In short I felt the NP was quite incompetent and a 3rd year medical student knew more then her. Plus I spent a whopping 12 days with this NP (for a 6 week rotation) and this was significant exposure? Hmm…no wonder they can’t even properly intrepet the results of a urinalysis and know when a U/A is positive and when it is inconsequential.

I say this: physicians should stop training NP’s. Let the NP’s train their own. Furthermore, physicain specialist should REFUSE to accept any referrals from an NP. Instead, they should insist that the patient be first seen by an MD or DO Internist, Family Physician or Pediatrician before they would ever consider seeing the patient. That way, the PCP can do the higher cognitive function that is necessary in medicine and stave off the inappropriate referrals thus driving up health care costs and we serve to strengthen our profession against the onslaught of Physician Wannabes i.e. NP’s.

Sorry to lump MSNs and DNPs together with more traditional nurses. I understand there are differences. My insititution houses a well regarded nursing program and has added a DNP pathway.

My own field of radiologic physics is adding a path of “doctor of medical physics”. I have mixed feelings about this. Our field was traditionally split into MS and PhDs, where the MS generally stick to clinic and PhDs a combination of clinic, teaching and research. However, there are some glaring differences between my field and primary care of patients. We are perfoming a service that cannot be fulfilled by any other professional. The are no nurse physicists or physician physicists.

My problem with these nursing programs and the idea of NPs taking a bigger provider role, is that physicians have an impecable training program. I have problems with the attitudes and entitlement as well as the artificial shortage, but I cannot argue they are not well trained. That’s why they call medical school undergraduate medical education… it is very broad and yields a deep understanding of the normal and abnornal human condition in general. In my training as a rad physicist, my first introduction to anatomy and physiology was a nursing class (the MD class was too much time committment on top of the graduate radiation and physics coursework). It was a bit of a joke–and this is a top 15 institution in the US. The med students, however, spent 20 hours a week in lecture and gross lab.

I’m not saying DNP students couldn’t go through the MD training. In fact, I’m arguing that they SHOULD… there should be more students in med school… and there should be incentives for them to become PCPs… but, I don’t think the DNP or MSN training begins to compare to the physician training. If we can restruction the system such that it accomodates more students, I don’t think we need an army of DNPs. They are a result of a broken system, not the prospective route of choice, in my opinion.

Furthermore, no one is talking about APN’s taking over primary care. Docs are still critical for advanced diagnostics or managment of complex clients across a lifespan. But you see your FNP for your pap smear, for your blood pressure or diabetes management, for your STD screening and treatment, for your immunizations, for your UTI, your leg laceration, your community-acquired PNA, for your prostate exam, for your prenatal care and delivery (if your FNP is also a CNM, which many are), CHF management… you get the picture? Your FNP should know when to refer you to oncology, to endocrinology, to cardiology, to ophthalmology… whatever. Your FNP will know when a routine client becomes a complex client. Your FNP should be able to recognize a medical emergency, and if you experience cardiac arrest in your FNP’s office, she or he can run a code on you (unlike many docs) since most of us have so damn much bedside experience. ABC’s, baby. Complex patients with multiple comorbidities, multiple system dysfunction, etc (still a significant percentage of the artery-clogged, addicted, depressed, anxiety-riddled, socially-isolated Amercian public) should be cared for by physcians, at least until the DNP becomes the standard degree for NPs (2015) and new NPs receive additional training during a one, two or even three year residency. Will this make the primary care doc obsolete? Maybe. Maybe not. Maybe anybody considering a career in primary care will go to nursing school instead. Or maybe it’ll actually be easier for a college grad with a degree in bio to just apply to med school than to earn another bachelor’s degree in nursing before embarking on a 4 year doctoral degree. I don’t know. If that med student graduates with the understanding that specialization is a more attractive option open to either him or her, then they will take it. If they believe strongly in the value of primary care and want the variety of patients and pathology available to the PCP, they’ll consider that route. If there’s a shortage of PCPs, maybe specialists will receive the overflow and be forced into providing what is actually primary care, thus making specialty less attractive as well, and the incentives won’t remain. Maybe the “nurse-free” incentive of specialty won’t remain if DNPs, armed with additional training and still in possession of that valuable nurse framework, begin specializing as well (NPs can already specialize in neonatology, acute care, geriatrics, pediatrics, midwifery, and they can do research and become educators and theorists and all kinds of stuff.) Maybe the market for specialists will reach a point of saturatation while the deficit in primary care remains such that a med student actually stands to make more money in primary care than in specialty because of competition for patients. Nursing can help meet some of the primary care need but can’t solve the problem by itself because advanced practice nurses are pulled from the pool of registered nurses and there’s already a major nursing shortage. Maybe the whole system will implode and you’ll have to meet a dude behind a dumpster to get penicillin and birth control. I don’t know. But I feel like much of this debate is hampered by this little mental box in which medicine is conceptualized as something based on what it has been versus what it could be and what nurses and doctors are based on what they have been versus what they are becoming and by what the “medical model” has been versus what it will be. JSmith said that there are fewer jerk doctors now than there has been in the past, indicating that the culture is capable of changing (via selection of med school applicants, increasing attention to bedside manner and contributions of other members of the health care team, and relaxation of some inhuman expectations). I know JSmith automatically links this reduction of jerk doctors phenomenon to a primary care shortage that has somehow caused by “less driven” people, but in my experience, the non-jerk doctors are just as driven and capable as their jerk counterparts (more so, actually). Furthermore, I would bet that doctors will soon be saying that NPs are sharper clinically and more capable now than they used to be, indicating that the education and training can expand to meet the needs of the health care environment. These things are not static. It’s silly to keep rehashing the status quo and defending turf. It’s time for vision. One thing I love about nursing: it’s a discipline with major, major vision.

JSmith talks about entitlement being linked to drive in medicine. One of the reasons I chose nursing over medicine (even though both were open to me) is because there is a distinct absence of the “entitlement” meme in nursing. I don’t know. There is a defensiveness that comes from being constantly questioned and put down or assumptions that we are sweet brainless little angels, but I guess wiping ass and helping old people walk around the unit and constantly following orders from doctors, patients, and families rids you of your entitlement. But the drive remains. If you doubt the drive within nursing, ask yourself how nurses went from a diploma or certificate based vocation to a major professional discipline with advanced practice and research, theory, and educational arms within 60 years? The evolving nature of medicine played a role, but nursing is a self-governing field that directs its own education, licensing, and professional trajectory. Even with these advances, nursing remains inclusive. The shortage of nursing spots usually means that nobody with a college GPA below 3.7 or so is admitted to a university-based nursing school, but ADN programs are still wide open and there are many routes for “advancement” in nursing, so, unlike MDs, not everyone who goes into nursing is an academic all-star or a person bred since infancy for professional “success”. I view this as a strength of nursing but I suppose some die-hard medical “realists” will cite some Darwin-esque philosophy and disagree with me, saying that unless a person gets an A+ in advanced OChem and engineering physics (which I did. Piece of cake compared to my ICU rotation in nursing school), they should be weeded out. Unless a person can stay awake and alert for 30 hours in a row for four years, they shouldn’t practice medicine. Whatever. A nurse who likes being a nurse or who hates the idea of more schooling or who can’t afford to go back to school (usually the case) can continue being a nurse, and a nurse who wants learn other skills or perform a different job can go back to school. I think that some med people, given the idea that they have somehow been specially selected, don’t like idea of this alternative route to advanced practice. Oh well.

I don’t know why the abuse the med school students and residents suffer breeds entitlement, but I have noticed that the medical model does confuse rigor and professional expectations with bodily, emotional, and social abuse, while at the same time sending this conflicting message that the person is being treated thus because they are a cut above, or because they are being bred for superiority. The medical model should certianly persist if it remains effective, especially if it’s the only path that’s going to nurture the brilliant type A future neurosurgeon, but a person’s preferred learning style does not correlate with raw intelligence or passion or drive and there’s no reason why the medical model and the nursing model can’t both educate people for careers in medicine.

JSmith, I understand that someone who has invested in themselves (or has had parents or society or whatever invest in them) enough to complete medical school would want a return on their investment. I don’t know why a return must equal $400k a year, but whatever. I’ve invested in myself and would like the opportunity to continue doing so, so lifestyle is more important to me. Power and prestige are nice, and I think it’s natural for MDs to protect theirs. I said that from the beginning. I only asked that this motive be acknowledged by docs fighting against NPs rather than them trying to pin their arguments all on the “minimal medical knowledge” of NPs. I have provided and defended evidence that characterizing NPs as having “minimal medical knowledge” or an lack of training or ability to function as independent health care providers is false and inappropriate. Still, I understand why MDs defend “their turf,” and even demand power and prestige… I’m not sure to what degree this should be accomplished by denying others power or prestige, or deluding oneself into believing that doctors are the only ones who experience hardship, abuse, stress, advanced education and training, etc. I’m not sure if professional power and prestige, or at least prestige, is a zero-sum entity in which the success of others depletes your own. I think doctors should ask themselves these questions before maligning all the “idiot” NPs they’ve worked with on a public forum under the benevolent guise of “just wanting to fix the primary care shortage.”

Anyhow, I’ve said my say. G’night y’all.

I agree with you that nurses running primary care is not good for our system. They are useful in their own right, but they lack the training to parse complex information… at least that has been my experience. I think the physician training model is a good one, but i have a problem with the entitlement and general attitudes. Many professions require a similiar level of skill, many years to obtain, etc., but i see no other professionals so entitled.

Airline pilots can spend up to 20 years to make captain of a widebody jet for a major. They deal with furloughs, loss of seniority, and meager pay as a way of life (and don’t give me the “it’s the same as driving a bus argument”). They make approximately 50-60% of a PCP 20 years into their career. The hudson river hero, Sullenburger, probably makes about $100-$120k.

I agree med students are leaving because of the money. It amazes me that no one sees an ethical dilema with this… This is exactly the problem. Medicine should be about treating and averting illness, not money. I think PCPs could stand to make a little more, but honestly, …$200,000 is not a bad living, and again, they don’t have any more training than many other professionals.

In fact, I think most medical professionals are artificially over-valued (perhaps even myself included) as a result of CMS, not in spite of it. I said it before, there is no other profession in which one is guarranteed such a high standard of living for simply completing a training program. Yes, it is difficult, but you need to realize, you are special, but not that special.

Again, nurses simply lack the classical training in complex systems and higher order reasoning. I think increasing the nurse component is wrong. But, with that said, many people who go into nursing or perhaps engineering, or whatever, could be excellent physicians, primary care or specialist. We create an articifial system that, in my opinion, has led to the attitudes I have discussed. Medicine is not that intellectually challenging and doesn’t require the over-achiever personality types that become successful applicants. It is not medicine that requires such, it is the process of getting into medicine. In addition, the process scares away many students who are more concerned with real problems are results, who certainly have the aptitude but don’t have the stomach for some of the hoops. We need to siginificantly expand medical school enrollements, add new schools, and add more residency slots. If we do these things, you can have primary care physicians rather than nurses. And in so doing, perhaps over time some of the entitement will fade. Don’t get me wrong, the cost structure and reimbursement scheme must be fixed as well, but increasing the the supply would help.

Here;s another thought off-the-cuff, why don’t we consider bifurcating the path? Medicine may have arrived to a point where we can do away with standard 4 years for all. How about you narrow your decision up front. Your want to study primary medicine or you want to specialize. You get the same degree but take different courses with more targeted rotations for the furture specialists. I’m sure if you did it on the front end, you would get more PCPs.

However, this could all lead to a shortage of dentists in the world…

You are right that there are some methodological limitations to some of the studies within the body of literature investigating this issue… (this does not mean they are all “poorly done at best”, however.) If you look closer, you’ll see that the specific studies I cited include longer than 12 month follow-up and a few have the statistical power to detect differences between MD and NP activities and care. Still, I’m aware of some of the limitations (though thanks for talking down to me, and for quoting a brief section from the 2005 Crochane abstract you found on PubMed, which reviewd 25 of over 4,000 articles on the subject). I suppose I just wanted to get one of you to actually investigate the issue for yourself rather than rely on your opinions or what a handful of eye-rolling ED docs think. I have my own objections to these types of studies, because I do not think it’s appropriate to measure NPs with physician standards. NP education is designed to address approximately 80% of what a primary care doc is expected to handle. Just because we are taught to refer that 1/100,000 case of Churg-Strauss rather than diagnose and treat it ourselves does not mean we can’t practice independently within our own scope of practice. I think there are better outcomes to measure in order to determine the value and capability of NPs than “similar to a physician.”

You were not the one implying that NPs are responsible for degrading primary care, but most other MDs in the larger debate happening here (as in on the CNN page) have. You snap at me and say that no one has claimed that NPs are responsible for the shortage, but I stated that I was responding to the implication, not the claim. This is not unreasonable since NPs have been cited as a reason why reimbursement for PC is crappy and for dissuading med students from PC, which are root causes identified in the PCP shortage. Therefore, NPs have been implicated in the shortage. You may think this is fair since today’s med students speaking up on the CNN article are saying that the evolving nature of NPs make primary care unattractive, but I think this is unfair because I believe NPs are a response (and a solution) to the PCP shortage and that the devaluing of PC began within the medical community itself. I may be willing to grant that NPs and PAs evolved as a solution but have become an aggravating factor in the shortage of primary care DOCTORS (though, I would not fault NPs or PAs for this phenomenon, and how do you measure this outside of one or two med students commenting on the CNN debate? And do the contributions that NPs make to primary care outweigh the fraction of a percent that they contribute to dissuading med students from joining PC?). I certainly think the implication that NPs have devalued the field is pretty shameful. It’s a multifactorial problem and I don’t want readers to latch onto the soundbite the NPs ruined it for all the med students.

It is not “pathetic” for me to ask that NPs and PAs be differentiated. Most docs don’t seem to have a problem with “midlevels” who remain beneath the supervision of a doctor. Currently, NPs are the only “midlevels” functioning with complete autonomy, and NPs are the only “midlevels” seeking to exand our scope of practice in states where we don’t function completely autonomously. At this point, PAs aren’t. This may be because nursing had a long history of self-governance and the education and training of NPs and PAs are very different. At this point, the trajectory is different. Unlike MDs/DOs, where the educational model, the training, and the trajectory are similar. These differences are not unimportant, like you claim, because MDs are objecting to the NP model of practice, not the PA model of practice.

“Medical students have been at the top of their class since before high school, competing against the best in a cut throat system and now are looking at what to do with a significant portion of their life.”

I suppose I would only like to remind people that “the best” don’t always end up in this “cut throat system” Most of the “best” never even have access to all of the advantages of your typical med student. I’m going to come across as an asshole by citing myself as an example here, but I did my undergrad on a full ride because I was my high school valedictorian (not at some tiny school. At a big school considered one of the best in the state). I wound up in nursing because I found undergrad bio and chem classes uninspiring and I wanted to get my hands on some patients before med school. I still intended to use nursing as a launching pad to med school. I finished all my med school prereqs and took my MCATs before deciding that the “cut throat” system didn’t nurture “the best” or necessarily contain “the best” to begin with (not to say that many med folks aren’t deeply admirable. But they’re not the only admirable folks on the planet.) Since nursing is an evolving field full of amazing people and amazing opportunities, I thought I’d be of more use here. I thought I could contribute more. My dad, who is a physician, seemed to agree. I know I’m not moving anyone to tears with my life story or anything. But my story is certainly not unqiue, because nursing is full of accomplished people who, for one reason or another, decided to stay here. If I, along with so many others that boggle my mind with how amazing they are, made the decision to stick with nursing, I believe “the best” should be going into primary care as well. The contradiction I pointed out is not invalid because it was not meant as a response to your hypothetical. It was meant as a response to a sentiment you reiterated yourself: “…those MS in their clinical years now are looked down on who state they’re going into primary care with the implicit assumption being that they must not be smart or hard working…” On the one hand, a doctor is not smart or hard working if she chooses primary care because apparently primary care is not challenging enough to attract smart and hard working people, but on the other hand primary care is beyond the scope of an NP because it is too challenging and should be the job of a smart and hard working physician. Embedded in this is either a contradiction or an ugly assumption about NPs being dumb and lazy. I don’t know how else to interpret this argument.

“That whole diatribe attacking my character was a straw-man argument and suggesting this has to do with power or prestige is insulting and dishonest.”

I did not attack your character specifically. I’m critiquing the collective MD response to “midlevels.” If you (or others) think that MDs resistance to NPs is not an effort to protect the power and prestige of medicine, I don’t know how to illuminate the matter for you. Here’s what JSmith said: “Can you imagine being a doc and having an NP as a supervisor because he or so has been there longer and what the hell, you’re all just primary care providers? This would be a catastrophe for medical care in this country.” Here’s what IDDOC said: “Frankly I think the AMA has really done us physicians a dis-service by allowing NPs and PA’s to extend there practice rights and we should fight whole heartedly to scale back there practice rights.” Note that he says the AMA has done PHYSICIANS a disservice, not patients. And by the by, the AMA never “allowed” NPs to extend “there” practice rights. The AMA fought this. And I’d also like to direct your attention to all the docs posting on the CNN article who have said that allowing NPs into primary care is an insult, because MDs work too hard to be so devalued. ? How is this not about power and prestige? I never suggested that this was unnatural or unexpected in any way. It’s what people do. It’s how they react. But for the medical discipline to lack any insight into its motive to protect its own power and prestige is… um, limiting. Dishonest. Whatever you want to call it. My motive is to protect the hard-earned autonomy and the reputation of NPs. I made this clear from the start and never claimed to be objective. I even said I could make arguments against my own case if I needed to, and I’d at least rather hear those arguments than “I once knew an NP who sucked.” That’s all.

Anyhow, I’m tired and don’t feel like being on the defense anymore. This has been an interesting, if depressing, exchange. I’m not interested in seeing nursing go the way of medicine (because nursing is amazing and I think “cut throat” is abusive, discriminatory, and not as effective as other alternative frameworks), but I am interested in making sure our clinical judgment and skills are up to snuff for today’s health care environment and for the future. Maybe I’ll see you on the free market, NF, and pepper you will all sorts of lucrative referrals. Perhaps my whole approach to this debate has been too reactionary, since MD feedback on NPs (whether good, bad or ugly) is useful to those of use who are interested in shaping the discipline for the future.