DNP versus MD?

[beetlerum]

I think we have a troll here.

From the American Associaion of Nurse Anesthetists:
http://www.aana.com/AccreditedPrograms/accreditedprograms.asp

Most are 24-27 months long. It's a Master's degree and basically it is 2 years long.

I think you need a bachelors in nursing first. If you don't have that, it's a four year program. Now you'll say "but docs need 4 years before the advanced degree." Well, yes, but really, how much of undergrad is training? C'mon now, be intellectually honest about these issues.

Nurses clearly do have a more superficial knowledge of the diseases, but does that mean they'll deliver worse care? I don't know, but it's not clear to me that they would. You can say they don't have residency, but so what? They can learn on the job. There's nothing magical about residency.

Basically, if docs want to say that NPs can deliver the same care as MDs because of having less training (which apparently confers some magical training aspect that can never be compensated for by on the job experience), then they need to cite studies. Hasn't anyone compared FPs to NPs?

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[velo]

I think we have a troll here.

From the American Associaion of Nurse Anesthetists:
http://www.aana.com/AccreditedPrograms/accreditedprograms.asp

Most are 24-27 months long. It's a Master's degree and basically it is 2 years long.

Maybe she meant you already have to be an RN to do it...or something? I don't know, we can only guess because she just said "get your facts striaght" instead of the more helpful "these are the facts."

Perhaps its viewed like a fellowship program? Still 2 years is much shorter than any residency in anesthesiology so I think your point is still valid, however crooked your facts apparently are.

 

[trudub]

I think you need a bachelors in nursing first. If you don't have that, it's a four year program. Now you'll say "but docs need 4 years before the advanced degree." Well, yes, but really, how much of undergrad is training? C'mon now, be intellectually honest about these issues.

Nurses clearly do have a more superficial knowledge of the diseases, but does that mean they'll deliver worse care? I don't know, but it's not clear to me that they would. You can say they don't have residency, but so what? They can learn on the job. There's nothing magical about residency.

Basically, if docs want to say that NPs can deliver the same care as MDs because of having less training (which apparently confers some magical training aspect that can never be compensated for by on the job experience), then they need to cite studies. Hasn't anyone compared FPs to NPs?

I think what some people are saying is not that an CRNA will deliver poorer care once they have been in practice for ten years and have received the on the job training you speak of. However, a CRNA can graduate and go immediately into practice. An MD cannot do that. Without a residency, they can immediately practice and do not necessarily have to get that on the job training. That is the magic of residency. It mandates that MD's receive on the job training with oversight.

 

[velo]

I think you need a bachelors in nursing first. If you don't have that, it's a four year program. Now you'll say "but docs need 4 years before the advanced degree." Well, yes, but really, how much of undergrad is training? C'mon now, be intellectually honest about these issues.

whoa whoa, that's right I forgot. You often get a nursing degree as an ugrad. So its 4+2 for the nursing (OR apparently just 4 years to do it straight away) compared to 4+4+4 for an MD Anesthesiologist.

Just keeps getting better doesn't it?

 

[Taurus]

Maybe she meant you already have to be an RN to do it...or something? I don't know, we can only guess because she just said "get your facts striaght" instead of the more helpful "these are the facts."

Maybe you're right. I just assumed that people knew CRNA's were Master's degrees and that you needed a bachelor's degree first to get a Master's. Should I also point out that the sky is blue?

 

[Taurus]

I think what some people are saying is not that an CRNA will deliver poorer care once they have been in practice for ten years and have received the on the job training you speak of. However, a CRNA can graduate and go immediately into practice. An MD cannot do that. Without a residency, they can immediately practice and do not necessarily have to get that on the job training. That is the magic of residency. It mandates that MD's receive on the job training with oversight.

I think that most CRNA programs include a semester long internship in the OR before graduation. So, they get some hands-on experience, but not as long as a doc obviously. At major hospitals that I've seen, the CRNA is under the supervision of a doc. The doc comes in during "take-off" and "landing" and pops in once in a while during the operation and the CRNA maintains and monitors the patient the rest of the time. What scares me is the idea that some hospitals/clinics, especially small and rural ones, have no docs around to supervise the CRNA. They're autonomous and it is completely legal in certain states. How would you like to be the first patient for a very green CRNA who has no doc or experienced CRNA supervision?

 

[saradoor]

whoa whoa, that's right I forgot. You often get a nursing degree as an ugrad. So its 4+2 for the nursing (OR apparently just 4 years to do it straight away) compared to 4+4+4 for an MD Anesthesiologist.

Just keeps getting better doesn't it?

FYI, CRNA requires more than 4+2. It is more like 4+2+2 but it is still shorter than an MD. Below is a strict copy from Wikipedia (http://en.wikipedia.org/wiki/Certified_Registered_Nurse_Anesthetist):

In the U.S., nurse anesthetists first complete registered nursing school at the baccalaureate level, a four-year program. Then, most nurse anesthesia programs in the United States require at the minimum two years of nursing experience in a critical or acute care environment. Following that, they then enroll in an accredited program of anesthesia education for an additional two to three years which combines theory, didactic education and clinical practice. Upon passage of a national certification examination, they are also certified by the Council on Certification of Nurse Anesthetists (CCNA). Most CRNAs have master's degrees in anesthesia. CRNAs also have Continuing Education requirements, and recertification program every two years thereafter.

 

[trudub]

FYI, CRNA requires more than 4+2. It is more like 4+2+2 but it is still shorter than an MD. Below is a strict copy from Wikipedia (http://en.wikipedia.org/wiki/Certified_Registered_Nurse_Anesthetist):

In the U.S., nurse anesthetists first complete registered nursing school at the baccalaureate level, a four-year program. Then, most nurse anesthesia programs in the United States require at the minimum two years of nursing experience in a critical or acute care environment. Following that, they then enroll in an accredited program of anesthesia education for an additional two to three years which combines theory, didactic education and clinical practice. Upon passage of a national certification examination, they are also certified by the Council on Certification of Nurse Anesthetists (CCNA). Most CRNAs have master's degrees in anesthesia. CRNAs also have Continuing Education requirements, and recertification program every two years thereafter.

It is not necessarily a requirement though to work between BSN and CRNA. I have a friend in CRNA program right now and he went straight from his BSN to CRNA program with no work in between. Some schools may require it, some may put emphasis on work experience for the application process but it is not universally required. Anesthesiologists do 4+4+4 without exception.

 

[Taurus]

FYI, CRNA requires more than 4+2. It is more like 4+2+2

Many CRNA programs require at least 2 years of prior nursing experience in like the ICU before admission. But, that is 2 years of a real job, getting paid real world salary and benefits. Many top MBA programs require work experience too. Working at a real job, however, is not like school or residency, which are structured training programs. You gain lots of great hands-on experience from working, but it does not substitue for accredited training programs which have specific objectives for the student to learn or experience before graduating.

 

[fab4fan]

That is what I have been asking for all along. Point me to the sites. Because word of mouth so far has included 2 NP's and a handful of doctors all saying the same thing. That was exactly what I was looking for when I brought this up, please point me in the right direction. I did not mean to start a war either. I think you got way too defensive way too early. I WANT you to correct me because I am hoping I have MISINFORMATION. So, if you could help me out, I would appreciate it.

As I said, you'd have to look at the standards related to the particular specialty, e.g. www.napnap.org is the certifying entity for pediatric nurse practitioners.

I am not going to list links to every nursing specialty. I suppose you could probably go to www.ana.org/ancc/ and find additional info there.

I just did a random Google search for standards of care for different nurse practitioner specialties and didn't have any trouble finding links for standards, so I'm not sure why you're having trouble.

 

[fab4fan]

if a doctor and nurse differ is opinion I think the doctor wins by default.

Wow. This is the kind of thinking that gets people into serious trouble.

 

[rn29306]

Maybe you're right. I just assumed that people knew CRNA's were Master's degrees and that you needed a bachelor's degree first to get a Master's. Should I also point out that the sky is blue?

How about if I made the statement: Medical school is only four years.

You'd be crying about how you need an undergrad and then residency to be a physician. Facts are facts. Yes, the actual CRNA school is 23-36 months, but it takes an undergrad to do this. Medical school is only four years, but you have to have undergrad + residency also.

Quit your bellyaching and stop making CRNA education sound like a technical school for welding and plumbing.

 

[Taurus]

How about if I made the statement: Medical school is only four years.

Really? Whew, thanks for clearing that up. I would never have known that. After all, this is a forum for medical students and I am a medical student.

Please do some research before making random, general statements without providing bona fide references. Go back to your nursing board.

 

[velo]

How about if I made the statement: Medical school is only four years.

I think we'd all agree that you are correct. Medical school is 4 years.

 

[ddmo]

\Nurses clearly do have a more superficial knowledge of the diseases, but does that mean they'll deliver worse care? I don't know, but it's not clear to me that they would. You can say they don't have residency, but so what? They can learn on the job. There's nothing magical about residency.

Basically, if docs want to say that NPs can deliver the same care as MDs because of having less training (which apparently confers some magical training aspect that can never be compensated for by on the job experience), then they need to cite studies. Hasn't anyone compared FPs to NPs?

The difference between residency and on the job training is oversight. Residents are not autonomous, their care is provided under the guidance of an attending physician or surgeon. Meanwhile, many NPs are practicing in clinics with little or no oversight from an MD, or at least someone with more experience than them, since they are often the top rung of the ladder in those circumstances. Not to mention the are pushing for more autonomy.

I would prefer the intern who has 20+ older residents and an attending overlooking his decisions taking care of me, than a fresh NP on his or her own in some clinic.

 

[Taurus]

I thought the DNP degree was just in the idea phase, but it's further along than I thought. Even my own school is beginning to offer the degree. Columbia is the first program and it enrolled its first class in the fall of 2005.

http://cpmcnet.columbia.edu/dept/nursing/programs/drnp_approved.html

From the description, it sure sounds like the DNP degree is designed to be the of equivalent of the physician degree in the eyes of insurers and regulators. This is especially true in those states that currently allow NP's to practice autonomously. Since not all states have done that, DNP's will probably be restricted to certain states for the time being, but it's just a matter of time before all the states fall in line. Heck, they even spend one of those years in "residency". How cute.

Here are some questions: Do they have the same scope of practice as physicians? Would they get the same reimbursements as physicians? What will their malpractice premiums be like? If there are few or no differences, then the creation of the DNP has effectively gutted the role of the primary care physician. In the next few years, there will be over 200 schools that offer this degree. It will flood the market with primary care practitioners. Together with PA's, maybe DNP's are the solution to the primary care crisis in this country. That's great news if you're a PA, NP, or DNP, but not as a physician because it will dilute your value.

To those of you who may say, so what? It's just primary care that is affected, right? Don't bet on it. They will try to encroach on as many medical fields as they can. I can even see the idolized derm specialty under assault from DNP's who want to pop your pimples and inject botox into you. Surgery is probably the only medical bastion that won't fall so easily.

I keep asking the same question over and over again: What have our medical leaders been doing while these changes have been occurring? They completely dropped the ball when they miscalculated in their physician demand projections. They have been standing idly by as the role and prestige of the physician is slowly being eroded away by these other professional groups. What changes and innovations have they come up with to stem that?

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Will this degree be recognized by third party payers?
Graduates will have the knowledge and skills to be eligible for reimbursement by all third party payers within state regulations. The Doctor of Nursing Practice degree will offer a clear credential to payers who increasingly want to apply standardized quality credentialing for all members in all states where they conduct business. Requirements for independent reimbursement of DrNP nurses will mirror requirements for physicians and will include: standard competencies, certification, scope of practice and a doctoral degree.

Why is this degree necessary?
Advanced practice nurse's practice authority and accountability are growing nationally. At the same time the public, payers, and policy makers are demanding providers be educated to assume this growing responsibility. Degree titles in the professions have long served to identify the education and abilities of its members. The DrNP title will provide a standard to identify those with the skills and knowledge to legitimately assume the highest level of clinical interaction with patients.

 

[fab4fan]

As quick as I am to defend my profession, I think the DNP degree is stupid. I think there's a place for NPs, but going to this level is just wrong. If someone wants that level of autonomy, go to medical school. Patients are already confused by all the different levels of providers; this is not going to help at all.

 

[LAZYGUY]

You are not alone. There was an article by the Texas Medical Association that quoted many nursing schools as being against this degree. There is a HUGE nursing shortage right now & many fear that plan will only propagate this end further. If you have nurses staying in school longer, or leaving clinical practice to enter these programs I can't help but see an even greater shortage occurring as a result of these programs cropping up.

It really has become an MD vs. RN fight. This is completely unnecessary...you have all these health care providers sticking a 36month curriculum to their current master's curriculum & now they are ready to be "doctors". But I guess that's better than what other groups have done in the past, such as CRNAs which have lobbied for more rights and have expanded their scope of practice not because of any additional education that they have attained but because they have resorted to taking these issues again and again to individual state governments until they find a politician that will side with them. In any case, you eventually find someone that will see your point, no matter how twisted or irrational it may be.

As quick as I am to defend my profession, I think the DNP degree is stupid. I think there's a place for NPs, but going to this level is just wrong. If someone wants that level of autonomy, go to medical school. Patients are already confused by all the different levels of providers; this is not going to help at all.

 

[LAZYGUY]

“The program is comprised of 30 credits of science underpinning practice, a year of full-time residency, and the completion of a scholarly portfolio of complex case studies, scholarly papers and published articles.
"We are extremely pleased to be the first academic institution in the country to offer a clinical doctorate in nursing that prepares nurses for practice at such a high level," stated Mary O'Neil Mundinger, DrPH, Dean and Centennial Professor in Health Policy at Columbia University School of Nursing. "The implications of the Doctor of Nursing Practice degree cannot be overstated. Currently, primary care is a medical specialty in decline. Due to the unique training provided during the DrNP program, graduates will be able to fill the gap that has been left in the primary care specialty.


This is just a bunch of crap. I would like to have a discussion with this Marry Mundinger lady as to how 30 credits of nursing education is going to "lift up the field of primary care". And what are these "unique training techniques" that will have such great implications on medicine?

It seems that individuals want to color something a different color using words and descriptions that really are not representive of the truth and in fact, utterly deceiving to the public.

 

[fab4fan]

Bedside nursing is pretty grim these days...nurses would find another way to leave if advanced practice wasn't an option.

In any case, the doctorate is just not the right way to go. The fact that the ANA is backing this tells me all I need to know about it. People with no clue about real pt. care deciding how pt. care should be delivered.

 

[LAZYGUY]

Yeah I agree, nurses are burning out with all the stuff they have to face and doctors are not supportive of them because they are too busy stroking their own egos. It is a shame that we have to lose great nurses alltogether. I can totally see myself doing the exact same thing if I were in their position. The system needs to be changed & unfortunately there are many problems that physicians have to face as well.

I sit back and think about the power that we could have if nurses & physicians stood together in one voice. imagine the changes that would take place....

Bedside nursing is pretty grim these days...nurses would find another way to leave if advanced practice wasn't an option.

In any case, the doctorate is just not the right way to go. The fact that the ANA is backing this tells me all I need to know about it. People with no clue about real pt. care deciding how pt. care should be delivered.

 

[erasable]

You are not alone. There was an article by the Texas Medical Association that quoted many nursing schools as being against this degree. There is a HUGE nursing shortage right now & many fear that plan will only propagate this end further. If you have nurses staying in school longer, or leaving clinical practice to enter these programs I can't help but see an even greater shortage occurring as a result of these programs cropping up.

Yes there is a shortage of nurses. Thus the certified nursing assistants are born. They will in turn lobby for the same rights as nurses, and given enough decades...the same rights as doctors. When the succeed, Certified assistants of certified nursing assistants will step foward...and so the story goes...turtles all the way down.

If someone wants that level of autonomy, go to medical school.

I think it's far more financially efficient and less stressful for nurses to just have legislatures mandate equal rights for them, rather than go back to med sch. Think about it: ~240,000$ for 4 yrs including living expenses, the opportunity cost of a nurse not working ~400,000$ for 4 years, and let's not forget nurses are human and get stressed over classes like we do.

 

[LAZYGUY]

well, unfortuately as sarcastic as your post is...it's not too far from what's happening even now.

Yes there is a shortage of nurses. Thus the certified nursing assistants are born. They will in turn lobby for the same rights as nurses, and given enough decades...the same rights as doctors. When the succeed, Certified assistants of certified nursing assistants will step foward...and so the story goes...turtles all the way down.



I think it's far more financially efficient and less stressful for nurses to just have legislatures mandate equal rights for them, rather than go back to med sch. Think about it: ~240,000$ for 4 yrs including living expenses, the opportunity cost of a nurse not working ~400,000$ for 4 years, and let's not forget nurses are human and get stressed over classes like we do.

 

[akaz]

I am basically against the practice of NP in place of MDs. My reasoning has nothing to do with economics. I lived on a reservation. The Indian Health Service mainly had NPs. We hardly had any physicians. We had some of the worst care possible. Maybe it was the lack of training. It also sets the precedence of well poor or rural people don't deserve physicians. Sorry you guys live in the sticks, you only get nurses. Most people were misdiagnosed. My favorite was when I was 14 yrs old. I was sick for a week with sore throat etc. I was told I had chronic fatigue syndrome. How chronic is a week? Anyway, they didn't bother to do a culture. I had strep. 3 weeks later I was very sick and hospitalized. These stories are the norm.

 

[fab4fan]

Yeah, well, there are lots of incompetent docs out there, too. What's the excuse for them, since they have more education? Just because you had a poor experience with an NP does not mean that all NPs are lousy.

There are bad practitioners in every profession. For every inept NP story you can tell, I can go you one better with a scary doctor tale.

 

[Empress]

People expect that when they get sick a doctor will take care of them. The public does not view seeing a doctor as a privelege but rather as a right....and it is.

I don't think the public will ever stand for this type of medical mediocrity.

I think that's somewhat underestimating what the public as whole really want from healthcare providers. They don't want doctors, they want an idealized version of a doctor.

They want someone to pay undivided attention to them for every little problem. They want to be included in their medical decisions, told what they really want to hear, and never to be judged. They want someone who will never, ever make a mistake because they will tell everyone they know how their doctor was wrong. They also want it all to be affordable, which can mean anything from the true definition of affordable to free care plus a foot rub.

Face it, patients don't care about a medical degree as much as the attention, compassion, perfection, affordability. If they can see a NP or PA and get most of what they want, they will. For the large part the US population is a fickle, capricious bunch with entitlement issues. Saying that they won't accept medical mediocrity is missing the big picture by a mile. It's not about the doctors, the public could give a fig less, they want an excellent healthcare experience.

 

[deleted87716]

I think that's somewhat underestimating what the public as whole really want from healthcare providers.

More like overestimating.

What do you expect from a public who likes their food fast, cheap, and bad for them?

 

[erasable]

Face it, patients don't care about a medical degree as much as the attention, compassion, perfection, affordability. If they can see a NP or PA and get most of what they want, they will. For the large part the US population is a fickle, capricious bunch with entitlement issues. Saying that they won't accept medical mediocrity is missing the big picture by a mile. It's not about the doctors, the public could give a fig less, they want an excellent healthcare experience.

I think you're overestimating NP's and PA's. Their existence does not necessarily bring us an excellent healthcare experience. I'd also like to point out that when one's life on the line attention, compassion, perfection, affordability are *lower* on one's list of priorities.

Yeah, well, there are lots of incompetent docs out there, too. What's the excuse for them, since they have more education? Just because you had a poor experience with an NP does not mean that all NPs are lousy.

No one is saying that all NPs are lousy. However, I think we can all agree that there exists a significant difference in the way NP/PA and physicians are trained.

 

[Empress]

I think you're overestimating NP's and PA's. Their existence does not necessarily bring us an excellent healthcare experience. I'd also like to point out that when one's life on the line attention, compassion, perfection, affordability are *lower* on one's list of priorities.

I am not overestimating NP/PAs roles at all. I am rather neutral on their role. I've met some excellent and some horrid NP/PAs, same with physicians. I don't think they provide excellent healthcare experience by themselves, it depends on their relationship with physicians and as members of the healthcare team overall.

 

[LAZYGUY]

Face it, patients don't care about a medical degree as much as the attention, compassion, perfection, affordability. If they can see a NP or PA and get most of what they want, they will. For the large part the US population is a fickle, capricious bunch with entitlement issues. Saying that they won't accept medical mediocrity is missing the big picture by a mile. It's not about the doctors, the public could give a fig less, they want an excellent healthcare experience.

BINGO!

 

[Taurus]

I'd also like to point out that when one's life on the line attention, compassion, perfection, affordability are *lower* on one's list of priorities.

Face it, patients don't care about a medical degree as much as the attention, compassion, perfection, affordability. If they can see a NP or PA and get most of what they want, they will. For the large part the US population is a fickle, capricious bunch with entitlement issues. Saying that they won't accept medical mediocrity is missing the big picture by a mile. It's not about the doctors, the public could give a fig less, they want an excellent healthcare experience.

I agree with both of you. For routine health maintenance, most people wouldn't consider their lives on the line and they probably wouldn't have a problem seeing either a physician, NP, PA, or RN. The experience will be better if the person is attentive, compassionate, and cheaper. If this weren't the case, you wouldn't be seeing health clinics popping up at retailers like Wal-Mart staffed by mid-levels. If something serious is discovered, then you can get referred to a physician with that specialty.

If your life is in immediate danger, you obviously want the best care you can get so that your life can be saved. Then, people want someone who is the most competent and experienced to take care of them. I think most people would agree that person would be a physician given all his/her training.

 

[schutzhund]

I agree with both of you. For routine health maintenance, most people wouldn't consider their lives on the line and they probably wouldn't have a problem seeing either a physician, NP, PA, or RN. The experience will be better if the person is attentive, compassionate, and cheaper. If this weren't the case, you wouldn't be seeing health clinics popping up at retailers like Wal-Mart staffed by mid-levels. If something serious is discovered, then you can get referred to a physician with that specialty.

If your life is in immediate danger, you obviously want the best care you can get so that your life can be saved. Then, people want someone who is the most competent and experienced to take care of them. I think most people would agree that person would be a physician given all his/her training.

Please do not make the mistake of thinking that the NPs plan only to deal with stuffy noses and colds. They specialize too. Don't think for a moment that ANY of the specialties are immune. The DNP is just one more step for them to claim every aspect of medicine is an extension of the practice of "nursing."

Read the ANA or the American Academy of Nurse Practitioners statement on the scope of "nursing" practice. Surf on over to allnurses.com and do some reading.

If you can draw any conclusion other than that they want to compete with physicians on EVERY level and in EVERY field, please let me know how.

 

[Taurus]

Please do not make the mistake of thinking that the NPs plan only to deal with stuffy noses and colds. They specialize too. Don't think for a moment that ANY of the specialties are immune. The DNP is just one more step for them to claim every aspect of medicine is an extension of the practice of "nursing."

Read the ANA or the American Academy of Nurse Practitioners statement on the scope of "nursing" practice. Surf on over to allnurses.com and do some reading.

If you can draw any conclusion other than that they want to compete with physicians on EVERY level and in EVERY field, please let me know how.

I completely agree with you. Only a naive person would think that the nursing groups wouldn't push for more authority and privileges on par with physicians.
Initially, it would be in primary care, but they will go after any "low hanging" or "easy picking" medical work like treating acne or injecting botox. If physicians say DNP's are not real doctors because they don't go through a full residency, then I don't see why residencies couldn't be created for DNP's too by the nursing groups.

Unless the AMA use their political clout to clearly define what is the practice of medicine, physicians will have to move up the food chain and acquire very specialized knowledge or we will compete directly with DNP's and PA's. So far, the AMA's response has been less than overwhelming:

http://216.239.51.104/search?q=cach...c+ama+resolution+211&hl=en&gl=us&ct=clnk&cd=6

 

[AngryBaby]

I completely agree with you. Only a naive person would think that the nursing groups wouldn't push for more authority and privileges on par with physicians.
Initially, it would be in primary care, but they will go after any "low hanging" or "easy picking" medical work like treating acne or injecting botox. If physicians say DNP's are not real doctors because they don't go through a full residency, then I don't see why residencies couldn't be created for DNP's too by the nursing groups.

I would think there's only so far they can go with this. If they actually gain access "low hanging medical work" then malpractice insurance will surely become a proportionately increasing issue. They'll eventually reach a point when insurance alone negates this "cost-effective" medical practice. Throw in that they want to be reimbursed like physicians and it becomes even less cost-effective. I agree it's developing issue, but I think there's far too many yet-to-be-determined variables to spell out Doomsday just yet.

I think this WalMart idea (of which I was ignorant) is a good way to help get at least primary care to the uninsured.

 

[Taurus]

I would think there's only so far they can go with this. If they actually gain access "low hanging medical work" then malpractice insurance will surely become a proportionately increasing issue. They'll eventually reach a point when insurance alone negates this "cost-effective" medical practice. Throw in that they want to be reimbursed like physicians and it becomes even less cost-effective. I agree it's developing issue, but I think there's far too many yet-to-be-determined variables to spell out Doomsday just yet.

I think this WalMart idea (of which I was ignorant) is a good way to help get at least primary care to the uninsured.

Since the DNP's would do routine cases and can always refer complex cases to a physician, I think that DNP's malpractice premiums would be lower than physicians'. Routine cases should have fewer complications and problems and hence lower liability. In addition, DNP's are now "doctors" so insurers may feel more comfortable about their ability to deliver care. If a particular DNP is too wreckless, then his/her individual premiums will substantially increase. It is analogous to the car insurance model. Car insurance companies look at the average risk for all drivers and charge everyone based on their age, location, etc. In any group, you have outliers and some people are wreckless drivers. Those drivers are charged much more than others. This is the same reason why certain specialties such as neurosurgery and Ob-Gyn have such high average insurance premiums because there are lots of complications and they are sued more often.

 

[AngryBaby]

Since the DNP's would do routine cases and can always refer complex cases to a physician, I think that DNP's malpractice premiums would be lower than physicians'. Routine cases should have fewer complications and problems and hence lower liability. In addition, DNP's are now "doctors" so insurers may feel more comfortable about their ability to deliver care. If a particular DNP is too wreckless, then his/her individual premiums will substantially increase. It is analogous to the car insurance model. Car insurance companies look at the average risk for all drivers and charge everyone based on their age, location, etc. In any group, you have outliers and some people are wreckless drivers. Those drivers are charged much more than others. This is the same reason why certain specialties such as neurosurgery and Ob-Gyn have such high average insurance premiums because there are lots of complications and they are sued more often.

That's actually my point, perhaps you were more concise. If DNP's want to start chipping away at the FP practice then their premiums will increase as well. If they stay at the WalMarts of the world then they won't be doing much in the way of infringing upon physicians turf. If they want more then their premiums will increase, their bills will increase, and eventually you don't have a cheaper FP but a similarly priced DNP with less training...that doesn't sound appealing.

 

[Red Beard]

That's actually my point, perhaps you were more concise. If DNP's want to start chipping away at the FP practice then their premiums will increase as well. If they stay at the WalMarts of the world then they won't be doing much in the way of infringing upon physicians turf. If they want more then their premiums will increase, their bills will increase, and eventually you don't have a cheaper FP but a similarly priced DNP with less training...that doesn't sound appealing.

Excellent point.

 

[Taurus]

That's actually my point, perhaps you were more concise. If DNP's want to start chipping away at the FP practice then their premiums will increase as well. If they stay at the WalMarts of the world then they won't be doing much in the way of infringing upon physicians turf. If they want more then their premiums will increase, their bills will increase, and eventually you don't have a cheaper FP but a similarly priced DNP with less training...that doesn't sound appealing.

1) Wal-Mart is just one example. Vast majority of them won't be working at Wal-Mart. If you read the literature for any of these DNP programs, these grads are being trained specifically for independent practice.

2) An important reason for the DNP degree is to justify to insurers and regulators that DNP's should be seen as the equivalent of primary care physicians. Therefore, they will lobby and demand the same reimbursement levels. Since they initially would do routine care, their malpractice premiums would be lower. Even if we assume their premiums would be the same as a physician's, their existence will lower the salaries and decrease job opportunities for all primary care physicians. The pie (number of patients who are seeking certains services) is only so big. If you have more people at the table (providers), everyone will get a smaller piece of the pie. In several years, there will be more DNP schools than MD/DO schools combined. I don't have the number of annual DNP graduates though. 100 per class?

I have heard the argument that since there is already shortage of nurses where will the students come from to fill these DNP schools? How many people are turned away from MD/DO schools every year? What about RN's who were turned down for CRNA school? Or people who were turned down for pharmacy, PT, or PA school? This will open a new avenue for these students to a meaningful, advanced degree. A nursing degree is not required to apply to these programs. Furthermore, if a DNP is a shortcut to primary care, people who could have gone to MD/DO school will instead choose this path. In a few years, see if DNP programs have any trouble filling their classes.

 

[beetlerum]

You all do realize that years of formal training is only one input into quality of care? It is a dogma in medicine that you input a certain number of years of formal training (as defined by doctors, on the job doesn`t count unless you mean residency) and out spits a certain level of competence. Unfortunately, this is not true. Many other factors matter. For example, perhaps NPs can spend more time with each patient and that also affects quality of care.

Also, there is such an irony in this debate. Doctors claim to hate the idea of socialized medicine and say they want capitalism. Yet they want all kinds of anti competitive laws to protect their "pie." If patients feel that the cost/quality mix is better for NPs, then they should get to go to NPs. And don't give me any bull about patients not knowing better. This has nothing to do doctors protecting patients. This is about doctors, like all interest groups, looking out for their own interests, fighting for anticompetitive laws that allow more doctors to earn higher salaries than the market will bear.

 

[Empress]

I have heard the argument that since there is already shortage of nurses where will the students come from to fill these DNP schools? How many people are turned away from MD/DO schools every year? What about RN's who were turned down for CRNA school? Or people who were turned down for pharmacy, PT, or PA school? This will open a new avenue for these students to a meaningful, advanced degree. .

The shortage of nurses isn't because of an inadequate number of people who want to be nurses; it's a combination of an aging population, rate of retiring nurses, people leaving the profession due to stress, and not enough professional nursing educators to teach students. Therefore, a professional bottleneck is happening.

The advanced professional degrees are also a carrot to entice people who would otherwise not entering nursing, like college-degreed men. As many people who are happy to have a associate degree in nursing and work bedside nursing all their career, there are many who have more ambition.

I don't really understand why it's a bad thing.

 

[UserNameNeeded]

In a hospital or clinical settings that has both DOs/MDs and DNPs, would everyone be referred to as "doctor" in front of patients? Isn't that misleading patients?

 

[jonb12997]

http://www.aacn.nche.edu/DNP/pdf/DNP.pdf policy statement by the american association of colleges of nursing

 

[jw83]

Wow, this is rather scarry. Less training and less regulation but the possibility of similar if not equal rights as MD/DOs. Does anyone know what we can do or who we can contact so that something is done about this?

 

[Taurus]

I don't really understand why it's a bad thing.

I don't know how I can make it any clearer. I guess that unless you have found yourself in a situation like I have where less trained and less abled but cheaper professionals infiltrate your industry then you probably don't know what it's like to have that feeling of losing control and dreading about your job and future of the career path you have chosen. It's like fighting a shadow. You can't compete unless you want to lower yourself to their standards. If my predictions come true, you will experience firsthand what I have been describing in my posts. By then, it probably will be too late for you to do anything about it.

Does anyone know what we can do or who we can contact so that something is done about this?

The genie is out of the bottle. Columbia already enrolled its first class in 2005. Other schools will start their programs very soon. The AMA is probably the only group that can do something, but I'm not optimistic. This country is aging and we need primary care providers in a hurry. DNP's fit the bill.

 

[erasable]

The genie is out of the bottle. Columbia already enrolled its first class in 2005. Other schools will start their programs very soon. The AMA is probably the only group that can do something, but I'm not optimistic. This country is aging and we need primary care providers in a hurry. DNP's fit the bill.

Unless the AMA use their political clout to clearly define what is the practice of medicine, physicians will have to move up the food chain and acquire very specialized knowledge or we will compete directly with DNP's and PA's. So far, the AMA's response has been less than overwhelming:

um...earlier Taurus said that "AMA's response has been less than overwhelming". Can anyone explain why is that so? And what can we do about it?

 

[EctopicFetus]

This sounds like typical MacGyver gloom and doom.

Truth is a lot of primary care spots go to FMGs who (in my not so limited experience) have a hard time communicating with patients.

During my 4 week medicine Sub-I I "translated" 4 times between my Indian residents and the inner city patients we saw. Truth is what would have happened if I wasnt there...

Bottom line this thing wont be as serious as you all think, the bulk of primary care is dealing with chronic diseases and prescribing different meds.

In the end the consumer isnt as dumb as everyone thinks.

 

[EctopicFetus]

um...earlier Taurus said that "AMA's response has been less than overwhelming". Can anyone explain why is that so? And what can we do about it?

The AMA is worthless. They are too busy lining their own pockets instead of lining the pockets of its members.

 

[Instatewaiter]

First of all, malpractice premiums for DNP's would not be lower than for primary care MDs. For an insurance company, an autonomous DNP with essentially the same rights (as an PCP) yet significantly less training would be a much greater risk to insure. It makes no difference whether a DNP mainly sees the 'easier cases.' 99% of what a PCP sees is a guy with a rash or a kid with a cough. Not too challanging. They need the insurance for those very difficult cases, for which they would be much better prepared than a DNP, I would hope. Plus, don't for a minute thing that Joe Public will not be quicker to jump on a Nurse doctor than a real MD. Insurance companies know all of this and will charge according to the percieved risk.

In terms of calling an MD, DO and DNP doctor, I think it is a ridiculous idea and confusing to a patient. DNP should still be called nurse, as it is no doubt a lower degree. If you want to be called doctor, go to a medical school. If I want to be a lawyer, I can't just make up my own degree, say a doctor of law instead of the traditional juris doctor. Rather, I have to go to law school and pass the Bar exam. If DNP wants to be called a doctor, go to med school and pass USMLE 1,2 & 3.

The DNP is basically the addition of a few classes onto a master's degree of nursing. I finished the classwork for a classical MS in biochemistry this year (~30 credit). All the courses I took, I will also take in medical school. In addition, I will have to take 5 more classes in the first year of med school (which would be 5 credits a piece in grad school) that I did not take in grad school. So essentially the first year of med school is comprable to about 55 grad level classes. 30-45 credits is the basic DNP. That would be like sending me, now, to do a residency of a year, and then giving me the rights and priveledges of a doctor. Whats worse is that nursing school no doubt less difficult than medical school.

Here is an example to demonstrate the above. An RN (I know, not an NP) in the department where I work recently took a 200 level anatomy and physiology course at the local college. This undergrad college is very easy and the course she took is known to be a joke. She got a C after working her butt off and is already a nurse. A practicing nurse, got a C in undergrad phys. While understandably, I will hear concerns that she only has a bachelors degree and not a masters, but it is an undergrad course in her field. It is representative of the scientific foundation a nurse gets and what a DNP would lack when compared to an MD.

With regards to the lack of response from the AMA, there is no major percieved risk. When needed, the AMA will come down hard. It and not the AACN is the authority on things medical. Right now, it is a great idea that we have more people to meet the demand. The DNP degree came along because patients have competing interests; they want good, personalized care while making it cheap. Kudos to the nurses for trying to meet the demand and the patients' intersts. Unfortunately, I fear that quality of care will deminish. While I agree that a nice and compasionate care provider is a good thing, it is NOT the most important when quality of care suffers. People would rather an A$$hole cure the disease than have a nice person hold their hand as they die. The most intellegent and able person should be in charge. It is the role of the AMA NOT THE PATIENT to decide who is fit to be called a doctor. While this may seem paternalistic, I would assert that most people do not know what is good for them when it comes to medical care. Furthermore, this paternalistic notion is the entire reason the AMA was created. Without the ability to understand all the facts, people cannot know what is good for them, so a group was set up to make major decisions for them.

I agree that more doctors should meet the nurses in the middle in terms of compasion and patient interaction, but to meet the nurses in the middle in terms of training is LUNACY. On paper the DNP is a good idea, in practice not so much.

 

[erasable]

I think that, early on, the malpractice premiums for DNP will be lower than primary care MDs.
1) DNPs are relatively new and have yet to accumulate enough lawsuits to warantee a reputation for being sued.
2) Just by track record, I think nurses in the past have been far less likely to be sued than doctors. The DNPs will be sure to hold those stats over the insurance companies heads.
3) Even in the present day, DNPs are probably serving underserved areas, since other areas can probably afford to hire a doctor. Members in underserved areas, even if they had the financial wherewithal, are unlikely the sue the few doctors they have. This further propels' DNPs record of low lawsuits frequencies.
Once the precedent of low malpractice premiums are set, I am sure DNPs will fight to keep them low.

First of all, malpractice premiums for DNP's would not be lower than for primary care MDs. For an insurance company, an autonomous DNP with essentially the same rights (as an PCP) yet significantly less training would be a much greater risk to insure. It makes no difference whether a DNP mainly sees the 'easier cases.' 99% of what a PCP sees is a guy with a rash or a kid with a cough. Not too challanging. They need the insurance for those very difficult cases, for which they would be much better prepared than a DNP, I would hope. Plus, don't for a minute thing that Joe Public will not be quicker to jump on a Nurse doctor than a real MD. Insurance companies know all of this and will charge according to the percieved risk

....People would rather an A$$hole cure the disease than have a nice person hold their hand as they die.

funny, but true

 

[saradoor]

In practice if more DNPs can work in community health centers to take care of the uninsured before they all rush to the emergency rooms for every little thing, it will free up doctors to help those who are insured and lower the overall health care cost on the local governments.

I don't mean to offend anyone but our health care system is largely a "you get what you paid for" system.