Should physicians let NP/PA take over primary care and anesthesia?

[NickNaylor]

You can't just make up a bs number like that. Experience counts for a lot but it doesn't replace formal training. And there are plenty of times where the pcp doesn't know what to do so they refer out

In the second year of medical school, they tell you that you see this this and this then it's this disease. In real life you get this maybe this another random thing out of left field and you also have this weird thing on their eye. Ten things on the differential, you get a consult and you still have no idea what is going on.

I can meet measures and manage chronic diseases right now. But I'm nowhere close to my attendings

The most difficult part of starting on the wards is having no idea what the "range" of various things can be. When you see your first person with SOB, it's difficult to gauge how "serious" the SOB is. When someone complains of having a headache, it's hard to figure out whether this is something you should be concerned about and is worthy of further investigation or whether it's something that can be put off for another visit. You get all the buzzwords in M2 and during studying, but, as you say, sadly patients don't use buzzwords.

That's really where the value of seeing a ton of patients and having an inordinate amount of clinical exposure comes in. Given enough time, you subconsciously develop a range of things from "malingering/not serious" to "oh **** we need to treat this right away." Given the already limited amount of clinical exposure NPs have and hearing anecdotally about some of the ways in which they gain that "clinical experience," that's where my greatest concern lies. There is no shortcut to gaining wisdom and experience.

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[criticalelement]

Most mid-levels want you to be successful and make more money..

Which dream world do you live in? They find you superfluous.

 

[member1000765]

Just an anecdote to pass along that I thought the SDN crowd might find entertaining.

My wife is a dental student. She said that recently they had NP students in their clinic observing them, during which time they were getting credit for experience hours. First, they were getting experience hours for the observing dental STUDENTS, not dental residents or practicing dentists. She said the student sat in a chair in the corner and never looked up; didn't care at all what was going on, yet was getting these experience hours that the NP's tout as such an important part of their education. If it was an isolated experience I wouldn't worry about it, but we occasionally have NP students floating around our resident clinics as well, and mine has been the same experience. They have sat in the corner, completely disinterested in what we are doing (even though I'm a surgical subspecialty, there's definitely applicable information you can learn for general practice).

Needless to say, I'm not impressed. The first batch of NP's that came around were mostly experienced nurses who had seen a lot of things and in general had a good knowledge base and understood their roles. Seems like the new batches are mostly kids coming out of college who don't feel like putting the initiative in to go through med school, don't pursue PA school for whatever the reason, and actually have no intentions of being a general nurse, but shortcutting the system and coming out with an NP degree and entering the workforce before most med students even graduate from medical school. That irritates me more than anything. With 4 years of med school, 5 of residency, and 2 of fellowship, I'll be 8 years behind my colleagues I graduated from college with who went into fast track NP programs and were out working after 3 years.

 

[Psai]

There are many medical school rejects in these new batches who relish the thought of looking and acting like a doctor while hating on the actual doctors. They go through nursing school with that same pisspoor attitude, actively avoiding patients who actually need their help, do a few useless group projects about bs. Then the do some classes on nursing theory and administration after which somehow they are given prescription pads and more freedom to work in any medical field they want than most medical school graduates. Makes sense to me

 

[FNP_Blix]

This is my experience as well. I realize that a series of anecdotes does not equal data, but I firmly believe that physicians can, will, and should outperform mid-levels in the primary care setting. From both public relations (patients) and monetary (insurance companies), I still think we overcome this challenge by focusing on quality. If someone wants an extra 10 minutes to talk about their hangnail, then by all means, go see a nurse practitioner. But if you want someone to distinguish between the knee pain that requires ibuprofen and rest vs. the knee pain that needs an MRI and ortho referral, then give me a physician.

You don't think ARNP knows how to do that? lol. I just finished rotations at a jail where NPs where running the clinics and infirmary's and we see all kinds of complicated pathologies and patients with multiple comorbidities. Just the other day, we did penicillin challenge on a patient that had gummatous syphillis. For all you braniacs on this forum, have you ever seen this in real life and do you know what level of syphillis this is? How many of you have actually done a pelvic exam? Do you what to look for? Can you tell if what you are looking at is just a cervical polyp, a nabothian cyst, or potentially cancerous? Do you know what p53 tumor supressing gene and it's role in endometiral cancer? Regarding your insult about us not being able to treat knee pain, have you ever actually aspirated a bursa and sent for culture to determine if its gout causing the pain?Do you know how to perform an anterior drawer test? Do you know what clue cells look like under the microscope? How many of you have actually experienced working with a patient that has Steven Johnson's syndrome and the PT ways over 700Ibs and has MDRO? Have you ever done chest compressions to save a life? Do you know how to treat a patient who has critically high K+ levels?...All these thing's I've experienced, have been involved with, and would know what to do to get the above examples/patient the help they need. ARNPs know much more than you think. And if you have such a problem with us, then as physicians, why hire us? But you wont not hire us because you know that you cant. You need us. So all you can do is complain about something you cant control.

 

[Pathman1000]

"the PT ways over 700Ibs"

I may not be a braniac but i know how to spell "weighs" correctly

 

[zero0]

You don't think ARNP knows how to do that? lol. I just finished rotations at a jail where NPs where running the clinics and infirmary's and we see all kinds of complicated pathologies and patients with multiple comorbidities. Just the other day, we did penicillin challenge on a patient that had gummatous syphillis. For all you braniacs on this forum, have you ever seen this in real life and do you know what level of syphillis this is? How many of you have actually done a pelvic exam? Do you what to look for? Can you tell if what you are looking at is just a cervical polyp, a nabothian cyst, or potentially cancerous? Do you know what p53 tumor supressing gene and it's role in endometiral cancer? Regarding your insult about us not being able to treat knee pain, have you ever actually aspirated a bursa and sent for culture to determine if its gout causing the pain?Do you know how to perform an anterior drawer test? Do you know what clue cells look like under the microscope? How many of you have actually experienced working with a patient that has Steven Johnson's syndrome and the PT ways over 700Ibs and has MDRO? Have you ever done chest compressions to save a life? Do you know how to treat a patient who has critically high K+ levels?...All these thing's I've experienced, have been involved with, and would know what to do to get the above examples/patient the help they need. ARNPs know much more than you think. And if you have such a problem with us, then as physicians, why hire us? But you wont not hire us because you know that you cant. You need us. So all you can do is complain about something you cant control.

Let me break it down for you. More NPs = more $$$... at the price of substandard care of course. In the hospital's case that's a win-win. They LOVE $$$ and hate patients... lazy good for nothings occupying all the beds...

 

[dadaddadaBATMAN]

You don't think ARNP knows how to do that? lol. I just finished rotations at a jail where NPs where running the clinics and infirmary's and we see all kinds of complicated pathologies and patients with multiple comorbidities. .

You don't think ARNP knows how to do that? lol. I just finished rotations at a jail where NPs where running the clinics and infirmary's and we see all kinds of complicated pathologies and patients with multiple comorbidities. Just the other day, we did penicillin challenge on a patient that had gummatous syphillis. For all you braniacs on this forum, have you ever seen this in real life and do you know what level of syphillis this is? How many of you have actually done a pelvic exam? Do you what to look for? Can you tell if what you are looking at is just a cervical polyp, a nabothian cyst, or potentially cancerous? Do you know what p53 tumor supressing gene and it's role in endometiral cancer? Regarding your insult about us not being able to treat knee pain, have you ever actually aspirated a bursa and sent for culture to determine if its gout causing the pain?Do you know how to perform an anterior drawer test? Do you know what clue cells look like under the microscope? How many of you have actually experienced working with a patient that has Steven Johnson's syndrome and the PT ways over 700Ibs and has MDRO? Have you ever done chest compressions to save a life? Do you know how to treat a patient who has critically high K+ levels?...All these thing's I've experienced, have been involved with, and would know what to do to get the above examples/patient the help they need. ARNPs know much more than you think. And if you have such a problem with us, then as physicians, why hire us? But you wont not hire us because you know that you cant. You need us. So all you can do is complain about something you cant control.

Hi Blix, in short yes I feel comfortable managing every one of those situations. I can go through them if you like, but I am not sure what that proves really (most of those are pretty easily googled). The pelvic exams I do these days are less of the chronic variety, and more the acute stuff (e.g. Did i lose my baby).

For your knowledge though, those are all situations that every third year medical student has been through (exception being tertiary syphilus, that must be from working in a prison ). Most of the questions you asked are covered in first or second year of medical school at a fair degree of depth.

Personally, I have found that nps and pas can be very useful in the right settings. My only real problem with nps is the variability of your education. I have met nps who were competent, and others who were significantly less so. The field needs standardization, and there needs to be more required clinical hours if people are going to go straight from college.

 

[Staphylococcus Aureus]

we did penicillin challenge on a patient that had gummatous syphillis. For all you braniacs on this forum, have you ever seen this in real life and do you know what level of syphillis this is? How many of you have actually done a pelvic exam? Do you what to look for? Can you tell if what you are looking at is just a cervical polyp, a nabothian cyst, or potentially cancerous? Do you know what p53 tumor supressing gene and it's role in endometiral cancer? Regarding your insult about us not being able to treat knee pain, have you ever actually aspirated a bursa and sent for culture to determine if its gout causing the pain?Do you know how to perform an anterior drawer test? Do you know what clue cells look like under the microscope? How many of you have actually experienced working with a patient that has Steven Johnson's syndrome and the PT ways over 700Ibs and has MDRO? Have you ever done chest compressions to save a life? Do you know how to treat a patient who has critically high K+ levels?...All these thing's I've experienced, have been involved with, and would know what to do to get the above examples/patient the help they need.

What an inferiority complex. If you want to have a d*ck measuring contest of medical experiences I know some EMTs that would run circles around you, "seeing" and being "involved with" isn't why the online NP degree is completely substandard training for the privileges gained through legislature.

Do you know what p53 tumor supressing gene and it's role in endometiral cancer?

The fact that you would ask that as a challenge shows you have a pre-med student's understanding of pathophysiology, which illustrates the point that NPs are ignorant of the basic science reasoning behind clinical decision making. I have no problem with NPs who know they are NPs, if you want to pretend to be something you're not you're going to be disappointed your whole career.

 

[dr zaius]

Obviously a fake post.

Or an NP student unintentionally proving the point of most physicians in this thread.

 

[allantois]

This is a non-issue outside of SDN.

 

[raiderette]

I want great FP doctors. Unlike many of you, they were the only doctors in the town where I spent my adolescence. From colds to pap smears to cancer, they were the first line of defense. No punting to a specialist unless it was major because it meant two months wait and a day off work. I have gone to NP and PAs and I am thankful my doctor was around for my family. She certainly ordered fewer tests.

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[cbrons]

You don't think ARNP knows how to do that? lol. I just finished rotations at a jail where NPs where running the clinics and infirmary's and we see all kinds of complicated pathologies and patients with multiple comorbidities. Just the other day, we did penicillin challenge on a patient that had gummatous syphillis. For all you braniacs on this forum, have you ever seen this in real life and do you know what level of syphillis this is? How many of you have actually done a pelvic exam? Do you what to look for? Can you tell if what you are looking at is just a cervical polyp, a nabothian cyst, or potentially cancerous? Do you know what p53 tumor supressing gene and it's role in endometiral cancer? Regarding your insult about us not being able to treat knee pain, have you ever actually aspirated a bursa and sent for culture to determine if its gout causing the pain?Do you know how to perform an anterior drawer test? Do you know what clue cells look like under the microscope? How many of you have actually experienced working with a patient that has Steven Johnson's syndrome and the PT ways over 700Ibs and has MDRO? Have you ever done chest compressions to save a life? Do you know how to treat a patient who has critically high K+ levels?...All these thing's I've experienced, have been involved with, and would know what to do to get the above examples/patient the help they need. ARNPs know much more than you think. And if you have such a problem with us, then as physicians, why hire us? But you wont not hire us because you know that you cant. You need us. So all you can do is complain about something you cant control.

Most 2nd year medical students know about every single thing you mentioned, even if they havent likely performed an arthrocentesis yet. For MD education, a rather voluminous amount of learning takes places before hands-on stuff. Which I think mid-levels forget about and dont understand. It is also why they believe seeing a disease process as a nurse +/- doing some procedure = having deep understanding of the underlying pathophysiology.

The fact is most of you don't even have a rudimentary understanding of basic physiology to ever to do much more than follow strict guidelines or algorithms written by physicians. This actually is completely fine, because that is the entire purpose of a nurse practitioner or PA anyway. Mid-levels were created and exist solely to extend traditionally physician-only services to patients of low/no complexity with no deviation fron algorithmic management.

Btw chest compressions rarely save lives.

 

[863168]

I officially don't give 2 ****s about this issue any longer. You can't fight dumb. It wins as soon as you begin. Give the people what they want. Here's my sentiment towards The Public summed up in the sublime words of the great Bojack Horseman: "Suck my d!ck..dumb****s!"

Fun fact, Bojack Horseman did not come up with this line. The line was actually "invented" by failed child actor Sarah Lynn after she refuses to go to rehabilitation because she has accepted that she can just coast on her current lifestyle:

I’m at a place right now where I never need to grow as a person or rise to an occasion because I can constantly just surround myself with sycophants and enablers until I die tragically young. Yeah it’s pretty tragic. Well, them’s the breaks. Take it sleazy, everybody. Oh, by the way, I called Vanessa Gecko, and I’m meeting with her tomorrow. Thanks for the suggestion. Hey, you guys want to hear my new catchphrase? Such a dick, dumb ****s!

- Season 1, Episode 3 - Bojack Horseman​

The irony is that within this thread the criticisms against NPs run oddly along the lines of the character flaws of Sarah Lynn. The reliance on outsourcing cases to other physicians, the lack of rigor in NP education, and a general sense of apathy that they have towards their own role as hands-on clinicians holistically insinuate that they are more interested in the NP title than providing the highest level of care for the patients around them. The fact that Sarah Lynn's old catchphrase was, "That's too much, man" bears resemblance to the case that NPs are perhaps thrown too fast into their acting careers rather than being able to understand the significance of their lines and when they are put on stage they can only rehash rote memorized lines rather than convey the underlying subtext.

On the other hand, @Nasrudin mixed up the origin as being from Bojack because he is the first person to reuse the line in a later episode. The main point that is raised in this episode is that Bojack acted as a figurative father to Sarah Lynn as he was her father while on set:

"[To Sarah Lynn (with audience)]:You stick with me, and I promise you, everything’s gonna be just fine. [To Sarah Lynn (alone)]:Hey, you see those people? Well, those boobs and jerk wads are the best friends you’ll ever have. Without them, you’re nothing. Remember that. Your family will never understand you, your lovers will leave you or try to change you, but your fans, you be good to them, and they’ll be good to you. The most important thing is, you got to give the people what they want, even if it kills you, even if it empties you out until there’s nothing left to empty. No matter what happens, no matter how much it hurts, you don’t stop dancing, and you don’t stop smiling, and you give those people what they want.

- Season 1, Episode 3 - Bojack Horseman​

The second layer of irony is that this type of unbreakable, dance-for-the-master type of absolutism characterizes the negative side of gaming the current medical education system. This is featured in @W19 thread on a poor surgical evaluation in which students highlighted the denial of self interest in order to gain a better letter of evaluation/higher honors for the rotation. There is a parallelism in where the sound advice bears resemblance to the advice given by Bojack to a young Sarah Lynn, "The most important thing is, you got to give the people what they want, even if it kills you, even if it empties you out until there's nothing left to empty. No matter what happens, no matter how much it hurts, you don't stop dancing, and you don't stop smiling, and you give those people what they want."

It's not surprising that many doctors end up following the same fate as Bojack Horseman. Burn out, fatigue, and ridicule for other people who have no idea what they went through in order to become a licensed physician. Then they feel incensed when they see NP candidates who aren't willing to dance, smile, or give the people what they want when they've put on their tapping shoes and danced the cha-cha through a floor of lava. Then to compound this they don't know what they don't know and they don't care about what they don't know. Their piss poor attitude exacerbates the issue to the point where even the physician looks at the public who is endorsing this movement without the same level of incredulity stating:

 

[heroesjourney]

I don't really think the question is necessary, imperative, or practical. My MD primary care doc employs an NP. I just called about a sore throat/cough. I could either wait a month to see my MD doc bc she's so booked with appointments or go the next day to see the NP. I went the next day and the NP found what was wrong (mono) and I left. There is so much demand relative to supply this question strikes me as absurd in its lack of context. I'm glad mid-levels exist. I don't think primary care docs need to "give" primary care or anesthesia to mid-levels. I think they can intelligently share and do just fine.

 

[cbrons]

I don't really think the question is necessary, imperative, or practical. My MD primary care doc employs an NP. I just called about a sore throat/cough. I could either wait a month to see my MD doc bc she's so booked with appointments or go the next day to see the NP. I went the next day and the NP found what was wrong (mono) and I left. There is so much demand relative to supply this question strikes me as absurd in its lack of context. I'm glad mid-levels exist. I don't think primary care docs need to "give" primary care or anesthesia to mid-levels. I think they can intelligently share and do just fine.

You are correct, it is absurd. For low to no complexity cases like yours, which could very easily have been managed by an R.N., mid-levels are very useful.

 

[hurtem&healem]

Fun fact, Bojack Horseman did not come up with this line. The line was actually "invented" by failed child actor Sarah Lynn after she refuses to go to rehabilitation because she has accepted that she can just coast on her current lifestyle:
...

 

[KnuxNole]

I know that several of my classmates in med school and some of my former co-residents are envious of NPs...and that if they were to do it again, they would go with the NP route. One of them in particular, mention how it's not worth to go through all of this schooling just for the added stress. "If I was a NP, I could be done with school faster AND have less responsibility and still do what I currently do!".

And, depending on the patient population, some prefer a NP to a MD. In some of the more smaller areas around my town, some are seen as demi-gods!

 

[Twomonty17]

I know that several of my classmates in med school and some of my former co-residents are envious of NPs...and that if they were to do it again, they would go with the NP route. One of them in particular, mention how it's not worth to go through all of this schooling just for the added stress. "If I was a NP, I could be done with school faster AND have less responsibility and still do what I currently do!".

And, depending on the patient population, some prefer a NP to a MD. In some of the more smaller areas around my town, some are seen as demi-gods!

Yeah I'm going to say your last paragraph is a hyperbole. I can't think of anyone that would prefer a NP over an MD given the chance. Especially in a smaller town where most people consider MDs as doctors and everything else as nurses.

 

[NYCdude]

You don't think ARNP knows how to do that? lol. I just finished rotations at a jail where NPs where running the clinics and infirmary's and we see all kinds of complicated pathologies and patients with multiple comorbidities. Just the other day, we did penicillin challenge on a patient that had gummatous syphillis. For all you braniacs on this forum, have you ever seen this in real life and do you know what level of syphillis this is? How many of you have actually done a pelvic exam? Do you what to look for? Can you tell if what you are looking at is just a cervical polyp, a nabothian cyst, or potentially cancerous? Do you know what p53 tumor supressing gene and it's role in endometiral cancer? Regarding your insult about us not being able to treat knee pain, have you ever actually aspirated a bursa and sent for culture to determine if its gout causing the pain?Do you know how to perform an anterior drawer test? Do you know what clue cells look like under the microscope? How many of you have actually experienced working with a patient that has Steven Johnson's syndrome and the PT ways over 700Ibs and has MDRO? Have you ever done chest compressions to save a life? Do you know how to treat a patient who has critically high K+ levels?...All these thing's I've experienced, have been involved with, and would know what to do to get the above examples/patient the help they need. ARNPs know much more than you think. And if you have such a problem with us, then as physicians, why hire us? But you wont not hire us because you know that you cant. You need us. So all you can do is complain about something you cant control.

This is one of the most cringeworthy things I have ever read. If you think all the things you listed were particularly challenging to understand or do, then NPs are even less qualified than I imagined in the first place lmao.

 

[Jabbed]

You don't think ARNP knows how to do that? lol. I just finished rotations at a jail where NPs where running the clinics and infirmary's and we see all kinds of complicated pathologies and patients with multiple comorbidities. Just the other day, we did penicillin challenge on a patient that had gummatous syphillis. For all you braniacs on this forum, have you ever seen this in real life and do you know what level of syphillis this is? How many of you have actually done a pelvic exam? Do you what to look for? Can you tell if what you are looking at is just a cervical polyp, a nabothian cyst, or potentially cancerous? Do you know what p53 tumor supressing gene and it's role in endometiral cancer? Regarding your insult about us not being able to treat knee pain, have you ever actually aspirated a bursa and sent for culture to determine if its gout causing the pain?Do you know how to perform an anterior drawer test? Do you know what clue cells look like under the microscope? How many of you have actually experienced working with a patient that has Steven Johnson's syndrome and the PT ways over 700Ibs and has MDRO? Have you ever done chest compressions to save a life? Do you know how to treat a patient who has critically high K+ levels?...All these thing's I've experienced, have been involved with, and would know what to do to get the above examples/patient the help they need. ARNPs know much more than you think. And if you have such a problem with us, then as physicians, why hire us? But you wont not hire us because you know that you cant. You need us. So all you can do is complain about something you cant control.

That's all pretty basic tbh.

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[Atlas Shrugged]

You also don't send knee aspirate for culture to determine whether gout is the etiology...

 

[Psai]

You don't think ARNP knows how to do that? lol. I just finished rotations at a jail where NPs where running the clinics and infirmary's and we see all kinds of complicated pathologies and patients with multiple comorbidities. Just the other day, we did penicillin challenge on a patient that had gummatous syphillis. For all you braniacs on this forum, have you ever seen this in real life and do you know what level of syphillis this is? How many of you have actually done a pelvic exam? Do you what to look for? Can you tell if what you are looking at is just a cervical polyp, a nabothian cyst, or potentially cancerous? Do you know what p53 tumor supressing gene and it's role in endometiral cancer? Regarding your insult about us not being able to treat knee pain, have you ever actually aspirated a bursa and sent for culture to determine if its gout causing the pain?Do you know how to perform an anterior drawer test? Do you know what clue cells look like under the microscope? How many of you have actually experienced working with a patient that has Steven Johnson's syndrome and the PT ways over 700Ibs and has MDRO? Have you ever done chest compressions to save a life? Do you know how to treat a patient who has critically high K+ levels?...All these thing's I've experienced, have been involved with, and would know what to do to get the above examples/patient the help they need. ARNPs know much more than you think. And if you have such a problem with us, then as physicians, why hire us? But you wont not hire us because you know that you cant. You need us. So all you can do is complain about something you cant control.

I liked the part where this post demonstrates the depth of your knowledge base
Also was impressed by the impeccable spelling

 

[FNP_Blix]

You also don't send knee aspirate for culture to determine whether gout is the etiology...

Yes you can, you can attempt to visualize urate crystals in the synovial fluid from any joint or bursa and then confirm with serum uric acid levels...not sure what your rational is and why you wouldn't but believe you're wrong here.

 

[FNP_Blix]

That's all pretty basic tbh.

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What an inferiority complex. If you want to have a d*ck measuring contest of medical experiences I know some EMTs that would run circles around you, "seeing" and being "involved with" isn't why the online NP degree is completely substandard training for the privileges gained through legislature.


The fact that you would ask that as a challenge shows you have a pre-med student's understanding of pathophysiology, which illustrates the point that NPs are ignorant of the basic science reasoning behind clinical decision making. I have no problem with NPs who know they are NPs, if you want to pretend to be something you're not you're going to be disappointed your whole career.

You completely exaggerated on your statement about EMTs "running circles around me". And also, I'm not in any online NP program. Like you, I look down upon those. I've been a nurse for over 5 years in various acute care settings, and probably can run circles around you my friend. Unlike many medical students and physicians, I don't have a superiority (or inferiority complex for that matter) and can take constructive criticism and get better each day. That's why I am successful in my field and have no problems working with actual physicians (unlike you guys who think you know everything). All the physicians I have done rotations with have learned to trust me quite quickly and we actually constructively debate on concepts and ideas. I've had my physician instructors not know a lot of stuff that I knew, and vis versa. Like last year I was with this physician and he didn't know what Centor criteria is or what a Curb 65 was. Also, regarding your point about me not knowing basic sciences to help in my clinical decision making, beyond some basic biochemistry concepts (e.g., pH partitioning, phase 1 & 2 of metabolism) needed in pharmacology and some other rudimentary aspects of organic chem, and biology - the most basic sciences you will ever utilize in your practice that is integrated with pathophysiology and pharmacology is the basic sciences of anatomy and physiology (1 & 2) and microbiology. Those science are the most used and are always present in everyday medicine in addition to pathophysiology and pharmacotherapeutics.

 

[DocVapor]

Yes you can, you can attempt to visualize urate crystals in the synovial fluid from any joint or bursa and then confirm with serum uric acid levels...not sure what your rational is and why you wouldn't but believe you're wrong here.

His point was that you don't culture crystals, you just look under a microscope for them like you said in this post. However your next statement is interesting, as it is possible to have gout without elevated serum uric acid levels, and the diagnosis is actually made by direct visualization of monosodium urate crystals and leukocyte infiltration in fluid aspirated from an inflamed joint. Your thinking is backwards here. And this is only the most basic part of diagnosis and management of gout, which is generally covered in the first 5 minutes of an hour long lecture on gout.

 

[FNP_Blix]

Most 2nd year medical students know about every single thing you mentioned, even if they havent likely performed an arthrocentesis yet. For MD education, a rather voluminous amount of learning takes places before hands-on stuff. Which I think mid-levels forget about and dont understand. It is also why they believe seeing a disease process as a nurse +/- doing some procedure = having deep understanding of the underlying pathophysiology.

The fact is most of you don't even have a rudimentary understanding of basic physiology to ever to do much more than follow strict guidelines or algorithms written by physicians. This actually is completely fine, because that is the entire purpose of a nurse practitioner or PA anyway. Mid-levels were created and exist solely to extend traditionally physician-only services to patients of low/no complexity with no deviation fron algorithmic management.

Btw chest compressions rarely save lives.

I don't just jump in and do procedures or manage patients with no knowledge of what I'm doing or without having guidance from a physician or preceptor. Of course we have to learn before we get out there and practice medicine. And I think ARNPs do have a pretty solid understanding of pathophysiology and physiology. Kind of insulting for you to say that but it's all good, kind of knew what I was getting into posting on this forum. You'll all see once you actually become physicians...you won't be able to survive without your nurses and you'll see why they get paid well too..cheers.

 

[FNP_Blix]

His point was that you don't culture crystals, you just look under a microscope for them like you said in this post. However your next statement is interesting, as it is possible to have gout without elevated serum uric acid levels, and the diagnosis is actually made by direct visualization of monosodium urate crystals and leukocyte infiltration in fluid aspirated from an inflamed joint. Your thinking is backwards here. And this is only the most basic part of diagnosis and management of gout, which is generally covered in the first 5 minutes of an hour long lecture on gout.

I know. If you want we can go more in depth buddy...

 

[FNP_Blix]

As condescending and rude as you guys are, I've never participated in a form like this and it's actually kind of fun talking to you guys, so thank you!

 

[bashwell]

As condescending and rude as you guys are, I've never participated in a form like this and it's actually kind of fun talking to you guys, so thank you!

If you think this forum is "condescending and rude," you should check out a place like allnurses.com! You'll be in for a real treat there as far as "condescending and rude". See what nurses say about doctors on nursing forums. For example, see posts nurses make about CRNAs vs anesthesiologists.

 

[Jabbed]

You completely exaggerated on your statement about EMTs "running circles around me". And also, I'm not in any online NP program. Like you, I look down upon those. I've been a nurse for over 5 years in various acute care settings, and probably can run circles around you my friend. Unlike many medical students and physicians, I don't have a superiority (or inferiority complex for that matter) and can take constructive criticism and get better each day. That's why I am successful in my field and have no problems working with actual physicians (unlike you guys who think you know everything). All the physicians I have done rotations with have learned to trust me quite quickly and we actually constructively debate on concepts and ideas. I've had my physician instructors not know a lot of stuff that I knew, and vis versa. Like last year I was with this physician and he didn't know what Centor criteria is or what a Curb 65 was. Also, regarding your point about me not knowing basic sciences to help in my clinical decision making, beyond some basic biochemistry concepts (e.g., pH partitioning, phase 1 & 2 of metabolism) needed in pharmacology and some other rudimentary aspects of organic chem, and biology - the most basic sciences you will ever utilize in your practice that is integrated with pathophysiology and pharmacology is the basic sciences of anatomy and physiology (1 & 2) and microbiology. Those science are the most used and are always present in everyday medicine in addition to pathophysiology and pharmacotherapeutics.

You won't like this analogy I'm sure, but hear me out.

I used to be a medical scribe for 4 years in a community ED. After 3 years, I truly thought that I "got it". I would know the workup for 90+% of the patients that came through the doors and I "knew" what the management would be for the vast majority of patients after watching the H&P. I even thought it was easy as it seemed mostly formulaic and I was literally standing next to the doc for the full shift listening to and observing everything that they would do. I would pick up on some of the teaching pearls that you mentioned in your earlier post and I really thought that I was something clever.

Fast forward 3 years into medical school and I'm semi-mortified at how cocky I was as an undergrad. Medicine really does take a highly structured learning pathway to learn and master and you cannot simply 'learn by doing'. Every one of your examples are singular points along a higher and more complex understanding of disease and medicine that can only be appreciated through exhaustive study and thousands of hours of application. Taking your point about syphilitic gummas for example: do you know the difference between gummas and condyloma lata? What abx do you use for penicillin-allergic patients? What's the difference between VDRL and FTA-ABS testing? How do you know when you've adequately treated neurosyphilis? When would you consider secondary syphilis in the ddx of a patient with non-specific viral syndrome and macular rash? Who should be screened for syphilis? What are common causes of false-positives when testing for syphilis? Would you recognize a syphilitic chancre and be able to differentiate it from other STD's or malignancy? This is all still basic material similar to what posted beforehand, but it's just highly unlikely that anyone would know ALL of this without a structured and rigorous education.

I don't say this to be a jerk, but the oft repeated adage "you don't know what you don't know" is so true. I'm well into my M4 year and kicking butt clinically and yet only starting to grasp how much I don't know. The worst part is that I know that if I were to have a frank conversation with my 3 year younger self I would find him to be a cocky little **** stain.

 

[DocVapor]

I know. If you want we can go more in depth buddy...

If you know it, why were you so nonchalant with your language? Precision with our language is important in medicine, and lack of precision indicates lack of knowledge.

 

[bashwell]

You don't think ARNP knows how to do that? lol. I just finished rotations at a jail where NPs where running the clinics and infirmary's and we see all kinds of complicated pathologies and patients with multiple comorbidities. Just the other day, we did penicillin challenge on a patient that had gummatous syphillis. For all you braniacs on this forum, have you ever seen this in real life and do you know what level of syphillis this is? How many of you have actually done a pelvic exam? Do you what to look for? Can you tell if what you are looking at is just a cervical polyp, a nabothian cyst, or potentially cancerous? Do you know what p53 tumor supressing gene and it's role in endometiral cancer? Regarding your insult about us not being able to treat knee pain, have you ever actually aspirated a bursa and sent for culture to determine if its gout causing the pain?Do you know how to perform an anterior drawer test? Do you know what clue cells look like under the microscope? How many of you have actually experienced working with a patient that has Steven Johnson's syndrome and the PT ways over 700Ibs and has MDRO? Have you ever done chest compressions to save a life? Do you know how to treat a patient who has critically high K+ levels?...All these thing's I've experienced, have been involved with, and would know what to do to get the above examples/patient the help they need. ARNPs know much more than you think. And if you have such a problem with us, then as physicians, why hire us? But you wont not hire us because you know that you cant. You need us. So all you can do is complain about something you cant control.

Yes to everything. Easily. This is like med school level at most. In fact, quite a bit of it is pre-med (e.g., p53, clue cells).

However, here's what's worrying. From your perspective, what you say is supposed to show how you as a nurse aren't ignorant, etc., but ironically it shows how little you as a nurse know while thinking you know a lot! It'd be like if a waiter started asking a seasoned experienced chef if they know how to cut vegetables, what an oven is, how to bake a cake, if they've ever served a medium rare steak to a customer, etc. Just think how that would sound to the chef! Dare I say it might even be considered "condescending and rude"?!

Tl;dr. The fact that you think all this is supposed to be impressive is instead depressive. Ignorance and arrogance make a bad couple.

 

[Stagg737]

You completely exaggerated on your statement about EMTs "running circles around me". And also, I'm not in any online NP program. Like you, I look down upon those. I've been a nurse for over 5 years in various acute care settings, and probably can run circles around you my friend. Unlike many medical students and physicians, I don't have a superiority (or inferiority complex for that matter) and can take constructive criticism and get better each day. That's why I am successful in my field and have no problems working with actual physicians (unlike you guys who think you know everything). All the physicians I have done rotations with have learned to trust me quite quickly and we actually constructively debate on concepts and ideas. I've had my physician instructors not know a lot of stuff that I knew, and vis versa. Like last year I was with this physician and he didn't know what Centor criteria is or what a Curb 65 was. Also, regarding your point about me not knowing basic sciences to help in my clinical decision making, beyond some basic biochemistry concepts (e.g., pH partitioning, phase 1 & 2 of metabolism) needed in pharmacology and some other rudimentary aspects of organic chem, and biology - the most basic sciences you will ever utilize in your practice that is integrated with pathophysiology and pharmacology is the basic sciences of anatomy and physiology (1 & 2) and microbiology. Those science are the most used and are always present in everyday medicine in addition to pathophysiology and pharmacotherapeutics.

If you're working with a PCP who has never heard of Centor score or Curb 65 criteria he needs to go back to residency. Additionally, nothing you've asked so far in this thread is something that a second year medical student shouldn't know (other than Centor score and Curb65, that's more 3rd year stuff). Yes, you have clinical knowledge, but if we were to compare the questions you're asking to what we are required to know as medical students, almost all of them would be considered basic questions and medical students would get their a$$es chewed out by an attending for not being able to answer them.

I don't just jump in and do procedures or manage patients with no knowledge of what I'm doing or without having guidance from a physician or preceptor. Of course we have to learn before we get out there and practice medicine. And I think ARNPs do have a pretty solid understanding of pathophysiology and physiology. Kind of insulting for you to say that but it's all good, kind of knew what I was getting into posting on this forum. You'll all see once you actually become physicians...you won't be able to survive without your nurses and you'll see why they get paid well too..cheers.

No one is arguing that nurses aren't important to our healthcare system. You all provide services which are essential to our system's existence and without nurses the healthcare in the US would collapse. What we're arguing is that the duties of a nurse and the duties of a physician are NOT the same, and that nurses simply don't have the knowledge to be making the same decisions as physicians. Yes, there are those rare few NPs/nurses who have years of experience and have taken it upon themselves to educate themselves to the point that they do have the knowledge to see most of the patients the physician would. Even for them, there are still patients that they don't know how to handle that every physician in their field can. On top of that, for every 1 of the brilliant NPs, there are 100 who shouldn't be seeing anyone independently yet many demand that they're just as knowledgeable and capable as physicians, which just is why it's such a problem in the eyes of most physicians.

 

[Psai]

Like you, I look down upon those. I've been a nurse for over 5 years in various acute care settings, and probably can run circles around you my friend. Unlike many medical students and physicians, I don't have a superiority (or inferiority complex for that matter

 

[FNP_Blix]

If you're working with a PCP who has never heard of Centor score or Curb 65 criteria he needs to go back to residency. Additionally, nothing you've asked so far in this thread is something that a second year medical student shouldn't know (other than Centor score and Curb65, that's more 3rd year stuff). Yes, you have clinical knowledge, but if we were to compare the questions you're asking to what we are required to know as medical students, almost all of them would be considered basic questions and medical students would get their a$$es chewed out by an attending for not being able to answer them.



No one is arguing that nurses aren't important to our healthcare system. You all provide services which are essential to our system's existence and without nurses the healthcare in the US would collapse. What we're arguing is that the duties of a nurse and the duties of a physician are NOT the same, and that nurses simply don't have the knowledge to be making the same decisions as physicians. Yes, there are those rare few NPs/nurses who have years of experience and have taken it upon themselves to educate themselves to the point that they do have the knowledge to see most of the patients the physician would. Even for them, there are still patients that they don't know how to handle that every physician in their field can. On top of that, for every 1 of the brilliant NPs, there are 100 who shouldn't be seeing anyone independently yet many demand that they're just as knowledgeable and capable as physicians, which just is why it's such a problem in the eyes of most physicians.

I don't argue that ARNP programs cover more subject matter. Medical students are trained to the extent that any one medical student can (and will likely) specialize in an area that requires an extremely deep level of understanding. Everyone in medical school is trained to that standard. Some of your classmates go on to become surgeons or cardiologists, for example... So I get that. NPs are trained to do primary care. ONLY that. No NP will ever (unless they go to medical school) become a neurosurgeon or a cardiovascular surgeon. We are trained to focus on only specific populations, in the primary care setting. So, why would I need to have such a deep understanding of lets say, Behcet Disease if im not going to be a pediatric rheumotologist? I know when to refer, when something is beyond my scope, and when it is beyond my knowledge base. ARNPs are trained to know their limits. The problem I have is with physicians trying to restrict us from being able to do that and us being underutilized. If tomorrow, you took away practice and prescribing authority from NPs, the system would most certainly crash and your outcomes as physicians would tumble.

 

[FNP_Blix]

Yes to everything. Easily. This is like med school level at most. In fact, quite a bit of it is pre-med (e.g., p53, clue cells).

However, here's what's worrying. From your perspective, what you say is supposed to show how you as a nurse aren't ignorant, etc., but ironically it shows how little you as a nurse know while thinking you know a lot! It'd be like if a waiter started asking a seasoned experienced chef if they know how to cut vegetables, what an oven is, how to bake a cake, if they've ever served a medium rare steak to a customer, etc. Just think how that would sound to the chef! Dare I say it might even be considered "condescending and rude"?!

Tl;dr. The fact that you think all this is supposed to be impressive is instead depressive. Ignorance and arrogance make a bad couple.

Well good, glad you had a productive medical training and I'm assuming you're a resident??? Regardless, my point is that We actually do get trained enough to do primary care and to practice independently. I have beef with the nursing establishment too. Like for example, I dont think any nurse should become ARNP unless they have at least 2 years acute care experience under their belt. I also dont think any program should be online. So I fear they are diluting things further. But for the vast majority of ARNPs that go to school the traditional route, with many years of great experience as nurses where judgement is learned, and all we do from day 1 is focus on disease processes and pharmacotherapeutics and pathophysiology - all things related to patient care - I feel you underestimate us greatly. And when you practice as a physician, you better hope that you have a good nurse practitioner or good nursing staff by your side.

 

[FNP_Blix]

If you know it, why were you so nonchalant with your language? Precision with our language is important in medicine, and lack of precision indicates lack of knowledge.

What I said was correct so I don't know what you're ranting on about. Get off your high horse. What do you want to know about Gout? Go ahead, ask me.

 

[Staphylococcus Aureus]

I'm not in any online NP program. Like you, I look down upon those. I've been a nurse for over 5 years in various acute care settings, and probably can run circles around you my friend.

All the physicians I have done rotations with have learned to trust me quite quickly and we actually constructively debate on concepts and ideas. I've had my physician instructors not know a lot of stuff that I knew

Do you hear yourself? This reeks of inferiority complex, you're trying to talk **** to students (it's not just students on this subforum btw). And if you think that pathology is impressive then no, I'm not kidding that a seasoned EMT has seen tenfold more than you.

beyond some basic biochemistry concepts (e.g., pH partitioning, phase 1 & 2 of metabolism) needed in pharmacology and some other rudimentary aspects of organic chem, and biology - the most basic sciences you will ever utilize in your practice that is integrated with pathophysiology and pharmacology is the basic sciences of anatomy and physiology (1 & 2) and microbiology.

It sounds like you're describing what is the equivalent to pre-medical coursework. Any 20 year old pre-med that might not even get into med school has passed these classes and knows what the p53 gene is. It's ironic you're deeming certain fields rudimentary to anyone here who has seen the child's play that is nursing science courses. Again the adage you don't know what you don't know applies. But why does it matter to you? Why can't you just give the best possible care in the role as an NP, because trying to pretend you have the same knowledge as a physician is a lie to yourself and others. It's like a PhD historian and a grade school history teacher, both jobs are vital, neither is "better", but to say it's the same training for the same job is simply untrue, and getting a 15 month online PhD in grade school history practice doesn't change that.

 

[bashwell]

I don't argue that ARNP programs cover more subject matter. Medical students are trained to the extent that any one medical student can (and will likely) specialize in an area that requires an extremely deep level of understanding. Everyone in medical school is trained to that standard. Some of your classmates go on to become surgeons or cardiologists, for example... So I get that. NPs are trained to do primary care. ONLY that. No NP will ever (unless they go to medical school) become a neurosurgeon or a cardiovascular surgeon. We are trained to focus on only specific populations, in the primary care setting. So, why would I need to have such a deep understanding of lets say, Behcet Disease if im not going to be a pediatric rheumotologist? I know when to refer, when something is beyond my scope, and when it is beyond my knowledge base. ARNPs are trained to know their limits. The problem I have is with physicians trying to restrict us from being able to do that and us being underutilized. If tomorrow, you took away practice and prescribing authority from NPs, the system would most certainly crash and your outcomes as physicians would tumble.

I think it'd be better for patients in general to gradually decrease NPs and gradually increase physician assistants, among others (e.g., anesthesiology assistants). It might take a couple of generations, but it'd be worth it in the long term.

 

[FNP_Blix]

Do you hear yourself? This reeks of inferiority complex, you're trying to talk **** to students (it's not just students on this subforum btw). And if you think that pathology is impressive then no, I'm not kidding that a seasoned EMT has seen tenfold more than you.

It sounds like you're describing what is the equivalent to pre-medical coursework. Again the adage you don't know what you don't know applies. But why does it matter to you? Why can't you just give the best possible care in the role as an NP, because trying to pretend you have the same knowledge as a physician is a lie to yourself and others. It's like a PhD historian and a grade school history teacher, both jobs are vital, neither is "better", but to say it's the same training for the same job is simply untrue, and getting a 15 month online PhD in grade school history practice doesn't change that.

Did I say that they are equivalent? And how do you know what I've seen? GTFO. Can you give me an example where in the primary care setting I will need to DIRECTLY apply concepts of physics. Does any of that actually help me identify a pathology and work up a patient and manage treatment? What you have is a superiority complex. All I see day in and day out on this site is bitter people like your self talking ****, and I just came here to test the waters with A** holes like your self. Lets see what you got. Can you pose a clinical problem that you think I can't answer related to primary care?

 

[bashwell]

Well good, glad you had a productive medical training and I'm assuming you're a resident??? Regardless, my point is that We actually do get trained enough to do primary care and to practice independently. I have beef with the nursing establishment too. Like for example, I dont think any nurse should become ARNP unless they have at least 2 years acute care experience under their belt. I also dont think any program should be online. So I fear they are diluting things further. But for the vast majority of ARNPs that go to school the traditional route, with many years of great experience as nurses where judgement is learned, and all we do from day 1 is focus on disease processes and pharmacotherapeutics and pathophysiology - all things related to patient care - I feel you underestimate us greatly. And when you practice as a physician, you better hope that you have a good nurse practitioner or good nursing staff by your side.

I'm only taking you at your own word. That's all I did. I just responded to what you said. I'm not "underestimating" you when I just respond to what you yourself have said about yourself.

Also, as you can see in all the other replies to you here, I'm not the only one. Other med students and physicians have vouched for this. Again, just read or re-read all their replies to you in this very thread.

I'd prefer a physician assistant to an NP if possible. Now more than before.

 

[FNP_Blix]

I think it'd be better for patients in general to gradually decrease NPs and gradually increase physician assistants, among others (e.g., anesthesiology assistants). It might take a couple of generations, but it'd be worth it in the long term.

Of course you would. Anything where the medical establishment can have their thumb on.

 

[FNP_Blix]

I think it'd be better for patients in general to gradually decrease NPs and gradually increase physician assistants, among others (e.g., anesthesiology assistants). It might take a couple of generations, but it'd be worth it in the long term.

Your "expert opinion" doesnt matter. Look at the metanalysis that show's how NPs in various countries, not just here help improve outcomes, and decrease mortality. Study after study continues to show how NPs are valuable. Bitter pill to swallow, but we're here to stay.

 

[nowaysanjose]

You have no standardized curriculum and no entrance requirements. Anybody and their grandma can get into an NP program and pass. Even if you had 20 years of nursing experience and went to the best NP program, you would still have less knowledge than a PA, who themselves admit having less than half of the knowledge of a physician. The only thing pushing this argument is BS outcomes studies that the public only reads the conclusions of, which actually are all worthless, like your education

 

[FNP_Blix]

You have no standardized curriculum and no entrance requirements. Anybody and their grandma can get into an NP program and pass. Even if you had 20 years of nursing experience and went to the best NP program, you would still have less knowledge than a PA, who themselves admit having less than half of the knowledge of a physician. The only thing pushing this argument is BS outcomes studies that the public only reads the conclusions of, which actually are all worthless, like your education

Well these studies are what we have to go by for right now, right? And outcome studies are actually extremely valuable. They prove the value of NPs and their competency to manage chronic issues. I agree with your statement, we don't get trained to the level as a physician. Read my other responses. But to do primary care? I would say yes we absolutely get the training. How difficult is it to manage someone with for instance, hypertension, UTI, or to give valuable advice on vaccination? If I can't recognize some uncommon exanthem, then guess what? That patient should see a dermatologist. We refer when needed, and as a primary care physician, you should be doing the same...

 

[bashwell]

Your "expert opinion" doesnt matter. Look at the metanalysis that show's how NPs in various countries, not just here help improve outcomes, and decrease mortality. Study after study continues to show how NPs are valuable. Bitter pill to swallow, but we're here to stay.

I never said I gave an "expert" opinion but thanks for putting words in my mouth. Although an opinion need not be "expert" to be correct.

Also, you should cite these "studies" if you think they're relevant. However, it's comparing apples to oranges to compare US healthcare to that of other nations since there are many confounding variables among other significant issues.

I get along fine with most NPs, but you seem to have something to prove. Still, I think it'd be better for patients in the long term to have PAs gradually fill the role of many NPs. By the way I never said we should entirely get rid of NPs.

 

[Staphylococcus Aureus]

For the record, I have no bad blood against NPs, I love NPs, except for the very few that want to have a d*ck measuring contests with doctors or even students.

Can you pose a clinical problem that you think I can't answer related to primary care?

When undiagnosed Bechet's disease (or heaven forbid, a disease that isn't grossly staring you in the face) comes to your office.

 

[FNP_Blix]

For the record, I have no bad blood against NPs, I love NPs, except for the very few that want to have a d*ck measuring contests with doctors or even students.


When undiagnosed Bechet's disease (or heaven forbid, a disease that isn't grossly staring you in the face) comes to your office.

First I would start with history. What are their symptoms? do they have the classic triad of symptoms that includes recurrent oral and genital ulcer, and uveitis? Are they of Mediterranean or Japanese descent? Patient with recurrent aphthous stomatitis, this would be part of my differential. I would first treat, and then if doesnt go away, would be a diagnosis of exclusion, and I would get specialist involved.

 

[FNP_Blix]

For the record, I have no bad blood against NPs, I love NPs, except for the very few that want to have a d*ck measuring contests with doctors or even students.


When undiagnosed Bechet's disease (or heaven forbid, a disease that isn't grossly staring you in the face) comes to your office.

And I love physicians man. I seek training whenever I can from doctors and I've had really good experiences with them. I am fortunate to be a nurse and pick their brains frequently.