How do we stop nurse practitioners?

[FNP_Blix]

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.

I appreciate your opinion and I too wish that we had stronger science background. I am actually looking at possibly going into medical school mySelf because I feel like I have more capacity to do more.

However, I never argued that NPs know as much as physicians justifying independent practice. I argue that because there is massive lack of access to healthcare, NPs serve a vital role in certain setting to deliver healthcare services, unimpeded. They practice within their scope and are not pretending to be doctors, and with the current data thats out there, it shows that we are safe and effective at what we do.

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[deleted480308]

I appreciate your opinion and I too wish that we had stronger science background. I am actually looking at possibly going into medical school mySelf because I feel like I have more capacity to do more.

However, I never argued that NPs know as much as physicians justifying independent practice. I argue that because there is massive lack of access to healthcare, NPs serve a vital role in certain setting to deliver healthcare services, unimpeded. They practice within their scope and are not pretending to be doctors, and with current data thats out there, shows tht we are safe and effective at what we do.

"their scope" does not properly include independent practice

 

[FNP_Blix]

"their scope" does not properly include independent practice

It does in certain setting. In family practice (more limited), retail clinics, urgent cares, etc., I believe NPs have as adequate training to practice independently.

 

[atomheart]

I'm at the end of my primary care rotations, and as a medical student my concerns and efforts in this discussion are probably misplaced/useless. My preceptors are either not concerned, or do not feel that the presence of NPs is in any way threatening which tells me a few things.

The first is that medical students overthink threats to the medical profession. Pretty obvious to attendings, it's just the nature of this risky and life consuming training path.

Second, not that they aren't a threat, but nurses in primary care are not a big enough threat, educationwise, that a trained PCP should feel worried about competition. The studies on outcomes and continuously enlarging scope haven't impressed my precepting physicians, and aren't enough to register as something worth their time. The death knell of the profession right now would more likely be something congressionally stupid that would make it financially impossible to be a primary care physician.

Third is that physicians really do not care for drama and politics in the office. The lobbyists are most effective in front of people who have power, and they are best left to the job of seeing that physicians aren't completely f****d by everything else going on in healthcare now. Individual specialty lobbies take care of their own incentives in credentialing scope of practice outside of the office. Otherwise physicians simply wouldn't spend a small fortune on their CME... as it turns out, credentials are as important in physicians finding jobs as outcomes apparently are in nurses getting paid. Even nurses should see the logic in this because they have their own credentialing system that they rely on for their job hierarchy.

My understanding of the second point most puts my puny mind at ease. Knowledge is incredibly important in medicine. Traditional PCPs can offer more efficiency and breadth of services...at least until nurses learn the protocols of the trade. But educationwise, NPs need to cover some ground, preferably immediately, if they desire their autonomous decision making to be respected. Reflecting on the number of times my preceptors have been consulted by the in office NPs...a lot of time is spent educating them. The more experienced NPs probably have had the benefit of a full medical education paid for in physician consults. Collaboration implies reciprocity, but that is not the reality I saw in the office. What I saw was closer to indentured servitude in exchange for a safety net. I have heard the exact same thing said about CRNAs before in the anesthesia forum. It's just reinventing the wheel of 'residency' without calling it residency, and without the benefit of earning credentials.

There is a tendency by nurses and even some physicians to simply downplay education altogether, and this is a mistake. If some nurses cannot function without a physician safety net today, independent nursing practice of medicine and surgery is just a political trophy for the nurses of tomorrow. Unacceptable. The idea of "practicing to the full extent of the license" is bs if you're constantly practicing at the level of a medicine intern.

 

[deleted480308]

I'm at the end of my primary care rotations, and as a medical student my concerns and efforts in this discussion are probably misplaced/useless. My preceptors are either not concerned, or do not feel that the presence of NPs is in any way threatening which tells me a few things.

The first is that medical students overthink threats to the medical profession. Pretty obvious to attendings, it's just the nature of this risky and life consuming training path.

Second, not that they aren't a threat, but nurses in primary care are not a big enough threat, educationwise, that a trained PCP should feel worried about competition. The studies on outcomes and continuously enlarging scope haven't impressed my precepting physicians, and aren't enough to register as something worth their time. The death knell of the profession right now would more likely be something congressionally stupid that would make it financially impossible to be a primary care physician.

Third is that physicians really do not care for drama and politics in the office. The lobbyists are most effective in front of people who have power, and they are best left to the job of seeing that physicians aren't completely f****d by everything else going on in healthcare now. Individual specialty lobbies take care of their own incentives in credentialing scope of practice outside of the office. Otherwise physicians simply wouldn't spend a small fortune on their CME... as it turns out, credentials are as important in physicians finding jobs as outcomes apparently are in nurses getting paid. Even nurses should see the logic in this because they have their own credentialing system that they rely on for their job hierarchy.

My understanding of the second point most puts my puny mind at ease. Knowledge is incredibly important in medicine. Traditional PCPs can offer more efficiency and breadth of services...at least until nurses learn the protocols of the trade. But educationwise, NPs need to cover some ground, preferably immediately, if they desire their autonomous decision making to be respected. Reflecting on the number of times my preceptors have been consulted by the in office NPs...a lot of time is spent educating them. The more experienced NPs probably have had the benefit of a full medical education paid for in physician consults. Collaboration implies reciprocity, but that is not the reality I saw in the office. What I saw was closer to indentured servitude in exchange for a safety net. I have heard the exact same thing said about CRNAs before in the anesthesia forum.

There is a tendency by nurses and even some physicians to simply downplay education altogether, and this is a mistake. If some nurses cannot function without a physician safety net today, independent nursing practice of medicine and surgery is just a political trophy for the nurses of tomorrow. Unacceptable. The idea of "practicing to the full extent of the license" is bs if you're constantly practicing at the level of a medicine intern.

"collaboration" is also a lie. It's a supervising agreement.

 

[FNP_Blix]

"collaboration" is also a lie. It's a supervising agreement.

It's actually reality Ron Swanson. Most physicians don't "supervise" and in Florida, a state with some of the strictest laws on NP practice, you don't even need to submit the forms saying that you collaborate.

 

[atomheart]

"collaboration" is also a lie. It's a supervising agreement.

Yep. Indentured servitude in exchange for a supervision safety net that could span an entire career. It's almost like a light went off, and now I regret wasting three years worrying about the 'ensuing plague of midlevels'. I certainly regret ever strongly considering midlevel schooling as a happy alternative to medical school.

What a s**t deal.

 

[deleted480308]

It's actually reality Ron Swanson. Most physicians don't "supervise" and in Florida, a state with some of the strictest laws on NP practice, you don't even need to submit the forms saying that you collaborate.

what you are describing is negligent supervision, not collaboration

 

[FNP_Blix]

what you are describing is negligent supervision, not collaboration

What I'm describing is appropriate for most NPs. Most employers recognize there are varying lengths of experience, and so they judge "supervision" based on that individual NPs skill. But overtime (sometimes after the 1st week, sometimes after a year) employers will typically gain trust in that provider. So no, its not negligent supervision. It starts as supervision and then becomes collaboration maybe...Once again, look at the data that's out there. Is there anything that indicates that we as an NPs are less safe with more lax laws? Do you have any sort of measure or data that proves your arguments? Once again, no, you don't.

God it's so annoying debating with you cheesy med students that only talk crap about my profession, but have no proof to say we are not safe...

 

[FNP_Blix]

I'm at the end of my primary care rotations, and as a medical student my concerns and efforts in this discussion are probably misplaced/useless. My preceptors are either not concerned, or do not feel that the presence of NPs is in any way threatening which tells me a few things.

The first is that medical students overthink threats to the medical profession. Pretty obvious to attendings, it's just the nature of this risky and life consuming training path.

Second, not that they aren't a threat, but nurses in primary care are not a big enough threat, educationwise, that a trained PCP should feel worried about competition. The studies on outcomes and continuously enlarging scope haven't impressed my precepting physicians, and aren't enough to register as something worth their time. The death knell of the profession right now would more likely be something congressionally stupid that would make it financially impossible to be a primary care physician.

Third is that physicians really do not care for drama and politics in the office. The lobbyists are most effective in front of people who have power, and they are best left to the job of seeing that physicians aren't completely f****d by everything else going on in healthcare now. Individual specialty lobbies take care of their own incentives in credentialing scope of practice outside of the office. Otherwise physicians simply wouldn't spend a small fortune on their CME... as it turns out, credentials are as important in physicians finding jobs as outcomes apparently are in nurses getting paid. Even nurses should see the logic in this because they have their own credentialing system that they rely on for their job hierarchy.

My understanding of the second point most puts my puny mind at ease. Knowledge is incredibly important in medicine. Traditional PCPs can offer more efficiency and breadth of services...at least until nurses learn the protocols of the trade. But educationwise, NPs need to cover some ground, preferably immediately, if they desire their autonomous decision making to be respected. Reflecting on the number of times my preceptors have been consulted by the in office NPs...a lot of time is spent educating them. The more experienced NPs probably have had the benefit of a full medical education paid for in physician consults. Collaboration implies reciprocity, but that is not the reality I saw in the office. What I saw was closer to indentured servitude in exchange for a safety net. I have heard the exact same thing said about CRNAs before in the anesthesia forum. It's just reinventing the wheel of 'residency' without calling it residency, and without the benefit of earning credentials.

There is a tendency by nurses and even some physicians to simply downplay education altogether, and this is a mistake. If some nurses cannot function without a physician safety net today, independent nursing practice of medicine and surgery is just a political trophy for the nurses of tomorrow. Unacceptable. The idea of "practicing to the full extent of the license" is bs if you're constantly practicing at the level of a medicine intern.

Congratulation Pink Floyd, sounds like what you learned from that conversation with your professor (just a little bit) is to get off the quaaludes and grow a pair. You med students act like we are this huge threat when we really aren't. And NP's don't justify independent practice because we claim to be academically at the same level as physicians. I never argued that. We justify independent practice because of the need to deliver care to the 20 million people now insured under the ACA. We are growing out of necessity until more of you come out of the wood work and start delivering health care in adequate numbers (maybe in 20-30 years). In short, you need our help...Until then, nothing is changing our trajectory. So get used to it.

 

[atomheart]

NP's don't justify independent practice because we claim to be academically at the same level as physicians. I never argued that.

I get emails and responses about this turd burger all the time:

That's the ex-president of the AANA for CRNAs, and FWIW a paper tiger. You gotta speak for yourself, there is plenty of militancy in the APRN world.

 

[FNP_Blix]

I get emails and responses about this turd burger all the time:

That's the ex-president of the AANA for CRNAs, and FWIW a paper tiger. You gotta speak for yourself, there is plenty of militancy in the APRN world.

lol turd burger. That's actually pretty funny. And, you mean like the militancy and under appreciation that nurses have experienced for decades by the elitist medical associations out there?

 

[atomheart]

lol turd burger. That's actually pretty funny. And, you mean like the militancy and under appreciation that nurses have experienced for decades by the elitist medical associations out there?

How would you like to be appreciated? It is very likely there will always be an income discrepancy.

 

[deleted480308]

What I'm describing is appropriate for most NPs. Most employers recognize there are varying lengths of experience, and so they judge "supervision" based on that individual NPs skill. But overtime (sometimes after the 1st week, sometimes after a year) employers will typically gain trust in that provider. So no, its not negligent supervision. It starts as supervision and then becomes collaboration maybe...Once again, look at the data that's out there. Is there anything that indicates that we as an NPs are less safe with more lax laws? Do you have any sort of measure or data that proves your arguments? Once again, no, you don't.

God it's so annoying debating with you cheesy med students that only talk crap about my profession, but have no proof to say we are not safe...

Collaboration implies a degree of input in both directions. A supervising doctor may decide that an NP requires less supervision this year than last year. That could be due to trust, laxiness, comfort with risk etc. But at no point is the NP reviewing the docs charts for correctness.

"Collaboration" is a word game that's being used to falsely imply parity. It's supervision, maybe well done supervision maybe not.....but it isn't collaboration

 

[deleted480308]

lol turd burger. That's actually pretty funny. And, you mean like the militancy and under appreciation that nurses have experienced for decades by the elitist medical associations out there?

I greatly appreciate NPs in their proper role

 

[FNP_Blix]

How would you like to be appreciated? It is very likely there will always be an income discrepancy.

Pay discrepancy, but minimal to no student debt. And with independent practice a possibility now, entrepreneurship and the potential to earn high is there... But how about for starters, you and your colleagues can appreciate nurses by not being malicious jerks. Until you appreciate nurses more, we will be your worst nightmare.

 

[FNP_Blix]

I greatly appreciate NPs in their proper role

I'm glad you do however we just will have to disagree on what our "proper role" is.

 

[FNP_Blix]

Collaboration implies a degree of input in both directions. A supervising doctor may decide that an NP requires less supervision this year than last year. That could be due to trust, laxiness, comfort with risk etc. But at no point is the NP reviewing the docs charts for correctness.

"Collaboration" is a word game that's being used to falsely imply parity. It's supervision, maybe well done supervision maybe not.....but it isn't collaboration

You can argue semantics all you want but the fact of the matter is that NPs practice independently in 20+ states and D.C. and this trend is growing. So whatever explanation helps you feel all warm and fuzzy inside, have at it, but NPs, CRNAs, and CNMs are becoming, more and more, their own providers. Better get used to it.

 

[atomheart]

Pay discrepancy, but minimal to no student debt. And with independent practice a possibility now, entrepreneurship and the potential to earn high is there... But how about for starters, you and your colleagues can appreciate nurses by not being malicious jerks. Until you appreciate nurses more, we will be your worst nightmare.

With autonomy, I'm convinced that entrepreneurship wont be an option for any but the most talented and financially minded midlevels, and nurse-in-a-box becomes their go-to "thing" outside of private offices and hospitals in the future. The evidence shows that we are all moving away from private entrepreneurship toward corporate ownership. I think hospitals--not necessarily patient insurers--will be the ultimate determinant of income potential. Yet risk:reward is a key component in physician training; If the income-debt load discrepancy does not favor physicians and their training pathways, there are few reasons to strive for physician training and credentials. Money, not responsibility, is the true pillar of medical hierarchy. In that regard, I am not worried about the future of medical hierarchy changing significantly:

"Despite the growing importance of various types of healthcare professionals, including nurse practitioners (NPs), physician assistants (PAs), pharmacists, therapists, nurses, home health aides, community care coordinators, and others, physicians continue to be the indispensable caregivers at the heart of the healthcare system. Consider that physicians:

• Handle over 1.2 billion patient visits a year, in offices, emergency departments and other settings (Centers for Disease Control and Prevention).
• Control 87% of all personal spending on healthcare through hospital admissions, test orders, prescriptions, procedures, treatment plans and related activities (Boston University School of Public Health).
• Generate $1.6 trillion in economic output collectively.
• Account for $2.2 million in economic output individually.
• Support 14 jobs each (National Economic Impact of Physicians. American Medical Association/IMS Health, March, 2014).
• Generate an average of $1.5 million for their affiliated hospitals in net revenue annually (Merritt Hawkins 2016 Survey of Physician Inpatient/outpatient Revenue).

The healthcare delivery system has been engaged in a process of evolution for decades, from the “golden age” of fee-for-service in the Sixties, Seventies and Eighties, to the proliferation of managed care in the Nineties, to the increasingly corporatized and value-driven system in place today.

Through each of these stages, little has been accomplished -- be it a hospital admission, prescription order, test, treatment plan, surgery or hospital discharge -- without the direction or supervision of a physician.

The healthcare sector now employs one in nine people in the U.S., up from one in 12 in 2000, and 35% of the nation’s job growth since 2007 has come in healthcare (New York Times, April 22, 2017). Virtually all of this employment growth and the economic impact it generates is tied directly or indirectly to the activities of physicians.

That is unlikely to change in the foreseeable future and explains why the services physicians provide are at a premium."

source: https://www.merritthawkins.com/uplo...hysician_Incentive_Review_Merritt_Hawkins.pdf

It seems that physicians really suck by individual specialty, but they are an economic force when taken together.

 

[FNP_Blix]

With autonomy, I'm convinced that entrepreneurship wont be an option for any but the most talented and financially minded midlevels, and nurse-in-a-box becomes their go-to "thing" outside of private offices and hospitals in the future. The evidence shows that we are all moving away from private entrepreneurship toward corporate ownership. I think hospitals--not necessarily patient insurers--will be the ultimate determinant of income potential. Yet risk:reward is a key component in physician training; If the income-debt load discrepancy does not favor physicians and their training pathways, there are few reasons to strive for physician training and credentials. Money, not responsibility, is the true pillar of medical hierarchy. In that regard, I am not worried about the future of medical hierarchy changing significantly:

"Despite the growing importance of various types of healthcare professionals, including nurse practitioners (NPs), physician assistants (PAs), pharmacists, therapists, nurses, home health aides, community care coordinators, and others, physicians continue to be the indispensable caregivers at the heart of the healthcare system. Consider that physicians:

• Handle over 1.2 billion patient visits a year, in offices, emergency departments and other settings (Centers for Disease Control and Prevention).
• Control 87% of all personal spending on healthcare through hospital admissions, test orders, prescriptions, procedures, treatment plans and related activities (Boston University School of Public Health).
• Generate $1.6 trillion in economic output collectively.
• Account for $2.2 million in economic output individually.
• Support 14 jobs each (National Economic Impact of Physicians. American Medical Association/IMS Health, March, 2014).
• Generate an average of $1.5 million for their affiliated hospitals in net revenue annually (Merritt Hawkins 2016 Survey of Physician Inpatient/outpatient Revenue).

The healthcare delivery system has been engaged in a process of evolution for decades, from the “golden age” of fee-for-service in the Sixties, Seventies and Eighties, to the proliferation of managed care in the Nineties, to the increasingly corporatized and value-driven system in place today.

Through each of these stages, little has been accomplished -- be it a hospital admission, prescription order, test, treatment plan, surgery or hospital discharge -- without the direction or supervision of a physician.

The healthcare sector now employs one in nine people in the U.S., up from one in 12 in 2000, and 35% of the nation’s job growth since 2007 has come in healthcare (New York Times, April 22, 2017). Virtually all of this employment growth and the economic impact it generates is tied directly or indirectly to the activities of physicians.

That is unlikely to change in the foreseeable future and explains why the services physicians provide are at a premium."

source: https://www.merritthawkins.com/uplo...hysician_Incentive_Review_Merritt_Hawkins.pdf

It seems that physicians really suck by individual specialty, but they are an economic force when taken together.

And honestly, that's a good thing. I don't know why you feel the need to prove to me (or maybe your trying to prove to yourself) that physicians are a pillar in the healthcare system. I've been in healthcare for over 8 years now and I too do realize the importance of physicians. I never said the role you guys play is not vital nor has that been the argument here...But with that said, nurses are increasingly playing a bigger role in healthcare and without us, there is no implementation of medical services, no reimbursement for services, no outcomes, nothing. We deserve a seat at the table and respect, just like physicians demand respect. We ARE equally important in this system and will continue to evolve and play a bigger and a more important role. That is why nurses enjoy above average salaries, lots of opportunities by government and military services, and upward & lateral mobility. Another thing worth mentioning is that the NP profession was rated the number 2 profession in the country next to a dentist. All you and your colleagues have been doing is disrespecting and spewing vitriol without once seeing my side of things, the progress we've made as a profession, and the role we play as nurses (at all levels).

 

[atomheart]

I never said the role you guys play is not vital nor has that been the argument here...

That is not the message received by students observing. When APRNs present studies in attempt to equate physician and nursing training for what appears to be nurses upside, they're going to get negative feedback from those in training, not positive thoughts from physicians. It's the kiss of death on a generation that might have better sympathized.

Also, for the record, it is you who came to this forum to convince. I'm doing what any medical student would do, which is put in the due diligence to understand the problem and determine my behavior and stance on the problem moving forward into my career. I already stated my previous apprehension in another post. I took my own time to find data that helps me better understand growth and demand (though the pamphlet section on income growth of midlevels might be of use to you).

 

[FNP_Blix]

That is not the message received by students observing. When APRNs present studies in attempt to equate physician and nursing training for what appears to be nurses upside, they're going to get negative feedback from those in training, not positive thoughts from physicians. It's the kiss of death on a generation that might have better sympathized.

Also, for the record, it is you who came to this forum to convince. I'm doing what any medical student would do, which is put in the due diligence to understand the problem and determine my behavior and stance on the problem moving forward into my career. I already stated my previous apprehension in another post. I took my own time to find data that helps me better understand growth and demand (though the pamphlet section on income growth of midlevels might be of use to you).

"Its the kiss of death on a generation that might have better sympathized"? Thats such crap. What is the title of this thead!? Did I start this conversation? You already had negative views before I ever came on here. I merely came here to get a feel for why you guys felt the way you did and in doing so, got a ton of negative hateful statements, in addition to inaccurate BS. So I felt obligated to debate. And at least I had the guts to. You think Im gonna just sit idly by while you guys publicly disparage my profession?

"I took my time to find my own data". Thats so laughable. This whole time you cited one or two papers (one of them being the New York times), and some anecdotal conversations with your proffesor. You provided squat to help your arguments. I have done way more research to support my points.

And again, who tried to argue that our training is equal? You clearly have not been reading my replies well.

 

[deleted480308]

"Its the kiss of death on a generation that might have better sympathized"? Thats such crap. What is the title of this thead!? Did I start this conversation? You already had negative views before I ever came on here. I merely came here to get a feel for why you guys felt the way you did and in doing so, got a ton of negative hateful statements, in addition to inaccurate BS. So I felt obligated to debate. And at least I had the guts to. You think Im gonna just sit idly by while you guys publicly disparage my profession?

And again, who tried to argue that our training is equal? You clearly have not been reading my replies well.

There's some hyperbole there...it's not hateful to say a profession needs supervision

 

[FNP_Blix]

There's some hyperbole there...it's not hateful to say a profession needs supervision

No, its not hyperbole. Just look at the tiltle of this thread and the comments by you guys that follow. You have no factual basis for your arguments, and just express these cruel and harsh criticisms about nurses when they are actually totally unwarranted. Therefore, the statements you guys make are exaggerations, and are hateful. I have to admit that you sb247 have been more professional than most but still, you have no basis for your arguments besides "this is how its been and we have more education"... You dont have to look far on SDN to find loathing statements about APNs.

 

[deleted480308]

No, its not hyperbole. Just look at the tiltle of this thread and the comments by you guys that follow. You have no factual basis for your arguments, and just express these cruel and harsh criticisms about nurses when they are actually totally unwarranted. Therefore, the statements you guys make are exaggerations, and are hateful. I have to admit that you sb247 have been more professional than most but still, you have no basis for your arguments besides "this is how its been and we have more education"... You dont have to look far on SDN to find loathing statements about APNs.

I think there is a notable difference between opinion here about nurses (they can be awesome) and nurses who think they should practice independently (no, no they shouldn't)

 

[FNP_Blix]

I think there is a notable difference between opinion here about nurses (they can be awesome) and nurses who think they should practice independently (no, no they shouldn't)

I think experienced RNs who become APNs and wen't to good schools can practice independently (in primary care, midwifery, and anesthesia) after a few years of practicing in a supervisory or collaborative role. They typically are more than capable. That is my position and many others, including physicians... Most APNs do not practice right out of school anyway and most choose to have some sort of collaborative or supervisory arrangement with a physician. The few APNs that are practicing independently are providing a valuable service to the underserved, and even fewer are practicing independently in areas of higher socioeconomic status. And even if they do practice in areas of higher socioeconomic status, then so what? They can provide many of the same medical services and probably at a better price. So if the consumer chooses to pick an APN over a physician, then that's their prerogative. In general, there simply aren't enough physicians to service the additional 20 million people that are now insured through the ACA...But we already wen't back and forth on this, so we will just have to agree to disagree.

 

[deleted480308]

I think experienced RNs who become APNs and wen't to good schools can practice independently (in primary care, midwifery, and anesthesia) after a few years of practicing in a supervisory or collaborative role. They typically are more than capable. That is my position and many others, including physicians... Most APNs do not practice right out of school anyway and most choose to have some sort of collaborative or supervisory arrangement with a physician. The few APNs that are practicing independently are providing a valuable service to the underserved, and even fewer are practicing independently in areas of higher socioeconomic status. And even if they do practice in areas of higher socioeconomic status, then so what? They can provide many of the same medical services and probably at a better price. So if the consumer chooses to pick an APN over a physician, then that's their prerogative. In general, there simply aren't enough physicians to service the additional 20 million people that are now insured through the ACA...But we already wen't back and forth on this, so we will just have to agree to disagree.

Supervised nps can still see patients, Independance isn't required

 

[atomheart]

You clearly have not been reading my replies well.

Because I have not been reading your replies well, I actually went back in time to catalogue some of your posts and better understand your position. I agree and sympathize with a lot of the things you have said (actually you said them several times to several different people). You are a pretty good brand ambassador for your consistency. Critically, there are a few trigger statements you repeat that could make physicians feel their training is unappreciated or underappreciated. I can agree that fear and anxiety perpetuates these discussions, so you should consider monitoring these statements. I have already accepted your position on equivalent outcomes taken in the context that nurses need some training after graduating to achieve them. On the other hand, your inquiry into data has started me questioning certain things which don't appear to be answered anywhere else:

• Why is there such a large need for so many different medical providers?
  • I think you and others partially answered this before for NPs with rural and primary care stats, and lack of med school and residency slots
  • I actually believe that the simplest explanation is to make $ for corporate overlords, but I'm having a difficult time finding clear evidence against your argument.
• What are the actual percentages and geographic distributions of the different medical providers?
  • I have had a hard time finding this data from reputable sources. I need this to determine if, as you say, the maldistribution problem is being solved, or will be solved by autonomous nurses or PAs.
  • However, this issue went to the backburner because you made it clear that need can be urban or rural. I agree, but now I need to determine if what nurses are doing fulfills the goals of the profession, or merely lines up with the will of corporate overlords.
  • It seems that many NPs end up in urgent care boxes or triaging for physicians in EDs. The same is true of PAs.
• What are the actual demand statistics for different providers?
  • You have mentioned these before for physicians using predictive pop-based models
  • The pamphlet I used help me determine who is actually immediately in demand via job search stats.
• Why are different providers in demand?
  • I would like to know how hospitals value doctors, and if they will hire them over a midlevel counterpart. I have seen some anecdotal evidence that box shops actually want the midlevel. This is even more important for specialties where midlevels are declaring true equivalence to physicians (anesthesia).
  • The pamphlet did not explain why a hospital would recruit an NP as opposed to a PA.
• Will full autonomy give nurses what they desire?
  • Your recent posts have given me the feeling that some nurses ultimately desire an end to medical hierarchy
  • Additionally, some feel that nurse autonomy would actually shield physicians from future lawsuits due to nurses working on a physicians license. This seems like a bad deal to nurses.
• Will full autonomy of nurses decrease demand for physicians?
  • Anecdotally, I have found the answer is no for PCPs. I cannot be certain for others like anesthesia.
• Does the presence of midlevels suppress fair income growth between different physician specialties?
  • Again, an important question in anesthesia, but also an interesting question for primary care since, as you admit, salaries are already suppressed disincentivizing the field to students
• What is the ultimate function of credentials?
  • I would like to know if credentials have any impact on the "free market" of medical services.
  • I would like to know if full autonomy trumps credentials in the eyes of payers (see: 'will full autonomy give nurses what they desire').
• How does everyone get paid?
  • Like was mentioned previously, I would like to see some info on how incomes get distributed when and if the healthcare system shifts away from FFS. I have looked into some info on Canada, for example, and found a larger discrepancy in FP and NP income than in the US.

I agree that there is a lot of anecdote...yet my apprehensions about future conflicts between physicians and midlevels has steadily declined over the course of my anecdotal findings, and have calmed my fears more than any data driven findings. I hope you can appreciate that my arguments have shifted beyond trying to figure out whether nurses are valued or whether outcomes are truly identical, and more to the heart of the fear and concerns of many of the people who have replied to you--what is the future of physicians?

 

[FNP_Blix]

Because I have not been reading your replies well, I actually went back in time to catalogue some of your posts and better understand your position. I agree and sympathize with a lot of the things you have said (actually you said them several times to several different people). You are a pretty good brand ambassador for your consistency. Critically, there are a few trigger statements you repeat that could make physicians feel their training is unappreciated or underappreciated. I can agree that fear and anxiety perpetuates these discussions, so you should consider monitoring these statements. I have already accepted your position on equivalent outcomes taken in the context that nurses need some training after graduating to achieve them. On the other hand, your inquiry into data has started me questioning certain things which don't appear to be answered anywhere else:

• Why is there such a large need for so many different medical providers?
  • I think you and others partially answered this before for NPs with rural and primary care stats, and lack of med school and residency slots
  • I actually believe that the simplest explanation is to make $ for corporate overlords, but I'm having a difficult time finding clear evidence against your argument.
• What are the actual percentages and geographic distributions of the different medical providers?
  • I have had a hard time finding this data from reputable sources. I need this to determine if, as you say, the maldistribution problem is being solved, or will be solved by autonomous nurses or PAs.
  • However, this issue went to the backburner because you made it clear that need can be urban or rural. I agree, but now I need to determine if what nurses are doing fulfills the goals of the profession, or merely lines up with the will of corporate overlords.
  • It seems that many NPs end up in urgent care boxes or triaging for physicians in EDs. The same is true of PAs.
• What are the actual demand statistics for different providers?
  • You have mentioned these before for physicians using predictive pop-based models
  • The pamphlet I used help me determine who is actually immediately in demand via job search stats.
• Why are different providers in demand?
  • I would like to know how hospitals value doctors, and if they will hire them over a midlevel counterpart. I have seen some anecdotal evidence that box shops actually want the midlevel. This is even more important for specialties where midlevels are declaring true equivalence to physicians (anesthesia).
  • The pamphlet did not explain why a hospital would recruit an NP as opposed to a PA.
• Will full autonomy give nurses what they desire?
  • Your recent posts have given me the feeling that some nurses ultimately desire an end to medical hierarchy
  • Additionally, some feel that nurse autonomy would actually shield physicians from future lawsuits due to nurses working on a physicians license. This seems like a bad deal to nurses.
• Will full autonomy of nurses decrease demand for physicians?
  • Anecdotally, I have found the answer is no for PCPs. I cannot be certain for others like anesthesia.
• Does the presence of midlevels suppress fair income growth between different physician specialties?
  • Again, an important question in anesthesia, but also an interesting question for primary care since, as you admit, salaries are already suppressed disincentivizing the field to students
• What is the ultimate function of credentials?
  • I would like to know if credentials have any impact on the "free market" of medical services.
  • I would like to know if full autonomy trumps credentials in the eyes of payers (see: 'will full autonomy give nurses what they desire').
• How does everyone get paid?
  • Like was mentioned previously, I would like to see some info on how incomes get distributed when and if the healthcare system shifts away from FFS. I have looked into some info on Canada, for example, and found a larger discrepancy in FP and NP income than in the US.

I agree that there is a lot of anecdote...yet my apprehensions about future conflicts between physicians and midlevels has steadily declined over the course of my anecdotal findings, and have calmed my fears more than any data driven findings. I hope you can appreciate that my arguments have shifted beyond trying to figure out whether nurses are valued or whether outcomes are truly identical, and more to the heart of the fear and concerns of many of the people who have replied to you--what is the future of physicians?

Wow, I was not expecting that reply, and I really appreciate that...Physicians will always be valued and the demand for physicians will always be there in all specialties, and through any changes in healthcare. Health care can be corporatized ad infinitum but that still won't take away from the contributions the medical profession has made, and the expertise they bring to the table. Also, the questions you posed are valid, and something I too would like to see clearer answers to.

 

[atomheart]

Wow, I was not expecting that reply, and I really appreciate that...Physicians will always be valued and the demand for physicians will always be there in all specialties, and through any changes in healthcare. Health care can be corporatized ad infinitum but that still won't take away from the contributions the medical profession has made, and the expertise they bring to the table. Also, the questions you posed are valid, and something I too would like to see clearer answers to.

You should strongly consider medical school, for the record. I did read a few times that you had no interest. You are still very young, and your career options are much broader and potentially more rewarding (sorry to be blunt) as a physician. It is not always clear whether the future promises of different associations will pan out according to economic shifts, but physicians have a fairly consistent track record (even DO/IMG). There are many in the field that would appreciate your dedication and argumentativeness being on their side.

 

[FNP_Blix]

You should strongly consider medical school, for the record. I did read a few times that you had no interest. You are still very young, and your career options are much broader and potentially more rewarding (sorry to be blunt) as a physician. It is not always clear whether the future promises of different associations will pan out according to economic shifts, but physicians have a fairly consistent track record (even DO/IMG). There are many in the field that would appreciate your dedication and argumentativeness being on their side.

Appreciate your honesty, and you're right. Because of the recent, relatively volatile history of the nursing profession, I wouldn't be surprised if advanced practice nurses (APN) experienced a down slope of it's J-curve in the next 20-30 years (around the time PCP reach adequate numbers). Unless they experience major overhaul to their standards and requirements (maybe Flexner style change), especially with this new generation of new grads not having enough experience as RNs and taking a much easier path to becoming an NP, I'm not sure how long we'll last...I'm looking into UNE pre-med right now. They have online didactics and I think that by the time I'm 30-31, I can take the MCAT and apply for med school...but we'll see.

 

[atomheart]

Appreciate your honesty, and you're right. Because of the recent, relatively volatile history of the nursing profession, I wouldn't be surprised if advanced practice nurses (APN) experienced a down slope of it's J-curve in the next 20-30 years (around the time PCP reach adequate numbers). Unless they experience major overhaul to their standards and requirements (maybe Flexner style change), especially with this new generation of new grads not having enough experience as RNs and taking a much easier path to becoming an NP, I'm not sure how long we'll last...I'm looking into UNE pre-med right now. They have online didactics and I think that by the time I'm 30-31, I can take the MCAT and apply for med school...but we'll see.

The resources on this site will ensure your success. Just do it. You're too damn smart to not succeed as a physician, not that the nursing profession doesn't need that. I started at 29 with a family, and you could easily do a premed in 1.5 years or less depending on your willpower, which of course you have.

 

[FNP_Blix]

The resources on this site will ensure your success. Just do it. You're too damn smart to not succeed as a physician, not that the nursing profession doesn't need that. I started at 29 with a family, and you could easily do a premed in 1.5 years or less depending on your willpower, which of course you have.

Thanks for the encouragement man. Where are you at now with your studies?

 

[atomheart]

Thanks for the encouragement man. Where are you at now with your studies?

3rd year. I'm not even close to the oldest person in my class, but I did end up at a DO school. Luckily there are a lot of people here who are just like me.

 

[FNP_Blix]

3rd year. I'm not even close to the oldest person in my class, but I did end up at a DO school. Luckily there are a lot of people here just like me.

That's actually pretty encouraging.

 

[William Shakespeare]

In my opinion, I think that independent practice for NPs is out of the question, and that’s based primarily on the differences in education. To be honest, I don’t think it should be legal to even become an NP via an online program. Hell, Med Schools don’t even accept online pre-req courses! Anyone who’s been a college student within the last decade knows online education is an absolute joke, and to think that we would want independent providers with an online FNP degree is ridiculous.

 

[Spleen27]

because

It's more like being able to identify that time when what looks like strep, isn't strep.

Guy considering med school vs. Pa school here -

Wouldn't you just jam that thing down their throat for a culture and then send it to the lab?

 

[Spleen27]

I greatly appreciate NPs in their proper role

This is from a while ago, but I'm a career changer considering going from law to medicine. I'm choosing between uprooting my family and financially imploding to pursue an MD, or getting an MSN or PA degree from a top 5 nursing or PA school. I'm doing a lot of research, and would appreciate your take on the proper role of an NP - in any setting, though I'm particularly interested in acute care. So if you have some thoughts on what their proper role is, I'd love to hear them.

(Also I agree based on comparing curricula between MSN, PA, and MD that an MSN isn't going to be qualified by their education to practice independently, though this is from an outsider (patient's) perspective since I'm still in a non-medical field.)

 

[DoubleBogey]

As someone who has multiple family members as PAs and physicians, and work in a community with multiple NPs, I can provide at least real-world view. The NPs I’ve seen typically manage most primary care stuff on their own - they have their own pt panel without any MD supervising them. Outcomes are likely similar for the more experienced NP. However, for the younger/newer ones you can notice an increase in risky meds being used - controlled substances ranging from wt loss meds to anxiolytics/pain meds. Same can be said about some outdated practices MDs have.

Even in my relatively new practice I already have received several pts who are considered “medically complex” and est with my practice from a prior NP’s service. Generally multiple end stage conditions and trying to keep them out of the hospital.

Outside of medical school, nobody really cares and there are enough pts to go around that everyone is too busy to worry about “fear of encroachment” discussions that only seem present in the minds of the insecure.

Go in to whatever field drives you and what you’re comfortable with. In the end, patients just need to be seen in a timely manner - not on a 3month waitlist, which is becoming all to common now.

 

[W19]

I am doing an IM Sub-I at one of the busiest hospital in the country and if NP can manage these train wreck patients that I see 2nd and 3rd year IM residents are managing, they should definitely be independent...

 

[GIS_FNP]

From purely billing perspective, NPs get reimbursed at 85% rate when using NP provider number. Primary Care Physicians get 100%. I hope this helps.

 

[Same Team_RN]

In my opinion, I think that independent practice for NPs is out of the question, and that’s based primarily on the differences in education. To be honest, I don’t think it should be legal to even become an NP via an online program. Hell, Med Schools don’t even accept online pre-req courses! Anyone who’s been a college student within the last decade knows online education is an absolute joke, and to think that we would want independent providers with an online FNP degree is ridiculous.

Who are you picking in the Stanley cup playoffs? Just looking for a team to bet against.

 

[rmbd2b12]

Why stop them? Let them reign free and have them buy their own malpractice insurance. Medicine is predominantly empirical anyways. We won't know if NP's/ PA's are better, worse or the same as doctors until we let them practice and analyze long term data. If NP's and PA's can show they are equivalent, then maybe doctors won't have to go through so much training, which will be better for future doctors. It would be even better if we could show equivalency with a computer algorithm and have computers do all the work. A race to the bottom in prices will be good for the healthcare system even if it means slashing doctors'/NPs'/PAs' salaries.

 

[Crayola227]

Why stop them? Let them reign free and have them buy their own malpractice insurance. Medicine is predominantly empirical anyways. We won't know if NP's/ PA's are better, worse or the same as doctors until we let them practice and analyze long term data. If NP's and PA's can show they are equivalent, then maybe doctors won't have to go through so much training, which will be better for future doctors. It would be even better if we could show equivalency with a computer algorithm and have computers do all the work. A race to the bottom in prices will be good for the healthcare system even if it means slashing doctors'/NPs'/PAs' salaries.

no

 

[AliBabaMD]

This is such a nasty thread to post. Why don't you focus on giving more healthcare to more people at lower cost? Why not focus on advocating for shorter residencies and shorter med school terms rather than hate on another profession who just happens to do it faster. Why do you believe that treating a cold or a flu takes 7 years of post-undergrad training (3 years residency, 4 years med school)?

Maybe, just maybe...you are wrong and the NPs are right!

AB

 

[Weirdy]

This is such a nasty thread to post. Why don't you focus on giving more healthcare to more people at lower cost? Why not focus on advocating for shorter residencies and shorter med school terms rather than hate on another profession who just happens to do it faster. Why do you believe that treating a cold or a flu takes 7 years of post-undergrad training (3 years residency, 4 years med school)?

Maybe, just maybe...you are wrong and the NPs are right!

AB

Your post history is interesting.

New account- check
Multiple posts at the same time or within minutes of each other in completely different threads with similar goals but different writing styles- check
Constantly throwing out your credentials "Hospital CEO, Hospital exec, blah blah blah" - check
Insisting people need "coaching, advice, someone to guide them, PM me" - check
Really bad advice- people need to differentiate themselves for medical school by pursuing medical mission trips, writing a book, entrepreneur opportunities- check

Get out of here dude.

 

[AliBabaMD]

Your post history is interesting.

New account- check
Multiple posts at the same time or within minutes of each other in completely different threads with similar goals but different writing styles- check
Constantly throwing out your credentials "Hospital CEO, Hospital exec, blah blah blah" - check
Insisting people need "coaching, advice, someone to guide them, PM me" - check
Really bad advice- people need to differentiate themselves for medical school by pursuing medical mission trips, writing a book, entrepreneur opportunities- check

Get out of here dude.

Such a nasty thread by a nothing short of a stalker.

I'm not throwing credentials around. It seems you are just interested in your own pipeline and shutting up anyone who doesn't agree with your beliefs. Sad. Take a break from the board and stop harassing

 

[AliBabaMD]

Your post history is interesting.

New account- check
Multiple posts at the same time or within minutes of each other in completely different threads with similar goals but different writing styles- check
Constantly throwing out your credentials "Hospital CEO, Hospital exec, blah blah blah" - check
Insisting people need "coaching, advice, someone to guide them, PM me" - check
Really bad advice- people need to differentiate themselves for medical school by pursuing medical mission trips, writing a book, entrepreneur opportunities- check

Get out of here dude.

oh and wait, you know a lot about good advice as a podiatry STUDENT.

I never said I know more or less than you, but it seems you like comparing yourself with others.

Let the OP pick what advice will be helpful and let different voices be heard.

 

[Weirdy]

Such a nasty thread by a nothing short of a stalker.

I'm not throwing credentials around. It seems you are just interested in your own pipeline and shutting up anyone who doesn't agree with your beliefs. Sad. Take a break from the board and stop harassing

Lol take a break from board and stop harassing?

I looked into it further because your post rate is frightening.

You're telling me an MD/Hospital Exec spent 9am- 1pm Central constantly spam everything from Occupational Therapy to D.O. threads non-stop?

Its so easy to shift guilt by pointing the same finger at someone. I am presenting facts based on your post history.

You started at 9am Central time and you STILL are posting non-stop. It has been 4 hours.

 

[Weirdy]

oh and wait, you know a lot about good advice as a podiatry STUDENT.

I never said I know more or less than you, but it seems you like comparing yourself with others.

Let the OP pick what advice will be helpful and let different voices be heard.

Really with the ad-hominem attacks? Come on man. I get along pretty well with every profession here.

I havn't compared myself to anyone on this thread either. I know my limitations as a podiatric medical student and openly admit it.

Again, you are making a non-argument to defend your reputation. Which for whatever ulterior motive you have, is necessary for you to gain influence on this website.