Medicine decries nurse doctorate exam being touted as equal to physician testing - page 5

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  1. by   ivanh3
    Quote from 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............
    I considered the CRNA route, got my ICU time in started the school search, but then my son came along and I really didn't want to miss out on the first 3 years. I chose the FNP route instead. The money will be adequate, and quite frankly I love the patient interaction.

    I think you are right about the money. Here is a good read: http://www.huffingtonpost.com/dr-chr..._b_214318.html. I know, I know the Huffington post, liberal safehaven that it is, but there is truth in his letter.
  2. by   dgenthusiast
    Quote from 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.
    Ivanh3, if it really makes you feel better knowing where I'm coming from, fine. I'm a premedical student just about to graduate. This doesn't necessarily disqualify anything I've said so far. The reason I didn't mention this earlier was because I was pretty sure people will jump on this fact and disregard what I was saying.

    You mention that you're talking about training and not outcomes. However, how can one claim to have have the knowledge and skills of a profession without similar training? Wouldn't DNP = MD imply that the training is similar? If not, how can people claim they are equivalent? If the training is not similar, they aren't trained in the same things and thus, they cannot be the same. If I said I can play baseball at the level of an MLB athlete, did I do this by playing little league? No. It's implied that I trained similarly as an MLB athlete; otherwise, how can I claim to be as good as they are without any significant similarities in training? Do you see what I'm saying? By saying DNP = MD, Mundinger et al were implying that they have the same level of training as physicians do.

    Thanks for the link to the study. I don't have time currently to look at it, but I will do it as soon as I find some free time.

    Edit: You guys keep bringing up the money issue. There's no doubt money plays a role in why doctors are bothered by this, but it's not the only reason as some posts seem to imply. When doctors have spent a better part of a decade (at the minimum) receiving medical training and someone comes along with a significantly less amount of training and says they're equivalent, do you not agree that this would be annoying? This is especially true when NPs/DNPs are trying to set up private practices in order to practice independently. Can you understand why physicians would be miffed if someone with significantly less training is claiming to be equivalent to physicians and is taking potential patients (and thus reimbursement) away from physicians?

    Edit2: To say that Mundinger is enthusiastic to bring the profession forward is an understatement. It's pretty clear that she wants DNP to equal MD and that she wants DNPs to be reimbursed at the same rate as MDs. If anything, this bit sounds greedy rather than doctors trying to protect the borders of their profession. In the article posted in the original post, there was a quote by Mundinger who was saying that DNPs should be reimbursed at the same level of physicians if they can pass a watered-down Step III. This sounds pretty suspicious.
    Last edit by dgenthusiast on Jun 11, '09
  3. by   dgenthusiast
    Quote from ivanh3
    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
    actually, i just looked at the study quickly (i quickly skimmed through its important points but didn't spend a significant portion of time dissecting it) and it doesn't really look like that great of a study. since you mentioned that core0 was a highly respected member, i'll quote his assessment of this study as well since it's likely to be considered more highly coming from him rather than me (who's new to this forum):

    "...please don't forget the really awful article in bmj where they hopelessly mixed up nps (and rns) in the uk and the us who have completely different scopes of practice.
    http://www.bmj.com/cgi/content/full/324/7341/819" -core0 (http://forums.studentdoctor.net/showthread.php?t=472176)

    so you can't really say that's a well-designed study that shows similar outcomes between nps and physicians in the us if they confuse the scope of practice of nps in the us.
  4. by   Ranier
    I'm a nurse (ED) who is also the wife of an osteopathic physician (family practice). I'm also the daughter of an ICU nurse. I'm still in my 20's and considering whether to enter an APN program or apply to medical school in the next few years.
  5. by   NurseDiane
    Ranier---Why don't you consider going to a CRNA program? 3 years, money is great, lifestyle is great (after school is over, of course).

    I, personally, do not think that the current state of medicine would make any nurse want to go to medical school. I know that my malpractice insurance as a CRNA is astronomical----my GYN has quit delivering babies, as she is married to an interventional radiologist and their combined malpractice insurance was about $350,000, more than what they made, they would have had to take a loan out to pay it. By the time you get out of medical school, you are at least $200,000 in the hole, then you face trying to get started in a pratice, on call every other night (unless you do something like Emergency Medicine or Derm)....maybe some would want to do it to fulfill their altruistic dreams, but if you think you're going to be raking money in hand over fist, those days are over, and it is only going to get worse as time goes on.

    I'm sorry if I am trashing your dream----I don't mean to. If you want to go to med school, I wish you the best of luck. But, having been there, I think that nurse anesthesia is a great route to go is you want to go into advanced nursing practice. I suppose a lot of nurses go the NP route because they like the patient interaction. I enjoyed the CRNA route because I loved critical care, and it is the most challenging thing a nurse can do. You take care of one patient at a time, all the time. You have autonomy. You are respected. There are a TON of jobs now for CRNA's. And at the end of the day, I walk out of the OR and my job is done. When I was younger, I used to love the trauma, the cardiac surgery, the neurosurgery, big vascular cases.........now that I am old and gray, I prefer bread-and-butter cases, elective stuff with patients that aren't so sick. I paid my dues and had fun doing it---I just prefer to have my heart beating at a normal rate rather than being tachycardic while someone is bleeding out or herniating on the table!!! LOL!!! I make a great living, and I love it. I enjoy going to work every day (with the odd day that I work with the surgeon who plays symphony music at volume level 9 all day!!!), and the comraderie among surgeons, the anesthesia people and the OR nurses is great.

    So, essentially, this post has nothing to do with a doctorate in nursing degree/MD disagreement. LOL.
  6. by   83studentnurse
    A DNP is not an MD, and so I find the "DNP = MD" question ridiculous. It's not the same degree, and I don't think that should be the issue.

    The main question is, is a DNP qualified to function as a primary health care provider (like an MD)? The answer must be yes. PAs and NPs already function like MDs in primary health, so DNPs can too (in my state, an NP with her master's can even have her own practice!). Could a DNP be a neurosurgeon, like an MD? Of course not. We already have master's prepared nurses functioning as adult, acute care, pediatric, neonatal, etc. primary care health providers, and surely the doctorate-prepared nurse would be even more compentent.

    There are plenty of advantages to going to medical school (over the DNP route). However, I also imagine there are certain benefits to being a DNP. The main one is evidenced by my primary care provider, an NP who recently earned her DNP. She is the most competent PCP I have ever had and was able to diagnose something 3 doctors before her missed; just as important, she also had a nurses' bedside manner and took the time to explain and teach me what was going on. She's not an MD and may not have the same competencies as one, but she has a great wealth of knowledge, many years of experience and the kindest heart (though DNPs may not have as many clinical hours of training as MDs, she is a new DNP and has decades more experience than a new MD). In my particular experience, she has given me the best combination of her medical and nursing knowledge and skills. Of course, if I had a heart defect I would go to a cardiac surgeon, or if I had cancer I would go to an oncologist. However, if I might use a certified nurse midwife to deliver my baby.

    I guess what I'm trying to say is that health care providers some in so many shapes and specialties which require particular skill sets. So, if DNPs are qualified to perform the responsibilities given them, why debate if DNP = MD? MD from one program doesn't equal MD from another program and doesn't equal DO, either. There are vast differences between students/practionners, between programs and between degrees.

    The second issue is what you CALL DNPs. Yes, they are doctors -- they have terminal degrees in nursing, just as someone with a PhD in English has a terminal degree or a PharmD has a terminal degree. In an age where people can graduate at 24 with a doctorate in Audiology or Pharmacy (3 years undergrad + 3 grad school = doctorate, which I find a little proposterous), I don't think it makes sense to argue that a DNP hasn't earned the doctoral right. It's confusing for lay people, though, to hear "Dr. Smith," when the person's a DNP. The DNP has earned the title "doctor" and the right to practice in the same capacity as a PCP MD, but a DNP is not what a lay person thinks of as "Doctor." I think it's probably just as well to leave that up to individual hospital and healthcare practice policy, however, rather than trying to a one-size-fits-all answer, don't you think?
  7. by   ivanh3
    Quote from dgenthusiast
    Ivanh3, if it really makes you feel better knowing where I'm coming from, fine. I'm a premedical student just about to graduate. This doesn't necessarily disqualify anything I've said so far. The reason I didn't mention this earlier was because I was pretty sure people will jump on this fact and disregard what I was saying.
    I think it gives you a different perspective which is what all dialogues need. No worries. DG doesn't stand for Denver General does it?

    Quote from dgenthusiast
    You mention that you're talking about training and not outcomes. However, how can one claim to have have the knowledge and skills of a profession without similar training? Wouldn't DNP = MD imply that the training is similar? If not, how can people claim they are equivalent? If the training is not similar, they aren't trained in the same things and thus, they cannot be the same. If I said I can play baseball at the level of an MLB athlete, did I do this by playing little league? No. It's implied that I trained similarly as an MLB athlete; otherwise, how can I claim to be as good as they are without any significant similarities in training? Do you see what I'm saying? By saying DNP = MD, Mundinger et al were implying that they have the same level of training as physicians do.
    I understand why you might think that, but that is not what she is saying. She is saying that the outcomes will be similar. Again no one is saying the training is the same. Here is something for you to consider. As you are graduating with your pre-med degree, I assume you have take your med school pre-req classes which usually at least include one year of physics and one year of organic. You will then go on to med school where I have no doubt that you will learn much and do quite well. Now here I am going to make an assumption: that you have no professional medical background like nurse, emt, paramedic, RT. I could be wrong, just going with the odds. You will pass all of your tests and then you will show up on your first day of your internship. Now I have a lot of experience working around interns and residents. I have met some really sharp ones too. What I have also learned, and please this is anecdotal at best, is that it is not rare for interns and residents to be completely clueless. It turns out that mastery of knowledge regarding that carbon ring might not help you assess a patient when the time comes. Now, don't get me wrong, residents/interns are no more clueless than a new grad NP or PA, probably less so. That is the nature of being new, and my opinion is this: as it is true in so many other fields, true learning really starts on the job. This is not to say by any means that training counts for nothing. I think training is critical, but I can't help but wonder sometimes if the whole point of training is just to survive it and those that do make through really start to put it together during residency/post graduation. I have had this discussion with quite a few physicians. I have asked just how much of the details do you remember from med school, and the answer is overwhelming very little. Well, they remember the pain. This is exactly why people specialize. I am a PALS/ACLS instructor. When I have family practice physicians come through the class they can sometimes (not all the time) be kind of shaky. They are not dumb, it is just not what they do. My brother in law is a physician. There is a ton of stuff he doesn't know because it falls outside of his specialty.

    How can you explain a resident getting their butt saved by an experienced RN? Man, I have seen this dozens of times. I know in my heart that the resident went on to become a great MD, but experience counts.

    How does this apply NP/PA=MD? I firmly believe that as an FNP/PA begins to work they will learn the exact same things that physicians do. Remember, I am talking family practice here. Also for the record, I don't believe in independent NP practice until they have a certain amount of time under their belt. I would like to see a tiered system where independence is granted based on time/evidence of competency.

    I think the BMJ study is solid. Yeah the practice varies, but so does practice here in the US. Each state is different. I respect core0, but I don't always agree with him. Let me ask you this: are you saying all these studies are completely worthless, and that there is nothing to be learned from them? I don't buy that.

    Sure we keep bringing up the money. If we are doing the same thing why should we not get paid the same. Again (and again and again) we are talking about family practice. It is not like family practice MDs are raking in the dough either. Talk about jumping off of a sinking ship. When you get to med school, do a little informal poll and see how many of your peers are going to flock to family practice, then compare that to all of the recent studies. New physicians want to be specialists: there is more money, less paperwork, and it is more exciting. I have heard an MD say, "Last thing I want to do is deal with coughs/runny noses all day". It just simply comes to this: equal work, equal pay. How is that not fair if the work is competently done.

    So if you physicians are not going to do it, who is? Is there or is there not a shortage of family practice providers right now? My primary provider is a DO who also has a PA in the office. If it is a non emergency, routine kind of thing I am looking at 4 weeks plus for an appointment. Now, if I am sick, he gets me in within a day or two, but still, a month?

    In any case, all of your points are valid and need to be discussed, but I think you are missing the point in that midlevels are trying to elevate their status because there is good evidence that indicates we do well where we are properly trained and have experience.

    Ivan
  8. by   ivanh3
    Quote from Ranier
    I'm a nurse (ED) who is also the wife of an osteopathic physician (family practice). I'm also the daughter of an ICU nurse. I'm still in my 20's and considering whether to enter an APN program or apply to medical school in the next few years.
    My wife is an ER nurse, and I was an ER nurse. There is a lot of thought that goes into that question. Getting into school, getting accepted into a residency, will that require a move, etc. I know of at least one husband/wife family practice team where there is an MD with an NP. Either way, I am sure you will do well.
  9. by   dgenthusiast
    Quote from 83studentnurse
    ...The main question is, is a DNP qualified to function as a primary health care provider (like an MD)? The answer must be yes. PAs and NPs already function like MDs in primary health, so DNPs can too (in my state, an NP with her master's can even have her own practice!). Could a DNP be a neurosurgeon, like an MD? Of course not. We already have master's prepared nurses functioning as adult, acute care, pediatric, neonatal, etc. primary care health providers, and surely the doctorate-prepared nurse would be even more compentent.

    I guess what I'm trying to say is that health care providers some in so many shapes and specialties which require particular skill sets. So, if DNPs are qualified to perform the responsibilities given them, why debate if DNP = MD? MD from one program doesn't equal MD from another program and doesn't equal DO, either. There are vast differences between students/practionners, between programs and between degrees...
    Regarding the first bolded point, have you looked at the DNP curricula? How do classes such as "Affecting Change through Effective Communication," "The Leader and Policy, Politics, Power and Ethics," etc, make you more competent at managing disease? This is from Rush University's curricula (http://www.rushu.rush.edu/servlet/Sa...entBlockDetail). How can you become more competent at diagnosing and managing complex patients when so much of the curricula consists of "fluff" courses? What's the point of having the DNP? Based on looking at various different DNP programs and their curricula, it appears as just degree inflation and that the programs are making money off of nursing professionals who want a doctorate degree.

    Regarding the second bolded part, that's just not true. The medical school curricula is pretty similar for all MD and DO schools accredited by the LCME. An MD from one program equals and MD from another program equals a DO. Sure, there may be some elitists out there who might've gone to an Ivy League and feel other schools are inferior, etc., but this is not as prevalent as you seem to suggest. Once again, MD and DO schools accredited by the LCME teach pretty much the same things (DO's do have OMM that MD's don't learn; this is the only difference) and produce similar quality physicians. LCME accreditation assures quality training. Can you say the same for the various DNP programs (including the ones that offer online training)? I'm not trying to attack or offend; I'm just pointing out that even the curricula between different DNP programs does not appear to be standardized.

    Quote from ivanh3
    I think it gives you a different perspective which is what all dialogues need. No worries. DG doesn't stand for Denver General does it?

    I understand why you might think that, but that is not what she is saying. She is saying that the outcomes will be similar. Again no one is saying the training is the same. Here is something for you to consider. As you are graduating with your pre-med degree, I assume you have take your med school pre-req classes which usually at least include one year of physics and one year of organic. You will then go on to med school where I have no doubt that you will learn much and do quite well. Now here I am going to make an assumption: that you have no professional medical background like nurse, emt, paramedic, RT. I could be wrong, just going with the odds. You will pass all of your tests and then you will show up on your first day of your internship. Now I have a lot of experience working around interns and residents. I have met some really sharp ones too. What I have also learned, and please this is anecdotal at best, is that it is not rare for interns and residents to be completely clueless. It turns out that mastery of knowledge regarding that carbon ring might not help you assess a patient when the time comes. Now, don't get me wrong, residents/interns are no more clueless than a new grad NP or PA, probably less so. That is the nature of being new, and my opinion is this: as it is true in so many other fields, true learning really starts on the job. This is not to say by any means that training counts for nothing. I think training is critical, but I can't help but wonder sometimes if the whole point of training is just to survive it and those that do make through really start to put it together during residency/post graduation. I have had this discussion with quite a few physicians. I have asked just how much of the details do you remember from med school, and the answer is overwhelming very little. Well, they remember the pain. This is exactly why people specialize. I am a PALS/ACLS instructor. When I have family practice physicians come through the class they can sometimes (not all the time) be kind of shaky. They are not dumb, it is just not what they do. My brother in law is a physician. There is a ton of stuff he doesn't know because it falls outside of his specialty.

    How can you explain a resident getting their butt saved by an experienced RN? Man, I have seen this dozens of times. I know in my heart that the resident went on to become a great MD, but experience counts.

    How does this apply NP/PA=MD? I firmly believe that as an FNP/PA begins to work they will learn the exact same things that physicians do. Remember, I am talking family practice here. Also for the record, I don't believe in independent NP practice until they have a certain amount of time under their belt. I would like to see a tiered system where independence is granted based on time/evidence of competency.

    I think the BMJ study is solid. Yeah the practice varies, but so does practice here in the US. Each state is different. I respect core0, but I don't always agree with him. Let me ask you this: are you saying all these studies are completely worthless, and that there is nothing to be learned from them? I don't buy that.

    Sure we keep bringing up the money. If we are doing the same thing why should we not get paid the same. Again (and again and again) we are talking about family practice. It is not like family practice MDs are raking in the dough either. Talk about jumping off of a sinking ship. When you get to med school, do a little informal poll and see how many of your peers are going to flock to family practice, then compare that to all of the recent studies. New physicians want to be specialists: there is more money, less paperwork, and it is more exciting. I have heard an MD say, "Last thing I want to do is deal with coughs/runny noses all day". It just simply comes to this: equal work, equal pay. How is that not fair if the work is competently done.

    So if you physicians are not going to do it, who is? Is there or is there not a shortage of family practice providers right now? My primary provider is a DO who also has a PA in the office. If it is a non emergency, routine kind of thing I am looking at 4 weeks plus for an appointment. Now, if I am sick, he gets me in within a day or two, but still, a month?

    In any case, all of your points are valid and need to be discussed, but I think you are missing the point in that midlevels are trying to elevate their status because there is good evidence that indicates we do well where we are properly trained and have experience.

    Ivan
    Ivan, actually the dg stands for disc golf. It's like real golf but played with a type of frisbee. It's relaxing and lots of fun, but also much cheaper than ball golf.

    About your point regarding NPs/PAs who have been in a department for a while helping new interns learn, that's absolutely true. But the interns learn as they proceed through residency and become attendings. I don't think, for the most part, anyone can say that NPs/PAs have the same knowledge base as a full-fledged attending (within the same specialty, that is). Of course, there might be an exception here and there, but the exception is not the rule. Regarding attendings not remembering much from medical school, that makes sense because for years after medical school, they've been focusing on their particular specialty. I don't think they'd forget much about the stuff they learned in medical school regarding their particular specialty (ie. I've talked to several neurologists who emphasize the importance of their neuroscience and neuroanatomy, especially neuroanatomy, courses from medical school). In my own experience, for example, I've become so used to upper level calculus, etc. that basic math/algebra from high school takes me longer to do than integral calculus; but that doesn't mean I can't do the basics and that I don't remember the concepts of trigonometry, etc. While there is a ton of memorization in the basic sciences, there are also a lot of concepts. Most may forget the details after they become attendings, but concepts tend to stick around for a long time. Does this make sense? It makes sense to me but I might be explaining it wrong.

    About the money aspect. You're right that family practioners make a significantly less amount of money than specialists. Wouldn't flooding the markets with NPs/DNPs who are practicing independently hurt these FPs even more (due to having to compete for patients)? Wouldn't this drive medical students away from FP even more, leading to an even greater PCP shortage? This has definitely been a concern for residents and attendings I've talked to. Another big worry that a lot of medical students, residents, and attendings have is if physicians gave leeway and allowed NPs/DNPs to become PCPs, whose to say they won't push for specialties as well? Would DNPs be content with just primary care or will there be a new Mundinger to push forth the movement towards becoming specialists as well? The specialties do offer more money and a better lifestyle as you yourself have mentioned. Once DNPs establish themselves in primary care, what's the guarantee they won't go after specialties in an effort to "further their education"? Would primary care just be the stepping stone to specialties? This is one of the biggest things residents I've talked to are worried about. For example, CRNAs wanting to practice pain medicine. According to http://www.asahq.org/Newsletters/200...Beat02-08.html, CRNAs wanted to be able to practice interventional pain management (which is usually a fellowship, if I recall correctly) after a "curricula of two weekend courses." I realize that this doesn't really have anything to do with NPs/DNPs right now, but who's to say they won't be pushing to practice as specialists once they've established themselves in primary care? That's a big thing scaring many medical students, residents, and attendings; that primary care would be used as a stepping stone into specialties. And you have to admit, it makes sense for physicians to feel threatened when the future is uncertain.

    Also, if DNPs want to be reimbursed at the same rate as physicians and if they also refer to specialists more often, wouldn't that actually increase health care costs rather than decrease? You didn't seem to mention this, but I was wondering what your thoughts are on this. And I know I've mentioned the DNP curricula several times, so I apologize if it's annoying to read the same thing again and again, but how does what the DNP programs currently teach benefit the diagnosis/management of patients? How does it make an NP more competent in a clinical setting to learn nursing theory?

    Edit: Regarding my statement about NPs/DNPs using primary care as a stepping stone to specialties, I found an article about an NP performing colonoscopies: http://www.endonurse.com/articles/6c1feat3.html. Ivan, you mentioned that NPs/DNPs want to help out only in primary care; I'd like to hear your opinion on things like this since colonoscopies are generally within the scope gastroenterologists and not really PCPs.
    Last edit by dgenthusiast on Jun 12, '09
  10. by   ivanh3
    Quote from dgenthusiast
    About your point regarding NPs/PAs who have been in a department for a while helping new interns learn, that's absolutely true. But the interns learn as they proceed through residency and become attendings. I don't think, for the most part, anyone can say that NPs/PAs have the same knowledge base as a full-fledged attending (within the same specialty, that is).
    Actually, I do believe this if the NP/PA has been doing it long enough. If they are treating the same patients often side by side with a physician, going to the same seminars, staying current on the literature/science, why would you expect otherwise?
    Quote from dgenthusiast
    Regarding attendings not remembering much from medical school, that makes sense because for years after medical school, they've been focusing on their particular specialty. I don't think they'd forget much about the stuff they learned in medical school regarding their particular specialty (ie. I've talked to several neurologists who emphasize the importance of their neuroscience and neuroanatomy, especially neuroanatomy, courses from medical school).
    I agree completely with that.
    Quote from dgenthusiast
    About the money aspect. You're right that family practitioners make a significantly less amount of money than specialists. Wouldn't flooding the markets with NPs/DNPs who are practicing independently hurt these FPs even more (due to having to compete for patients)? Wouldn't this drive medical students away from FP even more, leading to an even greater PCP shortage? This has definitely been a concern for residents and attendings I've talked to. Another big worry that a lot of medical students, residents, and attendings have is if physicians gave leeway and allowed NPs/DNPs to become PCPs, whose to say they won't push for specialties as well?
    NPs already are PCPs. I don't have a problem with midlevels functioning as specialists if and only if they can demonstrate competence. Also, when was the last time you were in a waiting room at a primary care office? Maybe it is just here in the Atlanta area, but there is plenty of work to go around in terms of primary care. It is more like the patients are competing for providers. Also, you do not have to keep saying DNP. The DNP does not add to the scope of an NP. Most NPs are not DNPs.
    Quote from dgenthusiast
    Would DNPs be content with just primary care or will there be a new Mundinger to push forth the movement towards becoming specialists as well? The specialties do offer more money and a better lifestyle as you yourself have mentioned. Once DNPs establish themselves in primary care, what's the guarantee they won't go after specialties in an effort to "further their education"? Would primary care just be the stepping stone to specialties? This is one of the biggest things residents I've talked to are worried about.
    It does sound like a slippery slope, and my response would be as above. If the midlevel can demonstrate competence then why not? The example of the GI NP is a good one. She does 600 colonoscopies a year. I don't recall if the article compared her competency in that procedure to that of a physican, but clearly she has demonstrated some skill.
    Quote from dgenthusiast
    Also, if DNPs want to be reimbursed at the same rate as physicians and if they also refer to specialists more often, wouldn't that actually increase health care costs rather than decrease?
    Only in the scenario that a family doc might not have sent that same patient to a specialist, and while I am sure that happens, I don't think it would be the norm, but I have nothing to back that up.
    Quote from dgenthusiast
    You didn't seem to mention this, but I was wondering what your thoughts are on this. And I know I've mentioned the DNP curricula several times, so I apologize if it's annoying to read the same thing again and again, but how does what the DNP programs currently teach benefit the diagnosis/management of patients? How does it make an NP more competent in a clinical setting to learn nursing theory?
    I am not the biggest fan of nursing theory, that is also a matter of record for me here on this site. Having said that, I do believe that learning promotes learning, and I don't see the harm in additional training of any kind. Again, for myself, I am not for the DNP. I say teach more at the masters level and just have the PhD.
    Quote from dgenthusiast
    Regarding my statement about NPs/DNPs using primary care as a stepping stone to specialties, I found an article about an NP performing colonoscopies: http://www.endonurse.com/articles/6c1feat3.html. Ivan, you mentioned that NPs/DNPs want to help out only in primary care; I'd like to hear your opinion on things like this since colonoscopies are generally within the scope gastroenterologists and not really PCPs.
    I addressed this article above, but I will add this: she is not working entirely independently (which is good). She is required to have physician back up. I am assuming that under normal circumstance a GI MD does not have this requirement.
    Last edit by ivanh3 on Jun 12, '09
  11. by   Therapist4Chnge
    Quote from Ranier
    Let's stop inventing these 40-credit/ online/ part-time/ direct-entry/ fluff-filled/ no-research "doctorates" that pale in comparison to the rigor of a PhD and then play victim when the rest of the medical world fails to respect it.
    Agreed.

    A doctoral degree (in any field) is meant to be a capstone experience that encompasses a body of work representative of the highest level of learning....not a part-time, online, fluff-filled degree. The person becomes an expert in their area of study....how is this possible in a DNP program when the training is so loosely organized?

    People have argued that it is a "clinical" degree....how? If the goal is to be a clinically based degree, why pad the curriculum with classes in "leadership" and "management"? There is nothing cohesive about the training, instead the curriculums are strung together classes with the promise of a doctorate.....in name only. Frankly, it is insulting to other doctoral level people because we have pushed through 6..7..8 years of FULL-TIME study to EARN our degrees, which cannot be had in a couple of years of part-time work.

    What need does a DNP meet? Management skills....there is an MBA (or MPH) for that. Research.....they have Ph.Ds for that. Advanced clinical training...they have NP/FNP/etc. programs. Degree creep, plain and simple.

    If people are serious about the NDP being about advanced training....make a curriculum that reflects that. Include intensive rotations. Require real classes. Put together a program that matches the rigors of other doctoral programs. In the current format it isn't even on par with a masters program, which is a disservice to the students.

    As for Ms. Mundinger....she is really doing a disservice to nursing by pushing her own political agenda. Nursing is a vital part of the healthcare system and trying to push through the DNP hurts every nurse (particularly NPs, etc) by adding another tier....bogus or not.
  12. by   NurseDiane
    LMAO--Isn't that what a lot of nurses "aspire" to? "TIERS"!?!?!? Nurse manager, assistant nurse manager, charge nurse, director of nursing, assistant director of nursing, assistant to the assistant director of nursing, RN level 1, RN level 2, RN level 3........

    The way nursing has "materialized" over the years ENCOURAGES these "tiers". What used to be a minimal management system has now become flooded with mid-level managers who like to think they are upper-level management, with more letters after their names. That is how I am seeing this DNP thing. If you want to get a PhD, then go through the rigors of getting it-- get your masters and then go on for a REAL PhD. Or not. I went and became a CRNA and I can GUARANTEE you that was as rigorous as any doctoral program and training around, even though it is only a master's degree.

    It seems to me that maybe this DNP program will get nurses into a Director of Nursing chair faster than if they actually had to go through the actual master's and then PhD training, with it's difficult schooling, even though they are saying that is for advanced "clinical" practice nurses. (I honestly don't know much about it, to tell you the truth, but it sounds silly.) And, LOL, I just looked it up a little bit, and found out that CRNA's programs will be DNP programs in a few years........:chuckle

    So, here's my new theory. Colleges are adding on additional years for advance practice nurses to get a couple more years of grad school tuition, at $600 per credit hour. Because there is absolutely no reason why this is necessary---I couldn't care less if I have a master's or doctorate to practice anesthesia. Adding on another year is not going to improve a CRNA's performance, and getting a couple more "letters" after my name won't improve my practice either. I suspect it is the same in other advanced practice areas as well.

    But, those nurses who are fixated on getting as many "letters" after their names will most certainly LOOOOOOOOVE this DNP stuff.
  13. by   AFbm87
    i apologize for stepping on any toes here but i have followed this discussion for some time and feel obligated to offer a different perspective. i will be beginning (already completed prereqs) nursing school (bsn) this fall and have a lot of interest in this subject because i aspire to venture into family practice one day. after completion of nursing school i plan on taking some additional pre-med classes and apply for med school (please no flaming). many people would criticize this plan by telling me that i am wasting my time going to nursing school if i want to be a doctor. i don’t feel that way. one of the reasons that i selected nursing was because it was flexible enough to accommodate my current lifestyle. i researched nursing practice enough to know what it (rn) encompasses and will be very proud the day that i can call myself a nurse. however, i really want to gain the knowledge that the md curriculum offers. currently i do not see that offered with the np or dnp program. i see that they are very rigorous in their own right but not comparable to an md or do program. i have heavily considered the np route and my only reservation is that i will not have training that an md does. i would love to see more studies demonstrating how mid-levels such as pas and nps compare to an md in competence and quality. i do not desire to do any more than family practice but i would like to know all that i can. that is why i was so intrigued at the idea of the dnp. increased clinical knowledge that would expand on what a np already knows sounded very promising, until hearing about the curriculum. i know that i am going into the nursing field with an interest the areas that apply to the study of medicine. however, i feel that many people enter nursing for a variety of reasons and that nursing offers more flexibility than many other healthcare opportunities; which is why many choose nursing. i have spent a lot of time with many different nurses (my mentor is a fnp working on a dnp currently teaching at a university) and each had their own motives for choosing nursing. most centered on patient care but many because of the great variety of career options that are available to nurses. i feel that the nursing practice has grown to encompass more than what some limit the title "nurse" to be. i see nurses as extremely valuable medical professionals that should not be limited to only traditional roles and a rigid limitation on their scope of practice. i am not so concerned with the various titles to pin onto a name but more the knowledge that i could acquire over time that would allow me to be the best pcp that i could be.
    Last edit by AFbm87 on Jun 21, '09

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