dissent

I agree, you should defer to the cardiologist especially if he/she is the one who started the med. I think calling someone who is an expert in the field a cowboy when they do off-label stuff may not be completely right. Now I don't know what he/she was doing (and it may have been outright wrong) but in more than a few circumstances, the label just isn't right. For instance, nifedipine XL is a labeled as a once daily med with a supposed max of 120 daily. For refractory hypertension it is given BID (especially in renal patients) and frequently 120mg BID (so double the supposed max daily dose). Lisinopril by label is again once daily and rarely given with an ARB since they end in the same common pathway. However, in patients with a highly active Renin-angiotensin-aldo axes it is often given BID or with an ARB. So, I guess what I am saying is perhaps he/she had a reason since he/she is the expert in the field.

I think the OP is asking why someone would prescribe flovent and flonase to the same patient

Everyone makes mistakes. Live and learn. In the end I think you learned a valuable lesson without having any harm come to anyone: don't prescribe a medicine you are not comfortable prescribing.

It would probably be similar to the PA to MD bridge- a 3 year program followed by residency.

At least in the past, the hopkins guide was free if you used it online. You just had to sign up for it. The PDA/smartphone version always cost money. I don't know if they started charging for the online version or not b/c it is obviously free on the Hopkins intranet. I think the hopkins guide is much easier to use and overall more robust than the sanford guide

Yup. For most drips you need to bolus to get to steady state prior to initiation of a drip (ie SL NTG or 400mcg prior to a nitro drip). For a GI bleed it is a standard initial dose (80 mg IV) and a standard drip dose 8mg per hour. It is the doctor's fault for not putting in an order for the initial order. Good for you and the pharmacist for catching it.

So actually the data aren't exactly a slam dunk and they definitely aren't strongly in favor. I would say they are overall, weakly in favor. Unfortunately there aren't any meta-analyses. Here are the RCTs. L-albuterol is WORSE than racemic albuterol- http://www.ncbi.nlm.nih.gov/pubmed/21275850 They are the same http://www.ncbi.nlm.nih.gov/pubmed/18044102 http://www.ncbi.nlm.nih.gov/pubmed/15988423 http://www.ncbi.nlm.nih.gov/pubmed/11742271 http://www.ncbi.nlm.nih.gov/pubmed/10200010 L-albuterol is BETTER than racemic albuterol http://www.ncbi.nlm.nih.gov/pubmed/16635694 http://www.ncbi.nlm.nih.gov/pubmed/15709454 http://www.ncbi.nlm.nih.gov/pubmed/14657817 Albuterol and L-albuterol are the same for hyperkalemia- http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1726786/pdf/v022p00366a.pdf

Oh and to answer the original question, you are probably not going to find a large percentage of the Canadian population that come to the US. Only those who are wealthy and are waiting for cancer tx or ortho surgery are likely to come.

Controlling for lifestyle choices (obesity, smoking) and heterogeneity of the US population (ie with infant mortality) you do not see the same difference in life expectancy. These things are not health care system related- they are population/lifestyle related. This is not to say the US system is perfect but it is academically dishonest to compare dissiimilar populations. Think about what would happen if a new cardiovascular drug showed improved mortality yet the they had 10% fewer obese people than control? Answer- it wouldn't pass peer review unless it controlled for these.

It's not.

Belittling or truthful? Quite frankly, anyone who pushes the DNP as much as you do without realizing its massive flaws has ulterior motives or a conflict of interest. So which is it?

I would highly recommend not going to this school. Foreign schools have a lot of problems compared to their US counterparts. There are those that are highly regarded (the UK, german and most australian schools), those that are accepted but with hurdles the graduates have to endure (SGU, Ross), and those where it is difficult for graduates to get residencies. This is the latter. Foreign, Non-european schools tend to have major problems compared to the US: 1) Attrition- they tend to have a high drop-out/fail-out rate 2) Their USMLE pass rate is miserable 3) Their rotations are very subpar 4) Their ability to get residencies is very limited From this school, it would be near impossible to get pretty much anything other than a family medicine residency, and even then, you would probably have difficulty getting an FM program to accept you. Do not underestimate the difficulty to get a residency in the US. No residency and all that money you spent means nothing.

I mean how bad of an error are we talking about? Was this HCTZ 50mg instead of 25 (ie no big deal)?

How long will it take you to finish the BSN and then the DNP? In terms of time to degree and practice I expect the DNP is going to be much much quicker: Medical school route: Peds: total of 9 years- 2 years for post-bac, 4 years for medical school, 3 of peds Peds ICU- total of 11-12 years (add 2-3 years for peds ICU) Peds onc or med onc: total of 12 years- 2post back, 4 med school, 3 of peds or medicine, 3 of peds-onc or med onc NPs do not do as much as a doctor does but as above there is a big difference in the length and depth of training and that explains the difference. Technically after a year of internship after medical school you can LEGALLY do whatever you want (onc/ICU/surgery) but no hospital is going to hire you and you'd be a fool to try. That means to work in an ICU or oncology you must do the extra training as an MD. Think about it this way, at the end of that internship, a physician-in-training will have roughly 7000-8000 clinical hours under their belt with a minimum of 500 of those spent in an ICU while most DNPs require only 1000 hours and not many of those will be spent in an ICU. The post-internship resident isn't going to be allowed to run an ICU alone and will have limited autonomy. Obviously the case is going to be similar for the DNP. The autonomy is going to be hospital dependent. Many ICUs will give NPs a lot of autonomy but there are definitely limitations. Where I have been, NPs dont put in central lines (with exception of PICCs which often aren't that useful in an ICU) or A-lines as well as various other major ICU procedures. These places have been teaching hospitals where there is a lot of cheap labor (residents) so the need for NPs is less. Oncology is a bit of a different bag. NPs tend to have less autonomy overall and in my experience have acted more as physician extenders. In the end I think the decision will hinge on whether the time is worth it and how much knowledge and independence you want. Add to that the knowledge that residency is very tough and you will be working 80 hours a week for 6 years to get into peds-critical care or peds-oncology during your 20s and 30s. Good luck

I think of it as expecting more from an extra year or so of loans. If it is supposed to be a clinical doctorate, it should have more clinical courses and vastly more clinical hours than a masters. Otherwise why have a doctorate? Milk it's students for more money? Try to compete with physicians (ie all political)? The research/statistic courses are somewhat helpful for reading literature but not at the expense a better foundation. I realize people like the idea of having a doctorate for entry but if it's adding little to a clinical practice, what is the use? I think students should speak up and expect more. Purely self directed learning is not the answer but without more basis in disease that is what it is coming down to. If self directed learning were adequate, we wouldn't need teachers and schools.

Your right, i'm sorry. What I meant was clinically useless courses. When you are spending half of your time learning about how to read a research paper or set up research or learning how the health care system is set up instead of actually how to treat patients you are not learning what should be a clinical practice doctorate. If you want this stuff, do an MPH. That's great you can read a research article of course you didn't learn how to properly treat or diagnose a host of clinical conditions. Your eyes cannot see what your brain doesn't know. But at least you can give a dissertation on health care delivery... Other NPs should be expecting more from their DNP rather than supporting this BS the administrators are saying is enough. If you want those classes and you really think they are needed, great. There should be twice as many credit hours in pharm, path and physio and twice as many clinical hours. If that means getting rid of the fluff, so be it. If you think they should stay then it means the DNP should be longer.

Many use the term fluff because soft sciences add nothing clinically, especially compared to hard science like pathophysiology or pharmacology. When most of a DNP is about learning to read research rather than actually being able to take care of patients, there is a problem- especially when the DNP curriculum is designed to provide care for patients. The DNP isn't a PhD in nursing; it is a clinical doctorate. As to the research classes showing the weaker students- so does any course. You could use an English literature to show you who are the weaker students but taking English lit (just like taking health policy courses) it's not going to make you a better clinician. The problem is that most DNP programs just don't have enough clinically relevant courses. Instead they add research/health policy courses which may be interesting but don't prepare you for bedside practice. Let's look at Duke's DNP program. Taking out the research capstone, 33 credits are clinically irrelevant and 33 are clinically useful. That's a problem in my opinion. Clinically "less useful" courses ( 33 credits) Research methods, research utilization and applied statistics- 8 credits Evidence based practice and applied statistics- 7 Data driven healthcare improvement- 3 Health system planning-3 Health system transformation- 3 Epidemiology- 3 credits Effective leadership- 3 Transforming the nation's health 3 Financial management and budget planning- 3 Clinically useful: 33 credits Health promotion- 3 Diagnostic reasoning- 4 Managing common acute and chronic problems - 6 Child health care-4 Sexual/reproductive health 4 Elective 12 credits

ACEi are vasoDILATORS. They reduce afterload. Especially in systolic heart failure they improve mortality. The data on efficacious treatments for diastolic dysfunction are lacking. Much of diastolic dysfunction is caused by hypertension (among other causes). As such, ACEi would be effective to a certain extent. Unfortunately the hypertrophy of the ventricle has already been done so reducing afterload will help only improve SV. The filling of the ventricle (the problem in diastolic dysfunction or HFpEF- heart failure with preserved ejection fraction) is going to be relatively unaffected.

I'd say similar clinical hours and similar education in path, pharm and physiology Sure but having 12 hours of useless research fluff and only 4 hours of pathophysiology isn't doing your patient any favors.

If you are talking about a systolic murmur then going anatomically from where the murmur is heard: Benign flow murmur Proximal aortic dissection Aortic sclerosis w/o physiologic stenosis Aortic stenosis Pulmonic stenosis ASD VSD PDA Tricuspid Regurg Mitral Regurg Endocarditis causing one or more of the above Rheumatic heart disease causing one or more of the above Aortic stenosis will often present with chest pain, heart failure, syncope which each have a massive ddx.

Which childhood disease covered by vaccines should exist? Hep B- acquiring Hep B early in childhood makes the likelihood of getting chronic hep B almost 90% while getting it in adulthood it is only around 10%. Most adults will clear it while children will not. DTP- all associated with high mortality and morbidity. Haemophilus B- causes meningitis and epiglotitis both conditions with high mortality in kids Pneumococcal- causes pneumonia, OM and meningitis again mortality and morbidity. Flu- high mortality in the young. Polio- paralysis MMR- high morbidity and can be fatal in kids occasionally. In pregnancy causes HUGE problems to the fetus. Varicella- morbidity Hep A- can cause acute liver failure although usually milder in kids. Meningococcal- meningitis- mortality, morbidity. Rotavirus- decent amt of morbidity. This is really the only one of the bunch that could potentially go. In terms of the gardasil vaccine, it is given so early so that kids don't get infected. Get 'em before they get sexaully active. I cannot tell you how many patients I see who have HPV causing cancer of the lady parts, cervix and vulva or intraepithelial neoplasias. It's so easy to prevent with a vaccine and HPV has become so ubiquitous that anyone who is sexually active these days gets exposed.

To be blunt, why on earth would someone pay extra money to see someone with less training than a physician? I think with more doctors doing concierge medicine you will see more of a 2 tiered system coming out. Demand for NPs probably will increase.

Watch out about doing your pre-recs in a community college... many med schools will outright not accept them and most view them as inferior to 4 year programs. Since the competition for acceptance to med school is fierce, taking your pre-recs at a community college could put you at a disadvantage, especially if you don't have upper level science classes to back it up. The average stats for matriculation are 3.7 GPA and 31 MCAT currently. Med school tuition is pretty bad. Texas is a nice exception but most schools charge over $20,000 if you are instate and 40-60K if you are out of state (for public schools, private schools tend to run in the 40-60K range regardless). Average debt is $158,000 for med school graduates. Unfortunately you can no longer defer your payments (another great change the gov't made recently) so you start compounding that interest the day you graduate. So during your 3-7 years of residency, you have to make payments yet you don't actually make enough to make payments so the interest just compounds. So, make the decision carefully. If you have questions, PM me. I worked with an admission committee during medical school.

The new work hours could really be an asset to NPs/PAs. The demand is going to go up. The ACGME (the people who run all the residencies) is planning on trimming the hours even further in the coming years. So in areas where residents are picking up the slack, that is going to have to be filled by others... which means more jobs for NPs/PAs In my experience at a major teaching hospital in Baltimore, the NPs/PAs tend to be more ancillary, functioning similarly to interns or 2nd year residents. They sometimes do minor consults (following up on chest tubes for the thoracic service), run the floors (for renal transplant) and monitor post-cath patients

Sorry to be technical but they are 16 hours (and were 30 hours). These hours are currently only for interns. Residents still do 28 hour shifts. I agree though, with the new hours, my hospital has gone to more NP/PA help with the work. Since the workload hasn't decreased and the hours interns can work have decreased, the extra work has to be filled in by someone. In some circumstances this falls on the residents or fellows. In others, to midlevel providers.