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.

For starters, I believed it to be factual, and no, I am not going to go run to the policy books every ten minutes. As to the comment regarding the Baylor PA's...yes they will still be PA's. But that's the whole point, a DNP is still and NP, no matter what, or how you try to paint it. AS far as precepting, considering they HAVE to rotate through the ED, and we only have one NP who is a new grad, and is not in any way ready to precept, they will either have to be with us, or not have their rotation here. It is really that simple. Strange, cause the program director approached ME about it. A policy that precludes PA's acting as preceptors might be one of the dumbest things I've ever heard......definitely one of the dumbest in a long time.

one of the big pushes by this administration, and by congress, as pertains to health reform is centered around "paying for performance"..... i am intimately involved with the mayo clinic health policy center, and this is one of their cornerstones as well. i'd like to hear from other people here as to their definition, and interpretation of what this means, and how it might impact your practice(s). here's some more info to digest as well: [color=#036c9b]http://healthpolicyandmarket.blogspot.com/ thoughts? some people are concerned that this could lead to a rationing of care. rationing already occurs to a large part. right now, we ration care by insurance status. patients without insurance, or without good insurance, cannot obtain appointments, and cannot get adequate care. rationing is inevitable. look at it this way. there are two factors here. 1. there is a finite amount of money available to pay for care. despite you having insurance, there is still only so much money in the pool. 2. there is a limit to the amount of resources, or care available. now, in order to provide unlimited care to everyone, you need to have an unlimited pool of money, which we do not have. therefore, one pool, or the other needs to be managed, or rationed effectively. it is simply reality. my question, is how should we ration care? my opinion is to really ration care in the last six months of life, and amongst the elderly. greater utilization of hospice for end stage patients. decreased use of multiple medications and procedures that cost a lot, but have little if any proven benefit. for example, in the uk, i understand that if you are 80 years old, and develop renal failure. you don't get dialysis. not usually. they have decided that at the age of 80, the amount of return that their society will get, measured against the massive costs, are not worth the investment. how would that go over here? these are kinds of difficult discussions that our "american idol" culture is going to have to face, and answer.

Sorry for the delay in responding, I was at policy meetings in DC and subsequently Chicago. Then I had to work 4 shifts straight in the ED. I have policy related concerns about the DNP degree, of which BTW, many of your own colleagues agree with, and NO ONE, with the exception of Menopetalli (?sp) has even attempted to answer. I guess because I was against the war in Iraq, I am an anti-american????? See how silly that sounds. Every committee, including pharmacy, finance, midlevels, etc.etc.etc. at Mayo Clinic is led by a physician. Every single one. Ours, the midlevel committee, is led, and chaired by an anesthesiologist. Mayo has significant concerns regarding the use of the title for several reasons, none of which are about any NP bias. Mayo has concerns because MANY of our patients are international patients who come expecting the world famous clinic to solve their complicated medical problems, some of these patients will not even know what an NP or PA is. Also, we tend to have higher profile patients, some of whom have quite a bit of wealth, they have certain expectations regarding their care, for better or worse. Mayo is an extremely conservative, Physician led and run institution, for many years, and yes, I have been here too long I think sometimes, we had a policy in place that stated that ANY patient who was new to Mayo Clinic MUST be seen by a physician. When we were attempting to get our fast track hallway off the ground in the ED, Mayo initially mandated that a physician staff it with us. It was like fighting against a brick wall, but finally, we got them to concede that problem focused exams and treatment for new patients could be accomplished independently by PA's and NP's. This policy has now changed, and states that any new self referred patient can be seen and managed independently by a midlevel provider as to their departments discretion. And believe me, this varies WIDELY by department. The policy also states that any new physician referred patient, must be seen by a physician, no exceptions. Mayo is very conservative, and for a long time, was considered, a "black hole" for midlevel providers, as advancement was considered very difficult, and autonomy is very limited. This has improved considerably, and in the ED, we have more autonomy than almost anywhere else in the institution. I also have to concede that the policy at Mayo has not been enacted yet. Largely, because we only have one DNP on staff, and she is an administrator whom I know well. In fact, we are having lunch this coming Thursday to discuss several other issues. I thought after our meeting in October, the language that was crafted would be enacted as policy, and in fact was told just that by our physician leadership, so just the other day I ran into one of our physician leaders, and asked him about this. His reply was that the language was still there, and the policy was waiting to be approved, BUT, that the Clinic was waiting to see how things played out in DC. I think personally, the leadership is hoping that congress will pre-empt them, and they won't have to be potentially seen as anti NP and subsequently have to deal with it. At any rate, it is not policy currently, contrary to what I was told, and I am a big enough person to admit when I was wrong. As far as Mayo-Scottsdale or Jacksonville, their policies can vary considerably from what Rochester does, as although they are under the Mayo umbrella, they function as distinct and separate entities. Please be aware, that although this is not policy currently, it was written, it is sitting with the Board right now, while DC plays out there game. The "Truth and Transparency" act has been introduced twice..First as HR5568 in the 05-06 congress, and then as the more recent introduction that is sitting in the house subcommittee. To think that the AMA will not puch forward with this again, after trying twice is folly. They are changing the language to remove opposition from other groups (Chiros, Optometry, Psych, Podiatry, etc), they are also making the language tougher as pertains to midlevels. And this affects PA's too. Those PA's that graduate from the Baylor EM program will be restricted as well. Lastly, I was recently approached about precepting Acute Care NP's as part of an ACNP clinical rotation at Mayo, and I said yes wholeheartedly.....

Yes, Rochester, Yes, level one trauma. OB is more difficult, as all OB patients are instructed to present at the other hospital (Mayo has TWO) to be seen by OB directly. Although, I certainly think a rotation over there would be beneficial. There would be rotations (I hope) with: Surgical ICU, Ortho Trauma Service, Ortho Hand, Spine, and hopefully OB at the other hospital. All other rotations would be IN the ED..including Critical Care, Peds, Psych, Medically complex patients, and some, but limited Fast Track exposure (more for learning how to manage 8-10 patients simultaneously, and learning how to manage an extremely rapid pace with fast turnover) We may also have to do some rotations with the LP clinic, and CT surgery for Chest Tubes, as procedures will be a stumbling block in the ED. I was told by one of the more senior attendings, that the MD residents WILL ALWAYS HAVE FIRST priority with procedures....so there is still some resistance. Right now, we are trying to gauge interest, and develop a curriculum.

Well, Mayo has always been a physician centric institution, and there was considerable concern amongst the physicians that allowing other providers to use the title would create significant confusion among patients, and as a physician led institution, they decided to take that position. Today, today was bad...I was used. 32 patients and counting.

It certainly could be, but currently, with the economic crisis hitting many academic institutions, and no, ours is not spared either, the impetus and design of such programs may not reach fruition currently. Which is truly too bad. For all of us. NP's and PA's.

Yeah, she finally gave up. She has like 7 years left until she can retire, and she is counting the days. She basically hates nursing now. Mayo does have a policy regarding nonphysician use of the title "doctor". It is restricted to DPM's, PsyD's, and OD's. We don't have any DC's working here. No one else can use that title in the clinical setting. It was just passed in October. I was at the meeting. Cleveland Clinic and Hopkins, according to our physician leadership are considering similar rules. Although I do not know if they have implemented them. Anyway, I'm bored, and tired after a long shift in the ED, time for some sleep, so I can do it all again tomorrow.

The "Gold Standard" comment, it was meant more from a medical legal perspective. Our standard of care will be held up next to a physicians. IF, a midlevel is being sued for malpractice, say a family practice PA, than the first thing the they will do (lawyers) is see if the PA's care matched the same standards of practice of a family physician. I don't necessarily always agree with that. But that's our system currently.

Yep, my mom is a nurse. I grew up around nurses all the time. And she was right. She used to say all the time, that "If only nurses could ever unite on ANYTHING, we could change medicine completely".....she was usually pretty frustrated by all the infighting and bickering.

Right, and the language that is being re-worded is primarily being done to assuage those groups. As far as the IOM, well, I'd like to see a link to a statement that they do not consider physician care to be the standard of care. The new language of the bill that we will likely see this year will allow for DC's, DPM's, OD's, and PsyD's to retain their title of doctor, but will prevent others from following suit. The AMA has conceded that point, else they know that their is virtually no possibility of the bill passing without having those other groups neutrality at the very least.