Over at the ACP Advocate Blog, we are asked:
An interesting take over there. There will be plenty of shortage in man power for extenders to fill some of the gap without affecting the MD supply. In other words, there's room for all of us.
My opinion? That notion is preposterous. Medical school prepares you physically. Residency prepares you mentally. Until you experience the intensity of both, you can't understand the importance physician level training. We can sit here and quibble back and forth about Dr Nurses meeting all the qualifications for leading a medical home.
Until Dr Nurse goes and does a 12,000 hour residency, no amount of anything will possibly prepare them for the intensity of complex patient care. I like to say that a lot of medical care is worthless. A lot of it is unnecessary. A lot of it can be managed at home with patient education. But when the tough cases of complex mulitiorgan failure show up at your door. When the uncommon presentations of common disease show up. When they come in with unstable vital signs. When they show up with a vague complaint, you want a physician trained person on the other side of that stethoscope.
I have worked with extenders just about finished with their training. I have nothing against them as a field. I think they have their place in the care model. However, if we are going to treat them as equals in managing medical homes without physician over site, I am horrified. I am horrified because I have helped train them. And I know they are woefully inadequate in their understanding of clinical medicine on so many levels. As much as I respect the nursing field, the training does not afford them the physician level experience that medical school and residency trains you for.
It's like United Airlines suddenly credentialing weekend flight instructors as their fleet of airline Captains. That's the difference in training. Just because you know how to fly, doesn't make you an airline Captain. There are reasons we have board certifications. If a doctor nurse can pass internal medicine board certification, then by all means, doctor nurse should should be able to practice medicine like an internist. If they can pass their cardiology boards, by all means, they should practice like a cardiologist. If they can pass the neurosurgery boards, by all means, they should practice like a neurosurgeon.
At that point all medical schools should be abandoned for nursing school and part time procedure schools should be opened up to teach us all how to hold a catheter, an endoscope and a scalpel.
There are no short cuts in medicine.
An interesting take over there. There will be plenty of shortage in man power for extenders to fill some of the gap without affecting the MD supply. In other words, there's room for all of us.
My opinion? That notion is preposterous. Medical school prepares you physically. Residency prepares you mentally. Until you experience the intensity of both, you can't understand the importance physician level training. We can sit here and quibble back and forth about Dr Nurses meeting all the qualifications for leading a medical home.
Until Dr Nurse goes and does a 12,000 hour residency, no amount of anything will possibly prepare them for the intensity of complex patient care. I like to say that a lot of medical care is worthless. A lot of it is unnecessary. A lot of it can be managed at home with patient education. But when the tough cases of complex mulitiorgan failure show up at your door. When the uncommon presentations of common disease show up. When they come in with unstable vital signs. When they show up with a vague complaint, you want a physician trained person on the other side of that stethoscope.
I have worked with extenders just about finished with their training. I have nothing against them as a field. I think they have their place in the care model. However, if we are going to treat them as equals in managing medical homes without physician over site, I am horrified. I am horrified because I have helped train them. And I know they are woefully inadequate in their understanding of clinical medicine on so many levels. As much as I respect the nursing field, the training does not afford them the physician level experience that medical school and residency trains you for.
It's like United Airlines suddenly credentialing weekend flight instructors as their fleet of airline Captains. That's the difference in training. Just because you know how to fly, doesn't make you an airline Captain. There are reasons we have board certifications. If a doctor nurse can pass internal medicine board certification, then by all means, doctor nurse should should be able to practice medicine like an internist. If they can pass their cardiology boards, by all means, they should practice like a cardiologist. If they can pass the neurosurgery boards, by all means, they should practice like a neurosurgeon.
At that point all medical schools should be abandoned for nursing school and part time procedure schools should be opened up to teach us all how to hold a catheter, an endoscope and a scalpel.
There are no short cuts in medicine.
Oh, good Lord, not another nurse does not equal doctor post! Enough already!
ReplyDeleteI always choose Nurse Practitioners over Dr's, always have.
ReplyDeleteThe only reason my PCP is a D.O is because we're friends, and I have the major hots for him. I see a NP for my neurology care.
Not to mention I was going to do the DNP before I decided to just bite the bullet and go or my D.O so I did not have to worry about opinions like this and the chance of not practicing autonomously. While I respect the D.O model greatly, I feel in theory the MD model is more rush, diagnose, prescribe, than a nice thorough assessment by an NP or a D.O.
Of course there's always variations from the norm. However with Primary Care being such a difficult field to attract med students into, Advance Practice Nurses can fill a great void in primary health care.
Amen to Justin. Speaking as a PA with a few years under her belt, primary care never interested me for a variety of reasons. Probably the same reasons med school graduates are not choosing it for residency. PAs as a group do not go to PA school to be the captain, they go to be part of the team. Lucky for me, I've found an MD to work with who respects what I know and knows I am not shy about asking for help when the need arises. I think as a team we provide better care than a single MD could ever manage. I feel like I've been reading more than my share of these posts lately.
ReplyDeleteIt needs to be said. The nurses keep plowing forward with ignorance. They ask for respect and resort to "Can't we all just get along?" If they wanted respected they shouldn't have had the audacity to assume they can't do our job as well or better with a joke of an education. Here comes a two tiered system not just in level of services available but now in quality of services delivered. I'm going into primary care and rotating with PA students and seeing NPs practice, I won't hire either of them. They exist solely as a byproduct of insurance intervention into medicine. If insurance continues to slash its fees for primary care, and all PCPs are forced to go concierge, you can bet there won't be a need for any of them.
ReplyDeleteEdit above: "assume they can do our job"
ReplyDeleteAnd so it goes - as a D.O. I find it insulting for you to compare our training to that of an DNP. It is common for idealistic pre-meds/D.O. students to disparage M.D. training but once you are in the real world you will see that it is really a matter of the individual. The bottom line is that Happy is right on - due to our extensive training, a physician whether D.O. or M.D., is not even close to equaled by mid-level providers.
ReplyDeleteDo your research. (D)NPs have a skew of abilities ranging from complete physician oversight to complete autonomy depending on the state...
ReplyDeleteI am in medical school right now. It is hard and hellish at times. Not to mention I have 6 plus more years to go with residency included. I also have a friend in a NP program. She will be done in 2. The education is very different. NPs should not be pushing to operate independently. That is not their role. Their role is to work in a team.
ReplyDeleteHappy:
"Why people are so offended when I say that nurses of any varying expanded educational degree will never be equal to an MD in practice expanse and understanding is beyond me."
I believe you meant "physician" here. As a D.O., I am taking the same classes, same boards (USMLE), and may attend an allopathic residency in Emergency med. so I get sick of hearing MD as synonymous with physician as it commonly is in magazines, media, and out of the mouths of MDs themselves.
NPs are important and valued but they are not meant to be running clinics on their own. You want the ability to do that? You should have to go to 4 years of college, 4 years of medical school, and a residency. Our primary care problem should be solved with incentives for primary care docs, loan repayment, and fair payment for preventative health services. PRIMARY CARE IS A SPECIALTY TOO.
http://dinosaurmusings.blogspot.com/2008/11/being-doctor.html
Happy- Just because you have happened to work with some PA's/NP's about to graduate doesn't mean you know the extent of what is covered in their education. I have worked with some MD's and DO's about to finish residency who were truly terrifying in their ignorance, but that doesn't mean I extrapolate and say that all MD's are unprepared.
ReplyDeleteAnonymous- you should have some respect for your colleagues and not call their education "a joke." I know some doctors that, even after at least 7 years of intensive education were " a joke" when it comes to critical thinking and actual patient care.
MD's/DO's need to learn to work WITH PA's/NP's, not against them in an antagonistic relationship. We all bring something different to the table that, if we work together, can better patient care.
There aren't two distinct groups called easy patients and difficult patients. There are the difficult ones and the ones that have the potential to be difficult. If that weren't the case, then NP/PA's could be ok in the primary care setting. As long as complications of illnesses, meds, etc. exist and make the situation potentially beyond their scope, they shouldn't be unsupervised with somebody who has more training.
ReplyDelete"I believe you meant "physician" here. As a D.O., I am taking the same classes, same boards (USMLE), and may attend an allopathic residency in Emergency med. so I get sick of hearing MD as synonymous with physician as it commonly is in magazines, media, and out of the mouths of MDs themselves."
ReplyDeleteThe preclusion to have bias against D.O's over MD's is ridiculous and frustrating.
If anything I think D.O's expand more into patient care as they are taught to view and treat the entire patient as a whole being, not just a single medical illness or symptom.
While in my hospital we have both working together, and they are all great drs, mostly, in hospital care you don't as often see the difference in the models. I know all dr's essentially give the same quality of care in the end, I just believe the D.O model was designed in a way I highly value and respect the way it focuses more on the entire patient,psycho socially, physically and mentally.
Michael. Point taken. And extenders do have a place in the patient care. I don't have a quarrel with that. However, I did say that if an extender could pass any specialty board they should be able to practice that specialty independently. By allowing extenders to practice independently, it makes our national boards meaningless. We should then abandon our national medical boards in favor of extender boards. I can certify a a PA for 1/2 the cost and get paid the same. I could call myself a superPA
ReplyDeleteAs a patient with a serious chronic illness, this very subject makes my blood run cold. I can't count the times, in the last 5 years since my diagnosis, that I've had to deal with nurses who have made mistakes, and then been too proud to admit them, and ended up trying to make me look bad instead. I love my doctors, but one of them got his staff from a cracker jax box.
ReplyDeleteAs difficult as it seems to be for even my well trained, excellent physicians, to organize and maintain continuity between himself, myself, and a half dozen or more specialists, I can not see this being done by NPs and PAs.
My sister in law went to school for 3 years to become a PA. She's a bright, no nonsense sort of lady. When she graduated, in her own description, she was launched into and unsuspecting, trusting world. She had not only not been prepared by school for day by day medical work in an office setting, but those she worked with assumed that she was, and ignored or derided many of her questions.
She's an honest woman, and it didn't take long for her to leave her new-found profession.
If this is tomorrow's healthcare, then we'd better expect a lot of preventable problems, even deaths, and for medmal to rise like a grand finale on the 4th of July.
It's frightening to ponder just where healthcare could be in a year or three ...
Happy are real world NPs actually saying that their assessment/clinical skills are as good as a Dr's? I have yet to meet an NP as of yet singing that tune. Can you seek the utility in a hospital employing CNM NPs? How about CRNAs? Or how about Rural FNPs where there is a significant deficit in Drs? Or how about FNPs working in community clinics treating and seeing the under served? Maybe this will suit you, how about PNP running vaccination clinics? Women's health clinics? Do I need to see a Dr to get a Pap smear? Does a pt need to see a Dr for treatment of a STI? I thought there were CDC perceptive algorithms for that.
ReplyDeleteI concur with Michael MD, this whole us vs them thing is getting old and in my opinion is myopic. Nobody wants to replace the Dr--not even the NP or PA. The only real truth is that there are 40 million Americans without insurance and NPs/PA can assist in treating this under-served population. I can see the utility in this. Can you?
-Sarah
Just to be realistic here...
ReplyDeleteWhere is the evidence that APNs do not provider the same quality care as their physician counterparts?
As opposed to spewing drivel which is baseless, lets get down to the reality. If CRNAs (who often do practice autonomously) or APNs did "screw up all the time" they wouldnt exist and we both know it.
If you cannot PROVE what you are saying then it is BS. End of story.
Where is the proof that bus drivers don't provide the same level of care as physicians? Where is the proof that long term Pepto Bismol is safe?
ReplyDeleteYou should be asking where the proof is that they DO provide the same level of care. Otherwise, the speculation is just as baseless as you claim for the opposite.
Well now im glad you said that.
ReplyDeletePlease do a little pub med search. FNPs and CRNAs have already proven it. Thanks for taking the bait.
"At that point all medical schools should be abandoned for nursing school and part time procedure schools should be opened up to teach us all how to hold a catheter, an endoscope and a scalpel."
ReplyDeleteI'm surprised no one else has commented on this gem. How offensive can you be? You seem to be implying that the only skills taught to us as nurses is how to hold instruments for MDs. You do seem to have a moment of clarity in your tirade where you acknowledge that nurses and MDs have totally different education tracts, this is true. I also disagree with you assuming that NPs and PAs want to be MDs. I could have made the choice to go to med school but I valued the total patient care view of nursing over looking at a patient as a case study. As an NP, I don't want to be an MD and find it insulting that people think that I am an NP because I couldn't be an MD. Nursing values very different things than medicine, the beauty of graduate nursing education is that it melds the nursing background into the medical model. While some of the things we learn our similar to med school students i.e.we are taught the same assessment skills you learned in med school, we, too, have on the job training in the form of required clinical hours, we do not strive to be MDs. We value the added autonomy given to us in the NP role, it allows us to combine our nursing background with advanced skills such as diagnosing and prescribing often times with better outcomes for things seen in primary care such as hypertension. You get paid much more than we do as a reward for all the extra hours you spend educating yourself, personally, I'm happy with the trade off of earning less and having the ability to foster my nursing roots while functioning in an expanded role, as long as I have colleagues that respect the nursing profession. I'm not sure that you do.
"Search PubMed" is akin to "I just know it's true, but I'm too busy to prove it to you". In other words, it's a non-answer.
ReplyDeleteThanks for taking the bait? Please. At least come to the fight with some ammo.
Anon 8:12.
ReplyDeleteI think you misinterpreted the comment.
"At that point all medical schools should be abandoned for nursing school and part time procedure schools should be opened up to teach us all how to hold a catheter, an endoscope and a scalpel."
What I think Dr Happy is saying is if a nonphysician wants the same responsibilities to practice independent medicine without oversight, then they should pass the same board certification that physicians need to pass for their certification. Otherwise, what's the point in establishing a minimum level of expertise for certification. Dr Happy's reference to opening procedural schools I think simply is saying is if a lesser certification process is deemed acceptable, then all practitioners should not need medical school but an adequate nursing training with specialized training in procedural medicine. I don't think there was any inference in the comment as to, "only skills taught to us as nurses is how to hold instruments for MDs." But then again, I actually understand what Happy is talking about, unclouded by ego.
This is a stupid argument. Doctors are not nurses. Nurses are not doctors.
ReplyDeleteActually, there's no argument. You wouldn't want a pediatrician managing adult onset diabetes for the same reason you wouldn't want an internal medicine physician delivering a baby. Why, different training.
Knowledge is very important for being a physician, to evaluate and establish a diagnosis based on signs, symptoms and an array of additional information. But to be a great provider of health care, you have to not only know your stuff, but I would argue more importantly, you have to know what you don't know. You have to know your limits and when to refer. If you don't know the bad stuff that can happen, diagnoses are missed. I was once taught that physicians don't go to medical school to learn the 90% of common medicine. They go to medical school and residency to know when they are dealing with the other 10%. The tricky part is, how do you know when you are dealing with a 90% or a 10%. "Most" of the time you will be right. If I were a patient, I would want my provider to be right more than "most" of the time. That comes with intense residency training and clinical exposure.
I'm starting to think you are the one with the hang ups. Most of the extenders that have commented have highlighted their differences, not compared themselves to MDs. We have tasks that overlap, sure, but we are not saying we are handling the complex medical cases you keep referring to. You keep restating your talking points, at this point I think you are only arguing with yourself.
ReplyDeleteAnon 8:58. let me give you an example to illustrate Happy's comment
ReplyDeleteAnon 8:12 "I could have made the choice to go to med school but I valued the total patient care view of nursing over looking at a patient as a case study."
I've been a doc twenty years. Believe it or not I too look at the WHOLE patient not a disease process. I have grown with some of these patients. Anon 8:12 is making an inappropriate "you docs treat case studies I treat PEOPLE" value judgement without any basis in studies, only her opinion. Think about it.
Happy "Yawn", you are trying to make a rational argument with someone who doesn't know the difference between supervision and consultation. You might as well as try and make this same argument
ReplyDeletewith your greyhounds.
For the record, the typical patient population with 5 plus chronic medical problems that are booked in an internist's outpatient day would be probably 20-50% depending on the internist's patient panel demographics. It takes time to manage all those medical problems well. Time that can't be addressed in one visit. A healthy pateint panel member visit is once a year. The complex and chronically ill need to be seen regularly. All you have shown is very minimal experience outside of the ER.
Hey docs. Scary, ain't it. Tail wagging the dog.
ReplyDeleteI loathe NPs but only after working with a cackle of them. They are government created entities designed for one purpose: to follow guidelines. Go to Amazon and check out their review books for their so-called boards. Go to Sermo and read the horror stories. I had my first experience with a group of these arrogant nurse p. who took short cuts to wear a white coat and are now rewarded with autonomy in 48 states. They are replacing MDs and being rewarded. They are combative, insecure and think, really think they know how to diagnose. Anyone can follow a cook book and doctors don't hold a light to the arrogance of nurses in general. These people wanted to call me by my first name and tried to explain medicine to me. For example, one NP told me he was concerned about abdominal wall abscess causing fistulas in a particular patient, and connecting with the bowel. He had discounted my suggesting that necrotizing fasciitis, spinal abscesses and endocarditis were concerns and that bowel fistulas are associated with enteric conditions for the most part. He wasn't so concerned with the spread of the infection along fascial planes. Holy crap. I was told to go to NPs for advice in this short-lived job. Every discussion became a burden as they are super insecure with we can do what doctors do. No you cannot NPs and you will never know the number of misdiagnosis you make when patients end up looking for MDs. Granted, MDs are generally jerks and biased but not applying knowledge to experience is different than not having the training in the first place. Face it, doctors have been slapped in the face, wasted money and time and sacrificed like soldiers. They will take over the specialties next. It has already been sanctioned. This is an international movement and will contribute greatly to the agenda of population control. Every profession has a type of person that goes into it. Medicine is a learned profession, along with Law and the Ministry. That is traditional wisdom. NPs are not and never will be MDs. They wanted a short cut. I don't begrudge them for taking what is available but I despise the government and insurers for stepping beyond their constitutional bounds and destroying medicine. I hate the term practitioner. It's a fallacious term.
ReplyDeleteNps operate on a different model than MDs. They are trained to recognize certain diseases, what to do when they encounter those diseases and when to refer. The DNP is an additional year of mostly administrative lessons and they are weak in pathophysiology and every other detailed subject of medical school. I saw a rheumatology consult recently that was 2.5 pages long. The entire reasoning of this professional was beautifully laid out. SOAP and then some. The plan however stated one thing: Motrin 800 mg tid! The NP model is practical healthcare versus the medical doctor model which is traditional academically based reasoning: perseveration to the payors in the game. When they tried to change the medical school curriculum, saying doctors learn too much, they met with grave resistance. Just Google medical school curriculum changes and see for yourself. The nursing lobby moved right in. So essentially folks, the current lay wisdom, since lay people pay the bills, is that anyone can do the job with a more practical training and bottom line approach. I think the boards we have to take are ridiculous and the sacrifices a waste of time. I wasted 300 K because a nurse can do what I can do? Holy crap.
ReplyDeleteWow...I'm an NP in NH...one of those states where we are not supervised by MD's. However, we are required to work in collaboration with a physician. I am fortunate as I work with a great bunch of doctors. We work in neonatal intensive care so we truly work as a team, rounding together and making plans together. We all benefit from each other's perspective.
ReplyDeleteHaving been a neonatal nurse for some years before going back to school to be educated as an NP, I can tell you that many of the residents that came through were pretty scary in how unsafe they were. And I have seen some who were brilliant yet couldn't put two and two together. Its NOT a rarity.
I've seen docs make mistakes and seen lives lost because of it, or futures severely compromised. It happens a lot. The difference here is that physicians tend to make alternate explanations. Nurses get drawn and quartered for writing the wrong temperature on the flow sheet. The MD's just keep on practicing.
For every negative about NP's there is an equal negative for MD's.
Let us please appreciate each others differences and find ways to work in collaboration. Most NP's don't want to be MD's - we could have gone to med school if those were the initials we wanted behind our names.
I believe there is room for both MD's and NP's. We each serve a purpose. MD's ARE better equipped to care for the medically complex patient in an outpatient setting. But well child check ups, yearly physicals, gyn care, etc does not require a physician. Use your talents where they are most needed! And allow us to use ours. And don't be so arrogant. MD is not equivalent to "no mistakes." Those happen a lot more than any of you are willing to admit.