Medicine decries nurse doctorate exam being touted as equal to physician testing - page 4

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  1. by   GilaRRT
    I still cannot understand the argument. I read the quotes where it was said the new DNP is not designed to make a nurse more like a doctor, but rather add additional skills to the existing NP. However, the rationale for a quasi USMLE exam was to test the DNP's on "medical" knowledge. In addition, it goes on to talk about NP's admitting patients. While this does occur, I usually see a midlevel do this because they are working with a physician group and have physician coverage and support. However, it does not seem this is the case with the new DNP.

    So, a new provider is tested on quasi "medical" knowledge with questions based on the USMLE, and can have admitting privileges without collaboration or support? Does this really sound like nursing? Yet, we argue everybody needs to get along and work as a team, while it seems we are the ones that are not being good team players.

    I agree with others. I have absolutely no problem with a nurse receiving a "clinical" doctoral degree. However, I do have a problem when we stop being nurses in practice, yet are still regulated by the BON. This sets a potentially dangerous precedent IMHO.
  2. by   dgenthusiast
    Quote from yelnikmcwawa
    however, i still feel it is ridiculous to say that nurses should not have doctorate clinical degrees available to them...and to be honest...yes, it is because everybody else is doing it. don't leave us out! but you're absolutely right that the degree should match the clinical expectations of it's graduates. it's an issue, i give you that. so let's be a part of the solution rather than sitting idly by and letting everyone else get their clinical doctorates!
    where are you getting this idea that no one wants you to get a clinical degree? i don't recall anyone saying that at all. i certainly haven't. all i've said is that the ama's statement is completely understandable considering the dnp is nowhere near the level of clinical education required to manage complex patients (not every patient has an easy pathology or only one pathology to worry about). furthering your knowledge through education is great. what the ama is saying is that what dnps are saying (not all of them but a small, but vocal, group) is not consistent with what they learn and the exam they take.

    whoever mentioned that usmle step iii appears easy because medical students have taken several hard exams prior to it, sure that may be part of it. but it is well known that out of the 3 step exams you have to take, the hardest is step i and the easiest is step iii. many interns take step iii without much studying at all. and dnps from columbia take it with however long they had to study in addition to taking a watered-down exam of an already easy exam; they still only had a 50% pass rate. and based to taking an exam that is not similar at all to physicians, some (like mundinger) are touting that they took exams that make them equivalent to physicians. if this isn't about money and being called doctor, i don't what is.

    and do = md. their training is inseparable for the most part. the only difference really lies in the small bit of omm that do's learn. there's actually a movement to give do's the title of md and no one's really opposed to it because their training is 99% the same. that's the key there. there's not much opposition to that because they're training is nearly the same. dnp training is not even close to being similar to medical training; that's why there's an opposition to dnps wanting to be equivalent to physicians and asking for equal reimbursements. now, do you understand why there's an opposition to this?

    ps. i'm not saying that all dnps are like this. it's just that this vocal group has given all dnps a very bad name because of their propaganda. i've heard so many residents say that they will never hire dnps and will hire only pa's based off the words that mundinger, et al are saying.

    edit: also, yelnikmcwawa, please stop saying the only reason there's opposition to the dnp is due to a turf war. there's so much more to this opposition than that. read what ranier had to say. he/she made some very good points.

    edit2: also, everyone else is being offered clinical doctorates? what can you do with a clinical doctorate degree in english or philosophy, for example? or were you only referring to pharmacists, etc.
    Last edit by dgenthusiast on Jun 11, '09
  3. by   ivanh3
    Quote from GilaRN
    So, a new provider is tested on quasi "medical" knowledge with questions based on the USMLE, and can have admitting privileges without collaboration or support? Does this really sound like nursing? Yet, we argue everybody needs to get along and work as a team, while it seems we are the ones that are not being good team players.

    I agree with others. I have absolutely no problem with a nurse receiving a "clinical" doctoral degree. However, I do have a problem when we stop being nurses in practice, yet are still regulated by the BON. This sets a potentially dangerous precedent IMHO.
    What you bring up is important, and I can appreciate your stance. However, once again when it comes to actual hands on patient practice, nurse practitioners are working in the medical model. I have debated this before with another nurse on this site who is very intelligent and very passionate that what NPs do is not medical. It is nursing. Though her stance is passionate and obviously from the heart, I couldn't disagree more. It is actions that speak loudest, and what NPs do is medical. When I am at my RN ICU job as a bedside nurse I work under a nursing model, of that I have no doubt. When I am at my NP rotation, however, my work is under the medical model: I assess (history and physical), diagnose (medical not nursing dx) and then I treat (based on my medical dx). If some want to call that nursing because it is done by a nurse practitioner, I guess that's true, but it seems awfully silly and unproductive to take that stance because by that measure then anything a nurse does, whether it is positive/negative, appropriate/inappropriate, evidence based practice/not EBP would be considered nursing simply because it was done by a nurse.

    I hear people say that the difference is holism and caring, and while I understand where that comes from, I don't think that is fair for two reasons. One, I have many physician friends, and a few physician relatives. They are holistic and they care. The notions that only nurses are holistic and caring does not work for me. Two, I have observed many FNPs in their practice and those that are really busy, don't have the time to be as holistic or as caring as they would like, the same as physicians under a similar set of circumstances.

    The problem is not just external, it is internal: If nurses can't come to terms that NPs work under the medical model in terms of actions (does not matter what you call it) then that disconnect will cause them problems.

    So yes a test, doesn't have to be the one in the article, but a test that is designed to test medical knowledge is not only appropriate, but mandatory. NPs are going out into practice and working under the medical model. There is no getting around it. Nor should there be. I don't know any working NPs that sweat this nursing v medical stuff. I am not saying they are not out there, I just have not run across them. If there are NPs that are reading this that disagree, as an NP student I would love to hear your take on this. Specifically, how is NP practice not under the medical model?
  4. by   dgenthusiast
    Quote from ivanh3
    Good for her. If we strive for greater competency then why not be reimbursed for it? If you want to call it greed then go ahead, and there is some merit there, but I think that is too strong of a word. You are right. It was not the same test and not the same level, and that is why we move forward to improve ourselves, individually and collectively.
    You're not striving for greater competency with a DNP degree though. Have you seen the curricula for getting a DNP? It's really a joke. All you're doing is paying thousands of dollars to earn the title of "doctor" without and substantial knowledge gain. So, if you're not learning enough to be anywhere close to the physician level of training, why should you be reimbursed the same as physicians? Please answer that for me because I honestly can't think of any good reason why someone wants physician-level income without the physician-level training, especially with such a subpar DNP curricula.

    Striving for competency doesn't mean you should be compensated well. Just because I try hard doesn't mean I deserve money. I actually have to perform well and have the knowledge base/competency to get the results that will show I deserve the money. Getting gold stars for trying hard stopped after elementary school.
  5. by   dgenthusiast
    Quick question, if DNPs are interested in practicing medicine, how come they're regulated by the Board of Nursing and not Medicine?

    Basically, what the physicians' argument comes down to is that you don't learn enough in the DNP curricula for it to constitute the title of "doctor." And I don't think anyone who looks at the DNP curricula can make a valid argument as to how what they learn constitutes as clinical training and a substitute for medical school.
  6. by   ivanh3
    Quote from dgenthusiast
    You're not striving for greater competency with a DNP degree though. Have you seen the curricula for getting a DNP? It's really a joke. All you're doing is paying thousands of dollars to earn the title of "doctor" without and substantial knowledge gain. So, if you're not learning enough to be anywhere close to the physician level of training, why should you be reimbursed the same as physicians? Please answer that for me because I honestly can't think of any good reason why someone wants physician-level income without the physician-level training, especially with such a subpar DNP curricula.

    Striving for competency doesn't mean you should be compensated well. Just because I try hard doesn't mean I deserve money. I actually have to perform well and have the knowledge base/competency to get the results that will show I deserve the money. Getting gold stars for trying hard stopped after elementary school.
    First of all, since you have not read my posts in this thread, let me repeat: I am NOT for the DNP. However, because I don't agree with it doesn't mean there shouldn't be a discussion, and no I don't believe it is a joke. Who are you to judge how much of a gain one would get from DNP courses? Have you taken them? I mean what is your background in nursing? How did you come to this conclusion? The whole stars/elementary school thing is just foolish.

    Since you don't have the answer let me explain it to you. If a boarded, licensed NP performs a certain task and that task is done competently, skillfully, and with similar patient outcomes then why should that person get less than someone else simply because that someone else is a physician? If the NP has been trained to do any given skill fully, then they should be paid equally. If they have been trained to only perform something in a limited fashion then fine and there certainly plenty of examples for that, but there are many skills that an FNP can do that are done the exact same way with similar skill level and patient outcomes as a family/internal medicine physician. This holds true for physicians as well. They get paid a certain amount and when they refer to a specialist often that specialist gets paid more.
  7. by   yelnikmcwawa
    Quote from dgenthusiast
    dnp training is not even close to being similar to medical training; that's why there's an opposition to dnps wanting to be equivalent to physicians and asking for equal reimbursements. now, do you understand why there's an opposition to this?

    ps. i'm not saying that all dnps are like this. it's just that this vocal group has given all dnps a very bad name because of their propaganda. i've heard so many residents say that they will never hire dnps and will hire only pa's based off the words that mundinger, et al are saying.

    edit: also, yelnikmcwawa, please stop saying the only reason there's opposition to the dnp is due to a turf war. there's so much more to this opposition than that. read what ranier had to say. he/she made some very good points.

    edit2: also, everyone else is being offered clinical doctorates? what can you do with a clinical doctorate degree in english or philosophy, for example? or were you only referring to pharmacists, etc.
    where in any of my posts did you see me state that dnps should have, or should be able to claim that they have the equivalent training of physicians??? nowhere did i state that. i have only talked about my support of having doctoral level, clinical training, in nursing being available.

    and the clinical doctorates i am speaking about are for all the health care and/or mental health care providers out there...psychologists, physical, speech, and occupational therapists, pharmacists, etc. what do you mean by a "clinical doctorate in english"??? a doctorate in english is not a "clinical" degree...they are not providing therapeutic health care.

    if a physical therapist can get a clinical, doctorate degree, then why not nurses? a phd in nursing cannot prescribe, but a master's level np can...the training is drastically different and the end goal of both degrees is as well. you're telling me to read ranier's posts...i have, so please read my posts and stop putting words in my mouth.

    shame on any nurse for stating that a dnp degree is the same as medical degree. but a few bad apples who want to claim their education is different than what it really is, shouldn't take away the educational training that some wish to get. some want to practice clinical nursing in a doctoral capacity, and i think that there should be nursing degrees available to those people.
    (it's a turf war)
  8. by   dgenthusiast
    But what I don't get is if you want to practice medicine, why do you want a clinical nursing degree? PAs, for example, fall under the board of medicine. Why cannot NPs/DNPs? Ivanh3, my view of the DNP curricula being subpar is derived from the many nurses, physicians, residents, and NPs themselves who have told me this. However, it doesn't take a genius to compare the DNP curricula and the medical school curricula side-by-side (seriously, open them both up and see how many similar courses they take...it's a very low percentage) and see that they are not the same. This is why I don't understand how some DNPs can say that their training is equivalent to those of physicians and that they deserve equal reimbursement. This is what physicians/AMA are opposing: DNPs are not being trained equally as physicians, yet some are being vocal in insisting that they are equivalent. This is not just a mere turf war.
  9. by   ivanh3
    Quote from dgenthusiast
    But what I don't get is if you want to practice medicine, why do you want a clinical nursing degree? PAs, for example, fall under the board of medicine. Why cannot NPs/DNPs? Ivanh3, my view of the DNP curricula being subpar is derived from the many nurses, physicians, residents, and NPs themselves who have told me this. However, it doesn't take a genius to compare the DNP curricula and the medical school curricula side-by-side (seriously, open them both up and see how many similar courses they take...it's a very low percentage) and see that they are not the same. This is why I don't understand how some DNPs can say that their training is equivalent to those of physicians and that they deserve equal reimbursement. This is what physicians/AMA are opposing: DNPs are not being trained equally as physicians, yet some are being vocal in insisting that they are equivalent. This is not just a mere turf war.
    Again, what is your background? Just curious.

    Show me once, where any nursing official or body has claimed that NP training, DNP or otherwise, is equivocal to MD or DO training? Just one. Please don't paraphrase. Quote and cite it please. Again, as an NP student I am very curious about that. In all my research for school and for here, I have not come across that. Look up my posts on this subject, I have already beat it down that the training that MD receive is far more extensive than that of NPs and that I feel that NP training needs to be upgraded.

    And you are right I am no genius. But you are completely omitting/ignoring that the treatment that some patient's receive from an NP is IDENTICAL to the treatment that they get from an MD. These illnesses and treatments can range from the basic cough/cold to managing dyslipidemias, CVD, and diabetes. There are thousands of NPs that do this all day long. The assumption is that when the patient becomes too complex the provider (NP, MD, or DO) will refer/collaborate with a peer or specialist. So what is the problem as long as a) everyone refers when needed and b) assessments/treatments are performed competently and c) patient outcome are similar/same?

    Absolutely, the NP is far more like to refer at an earlier stage than an MD/DO, but what about up until that point?

    In terms of who should be called doctor? That is easy. Anyone who has earned a doctorate and decorum dictates or the individual with the doctorate desires it. Here is a great article about the subject (from another thread here) This article does seem to focus on PhDs and MDs.
  10. by   Ranier
    Quote from ivanh3

    Show me once, where any nursing official or body has claimed that NP training, DNP or otherwise, is equivocal to MD or DO training? Just one. Please don't paraphrase. Quote and cite it please. Again, as an NP student I am very curious about that. In all my research for school and for here, I have not come across that.

    http://online.wsj.com/public/article_print/SB120710036831882059.html
    More than 200 nursing schools have established or plan to launch doctorate of nursing practice programs to equip graduates with skills the schools say are equivalent to primary-care physicians. The two-year programs, including a one-year residency, create a "hybrid practitioner" with more skills, knowledge and training than a nurse practitioner with a master's degree, says Mary Mundinger, dean of New York's Columbia University School of Nursing. She says DNPs are being trained to have more focus than doctors on coordinating care among many specialists and health-care settings...


    http://www.forbes.com/2007/11/27/nurses-doctors-practice-oped-cx_mom_1128nurses.html
    DNPs are the ideal candidates to fill the primary-care void and deliver a new, more comprehensive brand of care that starts with but goes well beyond conventional medical practice. In addition to expert diagnosis and treatment, DNP training places an emphasis on preventive care, risk reduction and promoting good health practices. These clinicians are peerless prevention specialists and coordinators of complex care. In other words, as a patient, you get the medical knowledge of a physician, with the added skills of a nursing professional...
    ...To that end, we are working to enable DNPs to take standardized exams similar in content and format to the test that physicians must pass to earn their M.D. degrees. By allowing DNPs to take this test, the medical establishment will give patients definitive evidence that these skilled clinicians have the ability to provide comprehensive care indistinguishable from physicians...



    I think these are just a sampling of the kinds of comments that bother physicians. DNPs are "peerless" coordinators of care? Says who? I think most residency-trained primary care physicians would disagree. And to claim that DNPs have "all the medical knowledge of a physician" is absurd.
  11. by   dgenthusiast
    Quote from ivanh3
    again, what is your background? just curious.

    show me once, where any nursing official or body has claimed that np training, dnp or otherwise, is equivocal to md or do training? just one. please don't paraphrase. quote and cite it please. again, as an np student i am very curious about that. in all my research for school and for here, i have not come across that. look up my posts on this subject, i have already beat it down that the training that md receive is far more extensive than that of nps and that i feel that np training needs to be upgraded.

    and you are right i am no genius. but you are completely omitting/ignoring that the treatment that some patient's receive from an np is identical to the treatment that they get from an md. these illnesses and treatments can range from the basic cough/cold to managing dyslipidemias, cvd, and diabetes. there are thousands of nps that do this all day long. the assumption is that when the patient becomes too complex the provider (np, md, or do) will refer/collaborate with a peer or specialist. so what is the problem as long as a) everyone refers when needed and b) assessments/treatments are performed competently and c) patient outcome are similar/same?

    absolutely, the np is far more like to refer at an earlier stage than an md/do, but what about up until that point?

    in terms of who should be called doctor? that is easy. anyone who has earned a doctorate and decorum dictates or the individual with the doctorate desires it. here is a great article about the subject (from another thread here) this article does seem to focus on phds and mds.
    hey, i never said that you weren't a genius or anything like that. it wasn't my intention to offend, so if i did, i apologize. anyways, to your first part about no nursing official or body saying that dnp = md, here are some links to articles:

    http://www.forbes.com/2007/11/27/nur...128nurses.html

    a particularly nice quote by mary mundinger from this article is: "these clinicians are peerless prevention specialists and coordinators of complex care. in other words, as a patient, you get the medical knowledge of a physician, with the added skills of a nursing professional."

    seems like she is saying not only that dnp = md, but dnp > md with the physician + "added skills of a nursing professional."

    http://www.tafp.org/news/stories/09.02.13.1.asp

    an interesting quote from this one is: '“research supports nps out-perform physicians in these areas,” claims one of the cnap handouts.' the thing is, the studies done so far to test these outcomes have been flawed. so, how can you make a claim that something is true when the study is flawed? i'll give an example of a flawed study later on in my post.

    http://forums.studentdoctor.net/show...0&postcount=46

    this one's a link to another forum where a medical student emailed linda pearson of the pearson report and this is her response. so, i have provided some sources of nursing officials in important positions who have suggested that dnp = md.

    regarding studies done on outcomes, i haven't come across any studies that weren't badly designed that suggest nps have similar outcomes to physicians. if i missed any study that recently came out that was well-designed and showed that nps have just as good outcomes as physicians when managing complex patients, please direct me to the link. anyways, here's an example of an outcome study between nps and physicians and the results from the study (ps: i'm quoting core0 from the sdn forums regarding the assessment of the validity of the study since he explains it pretty well):

    http://jama.ama-assn.org/cgi/content...e2=tf_ipsecsha

    "results no significant differences were found in patients' health status (nurse practitioners vs physicians) at 6 months (p = .92). physiologic test results for patients with diabetes (p = .82) or asthma (p = .77) were not different. for patients with hypertension, the diastolic value was statistically significantly lower for nurse practitioner patients (82 vs 85 mm hg; p = .04). no significant differences were found in health services utilization after either 6 months or 1 year. there were no differences in satisfaction ratings following the initial appointment (p = .88 for overall satisfaction). satisfaction ratings at 6 months differed for 1 of 4 dimensions measured (provider attributes), with physicians rated higher (4.2 vs 4.1 on a scale where 5 = excellent; p = .05).

    i bolded the really important part. what this really means is that we didn't design the study properly to test for the attributes that we meant to test for. the we took a value that was meaningless and found that there was a statistical significance. this is a textbook example of how not to do a study. but wait there is more. if you look at the bottom of the paper they promise to come back and look in two years when you should be able to see equivalence or superiority. hmm i'm looking through my back issues of jama. hmm can't seem to find it. oh its published in that highly read journal medical care research and review. here is the abstract:
    http://mcr.sagepub.com/cgi/content/abstract/61/3/332

    what they are really saying is that we did not have enough follow up to have a meaningful study." - core0

    so, i provided you some sources of where i'm getting information from and i ask you to do the same; i also provided links to some articles that seem to suggest that dnp = md and provided an example of a badly done study that really proves nothing. please point me towards studies that are not badly designed that show similar outcomes between nps/dnps and physicians. i'm interested in your reply.

    edit: looks like ranier beat me by a bit heh.
  12. by   NurseDiane
    As a CRNA, I have lived the battle between physicians and nurses for 13 years. Never mind that nurses were the people who first administered anesthesia, and doctors caught on that anesthesia could be classified as a "specialty" and stepped in to be doctors in this area. Anesthesiologists are especially miffed with nurses at this point in time, because SO MANY anesthsia practices are hiring CRNA's as practitioners because we are much cheaper than an anesthesiologist is, and we do the exact same things. Shoot, in my opinion, if you are going to go on for higher education in nursing, why not go for something that increases your earning potential exponentially? NP's don't make s**t. I don't really know about Doctorates in Nursing----I have never really even heard of that. All I know is that doctors get their drawers in a knot when they feel threatened----if there was no threat, they couldn't care less. The problem is that doctors want to MAKE MONEY!! They feel that they will be reimbursed less money if there is someone else who can do their job and won't command the ridiculous amounts of money that the doctor wants and expects. If the docs weren't money hungry pigs then perhaps there wouldn't be such a "battle" between the initials. It all has to do with money............
  13. by   ivanh3
    dgenthusiast, I am starting to wonder why you evade the background question. Are you even a nurse? PA? Doctor? Medical student/intern/resident? Ranier, you too, whats your story? Not slamming you, it just helps to understand where you are coming from. You mentioned core0, a PA that posts here and brings a lot of valuable insight to this forum.

    Good finds and good points guys, but you missed my point, or rather I wasn't clear. I am speaking of the training. MD 4 years undergrad, heavy sciences/patho, 4 years medical school, 10000 hours plus training NOT including clinical time during medical school. Compared to NPs who receive 4 years undergrad, light sciences, 2 years masters (plus 2 years or so for DNP, but not mandatory now) with 1000 hours give/take all total including undergrad. I still don't see where anyone has made the claim that NPs receive the same training as MD.

    You guys are talking about patient outcomes, and there are plenty o' claims there. I am sure some of these studies are flawed as David (core0) has pointed out. That is almost statistically certain, eh? However, I am sure that not all of the studies are flawed. Here is one by the BMJ: http://www.bmj.com/cgi/content/full/324/7341/819

    That study was a meta analysis and it looks pretty thorough and included many studies. It seems to indicate that NPs compare okay with family/GPs. NPs are not being compared to surgeons, specialist, etc. Why is this so hard to believe? Hell, there are laypeople out there armed with only Google who can figure things out. How about this girl who just diangosed her own Crohn's?

    Look, clearly Dr Mundinger is enthusiastic about the profession and wants to bring it forward. I am not particulary happy that she is not making any friends with the physican groups, but as she her herself has pointed out this stuff is in development and like I said before (in bold in fact) to me this whole testing thing indicates that NP training needs to be upgraded since DNP (a degree I am not even for) students are not passing an easier version of the test. What is it that you guys are not getting from my posts? I don't think you are reading them entirely, which is possible because I tend to write lengthy posts.

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