any NPs out there working in a hospital, preferably in peds or onc (but other opinions welcome!), want to comment on the scope of practice, constraints, autonomy, and/or amount of responsibility? Do MDs really not get that much time with patients? Do NPs do as much as a doctor does? What are the biggest differences? Anyone ever have the same choice and choose the NP?
Thanks for any thoughts or advice.

How long will it take you to finish the BSN and then the DNP?

In terms of time to degree and practice I expect the DNP is going to be much much quicker:

Medical school route:

Peds: total of 9 years- 2 years for post-bac, 4 years for medical school, 3 of peds

Peds ICU- total of 11-12 years (add 2-3 years for peds ICU)

Peds onc or med onc: total of 12 years- 2post back, 4 med school, 3 of peds or medicine, 3 of peds-onc or med onc

NPs do not do as much as a doctor does but as above there is a big difference in the length and depth of training and that explains the difference. Technically after a year of internship after medical school you can LEGALLY do whatever you want (onc/ICU/surgery) but no hospital is going to hire you and you'd be a fool to try. That means to work in an ICU or oncology you must do the extra training as an MD.

Think about it this way, at the end of that internship, a physician-in-training will have roughly 7000-8000 clinical hours under their belt with a minimum of 500 of those spent in an ICU while most DNPs require only 1000 hours and not many of those will be spent in an ICU. The post-internship resident isn't going to be allowed to run an ICU alone and will have limited autonomy. Obviously the case is going to be similar for the DNP.

The autonomy is going to be hospital dependent. Many ICUs will give NPs a lot of autonomy but there are definitely limitations. Where I have been, NPs dont put in central lines (with exception of PICCs which often aren't that useful in an ICU) or A-lines as well as various other major ICU procedures. These places have been teaching hospitals where there is a lot of cheap labor (residents) so the need for NPs is less.

Oncology is a bit of a different bag. NPs tend to have less autonomy overall and in my experience have acted more as physician extenders.

In the end I think the decision will hinge on whether the time is worth it and how much knowledge and independence you want. Add to that the knowledge that residency is very tough and you will be working 80 hours a week for 6 years to get into peds-critical care or peds-oncology during your 20s and 30s.

Good luck

Advanced Practice Columnist / Guide · Aug 18, 2011

First off, I agree with what dissent already stated about the difference in the length of training including a wide discrepancy in the actual clinical hours spent between the two disciplines. However, I would also give you my perspective from an NP standpoint. Unfortunately, I work in the adult side of the hospital as an ACNP so my thoughts will not necessarily be in line with pediatric practice. I do know that at one point we had a poster in this forum who works in the Pediatric ICU and is an AC-PNP.

Autonomy is a relative term. I am a nurse practitioner working alongside the Critical Care Medicine service of a major academic medical center with a full array of residencies and fellowships. Our service is set-up with a multidisciplinary team to begin with (attendings are Pulmonary Medicine-Critical Care, Anesthesiology-Critical Care, Nephrology-Critical Care, General Surgery-Ciritical care). We have a fellowship program in Adult Critical Care that is just as multidiscplinary (Fellows come from many residency backgrounds - Anesthesiology, Internal Medicine, General Surgery with program arranged with the city's Trauma Center, and Neurovascular). We have residents from Internal Medicine and Anesthesiology rotate through 5 ICU's, 4 of which the NP's have a presence as well.

The nurse practitioners do not run the ICU obviously because the ultimate responsibility for patient management rests on the attending. I think of my role as part of a team of critical care providers who manage the minute to minute and day to day changes that happen to our patients. Patient management is a team decision and is started on AM rounds and is updated as changes happen in the day and night. Unlike dissent's experience, we NP's have enough autonomy to do procedures on our own including central lines (triple lumens, introducers, dialysis catheters, and PICC) as well as arterial lines. But again, line placement is a team decision as the need for these lines come with an indication. Our residents also get to do these procedures but in our experience, residents in Anesthesiology are already proficient in these from their pre-op experience though the Internal Medicine residents need some help. We do not supervise line placement done by residents, the fellows do that.

The attending physicians definitely have no restrictions in their practice and has the ultimate say in management. That is the highest level one can achieve in critical care. There are many attendings in our group and each follow a 7-day rotation in the ICU when they round with our team. When they are not on their ICU week, the Anesthesiology-Critical Care attendings work in the OR, the Pulmonary-Critical Care attendings do clinic, and so forth. All the attendings are faculty at the medical school and have duties pertaining to undergraduate medical education and GME. Majority of the attendings are involved in research and some are big names nationally. The NP's only work 3 12-hour shifts a week and follow a Day-Night rotation schedule. The residents follow typical residency schedule (24-hr call q 3 days, nothing in excess of 80 hours a week).

From my standpoint, I am not earning as much as an attending but my work hours are actually a lot less if you look at it. My responsibilities are also less than the attending though I definitely answer for the outcomes of my actions in terms of patient management. In terms of lifestyle, you can say I am better off and I still get to work as a provider in a field I enjoy which is critical care. But then again, I am perpetually at a lower level as the attending. I would say that these are things you'll have to weigh on your own and figure out what is improtant to you.

WilliamsRower · Sep 28, 2011

Thank you both for your thoughtful responses -- it was very helpful to read those in making my decision. In the end I decided to go with medical school -- it was a gut feeling and as many times as I made pros and cons lists, the feeling was still there. So, thus begins a long journey! Thank you again.

Advanced Practice Columnist / Guide · Sep 28, 2011

Good luck to you.