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April 22, 2010

The Battle over Letting Nurse Practitioners Provide Primary Care

Maggie Mahar
 Twenty-eight states are now engaged in a heated debate over the difference between a doctor and a nurse: Legislators in these states are considering whether they should let a nurse practitioner (NP) with an advanced degree provide primary care, without having an M.D. looking over her shoulder.  To say that the proposal has upset some physicians would be an understatement. Consider this comment on “Fierce HealthCare”:

 “An NP has mostly on the job training...they NEVER went to a formal hard-to-get into school like medical school,” wrote one doctor. “I have worked with NPs before, and their basic knowledge of medical science is extremely weak. They only have experiential knowledge and very little of the underpinning principles. It would be like allowing flight attendants to land an airplane because pilots are too expensive. HEY NURSIE, IF YOU WANT TO WORK LIKE A DOCTOR...THEN GET YOUR BUTT INTO MEDICAL SCHOOL AND THEN DO RESIDENCY FOR ANOTHER 3-4 YEARS. NO ONE IS PREVENTING YOU IF YOU COULD HACK IT!” [his emphasis]

Fortunately, not all physicians exhibit the same degree of rancor. Some support the movement. Another “Fierce HealthCare” reader notes the commenter’s emphasis on just how brutal med school  can be: “The anger reflected in the previous comments reveals not only the writers' ignorance of scholastic achievement required of Nurse Practitioners, but mainly their fear that NPs will not be under physicians' control...Many older doctors' schooling and experience was conducted in punitive ways, sacrificing self esteem. It seems that anything less, isn't sufficient.”

The American Medical Association (AMA) represents many members of the old guard, and is intent on protecting the guild.  In some statehouses, the Associated Press (AP) reports: “Doctors have shown up in white coats to testify against nurse practitioner bills. The AMA, which supported the national health care overhaul, says that a doctor should supervise an NP at all times and in all settings. Just because there is a doctor shortage, the AMA argues, is no reason to put nurses in charge and endanger patients.”

But others argue that Nurse Practitioners have the needed training and that, in fact, doctors who have gone through the full medical school curriculum are over-qualified for a job that, today, is more about coordinating care than medical science.                              

Who Are Nurse Practitioners?

This raises the question: just who are these nurse practitioners, and how skilled are they?  Nurse Practitioners are registered nurses with a graduate degree, usually a masters, though by 2015, a doctorate, or a DNP, in nursing practice will be the standard for all graduating nurse practitioners, says Polly Bednash, executive director of the American Association of Colleges of Nursing.

The profession sprang up in the 1960s, partially in response to a shortage of primary care physicians in rural areas. This was the decade when doctors began to specialize. (With the passage of Medicare legislation in 1965, suddenly there was more money on the table to pay specialists, and at the same time, medical knowledge was advancing at a breathtaking rate. More and more physicians wanted to become part of the well-paid vanguard, on the cutting edge of medical science.)

Today, the share of medical students who choose primary care continues to drop. Health care reformers hope that the legislation will reverse the trend by providing better compensation for primary care physicians, and by offering generous scholarships and loan forgiveness to med students who choose primary care.

This should definitely help. But if we are going address the needs of a population where chronic illness is now a much greater problem than acute diseases, we desperately need more primary care providers. Today, Managed HealthCare Executive reports, “nurse practitioners are the only healthcare professionals” who are pursuing primary care in “increasing numbers.”  

Although there are many NP specialties (such as acute care, gerontology, family health, neonatology, pediatrics and mental health), about 80% of NPs have chosen primary care.

We need health care providers who want to be on the front line of managing chronic disease. NPs don’t seem deterred by the relatively low pay. Wealth is relative: while NPs, like most professionals, would like raises, they are not comparing their incomes to the $450,000 that an orthopedic surgeon might bring home.

This may help explain why research shows that patient satisfaction is often higher among patients who see NPs. These days, many primary care docs are burned out— and if a doctor isn’t happy in his chosen profession, chances are his patients will sense his malaise.

Low morale among PCPs is understandable. As a post on the Yale Journal for Humanities in Medicine (YJHM) blog points out:   “Compared to other physicians, primary care doctors are at the bottom of the social order in the medical hierarchy. They are also among the lowest paid despite the many time-consuming tasks such as filling out insurance forms, drug refills, nursing home and hospital documents that must be read and acted on. These are in addition to the many coordinating responsibilities that they perform for their patients.

For most of these tasks, many primary care doctors are actually ‘over-qualified.’” YJHM continues. “Clearly, while they have taken on the role of health care ‘coordinators’ they have become more dependent on specialists to take care of the sickest patients. Their ‘scientific’ medical role has decreased while their ‘coordinating" role has increased. For many primary care physicians their medical training is of less importance in their new roles.

 “It is wrong to insinuate that nurse practitioners do not have the medical training necessary to perform some and even many of the tasks that primary care doctors now perform,” the YJHM blog concludes.

Let me be clear: not all primary care doctors spend most of their time coordinating care and referring patients to specialists. In parts of the country where there are fewer specialists, PCPs do more of the work of diagnosis and treatment themselves. In addition, many primary care physicians work in large mutli-specialty practices where they are far less likely to be immersed in paperwork; often they are actively involved in teaching patients to manage their own chronic diseases. But it is true that the internist working solo or in a small private practice in many cities often finds himself/herself mediating care rather than providing care.

As for nurse practitioners, as they become a growing force in the medical profession, morale among them is rising. Twenty-three states now credential nurse practitioners as primary care providers, and given the legislation under consideration in states nationwide, that number is bound to grow. Nurse practitioners are feeling empowered. In 1990 there were 30,000 NPs in the U.S.  Today there are 115,000 according to the American Academy of Nurse Practitioners (AANP). And they know that they can do everything a doctor does: take the patient’s clinical history, perform physical exams, diagnose disease, order and interpret laboratory radiographic and other diagnostic tests, and prescribe medications.

NPs can prescribe under their own signature in every state, although in four, including Florida and Alabama, they cannot prescribe controlled substances and narcotics. This can make pain management difficult.           

While NPs Earn Less, They Spend More Time with Patients

Medicare, which sets the pace for payments by private insurance, pays nurse practitioners 85% of what it pays doctors. An office visit for a Medicare patient in Chicago, for example, pays a doctor about $70 and a nurse practitioner about $60. If these nurses provide primary care, this “saves money for the Medicare program,” Jan Towers, PhD, director of health policy for the American Association of Nurse Practitioners (AANP) points out.

In 2008, median pay for primary care doctors was $186,000 according to the American Medical Association, though some primary care docs make much less. Median income for nurse practitioners now averages $83,000 to $86,000.

Nurse practitioners also help rein in health care spending because they “advocate prevention and health promotion,” says Towers.  “As a result, there are multiple studies that show lower rates of emergency room visits and a lower number of hospital days by patients.” 

Going forward, I suspect that nurse practitioners will help run many of the new community clinics that reform legislation is funding. There, they will create the medical homes that newly insured low-income patients need, and help keep them out of ERs.

How will they do this?  Research published in BMJ suggests that NPs spend more time with patients than doctors do, and simultaneously, cut costs.  A study by Avorn and colleagues published in the Archives of Internal Medicine supports the thesis. The study used a sample of 501 physicians and 298 NPs who responded to a hypothetical scenario regarding a patient with epigastic pain (acute gastritis). The doctors and nurses were able to request additional information before recommending treatment. If they took an adequate history, the provider learned that the patient had ingested aspirin, coffee, and alcohol, and was under a great deal of psychosocial stress. Compared to NPs, the physician group was more likely to prescribe a medication without seeking the relevant history. NPs, in contrast, asked more questions, obtained a complete history, and were less likely to recommend prescription medications.

A 2004 study by Mundinger, Kane, and colleagues is now considered the most definitive research on the quality of NP care. It explored the outcomes of care in patients randomly assigned either to a physician or to a nurse practitioner for primary care after an emergency or urgent care visit. The NP practice had the same degree of independence as the physician: this made the study unique. After analyzing the services that patients used, and interviewing some 1,136 patients, the researchers determined that the health status of the NP patients and the physician patients were comparable at initial visits, 6 months, and 12 months. A follow-up study conducted two years later showed that patients confirmed continued comparable outcomes for the two groups of patients.

Jack Needleman, a health policy expert at the University of California Los Angeles School of Public Health rejects the argument that patients' health is put in jeopardy by nurse practitioners. “There's no evidence to support that,”  Needleman told the AP. “Other studies have shown that nurse practitioners are better at listening to patients. And they make good decisions about when to refer patients to doctors for more specialized care.”

Nurse Practitioner midwives also receive high marks. They attend 10% of all births in the U.S., 96 percent of which are in hospitals. A number of studies of low-to-moderate-risk women giving birth show that after controlling for all social and health risk factors, the risk of infant death with a nurse-midwife is as much as 19 percent lower, neonatal mortality as much as 3 percent lower, and low-birth-weight infants up to percent fewer than with physician-delivered babies. 

Other studies reveal lower rates of caesarian sections, as well as significantly fewer infant abrasions, perineal lacerations, and complications.

Researchers point out that it is possible that mothers who choose nurse practitioners to deliver their babies are healthier, or less inclined to want caesarians. But at least one study of high-risk mothers in an inner-city hospital suggested that midwives provide equally safe care in these more difficult cases. 

Some NPs point out that they must do better. As Chicago nurse practitioner Amanda Cockrell explained to the AP: “We're constantly having to prove ourselves.”

Medical evidence that NPs offer as good or better care threatens some physicians. “They're really scared that we're going to do something that will take money away from them. As long as we went out and only gave healthcare to poor people, nobody said anything,” Dee Swanson, president of the American Academy of Nurse Practitioners, told ModernHealthcare.com earlier this month. “Let's face it: We have a crisis in primary care in this country, and it's an area that physicians have not been interested in, or there wouldn't be a shortage.”

Some Insurers Balk at Paying NPs; Reformers Reward Them

Despite all of the convincing data about the quality of care that NPs provide, “Acceptance by health plans varies across the country," the AANP’s Towers told Managed Care Executive. "Some are fully onboard in certain parts of the country. But in other sections, health plans are still hesitant and require strings that we believe are unnecessary.

"Then there are cases where you work very well with a company, but there is a merger with a company that hasn't worked with nurse practitioners,” Towers adds. "You have to start all over again."

In California, where insurance plans do not recognize nurse practitioners, the state’s more than 10,000 NPs are beyond frustrated. Although private insurers pay for the services offered by NPs, they do so as if the NP’s collaborating physician provided the care. (This may give the insurer an opportunity to pay less for the same care.) 

In states where insurers shun NPs, patients are unable to name a nurse practitioner as their primary care provider, and this can lead to confusion. In addition, patients looking for a new primary care provider will only find physicians listed in their insurance company web sites and printed materials, even if well-trained nurse practitioners are available to serve them. (I can’t help but wonder, have these insurers succumbed to pressure from physician lobbies?)

When reform legislation kicks in and millions of formerly uninsured Americans begin to look for a PCP, many patients won’t be able to find a provider in California—unless the law changes.

This is one reason why the Josiah Macy Jr. Foundation, which funds programs designed to improve the education of health care professionals, recently recommended that regulators immediately act to remove legal and reimbursement barriers preventing nurse practitioners from providing primary care, and to empower them to lead multidisciplinary teams of primary-care providers. Dozens of health care organizations signed the report; the AMA was not among them, but the American College of Physicians was.

The Foundation’s proposal that nurse practitioners should manage health care organizations upsets some physicians. If NPs ran community clinics, they might supervise doctors, and even oversee programs training residents in primary care. "I would never want to see the nurse leading the team in a patient-centered medical home," Dr. James King, President of the American Academy of Family Physicians, said in 2008.

But the times are changing. Unlike some insurers, legislators who crafted health reform legislation seem to have paid attention to the research on quality. They are offering the same financial incentives to nurse practitioners that they offer to physicians:

10% bonuses from Medicare from 2011-16 to primary care providers, including nurse practitioners

• $50 million to nurse-managed health clinics that offer primary care to low-income patients.

• $50 million annually from 2012-15 for hospitals to train nurses with advanced degrees to care for Medicare patients.

Moreover—and here’s the surprise—the legislation boosts the Medicare reimbursement rate for certified nurse midwives to bring their pay to the same level as a doctor's.                              

A Nurse’s Training-- It’s Not the Same

These days, nurse practitioners are spending more time in school. For example, on top of four years in nursing school, Chicago NP Amanda Cockrell spent another three years in a nurse practitioner program, much of it working with patients.

By 2015, the American Association of Colleges of Nursing will require its approximately 200 members to offer a Ph.D. Johns Hopkins already has rolled out a forward-looking graduate program for nurse practitioners that focuses on evidence-based medicine.

But even while nurse practitioners put more years into education, both supporters and critics agree: the training is not the same.

Daniel Lucky of Modesto, Calif., an NP adjunct nursing lecturer with University of Southern Indiana and adjunct faculty for Indiana State University, says that nurse practitioners take a different approach:  "NP practice is based on the nursing model of care--not the medical model," he wrote in a commentary for the Evansville Courier Press. "Nursing teaches us that we should not reduce human beings to mere signs and symptoms, place a disease label on someone, give them a pill and send them off. As nurses we are trained to look at the entire patient from a holistic perspective and then, actively partner with the patient and family to not only correct problems, but also enhance optimal health. Nursing care places the patient--not the provider--as the central focal point.”

Critics put it differently: Texas physician Gary Floyd opposes giving nurse practitioners too much autonomy by arguing that “Nursing schools push a ‘care and comfort’ approach to giving care.”  Floyd, who serves on the Texas Medical Association's Council on Legislation, contrasts training in “comfort and care” to “the scientific perspective of medical schools that teach about disease processes and bodily interactions.” 

Here, I have to differ. As a patient, I’m a big fan of “comfort and care.”  Not all diseases can be cured. If I were suffering from a curable disease, I would trust the vast majority of nurse practitioners to refer me to a specialist who might know how to conquer the disease. Otherwise, I would like to stick with the provider who focuses on talking to me, listening to me, comforting me, and making sure that I’m not in pain. 
Health care reform means that we need to re-think medical school education. We don’t want to continue to train young doctors to fit into a system that we know is dysfunctional. Many medical educators suggest that we are making students take science courses that will be of little help when they actually practice medicine. Depending on his or her specialty, not all physicians need the same in-depth understanding of body chemistry or anatomy. Students are forced to memorize information that may well change as medical science evolves over the next five or ten years. When they are treating patients, they will look up the newest information on best practice, or the ideal dosage for patients who fit a particular medical profile,

In a 21st century medical school, many argue, students need more training in patient-centered medicine: how to educate patients so that they can collaborate in managing chronic diseases; how to share decision making with patients; how to manage pain;  how to tailor end-of-life care with an eye  to the individual patient’s greatest desires and worst fears.

 Don Berwick, President Obama’s candidate to head the Centers for Medicare and Medicaid, defines patient-centered care in a way that sounds much closer to the nursing school model. Berwick argues that it’s all about asking the patient: “What do you want and need?" "What is your way?" "How am I doing at meeting your needs?" "How could I do that better?" "How can I help you?"

Isn’t that what nurses—and even doctors—once asked? 

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Comments

Matt Freeman

Thank you, Maggie Mahar, for addressing the particularly biting online attacks against nurse practitioners.

There appear to be some fundamental misunderstandings about nurse practitioners and their education. In terms of my own experience, and the experiences of my classmates and students, we did take extensive basic science classes: chemistry, organic chemistry, biology (including long labs), and in the same classes as pre-med students.

The next problem is the assumption that we wanted to be physicians. For many of us, being an NP had an appeal: focusing on prevention, holistic care, patient education, and community well-being. For me, at least, I was not interested in the care of the medically complex patient. That's why I became an NP, not a physician.

The admissions requirements are rigorous, and they're getting tougher.

The schooling itself is not a picnic. It works differently than medical school, hence the problem. NP students work as nurses during their training, so the clinical hours are reduced.

But there are NPs who lack the training and skills to keep up. Some of the programs are weaker, and sometimes the clinical training isn't strong enough. But that's changing; and NPs as a profession are working to improve the standards.

Likewise, some of the arguments in favor NPs are demeaning to physicians. The notions that NPs "care more," "listen more," etc. may have a base in reality, but it would be best to focus on cost effectiveness and access to care.

There is also a tendency to place healthcare into "tiers," implying that NPs provide care "a step below" that of a physician. This ignores separation of professions and philosophies. NPs and physicians have overlapping, but different goals and training. It also sends a message to the patient seeing an NP that somehow he or she "isn't special enough" to see a physician.

NPs have done a poor job of educating the public about our training and skills. I still have patients who are surprised that I can write a prescription, order and interpret laboratory tests, and manage their care. Healthy and medically uncomplicated patients often convince themselves that they must see a physician.

Just as we try to solidify and articulate our arguments, physicians need to abandon claims about patient safety. There is no evidence to support this.

One of the most important steps will be access to NPs. As more patients see nurse practitioners, have positive experiences, and get better (or stay healthy), public opinion will crystallize.

Jennifer Scott ARNP, FNP-BC

Thank you for posting one of the most comprehensive articles addressing nurse practitioners that I have read in a long while. I will definitely make a reference post to this and I enjoyed reading Mat Freeman's input on your article as well. I agree that some of the arguments against NPs taking a bigger role in primary care are demeaning against doctors. We are not trying to usurp doctors but to supplement their ranks. We just would like to be acknowledged, as much as physicians, for the work that we do to take care of our patients. I also think that the research has proven that we provide comparable care and outcomes show this.

Maggie Mahar

Matthew & Jennifer--

Matthew--

Thanks very much for such a full and helpful comment.
I agree that as more patients see more NPs, they will feel more confident about the care that they are receiving.

At the same time, standards in some NP training programs need to be raised. Though I would add that standards in some MD residency programs also need to be raised.

Jeniffer--

First, thank you.

As you say, there is, in fact, much research showing that NPs provide comparable care. (I've looked at quite a bit of the research.)

And you put it well when you say that NPs are
"not trying to usurp doctors but to supplement their ranks."
This is certainly what I have heard from NPs who have written to me. Many NPs are very happy to work with doctors in practices that include NPs and doctors. Nurse midwife NPs deliver more than 90% of the babies they deliver in hospitals--where Ob/Gyns will be available to consult if the mother or baby gets into trouble.

NPs (like good doctors) want to be able consult with other medical professionals.They don't think of themselves as "knowing everything that anyone needs to know." (This tends to be a problem with an older generation of MDs.)

(There are programs where residents ---especially those training in primary care--receive very little supervision.)

Wanda

Nurse Practioners SHOULD NOT BE PERMITTED TO GIVE PRIMARY CARE AT ALL!!!! I took my son to the ER and a nurse practioner saw to his over all treatment, which in the end is costing the lost of his writing hand index finger because she was not trained in that field! She should have called for an ambulance and had him transported to another location that was! He is only nine and will be effected by this for the rest of his life! So, I will make this my GOAL in life to make sure CONGRESS stops Nurse Practioners from giving primary care to patients because who knows who all will die or be given wrong treatments because of their lack of training/lack of education!

Dava

In response to Wanda (5/6/2010) I am sorry about your son's misfortune, but one incident cannot be enough to replace all of the accumulated data about the safe care by APRN's. My husband was treated at one of the fine, large ER's in our state complete with orthopedic residency programs and had surgery on his wrist by an extremely well-known orthopedist specializing in hand care. In their evaluation, they all missed a break in the index finger which has resulted in the inability to use that finger and having to give up classical guitar. Bad things happen, but please don't think they happen because the provider is an APRN.

Jennifer Scott ARNP, FNP-BC

In response to Wanda, I am so sorry about the loss your young son's writing index finger. I can imagine (as a mother) the rage you must feel toward the NP that treated him at the facility. Some things must be taken into consideration. Is it possible that the severity of the injury most likely would have made the loss happen regardless of doctor or NP treatment? If in fact he or she was the one that made the treatment decision, without consulting a specialist, the case needs review and probable legal action. I would want compensation for my child if damage happened due to wrong treatment modalities regardless of what type of provider it was. If it was a rural ER, most do not have the specialist care that some cases need. Where I live sometimes makes for bad outcomes. Dava's comment above makes that point for me that regardless of what type of provider, mistakes happen. I hope that your son does well in life and I truly hope that you don't make judgments against all nurse practitioners based on this tragedy.

A crit care doc

Shameful. More and more nurses trying to grab $$$$ and responsibility, taking short cuts to doctors. Some of you even wear white coats as if that somehow legitimizes it! Only in the United States since it's all about politics and saving a quick buck. And then you turn around and want a *real* doctor when you or your relative gets sick!

CRNA = NP = PA = Strong nurse.

NONE = Doctor.

If you want to be one, do the time and the dedication.

Maggie Mahar

Wanda--I'm very sorry about your son, but agree with Dava and Jennifer: one incident does not mean that NPs should not be able to provide primary care. If a PCP had cared for your son, the results might have been the same.

Dava & Jeniffer-- Thank you for your comments.

Crit Care Doc--

Actually almost every country in Western Europe has more Nurse Practioners per capita than we do, and they provide much of the primary care in these countries. For example, nurse midwives delivery 85% of babies.

To better understand the training that NPs undergo, and their place in the medical world, I'd suggest reading Matt Freeman's comment.

Finally, it's interesting that doctors who don't want to deliver primary care because the pay is too low or the working conditions are too difficult don't want anyone else to do it either!

Jay

Out of curiosity, what is the difference in the clinical training time of doctors and nurse practitioners in terms of hours?

How much clinical training will a doctor have before gaining full licensing and how much will a NP have before becoming fully licensed?

fixemup

Jay...clinical hours vary from school to school, however, one should take into account that NPs generally have years of experience in nursing and medicine before they earn their MSN or Doctorate. For instance, I have ten years of experience working as an RN under the supervision of numerous physicians, surgeons, and other specialists. Nurses benefit from seeing the positive and negative results of various procedures/practices performed by physicians and usually because the physician is supportive of nurses and willing to teach them what they know, unlike the others who denigrate NPs.

My question is; what kind of training or how many clinical hours does a primary care physician have before entering medical school?

Mik

$83k Salary for a NP or PA is more than fair. You only do a little more schooling after undergrad, no residency, and never even take the harder pre-medical courses or med school courses. Most of my friends that went into nursing or PA school just couldn't cut it for their MD/DO. I'm sorry, but I would never take a family memeber to anything but a full fledged physician, not even a resident physician would suffice. I want an attending who is experienced and has proven themselves. You only have one body and one life, I'm not risking mine in the hands of someone who may have inferior training and reasoning skills and I don't see why anyone else would either.

James

fixemup,

The more important question is how many clinical hours of formal training does a NP have after nursing school?

medicalprovider

While nurse practitioners are certainly an asset to primary care, they are just not as educated as physicians in anatomy/physiology/histology/pathology/pharmacology. Medical students (even if they did not work as a healthcare provider prior to medical school), have far more depth and hours in their medical training in their 3rd/4th years of medical school and during residency than nurse practitioners do during their training. Physicians are not able to practice primary care straight out of medical school - they must complete a further 3 year residency in either internal medicine, family medicine, pediatrics, or psychiatry. Giving nurse practitioners identical practice rights and independence as physicians does not make sense, unless medical graduates become eligible to work in primary care straight out of medical school (not that I think this should happen - the extra training is there for a reason!).

The healthcare shortage is unfortunate, and I think it would be a great idea to compensate primary care physicians better and provide more loan repayment help to get more students interested in pursuing primary care. I do not, however, believe that the healthcare standards of our country should be lowered at the risk of harming patients.

Jim

The problem with this previous nursing experience argument is that nursing education and nurse experience still lack the scientific background that medical school provides, this allows a physician deductive reasoning on the very complicated pts and non text book presenting ones. A physicians understanding of the human body far exceeds that of a nurse, comparing the curriculums and rigors of these classes it is plain to see.

Nursing education focuses on algorithms (given this symptom, give this test, give treatment) without a true understanding of what is going on in the body in the mean time. This may work for many cases, but not all cases present this obviously and it is here when a physicians intimate scientific knowledge of the body can fill in.

As far as the primary care argument, this specialty requires a wide breadth of knowledge a d should not be scoffed at as simple. And with less ability to dx and treat based on my previous summation, there will be a large spike in referrals to specialists which will increase the cost of healthcare...it is quite obvious as well that NPs are not looking to just fill PCP void once autonmous but to move into more lucrative areas...this is just human nature, so let's not be naive about pt access argument. An NP like anyone else does not want to live in rural, historically less desirable areas

if you want to increase access for pts to medicine, increase residency spots for medical doctors! This is the bottle neck that thwarts pt access. Settling for a less trained substitute that will end up costing more does not make sense!

...on a side note, the nursing union has gotten too big for it's own good, lobbyists and politicians should not be deciding who can practice medicine, it should be the MEDICAL DOCTORS...who have made the most advancements in the field of healthcare in recent years....you will miss us...

Jay

Don't get me wrong. I have no problem with NP's playing a role in primary care, but at the same time I think its important to understand the differences in training between a physician and mid-level provider.

The curriculum I will follow in medical school seems to go much more in depth when one looks at the differences in curriculum.

In addition, requirements for "RN experience" vary when you look at programs all over the US.

I know of a few former PA's, nurses, and NP's that became doctors who have said they didn't realize how much of a gap in knowledge existed between the two careers until they went through medical school.

I'm making this comparison off of Duke's curriculum for an MSN on their website:

http://nursing.duke.edu/wysiwyg/down...e-mat-plan.pdf

I believe I read (I can't find the link maybe you know where it is) that before a doctor is allowed to independently practice they will have accumulated over 17,000 hours of training (this is counting both clinical years of medical school and residency).

Also, the article almost argues that the nursing model and philosophy introduces a new concept of "looking at the whole patient" as stated here:

"Nursing teaches us that we should not reduce human beings to mere signs and symptoms, place a disease label on someone, give them a pill and send them off. As nurses we are trained to look at the entire patient from a holistic perspective and then, actively partner with the patient and family to not only correct problems, but also enhance optimal health. Nursing care places the patient--not the provider--as the central focal point.”

Osteopathic physician have clung to this philosophy for years:

"In addition, these modern-day pioneers practice on the cutting edge of medicine. DOs combine today's medical technology with their ears to listen caringly to their patients, with their eyes to see their patients as whole persons, and with their hands to diagnose and treat patients for injury and illness." (http://www.osteopathic.org/index.cfm?PageID=ado_whatis)

However, I'd never argue that this is a DO only approach. Most of my physician mentors (who are MD's) are always reluctant to "just medicate" when they could look at the patient in context of the reason they're in their emergency room or hospital, and then make a more sensible clinical decision.

And I'd even go as far as saying that the philosophy that the person in the article mentions is something that is person dependent, not career dependent. I've met doctors and nurses with pretty lousy bedside manner.

I know I've rambled a lot, but the reason I even commented in the first place is that this article just rubs me the wrong way. It seems like whoever wrote this is trying to justify why they're the better alternative to seeing a doctor with statements like:

"Medical evidence that NPs offer as good or better care threatens some physicians. “They're really scared that we're going to do something that will take money away from them."

and

"Students are forced to memorize information that may well change as medical science evolves over the next five or ten years. When they are treating patients, they will look up the newest information on best practice, or the ideal dosage for patients who fit a particular medical profile..."

I just don't like the overall tone of this article. Like I said in the beginning, NP's and PA's serve a specific need in primary healthcare. I'm not saying they shouldn't play a role, but we should be very careful with determining what they can and can't do. Not for my sake or your sake, but for the patient's sake.

Therealdoc

Why don't we actually compare curricula of the DNP to the real doctors so everyone can see just how inadequate NP training is.

The DNP includes 36-40 credits of clinically useful courses and 600-1000 hours of clinical training.

A real doctor takes roughly 140 credits of clinically useful courses and a minimum of 15,000-17,000 clinical hours in medical school and residency. A specialist has thousands more. For instance a cardiologist has roughly 30,000 clinical hours.

So that is at a minimum 4 times as many classes and 24 TIMES as many clinical hours! NPs should never be independent. Anyone who has actually gone through the training realizes that even with the extensive training a physician has, there is still so much to know. The fact that NPs think they can do primary with such inadequate training demonstrates just how little they know.


THE REST IS THE MATH SHOWING HOW THIS WORKS OUT

DNP curriculum from duke: http://nursing.duke.edu/wysiwyg/downloads/DNP/Duke-Sample-Post-BSN-DNP-Adult-MAT-Plan-2010.pdf
You need 73 credits to go from a college degree to a doctorate! Furthermore, about 1/2 of those courses are fluff and add nothing to patient care. Things like research methods, Statistics, research utilization in nursing practice replace in depth understanding of pharmacology (drugs) and pathophysiology (how the body functions in disease states). The DNP generally has 3 credits of pathophysiology yet has more than twice that in statistics courses. So really, the DNP has 37 useful credits to get a doctorate. And this is from Duke!

What about training seeing patients? The DNP at Duke only requires 612 hours and these are counted as some of those 30-40 useful credits! At most, DNPs require 1000 hours.

It's kinda scary how inadequate that training is in order to practice medicine independently. You can't really count prior nursing experience as time practicing medicine because you weren't practicing medicine during that time nor were you thinking in a medical manner (ie. the way a physician would). Nursing clinical hours might help you transition into medicine but they are NOT a replacement for medical clinical hours.

Now, just for comparison, let's look at a med school curriculum. I'll point out all the fluff courses here too. Here's an example from Baylor School of Medicine for M1/M2 (http://www.bcm.edu/osa/handbook/?PMID=5608) and for M3/M4 (http://www.bcm.edu/osa/handbook/?PMID=7463):

Baylor only includes 20.5 fluff courses (Patient, Physician, and Society-1 & 2, Bioethics, Integrated Problem Solving 1 & 2.

So 20.5 credits of fluff may seem comparable to the DNP but there are 162.5 total credits at Baylor. So while the DNP is 50% fluff, medical school is less than 15% clinically useless fluff. Comparing non-fluff courses, the DNP is 36 credits. Medical school is 140. That is almost 4 times as many credit hours. And this doesn't include clinical training at all!

There are 2 years of full time clincial training ini medical school which average at least 60 clinical hours a week. It comes out to be between 4500-6000 hours for the 2 years (remember compared to 612 hours at Duke's DNP).

Then real doctors do a residency that is 80 hours a week for at minimum 3 years. With 3 weeks of vacation that is about 12000 hours. So in the end real doctors get 15000-18000 clinical hours before they can practice alone. And this is just for family doctors.

If you are talking about cardiologists, add another 12,000 clinical hours

Therealdoc

This is from a poster on studentdoctor.net who went to NP school and then went to medical school. It says it all:

"I have a unique perspective on this. I am a physician (i.e. I actually went to medical school). I was also a nurse and took NP classes.

There is absolutely NO comparison between the two. ZERO. Most NP programs contain less actual "medical" classes than you get in one semester of real medical school. Mine was 15 credit hours. The rest is nursing theory, research, nurse political activism and such. It is so unbelievably different, you can't compare the two. The truly scary thing is that they don't how much they don't know.

NPs, DNPs have absolutely NO right to independent practice. I think there is a role for them such as running coumadin clinics, helping with post-op evals, vaccinations and other such limited practice.

They simply do not have a fraction of the knowledge that the worst FM physician has. Not even close.

Imagine this. Would you let a fourth year medical student open up a clinic and do primary care? Heck no! And the fourth year medical student already has VAST more medical education than an NP or DNP.

If this does not bother you, it should."

Gabrielle

I don't think it matters how much nursing experience one has before earning a Master's. Dolling out pills is not the same as knowing and understanding medical science. You may know how to treat a disease, but you won't learn the pathophysiology of the disease through nursing.

The bottom line is that NPs don't have the basic science knowledge that medical doctors do. They don't learn how the body works from a physiological standpoint and what can go wrong at every step of the way. Doctors go through four years of med school, including two years of clinical rotations, followed by at least three years of residency where they're still taking national and board exams. They are tested on their knowledge over and over and over and over and over and over again, in a variety of life and death circumstances. Nurses can't say the same. Doctors are trained so stringently for a reason. That right there keeps them from being equal.

RN to DO

I would like to offer a bit of perspective as well on this debate. I became a nurse in 1998 via an Associate Degree program, taking and passing with flying colors the same NCLEX that BSNs must take to become RNs. I knew then that I did not want to finish my education, as I wanted more knowledge than nursing school offered. I continued into my BSN/MSN education right after graduation, finding a ton of bias against LPNs/ ADNs and diploma nurses from yesteryear in the 4 year programs, who wanted all nurses to be required to have at least a BSN to 'manage' patient care. The lesser degrees they felt were good enough to do grunt work. I was offended to say the least, as I was able to run circles around my counterparts from 4 year schools right out of the gates.

I ended up in the BSN/MSN program, because I was not sure where I wanted to go with my education, and it made sense to at least increase my standing in my current career. As I took the classes that were required to complete my BSN, I was more often offended than educated, inundated with left wing, liberal union propaganda given in the guise of nursing process text books, and my Nursing Theory book was basically a 30 lb book trying to discredit LPNs and ADNs. I was angry for all the years it took for me to complete that degree. I was completely disenchanted with nursing classes, and even though I had dual credit (for my BSN and for the NP program) I was having a hard time deciding whether or not to proceed in the NP program. Fortunately, after speaking with many of my doctor friends and family, I decided to go for it, even though it meant instead of 2 more years (for my NP) I would be in school 8-10 more years (because of the prereqs that I didn't need for NP school, like Genetics, Biochem, Organic Chem, Physics) plus the actual med school and residency.

I am so glad I went the route I have, as a 3rd year med student. Many of the people in my class who found I was a nurse thought I would have all kinds of advantages in the classroom, but not so much. Nursing does not focus on the science of the human body. After the first two years of medical school I have learned so much as to the Why of what I did in my TEN YEARS as a nurse, that I was actually upset. If nurses knew half of the Why for what we did on a daily basis, patient care would be SOOOO much better, but then doctors would be giving daily care for each patient.

Clinically, I may have a slight advantage, because of ten years of hands on experience, which cannot be taught in a classroom. I know many young nurses from when I trained them, that never put in actual hands-on, post-grad work, just graduated from their BSN and entered directly into a Masters program in Nursing for NP, Hospital Admin, or Community Health. I have always found it hard to swallow that those that have actually never had to work in the trenches getting their hands dirty are able to become the ones that are to dictate how that care is to be given.

So, I am thrilled to be able to get a Medical Education, and know that the two processes are vastly different. I have learned so much in the last two years, I can hardly believe it.

I would not say ever that NPs do not have a huge place in primary care, as there are a lot of mundane issues that do take up a Primary Care Doctor's time. Sore throats, allergies, med refills, physicals, well exams, etc. are easily something managed by a well prepared NP. We MUST have doctors there for when the mundane rapidly changes into a rare disease, or a critical incident. Please, anyone who reads this know that education and training are not the same.

medicalprovider

I am very glad to see a couple of nurse-to-physician perspectives on this board. This is probably the most convincing, since they can attest to the curricular differences in education between medical school and nurse practitioner training.

Tommy

I think most medical school students and even the residents will agree to the statement "You don't know what you don't know". I found this to be true. You don't know how hard Nursing school is until you've participate in it.
Having said that, I can say with confidence that most DNP do not know how rudimentary their diagnosis skill is until they have been in medical school.
My wife (I love her very much) is a DNP. While she was pursuing her DNP degree, I was finishing up my med school (MS3 at the time). During the very very few off times that I had, I would spend time helping her and her study group...study (lol too many study there). Any problems that the group had trouble understanding, they would ask me for help. Needless to say, I earned all of her DNP class mates respect.
I'm not saying that DNP is stupid (God forbid if my wife ever hear me say that), but I'm saying that their education were never designed for independent practice. I would say my wife's medical knowledge is above 99 percent of the general population, but her ability to analyze and diagnose symptoms are minuscule compares to a real medical doctor. Her science classes were watered down version of the pre-reg medical student had to take. She does not have the solid foundation that is needed to make advance diagnosis.
My wife is very good at what she does, and that is helping doctors manage care for patients.
I showed her this article yesterday and she chuckled and said "that's funny".

mrng

"Here, I have to differ. As a patient, I’m a big fan of “comfort and care.” Not all diseases can be cured. If I were suffering from a curable disease, I would trust the vast majority of nurse practitioners to refer me to a specialist who might know how to conquer the disease."

You just don't get it. Medicine is about curing your disease, not holding your hand. If you want comfort and care, go to a priest/minister/rabbi/whatever. Go to a family member. Go to a social worker. Go to a therapist.

Go to your DOCTOR for HEALING. This focus on handholding is immature and completely misses the point of why you go to a PCP. No, no one should be rude or dismissive of your concerns, but they're also not there to be your loving nanny. They're there to take care of your medical problems.

You just don't get it. How do they refer you to a specialist if they haven't received the training to diagnose you properly? How many things could they overlook with their 800 hours of clinical education? A medical student gets well over 800 hours of clinical education in their third year! That's BEFORE residency.

MD Student

I've met a couple of great NPs, and I have no doubt that there are some NPs who are really credits to their profession. Thing is, it seems like there are quite a few people who overestimate where "their profession" lies. I'm not trying to be derogatory in any way, but there is a reason why NPs/PAs are referred to as "midlevels."

Oh, and to say that "doctors who have gone through the full medical school curriculum are over-qualified for a job that, today, is more about coordinating care than medical science" is laughable for reasons already well covered by comments above.

observer

There's a HUGE difference in the training between NPs/DNPs and physicians. Do you really want someone with less than 10% of the training a physician receives to be taking care of you or your family? This is just a power/money grab for the nursing organization who hide behind the guise of patient care. NPs/DNPs are going into specialty fields like dermatology, etc, not so much primary care; they're just using primary care as a foothold to launch in the more lucrative specialties. Don't let their propaganda sway you!

Here's a sample curriculum from a BSN-DNP program (at Duke): http://nursing.duke.edu/wysiwyg/down...t_MAT_Plan.pdf

You need 73 credits to go from a college degree to a doctorate. That turns out to be less than 3 years.

Now, let's look at the fluff courses that aren't really clinically useful: Research Methods (3 credits), Health Services Program Planning and Outcomes Analysis (3 credits), Applied Statistics (2 credits), Research Utilization in Advanced Nursing Practice (3 credits), Data Driven Health Care Improvement (4 credits), Evidence Based Practice and Applied Statistics I & II (7 credits, since you told me medicine is not evidence based), Effective Leadership (2 credits), Transforming the Nation's Health (3 credits), DNP Capstone (6 credits), Health Systems Transformation (3 credits), Financial Management & Budget Planning (3 credits).

Here are the clinically useful courses: Population-Based Approach to Healthcare (3 credits), Clinical Pharmacology and Interventions for Advanced Practice Nursing (3 credits), Managing Common Acute and Chronic Health Problems I (3 credits), Selected Topics in Advanced Pathophysiology (3 credits), Diagnostic Reasoning & Physical Assessment in Advanced Nursing Practice (4 credits), Common Acute and Chronic Health Problems II (3 credits), Sexual and Reproductive Health (2 credits), Nurse Practitioner Residency: Adult Primary Care (3 credits), Electives (12 credits).

So, out of the 73 credits needed to go from BSN to DNP, 37 credits are not clinically useful. In addition, the number of required clinical hours is 612 hours (unless I miscounted something)!! Wow! And the NP program is designed the same way, with a bunch of fluff courses (11 credits out of 43 required are fluff) and requires 612 hours as well: http://nursing.duke.edu/wysiwyg/down...rriculum_2.pdf

Here are the curricula to several other programs:

* University of Arizona: http://www.nursing.arizona.edu/OSA/P...ndout_2008.pdf 31/74 credits are fluff.
* Loyola's MSN to DNP: http://www.luc.edu/nursing/dnp/curriculum.shtml (where are the basic science classes? They're all public health classes!!)
* MGH BSN to DNP: http://www.mghihp.edu/nursing/postpr...ulum.html?cw=1 (35/72 credits for Adult DNP are fluff while 46/83 credits for DNP in FM are fluff)

It's kinda scary how inadequate that training is in order to practice medicine independently. You can't really count prior nursing experience as time practicing medicine because you weren't practicing medicine during that time nor were you thinking in a medical manner (ie. the way a physician would). Nursing clinical hours might help you transition into medicine but they are NOT a replacement for medical clinical hours.

Now, just for comparison, let's look at a med school curriculum. I'll point out all the fluff courses here too. Here's an example from Baylor School of Medicine for M1/M2 (http://www.bcm.edu/osa/handbook/?PMID=5608) and for M3/M4 (http://www.bcm.edu/osa/handbook/?PMID=7463):

Fluff courses at Baylor School of Medicine during M1/M2 years ONLY: Patient, Physician, and Society-1 (4.5 credits), Patient, Physician, and Society-2 (6 credits), Bioethics (2.5 credits), Integrated Problem Solving 1 & 2 (10 credits).

Useful courses at Baylor School of Medicine during M1/M2 years ONLY: Foundations Basic to Science of Medicine: Core Concepts (14.5 credits), Cardiovascular-Renal-Resp (11.5 credits), GI-Met-Nut-Endo-Reproduction (14 credits), General Pathology & General Pharmacology (6.5 credits), Head & Neck Anatomy (4.5 credits), Immunology (5 credits), Behavioral Sciences (6.5 credits), Infectious Disease (13 credits), Nervous System (14 credits), Cardiology (4.5 credits), Respiratory (3.5 credits), Renal (4 credits), Hematology/Oncology (5 credits), Hard & Soft Tissues (3 credits), Gastroenterology (4 credits), Endocrinology (3.5 credits), GU/Gyn (3 credits), Genetics (3 credits), Age Related Topics (2.5 credits).

For only the M1/M2 years at Baylor, there's 162.5 total credits. Out of these 162.5 credits, 23 credits are fluff.

Core Clerkships during M3 (useful clinical training): Medicine (24 credits, 12 weeks), Surgery (16 credits, 8 weeks), Group A selective (8 credits, 4 weeks), Psychiatry (16 credits, 8 weeks), Neurology (8 credits, 4 weeks), Pediatrics (16 credits, 8 weeks), Ob/Gyn (16 credits, 8 weeks), Family & Community Medicine (8 credits, 4 weeks), Clinical Half-Day (includes Clincal Application of Radiology, Clinical Application of Pathology, Clinical Application of Nutrition, Clinical Evidence Based Medicine, Longitudinal Ambulatory Care Experience, and Apex -- 23 credits).

So, without even taking into consideration M4 electives and required subinternships (which are usually in Medicine and Surgery), medical students already have a far superior medical training than NPs or DNPs. Other examples of med school curricula:

* UMich M1/M2: http://www.med.umich.edu/lrc/medcurr...gram/m1m2.html
* UMich M3/M4: http://www.med.umich.edu/lrc/medcurr...gram/m3m4.html
* Duke: http://medschool.duke.edu/modules/so...index.php?id=2

You can get a BSN to DNP in about 3 years according to many programs I've looked at. Medicine involves 4 years of medical school and a minimum of 3 years of residency before allowing independent practice. Here's the math:

BSN to DNP: 2.5 - 3 years of training; longer if courses taken part-time; 600-1000 clinical hours!
BS/BA to MD/DO: 4 years med school + 3-5 years residency: 7-11 years of training; not possible part-time; clinical hours > 17000"

I also want to point out that there are really no valid studies suggesting that NP/DNP outcomes are equivalent to those of physicians. NPs/DNPs always mention that studies show that patients are more "satisfied" with the care/attention they receive from NPs/DNPs than from physicians. However, patient satisfaction =/= quality medical care. I talk to patients all the time when I'm volunteering in the ED, etc, and several have told me they feel much better after talking to someone. That does not mean I should be allowed to practice independently.

observer

Also note that after that rigorous training in medical school, physicians also have to go through an incredibly rigorous residency for a minimum of 3 years before being allowed to practice independently.

Primary care is one of the hardest specialties out there because of both the breadth and depth of knowledge you need to have. Letting NPs/DNPs who have less than 10% of the training physicians have practice independently is an incredibly bad idea. There are NO studies that suggest NPs/DNPs provide care equivalent to that provided by a board-certified physician (ie. the physician who has completed training). There are a lot of very badly designed studies looking at medically useless parameters such as patient satisfaction (which doesn't provide any info at all about the medical competency of the provider). You will see NPs/DNPs cite bad studies repeatedly. I urge all patients/readers to read those studies for themselves rather than be misled by others. You don't even need a basic stats course to notice the humongous flaws in most of those studies!

Not only that, NPs/DNPs are demanding equal reimbursements as physicians. Would you pay the same to be treated by a person who has a small fraction of the training the physician receives? It's not cost-effective nor is it safe. There goes one of the nursing organizations argument that they'll provide cheaper care. How will they be cheaper when they want to be reimbursed the same as physicians?

Also, like it was previously mentioned, these NPs/DNPs don't want to stay in primary care! They're using it as a foothold to jump into lucrative specialties, like dermatology. The following link was taken down after the nursing director was bombarded with angry emails from various medical organizations and physicians, but I've copied and pasted what was originally on the site before it was taken down:

http://health.usf.edu/nocms/nursing/AdmissionsPrograms/dnp_concentrations_derm.html

"USF offers the nation's first Dermatology Residency in a Doctorate of Nursing Practice (DNP) program. The DNP Dermatology Residency program is a collaboration with USF College of Nursing and Medicine, H. Lee Moffitt Cancer Center, Center for Dermatology and Skin Surgery, Bayonet and Memorial Wound Care Centers, and other community physician practices and institutions.

The DNP program includes a core curriculum identified by the American Association of Colleges of Nursing's "DNP Essentials" (AACN, 2006). The dermatology resident must complete 33 core and clinical cognate credit hours and 23 credit hours of dermatology residency which includes a standardized and formal curriculum, evidence-based project, and clinical hours. Total credit hours for the DNP degree and dermatology residency are 56 credit hours.

The program requires the resident to complete a series of clinical rotations that will progress in the level of complexity. In addition to the clinical rotations, residents are required to complete selected projects and to participate in the department's research program. Throughout the program, written and observed tests will be administered and each resident must complete required publication submissions, presentation of ground round lectures, and must obtain teaching experience as guest lecturers in the USF College of Nursing's Primary Care Nurse Practitioner program. Residents are expected to attend appropriate professional conferences and to participate in professional organizations.

The DNP Dermatology Residency Program (USF, 2008) is a challenging academic and clinical endeavor. The program consists of completing the course requirements for the USF DNP program and the dermatology residency. The DNP with a specialty in dermatology will provide a terminal practice degree to prepare advanced nurse practitioners to assume leadership roles in the practice, research, and the health care setting

The purpose of this program is to prepare the graduate for advanced practice in the specialty of dermatology at the doctoral level. It is expected that this program will serve as the benchmark and model for other doctoral dermatology residencies across the nation.

As the DNA, the NP Society, and the AAD work together to develop a core body of knowledge for the dermatology specialist, it will be important to keep in the forefront the effects of health care bills like HB 699 on the practice of nurse practitioners. Developing programs that are supported by these organizations create competent health care providers that are capable of treating various skin diseases seen in the dermatology setting. For the safety and well-being of our patients, it is imperative that dermatology NPs receive formal academic training and demonstrate competency through board certification. In time, the Florida Board of Medicine's perceptions of nurse practitioner practice may improve when future studies show that the development of these formal dermatology educational programs improves diagnostic and treatment skills and positive patient outcomes."

I hope you guys are starting to see the deceits put forth by the nursing organization. This is nothing but a power/money grab. NPs/DNPs will claim that they're going to fill in the primary care gap, but the truth is that they're no more interested in serving underserved areas than physicians are. The nursing dermatology "residency" (which is a joke...it's equivalent to about 2-3 weeks of real residency that physicians go through) is an example of this deceit. Also, notice how the web page was taken down after the director received so many appalled emails. A bit shady, don't you think? They use terms like "residency," "board-certification," etc that physicians use to try to trick the lay public into thinking they're equivalent to physicians. They are absolutely NOT! Take a look at their joke residencies/certifications and compare them to the rigors that physicians go through. The difference is incredibly huge.

Miguel

so nurses want to do doc stuff w/o going to med school? LOL, and know to justify this they are calling primary care work more of a cordination thing than taking care of patients. wow.

I remember that interview at fox news channel to an NP who was asked if people will pay less to see a NP over a MD and she said "NO, you are paying for a service". and then came a 5 second pause by the interviewer because he couldnt believe she was trying to sell the " will save money with NP's/dnp's doing primary care" but this lady was saying the opposite

tom smith

At the end of his life, in ancient Athens, legend has it that Socrates, after saying his
goodbyes to his friends, had one request of his countrymen:

He bade the Athenians to severely chastise his sons if they should
pretend to be more than they really are.

The Nurse Practitioner movement vividly demonstrates that:
1). What is Old is New again and
2). There really is nothing so very new under the sun.

George Rosenberg

The nurse practitioner is a scam created by nursing unions to play doctor and make doctor salaries without going through the schooling and hard work (residency) required to be a licensed MD. Most of these nurse practitioners don't have the intelligence and science background to even step foot into a US medical school.

If nurse practitioners want to practice medicine like medical doctors, then states should require nurse practitioners to be licensed by the state medical boards instead of their sham nursing boards.

These nurse practitioners should be ashamed of themselves. They are trying to portray themselves as victims of the "patriarchal" medical establishment. News to you nurses, the medical profession is already 50% women. Most medical schools graduate more female doctors than male doctors. If you are a woman and you have what it takes, you should go to medical school, instead of whining about it and trying to take the short cut to becoming a doctor.

Sandy Do

Clinical training isn't everything and does not provide all the skills necessary for someone to be able to adequately use deductive reasoning to solve complicated issues and treat patients who present with less than routine problems. Nursing education and experience lack the scientific background and knowledge that medical school provides.

NP/PAs definitely play an important role in relieving physicians in busy offices, but their role should be restricted to only treating the most routine and simple conditions, and they must be supervised. In no way is a NP equipped to independently open his/her own practice and see patients without supervision, and in no way does the training and skill of an NP replace that of a physician.

Confidence in your ability is one thing, but not knowing your limits is dangerous to the health of the nation. NPs may think their training is adequate, rigorous, and comparable to those of a MD/DO, but oftentimes the less people know, the more they think they know.

No way would a midlevel provider have been able to carefully dissect my very complicated medical condition (it is so rare that it would take a person with a strong medical and scientific background) and refer to the right specialists. I know, because over the years I have been to countless NPs who have missed minor details that only a doctor could put together simply dismissed my case for sometime more routine....because all an NP is trained to do is diagnose and treat routine every day things.

Sandy Do

Oh and another thing. Regarding "NPs spend more time with patients" - of course you get to spend more time with patients - YOU ARE RELIEVED OF THE BURDENS THAT PHYSICIANS HAVE TO DEAL WITH. You have less complicated patients and less responsibilities around the clinic/hospital!! It's like saying because the receptionist of a firm spends more time with the clients, that he/she better equipped to deal with the clients than the CEO of the company. See how that makes zero sense?

The answer isn't to increase the output of midlevel providers or lower standard of care so that NPs can pretend they're doctors. The answer is to increase medical school slots and residency slots, as well as tuition breaks for medical school students to encourage them into primary care practice.

James

Isn't there a NURSING SHORTAGE? Maybe nurses should worry about that before worrying about the primary care shortage. Sounds like a selfish power/money grab instead of "for the good of the patient".

maggiemahar

Everyone--

I'm impressed by how many comments this post has drawn.

Let me say --there is no reason for great fear on the part of doctors or patients. This is not a "power grab" by nurses.

Most NPs will be working with doctors--often primary care doctors-- to give them more time to work with the sickest patients. Some NPs will be working with chronically ill patients (diabetics, etc.) to help them learn how to manage their chronic diseases. Often NPs will be answering e-mails and phone calls to refill prescriptions, while answering straightforward questions--saving time for both doctors and patients who hate spending a half hour--or more--in a waiting room to see the doctor for 5 mintues and get a refill.

In some cases, NPs can work independently--and do a superb job--with docs available if needed, in the wings. The best examples is NP midwives. When they deliver a baby, there are many fewer C-sections and inductions (which tend to lead to C-sections). When OB-GYNs deliver babies in the U.S. the share of C-sections has been rising dramatically--up to 40%. And the number of maternal mortalities during childbirth also has been rising.

NP midwives tend to be more willing to let take nature take its course-- a much lower share of C-sections and inductions. And NPs are more likely to stay with the mother throughout the labor.

In the U.S. only 15% of babies are delivered by nurse-midwives. In Europe 85% of babes are delivered by nurse-midwives. The rate of C-sections, infant mortalities and maternal mortalities are significantly lower in Western Europe than in the U.S. This suggests that nurse midwvies are not doing great harm in Europe.

There are other areas of primary care where doctors who work with nurse-practioners report that they are very helpful--as good or better than the doctor himself: working with the "worried well," for instance, helping some older patients,
teaching patients about what they can do to help themselves.

Finally, training for NPs has been rising exponentially. The training is much more rigorous than in the past, and much more
attuned to 21st century medicine.

I'm very glad that this post drew so much interest. I just want to say: having more nurses in our health care system will only improve it. There is no reason to be concerned.

maggiemahar

Everyone--

I think that comments by people who have gone through nursing school and med school deserve our attention.

They argue that they learn things in med school that they would never learn in nursing school--not just what to do, but why. In med school, they learn far more about the human body.

I believe this. At the same time, I think that in many situations, NPs can do an excellent job. But we need to make sure that they are very well trained, and we need to be sure that they are working in situations where they can easily consult with an M.D., or refer the patient to an M.D.

The truth is that primary care docs do spend a great deal of time doing things that someone else could do: refilling prescriptions (which could be done by phone or e-mail by an NP who is looking at the patient's chart, knows what the medication is , and whether or not a refill is appropriate. (If not certain she can ask the doctor) Hooking patients up with referrals to specialists, explaining to the specialist why the PCP would like the specialist to see this patient. (Something that a receptionist could not easily do.) Most importantly: helping to manage chronic diseaes.


No doubt, MDs are better at diagnosing rare diseases. But most of us do not die of rare diseases and most of our health care dollars are not spent diagnosing and treating rare diseases. 80% of our health care dollars are spent on chronic diseases. These are, by definition, disease that patients live with for a long time. We understand some of these diseases pretty well (at least how to treat the symptoms, or even prevent the disease) --diabetes, severe chronic depression, congestive heart failure, etc). In many cases, we know how to "manage" (not cure) these chronic diseases, and if we can involve patients in managing their own disease, we can both prevent much suffering, and save billions.

Research shows that NPs can be very helpful in educating and counseling paitnets.

tom smith

Ms.Mahar-You no doubt mean well. To you, your arguments seem eminently reasonable.

Here is what you do not understand, having not worked in the health care system:

!). The NPs can do as you have described above. Then why do they need the
DNP degree? Answer is: they do NOT need it.

The DNP degree is precisely a platform to expand their scope of practice to a full
license to practice medicine. It WILL be used as an end-run around the medical
profession. The NPs see themselves as running whole hospitals and medical
institutions with this degree. Despite the lack of science or high academic standards
this degree really has. In other words, you are incredibly politically naive.

2). You generalize in broad, abstract terms about what U.S. healthcare needs and downplay
the fact that MDs can diagnose rare disease. What you don't see is that there are a large
number of rare diseases and that collectively they are NOT so insignificant.

The physician is responsible to his/her patient: We cannot say "oh, sorry, you had a
rare disease, so I really had no responsibility to diagnose that" TELL THAT LINE
OF GARBAGE AT YOUR MALPRACTICE TRIAL.

Furthermore: Many COMMON diseases present atypically- mono for instance- you
need broad and deep knowledge of medical science to see and understand this fact
as well as rare presentations of common diseases- and that saves medical dollars by
foregoing unneeded work-ups-and referrals.

You may mean well, but either deliberately or because of lack of comprehension,
you ARE NOT seeing the more negative and rather scheming aspirations of the
NP initiative. WHat other profession has to put up with lesser trained individuals
trying to pull the stunt that NPs are? Imagine this happening with Lawyers- no way,
and all they do is check statutes and case law. How about engineers putting up with
this garbage from 2-year community college /skilled trades people?

One more thing -everywhere medicine is practiced in the Federal government,
the State statutory laws do not apply. Hence NPs and psychologists and other
hangers-on dwell there and rise through the Admin ranks-where they become the
bosses of doctors, newly hired, trying to care for patients. They can and DO interfere
with the practice of good medicine and are incredibly self-righteous and entitled
about this - this happened to me as A GS-13 in the US army (by an entitled minority
NP). Now, with the DNP, we will have new "Surgeon Generals" of the Army, Navy,
Air Force and USPHS who are "DNPs". Ambition coupled with fraud here knows
no bounds- and this occurs because we are all cowed by political correctness to
never stand up and say "NO".

Like Cato the Elder [Cato the Censor] of ancient Roman Senate fame, who spoke
of Rome's absolute need to destroy Carthage for the survival of the city,

I, also, hold that POLITICAL CORRECTNESS MUST BE DESTROYED for America to
survive and return to the high standards that once she held and that are now
so sorely lacking.

maggiemahar

Tom--

Let me put it this way: many European countries make better use of nurse-practioners then we do.

For example, in Europe 85% of babies are delivered by nurse mid-wives. In the U.S. only 16% are delivered by nurse midwives.

In Europe they do many fewer C-sections and there is less induced labor.

In Europe both infant mortalities and maternal mortalities are much lower.

NPs who specialize in palliative care also add to the quality of U.S. healthcare. Typically, they work as part of a team, with a physchologist and an M.D.---all trained in palliative care. Each plays a vital role. If only M.D.s provided palliaitve care, we would have far too few. Not enough M.D.s want to go into palliative care--for difficult work, not terribly well paid, requires great compassion and patience as well as great skill in pain management, etc.

In some Scandanavian countires, a child rarely sees a pediatrician after his well-baby check-up. Unless he becomes seriously ill, he sees pediatric nurses througout most of his childhood. Overall health of children in these countires is better than in the U.S.

Finally, NPs doing primary care are often caring of patients that MD's won't take-- mainly poor patieints. To some degree this is because M.D.s feel that they are not paid enough, but to a large degree it's because low-income patients can be difficult. They are less likely to be compliant, more likely to forget to take their medication. If a patient is not well
educated, or if English is not his first lanaguage it may well be more complicated and time-consuming to explain something to him.

In rural areas and in community clinics in some areas, NPs provide much primary care. If more M.D.'s were willing to work in these places, they would be welcome.

Finally, DNP degrees are becoming more sophisticated. For instance, if memory serves, Johns Hopkins has a DNP that focuses on evidence-based medicine.

Too few MDs actually practice evidence-based medicine. DNPs trained to concentrate in this area can only add to the quality of health care.

This is not a "power grab"; this is about expanding the supply of medical professionals who can collaborate (not compete ) to offer sustainable, high quality care.

forven

personally, i would like to take my kids to a "Doctor" that has 7+ years of education and training in healthcare than someone who has 3 years of education.

Jim

Stop comparing the US to these other Euro countries...they have a much more homogeneous population with less immigration and better lifestyles...they are a much easier population to manage with better nutrition, less drug/alcohol abuse, and less introduction of foreign pathogens from other 3rd world countries....apples and oranges

To Maggie

A nurse midwife is NOT a nurse practitioner. You can't even make this simple distinction, how can I expect to discuss more complex topics with you?

Also, a recent meta-analysis of nurse midwife vs Ob/Gyns showed that infant mortality when delivered by nurse midwifes at home was almost TRIPLE that of Ob/Gyns. Yea, you're right...the nurses are doing a great job!

You also realize that infant mortality is a useless measure to look at right? The US tries to save far more premature babies than Europe does. Many European countries, if a baby is born prematurely, count it as an abortion...not as a mortality. There are so many different factors used to count infant mortality in different countries that it's an absolutely useless statistic to look at. Do you understand this simple concept? Or do you need to take more stats classes?

DNPs practice more evidence-based medicine than physicians?! Hah, don't make me laugh! NPs/DNPs continue to cite horribly flawed studies to say they're equivalent to physicians. And this is after taking several stats courses in their curricula. If NPs/DNPs don't understand basic stats enough to notice the huge flaws in the studies they continually cite, how in the heck are they going to follow evidence-based medicine?! They don't seem to understand basic stats! So, obviously, they're going to have a really hard time understanding the latest clinical research.

This is entirely a power/money grab by the nurses. It's disgusting that this "trusted" profession is using the guise of patient care as a way to encroach into medicine and make more money. Despicable. This is NOT about "expanding the supply of medical professionals who can collaborate (not compete ) to offer sustainable, high quality care." NPs/DNPs DO NOT provide high quality care...there is not a single well-done study out there that suggests this. It's not up to physicians to show that NPs/DNPs are bad for patients, it's up to NPs/DNPs to show that they can live up to the gold standard (ie. physician care). And, so far, the NPs/DNPs have horribly failed to do so.

This is a complete power grab! Don't believe me? Look at all the NP/DNP "residencies" (which are a joke since an resident can do these joke nursing residencies in a week or two) in dermatology and other lucrative fields. But they're helping primary care right? BS. This is a power/money grab and nothing more. I'm absolutely disgusted by the nursing organization. I would never ever hire an NP for my practice. They're incompetent and think they know more than they do. PAs have far superior training than NPs/DNPs receive but they're smart enough to realize that they shouldn't practice independently.

The ONLY reason NPs/DNPs can practice independently in some states is because of how powerful the nursing lobby is. That's it. Doesn't have anything to do with qualifications/training. It's all politics and not about patient care. Ugh.

maggiemahar

Jim--

Wrong on all counts.

Europe has 70 million immigrants; North America has 45 million.

Germany, the UK France and Spain all have a large number of immigrants.

There is more alcoholism in France, Spain and some other countires than in the U.S. Far more smoking in Europe than in the U.S. (This is deadlier than many iillegal drugs.)

Nutrition has fallen in Europe due to the spread of U.S. style "fast food."

Overall health is better in Europe because Western Europeans tolerate far less poverty. They pay significantly higher taxes.
In the U.S. a larger share of children live under the poverty line than in any other developed country in the world.

If we learned from health care systems in Europe we could hope to have equally good outcomes at a significantly lower cost per capita.

maggiemahar

forven--

Here's the problem: You might like your kids to see an M.D. , but an M.D. doesn't really want to see your kids.

The majority of graduating med students would rather become orthopedists, radiologists, cariologists or dermatologists. Far more lucrative.

Others say that treating healthy kids is simply boring. They didn't train for 7 years to give pain-killers to kids with earaches or stitch up small cuts. If they want to go into pediatrics they'd rather be a pediatric oncologist, or work in a pediatric ICU. There, they would feel more useful.

Then too, some complain about the working conditions. I know a pediatrician who gave up pediatrics after 3 years, went back to school and became a dermatologist. The problem: the parents.
Parents calling you at night over nothing. Parents wanting to spend 30 minutes talking about their healthy six-month old.
Hysterical parents. Obsessive parents. Narcissistic parents raising narcissistic children.

Being a dermatologist who specializes in cosmetic dermatology is much easier.

Secondly, well children really don't need to see an M.D. when they have a sore throat. An NP is perfectly well qualified to test for strep. If the sore throat doesn't go away, if fever doesn't go away, she can refer to an M.D. in case it's an unuusal disase.

A well child with lice (that he picked up at summer camp) doesn't need an M.D.

I could go on. If it makes you feel any better-- if one day your child goes to an elite university (say Cornell) and needs medical care, he will see an NP, not at MD. (My son was at Cornell for 4 years, only saw NPs--even when he was hit by a car (bruised and scraped but unscathed). MDs weren't available unless you were seriously hurt or seriously ill.) He liked the NPs.

tom smith

A few obvious points Ms. Mahar:

1).C.-Sections- You imply that we do more here because we lack NPs. Your conclusion
does not follow.
Europe does NOT have the malpractice problem we have here-
Behind every pregnant belly stands a lawyer.

But hey-if you want to claim credit for European NPs-go right ahead
even without any proof. Then add, without any evidence at all,
that maternal and infant mortalities are lower in Europe because
their thinking about NPs is so much more advanced
Really-no other factors can operate and account for this, right?

2). "Two few MDs actually practice evidence-based medicine."
Where do you get off saying this politically correct baloney read from
the NP "talking points".?

Who do you think CREATED evidence=based medicine?

Oh-I forgot- the NPs created it, of course.

3). You have not begun this site as a blog to uncover the truth- your bias is
plainly evident. I, on the other hand, have had to deal with the NP
movement and seen its politically correct, bash the traditional physician,
highlight all their supposed short-comings, extoll all the supposed virtues
of NPs and then deny the obvious objective of the movement?
The DNP is a POLITICAL DEGREE-NOT a science-based degree-other, than
perhaps some non-calculus based statistics and diffuse generalizations
about chronic diseases. The reality is that the standards just are not that
high.

But, by all means, feel free to claim the opposite, point at a few health-trends in
ENTIRE COUNTRIES, and where the U.S., comes up short, give credit to the
far wiser and more enlightened policy followed in Europe for allowing the
NPs to do whatever.

Sure, Ms. Mahar. Whatever you say.

There will be some readers who will not appreciate the insults to intelligence
that your "conclusions" imply.

We will have NPs do all the primary care in the U.S. Then, America will at
last catch-up to the European countries in everything-alcoholism,
nutrition, smoking, weight, gambling, neonatal mortality, and maternal
morbidity.

For America to recover and return to the high standards it once held,
political correctness must be destroyed. It absolutely infests this country,
and, without any doubt in my mind, we have become the laughing stock of
the world.

For the rest of the docs out there-I really would not expend the effort to
argue the merits here- this woman has already made up her mind,
neither logic nor evidence will change that.

Regarding the claims that "not enough MDs do this and that or are not
available to go to this place or that place, the AMA has a tool
through its (much-hated by NPs) "Scope-of Practice" partnership
that demonstrates the LIE that these claims actually represent- they literally
graph available MDs over geographic areas and directly compare to all
the other para-professionals demanding equal pay and equal privileges
(without, of course, the equal sacrifices or work done to get there).

tom smith

Here is another example of the REAL purpose of the NP
movement-it goes far beyond "primary care"

In iowa, the AMA has assisted the Iowa Board of Medicine(IBOM)
in suing the Iowa Board of Nursing because the IBON has
written rules allowing the NP(ARPN) to supervise
FLUOROSCOPY PROCEDURES performed in Radiology departments
by radiology staff and technicians in the State of Iowa. Suit filed
21 June 2010. Documented at AMA's Litigation Center under
Scope of Practice on its Issues in Advocacy.

So the NPs want to do it all- Now where does that leave all
the blathering stupidity about how caring they are, how they
take more time, are more compassionate, etc, etc?

The NPs want to do RADIOLOGY as well-well known as an (no
patient contact, or NPC) specialty.

While I recognize that no fact or circumstance could change the
the mind of Ms. Mahar, this note is for anyone actually looking at
objective evidence- if the arguments advanced by Ms. Mahar are actually
sound, then why in the world would NPs want to do RADIOLOGY?

Because it really IS a power/money grab- they want equal and full
practice recognition and rights-without the sweat that physicians had
to go through to earn a medical license- that is my answer, and I am certain it is the simplest explanation that fits the facts-ALL the facts.

SeanB

Nurses don't want to work in rural areas either. It's up to the individual person, not the title of their career. All of my sisters are NP's and they want to live in a high rise condo in the city. My girlfriend's a chemist and wants to live in a rural town in the midwest. NO correlation so stop using it as an argument.

BTW, my sisters are disgusted w/ this article. In no way do they nor their nursing colleagues want to or feel ready or trained properly to practice and take responsibility in the way the article explains. This notion seems to be only among a few hard headed nurses and not the general nurse population. Thank GOD.

maggiemahar

Sean B--

Not all nurses are intersted in becoming nurse practioners, or earning a PH.D.

But those willing to do the work and go through the training are adding to our medical workforce.

SeanB

My sisters and their nursing colleagues= NP's. Many NP's don't even believe in this nonsense which is why I said, " This notion seems to be only among a few hard headed nurses and not the general nurse population."

tom smith

A further point- the NP program does NOT require, as a preliminary requirement,
that a full year of College Physics be completed (because Nursing School does
not, in all cases, uniformly require it).

Medical Schools uniformly require it. The POINT of a full medical license is that
the doc holding it has completed the necessary preliminary training to
practice medicine in ALL ITS BRANCHES.

As you can see, in IOWA the NPs want to supervise Radiology and they
do not even know electromagnetic fields or Maxwell equations, or the
science behind the procedures.

INCREDIBLE.

No one says they cannot LEGITIMATELY undertake the training- but
they have to go through the same work as the rest of us, if they
want the same privileges- the arguments advanced here, as
in so many places in the United States today, are infested with
the modern curse of POLITICAL CORRECTNESS.

Once, and perhaps not so very long ago, the nurses would stand when the
doc came in the room to see his/her patients-
while I agree that such a thing is wholly unnecessary, the NPs now "argue" that
the care they provide is "patient-centered" instead of the "medical model"
which is "physician-centered".

Truly is this beyond belief- after the YEARS of every third-night call and
Residencies with back-breaking demands -all for the benefit of
countless patients in hospitals-not to mention the Burden of ultimate
responsibility with its attendant lawsuits- to have these know-nothing harpies
make outrageous politically-correct claims like this is fantastically insulting-
most docs just try to ignore it- AND THAT IS OUR MISTAKE.

The docs spend less time with a given patients because they have so many to
see and care for-NOT because of any lack of compassion or self-centeredness.

Again- For America to recover her high standards and to once again
be that "shining city on the hill" - a beacon of reason, science, integrity and
high standards- she MUST both remember her origins in
Western Civilization and POLITICAL CORRECTNESS MUST BE DESTROYED.

maggiemahar

Tom Smith

"Know-nothing harpies??" (Your description of NPs)

For readers not famliar with the term, a "harpy" is "a ravenous, filthy monster having a woman's head and a bird's body."

"Harpy" is also used to refer to "a shrewish woman" who is a nag or a scold.

I'm afraid you've given yourself away--and totally undermined your credibility.

FYI-- a significant number of NPs are men.


But I'm glad to hear that you don't think nurses should have to rise when a doctor enters the room. . .

SeanB

Tom Smith's central message is still relevant to the discussion. Don't change the subject by dissecting his wording or male/female representation in nursing.

maggiemahar

Tom--

As the original post indicates, we have much research showing that NPs do an excellent job in many fields.

You ignore this and tend to emphasize courses med students take.

Some are relevant to their later clinical practice; many are not-- as doctors themselves have noted in responding to this post on my blog, HealthBeat. Refomeres generallly concur that we need to redesign medical education.

Whether one took physics in college has little relevance when it comes to delivering a baby.

You ignore the studies on C-sections, who does them and why. (Fear of malpractice appears to have little to do with it. C-sections have not increased for older mothers, or mothers suffering complications. C-sections have shot up for women in their 20s, and they report that doctors insist, over their protests.

Finally, your comments are angry, in a way that suggests that emotions, not reason, are driving your argument.

The use of the word "harpies" reveals the source of your anger, much as if you had used the word "nigger" when debating
civil rights. I haven't heard "harpies" for years, but it is an equally ugly word, as the dictionary definition indicates.

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