Oregon equal pay for equal work law has been signed into law in an independent practice state with NP's and PA's getting paid FULL amount from private insurance. This means that a new grad NP's will be paid the same amount as an attending family physician and psychiatrist and also have the same rights and scope of practice as a family physician and psychiatrist.
With the tremendous push for equal pay and for autonomy for PA and NP, is there any reason for medical students to want to go into primary care anymore? I guess my question is, it seems so bizarre that someone would put themselves through hell when they could become a competent provider through the NP route or PA route.
So do you think with these new laws, PA's and NP's will ultimately lead primary care? will these laws drive away medical students from primary care? Is it financially reasonable for a medical student to become a family physician in an equal pay state?
As an sNP, I'm incredibly thrilled and happy at how much progress our profession has made. However, I also understand how some medical students hoping to go into family medicine can feel cheated and grumpy about it. What are ya'll thoughts?
What exactly about your experience, haven't not yet even begun clinical training yet alone had any actual clinical practice experience, makes you "more than qualified" to determine competent clinical practice?
One thing you need to keep in mind as your do your training is that the most dangerous providers are the ones that practice beyond their experience, knowledge, and training.
Congratulations, graduate school (in every discipline) is about the self-directed work that you do.
I commented that I was more than qualified to comment on the educational process of NPs. As I am, right this very moment, experiencing it. But, with your line of reasoning, you have no ability to comment on the education or practice of physicians or PAs. Not having directly experienced something does not mean you can't objectively analyze it. And the point of a formalized training program is to direct your study. 99% of graduate NP programs do not have an anatomy or physiology class at the graduate level. NPs should not have to seek training from other sources to obtain a complete education. And do not attempt to say that any undergraduate level course is an appropriate substitute for a graduate level course because why then would we have graduate level pathophysiology, etc? Training programs are lacking in these areas. All I'm saying.
What studies are you talking about? Please, cite them here. Now that you mention that they "will never be performed", example of landmark RCTs published in major peer-reviewed medical journals:
Mundinger, M. O., Kane, R. L., Lenz, E. R., Totten, A. M., Tsai, W. Y., Cleary, P. D., ... & Shelanski, M. L. (2000). Primary care outcomes in patients treated by nurse practitioners or physicians: a randomized trial. Jama, 283(1), 59-68.
Lenz, E. R., Mundinger, M. O. N., Kane, R. L., Hopkins, S. C., & Lin, S. X. (2004). Primary care outcomes in patients treated by nurse practitioners or physicians: two-year follow-up. Medical Care Research and Review, 61(3), 332-351.
First, these studies do not specify details of what the "screening criteria" were (a small blip mentions not currently having a PCP and planning to be in the area for 6 months, but doesn't clearly limit it to that). Then, the study loses 40% of patients at the recruitment stage, which doesn't directly bias in one way or another, but it does put the study validity into question with the absence of inclusion criteria. And the first study tracks primary care for an underwhelming total of 6 months post ED visit - a very short period of time for chronic conditions. Especially post ED visit - which happens to be their recruitment center - which would indicate a strong regression to the mean for all parties and certainly mask inter-group differences and, therefore, bias us towards the null. Even, the study itself admits to having a low statistical power. But most importantly these studies†don't distinguish between patients based on presenting condition. Saying that patients with asthma look the same in 6 months or 2 years is different depending on whether they presented to the ED for uncontrolled asthma, or presented to the ED for a stubbed toe or abdominal pain, etc. Further, they focus on diseases where diagnosis is extremely straight forward and treatment is absurdly standardized. In other words, with a study heavily biased towards the null. Even a registered nurse could follow the recommended AAP flow sheet for diagnosis and treatment of asthma, or the JNC for HTN or the ADA for diabetes. 9/10 times if you throw Advair, ACE or Metformin at these people you'll be practicing within the standard of care. I would also love a control group of patients who refused treatment and see how similar their measured outcomes would be. None of this is surprising, however, coming from studies with Mundinger as the lead author, as she is HEAVILY biased toward NPs given her background, much in the same way that studies published by drug companies are. Finally, they don't look at patient oriented outcomes. It doesn't really matter if the A1Cs were the same, does it. Which group had less complications? We aren't given that information. How were secondary causes or other comorbidities managed with these patients – if there were any at all. Maybe these patients were excluded but we aren't even given that information in the first place.
On the surface, they may look great, but if you get past the abstract you'll find they are incredibly flawed.
Why not make NP school longer than medical school with a 15 year residency program at the end? You wouldn't mind spending another few hundred thousand and working for basically free for 15 years would you? Especially when there is no evidence that outcomes would be any better. What would you use as your rationale to justify that additional cost and time?
NP education has it problems and we (practicing NPs and educators) need to tackle them, in my opinion, but there truly isn't any evidence right now to support it.
And hyperbole won't help your argument. No one suggested NPs go to school for an increased length of time. Only that an increased push for independence is unwarranted due to the short comings in their educational process - which can be easily fixed. Add about 2 more classes and require the students to spend more time in clinicals with formalized, observed instruction.
So you admit there are problems that need to be addressed, but don't think there is evidence that you and your colleagues should attempt to address them? Ok...?
You have made it clear that you think only practicing NPs have any ability to comment on this at all so I will bow out.
I commented that I was more than qualified to comment on the educational process of NPs. As I am, right this very moment, experiencing it.
You are beginning to experience it but you haven't had any clinical experience so you don't have any experience in the application of that knowledge.
FWIW I haven't commented at all on physician education or PA education, only the outcomes of that education on clinical practice, and even that is to cite the data not give an editorial.
...treatment is absurdly standardized. In other words, with a study heavily biased towards the null. Even a registered nurse could follow the recommended AAP flow sheet for diagnosis and treatment of asthma, or the JNC for HTN or the ADA for diabetes. 9/10 times if you throw Advair, ACE or Metformin at these people you'll be practicing within the standard of care.
This comment right here highlights your lack of education and experience. If you practice with this kind of approach you are going to kill people. Real-life practice is far more complicated than you assume it is. Please, before you step foot in clinical practice, consider some humility, you may find things are not as black and white as your textbook or flowchart.
None of this is surprising, however, coming from studies with Mundinger as the lead author, as she is HEAVILY biased toward NPs given her background, much in the same way that studies published by drug companies are.
This is the same conspiracy rubbish that anti-vaxxers use. This study was authored by a mix of nursing and medical researched and published in one of the most prestigious medical journals in the world. The results have been demonstrated over and over again. Please, cite a refuting study.
So you admit there are problems that need to be addressed, but don't think there is evidence that you and your colleagues should attempt to address them? Ok...?
Yes, personally I do feel there are problems with NP education as it stands right now, and many of my colleagues (including me) have been very proactive in attempting to correct them. I would prefer not to wait for the data to begin to swing.
You have made it clear that you think only practicing NPs have any ability to comment on this at all so I will bow out.
Please, comment if you wish, I'd be curious how you feel after some clinical experience.
I wouldnt mind leaving the primary care to nurse practitioners. at least the HTN, basic thyroid issues, diabetes, sinus congestion, bronchitis and all the commonalities really dont take much thought to manage in MOST cases. Please, have at it. The complex stuff can be referred out to specialists. As long as people know the red flags to watch out for then yeah 11 years of post secondary education is overkill for lots of stuff. But NP school is/was too easy and still needs to be a little bit harder, esp if people are opting for independant practice.
I do not see a shortage coming in primary care patients so yeah why not let NPs be the first line of defense.
But in regards to education quality in and of it self med school is much better than NP school and attracts a different crowd.
Where I am there is a significant lack of family physicians so just about all the clinics are staffed with NPs with maybe a physician rotating between several clinics. The problems come when these many inexperienced NPs refer patients who should be managed in primary care. Along with a lack of family MDs there are a limited number of specialists and when half of your schedule consists of referrals that are not requiring specialist you cause others to wait even longer for an appointment.
I don't know why I can't help myself here. Looking back through this thread, you've actually agreed with many of my points, but now it seems you're trying to be contrary for the sake of argument.
FWIW I haven't commented at all on physician education or PA education, only the outcomes of that education on clinical practice, and even that is to cite the data not give an editorial.
I'm a little confused by this because going back through this thread you have commented multiple times on MD and PA education, even going so far as to say you are involved in MD education. So how can you say that I can't comment on an educational process I am experiencing, but you can comment on other professions because med students rotate with you? Doesn't make sense.
This comment right here highlights your lack of education and experience. If you practice with this kind of approach you are going to kill people. Real-life practice is far more complicated than you assume it is. Please, before you step foot in clinical practice, consider some humility, you may find things are not as black and white as your textbook or flowchart.
Note how I said we could take REGISTERED NURSES and, using the current evidence based protocols that most clinicians use, achieve appropriate outcomes in patients with simple, straight forward asthma, HTN and diabetes (which, whether you like to admit it or not, are very standardized treatment algorithms). All in relation to the study which I was commenting on - not real life practice. This is a simplified argument, yes, but it gets the point across. Are RNs educated to do this? No. Are they able to? No. So for you to think I actually thought practice was this oversimplified was a stretch.
This is the same conspiracy rubbish that anti-vaxxers use. This study was authored by a mix of nursing and medical researched and published in one of the most prestigious medical journals in the world. The results have been demonstrated over and over again. Please, cite a refuting study.
OK, so we're completely ignoring my other comments on the studies? "It was published in JAMA" is your only retort? Re-read my reasons for why these studies are low impact. And as I mentioned earlier, to perform a *true* double blind randomized controlled trial between NP and MD care would be impossible.
Yes, personally I do feel there are problems with NP education as it stands right now, and many of my colleagues (including me) have been very proactive in attempting to correct them. I would prefer not to wait for the data to begin to swing.
"NP education has it problems and we (practicing NPs and educators) need to tackle them, in my opinion, but there truly isn't any evidence right now to support it."
Again, you have agree with me on many points if I read back through your previous comments. So I don't know why you are being so contrary to the point of contradicting yourself at times. Using poorly designed and conducted studies does not help your point. And, so, I guess I've decided I'll continue to argue these points even if you disregard them because I'm still in school.
I don't want to derail the thread so I will try and keep this short.
I simply feel that there is not a single NP program out there that adequately prepares students with their minimum requirements.
I don't know why I can't help myself here. Looking back through this thread, you've actually agreed with many of my points, but now it seems you're trying to be contrary for the sake of argument.
I disagree with your sweeping statement you made, and I don't think you have the experience and/or data to support your generalization. I am not being contrary but I do feel like posts like that should be challenged so other readers don't just take them as fact.
So how can you say that I can't comment on an educational process I am experiencing, but you can comment on other professions because med students rotate with you? Doesn't make sense.
Do you feel you have a good idea how the educational process you are experiencing is going to impact your clinical practice? Do you feel you can extrapolate that to all NP programs?
Note how I said we could take REGISTERED NURSES and, using the current evidence based protocols that most clinicians use, achieve appropriate outcomes in patients with simple, straight forward asthma, HTN and diabetes (which, whether you like to admit it or not, are very standardized treatment algorithms).
Again, get some clinical experience under your belt and see if you still feel that "standardized treatment algorithms" are easy to apply to clinical practice and don't require advanced practice to implement.
I'll continue to argue these points even if you disregard them because I'm still in school.
FWIW I think you will probably be a good NP if you approach it with the same kind of academic and intellectual vigor as this thread. I know it is unsolicited advice, but enjoy your time as a student and learn as much as you can, the NP ed battle can be fought in a few years, it will probably still be there. Again, take it or leave it, but it is very important in clinical practice to consider your education and experience and remaining inside of it. Best of luck in school.
Can you share with us what you and your colleagues have said or done to help correct this issue?
I don't want to speak for FNP, but from my point of view, I will talk about my experience in both academia and in practice. There are a number of people on Allnurses in general who use their own lived experience and use that to make broad general statements about nursing practice or education, and instead of coming up with pro-active solutions, they just complain. Many of us who have pursued any education beyond a BSN are happy that we did and understand the value of our education. When someone says "I simply feel that there is not a single NP program out there that adequately prepares students with their minimum requirements" I have to question their perspective. Has this person really looked into and knows the outcomes of every NP program? I don't even know that information and I teach graduate students.
Can you share with us what you and your colleagues have said or done to help correct this issue?
In short, we have worked with and continue to work with the following issues, including running some pilot studies which should shed some light on things within the next year:
1. Improving the pre-clinical and clinical experience. NP programs depend heavily on clinical experiences and there is a lack of standardization both within and across NP programs when it comes to the type and quality of these experiences. The pre-clinical experience has been suggested as an important factor in transitioning the RN into the provider role; we are looking at data from standardized patient experiences as pre-clincial preparation. Clinical experience, as mentioned, is variable and we are looking at ways to standardize this process. One of the most important factors is quality preceptors, and unfortunately, many programs are placing less preference on the quality of preceptor and instead allowing/forcing students to secure their own placements, at times with untrained preceptors and in less-than-ideal settings. We are working on pilot trials to identify and qualify these experience in hopes that we can ultimately change accreditation requirements if deemed necessary.
2. Standardizing the NP didactic curriculum. There are a number of topics being looked at and addressed/adjusted here. Again this ultimately falls to accreditation but there needs to be a effective model in place and that times a good deal of time. One of my personal pet peeves here is the fragmentation of the core clinical classes with the core pharmacology classes.
3. Preceptor training. We have looked at preceptor training as there is ample evidence from other disciplines that outcome quality is dependent on the effectiveness of the preceptor in their role; sadly many preceptors have never done any formal (or informal) training.
So, just a little of what I have been working on :)
So, just a little of what I have been working on :)
Those ideas sound great.
I wonder why nurse practitioner governing bodies have not put their foot down on low quality and/or recent proliferation of new programs. I know that new programs and easy admissions are lucrative to the actual school(s), but I don't see what benefit it provides to the governing NP boards. Maybe something behind the scenes.
I wonder why nurse practitioner governing bodies have not put their foot down on low quality and/or recent proliferation of new programs. I know that new programs and easy admissions are lucrative to the actual school(s), but I don't see what benefit it provides to the governing NP boards. Maybe something behind the scenes.
I'm not sure because my BON acts like it has no say in the matter of educational requirements. Sad thing is many of the higher-ups in the NP arena who I know are working for universities in some capacity and have a vested interest in squelching my complaints about NP education. Not that I ever complain, lol.
lol we all know its just a money bang. schools and BON get rich and people get to wear their white coats proudly. Everybody wins except the students at the tail end of the NP gold rush, currently working NPs, and the patients.
Dodongo, APRN, NP
793 Posts
I commented that I was more than qualified to comment on the educational process of NPs. As I am, right this very moment, experiencing it. But, with your line of reasoning, you have no ability to comment on the education or practice of physicians or PAs. Not having directly experienced something does not mean you can't objectively analyze it. And the point of a formalized training program is to direct your study. 99% of graduate NP programs do not have an anatomy or physiology class at the graduate level. NPs should not have to seek training from other sources to obtain a complete education. And do not attempt to say that any undergraduate level course is an appropriate substitute for a graduate level course because why then would we have graduate level pathophysiology, etc? Training programs are lacking in these areas. All I'm saying.
First, these studies do not specify details of what the "screening criteria" were (a small blip mentions not currently having a PCP and planning to be in the area for 6 months, but doesn't clearly limit it to that). Then, the study loses 40% of patients at the recruitment stage, which doesn't directly bias in one way or another, but it does put the study validity into question with the absence of inclusion criteria. And the first study tracks primary care for an underwhelming total of 6 months post ED visit - a very short period of time for chronic conditions. Especially post ED visit - which happens to be their recruitment center - which would indicate a strong regression to the mean for all parties and certainly mask inter-group differences and, therefore, bias us towards the null. Even, the study itself admits to having a low statistical power. But most importantly these studies†don't distinguish between patients based on presenting condition. Saying that patients with asthma look the same in 6 months or 2 years is different depending on whether they presented to the ED for uncontrolled asthma, or presented to the ED for a stubbed toe or abdominal pain, etc. Further, they focus on diseases where diagnosis is extremely straight forward and treatment is absurdly standardized. In other words, with a study heavily biased towards the null. Even a registered nurse could follow the recommended AAP flow sheet for diagnosis and treatment of asthma, or the JNC for HTN or the ADA for diabetes. 9/10 times if you throw Advair, ACE or Metformin at these people you'll be practicing within the standard of care. I would also love a control group of patients who refused treatment and see how similar their measured outcomes would be. None of this is surprising, however, coming from studies with Mundinger as the lead author, as she is HEAVILY biased toward NPs given her background, much in the same way that studies published by drug companies are. Finally, they don't look at patient oriented outcomes. It doesn't really matter if the A1Cs were the same, does it. Which group had less complications? We aren't given that information. How were secondary causes or other comorbidities managed with these patients – if there were any at all. Maybe these patients were excluded but we aren't even given that information in the first place.
On the surface, they may look great, but if you get past the abstract you'll find they are incredibly flawed.
And hyperbole won't help your argument. No one suggested NPs go to school for an increased length of time. Only that an increased push for independence is unwarranted due to the short comings in their educational process - which can be easily fixed. Add about 2 more classes and require the students to spend more time in clinicals with formalized, observed instruction.
So you admit there are problems that need to be addressed, but don't think there is evidence that you and your colleagues should attempt to address them? Ok...?
You have made it clear that you think only practicing NPs have any ability to comment on this at all so I will bow out.