pianoman511

There is really no way to monitor v leads with a 3 lead system. With the good old einthoven's triangle, the idea is that the three leads make a triangle which has a center point corresponding to the center of the chest. When looking at precordial leads, the V leads are one electrode and the "combination" of the standard leads are the other "electrode". Without all three leads that virtual electrode would not be in the center of the chest, so the precordial leads would not be looking "through" the heart. The reason to titrate the nitro to pain free is to resolve as much of the ongoing myocardial ischemia as possible. You kind of hit on it in your post when you said that the depression resolves when the pain resolves. They want the ischemia limited and also make the coronaries as dilated as possible. As a sidebar, with marked ST depression in V1 and V2 it might be more of either a right sided or even some posterior involvement. A septal infarct would more likely be seen in V3 or V4.

Valproic acid (theoretically) increases the level of GABA in the brain. Since GABA is an inhibitory neurotransmitter it may decrease pain signals in the central nervous system. http://www.biopsychiatry.com/gaba/pain.html

And what's the problem with practicing with physician oversight ? PAs are not advocating for independent practice rights since the degree (just as NP) was conceived with the idea that they would be mid-level practitioners with enough education and training to handle most (but not all) of the tasks a physician would perform. We have heard from many providers thus far that the physician oversight they receive serves more as a resource for care and not a hindrance to care.

Specialists require an internal medicine residency before their specialty training which does require the same amount (more in the case of family practice) than a PCP. No doubt NPs are doing a SIMILAR job than their PCP colleagues but it's not the SAME job. When a physician starts working they have completed many years of post graduate training where they are supervised (residency). And no, they aren't sleeping most of the time. Also, the experience during residency is completely different than on the job experience as an NP. If independent practice comes for all states, then NPs will have practice rights immediately after school ends, so the experience argument is null.

Almost all PA programs at this point (except around 3 - maybe less at this point) are masters programs (two years) which requires both a bachelors and health care experience which within itself is more clinical hours than what is in the ENTIRE DNP program (since it's not a clinical doctorate, but a NURSING practice doctorate). And why would you get a DNP if it afforded the same practice rights as a tmasters program ? (and many are online...)

I don't know the exact number of clinical hours, but the average is 80 hours a week for residents, resulting in about 4,000 clinical hours in a year (2005 numbers, but i don't think there has been much change - http://www.npr.org/templates/story/story.php?storyId=4512366 ). The shortest residencies are three years resulting in 12,000 clinical hours for residency. Then add in 3rd and 4th year rotations which generally mirror that of residency since students rotate with residents (can't post the article link - subscription service) which would add about 8,000 more - so actually 20,000 hours not including any extra time during 2nd year since some schools add that on. I would empasize that it doesn't take a smarter person to go to med school, just someone willing to sacrifice many years of their life in training and subsequent debt (personal, financial, social, etc). In terms of financial management, there is no linking to any proof that what you are saying is anything other than opinion (which is fine, since that's what most of us are posting). Bottom line, anyone can run a practice with lower overhead regardless of NP or MD/DO status. If one is an independent practitioner, they can charge whatever they want and manage their practice any way they want - but the costs will still be there.

No problem. NY State - http://www.nydoctorprofile.com/ Doc Finder - http://www.docboard.org/docfinder.html (links to other states) In the past there have been insurance companies which had direct links to doctor profiles in their provider searches, but the direct links appear to not be there any more (when i went looking again).

They already do, most states have doctor profiles that the public can freely access and some insurance companies link to those profiles when people go to the site to find a new pcp.

I won't be, but the public needs to know the differences in training and realize this can provide for suboptimal care. In addition if they go see a DNP ("doctor") then they need to know that it's not the same as an MD/DO (DOCTOR).

Just because doctors make more money does not mean they have more disposable income. I am not in any way saying i am better or smarter than any other profession. Nor would I have any idea how to do an accountant's job or vice-versa. What I am saying is that medicine is far more different and the stakes are higher than accounting. In addition, the cost of business is higher in the medical field. It is B.S. to continuously bash physicians as being inferior business people and elevating NPs as superior because you think all physicians have a god complex. Many physicians are getting their MBAs and/or hiring practice managers with business degrees and yes they listen to those people.

Experience is NOT the most important factor. If you are practicing independently then you have no one to "train you", something that is the whole idea behind a residency and is especially important if you have very little clinical training and would benefit from physician oversight. Sounds like what the nursing profession is advocating in BSNs and DNPs - in fact that's exactly what they are looking to do. It's all about the money.

Ok....i thought i did - it's no different than my argument all along. If someone does not have the training and education to perform the job then people will die or get suboptimal care.

More disposable income ? How do you arrive at that conclusion ? Also, medicine IS more challenging, otherwise college would be shorter, training would be easier, and there would be no standardized testing. I am not talking about someone being smarter than someone else - but to go through school and training and amass the knowledge to practice medicine is a task that is definitely more challenging than an accountant's job. Numbers on a page do not change, people have an infinite number of variables, many of which cannot be measured or factored in when a diagnosis is made or when a treatment is prescribed. I am just wondering why you have this opinion that physicians don't know how to manage their money ? I am sorry, but just because someone is an NP doesn't make them experts at practice management or money management and doesn't make them selfless enough to say that they will charge enough to break even and only see 5 patients a day.

They will be the same for an NP assuming independence as a practitioner. If the NP is charging less then why would they be able to see the same number of patients in a day ? Unfortunately one year of experience is a lot different than one year of "college" (btw medical school is not "college"). In addition, one year of working in a low acuity community hospital is a lot different than an urban hospital. I can learn in the office/hospital that you give antibiotics for strep throat or diuretics for CHF, but if I don't understand why they work then there's alot of things that can go wrong. And unfortunately, people don't make that call. It cost more than that per year in taxes to train, staff, and pay for apparatus for a fire department - yet it is paid nonetheless.

Four years of undergraduate training, four years of medical school, and 3-10 years in residency (average 3 for FP, 5-6 for IM). As for student loan debt, remember that most other professions either enter their chosen field earlier or allow for participants to work or make some income during school - not an option in medical school. There IS a disproportionate burden on physicians. And yes, medicine is more challenging than other professions. Also, this cost of business will affect NPs too.

If an RN with a few extra classes has even the option to practice independently then that's a problem. RN programs train nurses to assess patients and follow protocols and standards - not make independent diagnoses and prescribe medications.

Patients are more satisfied because of what NPs currently can provide (i.e. more time, patient education), but that will change with independent practice - between administrative costs, time spent with health insurance (see above), and pressure to increase number of patient visits. Also, frequently satisfaction may not correlate with outcomes - just because I like you as a provider may not mean my HTN or DM is under control. Also, please do not minimize what one year of education provides. It has already been emphasized about the lack of clinical coursework involved in NP educational programs and that one year of medical school or rotations involves more coursework or clinical hours in one week than any graduate program (most systems courses range from 10-15 credits - and there are 4-5 systems per semester !). That adds a lot in terms of education and while it may not be immediately quantifiable (since yes the average patient does not have a rare disorder or disease), it is still very important. There are not fires every day in the average suburb, yet firefighters train regularly to fight them (and train for different types of fires). If I only trained to fight house fires, and one day a year there was a fatal car fire, then overall you would say that I did a good job because I trained for what was more common. Unfortunately, if that's my car I would probably feel otherwise.

1) Because it would not make sense to pay someone a greater salary because they spend 10-15 years (on average) of college, professional, and post graduate training to do a profession that is among the most challenging, has one of the highest rates of liability (i.e. medical malpractice), and still one of the most respected professions ? In addition, physicians have the highest consumer confidence ratings among professions. And again (again), it has everything to do with maintaining costs. Most of the problem is administrative costs to deal with insurance companies, A recent survey (5/09) found that physicians spend an average of around $70,000 just on costs directly related to dealing with insurance companies (which is a large proportion of income). L. P. Casalino, S. Nicholson, D. N. Gans et al., "What Does It Cost Physician Practices to Interact with Health Insurance Plans?" Health Affairs Web Exclusive, May 14, 2009, w533-w543. In addition, the average student debt of the graduating medical student is $155,000 which equates to a $1,700 monthly payment. Assuming monthly payback that's approximately $60,000 in interest (which generally increases since the salary of residents prohibits most from beginning the payback until after residency which adds the compounded interest).

If I can go right from a 2 year RN program (associates) or even 4 year RN program (BSN) for a few months of post-grad training and be an independent practitioner that does not make one iota of sense. Period. Regardless of what opinions anyone has on the differences between a DNP program and MD/DO school.

If a healthcare practitioner is in independent practice then their scope of practice should mirror that of a physician. If you are offering the same services as that of a physician then why should the scope of practice differ ? Yes, NPs have different training and is not a clinical doctorate or masters but a doctorate in nursing practice with greatly decreased clinical time. The thing that worries me is (from American College of Nurse Practitioners: Education and certification requirements vary. Forty-two states require national certification as part of NP licensure. Just over half of the states require NPs to be prepared with a master's degree, while some states only require completion of a few months of post-RN education.

There are MANY physicians going out of business or enter group practice because they can't maintain costs. Many are doing the job for much less than the average salary of around $170,000 (hence the average) and then factor in the average $150,000 debt that they carry after medical school.

Regardless of the equivalency between the PA and MD/DO the training is very similar. Definitely more similar than either program to nursing or nurse practitioners. The training for a PA is modeled after that of medical school with half basic sciences and half clinical rotations. I never made the statement that PA school was equivalent to MD/DO school, but PA students make a choice when they start school, regardless of the reason, that they want to be a physician's assistant and assume the role of a midlevel provider with physician oversight. They understand the difference, and if they wanted complete autonomy and independent practice they would go to medical school. Each school may have minor differences in teaching, but for PA, MD, and DO schools there is a standardized curriculum which dictates the courses that students take to make them competant providers. Yes, there may be differences, but there are standardized, national tests that evaluate students at every step in the process. For medical schools alone there are three (actually four - step 2 for DO and MD are two parts) exams that make sure students are progressing along the way and ensure competancy. The current NBME exam for DNP, from what I understand, is based on retired USMLE Step 3 questions, for which the failure rate was 50% for the first round of students who took it. That exam does tests diagnostics and clinical medicine, but there is no equivalent exam to mirror step 2 which includes complete physican diagnosis and exam (which is even more important). If DNP students and medical students were able to take the same type of exam to evaluate competency then it would be more understandable to mirror the scope of practice (which would be an objective comparison regardless of training).

Physicians are not saying that primary care is terrible, but they simply want more fair reimbursement. The primary care physicians see more varied patients than do specialists and they need a broader base of medical knowledge to care for those patients. Many of them are more upset that they are not able to make a living doing what they love. Their choices are: don't practice because the cost is too high to have the care you want to provide, practice and do your best to maintain your practice still try to maintain the quality of care, or see one patient every 10-15 minutes, minimize patient interaction, but still provide care. Obviously we want to really push physicians towards the latter option by decreasing reimbursement. But I guess it's ok because we have tons of independently practicing NPs which will gladly do the same job, see less patients in the day (because they take more time with their patients), and get paid less...while maintaining a practice. Many people have insurance and most of the time the insurance is setting reimbursement rates, not the physician, and that rate is way too low to maintain costs. Not to mention the fact that physicians take at least 7-10 years to be in school full time without being able to have much additional income and incurring around a quarter million to half million in debt to be able to practice medicine.

I agree that the cost of practice is different for everyone, but in any case it is still a large factor in determining the number of patients you need to see every day to maintain financial viability. I lump PA school with medical school not because it is equivalent to medical school, but because it follows the medical model. The PA program has a year of sciences, physiology, pathology, etc. followed by clinical rotations in all specialties. PA programs are standardized and the curriculum is nearly the same across institutions. In addition many require at a minimum a thousand or more clinical hours for entry. The DNP degree varies greatly across institutions, some requiring no clinical experience for entry (i.e. direct entry programs), varied curriculum, and more nursing theory, statistics, and other courses than clinical or science courses. In that way it is greatly different than either PA or MD/DO school. You are correct, it does not need to be the same if you are calling the end result something different. A doctor of nursing practice is not a doctor of medicine or doctor of osteopathic medicine. That being said, a doctor of nursing practice is not trained to do the complete job of a medical/osteopathic medical doctor. That is why currently NPs are referred to as mid level providers. The training is NOT equivalent to physicians - that much has been stated multiple times already. Colleges and universities are not training people to do manual labor or something with a fixed set of variables, medicine involves many factors which are constantly changing. Just following a set of guidelines for treatment without looking at the complete picture and treating a case of strep throat while ignoring the rest of the patient may solve the immediate problem but not the whole problem (or may not be the problem at all).

I don't doubt that with your education and experience you are able to handle a complex patient. My question to you would be whether or not it helps you to have physician oversight or the option to consult them with a difficult patient ? Also, do you anticipate that anything will change with the way you practice now if NPs were given independent practice rights ? My question/concern is not that an experienced, competant provider is caring for complex patients, but that with independent practice rights, a new grad with very limited experience who doesn't have the experience and physician oversight is expected to manage the same type of patients. (I know some DNP programs have residencies, but they are not the same in terms of clinical hours and intensity of training as an MD/DO program)