My take: Dr. Nurses, supporting universal care

1) The WSJ reports on the doctorate of nursing practice programs, or so-called DNPs, aimed to capitalize on the primary care shortage.

My take: Even with a doctorate degree, nursing programs cannot equal the rigor or length of an allopathic medical school and residency. That is a fact.

However, physicians have no one to blame but themselves for mid-levels’ increasing role in health care delivery.

We have devalued primary care to a point where it is no longer desired by medical students. Someone has to do it, and the wave of mid-levels, chiropractors and minute clinics attempting to capitalize on the opportunity shortage is foreseeable.

2) 59 percent of U.S. doctors support government legislation to establish national health insurance.

My take: Not enough detail as to what kind of national health insurance plan is being supported. There are many ways the government can intervene. Contrary to the far-left, PNHP fanatics, there is more to the world than single-payer.

Universal coverage is indeed a laudable goal. If we had endless resources, there is no question it should be a priority. Simply hoisting universal coverage onto a system not ready for it is Massachusetts-like thinking foolhardy.

Here’s the bottom line. I support universal coverage, but not before controlling costs and expanding primary care access.

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  • Criminallopath

    If only ye had listened to the wise and sage words of Criminallopath and simply streamlined the process for opening more allopathic schools. Instead, what one sees is a steadily building momentum for using second tier providers for more and more healthcare provision. This will only increase both in quantity and scope once the general populace realizes that the world will not end just because the person treating them is not an MD. It is time to leave primary care to the second tier providers and have the MDs provide specialist care only.

  • Anonymous

    “It is time to leave primary care to the second tier providers and have the MDs provide specialist care only.”

    This seems to be what Medicare and Medicaid are pushing. However, if you are a complex patient, there is reason to doubt that your needs will be met by an NP, PA, or DrNP.

    This is, of course, assuming that some-one with a higher level of training will in fact go to primary care. Opting for less money and more responsibility over, say, a lucrative job working under supervision of a neurologist, is not an intuitive choice.

  • Anonymous

    I don’t understand the purpose of the doctor of nursing – they can make in excess of $100K doing exactly what I do for $120K. Are they going to receive special rates for office rent, decreased employee salary rates, professional liability immunity/decreased medical liability rates, increased Medicare/Medicaid payments or exemption from the upcoming Medicare payment cuts? Otherwise, how can they be expected to run their businesses and be profitable? It sounds like another profession wanting to practice medicine, but I don’t think they will ultimately be happy if they have to face the same non-free market realities that I and other primary care doctors deal with every day.

  • pat

    Very interesting that they chose the NBME to create their test. I thought that this was the most important part of the story, and points out a fact that is widely ignored by consumers.

    For many years in the past (actually up until now) NPs did not have a standardized credentialing or licensing test. As a matter of fact, despite all of the publicity that all NPs must have masters degrees, there were quite a number of certificate programs out there (California just discontinued two of their certificate programs this year…one at UC Davis, and one at Stanford, because of changes in California law).
    Few, if any states require NPs to pass an exam to practice…….just the degree or certificate will qualify them for licensure.

    PAs, on the other hand, have attended a program with standardized accreditation and taken an exam designed under contract with the National Board of Medical Examiners for almost 40 years. The PANCE, or Physician Assistant National Certification Examination, is required for licensure in all 50 states, designed by the NBME, and is based on the medical model of practice and education. It most resembles part III of the USMLE.

    Standardization of NP training and certification will help but it will be decades, if ever, for the licensing practice to catch up to where it is for PAs, MDs, and DOs, who are required to pass a standardized certification examination for licensure and entry into practice.

  • Catron

    The lead author of this “survey” is a Board member of PNHP, a single-payer activist group.

    The survey itself is a self-selected subset of AMA physicians, which means that it isn’t statistically sound.

    It’s just another exercise in single-payer agitprop.

  • Anonymous

    Since most of these “providers” will be women, they won’t be working full time or they will leave for childrearing. That is just the reality of the situation. Therefore, their will be a constant flow of inexperienced “providers” doing episodic care. Or more likely, they will go into Botox and Lasers. Why would they choose primary care?

  • Nurse Practitioner

    Pat, I’m afraid you have your facts wrong regarding NP certification/licensure. In all but 2 or 3 states, NPs are required to have passed either the ANCC or AANP exam to be licensed as a nurse practitioner. In addition, if NPs want to bill Medicare, they will need board certifcation from either of the 2 certifying bodies. Perhaps, you should do a little more research prior to making incorrect blanket statements regarding NP practice.

  • Annie

    The WSJ post is false, misleading and distorts the issue. Nurses are not widening the availability of doctoral level nursing education to advance a turf war with physicians and medical practice. For shockingly fact-based and appropriately sourced information dissecting the offending post and correcting the information, go here.

    It’s disappointing, but not surprising, that Kevin swallows this inferred gender-biased attack on a female dominated profession by accepting that doctoral level education is a threat, instead of addressing a separate profession’s critical need.

  • Anonymous

    Whenever corporate interests try to control the masses, they divide and rule amongst the lower echelons. That is exactly what is happening between primary care physicians and “mid-levels”. It is similar to a company bringing in scabs to replace striking workers, except in this case, no one is striking. In fact, we’re working harder than ever for a smaller piece of the pie.

    Those of us in primary care, be we physicians or “mid-levels” need to find common ground rather than disparities.

    Comrade Underpaid in Upstate New York

  • pat

    NP….the AANP/AANC requirements are very new in most states, a number of states still do not have them, and every state has grandfathered in the older non-certified/non-master’s NPs. the Medicare certification grandfathered in NPs practicing prior to the early 2000. Actually, the statements that “all nurse practitioners are certified” and “all nurse practitioners have master’s degrees is demonstrably not true; the stats are only slightly over 60% for either. The statistics are from the University of California at San Francisco Department of Nursing and can be found at:

    http://www.futurehealth.ucsf.edu/pdf_files/NP%20Scopes%20discussion%20Fall%202007%20121807.pdf

  • Anonymous

    What, exactly, is the point of the DNP degree? Is it an acknowledgement that existing masters and certificate prepared NPs aren’t competent and thus require more education? The argument about needing to prepare more nurse educators and researchers doesn’t make any sense. There are already PhD in Nursing programs, along with EdD and DNSc degress in existence- all of which prepare nurse faculty and researchers. Why not increase the number of these programs instead of inventing a new degree?

    Until someone can give a straight answer to this question, I think its pretty obvious what the DNP is all about- pumping out nurse practitioners with doctoral degrees in the hopes of eventually petitioning Medicare for 100% reimbursement and seeking federal funds to establish post-doctoral nursing residency programs. Its all one big disingenous attempt to become physician-equivalents while circumventing the rigors of medical school and residency.

  • Nurse Practitioner

    Pat, I’m wondering if you’ve read the very report that you refer to:

    “NPs in 42 states, excluding California, must be nationally certified in order to practice. The passage of a written examination is generally required for national certification.”

    Your original post stated: Few, if any states require NPs to pass an exam to practice…….just the degree or certificate will qualify them for licensure.” 42 states would seem to be more than a few.

    For detailed state by state analysis of NP practice, I’d like to direct you to the Pearson Report (http://www.webnp.net/ajnp.html)

    In addition, I don’t see anywhere in that overview that the University of California at San Franscisco’s Department of Nursing had anything to do with that report, though maybe I’m missing that.

  • Dan

    From the OP: Even with a doctorate degree, nursing programs cannot equal the rigor or length of an allopathic medical school and residency. That is a fact.

    I don’t actually have an opinion on this matter. In fact, I decided not to go to medical school for many of the reasons you talk about on this blog (http://dansthoughts.wordpress.com/2008/02/18/mddo-or-phd/). Moreover, as a consumer of health care i would prefer to see a physician for my primary care needs (I guess i do have an opinion then). However, what are the facts you are referring to on this matter? Specifically, how does one objectively measure rigor? And for the sake of argument…even if that is “fact,” why do you equate rigor and length with quality?

    Also, your explicit mention of allopathic medical schools imply that osteopathic schools are somehow less rigurous and that DNP schools can somehow be equally rigorous as DO schools? As it’s stated, you come across as more arrogant than supported by facts…not that they’re mutually exclusive.

  • Anonymous

    So when all the nurses complete advanced degrees, who is going to sit at the bedside on the wards?

    Who is actually going to provide carfe for patients?

    We already have a nursing shortage (for a lot of reasons). We need to increase the number of nurses, not the number of nurses with advanced training.

    Is there anyone left who actually wants to be the patient’s nurse? If not, what does this ocuntry need to do to change that?

  • Anonymous

    Primary Care doctors themselves create the demand for nurse practioners by hiring every one that they can get and the rest have no trouble finding someone to sign off on their care (a total farce BTW).

  • Anonymous

    I noticed that my PCP in Massachusetts went from being:

    A very smart guy who generally saw me within 15 minutes of my appointment time and talked to me for at least 10 minutes

    To a chronically late doctor who had 5 minutes to speak to me after I waited an extra 45 minutes to be seen for my scheduled appointment.

    Is this also a side-effect of the Massachusetts health care experiment? Or is it a side effect of the aging population? Or both?

    I feel like I’m competing with a lot more people for scarce doctor time. Maybe I’ve just seen him on a couple bad days?

    The day he was over an hour late, I could hear him in the next exam room talking at extreme length with an elderly woman who felt the need to debate every one of his instructions and repeatedly request clarification. I wish he could have just handed her an instruction sheet after she asked the same question for the third time.

  • savvydoc

    SavvyDoc…. Kevin you are absolutely right that universal health care does nothing if costs continue to go out of control. The system can absorb a small percentage of uninsured patients but that percentage is growing rapidly due to the incredible cost of care.

    http://savvydoc.wordpress.com/2008/03/26/savvydoc-easy-doctors-appointments-online/

  • Annie

    Re: providing clinical nursing care and the need for more nurses to be educated at the doctoral level, see this post. Unlike Kevin and the WSJ posts, it is fact-based, sourced apropriately and addresses the underlying need for doctorally educated nurses.

    If the uninformed public continues to demonstrate such disrespect for nurses, the question of who will be left to care for nurses is spot on. No one in their right mind will, surely.

  • Paul

    Let’s see, we’ve all been “providers” for years with no distinction in training etc. Now the NPs can actually call themselves “Doctor.” Poor PAs, guess that leaves them out in the cold.

    I SUPPORT universal health care without private insurance companies that pull $100 BILLION from healthcare every year.

  • The Happy Hospitalist

    Dan, as you say:
    “Specifically, how does one objectively measure rigor? And for the sake of argument…even if that is “fact,” why do you equate rigor and length with quality?”

    Take 100 people, have all of them get a 4 year nursing degree. Then, have them all get their Nurse Practioner degree or get their degree in PA school. Then, when they all have their degrees, have them start medical school.

    Rigor is defined by 100 people realizing that inspite of all their advanced degrees, they realize in their first week of med school that they are starting from square one, with an enormous black hole of understanding of the human body. And it will take 4 years of medical school and 3-7 years of residency before they even begin to understand.

    That is how you will get your definition of rigorous.

  • Anonymous

    Well again, Annie, I would ask: with the existence of PhD, EdD and DNSc doctoral degrees availble to nurses, what additional need is being served by the DNP degree that the other degrees cannot address? They all lead to doctorally-prepared nurses capable of serving as faculty and anyone with common sense will realize that the PhD in nursing is far better preparation for research. Why not expand these programs rather than create a new degree targeting nurse practitioners? Any nurse practitioner presumably holds at least a BSN and likely an MSN and is thus eligible to enter existing programs for any of those degrees.

  • Anonymous

    I work with NPs every single day (at a nursing home caring for patients with 5 different chronic conditions on 10 different meds).

    And every single day i marvel at the disparity between doctors and nurses in level (& type) of training.

    Today one of the NPs ordered a dermatology referral for an ecchymosis (ie. bruise). The patient wasn’t on coumadin, aspirin, or plavix – but that part wasn’t even addressed in the note. In fact, NOTHING was addressed except the need for a derm referral.

    Oh yeah, and the HbA1c was documented, as 9.8%. Of course, nothing was done about that part. Not even a referral to an actual doctor.

  • Anonymous

    What specific words in Kevin’s entry actually indicate a gender bias on his part? True the majority of nurses are women, but so are the majority of current medical students. And the most of them would probably concur with his position.

    As a woman in medicine, I find that accusation to be intellectually dishonest and cheap. You can debate the issue on its merits without resorting to baselessly accusing the “other side” of engaging in some kind of sexism because they happen to disagree with you.

    I assure you that I and most other physicans and medical students would feel similarly about a doctoral physician assistant degree, a field in which at least half are male.

  • Anonymous

    “I support universal coverage, but not before controlling costs and expanding primary care access.”

    You have to have universal coverage to have some massive “cost control” and “primary care expansion.” At least if you’re going to have it as a large organized plan.

  • Anonymous

    The difference between DNPs & EdDs, PhDs and such is DNPs are clinical focus. PhDs are research based, EdDs are education based (school). Moving NPs to a DNP is not dissimilar to moving pharmacists (masters level) to DPhs. As far as NPs not having a standard exam is partly true. It varies state to state. Here in Mississippi all NPs much pass an exam in order to practice. Simply having a MSN as a NP does not allow practice. Like medicine there are specialties: Geriatrics, Family, Adult Acute Care, Psych & Neonatal. Each has its own exam one must pass due to each being its own specialty.

    There’s my 2 cents.
    -Dave, MBA, CCRN, CFN

  • Anonymous

    Dave I appreciate your response but you’ve really only confirmed my point. Annie (and others, inlcuding Dr. Mudinger) have basically justified the creation of this degree as a means of getting more doctorally prepared nurses into research and faculty. As you plainly say, the purpose of the DNP is to better prepare existing nurse practitioners for clinical practice. More NPs does little to directly address the bedside RN shortage. So the question still remains, regarding this degree…. why?