Op-ED: Practicing Medicine vs Practicing Advanced Nursing

myoglobin, ASN, BSN, MSN · Dec 1, 2020

My problem with this article is that a "reasonable person" would read it and conclude that NP's should not have IP disregarding the fact that they have been practicing this way safely in more than 20 states for in some cases decades. Thus, although the words seem "nice" in tone the agenda reflects that of the AMA and their political allies.

It would also assert that most of the studies that have been done in a primary care setting indicate that NP's (mainly FNP's) achieve equal or superior outcome(s) https://www.AANP.org/advocacy/advocacy-resource/position-statements/quality-of-nurse-practitioner-practice thus begging the question if MD's should perhaps be trained more in a holistic, NP approach. I would not go so far as to require MD's to obtain their RN first or to operate under NP supervision (no doubt MD's are a valuable part of the health care team). What is without question is that NP's increase access for many who would otherwise not be able to afford access to primary care (like myself I am someone without insurance who uses an excellent fee for service NP on those occasions when the need presents). That having been said it is always optimal to increase our diagnostic abilities and to refer on those patients where more specialized MD care is more appropriate. It is also worthwhile to point out that expert systems and AI can further improve diagnostic abilities both for MD's and NP's https://www.thedailybeast.com/the-ai-doctor-will-see-you-now .

Rnis, BSN, DNP, APRN, NP · Dec 3, 2020

My initial thought reading the article is ........yawn. This is just the same turf war that has been going on for ages. I find it very hard to believe that she wasn't taught to make differential diagnoses or wasn't able to recognize what she doesn't know as a NP. We need to learn to work as team to make our healthcare system work..............but I don't really want to be on her team: ) why she talks about how inadequate she personally was as a NP (which I won't refute), she doesn't address the hundreds of studies that actually support NP/PAs providing quality care.

If this pandemic has taught us nothing.....the one thing we should walk away with is an appreciation for data/science. So often we got off course on the treatment of patients with this virus , jumping the gun with anecdotal evidence /reports but much of that was not born out in the data. I think this opinion piece, while part of the same propaganda strategy that has been in place........ does not reflect well on writer as a professional.

Neuro Guy NP, DNP, PhD, APRN · Dec 3, 2020

The article is click bait.

I'm not sure where they figure we don't learn anything about differential diagnosis. At the end if the day, we're not going to change everyone's minds so we have to stop thinking that way. There will always be MDs who prefer PAs, MDs who prefer NPs, and MDs who micromanage the NP/PA staff in states and practice settings that require supervision. As a profession, we have to vote with our feet - I.e leave practice settings or states that do not recognize the value that we bring. If a practice setting treats an NP like a secretary, the NP should leave! This is the most effective signal.

1 minute ago, Rnis said:

My initial thought reading the article is ........yawn. This is just the same turf war that has been going on for ages. I find it very hard to believe that she wasn't taught to make differential diagnoses or wasn't able to recognize what she doesn't know as a NP. We need to learn to work as team to make our healthcare system work..............but I don't really want to be on her team: ) why she talks about how inadequate she personally was as a NP (which I won't refute), she doesn't address the hundreds of studies that actually support NP/PAs providing quality care.

If this pandemic has taught us nothing.....the one thing we should walk away with is an appreciation for data/science. So often we got off course on the treatment of patients with this virus , jumping the gun with anecdotal evidence /reports but much of that was not born out in the data. I think this opinion piece, while part of the same propaganda strategy that has been in place........ does not reflect well on writer as a professional.

Correct. The article was pure anecdote. We also don't have any evidence that she's any more effective as a physician either. I'm willing to bet researching these two individuals might reveal something interesting, but it isn't worth the time.

FullGlass, BSN, MSN, NP · Dec 8, 2020

Dr. Rebekah Bernard really has an axe to grind against NPs and she has been at this for years. I am beginning to think her husband ran off with an NP or something.

This is an opinion piece and a poor one, at that. No evidence is provided to support the viewpoint, just anecdotes.

I don't know where the NP in the article went to school, but every NP I know does indeed know how to develop a list of differential diagnoses - we were taught this in school. So the assertion that NPs don't know how to form such a list is blatantly false.

As others have stated, there is overwhelming evidence that NPs provide good quality care. Furthermore, NPs are here to stay and so is independent practice, with half of states and the Veterans Administration granting that.

TheMoonisMyLantern, ADN, LPN, RN · Dec 11, 2020

Have there been any fresh studies on NP efficacy since the rise of online only for profit schools with the only admission standard of having a pulse?

myoglobin, ASN, BSN, MSN · Dec 11, 2020

I doubt there have and would be optimal to have ongoing studies. However, I do see a reason to disparage one online school verses another. The school that I went to The University of Southern Indiana was online (except clinical) and who is to say that it is better or worse than another school? Should standards be raised? Perhaps, but so long as the schools that exist are playing by the rules (and the students attending them are doing their best to do the same) then the emphasis should be on getting the best education from whatever school you attend, and maximizing your knowledge base before, during and after school. Medical schools are not exempt from these issues. For example one school located outside of the United States provides among the largest number of residencies in the United States. Indeed, here in Florida (where I reside) eight of the ten MD's that I contacted about my medical rotation had gone to that very medical school https://www.sgu.edu/blog/medical/sgu-residency-placement-facts/ .

Also, none of the above (or your comment) addresses that the allegations in the original post are presented without factual basis and are clearly presented with a negative agenda towards NP's. If NP's cannot get a "positive spin" on a site designed, paid for and utilized mostly by RN's then where can we?

TheMoonisMyLantern, ADN, LPN, RN · Dec 13, 2020

On 12/11/2020 at 11:07 AM, myoglobin said:

I doubt there have and would be optimal to have ongoing studies. However, I do see a reason to disparage one online school verses another. The school that I went to The University of Southern Indiana was online (except clinical) and who is to say that it is better or worse than another school? Should standards be raised? Perhaps, but so long as the schools that exist are playing by the rules (and the students attending them are doing their best to do the same) then the emphasis should be on getting the best education from whatever school you attend, and maximizing your knowledge base before, during and after school. Medical schools are not exempt from these issues. For example one school located outside of the United States provides among the largest number of residencies in the United States. Indeed, here in Florida (where I reside) eight of the ten MD's that I contacted about my medical rotation had gone to that very medical school https://www.sgu.edu/blog/medical/sgu-residency-placement-facts/ .

Also, none of the above (or your comment) addresses that the allegations in the original post are presented without factual basis and are clearly presented with a negative agenda towards NP's. If NP's cannot get a "positive spin" on a site designed, paid for and utilized mostly by RN's then where can we?

Hiring companies are starting to be the ones deciding that some online schools are not providing an adequate education needed for nurses to become providers. People have posted on this forum for a couple years now how graduates from schools like Walden are starting to be passed over for graduates from brick and mortar schools because they've had negative experiences with graduates from online for profit schools. I'm not saying that ALL graduates from those types of schools are unprepared because obviously you get what you put into your education. What I'm saying is that we should not be paying a college to teach ourselves how to become an NP. I believe online education has its place but NOT in its current iteration. If you believe that a Walden education is on par in regards to rigor and scope with your lowest ranked PA program, you're delusional (that's a generalized "you" not you specifically, Myoglobin). If nurse practitioners want to be able to continue to independently practice and gain IP status nationally, then their standards for education for entry into practice must reflect that desire. What these for profit online schools are doing is CRIMINAL. They're charging students an inflated tuition price for a medium that is essentially self study. If all you have to do is read a textbook and write a few papers to become an NP why not get rid of the middleman (the school) and let the BON hand out NP licenses if you pay the right price and read the right textbook. C'mon we both know there's a lot more to being a provider than what a textbook teaches. Most nurses know that, they know that much of what you learn requires hands on experience, oh wait, that's right NP schools don't require nursing experience prior to admission anymore so not all of those nurses have ANY real world experience and don't know what they don't know. Yes, I realize there's a big difference between being a staff nurse and a provider however bedside nursing experience is invaluable in many ways.

I sound like I don't like NP's. But the exact opposite is true. I am a HUGE supporter of NP's and PA's but especially NP's. I have two NP's that I see regularly for my own care. But I think NP education has gone down the wrong path in many ways. Lack of rigor, lack of admission reqs, lack of required nursing experience, lack of clinical placements, all being significant problems. We can hide behind studies that are quickly becoming dated, or we can acknowledge that NP education needs to be enhanced, because if that doesn't happen and NP's begin to harm patients and become a liability to their employers then you can say goodbye to IP and big salaries and hello to being a laughing stock in the medical community so much so some NP's may have to go back to being staff nurses, or in some case be a staff nurse for the first time.

myoglobin, ASN, BSN, MSN · Dec 13, 2020

OK, but the schools that exist are playing by the rules that exist. If you do not like them then lobby to change them (ie lobby to increase requirements). However, this is something that will happen (if all all) years in the future. Also, all current licensed practitioners will be grandfathered in to practice (including those from for profit schools). Also, as a graduate of an online program (The University of Southern Indiana). I had no problems finding a job (I was about 50% with interviews offering me a job). Then again I basically work for myself now (1099, the company provides bookings and bills insurance and provides some support services). This is just fine by me given that as a first year graduate I'm earning at least 25K each month now and will soon be earning over 30K per month seeing clients four days per week (even after paying 30% of my income and a $600.00 per month fee). Still, I believe there is room for improvement. In an "ideal" world I would have liked an additional two semesters focused maybe almost exclusively on therapy. Still, I can obtain that as a graduate. One CBT (post grad) program that I looked at takes about 18months and a DBT and EMDR credentialing program that I also investigated each take about an additional year. Honestly, at this point if I went back to school it would be for a PhD in nursing, but I will probably instead focus on creating a regional (perhaps eventually national) company that seeks to pay NP's (and therapists) about 75% (no fees with the ability to purchase health insurance through the company at the best discounted rates that I can achieve). and provide integrated, and holistic care to patients in those states that facilitate IP.

TheMoonisMyLantern, ADN, LPN, RN · Dec 13, 2020

5 hours ago, myoglobin said:

OK, but the schools that exist are playing by the rules that exist. If you do not like them then lobby to change them (ie lobby to increase requirements). However, this is something that will happen (if all all) years in the future. Also, all current licensed practitioners will be grandfathered in to practice (including those from for profit schools). Also, as a graduate of an online program (The University of Southern Indiana). I had no problems finding a job (I was about 50% with interviews offering me a job). Then again I basically work for myself now (1099, the company provides bookings and bills insurance and provides some support services). This is just fine by me given that as a first year graduate I'm earning at least 25K each month now and will soon be earning over 30K per month seeing clients four days per week (even after paying 30% of my income and a $600.00 per month fee). Still, I believe there is room for improvement. In an "ideal" world I would have liked an additional two semesters focused maybe almost exclusively on therapy. Still, I can obtain that as a graduate. One CBT (post grad) program that I looked at takes about 18months and a DBT and EMDR credentialing program that I also investigated each take about an additional year. Honestly, at this point if I went back to school it would be for a PhD in nursing, but I will probably instead focus on creating a regional (perhaps eventually national) company that seeks to pay NP's (and therapists) about 75% (no fees with the ability to purchase health insurance through the company at the best discounted rates that I can achieve). and provide integrated, and holistic care to patients in those states that facilitate IP.

I'm glad you didn't have a problem finding a job out of NP school, but there are many new grad NP's who are struggling to find work in large part due to online schools churning out NP's by the truckload many of which have fewer 5 years of nursing experience, have no desire to work primary care in rural or underserved areas or want to specialize straight out of school. And while those things may be achievable and even appropriate for a SMALL percentage of new grads, when it becomes the expectation for the MAJORITY that's a red flag. Now, PMHNP's are doing exceptionally well and in heavy demand currently. However everyone and his mother wants to become one even without having ANY experience in psychiatric nursing prior to assuming that role. I'm sorry but I am skeptical that an online education and 500 clinical hours are enough to prepare someone with no hands on experience with Acute or community psych to be a safe and competent at assessing, diagnosing, and prescribing psychotropics for MOST people that have no psychiatry experience. Sure psych is everywhere, but dealing with a psych patient in an ICU is much different than dealing with a patient in a psychiatric intensive treatment unit. I've worked with NP's that had a medical background instead of psychiatric, and on the inpatient side of things they made mistakes that a 1st year psychiatry resident would make such as being manipulated by patients to prescribe controlled substances, being unable to skillfully deescalate patients and even in some cases escalating a patient's behavior, being unable to adequately control violent behavior through pharmacological interventions, being unable to differentiate presentations of various personality disorders versus mood disorders, etc. Yes my experience is anecdotal and I know it doesn't speak for all providers but it certainly has made me critical of the current state of NP education. And yes I realize that with experience and continuing education that learning curve can be overcome but what are we paying schools for if that is what makes a good provider.

myoglobin, ASN, BSN, MSN · Dec 13, 2020

My point there is no current legal remedy as the schools that exist abide by the laws that exist. Any endeavor to change those rules will be years in the making. Also, the students attending those schools are in most cases doing the best they can with the tools afforded them to maximize their situation and education. Thus the emphasis should be maximizing your personal education and opportunity rather than denigrating NP’s. What advice would you offer the recent graduate from a for profit school? Should they burn their degree or maximize their education and go to an IP state and join me in earning over 200k per year? Also, I’ve personally seen MD psychiatrists with many years experience make some of the errors you allege. Even my own preceptor (an MD psychiatrist) and his co psychiatrists started benzo’s like they were candy (and benzo like drugs such as Restoril, estazolam) for insomnia rather than using CBTi and less harmful alternatives like Trazodone. In my experience NP’s are less likely to use benzo’s than MD’s and that is one good habit to build upon.

TheMoonisMyLantern, ADN, LPN, RN · Dec 13, 2020

12 minutes ago, myoglobin said:

My point there is no current legal remedy as the schools that exist abide by the laws that exist. Any endeavor to change those rules will be years in the making. Also, the students attending those schools are in most cases doing the best they can with the tools afforded them to maximize their situation and education. Thus the emphasis should be maximizing your personal education and opportunity rather than denigrating NP’s. What advice would you offer the recent graduate from a for profit school? Should they burn their degree or maximize their education and go to an IP state and join me in earning over 200k per year? Also, I’ve personally seen MD psychiatrists with many years experience make some of the errors you allege. Even my own preceptor (an MD psychiatrist) and his co psychiatrists started benzo’s like they were candy (and benzo like drugs such as Restoril, estazolam) for insomnia rather than using CBTi and less harmful alternatives like Trazodone. In my experience NP’s are less likely to use benzo’s than MD’s and that is one good habit to build upon.

For one I would heavily advise any nurse seeking to advance their education to thoroughly research the institution prior to applying and going in the debt to get the degree. No of course they shouldn't burn their degree but I think students that are able to overcome the limitations of their education and become competent, safe practitioners are the exception and not the rule. Sure I've seen MD's make mistakes in psychiatry, but I don't see it nearly as frequently as what I've seen with some of our NP's that lacked psych experience and unfortunately we seem to go through them quickly because they didn't know what they were getting into doing inpatient psychiatry.

Just the fact that you would encourage a new grad NP to practice independtly their first year of practice is just crazy to me! So many NP's and NP students come on here talking about how ill prepared they were by their schools for clinical practice, how much they struggled that first year. I don't care if your making 200k, what does it matter, if you're harming the patients you're seeing, and yes you can do significant harm in psychiatry if you don't stick to practicing what you are competent to do then you are practicing recklessly. Working independently and making triple figures doesn't equal competence. Acknowledging your limitations and seeking outside advice when needed is not weakness, it is a critical thing to do in medicine and nursing. None of us can know everything, I ask for help all the time when I come across something I'm not familiar with, that doesn't make me a terrible nurse. Likewise a NP that works with a physician is not less of a provider than an NP that works without a physician just because they aren't independent.