FP Journal Editor in chief wants to fully embrace NPs

[bradt9881]

Oh boy, more alphabet soup on the way.

Dr. Jane Doe, BSN, MSN, CCRN, FNP, DNP, BCEM

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Members don't see this ad.

 

[fab4fan]

Oh boy, more alphabet soup on the way.

Dr. Jane Doe, BSN, MSN, CCRN, FNP, DNP, BCEM

Wrong. She's probably also certified in emergency nursing. You forgot the CEN.

 

[bradt9881]

Wrong. She's probably also certified in emergency nursing. You forgot the CEN.

That's got to be at least a hundred bucks of embroidery on a thirty dollar lab coat....

 

[fab4fan]

Way too many letters for my progressive lenses to handle.

 

[Paseo Del Norte]

Hey, smoke em if you got em for all I care as long as you don't masquerade as a "doctor." It's fine to be proud of passing exams such as CEN and CCRN; however, it's more of a personal achievement as few in the greater world of medicine care IMHO.

Personally, I tend to judge the person and not the initials.

 

[Coastie]

What a *****.

Read the source here

Jeff Susman, MD
Editor-in-Chief
[email protected]

It is time—time to abandon our damagingly divisive, politically Pyrrhic, and ultimately unsustainable struggle with advanced practice nurses (APNs). I urge my fellow family physicians to accept—actually, to embrace—a full partnership with APNs.

Why do I call for such a fundamental change in policy? First, because it’s the reality.

In 16 states, nurse practitioners already practice independently. And in many more states, there is a clear indication that both the public and politicians favor further erosion of barriers to independent nursing practice. Indeed, such independence is outlined in “The Future of Nursing: Leading Change, Advancing Health,” published by the Institute of Medicine (IOM) in October 2010. Among the IOM’s conclusions:

-Nurses should practice to the full extent of their education and training.
-Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.
-Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States.

Second, I believe our arguments against such a shift in policy don’t hold up. Despite the endless arguments about outcomes, training, and patient preferences, I honestly believe that most nursing professionals—just like most physicians—practice within the bounds of their experience and training.

Indeed, the arguments family physicians make against APNs sound suspiciously like specialists’ arguments against us. (Surely, the gastroenterologists assert, their greater experience and expertise should favor colonoscopy privileges only for physicians within their specialty, not for lowly primary care practitioners.) Rather than repeating the cycle of oppression that we in family medicine battle as the oppressed, let’s celebrate differences in practice, explore opportunities for collaboration, and develop diverse models of care.

Third, I call for a fundamental shift in policy because I fear that, from a political perspective, we have much to lose by continuing to do battle on this front. Fighting fractures our support and reduces our effectiveness with our legislative, business, and consumer advocates.

Finally, I’m convinced that joining forces with APNs to develop innovative models of team care will lead to the best health outcomes. In a world of accountable health care organizations, health innovation zones, and medical “neighborhoods,” we gain far more from collaboration than from competition.

As we ring in the new year, let’s stop clinging to the past—and redirect our energies toward envisionin g the future of health care.
The Journal Of Family Practice ©2010 Quadrant HealthCom Inc.

 

[Coastie]

Anyone care to elaborate on why in God's name did the American Board of Physician Specialties appointMary O'Neill Mundinger to Board of Certification in Emergency Medicine? Of all people? Really? Genius.

http://www.benzinga.com/press-relea...on-in-emergency-medicine-bcem-appoints-public

ROFLMAO

 

[Obnoxious Dad]

If physicians want to blame somebody for the rising use of midlevels they should look in the mirror. There are probably 10,000 people per year who would like to get into medical school every year but can't get in because medical school classes have been kept artificially small.

Medical schools will try to make the case that an increase in physicians drives up health care costs. They will actually state with a straight face that the per student cost of medical school is $130,000 per year when LECOM can do it for about $15,000 per year.

Admissions offices will tell applicants from tough colleges that their 3.3 GPAs in engineering, physics and chemistry indicate that the applicant is intellectually unfit for medical school.

Residency programs will try to make the case that residents beyond the intern year cost the hospital money.

If you really want people to see physicians instead of NPs and PAs then its time to start screaming for increased class sizes at med schools and to get the bean counters at hospitals to be honest.

 

[VA Hopeful Dr]

If physicians want to blame somebody for the rising use of midlevels they should look in the mirror. There are probably 10,000 people per year who would like to get into medical school every year but can't get in because medical school classes have been kept artificially small.

Medical schools will try to make the case that an increase in physicians drives up health care costs. They will actually state with a straight face that the per student cost of medical school is $130,000 per year when LECOM can do it for about $15,000 per year.

Admissions offices will tell applicants from tough colleges that their 3.3 GPAs in engineering, physics and chemistry indicate that the applicant is intellectually unfit for medical school.

Residency programs will try to make the case that residents beyond the intern year cost the hospital money.

If you really want people to see physicians instead of NPs and PAs then its time to start screaming for increased class sizes at med schools and to get the bean counters at hospitals to be honest.

There is so much wrong with this, I almost don't know where to start.

1. Per the LECOM webpage, at the Erie campus total costs for 1 year for class of 2014 is $53, 290. Bradenton is between $54k and $56k. Seton Hall is between $51k and $53k. I don't know where your 15,000 is coming from, but its just flat wrong. Tuition alone at these places is averaging around $29,000.

2. I get tired of explaining this - med school admissions have no bearing at all on number of practicing physicians. I could increase admissions to 120,000 students per year, and we'd still only get X number of new doctors per year. The Federal Government (through medicare) dictates the number of funded resident spots per year. Many programs will fund additional slots at their own expense, but not everyone can afford to do that. Do we really want more MD/DOs out there who can't find residency training? That's an awful debt burden to then be unemployed.

3. A 3.3 GPA doesn't mean unfit for medical school. It means that there are many candidates with better GPAs who want those same spots. Medicine is competitive, deal with it.

4. Lastly, residents do tend to lose money for hospitals. Allow me to explain. In medical school, a standard IM floor team consisted of 2 seniors, 2 interns, and an attending. Our daily census hovered around 20 patients. Our one attending could easily do that on his own (heck, many hospitalists do more). So, a patient load that can pay for one hospitalist now has to pay for 4 residents and an attending. Each resident costs the hospital (in terms of salary and benefits) let's say $70,000/yr. That's $280,000/yr right there. The attending let's say makes $120,000. We're up to $400,000 now. The Federal Government gives around $100,000k per resident to the hospital. So we're just breaking even on 5 doctors doing the work of one without residents. Now, you must also remember that medicare doesn't reimburse for hospital care done by residents. For many of the admissions then, the hospital doesn't make money. In addition, studies have shown the resident services have slightly longer LOS than attending only services (ie. more $$$ loss).

Surgeons have it worse since, as I recall, an attending must be physically present in each OR during the majority of the case. Residents almost always take much longer on cases. You're cutting down the number of cases and having to pay extra salaries. Nothing about this is saving money for the hospital.

 

[Hernandez]

Now, you must also remember that medicare doesn't reimburse for hospital care done by residents. For many of the admissions then, the hospital doesn't make money.

so you honestly believe they can't bill for h&ps done on pts? they can and do bill, for those when the attending does the "i verified the residents exam and history independently and agree (with or without changes) with the pertinent findings" and they can bill off that, they can not bill off a medical students h&p.

 

[VA Hopeful Dr]

so you honestly believe they can't bill for h&ps done on pts? they can and do bill, for those when the attending does the "i verified the residents exam and history independently and agree (with or without changes) with the pertinent findings" and they can bill off that, they can not bill off a medical students h&p.

That's what I was told from numerous sources (although admittedly, none of them official CMS documents). It would be nice to have the official answer to that question.

 

[sarjasy]

For example; take a person with an "airway obstruction" to the rest of the world. In Nursonics, it is translated as "ineffective airway clearance." Understanding my profession is nothing more than translation. Heck, I would be more than happy to teach prospective physician medical directors the language. For a small fee of course...

Wrong. You simply don't appreciate the fact that nursing has its own unique body of knowledge - just ask any nursing prof! For example, medicine has no equivalent to "disturbed energy field," now do they?

And yes, unfortunately, that really is an official nursing diagnosis per NANDA.

 

[deleted6669]

For example, medicine has no equivalent to "disturbed energy field," now do they?
.

yes we do. we(at least the rheumatologists who believe it exists and isn't just a manifestation of depression) call it "fibromyalgia".

 

[Coastie]

That's what I was told from numerous sources (although admittedly, none of them official CMS documents). It would be nice to have the official answer to that question.

anesthesiology residents make hundreds of thousands of dollars, per resident, for the hospital each year....they are the most "lucrative" of any resident....


Hospitals definitely make money off of us. Not only in direct billing, but also in the money they *don't* have to spend. Resident coverage means not paying attendings for extra call, midlevels for nights, weekends, and call..etc...it adds up quick.

 

[core0]

so you honestly believe they can't bill for h&ps done on pts? they can and do bill, for those when the attending does the "i verified the residents exam and history independently and agree (with or without changes) with the pertinent findings" and they can bill off that, they can not bill off a medical students h&p.

Here is the official word from Medicare:
https://www.cms.gov/MLNProducts/downloads/gdelinesteachgresfctsht.pdf
The pertinent part:
Services furnished in teaching settings are paid under the Medicare Physician Fee Schedule (MPFS) if the services are:
■ Personally furnished by a physician who is not a resident;
■ Furnished by a resident when a teaching physician is physically present during the critical or key portions of the service; or
■ Furnished by residents under a primary care exception within an approved Graduate Medical Education (GME) Program.

The present part is the issue. In critical care billing the teaching physician has to be physically present in the unit but does not have to be in the room. In procedures the teaching physician has to be in the room while the "critical portions" of the procedure are going on. Most institutions have taken word present to mean immediately available - ie in the building. So if a patient comes in overnight and the teaching physician is not in the building they cannot bill for the H&P since they were not present during the key portion of the service. On the other hand if the H&P happens during the day and physician was present while it happened then they can bill for it as long as the teaching physician documents that they were physically present during the critical portions of the E/M and that they participated in the management (agree with the following exceptions etc..).

 

[Obnoxious Dad]

There is so much wrong with this, I almost don't know where to start.

1. Per the LECOM webpage, at the Erie campus total costs for 1 year for class of 2014 is $53, 290. Bradenton is between $54k and $56k. Seton Hall is between $51k and $53k. I don't know where your 15,000 is coming from, but its just flat wrong. Tuition alone at these places is averaging around $29,000.

2. I get tired of explaining this - med school admissions have no bearing at all on number of practicing physicians. I could increase admissions to 120,000 students per year, and we'd still only get X number of new doctors per year. The Federal Government (through medicare) dictates the number of funded resident spots per year. Many programs will fund additional slots at their own expense, but not everyone can afford to do that. Do we really want more MD/DOs out there who can't find residency training? That's an awful debt burden to then be unemployed.

3. A 3.3 GPA doesn't mean unfit for medical school. It means that there are many candidates with better GPAs who want those same spots. Medicine is competitive, deal with it.

4. Lastly, residents do tend to lose money for hospitals. Allow me to explain. In medical school, a standard IM floor team consisted of 2 seniors, 2 interns, and an attending. Our daily census hovered around 20 patients. Our one attending could easily do that on his own (heck, many hospitalists do more). So, a patient load that can pay for one hospitalist now has to pay for 4 residents and an attending. Each resident costs the hospital (in terms of salary and benefits) let's say $70,000/yr. That's $280,000/yr right there. The attending let's say makes $120,000. We're up to $400,000 now. The Federal Government gives around $100,000k per resident to the hospital. So we're just breaking even on 5 doctors doing the work of one without residents. Now, you must also remember that medicare doesn't reimburse for hospital care done by residents. For many of the admissions then, the hospital doesn't make money. In addition, studies have shown the resident services have slightly longer LOS than attending only services (ie. more $$$ loss).

Surgeons have it worse since, as I recall, an attending must be physically present in each OR during the majority of the case. Residents almost always take much longer on cases. You're cutting down the number of cases and having to pay extra salaries. Nothing about this is saving money for the hospital.

1. The $15,000 figure comes from the total expenses of LECOM as reported in its tax return spread across all 1,600 of its students. You are confusing a student's total cost of attendance with LECOM's cost of actually delivering education to its students. Get a CPA to download a copy of LECOM's Form 990 and then divide its total expenses by the number of students it has and you will arrive at about $15,000.

2. You are right that the total number of physicians is influenced by the number of residency spots but the $9,000,000,000 spread around by Medicare could be spent more efficiently. Show me any industrial engineering studies done by ANYBODY that attempt to get more out of residents per dollar spent.

3. A 3.3 in engineering, physics or chemistry will bar just about anyone regardless of their undergraduate institution from an allopathic medical school unless he or she lives in a state like Louisiana or South Dakota. Students in the physical sciences get rejected in favor of dance and anthropology majors from schools with average ACT's of 25. If you think the dance majors are better candidates for medical school than someone who can conquer two terms of calculus based physics and P Chem, you need to get off the Kool Aid.

4. As much as I hate to agree with Coastie, he's right about surgeons and anesthesiologists making gobs of money for hospitals. Medicare doesn't pay for residents' services because Medicare already forks over $9 billion per year for residents but there is no reason why private patients and insurance companies should be off the hook for services rendered by independent residents. They are getting a free ride.

 

[Dwindlin]

3. A 3.3 in engineering, physics or chemistry will bar just about anyone regardless of their undergraduate institution from an allopathic medical school unless he or she lives in a state like Louisiana or South Dakota. Students in the physical sciences get rejected in favor of dance and anthropology majors from schools with average ACT's of 25. If you think the dance majors are better candidates for medical school than someone who can conquer two terms of calculus based physics and P Chem, you need to get off the Kool Aid.

Pretty sure VA doc meant that a 3.3 won't cut it no matter your major. . .trust me there are plenty of 3.8 phys/eng/chem majors who want to go to med school too. Look at any med schools matriculating class profile, degrees outside of bio/phy sciences are still very much in the minority.

 

[Obnoxious Dad]

Pretty sure VA doc meant that a 3.3 won't cut it no matter your major. . .trust me there are plenty of 3.8 phys/eng/chem majors who want to go to med school too. Look at any med schools matriculating class profile, degrees outside of bio/phy sciences are still very much in the minority.

Per page 60 of the AAMC's 2010 MSAR PHYSICAL science majors account for 12% of the medical school matriculants every year. Physical science majors take more math and science classes, take harder science classes and take more of them at the same time than biology majors and there is absolutely no comparison between the rigor of physical science majors and majors in the humanities with nine science courses strategically taken to avoid a tough load.

The current failure of medical schools to normalize transcripts to account for the rigor of applicants' undergraduate school, major and course load is an absolute travesty. It rewards people who slither their way into med school. My kid, who actually made it into med school in spite of being a chemistry major, has told me that NOTHING in med school is as tough as P Chem.

Wait until you have a disease that some art history major can't diagnose. You might ask for a real scientist.

 

[VA Hopeful Dr]

anesthesiology residents make hundreds of thousands of dollars, per resident, for the hospital each year....they are the most "lucrative" of any resident....


Hospitals definitely make money off of us. Not only in direct billing, but also in the money they *don't* have to spend. Resident coverage means not paying attendings for extra call, midlevels for nights, weekends, and call..etc...it adds up quick.

I don't know much about anesthesiology residencies. Are y'all usually supervised on a 1:1 level by an attending or is the supervision more on the level of CRNAs? If its the latter case, then you're right - you make the hospital money. If its the former, I'm less convinced.

Many resident services still have to have an attending in house (surgery comes to mind) given their tighter supervision rules.

Once again, I don't buy it for everyone. FM/IM interns are capped at 5 admits per night in many places. You don't have to hire an extra anything to take an extra 5 patients in a given night.

 

[VA Hopeful Dr]

1. The $15,000 figure comes from the total expenses of LECOM as reported in its tax return spread across all 1,600 of its students. You are confusing a student's total cost of attendance with LECOM's cost of actually delivering education to its students. Get a CPA to download a copy of LECOM's Form 990 and then divide its total expenses by the number of students it has and you will arrive at about $15,000.

2. You are right that the total number of physicians is influenced by the number of residency spots but the $9,000,000,000 spread around by Medicare could be spent more efficiently. Show me any industrial engineering studies done by ANYBODY that attempt to get more out of residents per dollar spent.

3. A 3.3 in engineering, physics or chemistry will bar just about anyone regardless of their undergraduate institution from an allopathic medical school unless he or she lives in a state like Louisiana or South Dakota. Students in the physical sciences get rejected in favor of dance and anthropology majors from schools with average ACT's of 25. If you think the dance majors are better candidates for medical school than someone who can conquer two terms of calculus based physics and P Chem, you need to get off the Kool Aid.

4. As much as I hate to agree with Coastie, he's right about surgeons and anesthesiologists making gobs of money for hospitals. Medicare doesn't pay for residents' services because Medicare already forks over $9 billion per year for residents but there is no reason why private patients and insurance companies should be off the hook for services rendered by independent residents. They are getting a free ride.

1. Yeah, I saw your analysis in the LECOM thread after I posted this. My question is this: if costs are that low, why is tuition itself at least double that figure?

2. I won't argue that resident education could be more efficient in many ways. I think we'll see more effort in that direction with the new rules coming into effect in July.

3. I'm a chem major as well, so don't go throwing p-chem in my face. Ask a physics major, that class is a joke to them much like undergrad biology is to chemists. Chemistry and medicine are two different kinds of challenging. Med school is memorization like you've never seen while chemistry is just complex math applied to the physical world. Besides, the top student in my year of med school was a bio/dance double major. Our class president (top 10) was an art history major. From my experience, college major doesn't matter past the first month or two of school.

4. See reply to Coastie.

 

[VA Hopeful Dr]

Per page 60 of the AAMC's 2010 MSAR PHYSICAL science majors account for 12% of the medical school matriculants every year. Physical science majors take more math and science classes, take harder science classes and take more of them at the same time than biology majors and there is absolutely no comparison between the rigor of physical science majors and majors in the humanities with nine science courses strategically taken to avoid a tough load.

The current failure of medical schools to normalize transcripts to account for the rigor of applicants' undergraduate school, major and course load is an absolute travesty. It rewards people who slither their way into med school. My kid, who actually made it into med school in spite of being a chemistry major, has told me that NOTHING in med school is as tough as P Chem.

Wait until you have a disease that some art history major can't diagnose. You might ask for a real scientist.

You remind me of college me. I had absolutely no respect for humanities (other than math) or biology majors. That being said, as I pointed out previously, med school has almost nothing to do with chemistry. I'll agree with your son, nothing has intellectually challenged me more than p-chem. However, excelling in chemistry doesn't always translate into memorizing well (med school).

As for your last comment... you need to calm down a touch. If my doctor finished med school and residency, I don't care if his/her college major was free-fall sheep f-ing. He/she now has the skills and knowledge I need. That's all that matters.

 

[Obnoxious Dad]

1. Yeah, I saw your analysis in the LECOM thread after I posted this. My question is this: if costs are that low, why is tuition itself at least double that figure?

2. I won't argue that resident education could be more efficient in many ways. I think we'll see more effort in that direction with the new rules coming into effect in July.

3. I'm a chem major as well, so don't go throwing p-chem in my face. Ask a physics major, that class is a joke to them much like undergrad biology is to chemists. Chemistry and medicine are two different kinds of challenging. Med school is memorization like you've never seen while chemistry is just complex math applied to the physical world. Besides, the top student in my year of med school was a bio/dance double major. Our class president (top 10) was an art history major. From my experience, college major doesn't matter past the first month or two of school.

4. See reply to Coastie.

LECOM charges twice as much as their cost per student because LECOM can get away with it. Why would any DO applicant complain about LECOM's tuition of $30,000 when the University of Illinois charges non-residents $80,000 per year for the second and third year of med school?

LECOM takes its profits and uses them to keep expanding. If you add up the three campuses LECOM is now the biggest med school in the US.

I have a friend who died of testicular cancer because the physicians and physical therapists who saw him for his "idiopathic" low back pain couldn't figure out what was wrong with him. After reading an article in Penthouse about Testicular CA, he diagnosed himself. Maybe if he had seen a real scientist, he'd be alive today.

 

[VA Hopeful Dr]

LECOM charges twice as much as their cost per student because LECOM can get away with it. Why would any DO applicant complain about LECOM's tuition of $30,000 when the University of Illinois charges non-residents $80,000 per year for the second and third year of med school?

LECOM takes its profits and uses them to keep expanding. If you add up the three campuses LECOM is now the biggest med school in the US.

I have a friend who died of testicular cancer because the physicians and physical therapists who saw him for his "idiopathic" low back pain couldn't figure out what was wrong with him. After reading an article in Penthouse about Testicular CA, he diagnosed himself. Maybe if he had seen a real scientist, he'd be alive today.

Maybe my state is different, but after the first year of medical school if you've changed your state residency, you get in-state tuition rates which are probably on level of LECOM these days.

I'm very sorry to hear about your friend. Testicular cancer is a bad one if its not caught early. Question though: what did his physician major in during his college days? What about that case makes you think a physicist would have caught that while a biologist wouldn't? If anything, I think this just underscores the importance of a full physical exam (and testicular self-exams) especially given the huge number of conditions that can cause back pain. I'm not sure of the specifics here (I'm no oncologist), but usually if cancer is causing back pain that means it has already metastasized to bone and that is a very poor prognostic indication.

That said, we're all going to miss things sometimes - doctors are human too. I always just hope that it isn't anything that will cause long-term problems.

There's also an interesting discussion going on elsewhere on this forum as to whether or not physicians are truly scientists. You might search for that, I thought it was a pretty well thought out discussed.

 

[Coastie]

I don't know much about anesthesiology residencies. Are y'all usually supervised on a 1:1 level by an attending or is the supervision more on the level of CRNAs? If its the latter case, then you're right - you make the hospital money. If its the former, I'm less convinced.

Many resident services still have to have an attending in house (surgery comes to mind) given their tighter supervision rules.

Once again, I don't buy it for everyone. FM/IM interns are capped at 5 admits per night in many places. You don't have to hire an extra anything to take an extra 5 patients in a given night.

CRNA level...and that means they don't have to hire CRNAs at >200,000 a year (for 40 hours a week plus more vaca than residents) to replace us..do the math.

Same with other specialties, though. Think of the PA costs to replace an int med resident for comparable hours and schedule......astronomical.

 

[zenman]

Believe it or not, I am the biggest supporter of NP independence on SDN. If I had my way, I would kick every NP out of every practice and hospital in this country and force them to be independent.

Wish I could put my finger on the link about the group of women’s health NP’s who recently celebrated 20 years of practice in their successful NP only clinic.

Why can't people just go to doctors anymore? I'm not saying this to be cute, I really mean it.

I guess its stands to reason that you don’t know if many physicians have no clue either. It’s simple. They are not getting what they want. See more here:

“In the United States, approximately 38 percent of adults (about 4 in 10) and approximately 12 percent of children (about 1 in 9) are using some form of CAM….”

“People of all backgrounds use CAM. However, CAM use among adults is greater among women and those with higher levels of education and higher incomes.”

http://nccam.nih.gov/news/camstats/2007/camsurvey_fs1.htm

Those with higher levels of education (in many cases) and higher incomes are my target market. My mother didn’t raise a fool. I have to look up mangled care and insaurance to see how to spell them, lol!

 

[Socrates25]

I have a friend who died of testicular cancer because the physicians and physical therapists who saw him for his "idiopathic" low back pain couldn't figure out what was wrong with him. After reading an article in Penthouse about Testicular CA, he diagnosed himself. Maybe if he had seen a real scientist, he'd be alive today.

A "real scientist" would have known that testicular cancer only accounts for a tiny minority (e.g. < 3%) of all causes of back pain. Maybe you should become a "real scientist" before you try to pretend to know how they are different from "real" doctors.

 

[Socrates25]

Per page 60 of the AAMC's 2010 MSAR PHYSICAL science majors account for 12% of the medical school matriculants every year. Physical science majors take more math and science classes, take harder science classes and take more of them at the same time than biology majors and there is absolutely no comparison between the rigor of physical science majors and majors in the humanities with nine science courses strategically taken to avoid a tough load.

The current failure of medical schools to normalize transcripts to account for the rigor of applicants' undergraduate school, major and course load is an absolute travesty. It rewards people who slither their way into med school. My kid, who actually made it into med school in spite of being a chemistry major, has told me that NOTHING in med school is as tough as P Chem.

Wait until you have a disease that some art history major can't diagnose. You might ask for a real scientist.

You're obviously carrying a huge chip on your shoulder. What happened old man, did you get rejected to med school 30 years ago? Go cry about it somewhere else chump. Why dont you apply to any of the 50 third tier trash med schools now opening -- places like Rocky Mountain Vista who will accept anybody with a pulse and $100k in their bank account.


P.S. I'll see your pchem and raise you real/complex/fourier analysis, topology, and advanced quantum field theory (double major math/physics degree). I own your stupid kid in math/science, even though its been awhile since I had to do fourier transforms. Who's the "real scientist" now fool?

 

[Obnoxious Dad]

You're obviously carrying a huge chip on your shoulder. What happened old man, did you get rejected to med school 30 years ago? Go cry about it somewhere else chump. Why dont you apply to any of the 50 third tier trash med schools now opening -- places like Rocky Mountain Vista who will accept anybody with a pulse and $100k in their bank account.


P.S. I'll see your pchem and raise you real/complex/fourier analysis, topology, and advanced quantum field theory (double major math/physics degree). I own your stupid kid in math/science, even though its been awhile since I had to do fourier transforms. Who's the "real scientist" now fool?

The point of one paragraph of my original post was that that there are thousands of qualified applicants to medical schools who will never get admitted. I cited physical science majors with relatively low grade points among those who are irrationally rejected. (The last time I checked physics was included among the physical sciences.) I posted this within the context of a thread having to do with the incursion of midlevels in family practice and that physicians should blame themselves for this predicament.

Allow me to repeat myself. My kid IS in medical school. I never applied because I personally have no intention of seeing all of the gross stuff that physicians see.

 

[sarjasy]

You're obviously carrying a huge chip on your shoulder. What happened old man, did you get rejected to med school 30 years ago? Go cry about it somewhere else chump. Why dont you apply to any of the 50 third tier trash med schools now opening -- places like Rocky Mountain Vista who will accept anybody with a pulse and $100k in their bank account.


P.S. I'll see your pchem and raise you real/complex/fourier analysis, topology, and advanced quantum field theory (double major math/physics degree). I own your stupid kid in math/science, even though its been awhile since I had to do fourier transforms. Who's the "real scientist" now fool?

Wow. And who's the one with a chip on his shoulder? Sounds to me like someone has some unresolved inferiority/anger issues.

Had to come back and edit because there seems to be a need for some therapeutic intervenion here. Someone that rips a guy and his kid obviously needs such an intervention. Behind every angry and arrogant little boy is a scared and insecure little boy. I don't know you, but let me toss some ideas out. Was it the kids on the playground? You know, the big boys that push the skinny little boys around? Frustrated that you aced physical science but wasn't invited to play the pick-up basketball game? Maybe it was prom, when you went with a group of guys instead of...well...a girl. Or perhaps in college, when you got the highest grade in electrodynamics, but found yourself only able to muster a nasally snicker while pushing your taped-together horned-rimmed glasses up with your pinky when the hot chick glanced your way? Or is it that you are frustrated that the art education major is running circles around you in med school? Or is it, shall we say, a medical issue? There's Viagra for that. Is it that Harvard never called for an interview, or that they did and despite that, you still can't get a date? Was daddy not nice, or mommy not very loving? Just wanting to help here.

 

[VA Hopeful Dr]

CRNA level...and that means they don't have to hire CRNAs at >200,000 a year (for 40 hours a week plus more vaca than residents) to replace us..do the math.

Same with other specialties, though. Think of the PA costs to replace an int med resident for comparable hours and schedule......astronomical.

Yeah, then you gas-passing folks do pull in a big fat load of money to the hospital.

As for PA to replace IM residents... in most places you'd be replacing 2 residents, if not 3 with a PA. The PA is cheaper. I would also think that a good PA could do more than 5 admissions in a night, which is what interns are often capped at.

 

[fab4fan]

Wish I could put my finger on the link about the group of women’s health NP’s who recently celebrated 20 years of practice in their successful NP only clinic.


I guess its stands to reason that you don’t know if many physicians have no clue either. It’s simple. They are not getting what they want. See more here:

“In the United States, approximately 38 percent of adults (about 4 in 10) and approximately 12 percent of children (about 1 in 9) are using some form of CAM….”

“People of all backgrounds use CAM. However, CAM use among adults is greater among women and those with higher levels of education and higher incomes.”

http://nccam.nih.gov/news/camstats/2007/camsurvey_fs1.htm

Those with higher levels of education (in many cases) and higher incomes are my target market. My mother didn’t raise a fool. I have to look up mangled care and insaurance to see how to spell them, lol!

That's not what I meant, and you know it.

What's "insaurance"? Some kind of raptor?

 

[zenman]

That's not what I meant, and you know it.

What's "insaurance"? Some kind of raptor?

I was saying, tongue in cheek, that since I don't deal with mangled care (managed care) and insaurance (insurance), that I can't even spell them.

 

[fab4fan]

I was saying, tongue in cheek, that since I don't deal with mangled care (managed care) and insaurance (insurance), that I can't even spell them.

Sarcasm sort of sails over your head, doesn't it?

 

[NYRN]

How can I protect the patient being seen by an autonomous NP who doesn't know when to refer patient to a physician? That patient will only be seen by the NP until it's too late. Is it not the responsibility of the NP to know when they're above their heads? How many people would risk their health on NP's being wise enough to know when they don't know enough?

You and I both know the answers. Patients will get hurt -- many will die prematurely -- because of these marginally-trained NP's who don't feel that they need physician involvement. That's what they're taught in nursing school now. QUOTE]

I see this type of comment come from all the MD's on this board, but I can tell you, I have never had this experience in nursing or in NP school. I honestly don't know even 1 NP student or NP in practice that thinks they could (or even want to) replace MD's. All the people I was in the NP program with are looking foward to working with the MD's they have been working with as nurses, I don't know even one person that wants to eliminate the MD from the equation, including those who have been NP's for many years.

These DNP's and are going on TV saying things like you mentioned are nuts, and I don't think its fair that ALL nurses or NP's are grouped together with them. I'm sure in the future you will have PA's who will also be pushing for independant practice, and I know that these people will not be representative of the majority of PA's either.

I have been a nurse for a while, and I am now ready to take the next step and move up. Before I even went back to school I took it upon myself to learn as much as I could about medicine. Besides working in a large teaching hospital and picking the brains of the residents, I attend some of the lectures, rounds and conferences with the residents so I can learn more about medicine. Last year I started an NP program because I thought that the move to advanced practice nursing would be the more logical thing to do rather than finishing up prereq's and going to medical school. After completing that semester, I realized that an NP education is never going to prepare me to care for patients the way that I want to. I strive to practice independantly, but I do not want to fly the ship solo, unless I feel that I am prepared to do so. This is just what I want for myself. What I learned in those conferences I attended was way beyond anything I would learn in an NP program. I never went back, and am now in the process of taking the final prereqs to apply to medical school.

If I wanted the easy way out, I could be graduating in another year as as NP, but instead I'm busting my ass in O-chem and physics, and having nightmares about taking the MCAT

All of that being said, I still feel that NP's and PA's are valuable members of the healthcare team when they are working in a capacity that best utilizes their skills.

 

[zenman]

Sarcasm sort of sails over your head, doesn't it?

Well, your response made me think it went right over your head You know I have to question the judgment of anyone who thinks Dylan had the ability to sing other than to make a sound akin to cats in a barrel having their tails stepped on, lol!

 

[fab4fan]

Well, your response made me think it went right over your head You know I have to question the judgment of anyone who thinks Dylan had the ability to sing other than to make a sound akin to cats in a barrel having their tails stepped on, lol!

The world is divided into two groups of people: those who get Dylan, and those who don't. My sympathies to you.

 

[zenman]

The world is divided into two groups of people: those who get Dylan, and those who don't. My sympathies to you.

Well I do agree with you there. No sympathies needed however, especially for my ears.

 

[zenman]

LECOM charges twice as much as their cost per student because LECOM can get away with it. Why would any DO applicant complain about LECOM's tuition of $30,000 when the University of Illinois charges non-residents $80,000 per year for the second and third year of med school?

LECOM takes its profits and uses them to keep expanding. If you add up the three campuses LECOM is now the biggest med school in the US.

I have a friend who died of testicular cancer because the physicians and physical therapists who saw him for his "idiopathic" low back pain couldn't figure out what was wrong with him. After reading an article in Penthouse about Testicular CA, he diagnosed himself. Maybe if he had seen a real scientist, he'd be alive today.

A real scientist? Heck, any decent shaman would have picked that up.

 

[zenman]

I have been a nurse for a while, and I am now ready to take the next step and move up. Before I even went back to school I took it upon myself to learn as much as I could about medicine. Besides working in a large teaching hospital and picking the brains of the residents, I attend some of the lectures, rounds and conferences with the residents so I can learn more about medicine. Last year I started an NP program because I thought that the move to advanced practice nursing would be the more logical thing to do rather than finishing up prereq's and going to medical school. After completing that semester, I realized that an NP education is never going to prepare me to care for patients the way that I want to. I strive to practice independantly, but I do not want to fly the ship solo, unless I feel that I am prepared to do so. This is just what I want for myself. What I learned in those conferences I attended was way beyond anything I would learn in an NP program. I never went back, and am now in the process of taking the final prereqs to apply to medical school.

If I wanted the easy way out, I could be graduating in another year as as NP, but instead I'm busting my ass in O-chem and physics, and having nightmares about taking the MCAT

All of that being said, I still feel that NP's and PA's are valuable members of the healthcare team when they are working in a capacity that best utilizes their skills.

Have you really thought about how you want to care for patients? I dare say most physicians are told how they will practice in our current health care setting. After finishing a toxic educational program you'll go along in order to pay off your debt load and you'll wind up jaded and suicidal. You’ll base your practice on EBM, of which 90% is wrong http://www.theatlantic.com/magazine/...-science/8269/ That's the worse case scenario of course.

When I was doing my psych NP clinicals on a Marine base in Asia, a retired Navy Captain psychiatrist, who was now working as a civilian, told his daughter the best route would be as an NP vs a psychologist or psychiatrist. My psychiatrist preceptor told her the same thing. Just saying you might want to think really hard before you act.

I didn’t consider the NP route the easy way out, I considered it the smart way out.

 

[FutureDoc4]

Have you really thought about how you want to care for patients? I dare say most physicians are told how they will practice in our current health care setting. After finishing a toxic educational program you'll go along in order to pay off your debt load and you'll wind up jaded and suicidal. You’ll base your practice on EBM, of which 90% is wrong http://www.theatlantic.com/magazine/...-science/8269/ That's the worse case scenario of course.

When I was doing my psych NP clinicals on a Marine base in Asia, a retired Navy Captain psychiatrist, who was now working as a civilian, told his daughter the best route would be as an NP vs a psychologist or psychiatrist. My psychiatrist preceptor told her the same thing. Just saying you might want to think really hard before you act.

I didn’t consider the NP route the easy way out, I considered it the smart way out.

Although EBM isn't perfect, this statement (that >90% of EBM is wrong) makes you lose any credibility you had left.

Yes, drug/alcohol abuse/suicidal ideation is higher in physicians, but for a psychiatric "health care provider" stigmatizing others who are suffering from those problems speaks volumes about you.

 

[NYRN]

Have you really thought about how you want to care for patients? I dare say most physicians are told how they will practice in our current health care setting. After finishing a toxic educational program you'll go along in order to pay off your debt load and you'll wind up jaded and suicidal. You'll base your practice on EBM, of which 90% is wrong http://www.theatlantic.com/magazine/...-science/8269/ That's the worse case scenario of course.

When I was doing my psych NP clinicals on a Marine base in Asia, a retired Navy Captain psychiatrist, who was now working as a civilian, told his daughter the best route would be as an NP vs a psychologist or psychiatrist. My psychiatrist preceptor told her the same thing. Just saying you might want to think really hard before you act.

I didn't consider the NP route the easy way out, I considered it the smart way out.

Not saying that NP is an easy route, it isn't, but it is an easier route to finish this NP program than to go back to school for the next 6 years not including residency.

I have no interest in working in the field of psychiatry. I'm pretty sure I don't want to do surgery, but I am keeping an open mind as to what field I am going into. I am thinking maybe some sort of medical specialty like GI, Critical Care/Pulm, Cardiology. Not sure yet. I have plenty of attendings from many specialties that invite me to shadow them and join rounds whenever I want, when I'm in my gap year I fully plan on taking them up on their offer and seeing if there is anything that really interests me. I have been working in a large teaching hospital since I became a nurse, I know what I'm getting into.

I don't know what you mean by you don't practice evidenced based medicine. Nursing also practices by evidenced based guidelines, and guess what, they work!

 

[zenman]

Although EBM isn't perfect, this statement (that >90% of EBM is wrong) makes you lose any credibility you had left.

It's not my credibility we are talking about. It's the physician John Ioannidis and his team who tears apart medical research. "He charges that as much as 90 percent of the published medical information that doctors rely on is flawed."

Apparently you didn't read the article. He predicts that 80% of non-randomized studies are wrong, 25% of gold-standard randomized are wrong, and 10% of platinum-standard large randomized studies are wrong.

Please contact him with your concerns.

Yes, drug/alcohol abuse/suicidal ideation is higher in physicians, but for a psychiatric "health care provider" stigmatizing others who are suffering from those problems speaks volumes about you.

I'd really be interested in how you came to this conclusion. Are you thinking that me repeating facts is stigmatizing?

 

[zenman]

Not saying that NP is an easy route, it isn't, but it is an easier route to finish this NP program than to go back to school for the next 6 years not including residency.

I have no interest in working in the field of psychiatry. I'm pretty sure I don't want to do surgery, but I am keeping an open mind as to what field I am going into. I am thinking maybe some sort of medical specialty like GI, Critical Care/Pulm, Cardiology. Not sure yet. I have plenty of attendings from many specialties that invite me to shadow them and join rounds whenever I want, when I'm in my gap year I fully plan on taking them up on their offer and seeing if there is anything that really interests me. I have been working in a large teaching hospital since I became a nurse, I know what I'm getting into.

I don't know what you mean by you don't practice evidenced based medicine. Nursing also practices by evidenced based guidelines, and guess what, they work!

I don't dismiss EBM but when you consider the previous comments about how much published studies are wrong, I think one has to ethically think about it. Yes, I argued with one of my professors in my final semester and almost had to get a lawyer to finish school, however 2 professors that review my case passed me right away. I was correct and I knew it. Like I mentioned earlier, when you have a Vietnam vet sitting in front of you who has a 40 year old problem that you can't fix please tell me what the heck you are going do...give him more of the same EBM? Our Vets deserve better.

 

[Charles_Carmichael]

Have you really thought about how you want to care for patients? I dare say most physicians are told how they will practice in our current health care setting. After finishing a toxic educational program you'll go along in order to pay off your debt load and you'll wind up jaded and suicidal. You’ll base your practice on EBM, of which 90% is wrong http://www.theatlantic.com/magazine/...-science/8269/ That's the worse case scenario of course.

Toxic educational program? Being brainwashed by NPs/DNPs that MDs/DOs are evil is not toxic? Haha...jk...

Nice link btw: it leads to a 404 error when I click on it.

When I was doing my psych NP clinicals on a Marine base in Asia, a retired Navy Captain psychiatrist, who was now working as a civilian, told his daughter the best route would be as an NP vs a psychologist or psychiatrist. My psychiatrist preceptor told her the same thing. Just saying you might want to think really hard before you act.

Kind of ironic that you just blasted EBM and then, went ahead and described an anecdote. You should realize by now that anecdotes are next to useless...

I didn’t consider the NP route the easy way out, I considered it the smart way out.

You may consider it the "smart" way out. I consider it the easy way out. IMO (my opinion, no hard evidence here), NPs/DNPs are those who were either unwilling to go through medical training (ie. those with family obligations, etc) or were those who realized that they couldn't make the cut for medical training. Which one were you Zen?

 

[NYRN]

I don't dismiss EBM but when you consider the previous comments about how much published studies are wrong, I think one has to ethically think about it. Yes, I argued with one of my professors in my final semester and almost had to get a lawyer to finish school, however 2 professors that review my case passed me right away. I was correct and I knew it. Like I mentioned earlier, when you have a Vietnam vet sitting in front of you who has a 40 year old problem that you can't fix please tell me what the heck you are going do...give him more of the same EBM? Our Vets deserve better.

If you are saying that a one size fits all approach to care doesn't work, I won't disagree with you. In the case of the vet, if EBM approaches don't work, then the care provider changes the plan until they get it right. I don't think that makes EMB a crock.

 

[Taurus]

Maybe these medical organizations are finally growing a pair and start doing the studies that I have been clamoring for. Hopefully this is the first of many.

Plenty of kids' doctors, but in the wrong places, study shows
Wealthy areas of U.S. have too many pediatricians, many rural areas few or none

By CARLA K. JOHNSON
updated 1 hour 5 minutes ago 2010-12-20T05:14:33

CHICAGO &#8212; There are enough children's doctors in the United States, they just work in the wrong places, a new study finds. Some wealthy areas are oversaturated with pediatricians and family doctors. Other parts of the nation have few or none.

Nearly 1 million kids live in areas with no local children's doctor. By moving doctors, the study suggests, it would be possible for every child to have a pediatrician or family physician nearby.

There should be more focus on evening out the distribution than on increasing the overall supply of doctors for children, said lead author Dr. Scott Shipman of the Dartmouth Institute for Health Policy and Clinical Practice in Lebanon, N.H.

"I worry that it could get worse," Shipman said.

He said medical schools are graduating more students, but the result will be more doctors in places where there's already an over-supply. Indeed, previous studies have shown that doctors locate where supply is already high, rather than in areas with greater need.

Growth in the number of pediatricians and family physicians has outpaced increases in the U.S. child population, Shipman and his colleagues found. Yet the study's analysis shows nearly all 50 states have extremely uneven distribution of primary care doctors for children.

Mississippi had the highest proportion of children (42 percent) in low-supply regions, defined as areas with more than 3,000 children per children's doctor. Next were Arkansas, Oklahoma, Maine and Idaho.

Areas with an abundance of children's doctors were Washington, D.C., and Delaware, which had no children living in low-supply regions. Maryland, Washington and Wisconsin also had very few children living in low-supply areas.

The study used national data to calculate the per-child supply of working pediatricians and family physicians in geographic regions. Regions with many children's doctors were wealthier. Low-supply regions were mostly rural.

The study appears Monday in the journal Pediatrics.

States in fiscal crisis

The number of pediatricians has been on the rise, increasing by 51 percent from 1996 to 2006. The supply of family doctors grew by 35 percent in the same years. The population of children grew by only 9 percent during those years.

Federal funding has expanded in recent years for the National Health Service Corps, which offers loan forgiveness for doctors and other practitioners who locate in underserved areas. That may help, Shipman said.

Uninsured patients and the low payments from Medicaid keep doctors out of poor, rural areas, said Dr. Thomas Bodenheimer of the University of California, San Francisco, who wasn't involved in the new research but studies work force issues in primary care.

Don't look for help from state governments, said Dr. Roland Goertz, a family physician in Waco, Texas, and president of the American Academy of Family Physicians, who wasn't involved in the new study.

"Most states are in fiscal crisis. Without resources, it's going to be tough to turn it around," Goertz said.

Nurse practitioners can help, said Kristy Martyn, a pediatric nurse practitioner and researcher at University of Michigan's nursing school.
Story: Survey: Parents start to see TV, Internet the same

"The limiting factor is the numbers," Martyn said. "We need more pediatric nurse practitioners and nurse practitioners trained to provide care to children."

Some communities help a hometown student go to med school with the understanding the student will return home.

Dr. Katie Dias, 27, a third-year family practice resident in Kansas City, Mo., will begin her career in the rural northwest Missouri town where she grew up. With stipends from the state and the community hospital in tiny Albany, Mo., she'll start practicing with only $50,000 in student loans, much less than many other young doctors.

"I am definitely a small town girl," Dias said. "I feel very passionately about the community I grew up in. This is not a short-term commitment for me."​

 

[zenman]

Toxic educational program? Being brainwashed by NPs/DNPs that MDs/DOs are evil is not toxic? Haha...jk...

Nice link btw: it leads to a 404 error when I click on it.

Sorry, I copied the link off an SDN post. Should have known better. Try this one: http://www.theatlantic.com/magazine/archive/2010/11/lies-damned-lies-and-medical-science/8269/

Never personally heard of any brainwashing by NPs/DNPs that physicians are evil.

Kind of ironic that you just blasted EBM and then, went ahead and described an anecdote. You should realize by now that anecdotes are next to useless...

Well, when you tell a story about a conversation you had with a couple physicians and the daughter of one of the physicians, it's just that, a story. It's not a double-blind study. However, I consider anecdotes very useful, as they are the patient's story, and that patient desperately wants you to listen to him. That's what I do, listen to people, and I hear what they are saying.

We also have a form of therapy called Narrative Therapy, btw.

You may consider it the "smart" way out. I consider it the easy way out. IMO (my opinion, no hard evidence here), NPs/DNPs are those who were either unwilling to go through medical training (ie. those with family obligations, etc) or were those who realized that they couldn't make the cut for medical training. Which one were you Zen?

I was the guy who picked up Coke bottles off the side of the road in order to buy a used .22 cal rifle so I could shoot rabbits and squirrels in order to have something to eat. I then went into the ARMY in 1970, 3 days after graduating from HS. My health care career started as a medic and I never did consider being a physician.

If I were to tell you how "smart" I am you would break down and cry. But that's just an anecdote, isn't it?

 

[VA Hopeful Dr]

Sorry, I copied the link off an SDN post. Should have known better. Try this one: http://www.theatlantic.com/magazine/archive/2010/11/lies-damned-lies-and-medical-science/8269/

That story tells us nothing we don't already know. The human body is astoundingly complex, it would be nearly (if not completely) impossible to eliminate every variable except the one we're studying and to ensure that each person with disease X is actually the same. Even our best studies should only serve to get the physician to consider whatever it is the study is about. In an ideal world, after a big trial is published, we'd still wait a few more years for more studies about that topic to come out before we'd change how we do things. Granted that doesn't always happen, but that's how it should be.

Never personally heard of any brainwashing by NPs/DNPs that physicians are evil.

We don't get brainwashed like you think. Its just a widely held belief among physicians that we are the best trained at what we do. I would suggest that this is quite true, I can't think of any other practitioner that has our knowledge of medicine (let's leave out alternative medicine for now, that could be its own separate thread). Thus, when we see non-physicians trying to do the same work, we get understandably upset about it. But brainwashing that NPs are evil? I don't think so.

Well, when you tell a story about a conversation you had with a couple physicians and the daughter of one of the physicians, it's just that, a story. It's not a double-blind study. However, I consider anecdotes very useful, as they are the patient's story, and that patient desperately wants you to listen to him. That's what I do, listen to people, and I hear what they are saying.

We also have a form of therapy called Narrative Therapy, btw.

That is all true, and part of what I think makes a compassionate practitioner is willingness to listen. That being said, I think its unwise to go against what science we have based on what a single patient is saying (unless of course that patient has a very rare condition). Allow me a hypothetical. If a patient presents to your office with chest pain that he says morphine completely relives and he just wants to get some of that and go home, would you give him morphine and send him home or would you ignore him and get an EKG at minimum if not send to the ED?

I was the guy who picked up Coke bottles off the side of the road in order to buy a used .22 cal rifle so I could shoot rabbits and squirrels in order to have something to eat. I then went into the ARMY in 1970, 3 days after graduating from HS. My health care career started as a medic and I never did consider being a physician.

If I were to tell you how "smart" I am you would break down and cry. But that's just an anecdote, isn't it?

I wouldn't cry, but I would be kind of impressed at your marksmanship skills.

 

[zenman]

That story tells us nothing we don't already know. The human body is astoundingly complex, it would be nearly (if not completely) impossible to eliminate every variable except the one we're studying and to ensure that each person with disease X is actually the same. Even our best studies should only serve to get the physician to consider whatever it is the study is about. In an ideal world, after a big trial is published, we'd still wait a few more years for more studies about that topic to come out before we'd change how we do things. Granted that doesn't always happen, but that's how it should be.

Very well stated.

We don't get brainwashed like you think. Its just a widely held belief among physicians that we are the best trained at what we do. I would suggest that this is quite true, I can't think of any other practitioner that has our knowledge of medicine (let's leave out alternative medicine for now, that could be its own separate thread). Thus, when we see non-physicians trying to do the same work, we get understandably upset about it. But brainwashing that NPs are evil? I don't think so.

I don't think you get brainwashed, but some on this board think NP/DNP programs try to brainwash students against physicians. Personally, I've never heard it happen.

That is all true, and part of what I think makes a compassionate practitioner is willingness to listen. That being said, I think its unwise to go against what science we have based on what a single patient is saying (unless of course that patient has a very rare condition). Allow me a hypothetical. If a patient presents to your office with chest pain that he says morphine completely relives and he just wants to get some of that and go home, would you give him morphine and send him home or would you ignore him and get an EKG at minimum if not send to the ED?

I'd tell him he was in the wrong office and to present himself to his local PCP unless he wanted to go to the ED where I'm sure they would love to treat him. (But, before I sent him I might test him to see if he was lying and also ask him to point to the chest pain and I'd notice whether he did it with his finger or open palm/fist.)

I wouldn't cry, but I would be kind of impressed at your marksmanship skills.

I have been known to shoot a squirrel through and through the eyes and to drop a buzzard out of the sky...both with a .22 cal.

 

[MrMannix]

Wrong. You simply don't appreciate the fact that nursing has its own unique body of knowledge - just ask any nursing prof! For example, medicine has no equivalent to "disturbed energy field," now do they?

And yes, unfortunately, that really is an official nursing diagnosis per NANDA.

I feel so sorry for my cohorts. NANDA is such a waste of time.