physasst

Had breakfast with Polly Bednash, who is the Executive Director of the AACN, the current president and CEO of the AAMC, and my friend, and colleague, VP of the AAPA Bill Fenn. What a wonderful lady. We had some great discussions, we discussed the DNP, NP education, and the need for a lot more interaction, discussion, and partnership between both PA's and NP's. We may have some disagreements on a few things, but she actually acknowledged some of my concerns on here as well. I'm supposed to email her here shortly with some information on the ACC. WOW....surrounded by heavyweights...all of them. Attendees include: President Emeritus AAMC Chancellor Emory University Director, Division of Undergraduate Medical Education, AMA President and CEO of the Institute for Healthcare Improvement Professor and Dean of Vanderbilt School of Nursing CEO Henry Ford Medical Group Senior VP of the American Board of Medical Specialties CEO and Executive VP, American Colleges of Pharmacy CEO Accreditation Council for CME CEO National League Nursing President and CEO ACGME President American Association of Colleges of Osteopathic Medicine Coordinating Producer ABC News Health Care Task Force as well as NUMEROUS other deans and presidents of various medical schools. It was a good day. First session started with a review of the four cornerstones of health reform for the Mayo Clinic. Discussion also focused around reforming medical student education to NOT teach disease treatment, but to teach healthcare delivery. There was a lot of focus on integrated classes for medical students, WITH MANY classes being taken with other health professionals. For example. Anatomy. There was discussion that medical students, nursing students, PT students, and PA students ALL TAKE THE SAME ANATOMY COURSES TOGETHER. There was talk about incorporating a course that would solely teach and focus on teamwork, and (sorry Happy) teaching the physician that they are an EQUAL with other members on the team, and not always in charge. There was a lot of discussion about the Intermountain group, that manages 30,000 diabetic patients with only FOUR endocrinologists. HOW? They use non physician providers. The next session was about Licensure, Accreditation, and Certification. There was a lot of debate about having a SOLITARY interdisciplinary certifcation process. There was a talk about Professionalism, and having medical students NOT graded on individual exams to test medical knowledge that they won't remember, but to test them on the concepts, and the ability to find the answers when they need them. ALSO, to test them on HOW WELL THEY FUNCTION IN THE TEAM MODEL. The next session included Realigning the Health Care Training System Toward Coordinated Patient Centered Care, again discussing the team model, and dramatically changing the current medical school structure. Finally, we were asked to submit a singular answer from EVERY table as to HOW to best reform the health care system. Then, we had dinner, and a discussion on Driving Change in Academic Medicine. I'm tired now. A lot of information, a lot of very intense discussion amongst a group of highly accomplished and intelligent folks. Unfortunately, pursuant to another discussion on here. Anecdotally, I spoke with an NP at another meeting here at Mayo, who I believe may be the only NP with a DNP degree here. She likes working here, but is quite frustrated, as she stated that Mayo "does not recognize her degree". She thought it was worth it, and loves her additional education, but was told quite frankly that she SHOULD not use (note, not cannot), the title Doctor in the clinical setting. She was told essentially that it would not be in her best interest. Anyway, the nursing profession was well represented with Polly and Beverly Malone present. Thought you all might like to know

Wait, you have to staff with an attending???? Really? I work at three different ED's, and I only staff cases when I feel I need to. In fact, the one ED I work in doesn't even have any physicians on site. It's soley PA's at this point in time. Although, I don't think there would be any objection to an ACNP. At the main job, I have to staff all cases I see when working in critical, but otherwise, it's a little greyer. We are supposed to see all level 4 and 5 cases without any physician oversight, but sometimes we also see the "softer" level 3 patients independently as well.

Yep, and anecdotally at least, I have had several RN's, probably 4 or 5 come up to me over the past several months asking for more information about PA school, as they don't want to complete the DNP. Although, for one of them, they were more attracted to PA school for the more generalist education. How this plays out remains to be seen. Some of the NP's I work with seem to be pretty angry about the whole process involving the DNP, and several have said that they have absolutely no plans to complete any more schooling.

Amen, sister, amen. You are preaching to the choir here.

Nah, in the ED, I am treated as a colleague, NOT a subordinate, which seems to be the case in some of the other departments. I have complete authority to order, admit, consult, whatever. Many, if not most, of my patients only see me, and after so many years, I find that I consult the physicians only occasionally. I still do, even for straightforward patients that are supposed to be staffed according to institutional guidelines. I had a patient I cardioverted recently, and only told the attending, who was up to his shoulders in other patients, AFTER it was done. Another incident that happened a while back involved one of our junior PA's who was treating a patient with a very complicated dirty, layered wound. Well, the senior resident got a little uppity, and said to the attending, "Aren't you worried that she doesn't know what she's doing, what if she doesn't irrigate it well", to which the attending replied, "You would do well to remember that the PA's are staff, and that they are accorded the same respect as the attendings"-or something to that effect. I was like "wow". I haven't called one of the physicians "doctor" in more years than I can remember, the ED attendings actually prefer to be addressed on a first name basis, as we are thought of as colleagues again, not subordinates. In many other parts of Mayo, it is quite a different picture.

Ahhh, yes, the stem cell research position statement debate......I agree, that was worst. I don't mind the 10 year re-cert discussion, as I actually agree with that personally.

See, in our ER, I have full admitting, consulting and ordering privileges. I get treated as a colleague, and not a subordinate, however, I have friends in other departments, and I know that it is dramatically different in other areas. Many of my patients are never discussed with an attending. They trust however, that I will consult with them when needed. I haven't called anyone "Doctor" down here in longer than I can remember, the attendings prefer to work on a first name basis, as they view us as colleagues.... In fact, a funny story happened not long ago. One of our junior PA's shared this with me. She was sewing up a rather complex layered lac, and there was some concern about how much contamination might be in the wound, as it was quite dirty. One of the senior residents at the time, went to the attending, and demanded to know why the "PA was doing it" as she "might not clean it thoroughly, and aren't you worried about her abilities".......Hehe, the attending turned to him, and said, "I think you need to remember that the PA's here are staff, and you are just a resident, it would be in your best interest to remember this in the future." I was like...wow, REALLY???? Some other departments are becoming more progressive as well, but old habits die hard here. The economy is actually helping us with that here, as it might force their hand.

when i refer to poorly planned, i mean that it could have been executed better, and i am referring to this in his statement: but back to the dnp. what is sad is that the dnp is not standardized, and in many educational programs it is not a clinical doctorate. it will cost nps who are currently in practice $30-50,000 to acquire. and many, not all, but many of these programs will not make the nps who enter them better clinicians. and this: so now that we have proven that you do not have to be a "doctor", advanced practice nursing leadership (not most nps) have now said "you do need to be a doctor to provide primary care". i understand the politics behind the decision but i wish it was done in a different way. it really undercuts what we have been saying for 30 years so perhaps poorly planned was not the proper language, but i interpret dave's statement to mean that the dnp could have been more uniform, better implemented with a stronger clinical component, now perhaps that is an implementation thing, and not a planning shortfall, so perhaps it is poor implementation. but at any rate, i agree that the programs could be improved. and i would be all for that. if, i were asked to plan the dnp, it would be along the lines of completing your master's as an np first and always, and then making the dnp an option for those that want to be better clinicians, and it would be a two year program that would consist of at least 3000 clinical hours, and strong residency styled didactic component to complement it, with focuses in the current specialty areas of the np profession. that would be an outstanding program. if the np profession were to adopt such a stance, and structure their dnp programs uniformly in that kind of format, i would wholeheartedly support the advancement of the degree, and would applaud your efforts at every level. in short, i would be a fan. but the current iteration is not something that i can put my support behind. and as i said above i do want to work with np's.

Well, in Minnesota, PA's and I believe NP's can do the same things, neither of us can be completely independent, and both of us have similar prescriptive authority (II-V). Mayo has slightly more conservative policies regarding "midlevels" and while they are improving slightly. They are still more conservative than state law. Mayo pays PA's and NP's the same as far as I know, and sees us as interchangeable in our abilities. In fact almost every job posting on the Mayo site, will list "PA or NP wanted". Mayo was at a time regarded as a "black hole", not my words, but a friends, as pertains to midlevels, and their reputation in the midlevel community here is still recovering. Many departments still use PA's and NP's to see patients prior to a physician seeing them....and yes, like ALL of them, and they rely on the PA's and NP's to answer phone calls, and perform more administrative functions (scheduling, appointments, etc.) Like I said it is improving, but slowly. In the ED, we have probably the most progressive and aggressive practice agreements in the institution, so we are trying to slowly break down barriers, but Mayo is first and foremost a physician led and physician directed institution, and there is still a mentality here among a lot of the older physicians (you know, the one's in leadership positions with power) that "only a physician can do what a physician does". Change here occurs at a glacial pace, but count me among those trying to improve it. Mike

i would say, that i disagree with parts of mr mittman's assertions as well. i don't believe that we will be "forced" to have them. i agree with him that the dnp was poorly planned and is not being executed well. i also agree with him that joint residencies are becoming more necessary (although i believe, mine and dave's reasons differ for this). the aapa cannot even agree on a base degree (which i also agree with, i was an associates degree graduate as a pa, and i went on to finish my master's much later), and i'm sure as mr carpenter would agree, sitting in the hod and listening to the degree debate concerning a master's minimum requirement is one of them more mind numbing experiences one can have. i think that david is correct, i think that most pa's and the aapa would disagree with the assertion that we will all be "forced" to have doctorates.

Well, we have ONE ACNP in our ER.....we have six full time PA's, and then several PRN PA's as well. Our NP is having to complete her FNP training as well, as she will have to see peds patients soon, so that seems like a lot of extra work to me. Our physicians don't really care, they see PA's and NP's as "midlevel" providers, and Mayo as an institution sees us as completely interchangeable.

Dave Mittman is one of the most respected clinicians, in both PA and NP circles. I don't know him really well, as he is not really active in the AAPA anymore, but he was a founder of the ACC, The Clinical Advisor Journal, as well as many other projects. He's a pretty bright guy, and his assessment, as usual, is spot on.

This was a well worded post. Others on here continue to try and slam ANYONE who questions the validity, or necessity of the DNP. It's kinda sad, because there have been several physicians on here, and they continue to get mocked as well. Many states do not allow NP's to practice independently. Directing such strongly worded comments to medical students and physicians will not help your cause. This continues to be the problem with some in both the PA and NP communities, where people think that insults, and put-downs advance your interests. Change is happening for both professions, however, it needs to be balanced, carefully thought out, and deliberated. A working knowledge of not only your goals, but the political atmosphere, environment, and careful language must be used. For example, I had lunch when I was in DC last week with a congressional aide, we exchanged pleasantries, and then began to talk about cycling (a HUGE pastime of mine, that and triathlons), and in the period of an hour, by carefully listening, and reading between the lines, I learned more about the congressman and his health policy views, all by talking about cycling. I guess, what I'm trying to say...is polish......you need polish. Something, regrettably, I have not practiced here either. I myself, want to apologize to anyone on this board whom I have offended. That was never my intent. I merely have several policy related concerns about the DNP. I actually only came to this board to inquire about any interest in the residency that we are putting together, so again, to anyone to whom I came off a bit strong, my deepest apologies. I think of NP's as colleagues, and would really like to see us work together. Oh, and BTW..you might want to watch the HOR pretty closely over the next four weeks. There's a pretty big health care reform related bill, (the first of three in a row actually) coming out. Obama wants all three to through the house, committees, and senate by the end of June for his signature.

Oh, and also, there is a rumor, that Emory in Atlanta is pursuing a 2 year PA to MD completion program. NO, I don't have a link, but it is being discussed in various circles. It may only be rumor, but I've heard it several times now from different people.

I am fairly biased in all of my opinions, as are most people. I have no dislike for NP's or nursing, I have some concerns about the DNP degree..... IF you can definitively show that A. it dramatically improves patient care, and lowers M&M, improves outcomes.... and B. You can show that it either improves patients access to care, or at the very least, does not negatively effect it.. Then I will happily concede, that perhaps this a good idea, and I will support it. UNTIL those two things are shown to me, I will scream against from the tallest rooftops.