nurses-masquerading-as-doctors

[badasshairday]

AMA may actually get some more members now.

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Members don't see this ad.

 

[Law2Doc]

No, because the State Bar Associations crush them relentlessly with unauthorized practice of law lawsuits. ...

Just to reiterate my postings from another thread, in the profession of law there is a perfect roadmap for what medicine has to do here. Lawyers were besieged by paralegals trying to set up their own shops to do wills and contracts, realtors to do their own closings, accountants to handle various incorporation, reorg and tax law matters. In each case lawyers ran to court and squelched these threats as being violative of practicing law without a license. If the lawyers could convince the courts that it was important not to allow non-attorneys to engage in the unauthorized practice of law, do you really think medicine is that much less complicated that the courts would shrug their shoulders and say I don't see why you have to be a physician to practice medicine? Physicians need to organize, create a war chest, and get into court, and fast. This can be squelched, but won't so long as folks take the attitude that the pie is big enough that everyone can have a crumb. No, you need to defend your piece of the pie.

 

[dude1344]

Physicians need to organize, create a war chest, and get into court, and fast. This can be squelched, but won't so long as folks take the attitude that the pie is big enough that everyone can have a crumb. No, you need to defend your piece of the pie.

So... what's the best way to get our profession to do this?

 

[Maybeknot]

In each case lawyers ran to court and squelched these threats as being violative of practicing law without a license. If the lawyers could convince the courts that it was important not to allow non-attorneys to engage in the unauthorized practice of law, do you really think medicine is that much less complicated that the courts would shrug their shoulders and say I don't see why you have to be a physician to practice medicine? Physicians need to organize, create a war chest, and get into court, and fast. This can be squelched, but won't so long as folks take the attitude that the pie is big enough that everyone can have a crumb. No, you need to defend your piece of the pie.

Law2Doc, it's a bit different with medicine, don't you think? Lawyers are presenting their case to other lawyers (a judge) about protecting the domain of lawyers.

Perhaps if we convince them that the DNP's are also going to start giving legal advice, we'd have more of a chance....

And not to say that this isn't good advice; it's just not as simple as paying a bunch of lawyers to take these DNP's to court. We have to inform everyone that the DNP's are undertrained and undereducated for the job that they claim to be able to do. The problem is, the common person isn't going to know enough about medicine to be able to make a rational and unbiased judgement. I've been working on a website to try to simplify the issues; if you'd like to help contribute, please PM me and I'll give you the URL.

 

[Slack3r]

Law2Doc, it's a bit different with medicine, don't you think? Lawyers are presenting their case to other lawyers (a judge) about protecting the domain of lawyers.

It really isn't though. You just need to establish what "the practice of medicine" entails and why entities outside the BOM shouldn't be able to decide one day that their practitioners can suddenly practice medicine without that pesky medical training/residency.

 

[TheMan21]

I don't want to stray too far off-topic, but isn't the number of physicians who are actually part of the AMA actually very low? If all the docs who are so apalled by these developments actully joined the AMA and fought together, wouldn't that give the AMA much more influence in deciding the outcome of this debate?

 

[Rabbit Hole]

Just to reiterate my postings from another thread, in the profession of law there is a perfect roadmap for what medicine has to do here. Lawyers were besieged by paralegals trying to set up their own shops to do wills and contracts, realtors to do their own closings, accountants to handle various incorporation, reorg and tax law matters. In each case lawyers ran to court and squelched these threats as being violative of practicing law without a license. If the lawyers could convince the courts that it was important not to allow non-attorneys to engage in the unauthorized practice of law, do you really think medicine is that much less complicated that the courts would shrug their shoulders and say I don't see why you have to be a physician to practice medicine? Physicians need to organize, create a war chest, and get into court, and fast. This can be squelched, but won't so long as folks take the attitude that the pie is big enough that everyone can have a crumb. No, you need to defend your piece of the pie.

Law2Doc,

Could you please point me to the right direction where I can find out more about the previous case between lawyers and para-legals? Since you said we can learn from them I'd like to post that information up.

Also, how can we get the attention of lawyers to help us out? I mean, I see all these commercials on tv about "call us if you have mesothelioma you may be entitled to a cash settlement"... maybe we can divert those guys to work with us not against us.

 

[Winged Scapula]

I don't want to stray too far off-topic, but isn't the number of physicians who are actually part of the AMA actually very low? If all the docs who are so apalled by these developments actully joined the AMA and fought together, wouldn't that give the AMA much more influence in deciding the outcome of this debate?

About 30% IIRC.

 

[deleted87716]

I don't want to stray too far off-topic, but isn't the number of physicians who are actually part of the AMA actually very low? If all the docs who are so apalled by these developments actully joined the AMA and fought together, wouldn't that give the AMA much more influence in deciding the outcome of this debate?

That's what's known as "putting your money where your mouth is."

And, yes...if more doctors joined the AMA (or at least gave money to their PACs), we'd have a fighting chance.

 

[Rabbit Hole]

That's what's known as "putting your money where your mouth is."

And, yes...if more doctors joined the AMA (or at least gave money to their PACs), we'd have a fighting chance.

American Medical Association Political Action Committee

OpenSecrets.org - Health Professionals PAC Contributions

 

[Jet915]

About 30% IIRC.

After the AMA went to bed w/Obamacare, I am not joining although these new developments are encouraging...

 

[glade]

That's what's known as "putting your money where your mouth is."

And, yes...if more doctors joined the AMA (or at least gave money to their PACs), we'd have a fighting chance.

Maybe more doctors would join the AMA if it didn't suck balls all day long. The AMA is the "grown-up" version of AMSA. Both purport to represent their respective medical populations and both are extremely liberal organizations. The AMA is all-in with Obamacare and I don't care if only two doctors in the entire country belong to the AMA -- that should tell you immediately that the AMA is pointless. The only way the AMA or AMSA can even attract any members at all is by handing out freebies. AMSA has its book sales and the AMA will regularly send you advertisements for auto insurance or credit cards.

The AMA is like your Program Director. They don't care what you're going through, they just keep talking about "the integrity of patient care" and "the honor of being given the patients' trust" while you're on call and wanting to stab yourself in the head.

 

[deleted87716]

^ OK, then...if the AMA doesn't represent you, who does?

Neither the AMA nor any other physician organization is "all in" with healthcare reform in its current incarnation. However, to take a completely oppositional stance is to be shut out of the process altogether.

If you're not at the table, you're on the menu.

 

[Maybeknot]

^ OK, then...if the AMA doesn't represent you, who does?

Neither the AMA nor any other physician organization is "all in" with healthcare reform in its current incarnation. However, to take a completely oppositional stance is to be shut out of the process altogether.

If you're not at the table, you're on the menu.

It didn't take a completely oppositional stance. It merely rolled over and went back to sleep.

Looking at this health care bill, there are a dozen things that are flat out BAD for physicians-- from the reimbursement increases to mid-levels, increased funding for nurse-managed clinics, prohibitions on physician ownership of healthcare facilities, etc. etc.

All the AMA said, "hey fix the SGR and we'll do whatever you ask, Mr. President!"

That isn't representing the interests of its constituents. I will not waste my money on membership of a useless organization when it's time for renewal.

As far as who represents our interests, I suppose no one.. that's why physicians are taking it up the rear these days.

 

[glade]

^ OK, then...if the AMA doesn't represent you, who does?

Neither the AMA nor any other physician organization is "all in" with healthcare reform in its current incarnation. However, to take a completely oppositional stance is to be shut out of the process altogether.

If you're not at the table, you're on the menu.

Nobody represents physicians. But that's the point. Talk to any group of physicians and you'll realize that we all know that we aren't political to our detriment. We spend too much time working and actually *gasp* taking care of patients. Listen to all the people here who are outraged at "just" 80-hour workweeks, then ask yourself who has the time to be lobbying.

I'm going to repeat what I said: the AMA represents liberal physicians. Conservative physicians are generally the ones who are trying to make as much money as possible in private practice. Liberal physicians are often (not always) the ones who are sitting around in academia or administrations and, like I said, telling everyone else that they should be "honored" to "be permitted" to take care of patients. Because of this, they're the ones who form our so-called lobbies and totally misrepresent the positions of what I would say are the majority of physicians. Which is why the majority of physicians, if you ask them, look at the AMA with scorn and derision.

What to do? Lobby with your feet, which is what physicians do. Look at Texas. Texas has tort reform and physicians flood the state. Look at liberal states with no tort reform. A lot of them are desperate for doctors. Be like the Urologist who put up the sign in Florida. Guess who railed against that guy? The same pansies I was talking about in the AMA and academia who started talking about "Hippocratic Oath" and "isn't this unethical?" (Answer: it has nothing to do with the Hippocratic Oath and no, it's not.)

 

[Rabbit Hole]

I don’t mean to sound like a marketing guy (I’m a lawyer, after all), but the AMA does exist to advocate on these and other issues for all physicians because we understand that you spend your time on your patients and not on politics. My own internist, who I trust with my life, tells me that she reads journals, not AMA e-mails, but she’s glad there’s an AMA to fight for her. Sounds like the right choice to me!

The above is a quote from the email sent to Winged Scapula from the AMA Legal Counsel.

Nobody represents physicians. But that's the point. Talk to any group of physicians and you'll realize that we all know that we aren't political to our detriment. We spend too much time working and actually *gasp* taking care of patients. Listen to all the people here who are outraged at "just" 80-hour workweeks, then ask yourself who has the time to be lobbying.

I'm going to repeat what I said: the AMA represents liberal physicians. Conservative physicians are generally the ones who are trying to make as much money as possible in private practice. Liberal physicians are often (not always) the ones who are sitting around in academia or administrations and, like I said, telling everyone else that they should be "honored" to "be permitted" to take care of patients. Because of this, they're the ones who form our so-called lobbies and totally misrepresent the positions of what I would say are the majority of physicians. Which is why the majority of physicians, if you ask them, look at the AMA with scorn and derision.

What to do? Lobby with your feet, which is what physicians do. Look at Texas. Texas has tort reform and physicians flood the state. Look at liberal states with no tort reform. A lot of them are desperate for doctors. Be like the Urologist who put up the sign in Florida. Guess who railed against that guy? The same pansies I was talking about in the AMA and academia who started talking about "Hippocratic Oath" and "isn't this unethical?" (Answer: it has nothing to do with the Hippocratic Oath and no, it's not.)

So what exactly are YOU doing to make the situation better? You said the positions of what you consider the "majority of physicians" is totally misrepresented by the AMA - why do you think that is? Why doesn't this silent majority speak up and let the AMA know how they really feel?

You can blame the AMA all you want but the blame belongs to individual physicians sitting back and doing nothing besides expressing their rage on the internet when all is over and done, when it's too late. You're pissed off at those who actually do something worthwhile to make an impact? You anger is displaced - be pissed off at what you consider the "silent majority" for their inaction, for expecting the AMA to read their minds, for yelling at the news on the TV screen when they learn about policies put into law that has been in the works for months-years. This is why we find ourselves in this DNP mess - being totally unaware and apathetic. The DNP organizations know this and have been laughing all the way as they successfully push their agenda facing hardly any opposition. They're doing something, the AMA is trying to do something, I ask you, what the hell have you done?

 

[deleted87716]

ask yourself who has the time to be lobbying

Some of us make the time. What we need is your (financial) support. Send money to your PACs. It's (literally) the least you can do.

If you don't, you aren't "voting with your feet." You aren't voting at all.

 

[glade]

You can blame the AMA all you want but the blame belongs to individual physicians sitting back and doing nothing besides expressing their rage on the internet when all is over and done, when it's too late. You're pissed off at those who actually do something worthwhile to make an impact? You anger is displaced - be pissed off at what you consider the "silent majority" for their inaction, for expecting the AMA to read their minds, for yelling at the news on the TV screen when they learn about policies put into law that has been in the works for months-years. This is why we find ourselves in this DNP mess - being totally unaware and apathetic. The DNP organizations know this and have been laughing all the way as they successfully push their agenda facing hardly any opposition. They're doing something, the AMA is trying to do something, I ask you, what the hell have you done?

Your rhetorical question is simply that. The argument you present is "either follow the AMA, which is supporting the problem while ostensibly representing physicians, or else shut up." Neither of which I have to accept, despite your naggy "what the hell have you done" question.

The people who put us in the DNP mess are the people who created the problem in the first place. Namely, the people who want government-run health-care. A free market would be just that: free. Not enough primary care doctors? Guess what, the salaries would go through the roof until it equilibrated. Too many specialists? Guess what, the salaries would fall accordingly. The problem is that we don't have a free market. We have price controls in the form of regulated reimbursements. And every so often, if the government doesn't feel like paying any more, they just say "oh, UTIs are a 'never should happen' event, so we just won't pay for it." Oh, OK, then I'll stop treating it because I can also pretend UTIs never occur, just like the government.

Frankly, it's very easy to deal with the DNP issue. All you have to do is have a set of testicles, which a lot of people lack. I said it in one of the other DNP-related threads: simply refuse to accept patients from DNPs. Guess how long the DNP fad will last then? About 0.367 seconds. I don't need a lobby or a group of lawyers to do anything. That's why you and other doctors act helpless, though, because you bought into the notion that we "must" treat everyone and turning away anyone for anything constitutes "an ethical breach of your required duties." This isn't junior high and I don't buy horse ****.

 

[Maybeknot]

So what exactly are YOU doing to make the situation better? You said the positions of what you consider the "majority of physicians" is totally misrepresented by the AMA - why do you think that is? Why doesn't this silent majority speak up and let the AMA know how they really feel?

You have a very good point. I am currently an AMA member but I do not plan to renew my membership. I will send an email to them explaining why I don't believe they are serving my interests as a physician.

 

[Rabbit Hole]

Your rhetorical question is simply that. The argument you present is "either follow the AMA, which is supporting the problem while ostensibly representing physicians, or else shut up." Neither of which I have to accept, despite your naggy "what the hell have you done" question.

Do you honestly believe that is the message I was trying to put forward in my previous post?

Frankly, it's very easy to deal with the DNP issue. All you have to do is have a set of testicles, which a lot of people lack. I said it in one of the other DNP-related threads: simply refuse to accept patients from DNPs. Guess how long the DNP fad will last then? About 0.367 seconds. I don't need a lobby or a group of lawyers to do anything. That's why you and other doctors act helpless, though, because you bought into the notion that we "must" treat everyone and turning away anyone for anything constitutes "an ethical breach of your required duties." This isn't junior high and I don't buy horse ****.

Don't worry, you won't have to refuse that many patients because the DNPs will just be referring them to their DNP colleagues in other "specialties". If you want to wait for the day that DNPs completely take over primary care and then seed their way into specialties while we collect body bags for the pathologists - be my guest.

I don't care how disillusioned you are - quality patient care is the basic principle of our profession and it should be the foundation that we build our arguments on. If you're willing to abandon that ideal you're nothing more than a turncoat.

Your suggestions are not based in reality and your understanding of this situation is *******ed* at best.

 

[badasshairday]

The people who put us in the DNP mess are the people who created the problem in the first place. Namely, the people who want government-run health-care. A free market would be just that: free. Not enough primary care doctors? Guess what, the salaries would go through the roof until it equilibrated. Too many specialists? Guess what, the salaries would fall accordingly. The problem is that we don't have a free market. We have price controls in the form of regulated reimbursements. And every so often, if the government doesn't feel like paying any more, they just say "oh, UTIs are a 'never should happen' event, so we just won't pay for it." Oh, OK, then I'll stop treating it because I can also pretend UTIs never occur, just like the government.

Frankly, it's very easy to deal with the DNP issue. All you have to do is have a set of testicles, which a lot of people lack. I said it in one of the other DNP-related threads: simply refuse to accept patients from DNPs. Guess how long the DNP fad will last then? About 0.367 seconds. I don't need a lobby or a group of lawyers to do anything. That's why you and other doctors act helpless, though, because you bought into the notion that we "must" treat everyone and turning away anyone for anything constitutes "an ethical breach of your required duties." This isn't junior high and I don't buy horse ****.

Good post. They want to be independent, let em' have it.

 

[deleted87716]

it's very easy to deal with the DNP issue...simply refuse to accept patients from DNPs.

It's not that simple.

If you're in-network with a commercial carrier, you can't refuse to accept referrals based solely on your disdain for a particular referring provider. The patient or the referring provider could simply send a letter of complaint to the insurance carrier, and you would likely be dropped from the plan.

 

[glade]

It's not that simple.

If you're in-network with a commercial carrier, you can't refuse to accept referrals based solely on your disdain for a particular referring provider. The patient or the referring provider could simply send a letter of complaint to the insurance carrier, and you would likely be dropped from the plan.

Absolutely. And when your network starts using DNPs, you leave.

Stop acting helpless. If I asked you what kind of practice I could have after residency, you'd pepper me with questions and tell me there are near-limitless options available to me. But when faced with DNPs, you act like we're all nailed to the floor.

 

[glade]

I don't care how disillusioned you are - quality patient care is the basic principle of our profession and it should be the foundation that we build our arguments on. If you're willing to abandon that ideal you're nothing more than a turncoat.

Since you're a medical student, I'll be nice and not use my foot to perform a rectal exam on you. You're entitled to your four years of shiny-eyed stupidity before you enter the real world.

 

[Rokitansky]

Some of us make the time. What we need is your (financial) support. Send money to your PACs. It's (literally) the least you can do.

If you don't, you aren't "voting with your feet." You aren't voting at all.

Excellent points.

I want to add that most medical students, despite being burdened with debt, are more than likely able to make modest monetary contributions as well. Furthermore, many of us have some free time during our breaks and can offer our talents and energy as volunteers.

 

[deleted87716]

Absolutely. And when your network starts using DNPs, you leave.

What do you mean "your network?" I'm talking about simply accepting any given insurance plan.

By "leave," you'd have to mean dropping insurance and going cash-only. Kind of a drastic decision to make out of spite.

 

[bawer234]

Excellent points.

I want to add that most medical students, despite being burdened with debt, are more than likely able to make modest monetary contributions as well. Furthermore, many of us have some free time during our breaks and can offer our talents and energy as volunteers.

God i hope you're joking

 

[Rokitansky]

God i hope you're joking

Why?

A close friend of mine who attends medical school in my home state, and is a student member of two state physician organizations, testified during a state senate hearing regarding a tort reform bill. The legislators were very interested in the future physician's perspective and clearly understood how malpractice costs and fears drive increasingly larger numbers of students away from certain specialties. It was a valuable perspective and supplemented the testimony of practicing physicians, state health officials, etc.

 

[doctorperez]

Physicians need to organize, create a war chest, and get into court, and fast.

That's right, this is the kind of involvement I will second
So stop whining y'all and let's start chiping in to take this issue to the courts

 

[lipomas]

Absolutely. And when your network starts using DNPs, you leave.

Stop acting helpless. If I asked you what kind of practice I could have after residency, you'd pepper me with questions and tell me there are near-limitless options available to me. But when faced with DNPs, you act like we're all nailed to the floor.

What would you do with primary care practices that employ NPs to see patients? Would you refuse anyone who comes from these practices? In my area it seems like most of the primary care practices, especially the pediatric ones, have a couple of NPs who take care of urgent care issues or see follow-ups. The physicians LIKE having the NPs because the physicians can make more money.

Or are you saying there is a difference between an NP doing primary care duties and a DNP?

I am a pathologist so I have much less of an axe to grind in this issue, by the way. I don't like encroaching midlevels either. But you have to acknowledge their importance in many many areas of medicine right now.

 

[glade]

What would you do with primary care practices that employ NPs to see patients?

That's a complicated question. Let me address a few points. First of all, the simple answer is that would be fine. Even if you were opposed to NPs or PAs practicing as primary care "physicians," that's clearly different. They're practicing under a physician in that practice, so they're acting as they should be. That's different from what is being proposed, which is to say that they would be independent practitioners.

But what is more complicated about that question is that this is the viewpoint that led to the problem, really. It's physicians who abrogate their duties and say "well, I'll use these mid-levels in order to help me see more patients." You know what that is? That's laziness because most of the time that results in shifting of work to some other doctor. And that's what kills me. Everyone in the medical field talks endlessly about their "duty" towards patient care. And the reality is the complete opposite, which is why I rarely listen to people who talk big about patient care.

Primary care physicians will be on call 24/7, but then a patient will call them and say "I have a problem." What does the primary do? Send them to the ER and have some ER guy see them to make sure there's no disaster, then go back to sleep. What does the ER guy do? Consult someone to see them to make sure there's no disaster. What does the consultant do? Have their resident see the patient to make sure there's no disaster. If there's no resident, they just order labwork or scan the patient and see them in the morning.

Throw in a mid-level and all you do is put in place a filter of a person who is qualified to answer simple questions and that's it. I've been consulted by services with mid-levels and it's basically as if the mid-level is a non-existant swinging door. (That would be an open doorframe for anyone who is wondering.) It's nice for primaries, who can say that "someone is available to my patients 24/7."

 

[Duluth]

An honest question, as a nurse:

I have heard the argument that a DNP should not be called "Doctor" in a clinical situation. The reasoning behind this is eliminating patient confusion. I agree with this.

Given the interest in eliminating patient confusion, would those who agree with this also support a change in title from Physician Assistant to Physician Associate? On more than one occasion I have seen patients believe that a PA was in fact just an assistant. One lady asked a PA I was with why they didn't become a nurse, because they seemed too smart to just be a medical assistant.

The term assistant is as misleading as calling a nurse Doctor nurse.

 

[Eta Carinae]

An honest question, as a nurse:

I have heard the argument that a DNP should not be called "Doctor" in a clinical situation. The reasoning behind this is eliminating patient confusion. I agree with this.

Given the interest in eliminating patient confusion, would those who agree with this also support a change in title from Physician Assistant to Physician Associate? On more than one occasion I have seen patients believe that a PA was in fact just an assistant. One lady asked a PA I was with why they didn't become a nurse, because they seemed too smart to just be a medical assistant.

The term assistant is as misleading as calling a nurse Doctor nurse.

It would have been great to explain to the patient the difference between a medical assistant, a nurse and a physician assistant.

As long as technical schools, nursing schools, medical schools, guys on LSD hallucinating yet another personnel level laugh, keep extending the delivery chain by inserting layer after layer of midlevel positions, the public will continue to be confused. And you can't blame them.

I for one cannot tell you why a PA is beneficial compared to a nurse. I cannot tell you the difference between an AA and a CRNA and what one contributes distinctly from the other in anesthesia care.

Frankly, I am not as concerned about the differences between the midlevel layers as I am with ensuring that the most qualified provider is directly and/or ultimately responsible for the patient's care. And that should also be an MD- even if it is in a supervisory role in the case of underserved/remote regions.

Changing the title from 'Assistant' to 'Associate' does nothing to eliminate the confusion. The problem is not the title, its the surfeit of cooks in the kitchen.

 

[Duluth]

It would have been great to explain to the patient the difference between a medical assistant, a nurse and a physician assistant.

Given this solution, could you not justify the term "Doctor" with regard to a DNP in a clinical situation, provided you give the same education you want to give my little old lady who thought the PA was a medical assistant?

As long as technical schools, nursing schools, medical schools, guys on PCP hallucinating yet another personnel level laugh, keep extending the medical care chain by inserting layer after layer of midlevel positions, the public will continue to be confused. And you can't blame them.

I for one cannot tell you why a PA is beneficial compared to a nurse. I cannot tell you the difference between an AA and a CRNA and what one contributes distinctly from the other in anesthesia care.

Very interesting. Perhaps we should include education on the role, education, and philosophy of each member of the health care team in Medical, PA, and nursing school. I'm sure it would only take a couple of hours to go over, in depth, didactic and clinical differences. Maybe this could plant a seed of understanding, especially between nurses and physicians who seem to have no concept of the others education and philosophy.

Every DNP thread I read is filled with misconceptions and false fears. This is coming from a nurse who had originally wanted to become a DNP but was mortified when I saw the didactic and clinical education. I'm going PA instead. That does not mean it is okay to allow fase asertions to be circulated, steering up more fear and misconceptions. The same can be said of allnurses.com posts about NP's and physicians. Both sides are equally oblivious to the other it would seem.

Frankly, I am not as concerned about the differences between the midlevel layers as I am with ensuring that the most qualified provider is directly and/or ultimately responsible for the patient's care. And that should also be an MD- even if it is in a supervisory role in the case of underserved/remote regions.

In regard to ultimate culpability, can we include DO's as well? I think you make a perfectly reasonable assertion. A physician should be ultimately responsible. However, if this tilts toward control over economic concerns, rather than true collaboration, we have lost the benefit to the patient that we had initially gained by including both PA's and NP's in the health care team. Remember, the midlevel has sprung up because of a lack of physicians to fill health care needs.

Changing the title from 'Assistant' to 'Associate' does nothing to eliminate the confusion. The problem is not the title, its the surfeit of cooks in the kitchen.

I would disagree. The term assistant and associate are two entirely different entities. Language has power and meaning. Assistant denotes a subordinate or one who assists. This may have been true when the PA profession changed its name, at the beckon of the AMA, but is far from the truth now. The term associate denotes a mutualistic relationship built on collaboration.

We have too many types of cooks, I agree, but still do not have enough cooks. I cannot speak for NP's, but you would be hard pressed to find physician or PA unemployment rates anywhere near that of other professions. Physicians and PA's who want work and are willing to work will get employment. There is still a gaping hole in our heath care system. This hole will only expand as we flood the system with 33 million more insured potential patients.

 

[willow18]

I'm as angry about this DNP thing as the next guy, but the article linked by the OP is completely out of line.

I'll just refute this talking point NP/PA's love to mention: that many studies have shown outcomes to be similar and patient satisfaction increased. Outcomes may have been similar but patient population wasn't; i.e. the complicated cases were seen by the physician or the study focused on a specific disease. I haven't been able to find anything else on PubMed.

When I see a randomized trial of "everyone who walks in the door" with follow up "gold standard" testing in any medical setting involving diagnostics and therapeutics (not just managment), then I'll believe it. Oh, and in this perfect trial that will never happen, the NP's/PA's and doctors should both be newly minted grads out of their respective "residencies". I'm tired of hearing from midlevels how they're so much better because they have 17 years of experience (under supervision by a physician). Doh! And I don't care about patient satisfaction; not at least until we establish parity on a medicine level.

And honestly, if multiple studies show similar outcomes, we should re-evaluate the current training model.

 

[Eta Carinae]

@Duluth,

the issue you are debating is moot.

Do some reading.

When you are done, perhaps you'd like to continue this discussion with a fellow health student or midlevel?

awesome

 

[Eta Carinae]

Given this solution, could you not justify the term "Doctor" with regard to a DNP in a clinical situation, provided you give the same education you want to give my little old lady who thought the PA was a medical assistant?

Very interesting. Perhaps we should include education on the role, education, and philosophy of each member of the health care team in Medical, PA, and nursing school. I'm sure it would only take a couple of hours to go over, in depth, didactic and clinical differences. Maybe this could plant a seed of understanding, especially between nurses and physicians who seem to have no concept of the others education and philosophy.

Every DNP thread I read is filled with misconceptions and false fears. This is coming from a nurse who had originally wanted to become a DNP but was mortified when I saw the didactic and clinical education. I'm going PA instead. That does not mean it is okay to allow fase asertions to be circulated, steering up more fear and misconceptions. The same can be said of allnurses.com posts about NP's and physicians. Both sides are equally oblivious to the other it would seem.

In regard to ultimate culpability, can we include DO's as well? I think you make a perfectly reasonable assertion. A physician should be ultimately responsible. However, if this tilts toward control over economic concerns, rather than true collaboration, we have lost the benefit to the patient that we had initially gained by including both PA's and NP's in the health care team. Remember, the midlevel has sprung up because of a lack of physicians to fill health care needs.

I would disagree. The term assistant and associate are two entirely different entities. Language has power and meaning. Assistant denotes a subordinate or one who assists. This may have been true when the PA profession changed its name, at the beckon of the AMA, but is far from the truth now. The term associate denotes a mutualistic relationship built on collaboration.

We have too many types of cooks, I agree, but still do not have enough cooks. I cannot speak for NP's, but you would be hard pressed to find physician or PA unemployment rates anywhere near that of other professions. Physicians and PA's who want work and are willing to work will get employment. There is still a gaping hole in our heath care system. This hole will only expand as we flood the system with 33 million more insured potential patients.

For the love of zod, I have no interest in debating the need for midlevels...particularly with one. Thanks.

And somewhere in my post, I believe I indicated as much.

 

[Slack3r]

We have too many types of cooks, I agree, but still do not have enough cooks. I cannot speak for NP's, but you would be hard pressed to find physician or PA unemployment rates anywhere near that of other professions. Physicians and PA's who want work and are willing to work will get employment. There is still a gaping hole in our heath care system. This hole will only expand as we flood the system with 33 million more insured potential patients.

Unless you're a pathologist.

 

[Dr Oops]

I would disagree. The term assistant and associate are two entirely different entities. Language has power and meaning. Assistant denotes a subordinate or one who assists. This may have been true when the PA profession changed its name, at the beckon of the AMA, but is far from the truth now. The term associate denotes a mutualistic relationship built on collaboration.

but they are subordinate to the physician, they are under their supervision. This isnt demeaning, its just what it is. Just like a resident is subordinate to an attending.

 

[Eta Carinae]

Causes Delusions (of grandeur, mostly). Like assuming a "mutualistic" relationship :

Originally Posted by Duluth

I would disagree. The term assistant and associate are two entirely different entities. Language has power and meaning. Assistant denotes a subordinate or one who assists. This may have been true when the PA profession changed its name, at the beckon of the AMA, but is far from the truth now. The term associate denotes a mutualistic relationship built on collaboration.

 

[VA Hopeful Dr]

It would have been great to explain to the patient the difference between a medical assistant, a nurse and a physician assistant.

As long as technical schools, nursing schools, medical schools, guys on PCP hallucinating yet another personnel level laugh, keep extending the medical care chain by inserting layer after layer of midlevel positions, the public will continue to be confused. And you can't blame them.

I for one cannot tell you why a PA is beneficial compared to a nurse. I cannot tell you the difference between an AA and a CRNA and what one contributes distinctly from the other in anesthesia care.

Frankly, I am not as concerned about the differences between the midlevel layers as I am with ensuring that the most qualified provider is directly and/or ultimately responsible for the patient's care. And that should also be an MD- even if it is in a supervisory role in the case of underserved/remote regions.

Changing the title from 'Assistant' to 'Associate' does nothing to eliminate the confusion. The problem is not the title, its the surfeit of cooks in the kitchen.

In my state, PAs are regulated by the medical board while nurses are regulated by the nursing board. That's why PAs are more beneficial to my mind. Also, the PAs scope of practice is defined by the supervising physician.

 

[Maybeknot]

Is this person a medical doctor? Yes No Not sure
Orthopedic Surgeon 94 3 3
Obstetrician/Gynecologist. 92 5 3
General or Family Practitioner 88 8 3
Dentist 77 20 3
Anesthesiologist 76 16 8
Psychiatrist 74 20 6
Ophthalmologist 69 14 17
Podiatrist 67 22 11
Optometrist 54 36 10
Psychologist 49 44 8
Chiropractor 38 53 9
Doctor of Nursing Practice 38 37 25
Audiologist 33 40 27
Otolaryngologist 32 13 55
Nurse Practitioner 29 63 7
Physical Therapist 26 68 6
Dental assistant 12 82 5
Midwife 11 82 7

Dang. The AAO-HNS has got some educatin' to do.

 

[Slack3r]

Dang. The AAO-HNS has got some educatin' to do.

What is this you're citing?

 

[Charles_Carmichael]

What is this you're citing?

It's from the attachment in WS's post:

Here's the latest from AMA Legal Counsel...

Dear Dr. Cox:

Your frustration is shared by many physicians, which is one of the reasons why – as you have heard – the AMA has begun a Truth in Advertising campaign to help states enact legislation that would require all health care professionals to truthfully disclose their level of education, training and licensure in all advertisements and communications. There also are other provisions to our model legislation to help increase clarity for patients – and we are working to enlist allies to assist states when they move on such TIA legislation.

To show the depth of public confusion, I have attached a survey we conducted in 2008. The DNP issue is just one piece, unfortunately.

I don't mean to sound like a marketing guy (I'm a lawyer, after all), but the AMA does exist to advocate on these and other issues for all physicians because we understand that you spend your time on your patients and not on politics. My own internist, who I trust with my life, tells me that she reads journals, not AMA e-mails, but she's glad there's an AMA to fight for her. Sounds like the right choice to me!

I don't know if you have made a decision whether to join this year, but please know that we'd really love to have you! Also, even if you decide not to join, I would love to be able to quote you for potential advocacy pieces re: the fact that patients do not know the differences btw M.D., D.N.P., P.A., Au.D. , N.D. , A.R.N.P., Psy.D., Sc.D., etc. I won't use it without your permission.

Thank you again, and please do not hesitate to contact me if you need anything.

Daniel

View attachment 14660

 

[mooshika]

What I am curious about, is evidence that supports how this is directly affecting physicians in terms of job security and professional "encroachment" - meaning what physicians have been actually put out of work by the use of mid-level practitioners and how exactly is this happening?

I understand that many are angered by the principal of the issue, feeling somehow undermined or disrespected, and a lot of the arguments here appear to be based on perceptions that there is a real conspiracy to intentionally undermine physicians by a small faction of DNP's who seek to mislead patients into believing that they are medical doctors, or something like that... and I believe that maybe this is happening somewhere, but it seems exhausting to me, for people to go to those lengths just to discredit doctors or to care that much that some patient "thinks" that they are an MD and not an advanced practice nurse. Just think about how pathetic that is and what kind of person feels the need to do that... I can't imagine why something so crazy would present such a serious threat? The media appears to be having a ball lighting fires here, creating dissent and drama.

By no means am I an expert in this issue, and I realize that there are important issues to work out, but what I am curious about is exactly how, factually, physician practice or job security is specifically negatively affected by this?

Since physicians spend a great deal more time studying science, and applying that science to real life issues in clinical settings than nurses do, as has been sufficiently documented here and elsewhere (my personal motivation for studying medicine), it would follow that some data would be welcomed here, and this issue could be handled in a more scientific manner and in a less emotionally charged crusade where it seem lots of feelings are being hurt and feet are being stepped on.

Please don't slam me here - I am truly curious how the mid-level practitioners are actually putting high level clinicians out of work, and where this is happening. Based on what I have read and seen happening around me, is that a vacuum was created first - due to ridiculous and unfair low pay, and lack of general respect for family practice by even the medical community (it's just not that glamorous anymore and the pay kinda sucks?) - physicians are abandoning general medicine and family practice for good reason, so there was a vacuum created rather than NP's and DNP's actually pushing doctors out of practice? (Do they really have that much power? Maybe so in the eyes of the public?)

Physicians are always going to be the highest level of medical practice, and most reasonable people know that, and realize that there is a significant difference in the focus and training of different professionals, so it seems impossible to me for a nurse to actually take the place of a physician, just by the nature of their respective definitions.

It seems like patients are going to think all kinds of things that no one can control, ever. I would think that as long as everybody is professional and sticks to doing their respective jobs, there should not be such a problem. And advocating for the necessity of having high level practitioners managing general medicine and family medicine practices, providing more incentives for med students to choose family practice as a specialty, and educating the public about how important the physicians are in the equation - some education and promotion, rather than coming from a defensive POV, that tends to attract negative attention.

The psychologists and psychiatrists both get called "Doctor" where I work, and there is no apparent effort to distinguish between them because they both do evals and IVC's and most people don't concern themselves with distinctions for the patients, they are all just referred to as "the doctors."

I realize that psychologists and a doctoral nurse practitioner are essentially different in function and intent, but a psychologist has little or no medical training, and none of the medical science and pharm training that even an NP has (or I have for that matter), yet there is little noise about psychologists masquerading as physicians, which one could easily say that they do since they don't make an announcement when they walk into a patient's room to do an evaluation. They say, Hi, my name is Doctor X.

Moo.

 

[glade]

Nobody is being put out of work. The anger is based on two things. a) A belief that nurses are not trained to practice medicine, which, if you've ever worked with nurses, is true. They don't even think in that manner. Their knowledge is merely rote, meaning "I saw someone do this once on one patient and it worked, I bet it will work here." b) The anger that physicians are expected to go through medical school and residency, missing out on the prime years of their lives and sacrificing their personal lives and being abused in legal ways and nurses or PAs can just waltz in and suddenly be called "doctor." There's already anger that nurses, simply due to unionization, can make six figure incomes working less than half the time that a doctor does, with far less thinking and far less legal and professional responsibility and culpability.

 

[FutureDoc4]

What I am curious about, is evidence that supports how this is directly affecting physicians in terms of job security and professional "encroachment" - meaning what physicians have been actually put out of work by the use of mid-level practitioners and how exactly is this happening?

I understand that many are angered by the principal of the issue, feeling somehow undermined or disrespected, and a lot of the arguments here appear to be based on perceptions that there is a real conspiracy to intentionally undermine physicians by a small faction of DNP's who seek to mislead patients into believing that they are medical doctors, or something like that... and I believe that maybe this is happening somewhere, but it seems exhausting to me, for people to go to those lengths just to discredit doctors or to care that much that some patient "thinks" that they are an MD and not an advanced practice nurse. Just think about how pathetic that is and what kind of person feels the need to do that... I can't imagine why something so crazy would present such a serious threat? The media appears to be having a ball lighting fires here, creating dissent and drama.

By no means am I an expert in this issue, and I realize that there are important issues to work out, but what I am curious about is exactly how, factually, physician practice or job security is specifically negatively affected by this?

Since physicians spend a great deal more time studying science, and applying that science to real life issues in clinical settings than nurses do, as has been sufficiently documented here and elsewhere (my personal motivation for studying medicine), it would follow that some data would be welcomed here, and this issue could be handled in a more scientific manner and in a less emotionally charged crusade where it seem lots of feelings are being hurt and feet are being stepped on.

Please don't slam me here - I am truly curious how the mid-level practitioners are actually putting high level clinicians out of work, and where this is happening. Based on what I have read and seen happening around me, is that a vacuum was created first - due to ridiculous and unfair low pay, and lack of general respect for family practice by even the medical community (it's just not that glamorous anymore and the pay kinda sucks?) - physicians are abandoning general medicine and family practice for good reason, so there was a vacuum created rather than NP's and DNP's actually pushing doctors out of practice? (Do they really have that much power? Maybe so in the eyes of the public?)

Physicians are always going to be the highest level of medical practice, and most reasonable people know that, and realize that there is a significant difference in the focus and training of different professionals, so it seems impossible to me for a nurse to actually take the place of a physician, just by the nature of their respective definitions.

It seems like patients are going to think all kinds of things that no one can control, ever. I would think that as long as everybody is professional and sticks to doing their respective jobs, there should not be such a problem. And advocating for the necessity of having high level practitioners managing general medicine and family medicine practices, providing more incentives for med students to choose family practice as a specialty, and educating the public about how important the physicians are in the equation - some education and promotion, rather than coming from a defensive POV, that tends to attract negative attention.

The psychologists and psychiatrists both get called "Doctor" where I work, and there is no apparent effort to distinguish between them because they both do evals and IVC's and most people don't concern themselves with distinctions for the patients, they are all just referred to as "the doctors."

I realize that psychologists and a doctoral nurse practitioner are essentially different in function and intent, but a psychologist has little or no medical training, and none of the medical science and pharm training that even an NP has (or I have for that matter), yet there is little noise about psychologists masquerading as physicians, which one could easily say that they do since they don't make an announcement when they walk into a patient's room to do an evaluation. They say, Hi, my name is Doctor X.

Moo.

You touch on so many issues here its tough to respond to all of them. I suggest you do three things to really see what the issues are:

1) Read through the other thread on this completel (DNPs with Dermatology Residency in the General Residency Forum). This should give you some good insight into many of your questions

2) Take a look a this website that someone here has recently created that really lays out the issues http://www.no-shortcuts.org/

3) Come back with any more questions you have after doing those things.

 

[mooshika]

I read "anger" is based on a "belief" and I'm wondering about some data, or facts? I'm not sure where the scientific basis is on below... these are perceptions and assumptions -which is fine, as an opinion, but in order to understand this on anything other than an emotional level I was looking for some science, the kind that takes some real thinking and interpretation, and not just rote imitation or emotionality. Im just wondering where, if this fight is going to be won, the case can be actually made on something other than resentment, anger or hurt feelings? How are physicians actually being hurt and what, technically is actually happening that has any real material effect on anything you do on a daily basis that will change the practice of medicine now and in the future? Do you want more money or something? That would be good all around and for me, I could actually afford to go into family medicine.

If no one is being put out of work, and no one is loosing any cashola, and you are happy with what you are thinking and doing and earning, what's the actual problema? Party on!

Nobody is being put out of work. The anger is based on two things. a) A belief that nurses are not trained to practice medicine, which, if you've ever worked with nurses, is true. They don't even think in that manner. Their knowledge is merely rote, meaning "I saw someone do this once on one patient and it worked, I bet it will work here." b) The anger that physicians are expected to go through medical school and residency, missing out on the prime years of their lives and sacrificing their personal lives and being abused in legal ways and nurses or PAs can just waltz in and suddenly be called "doctor." There's already anger that nurses, simply due to unionization, can make six figure incomes working less than half the time that a doctor does, with far less thinking and far less legal and professional responsibility and culpability.

 

[FutureDoc4]

I read "anger" is based on a "belief" and I'm wondering about some data, or facts? I'm not sure where the scientific basis is on below... these are perceptions and assumptions -which is fine, as an opinion, but in order to understand this on anything other than an emotional level I was looking for some science, the kind that takes some real thinking and interpretation, and not just rote imitation or emotionality. Im just wondering where, if this fight is going to be won, the case can be actually made on something other than resentment, anger or hurt feelings? How are physicians actually being hurt and what, technically is actually happening that has any real material effect on anything you do on a daily basis that will change the practice of medicine now and in the future? Do you want more money or something? That would be good all around and for me, I could actually afford to go into family medicine.

If no one is being put out of work, and no one is loosing any cashola, and you are happy with what you are thinking and doing and earning, what's the actual problema? Party on!

Sigh.... you clearly didn't do either thing I recommended (cause they would of addressed your comments) and you are just trolling.

The bottom line, patients are the ones who will suffer from this, and its our job to protect them. If you want to understand the issues, I urge you to do what I said above.

 

[Maybeknot]

I feel we're being trolled here, but on the small chance this is real...

I read "anger" is based on a "belief" and I'm wondering about some data, or facts? I'm not sure where the scientific basis is on below... these are perceptions and assumptions -which is fine, as an opinion, but in order to understand this on anything other than an emotional level I was looking for some science, the kind that takes some real thinking and interpretation, and not just rote imitation or emotionality. Im just wondering where, if this fight is going to be won, the case can be actually made on something other than resentment, anger or hurt feelings? How are physicians actually being hurt and what, technically is actually happening that has any real material effect on anything you do on a daily basis that will change the practice of medicine now and in the future? Do you want more money or something? That would be good all around and for me, I could actually afford to go into family medicine.

If no one is being put out of work, and no one is loosing any cashola, and you are happy with what you are thinking and doing and earning, what's the actual problema? Party on!

Mary Mundinger, who started this whole nurses-as-doctors fad, has openly stated that her goal is to have nurses in charge of health care teams. I.e., physicians will report to nurses, because nurses are trained to "treat the patient," while doctors "treat the disease." Mundinger has said exactly this. Hm. Mundinger retired as Dean of the Nursing School at Columbia to pursue this goal.

Now, in terms of scientific basis, it's a little hard to give you any concrete data because, well, this change hasn't happened yet. All we can do is give inferences based on logical steps, and here are a few of mine:
1. Those interested in primary care are going to be deterred from going the medical school route, because if you can do it cheaper and easier as a DNP, why would you put yourself through the extra rigor and cost of medical school?
2. As a result, the primary care field will increasingly be dominated by DNP's, and the primary care physician will become a rarity.
3. When DNP's control primary care, they will control all of health care. Why? Because they have all the referral power. Thus, if DNP's decide (and they already have, and there's plenty of proof out there) that they can subspecialize and become nurse-dermatologists and nurse-cardiologists, the primary care DNP's will simply choose to refer their patients to nurse-specialists.

Now this isn't answering your question, but I pose that your question isn't a good one to ask about this situation. To say, "hey, physicians are not going to be hurt by increasing nurse scope of practice" as a justification for increasing nurse scope of practice is fool-hardy.