Nurses are Not Doctors

Nurses General Nursing

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An article appeared today in the New York Times as a followup to a bill passed in New York granting nurse practitioners the right to provide primary care without the oversight of a physician. The authors of the bill state "mandatory collaboration with a physician no longer serves a clinical purpose and reduces much-needed access to primary care". The need for more primary care providers is due to the shortage of primary-care physicians, the aging boomer population, and the Affordable Care Act.

Although the president of the American Association of Nurse Practitioners feels that the current "hierarchical, physician-centric structure" is not necessary, many physicians disagree citing that the clinical importance of the physician's expertise is being underestimated and that the cost-effectiveness of nurse practitioners is being over-estimated.

Many physicians also feel that "nurse practitioners are worthy professionals and are absolutely essential to patient care. But they are not doctors."

What are your thoughts on this? Where do nurse practitioners fit into the healthcare hierarchy?

For the complete article go to Nurses are Not Doctors

Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
This is just wrong. In every sense, I'm sorry. In order to get into American medical school, an MD or DO program, you need a bachelors degree. The course requirements you see are contingent upon completing a bachelors degree. You can't apply with just those courses and no bachelors degree. Please find any medical school (a real one, MD) that doesn't require a bachelors and I will shut up and disappear forever.

SO it turns out you are about 99% right and I am ALMOST completely wrong. So plenty of medical schools do not list a bachelors degree as a requirement, but almost all who get accepted do have an undergad degree. In my career I have known three residents who did not have a degree. They graduated from the University of Chicago, The Medical College of Wisconsin, and Ross University. I called one who is a fishing buddy of mine and according to him he was a special circumstance and was admitted without a bachelors degree, though he did have more than 90 credits and all premed requirements. Because of the relatively high number of non bachelors degreed residents I have known (3) I was under the impression it was higher. So I will stand corrected. However even if I was right and you were wrong I wouldn't want you to go away. I appreciate your perspective.

As a point of interest, the Medical College of Wisconsin is starting a 3 year medical school not far from my home.

Maybe you are referring to foreign medical grads that have the MBBS but they are not as common in the average hospital (unless you are working in a community hospital that is kind of desperate and just takes all foreign docs) but the MBBS is the equivalent to a medical doctorate in that country. It takes 6-7 years to get so it's clearly not just a bachelors.

I was including them, since they usually head directly to medical school from secondary school. BTW while it is well understood that the MBBS is equivalent, it is called a bachelor degree. Maybe you don't yet know this but in nursing what a degree is actually called is far more important than the education behind it, as we have seen from many recent discussions on this list.

They are very common where I work.

even if this was true, who cares about how much non-medical education you have?

It may not be important to medical types, but it is all important in nursing. As we have seen with the ADN vs BSN debate where the ADN programs are essentially providing the same nursing education as the BSN, but in no way is considered equivalent to the BSN. Same goes for the MSN vs DNP debate for APNs.

Lastly, as I stated in the last post, EVERY physician (MD/DO) has a doctorate degree.

You mean except the ones that don't. MBBS.

The MD is a doctorate. If you don't believe me here's trusty Wikipedia: Doctor of Medicine - Wikipedia, the free encyclopedia. This means, for those keeping score, an MD has 4 yrs undergrad + 4 yrs medical doctorate

Or three years medical doctorate with the recent rise of three year medical schools in the USA.

and then 3-7 yrs of postgrad training aka residency. We spend on average 8 yrs in school post secondary, which is 4 more than the typical BSN.

How much of that 8 years of school is something other than medical education? Isn't the non medical education about the same for both?

Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
I haven't compared myself to residents. You will see, if you actually have read my words,

So I just read the whole discussion over on Studentdoc.net related to this discussion on allnurses. Turns out their reading comprehension sucks. Plenty of what has been discussed here has been obviously misunderstood over on that list. Misunderstandings that could have been prevented by actually reading what we have written. Rather disappointing for what is supposed to be among the most educated in society.

Specializes in Adult Internal Medicine.
So I just read the whole discussion over on Studentdoc.net related to this discussion on allnurses. Turns out their reading comprehension sucks. Plenty of what has been discussed here has been obviously misunderstood over on that list. Misunderstandings that could have been prevented by actually reading what we have written. Rather disappointing for what is supposed to be among the most educated in society.

Lots of idealistic posts demonstrating too much time in a textbook and too little time in front of a patient.

Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
My personal opinion, I agree with a lot of what you said. I wouldn't say physicians don't want these jobs, the residencies for primary care fill 100% every year with 1000s of people who didn't match into a residency begging for anything.

IMO physicians have brought this on themselves. I live in a very rural area with limited access to medical care. the nearest small, critical access hospital is a 45 min drive away IF the roads are clear and good. There are 4 physicians who practice from that hospital. Getting an appointment with one of them is a months long procedure. Out little town used to have Ol' Doc Westfall. When he wanted to retire there were no physician takers. For years attempts were made to recruit a physician to our little rural town without any luck. 10 or so years ago an NP opened an office. She is wonderful and we can often get a same day appointment with her and she takes emergent care walk ins suture etc. She manages milk CHF, HTN and diabetes in many local people who otherwise simply would be unable to regularly see a provider. I can't imagine how many of these people DON'T end up in the ER because she in managing them.

She also had admitting privileges at the closest hospital and rounds on patients in a area nursing home.

It was physicians not wanting to practice in a rural area without much in the way of cultural attractions (but good hunting and fishing!) or high compensation who created the opportunity for the NP. While I think many area residents would have preferred to have had a physician rather than an NP in the past, I doubt that is still true now after years of good and competent care by our own local NP.

Specializes in Anesthesia.
Did you not see the graph in page 7 on the discrepancy between Total Applicants and Total PGY-1 positions?

Yeah and all that research on outcomes is funded by nursing interest groups who have a direct stake in the research involved, are very short in length - 6 mos. to 1 year which are like nothing, and are on terrible endpoints like blood pressure, hemoglobin A1C and not actual outcomes like mortality. Yet when DNPs took a certification exam similar to USMLE Step 3 - 50% of them failed: American Board of Comprehensive Care - Exam Pass Rates & Practice Analysis

There is no chart on page 7, but referring to the chart on page 8 there was over 120 FP residencies not filled and over a 1000 FP residency spots were given to foreign medical school graduates. That indicates what is well known that most physicians do not want to train in primary care.

There is no indication that taking the USMLE makes better providers. Nurses/NPs could take and pass the USMLE at similar pass rates as medical students, but then NP training would have to become less specialized and the NP classes would have to be focused on the USMLE and their classes would be exactly like medical school. Then you have to wonder for what reason. NPs are already proven to be cost-effective safe healthcare providers that take their own NP licensing exam. It would be interesting to see what the pass rates for physicians were on the NP licensing exams since most schools that utilize standardized testing teach to pass those standardized tests.

First of all not all these studies were funded by nursing interest groups that is a lie, and a lot these studies look at multiple years of study data not just 6-12mo, so that is lie two.

Now let's play conspiracy game and turn it back around. The AMA is the largest medical association in the U.S.. The AMA spends over 18 million annually on lobbying alone. With the millions of dollars that the AMA receives every year do you not think the AMA could have published a study showing better outcomes by physicians versus NPs if there was any data out there? The answer is of course they could have, but the data is not there or the AMA would have published it, so the conspiracy theory that nursing organizations are making up all this data is lie number three in this conspiracy theory.

https://www.opensecrets.org/orgs/summary.php?id=D000000068

I seem to be on the other side of the fence, but I must say you make some very valid points.

The article is a typical example of a doctor's point of view. We are the only ones, our years of training = quality, just give us more money because we're not getting what we think we're entitled to because of aforementioned. Only one difference her is that, according to "some research", conveniently not cited, NPs "tend" to order more MRIs and stuff - so that they can somehow "compensate" bleak spots in their training.

Now, I'd like to ask: who is to blame for an epidemic of prescription opioid abuse? Who orders (and does) all these "spine pain shots" which sickened and killed some few hundred patients quite recently without any credible evidence of providing any more benefits than placebo? Who initiated situation when every 1 school aged kid out of 10 is supposed to have ADHD (CDC - ADHD, Data and Statistics - NCBDDD) and therefore can be prescribed drugs with high addiction potential? Who initiated "research" encouraging prescription of statins for children for unknown periods of time and with no clear ideas of long-term side effects? (Use of Statins for Dyslipidemia in the Pediatric Population) Who, last but not least, authorizes open heart surgeries on patients with end-stage dementia, hip replacements for non-compensated diabetics and dialysis for patients who are practically in rigor mortis already???

I can continue on, and on, and on. And something tells me that most of that has nothing to do with "inadequately trained" NPs and a lot with MDs with their years and years of training and schooling.

If doctors would like to gain back their authority in primary care, they just have to begin doing the said primary care themselves. Not by sitting in cozy offices "supervising" and writing scripts, but actually spending time with patients, teaching them, coaching them and supporting them. In short, they have to do what they were successfully doing 50 years ago. If they are unwilling to do it, someone else has to pick up the slack and get the privileges.

Specializes in Oncology.
She manages milk CHF, HTN and diabetes in many local people who otherwise simply would be unable to regularly see a provider.

I have to ask if milk CHF is CHF caused by fluid overload from overindulging milk?

Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
I have to ask if milk CHF is CHF caused by fluid overload from overindulging milk?

"milk" was supposed to be COPD! Sorry.

I have to ask if milk CHF is CHF caused by fluid overload from overindulging milk?

I was about to ask what the heck is milk CHF haha

Specializes in Oncology.
"milk" was supposed to be COPD! Sorry.

And here I thought your town just really liked their milk. I noticed osteoporosis wasn't on your list of commonly treated ailments.

Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
And here I thought your town just really liked their milk. I noticed osteoporosis wasn't on your list of commonly treated ailments.

Oh they do really like their milk. The county I live in has more dairy farms than any other in the country.

The point is still the same. Most physicians chose not to train or work in FP, especially U.S. trained physicians. There are more opportunities for healthcare providers in FP than physicians can possibly hope to fill, and there is no research that shows that forcing NPs to have collaborative agreements help patients or the healthcare system. There is in fact research that shows that independent NPs can and do provide just as superior care as physicians, and that independent NPs are viable solution to the shortage of providers in Family Practice.

http://www.nrmp.org/wp-content/uploads/2013/08/resultsanddata2013.pdf According to the data there doesn't seem to be a lot of scrabbling for U.S. medical school graduates/seniors to find residency spots.

This can be a little misleading. FM isn't the only field. Primary care also includes IM, Peds, Ob-Gyn. I would be less than honest if I tried to claim that medical students are fighting each other to go into primary care, but that doesn't mean we aren't churning out doctors in primary care fields. For family medicine the residencies fill every year, almost 100% in the match and any that didn't will get any med students that weren't able to get a spot in the match or the soap. Every year 100s of medical students walk away with no spot in anything and have an expensive piece of paper that they can't get a job with until they complete a residency, so it isn't true to say "look they don't want to go into primary care! None of them are going into PC residencies." They are. There just aren't enough residency spots to crank out enough FM docs... And that many who do complete the residency don't want to work in underserved areas, like the one another poster described. Add to that the docs who go through IM, Peds often specialize.

We have a huge access problem and I agree, we have more spots than we have physicians to fill. However, the scope for NPs keeps expanding and expanding. I know it's n=1 but many NPs I know say they gain their skills from clinical experience AFTER their NP program, similar to what residency would be for us (since many NPs function in similar roles to residents where they see patients but are supervised by patients. Why not standardize the clinical experience to make sure all NPs receive the proper training. In the studies that are repeatedly mentioned do they indicate if these Studies were done without MD "supervision."

I still don't understand if 2 people, NP and FM doc, are doing the exact same job and seeing the same patients but they take diff exams, they have different licensing, and different malpractice liability. Can anyone explain that?

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