The Advanced Nurse Practitioner Provider Specialists Experiment

[ILE2014]

It's not really fair for us to criticize nurses for being educated online when medical students by and large watch lectures online and disdain coming to school, wishing they could do everything online.

It's more accurate to criticize lack of standardization in NP curriculums.

Standardize curriculum, have a residency of some sort, require supervising physician, and don't allow independent practice.

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[DermViser]

Standardize curriculum, have a residency of some sort, require supervising physician, and don't allow independent practice.

The whole point of them getting the doctorate is NOT to require a supervising physician.

 

[BestDoctorEver]

If you're going to call out someone, like Winged Scapula, you should realize the circumstances and the why behind the case.

That was why I 'tagged' her so she can explain the circumstances behind it if she chooses to...

 

[ILE2014]

The purpose of a midlevel is to fill in the gaps. See patients in the clinic with basic problems and round on patients in the hospital. Its incredible to me how many PAs and NPs wont ask docs for advice on a patient just because they think they can figure it out for themselves. News flash... good doctors collaborate too.

 

[ILE2014]

The whole point of them getting the doctorate is NOT to require a supervising physician.

Yeah thats the problem. It shouldn't happen. Period. But there are a lot of NPs that think they aren't trained to practice on their own. They just don't come out of the woodwork as often as the ego-driven irritating NP that thinks pushing meds for 20 years makes them a doctor. Next time an NP gives me the "come on we're doctors too" speech, I'll be sure to ask them if they let their dental hygienist who has 20 years experience perform their root canal cause they're basically a dentist...

 

[tdram]

Shouldn't it be more about the person and less about whether they are a PA or NP? I know plenty of bad PAs too. This is kind of my point and why I finally created an account to post on here. I would happily take a re-cert exam or spend more time on CME. Grouping all NPs together as worse than PAs is a shame. There are plenty of us that know our scope of practice and are competent.

Yeah the only problem is it's hard to know what you're getting when you hire an NP. The PA programs have way better quality control and certification requirements. If NPs had more stringent requirements, standardized curriculum, recertification requirements, etc, they would be more desirable when compared to a PA.

 

[ILE2014]

Yeah the only problem is it's hard to know what you're getting when you hire an NP. The PA programs have way better quality control and certification requirements. If NPs had more stringent requirements, standardized curriculum, recertification requirements, etc, they would be more desirable when compared to a PA.

Overall, I think you're right. I've been able to move around quite a bit and have been able to get hired fairly quickly in the past. Lets hope that continues for the rest of my career.

 

[tdram]

Overall, I think you're right. I've been able to move around quite a bit and have been able to get hired fairly quickly in the past. Lets hope that continues for the rest of my career.

I'm sure you'll be able to get hired. I'm just saying your profession is doing you a disservice by not having the type of quality control I mentioned. A lot of NPs are biting off way more than they can chew and there's going to be problems in the long run for the whole profession if things aren't tightened up. It may not affect you because you've already developed your own reputation but it will affect the new NPs coming out who are going to be lumped in with everyone else.

 

[ILE2014]

I'm sure you'll be able to get hired. I'm just saying your profession is doing you a disservice by not having the type of quality control I mentioned. A lot of NPs are biting off way more than they can chew and there's going to be problems in the long run for the whole profession if things aren't tightened up. It may not affect you because you've already developed your own reputation but it will affect the new NPs coming out who are going to be lumped in with everyone else.

True. One thing I will say is that in the last few years the Board of Nursing has increased the score required to pass the certification exams and has increased the amount of clinical hours required. Thats at least a step in the right direction.

 

[DermViser]

True. One thing I will say is that in the last few years the Board of Nursing has increased the score required to pass the certification exams and has increased the amount of clinical hours required. Thats at least a step in the right direction.

They should concentrate on getting a majority of their students to pass the DNP certification exam, first (i.e. greater than 50%).

 

[ILE2014]

They should concentrate on getting a majority of their students to pass the DNP certification exam, first (i.e. greater than 50%).

Those statistics were not national and had a tiny sample size. In 2008, 45 DNP graduates took the exam and slightly less than 50% passed; in 2009, 19 DNP graduates took the exam with a 57% passing rate.

 

[DermViser]

Those statistics were not national and had a tiny sample size. In 2008, 45 DNP graduates took the exam and slightly less than 50% passed; in 2009, 19 DNP graduates took the exam with a 57% passing rate.

 

[ILE2014]

But point well taken... Can't argue with the fact that many DNPs can't pass the USMLE 3 and want to practice independently. Those numbers don't lie.

 

[Winged Scapula]

That was why I 'tagged' her so she can explain the circumstances behind it if she chooses to...

I've worked with NPs and PAs for many years, predating my medical career back to when I was a medical research associate.

Back in the day I had no idea about the difference in training and was unable to assess medical knowledge base (because I had none myself) but as a graduate psychology student I was able to observe and analyze differences in behavior and personality and made some assumptions about the root of those differences.

Our preference for a PA in *our office* has to do with my observation that the training is more similar to that of a physician, what appeared to be more of a team approach, and my distaste for the political posturing of the latter's national organization. My business partners are now "sold" and have recognized the benefit of a PA over an NP. Because we live in a state where NPs have independent practice rights and work in a very high litigation speciality, we prefer a provider that is supervised by the physicians. However, should the time come in the future when we hire another MLP, I will consider an NP/Nurse Navigator on a case by case basis.

 

[ILE2014]

I've worked with NPs and PAs for many years, predating my medical career back to when I was a medical research associate.

Back in the day I had no idea about the difference in training and was unable to assess medical knowledge base (because I had none myself) but as a graduate psychology student I was able to observe and analyze differences in behavior and personality and made some assumptions about the root of those differences.

Our preference for a PA in *our office* has to do with my observation that the training is more similar to that of a physician, what appeared to be more of a team approach, and my distaste for the political posturing of the latter's national organization. My business partners are now "sold" and have recognized the benefit of a PA over an NP. Because we live in a state where NPs have independent practice rights and work in a very high litigation speciality, we prefer a provider that is supervised by the physicians. However, should the time come in the future when we hire another MLP, I will consider an NP/Nurse Navigator on a case by case basis.

If an NP practices in a state that has independent rights, can the NP not also be supervised by a physician or in most cases is it just that the NP doesn't want or think they need the supervision?

Also what type of supervision do you give PAs? Auditing charts etc or having to sign off on the prescriptions and orders? In our office NPs and PAs have the same supervision.

I completely agree with you on the training aspect. No doubt the school education of a PA is better. As time goes on though, I think the NP profession is attracting more well rounded candidates than it has in the past. I chose the NP route over PA because I had my MPH and thought after 10-15 years of practice maybe i'd want to do management and hospital admin, a field that has fewer opportunities for a PA. I hope the BON implements some of the changes they've been talking about to make a more streamlined curriculum.

Thanks for your insight on this, Winged Scapula, always nice to know why physicians have a preference one way or the other.

 

[BestDoctorEver]

If an NP practices in a state that has independent rights, can the NP not also be supervised by a physician or in most cases is it just that the NP doesn't want or think they need the supervision?

Also what type of supervision do you give PAs? Auditing charts etc or having to sign off on the prescriptions and orders? In our office NPs and PAs have the same supervision.

I completely agree with you on the training aspect. No doubt the school education of a PA is better. As time goes on though, I think the NP profession is attracting more well rounded candidates that it has in the past. I chose the NP route of PA because I had my MPH and thought after 10-15 years of practice maybe i'd want to do management and hospital admin, a field that has a lot fewer opportunities for a PA. I hope the BON implements some of the changes they've been talking about to make a more streamlined curriculum.

Thanks for your insight on this, Winged Scapula, always nice to know why physicians have a preference one way or the other.

You are probably the first NP who actually admit that... Even you put the NP vs. PA curricula side by side, NP won't acknowledge that PA curriculum is better... They always come up with some BS about PAs don't have previous healthcare experience and can have a degree in anything before becoming PA.

 

[ILE2014]

You are probably the first NP who actually admit that... Even you put the NP vs. PA curricula side by side, NP won't acknowledge that PA curriculum is better... They always come up with some BS about PAs don't have previous healthcare experience and can have a degree in anything before becoming PA.

I mean look at the classes. PA's have a great curriculum. I did a lot of research on the two paths before choosing and I knew that if I chose NP (so that later I could do admin) I would have to work harder than those coming right out of PA school. I think now with a little experience its worked out, but maybe thats because im a smart curious person that wants to keep learning. I also totally lucked out with the school I chose. I went to an awesome school that was attached to a med school. I learned a lot about how hard docs work and I think the residents and med students got a chance to see how smart and efficient NPs can be. Not the norm though. Even still, after considering that I got a great NP education, I would never in a million years think that I have knowledge and skills to safely practice independently without a supervising physicians.

 

[ILE2014]

They always come up with some BS about PAs don't have previous healthcare experience and can have a degree in anything before becoming PA.

lol. seriously? PAs often have a lot of healthcare experience. Its the rare student that matriculates into PA school with little to no health care experience..



Admitting that PAs come out of school with a better education doesn't change my life or make me feel inferior... A good NP or PA will get hired either way.
What is wrong with giving in every now and then and admitting that someone else may have a good way of doing something? Sad sad sad.

 

[tdram]

lol. seriously? PAs often have a lot of healthcare experience. Its the rare student that matriculates into PA school with little to no health care experience..



Admitting that PAs come out of school with a better education doesn't change my life or make me feel inferior... A good NP or PA will get hired either way.
What is wrong with giving in every now and then and admitting that someone else may have a good way of doing something? Sad sad sad.

No one wants to admit that they're not the best!

I witnessed an NP vs PA fight first hand at one of the clinics I rotated. There was this document that needed signing and it said MD/DO or NP signature only. The PA got it and was upset that they didn't accept a PA signature and had to get the NP to sign it. That led to an argument between the NP and PA about each other's education. It got heated. Clearly all is not well and harmonious in the midlevel camp.

The MD was nowhere in sight because he was in his office wheeling and dealing business deals for his clinic, while the midlevels saw all the patients.

 

[ILE2014]

No one wants to admit that they're not the best!

I witnessed an NP vs PA fight first hand at one of the clinics I rotated. There was this document that needed signing and it said MD/DO or NP signature only. The PA got it and was upset that they didn't accept a PA signature and had to get the NP to sign it. That led to an argument between the NP and PA. Clearly all is not well and harmonious in the midlevel camp.

I didn't get as solid of an education as a PA coming right out of school, but that doesn't mean I can't be a better midlevel

 

[tdram]

I didn't get as solid of an education as a PA coming right out of school, but that doesn't mean I can't be a better midlevel

Yeah I mean anyone can get better with effort and practice. The point of the education is that you have a minimum guarantee that the person has at least learned a baseline amount of whatever that degree requires. So you are less likely to get the benefit of the doubt as the PA would to a person who has no way of accurate assessing your entire skill and knowledge base and has to go with the baseline of what an NP degree gives someone skill wise.

 

[ILE2014]

Yeah I mean anyone can get better with effort and practice. The point of the education is that you have a minimum guarantee that the person has at least learned a baseline amount of whatever that degree requires. So you are less likely to get the benefit of the doubt as the PA would to a person who has no way of accurate assessing your entire skill and knowledge base and has to go with the baseline of what an NP degree gives someone skill wise.

Yep.

 

[username456789]

But point well taken... Can't argue with the fact that many DNPs can't pass the USMLE 3 and want to practice independently. Those numbers don't lie.

Just to clarify, it was a very watered down/easier version of the USMLE Step 3. They were not taking Step 3.

 

[fab4fan]

I've worked with NPs and PAs for many years, predating my medical career back to when I was a medical research associate.

Back in the day I had no idea about the difference in training and was unable to assess medical knowledge base (because I had none myself) but as a graduate psychology student I was able to observe and analyze differences in behavior and personality and made some assumptions about the root of those differences.

Our preference for a PA in *our office* has to do with my observation that the training is more similar to that of a physician, what appeared to be more of a team approach, and my distaste for the political posturing of the latter's national organization. My business partners are now "sold" and have recognized the benefit of a PA over an NP. Because we live in a state where NPs have independent practice rights and work in a very high litigation speciality, we prefer a provider that is supervised by the physicians. However, should the time come in the future when we hire another MLP, I will consider an NP/Nurse Navigator on a case by case basis.

I think a nurse navigator would be a boon to a practice like yours. We had several of them in the oncology practice where I worked. No issues with a desire for independent practice, and patients get the kind of support and education the doctor isn't able to provide due to scheduling.

 

[Winged Scapula]

I think a nurse navigator would be a boon to a practice like yours. We had several of them in the oncology practice where I worked. No issues with a desire for independent practice, and patients get the kind of support and education the doctor isn't able to provide due to scheduling.

We had a nurse navigator until a year ago. She was having some health problems and then decided to move out of town to be closer to family. The patients loved her and as you said, she could provide a lot of resources especially those in the community, that the providers did not have time to review with patients. She was actually the first credentialed nurse navigator in the entire state.

We may hire another one at some point in the future for those reasons and the ones you listed about independent practice.

 

[seemz]

After reading these posts I'm amazed at how quickly well-educated individuals so easily display their ignorance and fears of inadequacy. The ship has sailed boys. The data is out and clear. NP’s provide at least equivalent, if not superior care to physicians in many areas of care. To address one post, my local state representative brings his entire family to our NP OWNED clinic. So pause, how could this be? Let this “lesser educated” NP help you out. Your 100+ year outdated educational paradigm is fraught with wasted education. I’ve been providing superior clinical care for 27 years. Long before most of you have put on your own first band aid. The constant physician rhetoric is so pathetic. Rather than attempting to re-shape our weakened healthcare system so many of you focus on holding on to your now lost power position. The cause of your own demise lies in your confusion that healthcare revolves around you rather than the patient. So let this NP add to your so very prideful vault of knowledge. Re-group and start focusing on the system rather than your ego’s.

 

[general admission]

After reading these posts I'm amazed at how quickly well-educated individuals so easily display their ignorance and fears of inadequacy. The ship has sailed boys. The data is out and clear. NP’s provide at least equivalent, if not superior care to physicians in many areas of care. To address one post, my local state representative brings his entire family to our NP OWNED clinic. So pause, how could this be? Let this “lesser educated” NP help you out. Your 100+ year outdated educational paradigm is fraught with wasted education. I’ve been providing superior clinical care for 27 years. Long before most of you have put on your own first band aid. The constant physician rhetoric is so pathetic. Rather than attempting to re-shape our weakened healthcare system so many of you focus on holding on to your now lost power position. The cause of your own demise lies in your confusion that healthcare revolves around you rather than the patient. So let this NP add to your so very prideful vault of knowledge. Re-group and start focusing on the system rather than your ego’s.

Also, *egos

 

[pathologyDO]

After reading these posts I'm amazed at how quickly well-educated individuals so easily display their ignorance and fears of inadequacy. The ship has sailed boys. The data is out and clear. NP’s provide at least equivalent, if not superior care to physicians in many areas of care. To address one post, my local state representative brings his entire family to our NP OWNED clinic. So pause, how could this be? Let this “lesser educated” NP help you out. Your 100+ year outdated educational paradigm is fraught with wasted education. I’ve been providing superior clinical care for 27 years. Long before most of you have put on your own first band aid. The constant physician rhetoric is so pathetic. Rather than attempting to re-shape our weakened healthcare system so many of you focus on holding on to your now lost power position. The cause of your own demise lies in your confusion that healthcare revolves around you rather than the patient. So let this NP add to your so very prideful vault of knowledge. Re-group and start focusing on the system rather than your ego’s.

Already banned? Bwahahaha

 

[Ost3oclast]

After reading these posts I'm amazed at how quickly well-educated individuals so easily display their ignorance and fears of inadequacy. The ship has sailed boys. The data is out and clear. NP’s provide at least equivalent, if not superior care to physicians in many areas of care. To address one post, my local state representative brings his entire family to our NP OWNED clinic. So pause, how could this be? Let this “lesser educated” NP help you out. Your 100+ year outdated educational paradigm is fraught with wasted education. I’ve been providing superior clinical care for 27 years. Long before most of you have put on your own first band aid. The constant physician rhetoric is so pathetic. Rather than attempting to re-shape our weakened healthcare system so many of you focus on holding on to your now lost power position. The cause of your own demise lies in your confusion that healthcare revolves around you rather than the patient. So let this NP add to your so very prideful vault of knowledge. Re-group and start focusing on the system rather than your ego’s.

Lol they will never provide equal care as surgeons though....which is one of the MANY reasons I'm most likely going to pursue a surgery career. Good luck convincing the general public to allow a nurse to cut on people.

 

[cbrons]

After reading these posts I'm amazed at how quickly well-educated individuals so easily display their ignorance and fears of inadequacy. The ship has sailed boys. The data is out and clear. NP’s provide at least equivalent, if not superior care to physicians in many areas of care. To address one post, my local state representative brings his entire family to our NP OWNED clinic. So pause, how could this be? Let this “lesser educated” NP help you out. Your 100+ year outdated educational paradigm is fraught with wasted education. I’ve been providing superior clinical care for 27 years. Long before most of you have put on your own first band aid. The constant physician rhetoric is so pathetic. Rather than attempting to re-shape our weakened healthcare system so many of you focus on holding on to your now lost power position. The cause of your own demise lies in your confusion that healthcare revolves around you rather than the patient. So let this NP add to your so very prideful vault of knowledge. Re-group and start focusing on the system rather than your ego’s.

What data? Lol.

I had to explain to a DNP student what pre-renal azotemia is. She will be practicing independently in 2 months. Can a physician please tell me if this is a concept that is important to understand in actual practice or is it just mental masturbation?

I had an NP who had no idea what a prothrombin time was (who had a patient sitting in her office with a history of atrial fibrillation who needed warfarin). Can someone please tell me if this is important knowledge in actual practice.

 

[qwerty89]

http://np.reddit.com/r/nursing/comments/2kwk37/why_the_doctorate_of_nursing_practice_is_a_giant/

"I became a registered nurse a few years ago.. I worked at the bedside of pretty sick patients. A guy got attacked by a deer and ended up with compartment syndrome, a guy fell off his motorcycle and degloved his foot (awesome), a lady was shot a bunch by her husband and then she lived and kicked ass. It was exhausting, and sometimes I despised the paperwork and long hours. Mostly, though, I loved it. Eventually, I moved to a bigger city and worked in an Intensive Care Unit. I got to put leeches in an open neck dissection (please try leeches sometime, it. is. the. best), take care of countless strokes, and become pretty proficient with the drain we use to help make sure your head doesn't explode.

Then, I decided to become a Nurse Practitioner. I wanted to have a broader understanding of the pathophysiology underlying the disease and treatment I was applying per the physician's orders. I wanted to delve into WHY the medications worked and HOW they affected the human body. It was the obvious next step in my career. With the certification and licensing as a NP, I would be expected to grasp all these concepts as I was doling out antibiotics and referrals to my patients.

Getting my Master's in Science of Nursing with a specialty as an Adult- Gerontology Nurse Practitioner was a breeze and practically no one failed out. I went to one of the top nursing schools in the country. I'm thinking, people in medical school fail out all the time. I barely did anything in my clinical time, which was minimal (approximately 16-20 hours/wk x 36 weeks). There were some really stupid, not smart people in my classes who somehow graduated with me. Why are we, as a profession, trying to get the same goods as physicians, but our academic preparation doesn't reflect that? There were just as many nurse practitioners graduating from my university as there were registered nurses. As a result, when I went to look for a NP job, the market has become completely saturated with us. Meanwhile there remains a bedside nurse shortage. We are pushed and pushed to get a terminal degree (don't even get me started on the fact that physical therapists need a doctorate now). And because the Ivory Tower Nurses are advocating so desperately for that penultimate list of fancy letters behind every nurse's name, there is no selectivity anymore. You get a doctorate! You get a doctorate! You get a doctorate! (Obviously, in Oprah's voice). They want everyone to have a master's or doctorate, so we can prove to the world that we are not the "doctor's handmaiden." Let's prove to the world that we aren't a doctor's handmaiden by knowing our **** and having way harder, science-based preparation.

The AANP, along with other nursing organizations, are calling for all Nurse Practitioners to be doctorally- prepared. Most MSN programs have been replaced by DNPs. In concept, this is a wonderful idea to increase the practical knowledge base of advanced providers. In practice, it is more politically strategic. Do I think I need an education beyond a master's degree to be at the top of my game as an advanced provider? Absolutely! Do I think the DNP provides the kind of education needed to be a great advanced provider? Negative.

The DNP is a fluffy degree, with really no discernible difference from the PhD. There are no additional pharmacology classes, physiology classes, assessment classes, or clinicals/residencies. What I assumed was that I would be able to spend more time gaining clinical hours with an expert in the field, similar to how a medical doctor performs residency. The DNP is about additional research courses, learning about health disparities, and a singular practice project in which I apply research to my current work setting. Learning about how to provide equitable care is important in healthcare, however it will not help me diagnose the patient sitting in front of me. My patients care more about me having a firm handle on their illness, and the social worker can help take care of their financial concerns.

Now, why is this a strategic political move? Because NPs strive for autonomy. We want to eat from the same plate as physicians without the same training. So, if we can push NPs to get their doctorate of nursing practice then we can all say we are Doctors and The Man can't tell us that we have a limited education. "I'm Dr. Nurse. I learned all about how Hispanics generally receive less care than white people, that is why I can prescribe medicine now. Now let me DECIDE YOUR FATE."

The problem is- We have a limited education. I love NPs. I love me and my colleagues and friends! I prefer experienced NPs over doctors when it comes to primary care because they generally have more time available, tend to be more open, communicative, understanding, and thoughtful about social and community factors in connection with one's health. However, how much education do we really need shoved down our throats' about how socioeconomics and culture affect the body? If the DNP had reached its full potential of being a MEDICAL EDUCATION to supplement the NURSING FOUNDATIONS that I have already studied for 6 years, then it would be an excellent addition to what is already an incredible profession. Instead, it is a worthless degree created to increase revenue and social standing instead of improving upon the skills needed to be a competent medical provider.

Edit: Penultimate should be ultimate...because someone felt it was necessary to let me to know that they are better at words than me 3 months after this was posted."

 

[NickNaylor]

had an NP who had no idea what a prothrombin time was (who had a patient sitting in her office with a history of atrial fibrillation who needed warfarin). Can someone please tell me if this is important knowledge in actual practice.

Nah.

 

[NickNaylor]

After reading these posts I'm amazed at how quickly well-educated individuals so easily display their ignorance and fears of inadequacy. The ship has sailed boys. The data is out and clear. NP’s provide at least equivalent, if not superior care to physicians in many areas of care. To address one post, my local state representative brings his entire family to our NP OWNED clinic. So pause, how could this be? Let this “lesser educated” NP help you out. Your 100+ year outdated educational paradigm is fraught with wasted education. I’ve been providing superior clinical care for 27 years. Long before most of you have put on your own first band aid. The constant physician rhetoric is so pathetic. Rather than attempting to re-shape our weakened healthcare system so many of you focus on holding on to your now lost power position. The cause of your own demise lies in your confusion that healthcare revolves around you rather than the patient. So let this NP add to your so very prideful vault of knowledge. Re-group and start focusing on the system rather than your ego’s.

I'm less concerned about the "power" and more concerned about equality in training and credentialing. If I can go through 2-3 years of near worthless training and yet have the same role (effectively) as a physician, why on earth would I spend the 7+ years in order to become a physician?

The idea that the training pathways of NPs and MDs/DOs is even close to equivalent is an absolute joke.

 

[PL198]

I'm less concerned about the "power" and more concerned about equality in training and credentialing. If I can go through 2-3 years of near worthless training and yet have the same role (effectively) as a physician, why on earth would I spend the 7+ years in order to become a physician?

The idea that the training pathways of NPs and MDs/DOs is even close to equivalent is an absolute joke.

Exactly. I don't understand why this isn't beat into everyone's heads whenever this discussion is brought up in any setting.

if the statement that NP get equal roles and outcomes as physicians, then what is the point of medical school? it's hilarious that the schools with all their BS end up pushing midlevels, yet if midlevels were actually comparable to physicians, then the schools wouldn't have a purpose.... This is the overriding and unquestionable destructing point of the entire argument.

 

[cbrons]

Keep in mind that many of the studies showing np's effectiveness are from when nps were rns for many years who went back to school, not the current crop of post-baccalaureate students. They still need to work out some sort of post-grad supervised training and licensing exams before they can really claim equivalency for these students who do 2.5 year rn/np programs with pretty minimal clinical experience. I certainly wouldn't be ready to practice independently right off the bat after 4 years of medical school, let alone 2.5, one of which is more focused on nursing skills than pathophys and treatment.


Sent from my iPhone using Tapatalk

Pretty sure those studies don't show effectiveness, all they show is non-inferiority specifically in terms out outcomes for very narrow conditions (i.e. diabetes). But so what? The prescriber follows national guidelines based on an HBA1C level. Over 8.6 (or w/e it is) you get dual therapy (metformin + sulfonylurea or SGLT2-i or GLP analog whatever). It is a very simple algorithm.

There are no studies comparing mortality in an all physician-run ICU vs. an all NP-run ICU. Why? Because such studies would be highly unethical.

 

[URMD]

My 2c.

I am just starting medical school but from what i've seen in my limited shadowing experience and from what other physicians have told me mid-level providers can be an invaluable asset to any healthcare team when properly managed. It allows the MD to focus on the more complex time consuming cases that a mid-level cannot deal with - no1 wants to practice below the scope of their education so this model is perfect for that.

I agree with @ILE2014 - it does seem that most of the animosity towards NP are the older generation who had been practicing nursing for a long time before getting their NP degree. From what I saw,even RN nurses always talked about how 'junior doctors' didn't take their advice well even though they have a lot more 'clinical experience' than a fresh resident or medical graduate. When you take this mindset and you get an advanced degree which allows you to say your also a 'doctor' it is easy to see how the scenario will play out. But those who go directly to NP or who take a shorter path don't develop that kind of mindset, because they cannot really call themselves experienced in clinical care if you only need to do it for (what, 3 years?) before being eligible to get the NP. So the younger ones tend to be easier to manage in the healthcare team.

The problem is that those kinds of NP are the ones that make the most noise, and as MD's dont have indepth insight into the NP field because they are not actually inside it they only see what they hear. What they hear is NP lobbying for independent practice and in some places equal compensation. So they take that and generalize it to the NP field. Which you could say is wrong, but is also human. There are countless examples of this kind of behaviour in multiple scenarios not only limited to healthcare.

Then there's also the lack of regulation in the field. While there are good NP's and bad NP's just like any profession, the lack of regulation makes it so that you cannot expect a certain standard of competency when you hire an NP, such that some NP's can be as good as fellows (what i've read here on SDN) and some NP's can be worse than 3rd year medical students (what ive read on SDN). At least with PA's you know that a bad PA will never be that bad because he would fail his qualifying and recertification exams otherwise.
As an employer, deciding between these 2 mid-levels based only on perceived quality of care (are NP's cheaper than PAs?), you cannot fault the employer for going PA. its more of a 'sure bet' rather than a 'gamble' that an NP currently seems to be.

Do I have all the points correct?

 

[midweststudent1]

I don't understand why people keep saying that we should let the NPs have all the easy cases so physicians can work on the "difficult ones"?

If I'm working Family Practice, it would seem that I would want a few sore throats/ day to give me a break from all of the CHF/diabetic/20rx patients. I dunno, maybe I'm young and lazy

 

[jewelfish]

While I completely understand and agree with the concern about midlevels racing into specialist positions without adequate education, becoming a doc has incredibly high barriers to entry, and it is reaping less benefits than it used to. Please don't get me wrong - I greatly respect physician knowledge and training. It has saved my own life more than once. However, this other option has arisen that is realistically attainable by more prospective professionals, requires less money and time investment, costs healthcare admins less, leads to a very similar role, and pays a very livable wage. No wonder it has flourished.

As others have said, some midlevels may be (loudly) seeking parity, but many are not. Given all this, I don't think it makes much sense to look at "midlevel creep" as an attack on physicians as much as a multi-directional response to increased options in healthcare professions. If you really need a culprit, blame the PCP shortage in the 60s, I guess.

IMO it makes more sense to look at what can be done to make healthcare a better system for everyone, physicians, midlevels, and patients alike. Like first trying to get healthcare the hell out of insurance companies' pockets... lobbying for increased standardization and certification for midlevels... and then maybe looking into adjusting some more archaic and limiting elements within the process of becoming a physician...

 

[Psai]

Saw a patient who was so poorly mismanaged by an np that they were admitted inpatient floridly manic. They were on a bunch of meds, none of which were mood stabilizers despite a long history of hypomania, and all were inappropriate choices. It was ridiculous

The whole issue with primary care is that you don't know if that cough is just a uri or if it's something more dangerous. It's insane that we label cases as easy or difficult as if these mid levels will do a better job of determining the difference than doctors

 

[midweststudent1]

Saw a patient who was so poorly mismanaged by an np that they were admitted inpatient floridly manic. They were on a bunch of meds, none of which were mood stabilizers despite a long history of mania, and all were inappropriate choices. It was ridiculous

The whole issue with primary care is that you don't know if that cough is just a uri or if it's something more dangerous. It's insane that we label cases as easy or difficult as if these mid levels will do a better job of determining the difference than doctors

What needs to happen, is cases like you mentioned, where there was a long history of sub-standard care, need to be tried for malpractice. If it would be expected for a physician to treat a condition well, then the NP should be held to the same standard

 

[wiggitywack12]

Is there a legal limit for how many NPs can be trained in a given year? The only way to prevent an increase in mismanaged care is to increase the score needed to pass any entrance exam, decrease the number of seats in training programs, increase training time at least a year and ban practice outside of supervision by a physician.

The problem with advanced nurse practitioners is only a physician whose been extensively trained in an area could recognize more complex pathologies and if we start trying to rank what's "easy" enough for a nurse to handle on their own, too many patients will fall through the cracks because a nurse couldn't identify a life threatening detail in a case and misdirected their course of treatment.

Training US doctors is rigorous for a reason. If you want to be a doctor, then compete for a spot in medical school simple as that, for the sake of the patients there really can't be this short cut kind-of-but-not-really a doctor stuff going on. Its dangerous. What's worse is a lot of patients aren't really educated on the differences and since every one is wearing a white coat they just sort of assume they all share the same knowledge base, so if one option presents itself as cheaper people will automatically assume its the better deal when it isn't.

 

[NickNaylor]

Is there a legal limit for how many NPs can be trained in a given year? The only way to prevent an increase in mismanaged care is to increase the score needed to pass any entrance exam, decrease the number of seats in training programs, increase training time at least a year and ban practice outside of supervision by a physician.

The problem with advanced nurse practitioners is only a physician whose been extensively trained in an area could recognize more complex pathologies and if we start trying to rank what's "easy" enough for a nurse to handle on their own, too many patients will fall through the cracks because a nurse couldn't identify a life threatening detail in a case and misdirected their course of treatment.

Training US doctors is rigorous for a reason. If you want to be a doctor, then compete for a spot in medical school simple as that, for the sake of the patients there really can't be this short cut kind-of-but-not-really a doctor stuff going on. Its dangerous. What's worse is a lot of patients aren't really educated on the differences and since every one is wearing a white coat they just sort of assume they all share the same knowledge base, so if one option presents itself as cheaper people will automatically assume its the better deal when it isn't.

There is no limit because the NP training pathway completely sidesteps anything resembling a residency; since residency positions are funded with government funds, the physician workforce is de facto managed by the government. No such limitation exists in the NP world.

Eventually I imagine that NPs will find themselves in a plight similar to that of lawyers: tons of people rush into the field with supply eventually overcoming demand. The only real way to counteract that is to continue increasing the number of jobs available to NPs (i.e., increasing scope of practice), which the AANP lobby is doing in earnest.

 

[Psyche Estrelle]

I don't understand why people keep saying that we should let the NPs have all the easy cases so physicians can work on the "difficult ones"?

If I'm working Family Practice, it would seem that I would want a few sore throats/ day to give me a break from all of the CHF/diabetic/20rx patients. I dunno, maybe I'm young and lazy

I think this is a totally legitimate question.

I previously had no problem with NPs (and especially no problem with PAs) but now that I am directly supervising one for the first time (by the orders of our medical director, not willingly), I am beginning to realize just how much work it is. The NP I am supervising apparently has 3-4 years of practice experience after NP school, but I am having a hard time believing it because she is without a doubt at the level of a weak, but extremely overconfident PGY1.

I would be fine with that - I mean, it's what we signed up for when we hired her, right? - but yesterday she made a comment that managed to ruffle my feathers:

"NPs are not supposed to see anywhere near as many patients as MDs. That's not within our scope. The Board [?] mandates that. I see that you are seeing 4 patients an hour, sometimes 5, I'm never supposed to be seeing that many."

So then what the flying f*ck is the point of even having you here then? This is an all-Medicaid clinic, not a concierge practice. I thought the whole point of having you here was to help manage the high volume by seeing the less acute and less complicated patients. You know, the ones that actually take 10 to 15 minutes. What's the point if you can barely handle 2 patients an hour, and refuse to see more?

No wonder they have the gall to argue they give "better care." The playing field isn't even close to being equal in any conceivable way.

 

[URMD]

I think this is a totally legitimate question.

I previously had no problem with NPs (and especially no problem with PAs) but now that I am directly supervising one for the first time (by the orders of our medical director, not willingly), I am beginning to realize just how much work it is. The NP I am supervising apparently has 3-4 years of practice experience after NP school, but I am having a hard time believing it because she is without a doubt at the level of a weak, but extremely overconfident PGY1.

I would be fine with that - I mean, it's what we signed up for when we hired her, right? - but yesterday she made a comment that managed to ruffle my feathers:

"NPs are not supposed to see anywhere near as many patients as MDs. That's not within our scope. The Board [?] mandates that. I see that you are seeing 4 patients an hour, sometimes 5, I'm never supposed to be seeing that many."

So then what the flying f*ck is the point of even having you here then? This is an all-Medicaid clinic, not a concierge practice. I thought the whole point of having you here was to help manage the high volume by seeing the less acute and less complicated patients. You know, the ones that actually take 10 to 15 minutes. What's the point if you can barely handle 2 patients an hour, and refuse to see more?

No wonder they have the gall to argue they give "better care." The playing field isn't even close to being equal in any conceivable way.

This is what many say that once NP go into independent practice and realize that in order to meet overhead and make ends meet they will have to spend 10-15 minutes per patient they will realize that they made a mistake.

 

[midweststudent1]

I think this is a totally legitimate question.

I previously had no problem with NPs (and especially no problem with PAs) but now that I am directly supervising one for the first time (by the orders of our medical director, not willingly), I am beginning to realize just how much work it is. The NP I am supervising apparently has 3-4 years of practice experience after NP school, but I am having a hard time believing it because she is without a doubt at the level of a weak, but extremely overconfident PGY1.

I would be fine with that - I mean, it's what we signed up for when we hired her, right? - but yesterday she made a comment that managed to ruffle my feathers:

"NPs are not supposed to see anywhere near as many patients as MDs. That's not within our scope. The Board [?] mandates that. I see that you are seeing 4 patients an hour, sometimes 5, I'm never supposed to be seeing that many."

So then what the flying f*ck is the point of even having you here then? This is an all-Medicaid clinic, not a concierge practice. I thought the whole point of having you here was to help manage the high volume by seeing the less acute and less complicated patients. You know, the ones that actually take 10 to 15 minutes. What's the point if you can barely handle 2 patients an hour, and refuse to see more?

No wonder they have the gall to argue they give "better care." The playing field isn't even close to being equal in any conceivable way.

is it possible to point out to your medical director how few patients the NP is seeing, and then also the extra time that you are having to spend overseeing them? I would think that it's costing the clinic more than what they gain?

 

[NickNaylor]

I think this is a totally legitimate question.

I previously had no problem with NPs (and especially no problem with PAs) but now that I am directly supervising one for the first time (by the orders of our medical director, not willingly), I am beginning to realize just how much work it is. The NP I am supervising apparently has 3-4 years of practice experience after NP school, but I am having a hard time believing it because she is without a doubt at the level of a weak, but extremely overconfident PGY1.

I would be fine with that - I mean, it's what we signed up for when we hired her, right? - but yesterday she made a comment that managed to ruffle my feathers:

"NPs are not supposed to see anywhere near as many patients as MDs. That's not within our scope. The Board [?] mandates that. I see that you are seeing 4 patients an hour, sometimes 5, I'm never supposed to be seeing that many."

So then what the flying f*ck is the point of even having you here then? This is an all-Medicaid clinic, not a concierge practice. I thought the whole point of having you here was to help manage the high volume by seeing the less acute and less complicated patients. You know, the ones that actually take 10 to 15 minutes. What's the point if you can barely handle 2 patients an hour, and refuse to see more?

No wonder they have the gall to argue they give "better care." The playing field isn't even close to being equal in any conceivable way.

But patients love NPs because they spend more time with them during regular visits!

 

[Psyche Estrelle]

is it possible to point out to your medical director how few patients the NP is seeing, and then also the extra time that you are having to spend overseeing them? I would think that it's costing the clinic more than what they gain?

Right now she's in "training" so she's actually supposed to be seeing only 2 an hour. She obviously thinks this is how it's supposed to be and is blissfully unaware she is on nothing more than a temporary baby schedule. My med director does expect to ramp her up, so she's in store for a rude surprise... which I have absolutely no intention of warning her about

 

[URMD]

Right now she's in "training" so she's actually supposed to be seeing only 2 an hour. She obviously thinks this is how it's supposed to be and is blissfully unaware she is on nothing more than a temporary baby schedule. My med director does expect to ramp her up, so she's in store for a rude surprise... which I have absolutely no intention of warning her about

In training? wut? is that like a mini-residency for new NP grads? I thought she already trained in NP school.

 

[Psyche Estrelle]

In training? wut? is that like a mini-residency for new NP grads? I thought she already trained in NP school.

Lol I know, but it's actually more to to give the new hire time to learn the EMR. The doctors get a baby schedule at first too. At FIRST.

 

[Stormleadr]

I realize this is an old topic, but one I feel continues to push ahead and become more and more pertinent over time. I do not wish to discourage but rather make aware of what reality is at least from my experiences.

Some Background:
Undergrad BSN, work ICU RN for 6 years ( last three of those 6 yrs took night course to obtain my pre requisites for med school and sitting for MCAT).
Advised by many specialists Surgeons Nephrologists, Intensivists, Cardiologist, and alike that if you want to fly the plane you go to Pilot school.

I did my IM residency at 2 large inner city level 2 trauma centers in Philadelphia which were part of our residency.

After residency I worked as a Hospitalist / pseudo intensivist running an ICU and managing vent patients in a small Hospital for about 1 yr. From there I moved to Florida where joined a Private practice doing inpatient and outpatient care.

Since my time in nursing and medicine, I have witnessed the evolution ( or de evolution depending on your view ) of Medical care in the USA.
Managed care ( HMO's) and the advancement and struggles of the field of NP vs PA battling for dominance in a similar market for jobs, the results of which can be summed up of bad mouthing each other, and pseudo higher degrees to try to justify their training over the other.
I have known ICU RN's who have gone onto get their NP degree and then state to my face their training and knowledge is equal to any Doctors without any provocation for this statement ( ie I am here, hear me roar). I attended a Physician recruitment seminar in Las Vegas, NV of which the ABIM sent a representative to address the recruiters, and not knowing an Internist was in the crowd stated, " we are happy to see so many NP's taking up the shortage of PCP and specialists in medicine, our data shows the shortage is NOT do to enough medical school spots, Not lower reimbursement from Insurers, not more red tape and paper work bogging down physicians but rather a shift of most medical school graduates preferring to become specialists" I raised my hand for the speaker was called on and I stood up and replied to the speaker, " I am an internist and I don't care nor agree with what your data tells you I can assure you, that I and many of my colleagues all share the same sentiment, Low reimbursement, red tape to get reimbursement, red tape and barriers to treat our patients, as well as bureaucracy, is killing practices, along with medical malpractice costs after 5 yrs on the primary care providers salary is nearly impossible. I proceeded to advise her the acceptance of NP's and lack of support for Internists will undo decades of time proven practices of medicine leading to the collapse of the medical field as we know it and they might as well get ready to change their name to the ABNP's"
The speaker was silent and dumb founded to say the least.

Watching the events going on in different states and across the USA even in my home state, I predict that the less then Medical training of ARNP PhD's will only deteriorate the remaining scope of practice across multiple medical specialists in the USA. When I am old and retired I have no doubt I will go to a Doctors office expecting to see an MD or DO only to find out at a later time it was a ARNP PhD who not wrongfully called herself Doctor as MOST patients are totally unaware of today.

It honestly, makes me wonder why I spent 3 yrs after my bachelors to get my pre med requirements ( and took difficult sciences) to get into med school then busted my hump to do well in Medical school let alone the $250K price tag of this education, I am still paying on and will be until I am 70. And then to consider my 3 yrs of IM residency on call every 3rd night, and 120 hrs per week on the job ( yes before they limited residency hrs even with limits its still alot of time). Only to be told or have someone who has a BSN, then 2 yrs for Masters and 1-2 yrs to get their PhD and clinical time which doesn't even come close to our residency time or clinical time in Medical school. Proceed to tell me they our my equal and just as good and some claiming to be even better then a Physician??? ( Hmmm ok so if thats the case I guess all those years of training was just one big expensive waste of resources and time).

It has been noted that there is programs under development where NP can attend for one yr and get their MD degree, Great a short cut..........Love it.
I believe they already have a program like this....its called go to Medical school and residency???
Also there are ARNP's who have " advanced specialty training" ie cardiology pulmolonary, nephrology??? Why do we have to do Fellowships then?? I requested privileges to do stress test at Hospital as I have done them before, my request was sent to the main cardiology group at the hospital who rejected my request, as I did not do a Cardiology Fellowship. This same Cardiology group did their stress tests at a local imaging center where I did them and they had the ARNP there doing the stress tests?? I am sorry did she do a cardiology fellowship, or even as much cardiology as I did in my internal medicine residency??

To sum it up I sincerely hope that someone ( Politician, Medical association, finally speaks up and stops this craziness other wise I feel the Medical field will continue to dwindle as lower cost, less trained individuals, enter the market spurred by Insurers, Lobbyists, and Politicians).
One organization I support that has great topics and news on changes in the field is the American Association of Physicians & Surgeons (AAPS ) you can google them I dare not place a link in here as fear I may infringe on someone rules as maybe infraction of posting, all I can say is read for yourself its free for most areas of their website, yes medical students to Mid levels are welcome. I do not work for them in anyway nor receive compensation for mentioning them, just found them more proactive then the AMA.

One last history tid bit, I at one time had my own practice I started from scratch, on call at 2 hospitals admitted on average 10-12 people per night on call with > 50% uninsured as high as 70%, for which I never got paid by those patients, Insurance company's played games and jerked me around, billing company's screwed up and jerked me around at times, and patients even one's who claimed to love me I had to chase them to pay, co-pays or deductibles.

In 6 years of running my practice in Palm Beach county ( richest county in FL) from 2006 until 2012 I brought in $1.8 million GROSS ( ie before all expenses,Taxes, salary's, med mal, electric, rent, etc ) In the same 6 years I ate in unpaid services from uninsured, Insurance companies stiffing me and patients who were insured stiffing me to the sum of OVER $2.8 million. I finally gave up and closed the practice as did 3 other local IM PCP's I know, do to the same issues. One Internist went to the VA out of state, another left the state, and the 3rd one became a full time Hospitalist, as he stated running his practice was no longer financially feasible.

I now work for Urgent Care as a medical director and still do direct patient care being an employee is better then owning ones own solo practice, but even then most Doctors at my clinics are concerned corporate owners may get rid of Doctors altogether and replace all of us with cheaper ARNP's or PA's that is the future we have to look forward to.

I am happy to hear and get opposing views and comments, but if you think these obstacles won't happen to you; you are fooling yourself until you get out in the real world