How I would end the war between nurse practitioners and doctors

One of the more contentious topics on my site is the scope of practice for non-physician providers, such as nurse practitioners.  This echos the debate on the national stage where leaders of physician organizations, who want to protect their scope of practice, conflict with those of nurse practitioners’, who want to perform the tasks that physicians traditionally have.

Simply Google “nurse practitioner” on this site, for instance, and you’ll see what I mean.

So the results of a recent New England Journal of Medicine survey comes as no surprise.

According to the study,

… nurse practitioners were more likely than physicians to believe that they should lead medical homes, be allowed hospital admitting privileges, and be paid equally for the same clinical services. When asked whether they agreed with the statement that physicians provide a higher-quality examination and consultation than do nurse practitioners during the same type of primary care visit, 66.1% of physicians agreed and 75.3% of nurse practitioners disagreed.

And that’s a problem, considering these two groups will soon be working together in patient-centered medical homes, the supposed future of primary care.  Most nurse practitioners believe they are qualified to lead them.  Physicians disagree.

The president-elect of the American Academy of Family Physicians makes it clear: “Family physicians work with nurse practitioners across the country. They are critical players on the health care team — but they are not physicians. A physician-led patient-centered medical home ensures we have the health care professionals we need and that every patient gets the right care from the right medical professional at the right time.”

Given the shortage of primary care doctors, we should give nurse practitioners the opportunity to earn the responsibilities of physicians.  But how can we ensure that the differences in training (physicians receive almost 4 times as many hours) doesn’t impact patient care?

Unify primary care certification.  Make anyone who wants the responsibilities of a physician and lead a medical home, doctor or nurse, pass the same test.

Consider the Doctor of Osteopathy.  Osteopathy is still viewed with suspicion by some, like this writer at Forbes who says, “osteopathy started out as little more than pseudoscience,” and that, “students enrolling at colleges of osteopathy have lower grades than students entering medical schools, suggesting (though this is not proof, of course) that D.O. schools provide an alternative route to a medical degree for those who aren’t good enough to get into normal medical schools.”

But despite the differences in training, osteopaths have generally been viewed by both the medical community and the public as equal to allopathic physicians.  Why? Osteopaths have to pass the same exams MDs do in order to be board certified.

According to the NEJM survey, most nurse practitioners want to lead medical homes, admit patients, and receive the same pay for performing similar clinical services as doctors.  And given the shortage of primary care clinicians, they should be given the chance to.

Require primary care doctors and nurse practitioners to pass the same certification test. In the eyes of some doctors, this will “legitimize” the ability of nurse practitioners to lead medical homes.  And nurse practitioners who pass this hypothetical test can finally receive the physician responsibilities they want.

Everybody wins.

How I would end the war between nurse practitioners and doctorsKevin Pho is co-author of Establishing, Managing, and Protecting Your Online Reputation: A Social Media Guide for Physicians and Medical Practices. He is founder and editor, KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

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  • http://www.facebook.com/people/Jason-Simpson/100001631757606 Jason Simpson

    NPs dont want that.

    NPs already tried to take the same test, and they failed miserably.

    In 2009, the DNP graduates of Columbia University, the best most recognized DNP program in the world, tried to pass a watered down version of the USMLE Step 3 exam.

    80% of them failed it.

    • icecoldchickenwings

      I am unfamiliar with this experiment. Was it a watered down USMLE 3 or the real deal? Is talk like this from other doctors (Like Kevin) really just mean up to and including Step 3 without any IM, Peds, or FP certification? Most hospitals these days will not let MDs have provileges without board certification?

    • Daniel

      I flipped through an NP review book and found the questions extremely easy in comparison to USMLE practice questions. If the practice questions reflect the actual exams and practitioners’ knowledge base, no contest between NP and MD/DO.

    • Stephen

      Do you have a citation for this study? I can’t find it. Thanks!

  • icecoldchickenwings

    Kevin,

    You say that everyone should take the same certification exam. Do you mean USMLE steps 1, 2, and 3? And if so then that would be equivalent to IM or FP docs being not becoming board certified following that testing? If you are suggesting that they can skip the USMLE 3 part exam and just sit for the Family Practice (or other boards) then that is exceedingly unequal compared to medical students. If they have to take all three steps and then the same board certification exam then what would the difference be other than a different (and maybe cheaper ) school?

    • Erica Newkirk

      Nurse Practitioners sit for two board exams: the NCLEX exam to become an RN and later a board exam within their chosen specialty (Family Nurse Practitioners certify through the ANCC). Physician Assistants sit for a single board exam, the PANCE, and then they take a re-certification 5-6 years into their practice called the PANRE. There are some pretty extreme differences between the three different certification pathways. I think that a single unifying exam would certainly be a step in the right direction. Forcing everyone to sit for every single board exam along the way…well I suppose there wouldn’t be three different types of providers anymore would there?

      As a Nurse Practitioner I would love to have the opportunity to sit for the boards within my specialty. I think that many Nurse Practitioners – and Physician Assistants – would agree. That being said, I also admit that I like the role of the Mid-level, and don’t have any aspirations to practice independently of a supervising MD. Frankly, that’s the whole reason I became an NP in the first place.

      • icecoldchickenwings

        Thank you for the response. I have a better understanding of your training as a result.

      • Jhlavin

        Erica, thanks for your comment and I would agree as a PA in a subspecialty for over 22 years. The only change I would make is dropping the “mid-level” or “extender” descriptors. I practice at a HIGH level and work “in association with”. I make autonomous decisions routinely and bring in the physician as part of our patient care flow. A lot of great comments on this article.

        • Guest

          This is not meant in a snarky way at all, but what would you prefer to be called?

          • Jhlavin

            I would not take it as snarky. It’s an important question. PAs are working towards the “physician associate” descriptor. In fact, this was the original one over 40 years ago and some schools, e.g. University of Oklahoma, still use it. In answer to your question, the term “Advanced Practice Clinician” or “Advanced Professionals”. I think this describes what NPs and PAs really contribute.

        • Guest

          A Physician’s Assistant is not a Physician, just as a Nurse’s Assistant is not a Nurse. Demanding that people pretend otherwise is silly.

          • Jhlavin

            Could not agree more, that is why Physician Associate is the right term for the profession. Furthermore, a physician assistant is not an assistant – seeing us as this is just silly.

  • jayceemd

    Not to take the focus off the main point of this article (which I agree with – if nurse practitioners want the same responsibilities as physicians, they need to be able to demonstrate that they are fully qualified to have them just like any MD candidate in training) – but DO’s and MD’s don’t have to pass the same exam in order to practice medicine. DO’s have to pass the COMLEX and MD’s have to pass the USMLE Steps 1-3. The only circumstance in which DO’s and MD’s are held to the same standard (if we agree that this is accomplished by passing the same standardized examination) is when DO’s want to do their residency training at an allopathic (MD) residency program. I may be mis(or un-)informed, so please correct me if I’m wrong about this.

    • http://www.kevinmd.com kevinmd

      Sorry for not being clearer. I was referring to the same post-residency board certification exams. For instance, both MD and DO-trained emergency physicians take the same exam in order to be board certified.

      Kevin

      • icecoldchickenwings

        Then why would anyone Go to medical school to do primary care. Just go to nursing school, you can work part way through the Nursing degree, and financially it is likely way cheaper.

      • ninguem

        I want to know why the license fee is so much cheaper. If we’re the same, we should have the same cost to the state to regulate. I want my license fee set at the NP rate.

        If our education is the same, I want to pay the NP/PA rate at CME meetings too.

      • jayceemd

        Thanks for the clarification! I was unaware of that fact.

      • Daniel

        The American Osteopathic Association has it’s own set of specialty boards with their own exams. DO physicians that train at AOA residency programs receive training and are tested on osteopathic manipulation.

      • Guest

        In my state (MI) and many others MD and DOs have different board exams.

        Also, that Forbes article was the most un-researched and insulting piece of writing to anyone who practices osteopathy. He continually referred to us as ODs (optometrists), and made many other bogus statements based on nothing other than his uninformed notions about an noble profession that has been around for over a century.

        Kevin, I love your blog. I read it every day. Please please please never cite that article ever again.

      • greatguy999

        But Kevin, I am not sure asking them to take the same tests will address the problem. Not all MDs are qualified to take those tests. Even MDs who graduate from medical schools must satisfactorily go through 3+ years of residency training to be qualified enough to take them. This automatically disqualifies NPs/PAs, etc

        • smallfarm1

          It might be interesting to have a large sample of NP’s take the exam to expand on the early comment about 45 taking the exam.

  • Max E Nurse

    Oh dear… Can’t two groups of professionals with a common goal work together? NP’s do it differently to physician’s and thus vice versa. You seem to be acting like rivals not complimentary clinicians. If NP’s do the same qualifications as drs… they would be doctors…clones of your idea of the superior race of clinicians… Now obviously you think you are perfect and the NP’s are imperfect so you want them wiped out… Hitler had a similar idea! Not the greatest role model…

    • ninguem

      Godwin’s law, first post.

      Congratulations.

      • jayceemd

        If I could “thumbs up” this more than once, I would!

      • Max E Nurse

        Was my comment too good?…it appears to have been deleted! Not enough physician bias?

        • http://www.kevinmd.com kevinmd

          Comments are automatically deleted by the system once it receives a certain amount of flags by the readers.

          Kevin

          • smallfarm1

            Hmmm, Max might be right.

  • frances

    When I had to decide about which of two types of heart surgery to have, neither my excellent cardiologist or the top heart surgeon could advise me, although they described each one. Frustrated, I watched both procedures on YouTube and reached a conclusion but I was reluctant to trust it. I decided to speak with a nurse in the cardiology department of the hospital I told her my reasons and she shared what she’d observed during and after both procedures and how the patients fared. It validated what I’d seen. If you see a nurse-practitioner and you’re not sure you’ve been given the best diagnosis or advice, do exactly what you’d do in that situation with an MD: get a second opinion.

  • rtpinfla

    As a physician, I say go ahead and let NP’s do anything they want. Give them admitting privileges, let them work independently, put them in charge of the medical homes, and even let them consult amongst themselves for complicated cases. While we’re at it, why not let them do surgery if they feel qualified. They can also assume the liability that goes with all that which is OK, since it sounds like they are pretty confident in their capabilities. If a patient believes he/she is getting good care from an NP- that’s OK by me.
    In the meantime, I’ll make sure that the general public knows I am available to them, that I am board certified, that I have at least 4x the training they received, and am therefore probably better qualified to handle more complex problems. There are and will continue to be plenty of patients that insist on getting care from a physician. There will also be some fraction of an independent NP’s patient panel that will eventually come to see me, either because they are referred by said NP (if they are smart enough to know when they are in over there head) or they will come without a referral because they aren’t getting better for whatever reason (if the NP doesn’t know they are in over their head).
    It’s all good.

    • icecoldchickenwings

      You and I share fairly similar opinions on this subject, however this strategy falls apart when you start considering pay for performance. The free standing PA/NP offices will be able to collect a cadre of patients who are not as complicated, who they can spend more time with, get better satisfaction scores, and have an easier time of meeting treatment goals, while all the while turfing the harder cases to MD’s because then they will conveniently not be doctors. Your idea has merit but their training is less. So either the market decides or heaven forbid CMS decides what an NP’s work is worth without working under an MD.

      I worked at a multispecialty group where during a pilot study the Endos had he worst A1cs (had all the complicated/noncompliant patients and would have gotten paid less for diabetes during the study period. I’m with you, but the reimbursement issue needs to be worked out.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        It’s not just the P4P. The underlying assumption that patients will gravitate to better quality may in itself be incorrect because the parallel development of ACOs, managed care and and narrow networks will severely limit people’s ability to choose where they get their care. My guess is that “purchasers” will prefer NPs because they will never pay them as much as doctors, and because they will have a much easier time imposing “cost-effective” protocols on non-physicians. And even if a few doctors are retained in-network, chances are that there will be higher copays for a doctor, partly justified by the skewed performance metrics you mention above, and partly just because they can.

        • icecoldchickenwings

          I agree. The idea holds until you get to compensation.

          • Guest

            Hearing the debates in the comments here reminds me of the types of debates that came up before Walmart would move into a town. The mom & pop stores would say to stay in business they would offer higher quality products and excellent customer service to combat the low prices WalMart would offer.
            The mom & pop stores promptly went out of business when WalMart opened its doors. The consumers had spoken.
            I guess my concerns about the future are 2 fold. (1) Will people care about quality when it will cost more to obtain it? Do most people really even know the difference between the quality of physician care versus the quality of midlevel care? Or will people go where the beancounters tell them to go? Will they be duped into thinking the quality is just as good?
            (2) Will physicians go the way of the mom & pop store? If no one will pay for the service and the bean counters will penalize them for “poorer outcomes” because they will get the tougher cases, how will they stay in practice?
            It’s scary and troubling to me.

          • icecoldchickenwings

            1.) People with money and access will care about quality. Lots of people probably won’t know the difference in quality (see the reportable measures and P4P scenario I described as above.) beyond wanting to see a doctor because PA/NP’s are not doctors. Many people are already told where to go where the beancounters tell them to go (see out of network physicians). Yes they will be duped, I think many doctors (or at least doctor groups) have been duped into the whole ACO and P4P business, because I think it’s just capitation on steroids.

            2.) Primary care physicians will go the way of the mom and pop store. At least free standing primary care pratices will go the way of the mom and pop store. IF they didn’t get herded into corp med or hospital med in the first place, because of facility fees, then they woudn’t be part of the “human resources” department in the hospital system in the first place. Once there they are vulnerable to be replaced by “lower cost” labor which is what your typical hospital CEO/Admin type views a PA vs. an MD any quality differences be damned.

            I don’t think specialists are safe either, lots of cardiology groups now work for a hospital (again lowering reimbursement for healthcare and non-viability of independent practice without facility fees). Low represented specialties such as Endocrinology (5,000), Allergy (5,000), Dermatology? (17,000), and some surgical subspecialties may be safe for awhile as well. Anecdotaly their is more resistance to see a PA/NP for specialty care than primary care.

            But yes, the partnership of big insurance, big government, and big pharma should be scary and troubling to you. Should current trends continue, the free standing small primary care doctors office will soon be a relic equivalent to the black doctor bag for house calls.

          • buzzkillerjsmith

            If you are a med student who goes into primary care, you are a damn fool. And I’ve been a PCP for 24 years come July.

          • Ryan

            With such glowing endorsements like these, it’s no wonder we have a shortage of PCPs.

          • buzzkillerjsmith

            You think it’s bad now….

          • greatguy999

            PCP is a broad term applied to FP, internists, outpatient practice and pediatricians. How about hospitalists?

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            As it should be….
            Note that there are no Walmarts in Manhattan, but there are plenty of fancy boutiques….
            The trick is to begin the infestation were people are already poor and less able to foresee that lower price outlets lead to depressed wages for themselves and even worse poverty. “Quality” is redefined through marketing and PR to mean whatever Walmart owners want it to be. Highly educated and affluent communities know better.
            So where we once had reasonably egalitarian mom & pop shops, now we have two separate systems. This is why I can’t understand why this scheme garners so much support from liberal quarters…

          • icecoldchickenwings

            Because herding doctors into large hospital systems makes them easier to control with P4P and other metrics. Thousands of independent doctor practicies all across the country are much much harder to control than centralized, hospital systems. You work for a hospital you can’t refuse to see Medicare/Medicaid, the fact that a large portion of the money goes to hospitals and administrators is immaterial (is actually self reinforcing because that is who is lobbying for these changes with $$$$). Want to make a change in business or patient care in private practice, have a meeting. Want to make a change as a doctor in a hospital, get ready to slog through months of committee meetings.

          • greatguy999

            I don’t think doctors are likely to go the way of mom and pop shop in a town with a newly established WalMart. Maybe an alternative would be that more doctors will opt out of insurance payments altogether. Price alone does not determine customer behavior, though it is an important consideration. All you need are a few well published cases of egregious mistakes by NPs, and patients will demand better care from MDs.
            Same principle applies to why patients from all over the world still come to America for care. There are cheaper alternatives everywhere. Also, we still have FedEx and UPS thriving, even in the face of the much cheaper USPS.

          • nomidazolam

            As more of us patients get to experience the mid-level providers, we will opt for a real doctor, not some arrogant wannabee. I have a medical blog and I have had to deal with these people for years. I find them unacceptable, simply from a personal viewpoint. You would not BELIEVE the things that crna’s, np’s and the like write in my comments! It used to shock me. I’m sure it shocks my readers. I’ve never seen such behavior from adults, and these people want me to trust them with my life and well-being? Not in this lifetime. The “tude” seems to be fairly widespread among mid-levels.

          • Guest

            What’s the name of your blog? Would love to check it out. I’m a physician, btw. Promise not to make any snarky comments :)

        • rtpinfla

          Very true. I can definitely see serious issues but think compensation COULD be worked out. Indeed, it would HAVE to be worked out. Amongst other things, it would mean eliminating the pay for performance, or at least accounting for the confounders in using these calculations. Even giving performance “bonuses” (rather than imposing penalties) based on A1C’s, lipids, etc. is a horrible idea for the very reasons you cite. If physician access is severely curtailed, I am fairly certain that medium to long term outcomes will eventually start to fall. That’s when the purchasers will feel the cost in higher hospitalization rates and sequale of uncontrolled disease.
          It sounds like the NP’s would expect pay equal to physicians if they are providing the same level of work but I agree the market would never allow that. Their attractiveness to health care purchasers is they they would be considered a cheaper alternative to physicians. They also like to tout that they actually take more time with their patients- but they will eventually fall under the same or even more severe time limitations physicians currently face since their panels would be “uncomplicated”. They will find that they will NOT be able to have their cake and eat it too. How about a 10 minute visit or even 7 minutes? To the NP’s I would say, “Be careful hat you wish for, you might just get it”.

      • njfamilydoc

        agree

      • greatguy999

        Sounds similar to our approach to educating our kids: punish their teachers for our kids’ failings. Which doesn’t just make any sense.
        P4P will ultimately benefit the NPs, followed by primary care, but will punish the subspecialists the most, because the higher the hierarchy the more complicated the cases and therefore the less satisfactory the results will be.

    • NPforever!

      When NPs talk about expanding their scope of practice, they never talk about MDs being “smart enough” or “in over their head”, or about insulting MDs at all. As a NP who has worked at 2 top hospitals in Boston (Brigham and Women’s and Mass General), I have to say thank goodness the physicians that work there do not engage in this type of nonsense. There are MANY NPs employed throughout MGH and there are NP run units and ICUs – who take care of all the cases. Not to mention the SICU at Memorial Sloan Kettering Cancer Center that incorporates NPs and residents. The “easier” cases are not delegated to the NPs. Yes this has nothing to do with medical homes, but the concept is similar. The NP and MD are separate entities with separate roles that should respect each other and make valuable contributions toward patient care. Like you said, there are plenty of folks who will want to be under the care of a physician. You can still get your point across without trying to insult another profession. Although tone cannot be conveyed in a blog, it does come across a bit bitter, angry or threatened. I think this is where the physician will lose every time – with ridiculous comments and extreme what ifs

  • Ryan

    Board exams are all well and good – information is just that – data that can be learned. What I want to see is the information in practice. The integration of all the data gathered through years of education (whether it be nursing/NP school or medical school).

    An extreme version of what is currently the USMLE Step 2 CS would be excellent. Numerous, in-depth patient scenarios to test actual practice, not just book knowledge.

    • Elvish

      USMLE 2 CS is a joke.
      We need something like PACES of RCP-UK for everyone who wishes to practice medicine independently.

      • greatguy999

        Have you seen USMLE step 3 CCS?

        • Elvish

          Are you comparing a computerized test to PACES ?
          You can always check a box for Ophthalmoscopy or ECG on a computer and get some numbers back. It is easy.

          -Do you think the average resident nowadays is able to classify hypertensive retinopathy on an ophthalmoscopy ?
          -Do you think the average resident will be able to comfortably interpret a CXR ?

          Remember, most residencies now, require residents to take Step 3 by the end of the first year.

          It would be interesting if we switch to something like PACES, NZREX clinical or even PLAB 2.

  • PrimaryCareDoc

    The comments on that allnurses link are scary. They seem to think that the fact that only 50% passed is indicative of it being a bad test, rather than the fact that they are not qualified. The fact is, the first time pass rate for MDs taking the USMLE is 97%. I passed with flying colors and I didn’t even study for it. I didn’t have to, because my med school and residency experience had prepared me so well.

    • Mika

      If 50% failed it, it’s obviously too hard and must be dumbed down even further.

      /sarc

    • Guest

      Amusing also is that (1) the questions were watered down and (2) the passing requirement was lowered and (3) 50% still couldn’t pass.
      I don’t think a person in here has issue with NPs or DNPs practicing on a patient care team. It’s their demands for equality with physicians that’s so offensive! Either do the same amount of school or take the same exams, but don’t demand equality unless you earn it.

  • http://twitter.com/Cholerajoe Dr Roy Arnold

    If NP’s and MD/DO’s have the same qualifications, why do I as a General Internist keep receiving NP referrals for patients who are “too complicated?” I haven’t yet received such a patient from an FP.

    • ninguem

      Do you accept the referrals?

      • Mengles

        And even more importantly, will he accept referrals once P4P goes into effect, as described by icecoldchickenwings.

        • Dr. Drake Ramoray

          Icecoldchickenwings is now Dr. Drake Ramoray

          • ninguem

            What happened, you ran out of wing sauce?

          • Guest

            Love the new handle

    • Guest

      It is interesting how many physicians expect NP’s to refer with almost every patient to “lower the liability”, and then use those very referrals as evidence that the NP’s cannot handle patients on their own…

  • ninguem

    Nice article chickenwings.

  • Elvish

    “Require primary care doctors and nurse practitioners to pass the same certification test.”

    Can Nurse Practitioners apply for the examinations of the Royal Colleges of Physicians in the UK and Ireland ?
    The answer is NO.

    Two reasons why many are suggesting that Primary Care should be managed by non-doctors:

    1. They don`t know how challenging primary care is .
    2. Primary care training is deficient and simplified in the United States.

    Only in America, doctors have to fight nurses for turf.
    This is the rock bottom for American physicians.

    • buzzkillerjsmith

      Maybe not rock bottom. Give it a few years before making the call on rock bottom.

  • Fourth year med student

    Are insurance companies willing to insure NPs? If the tort system remains in its current state, an independent NP in obstetrics for example has the same liabilities as an ob/gyn physician. If they cannot acquire malpractice insurance at a sustainable rate, then this entire argument is moot.

    Just finished up my risk management course and I thought I’d point this out.

    • http://www.facebook.com/cyndee.malowitz Cyndee Malowitz

      Now you do understand that NPs have been practicing completely independent for years in several states. I’m assuming they carry malpractice insurance.

      • Guest

        Do you?

        • Fourth year med student

          No I did not. I am always open to being educated, but it seems like this topic is covered in detail under a different opinion article so I will try to join that conversation.

  • buzzkillerjsmith

    Corpmed grossly overcharges with facility fees and then tries to hire midlevels to save a few bucks on docs. They’ve learned their lesson well: Profit =revenue-costs. Beautiful.

    Corpmed. I should have got an AB in health care management from the College of St. Scholastica in Duluth MN. One of my former supervisors had this eminent qualification. My only consolation is that I once sewed up a lac on her and skimped on the lidocaine (not really but the thought did cross my mind). Of course now midlevels sew up the lacs.

  • David Capo, MD, MPH

    Excellent solution Kevin.

  • http://www.texmed.org/ stlevine

    Texas, long the home of strident battles between physicians and APRNs, has a creative new solution that is about to become law. Our Senate Bill 406 should go to Gov. Rick Perry’s desk for signature this week, with the support of the Texas Medical Association, the Coalition for Nurses in Advanced Practice, and Texas Academy of Physician Assistants.

    It firmly establishes a “physician-led medical team.” The legislation is the result of many months of discussions among TMA, the Texas Academy of Family Physicians, APRNs, and PAs. It establishes a more collaborative, delegated practice that allows members of the health care team to practice to their level of education and training. Physicians, APRNs, and PAs are natural partners in the delivery of appropriate and compassionate patient care. This bill strengthens that partnership.

  • Cheryl Wicker

    For those who say NPs “don’t want” to take the same boards, you are completely mistaken. As a Nurse Practitioner, I would love to take the same boards. It would also force the NP schools to put “meat” into the DNP program so that graduates can pass the boards. It would be the one thing that would encourage me go back to school for my DNP after 19 years of experience as a NP.

    As far as supervision, I would prefer to work with a physician, as physicians I work with would prefer to work with a NP. After 18 years of experience, I have knowledge I can give MDs, especially new ones, as they have knowledge they can give to me. Its all about growing and learning in our profession so that we can give the best medical care to our patients.

    So far, even if I don’t take the standard medical board, why can’t I lead a patient centered medical home? Sure, someone else may have more medical knowledge than I, and a physician should be involved, but I would certainly defer to superior wisdom for the care of a patient.

    • greatguy999

      By the time the DNP put some meat into the DNP program, what do you think you’ll have? A medical school!
      If you lead the medical home, what would MDs do then? be relegated to being consultants?

      • Cheryl Wicker

        MDs would be part of the team such as where I work now. Nobody is the official “leader” though the MD I work with is the Medical Director. I am in charge of quality of care and our office manager is in charge of monetary and staff issues. Not all physicians are leaders. Medical knowledge doesn’t equal leadership.

  • Theresa Bubenzer

    Brilliant. Now, how to make it so?

  • daniel ramos

    Although DO’s are eligible to take the USMLE, they can instead take the COMLEX, therefore it is incorrect to say that DOs and MD’s have to pass the same boards when each respective licensing agency has their own board exam. Regardless, each has earned the right to be called ‘doctor’ regardless of how some might view DO’s. NP’s on the other hand have NOTattended medical school and despite the fact that they some think they can provide care equal or better to that of a physician, they are NOT physicians, they are NPs. Bottom line is that If you want to be called ‘doctor’ and want to be paid as a doctor, you will need to apply to medical school, regardless of how skilled you may view yourself as being.

    • greatguy999

      Aren’t you splitting hairs here? COMLEX, for all intents and purposes, is probably of the same standard as the USMLE, and is roughly equivalent of the test. And, in case you forgot, not all practicing MDs in America took the same tests. Some took USMLE. Others took FMGEMS; some earned MDs; others came in with MBBS. But they are all MDs; just like the DOs.
      But I agree with rest of your arguments.

  • smallfarm1

    Lots of interesting ideas and thoughts here. I’m a newer FNP, 3 yrs old. Was a nurse for 10 yrs before in ICU/CCU and ED. Several things have struck me recently regarding the Doctor vs Midlevel “war.” 1. No consideration of my clinical time as a nurse. 2080 hrs a year for full time employment, 20,800 hrs working next to and with providers and patients. 2. Blatant attacks on NP’s themselves because of the DNP title, such as the bill in FL that will restrict the title “Doctor,” and prevent DNP’s from using the term. 3. Some one mentioned the DNP as not having enough meat. I happen to agree. My wife wonders when I’ll be going back, again, to get my DNP. My answer is not until they provide a clinical leg to the program. I really don’t think I need another Research or Statistics class. 4. I don’t believe, at least in my experience, that NP’s are shy about admitting when they are in over their heads, and not hesitant about referring.
    The plan fact of the matter is next year we are going to have millions of new patients to take care of and Washington did not think to increase the supply of providers. NP’s can certainly help, and lets be reasonable, like allowing us to write prescriptions unhindered.

    • njfamilydoc

      …a simple example of a NP doing an admission for Sepsis (without actually mentioning the word)…
      A/P:
      1. Leucocytosis – ID consult
      2. Tachycardia – Cardiology consult
      3. Abdominal Pain – GI consult
      4. Shortness of breath – Pulmonary consult

      Will start Rocephin and Zithromax at this time. (… even though there is no infiltrate noted on CXR)…

      Now, I don’t mean that every NP is like that but with the large influx of new NPs… this is what I am seeing.
      The issue is when each of the above consultants send their NP to evaluate… or on the other hand… how many doctors to treat or make a diagnosis?

      • smallfarm1

        Oh if I only had those kind of resources to call on at night, or during the day! I work in a CAH. And if the above is really happening, then your institution needs to provide more education. Oh and how about addressing any one of my 4 points?

      • NPforever!

        Well if the NP is actually doing this then that person needs more education or needs to be fired. Sounds like this person is still practicing like a nurse and not a provider. Is this person an inpatient NP? ALWAYS make sure any NP that practices inpatient is an Acute Care NP – not family or adult – otherwise they are WAY out of their element. Take it from me – an acute care NP – there is a HUGE difference in the training. Family NPs are trained for primary care and acute care NPs are trained for inpatient/ICU, differential diagnosis etc.. As a NP, you don’t want to use consults as a substitute for actually thinking and diagnosing a patient. Although I must say – many MDs do this as well…..sadly. Trust me, for as many bad NPs there are just as many bad MDs. Some people just aren’t meant for either profession. A good NP knows the value of a good physician. A good MD knows the value of a good RN/NP! We all must remember that – but don’t let one bad apple ruin the bunch. If there are many bad apples, it’s time to reevaluate what type of training and background you need to suit a particular position. Remember it’s QUALITY, not QUANTITY. Many years of experience is no substitute for clinical judgement/critical thinking skills or intellectual curiosity. Some people just don’t have this no matter how many years they have under their belt.

    • njfamilydoc

      1. No consideration of my clinical time as a nurse. 2080 hrs a year for full time employment, 20,800 hrs working next to and with providers and patients. – but not as a physician writing the orders. I’m sure you can put an IV line or reposition the better than any MD out there but just like an internist is not a surgeon and a chiropractor is not an orthopedic surgeon, similarly a NP is not an MD… are some NPs better than some of the MDs out there… absolutely… and I’m sure you are one of them and maybe some of the people that you work with agree with this… but how do you prove that to the others who don’t know you: take the USMLEs and let the courts hold you in the same regard as an MD in case of a lawsuit… then, and only then, welcome to the club! You can even take my job… in this environment… maybe you will have fun…

      2. Blatant attacks on NP’s themselves because of the DNP title, such as the bill in FL that will restrict the title “Doctor,” and prevent DNP’s from using the term. : Well, just like Dentists and Chiropractors are not regarded as “Doctors”… the world relates the term “doctor” to a physician… and if you are not a physician… it would be simply deceitful no matter what logic is used… Ask the common folks if they will agree to call a non physician a “doctor”… or what do the people think when they hear the word “doctor”? If you fall in that category or you are that person… be my guest!

      3. Some one mentioned the DNP as not having enough meat. I happen to agree. My wife wonders when I’ll be going back, again, to get my DNP. My answer is not until they provide a clinical leg to the program. I really don’t think I need another Research or Statistics class. : I don’t care about this… if you want to be a physician… I’m not going to ask you to go to med school… take the same exams and go thru 3 yrs of residency and assume the same liability… that’s more than enough meat…

      4. I don’t believe, at least in my experience, that NP’s are shy about admitting when they are in over their heads, and not hesitant about referring. : If I am working with a NP… I would rather they refer as much as possible to have as many doctors on board to lower the liability risk… although I agree this has nothing to do with trust or level of skill… just as long as my name is on the chart and I’m not there, I want as much protection that I can get in this crazy litigious healthcare environment…

      The example of the NP that I gave below with a better NP would have been as follows in a hospital, although not much different (and a lot of internists are doing the same):
      1. Sepsis – etiology not clear, will start broad spectrum abx and will consult ID.
      2. Tachycardia – likely due to sepsis. A-fib is not ruled out, will call cardiology…
      3. Abdominal pain – CT scan does not reveal any acute etiology. Will consult GI for opinion.
      4. Dyspnea – CXR is neg; mild wheezing noted. Will start resp tx and consult Pulmonary…

      … now it sounds “smart” while doing the same thing anyways… THIS… I agree… anyone can do… :)

  • Your NeighbourlyDr.

    I disagree, an MD is an MD and NP is an NP we just must learn to play fair and stop blurring the lines. Americans must learn from the British, Australians to work in harmony with different professional levels. We have plenty of unemployed eligible American Medical graduates who would love to be trained to work in primary care. They already invested in the Medical School route!

    • Dave Mittman, PA, DFAAPA

      Some neighbor. Your friends count so others don’t.What the heck is that?
      If NPs and PAs are competent-and we are in primary care then Kevin is correct.
      Sorry your friends made poor career choices.
      Dave

    • SzwakyD

      While I can’t speak for Australia, what in the world do you mean by learn from the British??? 10 years ago when I spoke to a group of British Physicians they said mid-levels “would never” come to be in Britain. Even now with the advent of PA programs, they are having a tough time of it. The program at the University of Birmingham closed down after only three years and any graduates have a difficult time finding employment. I know because I precepted several students from Britain here in the states. How are they an example for working together?

  • SzwakyD

    Ummmm, why did you leave PA’s out of this concept?

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