How do we stop nurse practitioners?

[atomheart]

Oh wow I thought I was arguing with somebody that has actually practiced medicine and has real life experience lol. That explains your bluster. Okay well Im done debating with you. Your a waste of my time...and just so you know, Im there "when the doors are closed" too. Most physicians I've met treat NPs where I work as colleagues. You too will have to learn to work with us. So strap yourself in and learn to accept the reality of healthcare that you're about to embark on.

Everyone you've 'debated' here has been a student. Why don't you go ahead and stop posting altogether.

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[FNP_Blix]

Everyone you've 'debated' here has been a student. Why don't you go ahead and stop posting altogether.

Not everyone actually. On other threads, and this one too, I've debated with physicians with actual experience and anecdotes worth listening to. Those are the ones I'd prefer to hear from...but with that said, I didn't come here to just shake the bee hive and piss medical students off. On a google search when you see a thread with a title called "how do we stop nurse practitioners", I felt inclined to come here and give you my thoughts, anecdotes, and provide data to support my profession and the contributions we make. Its my hope that if and when you are physician that you will mature and your outlook will change.

 

[FNP_Blix]

NP's and PA's do not have the training needed to practice full-scope medicine. Then again you could say that some general practitioners are not as skilled as others.

Who am I to judge someone who became an NP or a PA. I know good ones and I know some terrible ones.

My argument is that in medicine, you should have the right as to who you want to see. And that doesn't mean pick the MD/DO over the PA or NP all the time. If I had a minor condition, I would probably want to be seen by the PA or NP. If I had what I felt was a more complex issue, I would certainly want to be seen by an MD.

If you truly relegated PA's and NP's to "easy medicine" then I think you'd make medicine more efficient but then again why would you pay PA's and NP's that kind of money to practice "easy medicine" to begin with.

I like most of what you said, and I agree, patients should be able to choose. Unfortunately, that just isn't possible all of the time depending on the setting. I just disagree that everything we see is "easy medicine." I know that I'm quite capable of taking care of issues more complicated than a cough or a cold. I work both as an RN and an NP. In the ICU where I work as an RN, Acute care NPs do about 85%-90% of the work in the ICU for their internist. The other 10%-15% they of course consults with the collaborating physician. Basic stuff is a part of what the NPs do, but they can do so much more than that, and so often times in settings where they have this mentality, NPs are underutilized. These places typically end up short staffed because it just isn't stimulating enough and NPs end up leaving..That said, in family medicine or primary care, a FNP is also capable of managing much more than coughs and colds and can manage a myriad of chronic illnesses and triage more acute complaints. NPs are also very good at creating trusting relationships with their patients and are very good at educating and inducing better compliance.

 

[aformerstudent]

I like most of what you said, and I agree, patients should be able to choose. Unfortunately, that just isn't possible all of the time depending on the setting. I just disagree that everything we see is "easy medicine." I know that I'm quite capable of taking care of issues more complicated than a cough or a cold. I work both as an RN and an NP. In the ICU where I work as an RN, Acute care NPs do about 85%-90% of the work in the ICU for their internist. The other 10%-15% she of course consults wither her collaborating physician. Basic stuff is a part of what the NPs do, but they can do so much more than that. In family medicine or primary care, a FNP is also capable of managing much more than coughs and colds and can manage a myriad of chronic illnesses and triage more acute complaints. NPs are also very good at creating trusting relationships with their patients and are very good at educating and inducing better compliance.

I agree with you actually. In my earlier post a week or so ago I had discussed how we had a very positive experience with an NP at a vascular practice. I agree with the "trusting relationships and better compliance" too. What I meant by "easy medicine" was routine care and routine care can encompass more than just coughs and colds. To me, that's easy medicine so that's why I referred to it as such. If I'm very sick however and by sick I mean incapacitated then I want not just an MD but a well-qualified MD to give me the answers I am looking for as the margin of error becomes more slim the more sick you are. If they sent an NP or PA my way, I'd politely decline because I want someone who's training I feel more confident with. That's not disrespecting NP's or PA's either.

It comes down to understanding the level of training involved. Medicine isn't easy and if someone can make it through medical school and become licensed, that person has earned my confidence regardless who they are. They'd have to be a complete jackass for me to lose my respect for them, and they exist too.

 

[SterlingMaloryArcher]

]

The pay we earn is fair considering how much revenue we produce for a practice and the services we provide.

Your best argument

 

[FNP_Blix]

Your best argument

You being flippant or you serious? lol can't tell.

 

[SterlingMaloryArcher]

You being flippant or you serious? lol can't tell.

Serious

 

[Gastrapathy]

See my prior post. The "value" piece is debatable at best.

 

[FNP_Blix]

See my prior post. The "value" piece is debatable at best.

I saw your previous post. It sounds like you own or manage some practice? So I respect your opinion, but I also would have to respectfully disagree. Some employers choose not to hire NPs and they have their reasons. However, I highly doubt its always due to lack of value that NPs may potentially bring to a practice; or the fact that they demand too many breaks and huge salaries.

Having an NP on staff can greatly increase the number of patients that a practice can see, retain patients, while keeping costs down. NPs on average earn about $100,000 per year vs the $189,000 a FM physician earns. When you adjust annual revenue for salary, then it doesn't take much to see the value NPs can potentially bring to an employer.

I realize it gets much more complicated than that when using RVUs and CPT data to analyze a provider's value, in addition to situational set backs, however, in my opinion (among thousands of others) would agree that hiring NPs is financially a good investment. Its also about making sure you hire someone that is the right fit.

In your case, it sounds like that it may be more worth your while to hire a more experienced NP who is more skilled and able to see larger panels. Doesnt sound like you want a green NP as admittedly it takes approximately 1 year after graduation to get an NP up to speed and efficient. Many though see that training a new NP as an investment and find value in even doing that.

Nevertheless, if you don't see their value, again, I respect your opinion, and wont try to convince you.

 

[Gastrapathy]

Here's an excerpt from an interview with President of Northwest Permanente Medical Group from 2012 in which he states his plan to stop using midlevels as PCPs.

Niche Care for Nurse Practitioners and Physician Assistants

On a philosophical level, Weisz believes nurse practitioners and physician assistants are better at niche care – becoming an expert in one or several diseases. “Don’t forget I went to medical school, and it’s complicated to take care of patients,” he said.

Nurse practitioners could manage a panel of diabetics, chronic congestive heart failure or well baby visits. Now they usually take care of everything a patient may need.

“I’m going to try and focus them more on niche care,” he said. And, if nurse practitioners and physician assistants need more training diabetes, physicians can teach them.

Weisz realizes everyone might not appreciate this new focus and developed a similar approach while working in southern California. “Anytime you change anything in healthcare people are always upset. But, you have to do what’s right for the patient. It’s very hard for a doctor to assess a patient and they went to medical school for four years. If someone comes in with acute abdominal pain, it’s a complicated thing. Can they feel the spleen, feel the liver, do they know what tests to order? It’s hard for doctors to figure out and even harder for people who haven’t gone to medical school.”

 

[Mad Jack]

Okay go get a life for a few hours sb247. Enjoy the sun or something. Im at work now saving lives right now in MSICU.

And you linked Columbia. Like one of the best schools. Their programs are shorter but excellent.

And yet you say PAs can't be trained in two years, despite the fact that PA programs have enough minimum hours to put Columbia to shame.

 

[Mad Jack]

So the problem is that physician specialties are so specific that actual services are spread thin, requiring that expensive and complicated tertiary care services be centered in large hospital institutions or areas with high catchment. That is the maldistribution issue that has allowed midlevel growth. There are definitely plenty of physicians graduating with new schools being opened all the time, so shortage issues are rapidly disappearing. The maldistribution issue is not.

Though many could live and practice primary care in rural areas, NP and PAs are not trained to practice full scope medicine as an FM graduate theoretically could (many PCPs do not for reasons I mentioned in previous posts). This frequently requires midlevels to refer out for tertiary services (Ob, radiology, ENT, Cardiology, etc). It simply does not make sense for midlevels to practice in rural areas, though it is nice that midlevels are moving there, and I'm sure that many appreciate what they can offer. You are propagating an illusion that full care access is being provided when it is certainly not. It is not that physicians are refusing to answer the call, but that full access to medicine is more complicated than people believe; almost everybody will require tertiary services at some point in their life, and the belief that primary care access alone solves the care issue is just flat out wrong. The trend over the next 50 years will be midlevels going into tertiary care services in larger cities and bulking up "access" there. Private specialized training centers (e.g, CRNA schools) will proliferate for this purpose. It just so happens that the lowest hanging fruit is ambulatory services that do not require intensive training.

Medical services are changing which makes people uneasy, esp when tuition plus other training fees can exceed half a million USD per physician. There will be physician pushback with definite consequences that some midlevels will not appreciate if this trend continues. One thing that certainly needs to happen by physicians (rather than nurses) is operationally defining professional differences in scope of practice and responsibility, which could restrict midlevel income and opportunities. I agree with your sentiment that most people are looking for a good life, but all must pay the tollkeeper to find reward in this crappy US healthcare system. Believe that the crappiness will be distributed equitably by your physician peers.

New schools do nothing to alleviate the physician shortage, omg when will this meme die. Only new residency positions create more practicing physicians, as all positions currently not filled by US graduates get filled by IMGs.

 

[FNP_Blix]

Here's an excerpt from an interview with President of Northwest Permanente Medical Group from 2012 in which he states his plan to stop using midlevels as PCPs.

Niche Care for Nurse Practitioners and Physician Assistants

On a philosophical level, Weisz believes nurse practitioners and physician assistants are better at niche care – becoming an expert in one or several diseases. “Don’t forget I went to medical school, and it’s complicated to take care of patients,” he said.

Nurse practitioners could manage a panel of diabetics, chronic congestive heart failure or well baby visits. Now they usually take care of everything a patient may need.

“I’m going to try and focus them more on niche care,” he said. And, if nurse practitioners and physician assistants need more training diabetes, physicians can teach them.

Weisz realizes everyone might not appreciate this new focus and developed a similar approach while working in southern California. “Anytime you change anything in healthcare people are always upset. But, you have to do what’s right for the patient. It’s very hard for a doctor to assess a patient and they went to medical school for four years. If someone comes in with acute abdominal pain, it’s a complicated thing. Can they feel the spleen, feel the liver, do they know what tests to order? It’s hard for doctors to figure out and even harder for people who haven’t gone to medical school.”

I thought you were making a financial argument. What this man is saying simply is just not true. Basically he is calling for the underutilization of NPs. We are absolutely trained on working up a complaint of abdominal pain. FNPs are trained across the lifespan.

 

[FNP_Blix]

And yet you say PAs can't be trained in two years, despite the fact that PA programs have enough minimum hours to put Columbia to shame.

We have debated this before mad jack and we already know that we disagree on this point (with the exception of psych NPs). There are exceptions. PAs are not all going through grad programs and they all don't have experience coming in. There are inconsistencies in both professions. However, my position is that, for the average NP, most of the time, we have way more experience that we bring to the table (avg. 10-11 years of RN experience). Also, we are not trained as generalist like PAs (hence less clinical and didactic hours). In my opinion, for how much latitude a PA has, frankly, they don't do enough hours.

 

[Gastrapathy]

"this man" wasn't calling for anything. This physician was explaining the plan that he subsequently implemented and other large multispecialty groups have done the same. This is the power of working in a physician-run organization. You don't have to debate nurses. You can do the right thing.

I believe that the amount of rework, extra consultations, and coverage issues created by midlevels as PCPs erodes any perceived savings (value). Dr Weisz believes that physician primary care provides better care (quality). We don't need to convince a nurse that we are right. For the young prospective primary care physicians, the message is to take heart. Look who values you.

 

[Mad Jack]

We have debated this before mad jack and we already know that we disagree on this point (with the exception of psych NPs). There are exceptions. PAs are not all going through grad programs and they all don't have experience coming in. There are inconsistencies in both professions. However, my position is that, for the average NP, most of the time, we have way more experience that we bring to the table (avg. 10-11 years of RN experience). Also, we are not trained as generalist like PAs (hence less clinical and didactic hours). In my opinion, for how much latitude a PA has, frankly, they don't do enough hours.

The non-graduate PA programs have the exact same requirements as graduate-level PA programs in their curriculums. PAs have less hours than a medical student entering residency, but they have less responsibility than a medical student entering residency and in most states and fields must practice under a physician that is responsible for their further training and work, unlike NPs, which are free to do whatever with their 650 clinical hours and no oversight.

 

[atomheart]

New schools do nothing to alleviate the physician shortage, omg when will this meme die. Only new residency positions create more practicing physicians, as all positions currently not filled by US graduates get filled by IMGs.

lol, yes I know. I was arguing semantics with Mr. Data above who is all about shortages, whatever that may mean. Physician = Graduated Medical Student, Nurse = not a physician. A shortage could mean a lot of different things, but yes I understand that most people use that to mean practicing physician shortage.

Also, I'm a dumb DO student who doesn't know anything about medicine, and I'm just disgruntled by the overuse of physician shortages to justify anything.

 

[FNP_Blix]

"this man" wasn't calling for anything. This physician was explaining the plan that he subsequently implemented and other large multispecialty groups have done the same. This is the power of working in a physician-run organization. You don't have to debate nurses. You can do the right thing.

I believe that the amount of rework, extra consultations, and coverage issues created by midlevels as PCPs erodes any perceived savings (value). Dr Weisz believes that physician primary care provides better care (quality). We don't need to convince a nurse that we are right. For the young prospective primary care physicians, the message is to take heart. Look who values you.

This isn't a change in policy, nor is this change substantiated by anything rooted in facts. Regardless, many NPs are actually okay with working in niches like this, so really, I'm not worried about it. You are talking about a couple of groups in an area of California that decided to make this change, and that's actually okay. Personally, I prefer urgent care and primary care type settings and seeing patients across the lifespan. That is what my training gave me the ability to do.

Regarding your comment about not having to convince nurses, or not having to debate with nurses, you better believe that nurses have influence and that if you want healthcare to be good in this country and copacetic, you will include nurses in these discussions. Physicians have no choice but to reach across the isle, and work with nurses when it comes to their profession and scope of practice (among other major healthcare policy changes). We too have the best interest of patient's in mind, and you are delusional if you think otherwise.

This so called example that you provided me in California I truly doubt will have any traction across the country at a policy level. There are many other smart people out there besides physicians, with influence, that realize that there is a shortage, and that NPs are a solid solution to mitigate that shortage for decades to come. Limiting our ability to practice and underutilizing us is not a solution to that problem.

 

[FNP_Blix]

The non-graduate PA programs have the exact same requirements as graduate-level PA programs in their curriculums. PAs have less hours than a medical student entering residency, but they have less responsibility than a medical student entering residency and in most states and fields must practice under a physician that is responsible for their further training and work, unlike NPs, which are free to do whatever with their 650 clinical hours and no oversight.

Okay but what you still don't seem to understand is that a MSN or DNP affords the graduate more than just clinical knowledge. That is why nursing has so much more influence than the PA profession does. We are educated on disseminating evidence based studies into practice, healthcare policy, nursing theory (which basically teaches nurses how to develop nursing care models for hospitals and/or at the macro level), health promotion, disease prevention, law, etc. That is the graduate level part of nursing. Our model of education is much different and making a comparison solely based on clinical hours is misleading and a blatant misrepresentation of what NPs actually learn and can do.

Regarding our medical training, once again, we are trained on specific population groups (FNPs having the broadest scope) and not as generalists. As an FNP, I am not permitted to deliver babies or fill the role as a psych NP. PAs (in theory) can switch specialties at any time and practice. My argument is that for how much latitude they have, they just barely scratch the surface. You can't honestly tell me that for a practitioner that can switch specialties and supposedly work in any area of medicine, that 2 years of education, with variable prior medical or healthcare experience, is enough.

Don't get me wrong. There are excellent PAs out there. But I just don't agree that their education is somehow superior. If NPs were trained as generalists like PAs at the graduate level, the amount of training we would receive would be more comparable to that of a physicians training, not a PA.

 

[Mad Jack]

Okay but what you still don't seem to understand is that a MSN or DNP affords the graduate more than just clinical knowledge. That is why nursing has so much more influence than the PA profession does. We are educated on disseminating evidence based studies into practice, healthcare policy, nursing theory (which basically teaches nurses how to develop nursing care models for hospitals and/or at the macro level), health promotion, disease prevention, law, etc. That is the graduate level part of nursing. Our model of education is much different and making a comparison solely based on clinical hours is misleading and a blatant misrepresentation of what NPs actually learn and can do.

Regarding our medical training, once again, we are trained on a specific population groups and not as generalists. As an FNP, I am not permitted to deliver babies or fill the role as a psych NP. PAs (in theory) can switch specialties at any time and practice. My argument is that for how much latitude they have, they just barely scratch the surface. You can't honestly tell me that for a practitioner that can switch specialties and supposedly work in any area of medicine, that 2 years of education, with variable prior medical or healthcare experience, is enough.

Don't get me wrong. There are excellent PAs out there. But I just don't agree that their education is somehow superior. If NPs were trained as generalists like PAs at the graduate level, the amount of training we would receive would be more comparable to that of a physicians training, not a PA.

It's sufficient training to assist a physician in any specialty.

 

[FNP_Blix]

It's sufficient training to assist a physician in any specialty.

I agree, they can certainly assist. So what's your point? You derailed this debate (sort of your MO) and have contributed nothing to the conversation that is at hand.

 

[Mad Jack]

I agree, they can certainly assist. So what's your point? You derailed this debate (sort of your MO) and have contributed nothing to the conversation that is at hand.

I've contributed plenty- hire NPs, milk them for profit, and participate in lawsuits aggressively when NPs are named. That's how you live in the post-NP world.

 

[FNP_Blix]

lol, yes I know. I was arguing semantics with Mr. Data above who is all about shortages, whatever that may mean. Physician = Graduated Medical Student, Nurse = not a physician. A shortage could mean a lot of different things, but yes I understand that most people use that to mean practicing physician shortage.

Also, I'm a dumb DO student who doesn't know anything about medicine, and I'm just disgruntled by the overuse of physician shortages to justify anything.

Mr. Data over here has provided more to support his arguments than you have. All you've provided is a bunch of sorry anecdotes and projected your wishful thinking.

 

[KGflyboy]

Oh wow I thought I was arguing with somebody that has actually practiced medicine and has real life experience lol. That explains your bluster. Okay well I think I'm done debating with you. Your wasting my time because so far you have offered no real life experience or evidence to support your arguments...and just so you know, Im there "when the doors are closed" too. Most physicians I've met treat NPs where I work as colleagues. You too will have to learn to work with us. So strap yourself in and learn to accept the reality of healthcare that you're about to embark on.

I have real world experience. And I know what the other poster was referring to. It seems as though many NPs in the hospital are used as physician extenders. They help with discharges and rounding on patients that don't need many changes to the plan. I'm sure some places operate differently, but this is my experience. However, I have noticed the NPs who are strictly working as originally intended, physician extenders, seem to be the ones most likely to voice opinions in person or online about how they provide "equal or better" care than the physicians they work with. Physicians as a whole are on to this mentality. They won't call you out publicly because we have nothing to prove. We know who is directing a patient's evaluation and care. And I'm still waiting on an example of a hospital with NPs running the ICU.

 

[FNP_Blix]

I have real world experience. And I k ow what the other poster was referring to. It seems as though many NPs in the hospital are used as physician extenders. They help with discharged and rounding with stable patients that don't need many changes to the plan. I'm sure some places operate differently, but this is my experience. However, I have noticed the NPs who are strictly working as originally intended, physician extenders, seem to be the ones most likely to voice opinions in person or online about how they provide "equal or better" care than the physicians they work with. Physicians as a whole are on to this mentality. They won't call you out publicly because we have nothing to prove. We know who is directing a patient's evaluation and care. And I'm still waiting on an example of a hospital with NPs running the ICU.

And that's fine. I am not arguing that NPs will be the only dominant figure of medicine. I will give respect where its due, and physicians def. are the heavy hitters of medicine and finding cures, etc. What I've been arguing this whole time is a much different message. Please review my points and though you won't likely admit it, you will know deep down that I'm correct on so many levels (at least I hope lol).

What I meant by that statement was that at the hospital I work at (and many others), is that the acute care NPs are on call 24/7. They do around 90% of the work. The Internist I see only during daily rounds and when diagnostic conundrums arise. He is actually really great and allows his NPs a lot of autonomy. His group actually prefers NPs because they are easier to train. Plus Acute Care NPs are superior as extenders in that setting, compared to PAs, because their primary focus is on the acute care setting. That said, the NPs that work with him in particular have a professional and happy relationship. Let me be clear, I don't believe that NPs can practice completely independent in that setting. Sorry for the misunderstanding there.

 

[KGflyboy]

And that's fine. I am not arguing that NPs will be the dominant figue of medicine. I will give respect where its due, and physicians def. are the heavy hitters of medicine. What I've been arguing this whole time is a much different message. Please review my points and though you won't admit, you will likely see deep down that I'm correct on so many levels.

What I meant my that statement was that at the hospital I work at, the acute care NPs are on call 24/7. They do around 90% of the work. The Internist I see only during daily rounds and when diagnostic conundrums arise. He is actually really great and allows his NPs a lot of autonomy. His group actually prefers NPs because they are easier to train. Plus Acute Care NPs are superior as extenders compared to PAs because their primary focus is on the acute care setting. That said, the NPs that work with him in particular have a professional and happy relationship. Let me be clear, I don't believe that NPs can practice completely independent in that setting. Sorry for the misunderstanding there.

That's more similar to how I see NPs working in the hospitals. To be fair to you, I should acknowledge I've never had a bad experience with the NPs at my hospital. They are great. But that's partly because they tend to acknowledge how the team works. The physician looks over their plans, see their patients, and adjust the plans when needed. People who post on forums tend to be opinionated and outspoken. However, even in real life, all bets are off once independent practice is discussed. That conversation is often just avoided to prevent conversations like this thread playing out in the work place.

 

[FNP_Blix]

What do you guys think about NPs running medical homes? When it comes to primary care, we should absolutely be independent (for reasons I mentioned previously), but I think taking it even a step further, NPs should also be leading their own medical homes as well. That is a whole other issue that I would like to hear from you about. NPs are beginning to play a massive role in primary care in this country, so my position is that barriers for that should also be broken. Your thoughts?

1) Medscape: Medscape Access
2) Nurse-Managed Health Centers And Patient-Centered Medical Homes Could Mitigate Expected Primary Care Physician Shortage

 

[FNP_Blix]

That's more similar to how I see NPs working in the hospitals. To be fair to you, I should acknowledge I've never had a bad experience with the NPs at my hospital. They are great. But that's partly because they tend to acknowledge how the team works. The physician looks over their plans, see their patients, and adjust the plans when needed. People who post on forums tend to be opinionated and outspoken. However, even in real life, all bets are off once independent practice is discussed. That conversation is often just avoided to prevent conversations like this thread playing out in the work place.

Yea I know. These conversation occur during debates at policy level, however, usually require a professional mediator lol. And I appreciate your practicality and your politeness. I agree that 99% of the time, physicians and NPs get along great. Just the topic of independence is a sticky one.

And while I appreciate your opinion, I still hold that independent practice for NPs is a must in primary care. There is no question about it. In addition, barriers for CNMs and CRNAs also need to be torn down. As it was noted by this physician, the ship is sinking and we need nurses' help:

Giving Nurses a Leading Role in the Future of Health Care

 

[FNP_Blix]

I've contributed plenty- hire NPs, milk them for profit, and participate in lawsuits aggressively when NPs are named. That's how you live in the post-NP world.

Why let someone like you "milk profits" when I can just open up my own practice and have an NP ran clinic? And what world are you living in? Right now we are expanding so your just projecting some fantasy...Although I'm actually happy to hear that you hire NPs, I just wonder how they would feel if they read your posts on here.

 

[Mad Jack]

Why let someone like you "milk profits" when I can just open up my own practice and have an NP ran clinic? And what world are you living in? Right now we are expanding so your just projecting some fantasy...Although I'm actually happy to hear that you hire NPs, I just wonder how they would feel if they read your posts on here.

Most NPs aren't very business inclined. They'd rather collect their W2 and go home than start a business. The same also goes for the current generation of physicians, but NPs provide a much better payoff to headache ratio if you're looking to maximize profits.

 

[FNP_Blix]

Most NPs aren't very business inclined. They'd rather collect their W2 and go home than start a business. The same also goes for the current generation of physicians, but NPs provide a much better payoff to headache ratio if you're looking to maximize profits.

haha "payoff to headache ratio" not gonna lie I actually laughed out loud when I read that!...as much as we disagreed mad jack, I get the feeling that you're a funny guy in real life and would be fun to work with...I could be wrong though

 

[deleted480308]

What do you guys think about NPs running medical homes? When it comes to primary care, we should absolutely be independent (for reasons I mentioned previously), but I think taking it even a step further, NPs should also be leading their own medical homes as well. That is a whole other issue that I would like to hear from you about. NPs are beginning to play a massive role in primary care in this country, so my position is that barriers for that should also be broken. Your thoughts?

1) Medscape: Medscape Access
2) Nurse-Managed Health Centers And Patient-Centered Medical Homes Could Mitigate Expected Primary Care Physician Shortage

No. Not appropriate

 

[FNP_Blix]

No. Not appropriate

They already do in some areas, and quite successfully I might add. So why not?

 

[Mad Jack]

haha "payoff to headache ratio" not gonna lie I actually laughed out loud when I read that!...as much as we disagreed mad jack, I get the feeling that you're a funny guy in real life and would be fun to work with...I could be wrong though

I'm generally regarded as "pretty alright I guess" by most coworkers.

 

[857770]

Okay but what you still don't seem to understand is that a MSN or DNP affords the graduate more than just clinical knowledge. That is why nursing has so much more influence than the PA profession does. We are educated on disseminating evidence based studies into practice, healthcare policy, nursing theory (which basically teaches nurses how to develop nursing care models for hospitals and/or at the macro level), health promotion, disease prevention, law, etc. That is the graduate level part of nursing. Our model of education is much different and making a comparison solely based on clinical hours is misleading and a blatant misrepresentation of what NPs actually learn and can do.

Regarding our medical training, once again, we are trained on specific population groups (FNPs having the broadest scope) and not as generalists. As an FNP, I am not permitted to deliver babies or fill the role as a psych NP. PAs (in theory) can switch specialties at any time and practice. My argument is that for how much latitude they have, they just barely scratch the surface. You can't honestly tell me that for a practitioner that can switch specialties and supposedly work in any area of medicine, that 2 years of education, with variable prior medical or healthcare experience, is enough.

Don't get me wrong. There are excellent PAs out there. But I just don't agree that their education is somehow superior. If NPs were trained as generalists like PAs at the graduate level, the amount of training we would receive would be more comparable to that of a physicians training, not a PA.

Not at all. For NPs to compare themselves to physicians, they need a much much much more rigorous scientific background in the basic sciences and the medical sciences. At least PA training covers some of the medical sciences that physicians get. Even then PA training is not nearly at the depth and breadth that a medical student gets.

NP training is so poor that that is why only PAs can become physicians through bridge programs.

 

[857770]

@FNP_Blix You keep stating that RN experience counts. Well, CNAs are around alot, some for many years, should their experience count too. Ludicrous!

 

[FNP_Blix]

Not at all. For NPs to compare themselves to physicians, they need a much much much more rigorous scientific background in the basic sciences and the medical sciences. At least PA training covers some of the medical sciences that physicians get. Even then PA training is not nearly at the depth and breadth that a medical student gets.

NP training is so poor that that is why only PAs can become physicians through bridge programs.

I disagree that our education "is so poor." If our eduction was so poor, then why do we have the outcomes that we have. Why is it that we have been granted independence in 20+ states, have some authority to run our own "medical" homes, and have been granted independence in VA hospitals? And don't give me that "strong lobby" crap. Physicians have strong lobbies too, yet have been unable to convince legislators and the public that we are the "poor" providers you say we are. Why have you been unable to prove that we are poor providers? Because the proof is there. Just because we are not educated in the medical model does not make us unable to cross disciplines, and provide healthcare services to millions of people with quality and competence.

The reason I said our education would be comparable to that of a physicians (if trained as generalists like PAs) is because our focus in specific areas is greater than that of PAs education. Even as an FNP (who's trained across the lifespan), if I wan't credentialing to work in areas such as psych, neonatology, and acute care for example, I would need a minimum of an additional two more years of post graduate formal education. The total amount of training and time spent to obtain that latitude of clinical expertise would be comparable to that of a physicians training, undoubtedly. Not a PAs.

 

[FNP_Blix]

And no, that comparison is not analogous. Vet techs work under the license of veterinarians and have not developed their own body of knowledge or philosophy for training. Nurses have distinguished themselves as a completely separate entity, with their own knowledge base, theory's, research, and science. That distinction makes nursing completely different as a profession and allows for the development of their own providers, separate to that of MDs or DOs.

Don't get me wrong. I'm not saying that we are the giants or the gold standard in medicine. However, I do believe that the nursing profession will continue to grow and further distinguish itself. Nursing is multidisciplinary and has proven to be capable of practicing in multiple arenas, including medicine.

 

[atomheart]

What is a good outcome for someone working in primary care? What's a poor provider in primary care?

What qualities does it take to be the same as a primary care physician?

I feel like everyone on this forum and in this thread really wants to know the truth. Maybe it was mentioned a few pages back. Link me.

 

[857770]

And no, that comparison is not analogous. Vet techs work under the license of veterinarians and have not developed their own body of knowledge or philosophy for training. Nurses have distinguished themselves as a completely separate entity, with their own knowledge base, theory's, research, and science. That distinction makes nursing completely different as a profession and allows for the development of their own providers, separate to that of MDs or DOs.

Don't get me wrong. I'm not saying that we are the giants or the gold standard in medicine. However, I do believe that the nursing profession will continue to grow and further distinguish itself. Nursing is multidisciplinary and has proven to be capable of practicing in multiple arenas, including medicine.

You don't get it. You keep repeating that years of RN experience counts. That is completely different than the role of a provider. There are many medical students that come from other healthcare backgrounds, but they still need to do a residency because that experience as a pre-med doesn't count the way you think it does for NPs.

 

[Mad Jack]

I disagree that our education "is so poor." If our eduction was so poor, then why do we have the outcomes that we have. Why is it that we have been granted independence in 20+ states, have some authority to run our own "medical" homes, and have been granted independence in VA hospitals? And don't give me that "strong lobby" crap. Physicians have strong lobbies too, yet have been unable to convince legislators and the public that we are the "poor" providers you say we are. Why have you been unable to prove that we are poor providers? Because the proof is there. Just because we are not educated in the medical model does not make us unable to cross disciplines, and provide healthcare services to millions of people with quality and competence.

The reason I said our education would be comparable to that of a physicians (if trained as generalists like PAs) is because our focus in specific areas is greater than that of PAs education. Even as an FNP (who's trained across the lifespan), if I wan't credentialing to work in areas such as psych, neonatology, and acute care for example, I would need a minimum of an additional two more years of post graduate formal education. The total amount of training and time spent to obtain that latitude of clinical expertise would be comparable to that of a physicians training, undoubtedly. Not a PAs.

The nursing lobby is far more powerful than the physician lobby and is the only reason you have independent practice. Nurses have a largely consolidated lobby, while physicians have a lobbying group for each specialty- even the strongest one is not even a tenth the size of the ANA.

 

[FNP_Blix]

You don't get it. You keep repeating that years of RN experience counts. That is completely different than the role of a provider. There are many medical students that come from other healthcare backgrounds, but they still need to do a residency because that experience as a pre-med doesn't count the way you think it does for NPs.

I beg to differ, it absolutely does.

 

[FNP_Blix]

The nursing lobby is far more powerful than the physician lobby and is the only reason you have independent practice. Nurses have a largely consolidated lobby, while physicians have a lobbying group for each specialty- even the strongest one is not even a tenth the size of the ANA.

Any evidence or data to support that claim?

 

[Mad Jack]

I disagree that our education "is so poor." If our eduction was so poor, then why do we have the outcomes that we have. Why is it that we have been granted independence in 20+ states, have some authority to run our own "medical" homes, and have been granted independence in VA hospitals? And don't give me that "strong lobby" crap. Physicians have strong lobbies too, yet have been unable to convince legislators and the public that we are the "poor" providers you say we are. Why have you been unable to prove that we are poor providers? Because the proof is there. Just because we are not educated in the medical model does not make us unable to cross disciplines, and provide healthcare services to millions of people with quality and competence.

The reason I said our education would be comparable to that of a physicians (if trained as generalists like PAs) is because our focus in specific areas is greater than that of PAs education. Even as an FNP (who's trained across the lifespan), if I wan't credentialing to work in areas such as psych, neonatology, and acute care for example, I would need a minimum of an additional two more years of post graduate formal education. The total amount of training and time spent to obtain that latitude of clinical expertise would be comparable to that of a physicians training, undoubtedly. Not a PAs.

But the average PA has more hours in the same areas of practice as a FNP, and generally far higher quality rotations within those areas. You can talk philosophy all you want, but medicine is the gold standard of medical decision making worldwide for a reason, and PAs are trained in that gold-standard model. They essentially have 2/3 of the training a fresh physician has, and I'll take 2/3 of a physician over 9/3 of a nurse or whatever NPs think they are.

 

[FNP_Blix]

But the average PA has more hours in the same areas of practice as a FNP, and generally far higher quality rotations within those areas. You can talk philosophy all you want, but medicine is the gold standard of medical decision making worldwide for a reason, and PAs are trained in that gold-standard model. They essentially have 2/3 of the training a fresh physician has, and I'll take 2/3 of a physician over 9/3 of a nurse or whatever NPs think they are.

Yet you hire NPs

 

[Mad Jack]

Yet you hire NPs

Plan to hire, eventually. There are three areas in which NPs are superior to PAs: neonatology, anesthesia, and psychiatry. I should have stated "when it comes to anything aside from these three things," which I thought about, but I was out to dinner and typing on my phone so the extra words seemed like too much of a hassle.

Any evidence or data to support that claim?

I was being sarcastic

 

[FNP_Blix]

Plan to hire, eventually. There are three areas in which NPs are superior to PAs: neonatology, anesthesia, and psychiatry. I should have stated "when it comes to anything aside from these three things," which I thought about, but I was out to dinner and typing on my phone so the extra words seemed like too much of a hassle.

I was being sarcastic

You didnt sound like you were being sarcastic ...and actually, with a majority of NP programs, when you include a BSN-RN education plus the prerequisite of experience as an RN, our education transcends that of a PAs education. That same focus and quality that you described with neonatal and psych NPs is the same for FNPs, ACNPs, etc. Like I mentioned earlier, many work places prefer NPs for the above reasons I stated now and before. They typically are far more confident in their abilities and learn much quicker on the job once they are working.

 

[atomheart]

Yet you hire NPs

That's a fourth year med stud you're debating iirc.

So uh. Where's that link on what exactly an 'outcome' is in a fp clinic? What the heck is a 'good' PCP? I asked my preceptor about pcmh today and he likes them except they cannot get funding and insurance companies don't like them. They're an Obamacare era pipe dream that will never come to fruition. Maybe those concierge NPs in Colorado will make it work.

 

[FNP_Blix]

That's a fourth year med stud you're debating iirc.

So uh. Where's that link on what exactly an 'outcome' is in a fp clinic? What the heck is a 'good' PCP? I asked my preceptor about pcmh today and he likes them except they cannot get funding and insurance companies don't like them. They're an Obamacare era pipe dream that will never come to fruition. Maybe those concierge NPs in Colorado will make it work.

Okay, so to seriously answer your question, I should preface that this is actually not an easy question to answer for both physicians and nurse practitioners. The simplest answer would be, the clinician that has the broadest knowledge base who therefore, in theory, would provide the highest quality of care. However, it is not that simple...Capturing all interactions and points of care, and measuring value is very difficult, so typically reimbursement (essentially a measure and reward of ones quality) is based on broad categories. They are measured to determine "quality" and what that provider should earn. In the U.S. we have RVUs and CPTs to theoretically capture quality data and of course determine the reimbursement providers receive. Because our system is moving away from fee-for-services and is pushing health promotion and disease prevention, quality outcomes data that is often collected and at the forefront include related categories like breast cancer screening, cervical cancer screening, diabetes care, hypertension care, and smoking cessation. Other measures that supposedly determines a providers "quality" include things like reduced hospital admissions, VTE prophylaxis, decreased mortality, less use of diagnostic testing, compliance with core measures, patient satisfaction, etc...

Now before you go on a tirade on how stupid this is, this actually (at present) will determine how you get paid...Does that actually fully measure a provider's quality, all of the time? Absolutely not. However, it is very difficult to determine every single NP's or physicians' ability to differentiate, say, a diagnosis of granuloma inguinale vs. HPV lesion...What is easier to measure is if you forgot to screen someone for cervical cancer, poorly manage diabetes, or determine if your patients are frequently ending up in the hospital...These categories all translate to dollars in your pocket, and ends up decreasing the financial burden to society. Not to mention, these categories are actually important points of measure because if followed, will save patient lives, considering these categories constitute a huge portion of the comorbidities in our population today...

Currently, most of the data out there on NPs points to us performing really well in all these categories of measure (regardless of the setting or autonomy). That is, in part, how NPs have gained recognition and how their quality of care has been proven. A big focus of our education is on health promotion, disease prevention, and patient centered care, so that all makes sense.

Here are two sources that explain this better:
1) Medscape: Medscape Access
2) Nurse-Managed Health Centers And Patient-Centered Medical Homes Could Mitigate Expected Primary Care Physician Shortage

 

[57A]

I normally read SDN and not post. But, I couldn't resist posting now that I saw this thread.

I am a former nurse practioner who now attends medical school. My NP program was not online, and I have a lot of experience as a floor nurse and as an NP. Anyway, while working as an NP, I found that I wanted to know more; I wanted to know more about the "why's" and the science behind things. So, I decided to apply to med school. I did my prereqs, some research, and my MCAT. When I finally got in, I thought I would be ahead of my classmates because I had worked as an NP.

I found that I had to work just as hard as everyone else. My previous experience as an NP and a floor nurse helps me with my clinicals. Other than that that is it.

One thing that I learned is that there is so much that I didn't know as an NP. And it is scary to think that I had actually wanted to be an NP that practiced independently. So it really is true: I didn't know how much I didn't know until going to medical school.