MD vs NP: Principles for a civil online discourse

For busy and opinionated physicians, online comments are both catharsis and a form of self-expression. After all, doctors are in the thick of it. We see how policies affect our patients. We know how politics affect our profession. While traditional editorials require time, editing, and an editor’s decision to publish the piece, online comments provide an easy and instantaneous way for even the most overworked and harried physicians to vent publicly. Seeing one’s opinion stream smoothly from brain to fingertips to computer screen feels good.

It is miraculously simple, but it can be problematic. Amid the stresses of patient care in an increasingly complex health care system, the temptation to unleash anger online can be hard to resist. Making sure our voices resonate with equanimity, with professionalism, with decorum, respect, and tolerance takes work.

In some online discussions, the voices have become ugly.

The highly charged scope-of-practice debate. Consider the debate about whether nurse practitioners should be able to practice independently. Kevin Pho regularly features posts by and about NPs. Like bees to nectar, a post on the topic is sure to draw dozens of anonymous, hate-filled comments. As Pauline Chen related recently in the New York Times, there’s a sizeable gulf between doctors’ and nurses’ assessments of the training, skills and abilities of NPs.

That’s putting it mildly.

When one of us wrote an article advocating independence for nurse practitioners, a reader (a doctoral-trained nurse practitioner) responded via email — an articulate, smart, knowledgeable, and witty response that not only illuminated one nurse practitioner’s perspective, but offered a glimpse into the nurse practitioner alternative universe that physicians know so little about. The correspondence inspired the reader to add to the public conversation by writing his own advocacy piece.

Within hours of his posting, there was so much hate speech directed at him — including a complaint sent directly to the president of the university where he works — that he feared for his safety. He had the piece taken down, effectively silencing himself.

It’s not hard to understand that some doctors feel directly threatened by nurse practitioners seeking to practice to the full extent of their education. “How,” some primary care doctors ask, “can someone with significantly less training, and very different training, do the same work as well as we do?” Many commenters (both physicians and other readers) cite anecdotes, perhaps unwittingly overlooking the canon of research demonstrating equal or better patient outcomes between physicians and nurse practitioners. Anecdotes can be a reasonable springboard for meaningful dialogue but they cannot be the only source of data. An angry anecdote is the lowest form of evidence; not surprisingly, responses may be divisive and escalating.

Change is occurring so quickly in American health care that many physicians feel that they are drowning. Disabused of their hopes for higher social status and struggling to keep their practices afloat, primary care physicians labor to adapt to each transformation of health care delivery. Even medical organizations like the American Medical Association and the American Academy of Family Practice that preach collaboration among specialties draw a line at welcoming nurse practitioners as partners rather than subordinates.

If nothing else, doctors and nurse practitioners can surely agree that sniping about characteristics inherent in different professions – professions that share end goals – is counterproductive. Progress can’t happen in a context of disheartening, rude, and sometimes appalling comments. Such vitriol empowers and encourages similar animus in comments from non-physicians. This can legitimize public misperceptions of nurse practitioners and validate physicians’ claims.

Both professions are held to the highest ethical standards in society. If professionalism is truly a core value and competency of physicians and nurses, then we need to practice what we preach. Act professionally. Appreciate other viewpoints as an opportunity to learn. Invite nurse practitioners to the table. Welcome their efforts to improve the health of the nation. And, most importantly, work together for the good of our patients.

Physicians and nurse practitioners can agree to disagree while keeping it civil. The art of listening, after all, is a cornerstone of both medicine and nursing.

Bullying is never the answer.

Principles for a civil online discourse 

The etiquette of online commenting is unusual in that much of the time people add to the conversation and do not return. Occasionally, of course, voluminous dialogue ensues. Here are a few suggestions for keeping online comments civil:

  • Anecdotes are fine, but avoid drawing generalizations from one story. (“We had that dumb NP once. She didn’t know where the gallbladder is located. So NPs must all be dumb.”)
  • Identify the underlying emotion of a comment that irks you, and name it when you respond. (“Doctor Strangelove, it sounds like you’re frustrated that NPs have fewer hours of training and are asking for the same salary as MDs. Here’s my take: ….”)
  • Name-calling is out. Polite, respectful comments are more likely to be taken seriously, and to stimulate a productive conversation. ( “SJ, I appreciate hearing your viewpoint. Here is WHY I disagree with you.”)
  • Own your comments. Instead of making broad generalizations, make it clear that you are offering your opinion. (Rather than saying, “NPs simply should not be practicing without some sort of physician supervision,” say “I don’t think NPs should practice without any physician supervision.”)
  • Consider phrasing your comment in the form of a question. (“I’m troubled by the thought of NPs working in a rural area with no access to collaborating physicians. Does anyone have experience with that?”)
  • Go for the win-win. (“The demographics, economics and politics of health care reform suggest there’s enough pie for all of us in the primary care world. We are all undervalued and overworked. By uniting in cause and working with each other, both groups stand to gain in terms of creativity, relationships, and (dare we say) income.”)
  • Find the best alternative to a negotiated agreement (known as “BATNA” — taken from the classic tome, Getting to Yes). (“NPs are here to stay, with increasing autonomy across more and more states. Let’s find a way to work together — whether you’re a doctor or NP, our end goals are the same.”)

John Schumann is an internal medicine physician who blogs at GlassHospitalAnna Reisman is an internal medicine physician who contributes to Slate. She can be reached on Twitter @annareisman. Matthew Freeman is a nurse practitioner.  This article was originally published in Health Affairs.

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  • Ron Smith

    I’m a thirty-year veteran Pediatrician. I began my first months rotation in the EOPC level 3 neonatal unit at St. Francis hospital (the pink palace) in Tulsa, OK.

    Neonatology was one of the first places nurse practitioners were employed and my experience with them was positive.

    In my ‘solo’ practice today, I employ two nurse practitioners. They are respected and appreciated. They also respect me as a physician. There is none of the sniping that I see hear between the physicians and nurse practitioners.

    They thrive in my practice because it gives them the ability to use and perfect their skills in a place where I’m there for their supervision. They have more confidence because they know that I’m there for them in a something more than a token supervisory capacity.

    For my part, they provide an extension of me in the practice. When they do a good job, they allow us (the whole ‘team’ of providers, nursing staff, and non-nursing staff) to translate all our skills into a great parent and patient experience. I want for my patients and parents what I would want for my daughter and grandchildren.

    Nurse practitioners didn’t get the intense experience of physicians that I got in my residency, but I didn’t get the caring, low level of constant tlc that nurses first learn to provide. These two perspectives are joined together like a hand and glove. We all discuss patient issues and present a unified practice face.

    I love my NPs and I like to think that together we will be a bright spot in the lives of our families and a great place for us all to share the significant part of our lives called ‘work.’

    Ron Smith, MD
    www (adot) ronsmithmd (adot) com

    • NPPCP

      Dr. Smith, perhaps your NP partners do not feel comfortable practicing without some sort of backup. Many physicians feel the same way. They practice in large institutions or other organizations where they have others around them. I think it is honorable to practice up to your level of expertise and comfort. Your NP partners are an example of one practice type NPs prefer. But that is not the only type of practice available to us. Some of us, with years of experience, are comfortable utilizing a team of specialists outside our practice (and no, I don’t over refer or over test). While I am grateful those NPs are available to you, their practice style is only one of many.

      • azmd

        Along the lines of maintaining a civil MD/NP discourse, I would suggest that it’s also productive to try and avoid covertly snarky mischaracterizations. Comparing doctors’ working in large institutions (which are frequently teaching hospitals, which means that the doctors in question are actually there b/c they are holding down prestigious faculty appointments) to NPs needing supervision, is a little (to say the least) insulting to those doctors. There are numerous reasons that doctors choose to practice in a group or institutional setting but feeling a need for supervision isn’t typically one of them.

        • NPPCP

          I meant no disrespect. I am only pointing out that we all practice where we are comfortable. That was the end goal of the post. And I am definitely not saying that all physicians who practice in large institutions are not comfortable with private practice. I am very sorry about that. I know the best and brightest work in places like that.

          • azmd

            Thanks, I think it’s a good example of how well-intentioned remarks can end up being offensive to others, with subsequent suggestions (as above) that people should be censored. You have a right to make statements which I disagree with, and I have a right to point out the way in which I feel that your remarks are inaccurate. Proposing that neither of us have that right, and that we should limit ourselves to sanitized and non-controversial statements, in the end, is censorship.

          • NPPCP

            Doctor, I agree. It is the vitriol and unwillingness to engage in discourse that I am opposed to. But, in the end, I understand that in and of itself is censorship. What I mean is, if you don’t want to talk to me, you don’t have to. I recognize that. Thank you.

      • Ron Smith

        I don’t think that wanting to practice independent of physician supervision was ever what any of the NPs that I’ve know over the years wanted. If that is what you aspire to do then you should pursue that in what is legally recognized by the state or area that you practice.

        In Georgia, that does require a prescribed course of medical study that is different from a nurse practitioner. I would encourage to go forward and get a medical degree and be so licensed. You will likely be quite good at it!

        While it may seem that you reach a comfort level that you feel warrants independence, I would give you my experience that even after thirty years, I do see things that I’ve never seen. In the past when I was a much younger physician it was easy to cross the line into overconfidence.

        What I suggest is that nurse practitioners and physicians not be independent of each other but complementary. My nurse practitioners develop a level of confidence in working with me that makes them excel. It does not make them want to be independent entities though.

        In the course of comparing primary care with specialists, there is not the same comparison. Primary does not mean that you are a lesser qualified provider. It means that you choose a role where you have to be much better at many, many things. I would hazard to guess that my Pediatric GI colleagues that I refer to often would be far less adept at caring for the the women I see all the time who are having problems nursing. They may often have less appreciation for things like well-honed sense of a normal developmental progression for example. Other things could be cited.

        These are not deficiencies. These are honed medical skills adapted to the different roles that we play in the care of the patient.

        It is not useful in medicine I think to have a divisiveness which pits physicians and nurse practitioners against each other. My NPs would do well for example in minute clinics where there is far less supervision, but with me they really get to stretch their clinic skill muscles in a far greater way. They will on occasion teach me new things, but the point is not are NPs qualified to be MDs. That is a legal point as I mentioned that is stated within things like the state boards.

        I think it best to pursue a unified provider front rather than NPs trying to wrest independence from supervision. I want you to be well trained, safe, and have great clinical careers. My grandchildren see our nurse practitioners so I have great confidence.

        I think that is really the only way for all of us to continue to be really useful in our work.

        Warmest regards,

        Ron Smith, MD

        ‘Dr. Ron’

      • Mengles

        The research literature says otherwise, that NPs overrefer, over prescribe, and get too many lab tests and imaging.

        • NPPCP

          Respectfully, no it doesn’t. I would ask you to show me one piece that definititively shows this. Thank you.

    • Mengles

      The issue is not nurse practitioners practicing UNDER a physician as your practice is where “these two perspectives are joined together like a hand and glove.” No one is arguing against that. However, people like Dr. Reisman believe they should practice INDEPENDENTLY. Hence the hand never meets the glove.

      • https://www.facebook.com/arobert6 Alice Robertson

        They already can do that in many states, and it’s going to spread because doctors want it to. Conglomerated medicine wants cheaper labor costs because they claim Obamacare with it’s bundling, etc. is making it extremely hard on them. And doctors run conglomerated medicine.

      • Ron Smith

        Hmm, here are some further thoughts. I don’t think that nurse practitioners should be practicing independently, personally. The educational process is primarily apprenticeship for nurse practitioners as opposed to an immersive forging like red hot metal in a blacksmith’s slack tub for MDs. The two experiences are quite different.

        Beyond that there’s something else that I think is worth considering though. Financially, an NP is likely to do better not working independently than they would be dependently. My practice manager and I were discussing just the other day how that with the Medicaid CMOs, our reimbursement is quite a bit less in the state of Georgia when our NPs see those patients. This is not so for third party insurers.

        I can almost guarantee that NPs are going to be abused by the system if they work independently. Independence may sound good at first financially, but I suspect that it will very shortly be a bitter pill to swallow.

        One of our NPs whose husband works for a railroad recently became pregnant with their second child and they had to relocate to north Atlanta closer to parents. She has interviewed at several practices. They required NPs to see some 40 plus patients a day. They really didn’t have an caring attitude for her either. The reason is that practices get remunerated so significantly less for Medicaid patients, those numbers are required for the practice to justify their salary.

        In our practice she was scheduled just like me and we were all seeing about 25 patients a day. She was doing a great job and had the security and respect within it. She participated in financial work incentives of the practice. We work as a team and have so far weathered the healthcare hurricane pretty well.

        What I foresee if NPs don’t see to partner closely with physicians is that the government is going to abuse them to care for the ever-growing numbers of Medicaid enrollees. Independence from physician supervision will lead to government abuse of NPs almost certainly.

        My perception is that the disrespect that MDs have had for NPs has led to the current schism which has deteriorated into a mud fight about money, qualifications, and other peripheral issues. The truth is that MDs need NPs and NPs need MDs. If we are not unified, the healthcare maelstrom is going to have its way with all of us. If we do become unified then not only can we all make a respectable living, but we can enjoy caring for patients instead of being crushed by the load.

        Warmest regards,

        Ron Smith, MD
        ‘Dr. Ron’
        www (adot) ronsmithmd (adot) com

        • NPPCP

          Dr. Smith, we shall see. This may be true.

  • http://www.myheartsisters.org/ Carolyn Thomas

    Congratulations on such a thoughtful assessment of this disturbing online trend, and particularly for your very useful list of suggestions for keeping online comments civil – no matter what the discussion topic is.

    I’m neither a physician nor an NP, but merely a dull-witted heart attack survivor who has seen my share of the “ugly voices” you cite. These voices are often perfect examples of what Dr. Henry Potts’ study in the U.K. described as “disinhibition”, as reported in the journal, Health Information On The Internet. His take on this issue is that it’s the nature of online communication, the absence of social cues, and the perceived intimacy/anonymity that makes people less inhibited in their online behaviour. Disinhibition, he explains, can be problematic online when it leads to ‘flaming’ (deliberately provocative or insulting comments).

    I have another suggestion to add to your list: if physicians used their real names to initiate/respond to online discussions about NPs (or anything else), it might go a long way to eradicate those “anonymous, hate-filled comments” you mention. See also: “Should Doctors Use Their Real Names on Social Media?” – http://ethicalnag.org/2013/05/10/anonymous-doctors-social-media/

    ‘Flaming’ is the work of the cowardly anonymous. Try signing a hate-filled comment with your own name, docs, and I guarantee you’ll have second thoughts before you click the ‘send’ button. Maybe the prospect of your patients, colleagues, family and friends seeing this hatred exposed in all its naked unprofessional glory will slow you down.

    • Suzi Q 38

      We call those doctors: “Dr. Troll.”
      The ones that are really bad are the ones that choose the name “Guest.” At least pick a fake name that is consistent.

      All this anger released on NP’s is not going to change anything.
      They have a right to work in the U.S. just like anyone else does.

      No they aren’t doctors, but doctors, are not nurse practitioners.

      Some of the posts are so angry and vile that I think that they sound all the more insecure and desperate…unbecoming behavior to any confident physician.

    • buzzkillerjsmith

      Behaviour?! Behavior, please. This is a US-based site. Just sayin’.
      Sorry. That wasn’t really me. It was the disinhibition talking.

  • NPPCP

    I very much appreciate this article. I have owned a private NP practice for three years seeing every kind of patient that walks through the door. We are a chronic disease management clinic. We are successful (healthcare reform hasn’t fully kicked in yet so we shall see). I think my biggest frustration is to see the select few physicians here completely disregard the fact that we are already practicing independently. It is already happening. There is no uptick in lawsuits, no unhappy patients, we fully disclose who we are and require everyone to sign a disclosure agreement that there are no physicians (MDs DOs) in our clinic before we will even see them. One commenter even mentioned at one point that what we do is CRIMINAL. That was very disturbing and had no basis in fact. Another very concerning issue to me is that although there IS plenty of research to study our care, if it is a positive piece of research, the select few physicians here immediately dismiss it as a poor study or “funded by a nursing organization.” Isn’t it blatantly obvious that every piece of research cannot be wrong? These folks know that and continue to tear to pieces despite that fact. I don’t even cling to every piece of these studies but they are not all invalid. Then, there are publicly successful practices like Kim Byars NP. Look at her Facebook page. She is doing incredible work; the very work that society needs. They love her. Her patients love her. But here, and other places? She is nothing but an idiot. How can this be? As I mentioned above, she is already successful. So any anger directed toward her is invalid and untrue. In my practice? I prefer anonymity for OBVIOUS REASONS. Every chronic and acute illness you can imagine is managed there – by two NPs and two RNs. Yes, it is. Our community is so grateful we are here. And we are dumbstruck and honored that they receive care from us. So what is left? Some NPs desire to own their own practice, collaborate with physician specialists, ask for help when they need it – like family physicians do as well. So, be thankful we are willing to take up the task. The old worn out “we are already independent in 17 states and DC” is actually true. This is dismissed by organizations like the California Medical Society. There is direct evidence, every day evidence, evidence in action, against everything they say. It is happening in all of the states around them. There are no safety issues. This is not my opinion – it is a fact. I can imagine if there were a slew of lawsuits against us for practicing “independently”, it would show up here first. But, there are none. Why would a legislature not look at research from the other states, the IOM report, the NGA report, actual practice in action? California again – money. Nothing else, money. Texas and the recent piece of legislation? Money. So, yes NPs will assume a large part of primary care – we already are. There are 6,000 NP owned, NP only practices right now – mine being one of them. So, let’s work together – I, like any other American like independence and freedom. Yet, I go to my trusted specialists like all other caregivers do when it is time. I already work in a “team”. I fully understand it is not the team the AAFP would choose for me, but in the end, it is the exact same team, accomplishing the exact same end goal. Thank you, very respectfully posted.

    • Cyndee Malowitz

      I own a very successful minor emergency clinic (Bay Area Quick Care). I’m thrilled to see other NPs going into business and becoming successful as well!

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

    I think you are trivializing the underlying problem, and I think you are falling victim to the same tactics you advocate others to refrain from.

    The post begins with an anecdotal story about some reactions to some post that presumably caused someone to withdraw some opinion piece published somewhere. While I have no doubt that this happened, I can’t help but wounder if this was a nice, friendly, collaborative and polite opinion piece. I also wonder about the reasons one may have for retracting a nice and polite opinion piece… Never mind…

    More important than the form of this debate is its substance. It is entirely possible that, as you state, physicians feel “[d]isabused of their hopes for higher social status” (is this a polite statement?) and hence the high passions, but I believe the problem is a bit more complex, and it has to do with corporate entities creating a tiered health care system, with one small tier staffed by physicians and a larger tier staffed by cheaper labor. The problem here is not that a nurse or a technician or a herbalist or anyone else can “practice independently”. The problem for the American people begins when health insurers decree that minimum benefits do not include doctor visits or procedures or whatever comes next. It will of course start with Medicaid and the cheap plans offered on exchanges, and it will start with nurses who are hired by corporate entities to practice “independently”.

    I don’t believe physicians will be disabused of anything in this brave new system. The remaining 99% will.

    • NPPCP

      “cheaper labor” – could you not type Nurse Practitioner? Why would you use “nurse” and not “Nurse Practitioner? You know the difference. And why would you include”technician” or “herbalist” in comparison? The reasons are obvious – just wondering. And the article to which the OP was referring was posted HERE I believe. And this DNP was decimated on this blog.

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

        Because the “Nurse Practitioner” problem is just the tip of the iceberg and there are already similar “initiatives” involving other professions such as dental assistants, and because this is not personal. It’s business and it is entirely about cheaper labor.

        • NPPCP

          So, and I am asking respectfully, when its “business”, respect for professions and one another is out the door? I am a business owner, a successful one, and I am still able to treat other professions and colleagues with respect. You always manage to remain respectful to physicians. You never call them “provider” or “expensive labor”. So I’m confused. Is your business them?

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

            I do not call physicians (or NPs) “providers” and I don’t refer to patients as “consumers”. This terminology has a goal in mind, a goal I strongly disagree with.
            Asking people to maintain conversational decorum when the debate involves restricting availability of medical services for most Americans is a bit off mark.
            My “business” is that poor people have unfettered access to a doctor when they need medical attention.

          • NPPCP

            Well, at least we are getting to the heart of it. You won’t come out and say it (your choice), so I will say it for you (sometimes dangerous): Every citizen should have a “doctor” which means physician, NPs are cheap labor tools and not individual professionals in their own right. Physicians are the only acceptable form of care for you and if you MUST see a “nurse”, it will only be under the strictest of physician supervision. I’ll clear that up about you and we can go on. It’s important to know this because you post on almost every article – and you have a personal position and agenda. It is just hard to see because you are not a healthcare professional.

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

            You know, one has to wonder about the reason for this collapse in constructive discourse…..

            I do have a personal position and agenda. Everybody should have a personal position and agenda. The difference here is that I don’t make money from my “agenda”.

          • Guest

            Here is the exact reason these discourses fall apart. Many physicians do not respect NPs and PAs functioning independently and are vocal about it. The NPs and PAs already have insecurity issues about being second class citizens and fight back screaming. The comments devolve into what we are seeing now. Cyndee is the largest physician basher and does so with no qualms whatsoever. That’s fine, it’s her right.

            But we shouldn’t pretend that the physicians are the only ones causing degeneration of civil discourse in these posts. Honestly, it seems the least rational and most screechy are the NPs.

            For the record, I am neither a physician nor NP nor PA.

          • Suzi Q 38

            “For the record, I am neither a physician nor NP nor PA….”

            Since you can’t even choose a fake name, you could be a “troll.”

          • https://www.facebook.com/arobert6 Alice Robertson

            LOL Right so if have no dog in the race…come out…come out …whoever the hell you are!:)

          • Suzi Q 38

            Good luck with Obamacare on the horizon.
            Even Buzzkiller Smith utilizes an NP every now an then.

          • NPPCP

            Yes. I know buzzkiller is a BIG PCMH believer!!

          • Suzi Q 38

            Forgive me, I am only a professional patient.
            What is a PCMH??Primary Care…..??

          • buzzkillerjsmith

            Don’t get me going.

          • buzzkillerjsmith

            Hey! I can speak for myself! I don’t “utilize” an NP. I am treated by one, a very nice and competent one.

          • Suzi Q 38

            Duly noted.
            That is what I meant, but how could you know.
            I seem to remember that you were positive about your NP.

          • buzzkillerjsmith

            That was a joke, S. Sometimes humor (not humour) doesn’t work well on the internet.

          • https://www.facebook.com/arobert6 Alice Robertson

            The only problem is that after my daughter’s pretty rough surgeries for cancer (that a bloomin ENT let spread) it’s the nurses who clean up doctor’s messes for the many days you are at the hospital. The doctors are hard to get ahold of, the residents overworked and can take hours to call the nurse back (because they proclaim they are the doctor’s whipping boys). So patients LIKE nurses…even love them….I can’t tell you how much I rely on them for care for the five days you are there. As a parent you are fearful to fall asleep because the reisdents come in on the weekends (when the doctor is scarce) and if you drift off you miss them. Somewhere there has to be respect for each one, not a demeaning because you went to school longer.

            So some doctors went to school 8 years and some 14 years. How about the anonymous posters start to make up names that reflect their level of disdain for others so we don’t have to weed through some much of your dismissive shite?:)

            There says Alice straightening her skirt, fluffing her hair and wondering if I should start to use credentials when posting? Because she was dismissed days ago by a doctor who goes to extreme measures to only talk to his peers and told me without medical school I guess I don’t have a clue. Why thank you Dr. Arsehole! Ha! Too much fun!

          • Suzi Q 38

            I agree about the nurses. The doctors stop by and say hi with their little entourage of med students.

            The nurses are the ones who care for us for an entire shift.

            Some physicians talk about the lack of respect that they get these days. Maybe they are right. Keep in mind that maybe they need to dish out more respect to others in order to received such.

          • Cyndee Malowitz

            In an earlier post you said this was all about business and cheap labor. You referred to the nurse practitioner “problem” and said that dental assistants might soon be another problem. Now you state that your “business” is about poor people having access to care. ???

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

            Is it so difficult to grasp that “business” is not always about cash, or pieces of some pie?
            And I did not say access to “care”. I don’t know what “care” means in this context.

          • Cyndee Malowitz

            Oh right…you want patients to have access to a DOCTOR who uses your product. I totally get it now.

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

            No, you don’t, but don’t let it stop you…

          • https://www.facebook.com/arobert6 Alice Robertson

            That’s a very good question because the government has infiltrated business at a staggering rate to the point people I know have been hurt. They were middle class but will be poor but the working poor who just lost ten hours a week of pay and their insurance and can’t get government help nor afford the health exchanges.

          • kjindal

            again, voting a comment like this “down” is immature & childlike. What could one possibly disagree with in MGAs post here?

          • NPPCP

            Kjindal, I agree. It is her opinion. Just remember – for even the most thoughtful posts, NPs are barraged with thumbs down. This is child’s play. I know you already know this. But in case you don’t watch in the future.

        • Cyndee Malowitz

          The nurse practitioner PROBLEM? Excuse me? I’ll make sure to forward your comment to the FTC.

          It all comes down to competition. If you can’t successfully compete in a free market, then maybe you should go work for someone else.

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

            Thank you for your civil and collaborative comment, which is completely off target by the way, since I am not a physician.

          • Cyndee Malowitz

            But you make money from physicians buying your product. Aren’t you the owner of “BizMed.” So which is it Margalit Gur-Arie? Do you care more about physicians being able to buy your product or are you more concerned about patients having access to care?

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

            You are funny….. Thanks for the free advertising.

            If you know anything about PCMH, then you know that it applies equally to physicians and NPs. You should have noted that the product is free for individual practices. I make money by helping health plans roll out whatever initiatives they desire and I use that money to help preserve independent private practice.

            Now that we discussed the completely unrelated nature of my business, shall we go back to the subject at hand? You are being used by corporate medicine, and I am not sure why you can’t see that.

          • Cyndee Malowitz

            I’m not being used by corporate medicine. I own a very successful practice and the majority of my patients are paying cash to see me.

          • NPPCP

            Why was the comment deleted concerning the fact that you own BizMed? I don’t understand that? And the nature of your business is very related. You are kind of an anomaly on this site and it is very curious. That’s why I keep asking.

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

            I can’t answer that question, since I am a guest on this site, just like you are. My guess is that there are rules of conduct that all guests are expected to follow.
            Thank you for your persistence in asking the same question. As you can see, I don’t post anonymously. I link to my own blog, but I am not here to promote my company. I am here because, as I said before, health care is something that should concern every person living in this country, and perhaps to a greater extent than it concerns the “industry” itself.

            I know, you may be perceiving my comments to be in opposition to NPs, but I am actually more concerned with the bigger picture, of which NPs practice definitions are just a first step in an insidious grand design to deny as much care as possible to those with limited ability to pay.
            Perhaps it takes an anomalous outsider to see beyond the immediate interests of this or that party, because I can assure you that the end game here is not to replace doctors with nurse practitioners. You are a pretty expensive resource as well, and a few years from now you will be fighting on the other side of this battlefield. It will however be too late. It is probably too late now.

        • https://www.facebook.com/arobert6 Alice Robertson

          You got two dislikes on this. Hmmm…..why is the truth so hard to digest?

      • azmd

        At the end of the day, we docs are “expensive labor” (as we keep being reminded over and over) and by logical extension, NPs, PAs and other midlevels are “cheaper labor.” One of the problems with the healthcare debate is the perception that it’s not all right for a doctor to call a spade a spade, even as market forces are being used to control and limit him or her in the pursuit of a career. Our acquiescence to the idea that it is somehow distasteful for docs to get involved in conversations about compensation and labor costs, has resulted in our not having a place at the table when our compensation and labor costs are being discussed and our professional fates decided by others.

        • NPPCP

          I am more on your side than you know. Moving down the “professional healthcare provider” food chain if you will, NPs feel exactly like you. We aren’t interested in corporations or physician societies dictating our compensation as well.

          • azmd

            Right, that’s why we all need to stick together which pieces like the original post, with it’s condescending tone, don’t exactly facilitate.

        • https://www.facebook.com/arobert6 Alice Robertson

          While doctors will rah rah your rant, I just have to say it’s not what you are making, it’s not that you are vocal it’s the dismissing of patients. You were involved in a thread where I took a terrible beating from anonymous Joe who said he was a doctor and just went beserk and told “Alice” to “Shut up”. You didn’t complain about Joe, but you did about Suzi and my own opinion. Now how is that the patient’s fault for telling the truth? It would seem doctors are still missing the point because they can’t listen to patients.

          • azmd

            I have to say that I honestly don’t remember the thread you are talking about, and if you do, then I think it’s possible you are feeling too personally involved with these discussions…

          • https://www.facebook.com/arobert6 Alice Robertson

            No you have a memory of convenience. Odd Joe didn’t lost posting ability for a day or get ratted on. It was on the “Dear Patients: My skill set no longer matches your needs **Aug 29, 2013 … Alice, frankly I think YOU need to shut up and quit whining. You are so adamant and in need to prove your point. If it’s such a big deal, wh****

          • azmd

            Nope. Still don’t remember. Sorry. Once I see drama developing in a discussion I usually move on.

          • https://www.facebook.com/arobert6 Alice Robertson

            That’s because for some strange reason Joe’s comments were deleted in last few hours. Someone has an alter ego.

          • azmd

            Someone call the ACLU!

          • https://www.facebook.com/arobert6 Alice Robertson

            You would get a better response than you are willing to give to patients who dare to share that doctors have a segment of narcissism running amok and rat on posters in an effort to shut them down. Odd that you don’t complain when patients get personally dressed down, only when people post your doctor’s wages.

          • azmd

            I think you are getting confused between “complaining” and “refuting.”

          • https://www.facebook.com/arobert6 Alice Robertson

            Nope…I don’t mince words…that’s what got me deleted.

          • https://www.facebook.com/arobert6 Alice Robertson

            So no drama alert here when people are ratting to the owner to get comments censored? Okay…I’ll go with that…considering I am on a site that says it encourages lively debate. Yes, until a doctor complains?

          • Mengles

            We’ve seen your posts on the putting down of doctors.

          • https://www.facebook.com/arobert6 Alice Robertson

            Omg….that obvious…and Mr. Anonymous Mengles is so kind in his responses to patients? I have seen some pretty terrible responses from you.

      • Cyndee Malowitz

        The physicians I know have never even heard of “KevinMD,” – they’re too busy taking care of patients. I wonder if physicians are truly the ones behind all these hateful comments geared towards NPs?

        • Guest

          You’ve said this numerous times, but why are people “too busy taking care of patients” unable to read or have knowledge of medical blogs? Lots of people I work with have never heard of these blogs. It certainly doesn’t make them better or worse practitioners (which is clearly what you are inferring).

          Additionally, you are here constantly, so what are you inferring about yourself!!!

          • Cyndee Malowitz

            Ha! The only time I’m able to read this blog is when someone is filling in for me. The only reason I’ve been able to do it lately is because I’ve been in Nicaragua.

          • https://www.facebook.com/arobert6 Alice Robertson

            You know you did well until you got personal. An anonymous poster shouldn’t be allowed to belittle someone who is braver than the anonymous poster by actually putting their real self to their opinion. I really think if a poster wants to get personal then do so under your real name like Cyndee and I do. Otherwise I think it’s a type of foul play to hide under disguise of anonymity while insulting on a personal level.

            By your own measure many doctors and bureaucrats come on here without apology during the day when they are at work. Who cares? If their patients don’t like it let their patients or employer complain.

          • Suzi Q 38

            Alice, you and Cyndee are brave.

        • kjindal

          firstly today is sunday.

          secondly, why does taking care of patients preclude being involved in civil discourse? we all do things we’re interested in, despite our busy work & family lives. I enjoy reading about history & current events, watching movies, TV etc, and reading & contributing to blog sites like this. Your implication that the physicians you know are beneath such activities is disingenuous. Hateful comments on this blog are as often or more often from NPs than MDs.

          Worse still, they are often devoid of a position or idea, and rather purely inflammatory.

        • Suzi Q 38

          The fact is we do not know if they are really physicians. They could be the physician’s Spouse or partner, LOL.

          • https://www.facebook.com/arobert6 Alice Robertson

            Well a lot of them are bloody eejets posting under “Guest” accounts they make and pressing “Like” to their own posts because they are narcissists who would eat themselves if they were a piece of chocolate! Ha!

          • Suzi Q 38

            So true.
            Once in awhile the “guest” is exceptionally nice.
            Even then, I am thinking, which “guest” is this??
            Once I asked “guest” to choose a fake name.
            I gave h/her suggestions..use a pet’s name, for example. She changed her name from “Guest” to “Annie.” I liked that.

            At least I knew which “Guest” I was talking to.

            When they are really vile and rude, I KNOW that they are “trolls.”

          • https://www.facebook.com/arobert6 Alice Robertson

            Yeah such ill-mannered “Guests” who really shouldn’t be invited to the table with such poor manners. At least I will own up to my own struggles….but what’s bothersome is I could make up a “Dr. Peabrain” identity and come here and get respect and the silly doctors posting and responding only to their own breed wouldn’t even know they were posting to someone who is jerking their chain.

  • kjindal

    I find the tone & content of this entire post very condescending. You three must think very highly of yourselves to advise us underlings how to “play nice” on a physician blog site!

    • kjindal

      why would any intelligent thinking person vote this comment down? Do you NOT see the condescension of the original post? Or do you ENJOY being spoken to like a child?

      • Guest

        My comments keep getting deleted!

        • https://www.facebook.com/arobert6 Alice Robertson

          Is your Disqus account shut down completely? My account was, but you can write to them if you desire to.

          • Guest

            Not yet…but another comment deleted.

          • https://www.facebook.com/arobert6 Alice Robertson

            Well that’s because a doctor(s) is upset and the owner is the only one who can do this (or someone can make a guest account and flag you until it’s gone, but that’s not what happened here0. Or as this thread shows find a way a doctor can make money off ya’!:) It was a complete shut down on accounts that left you without posting privileges anywhere…it would be like the top terrorist level to prevent spam. It’s an abuse really…and write to Disqus about it if it’s more than just a comment, or post at Wikipedia or elsewhere). Just keep copies of your posts so they can be reposted because they can only shut your whole account for a short time because of Disqus rules for owners. Or just make an account on someone else’s computer or phone. I mean if it’s a public website like this they can’t shut down every computer in the world to shut up patients. And read quick before we are reported again! Ha!

    • Guest

      I rather agree. The internet, not just medical sites, is like the wild west. Mistreatment and abuse occurs everywhere. If you can’t take the heat, stay away from the blogs where anonymous comments are allowed.

      Nurse practitioner Freeman invites his own scorn by posting openly about his practices that do not meet the standard of care. Then he whines that “doctors are mean!”

      Looking at this thread it should be clear who the nastiest and most vitriolic posters are – the NPs. But, they are still the unappreciated step children of medicine so we must treat them with kid gloves. Why? If they are up to snuff they can prove themselves (and I have no doubt that many of them are excellent).

      • Suzi Q 38

        It is more like some of the insecure and needy physicians like to put them down.

        I am glad that you say that you do not have a doubt that many of the NP’s are excellent.

    • buzzkillerjsmith

      That’s right. If you can’t be mean on the internet, where can you be mean? It’s not as if we’re fighting each other in the streets, which, for the record, I do not advocate.

      That said, this whole NP vs. MD debate is mostly pointless, except insofar as we enjoy being angry and angering others. Minds are not changed.

      • https://www.facebook.com/arobert6 Alice Robertson

        You are right…but the times have changed and there isn’t much that can be done about that. If you go back about three years here you will see doctors just losing their minds over the debate, but it has changed a bit because doctors realized they could work with them. I remember doctors were calling the NP’s “Noctors”. It was a futile debate then and now. The only difference is a doctor isn’t attacked for admitting they work with one and like them. So medicine adapted. Many of my friend’s children are going to college to be Physician Assistants. They believe it’s a great job with a lot of opportunities for them.

        • buzzkillerjsmith

          I started working with NPs 24 years ago, 26 if you count residency. No problems with them except for the incompetent ones. Of course incompetent docs are no bowls of cherries either.

          • ambrozia web

            NPs have long had to deal with that issue: If an NP makes an error all NPs are made to blame. Thank-you for the recognizing and posting about it.

        • ambrozia web

          Many NPs already have the legal title Dr…it’s a degree not a profession. I’ve heard some protest to calling an NP Dr with the idea that the patient won’t know the difference (a long-time argument) I’ve always wondered if psychiatrists had the same issue with psychologists. They are both referred to as Dr, even by MDs. This is not a sarcastic statement…I’m really asking a question.

  • Robert Bowman

    These are good guidelines. A focus on controversy magnified by media outlets for their own purposes can contribute to prevention of problem solving – much needed problem solving with regard to primary care services for most Americans.

    The primary care pie is, however, not big enough for everyone and this is most specific to the needs of the American people. The available primary care pie of spending is too small and the design works for a minority while the majority have limitations in spending and in access.

    Right now we remain in Never Change Land in primary care – a result of decades of designs for training flexible for either primary care or non-primary care result, designs for more support for procedural versus cognitive services, and designs sending too little spending to support enough graduates in primary care careers – especially where they are needed.

  • EmilyAnon

    Who is deleting the comments here so quickly. I tried to respond to a couple posts just minutes after I got the e-mail notification, and the post was already deleted. One was to Alice, the other to ‘guest’ aka Noni. Are these taken down by negative votes? Frustrating.

    • NPPCP

      What is going on? Even the worst flaming posters on here would not want to suppress free speech in order to maintain control would they?

      • Suzi Q 38

        Who censored Alice??
        Did she annoy a physician?
        For all the physicians talk about free speech,
        They censor a patient??
        Why?

        • Anthony D

          Equality at its worse, don’t ya think!!

    • Guest

      Maybe Kevin is moderating this one extra closely to avoid the disaster that happened with Matt Freeman’s previous blog post? Either way, I don’t much appreciate being censored! I’m sure no one does.

  • respect123456

    Well the doctors censored Alice and deleted her comments and banned her from posting. They made her point for her.

    • NPPCP

      No way??!!! Are you serious?

    • Anthony D

      Man, that blows! I guess freedom of speech went out the window huh?

      • NPPCP

        What does this mean? Are you upset about the comments being deleted as well my friend?

        • Anthony D

          “Are you upset about the comments being deleted as well my friend?”

          You got it!

          • https://www.facebook.com/arobert6 Alice Robertson

            All my comments and respects are gone so it is Kevin doing it and it is personal to protect doctors.

            ——————————

          • Anthony D

            But I still see your comments when I click on your user name!

          • Suzi Q 38

            I agree.
            We need her “voice.”
            Physicians should be confident enough to take an opposing opinion or two.

    • azmd

      Actually a number of us doctors have noticed our posts being censored from time to time so I wouldn’t take it personally.

      • Suzi Q 38

        I don’t think that they should be censored, either.

        • https://www.facebook.com/arobert6 Alice Robertson

          No it went beyond censoring. My account was completely shut down and for hours I could see nothing. Disqus says it was owner of the site who does this not them. I couldn’t even see the posts of those I follow or my AlterNet posts because it was a complete non-posting ability.

          • Anthony D

            No, I’m still here! Thanks for asking.

  • buzzkillerjsmith

    The MD-NP conflict is a temporary thing and less important than you might think. We’re in a transitional stage, with still a fair number of general docs even as med students continue to choose subspecialties.

    There will growing pains. They’ll be more MD-NP conflict, mainly limited to primary care, especially an both become enserfed to an even greater extent by CorpMed. Unhappy employees snipe at each other.

    There will also be more conflict as docs perceive NPs taking their business, especially since many docs believe NPs are not qualified to practice without supervision.

    I don’t intend to comment on that point one way or another, but I do think that most NPs do a good job, and, in particular, they get better as they get more experienced, as do MDs and PAs. In any case quality of care is not the main issue here. The issue is medical students’ choices. And those choices are pointing in a particular direction.

    I am saddened by the destruction of my specialty, but that destruction can in no way be laid at the feet of NPs. The destruction is caused by a combination of factors that we have discussed at this site over and over. In any case, the proportion of docs sub-specializing will likely increase. Sure, there’s a lot of chatter these days about the centrality of primary care as the ACA kicks in, but I don’t expect it to last over the long term unless American society has an epiphany. The epiphany that having physicians in primary care is important for the society. I don’t expect that epiphany but have certainly been wrong before.

    In time, perhaps not too much time, seeing a physician in primary care will not necessarily be usual care. In a lot of clinics it’s that way already. At my doc’s office sometimes I see an MD, sometimes an NP.

    • Guest

      I personally don’t see how independent NPs can fare any better than independent docs in the current primary care environment. The reimbursements are terrible and the bureaucracy untenable. So, I honestly have respect for any NP willing to enter into this environment. As long as we all have choices whether we can see an MD, DO, NP, PA, herbalist, chiropractor or shaman for our needs I have no issue with whomever wants to hang up their shingle.

      • buzzkillerjsmith

        Unless your doing only housecalls or concierge or similar, I think solo or two or 3 per group is not workable in primary care med, at least not for me. A bigger group, say 4 to 10, lets you share call and expenses.

        I think the sam dynamic holds for NPs, but you’d have to ask them.

        • buzzkillerjsmith

          you’re, not your, same, not sam. I need a transcriptionist badly.

          • https://www.facebook.com/arobert6 Alice Robertson

            I post from a mobile device and it woks wik a too yer old rote it sometimes! Ha! Just hit “Edit” when you notice mistakes. I do that when I get home to fix the preschool language:) Oh brother…..here we go again……..:)!

  • macbook

    If we don’t agree with NPs practicing in primary care, then we need to stop hiring them or teaching them. I understand why they are being used, but personally, I just don’t agree with the way things are moving in healthcare and I think while it may be “cheaper”, we are justr destroying the way primary care should be practiced. A ton of physicians feel this way. But we are partially to blame for this problem because we hire them in our practices and teach them. If you don’t agree with it, then don’t do either.

    • Mengles

      It has nothing to do with “practicing primary care” as Nurse Practioners are flocking to specialties like Dermatology and Gastroenterology. It has very much to do with a power and money grab. That’s why they first advertised themselves to politicians in legislative bodies (bc they can’t actually do it based on their merits) as being the cheaper option to doctors which would save the healthcare system money. However, now that they are getting their power through legislative fixes, now all of a sudden they want to be paid on par with doctors, thus NOT saving the system money.

      • macbook

        I had no idea that they were asking for pay on par with doctors. That is totally ridiculous (to put it lightly). Not only is that not “cheaper” but that will probably end of up costing the system more in the long run anyway in other ways. And on principal, it’s just not right.

        • Guest

          My understanding is that they were receiving equal pay from some insurers. I don’t think medicaid or medicare pay them equally. But some insurers do which begs the question – where is the cost savings?

        • Cyndee Malowitz

          Macbook – 98% of NPs work FOR physicians. The PHYSICIAN gets reimbursed the “doctor” rate for the NP’s visits. The NP certainly isn’t getting that money – it’s goes into the MD’s pocket.

          Furthermore, NP business owners are NOT getting reimbursed the “doctor” rate – insurance companies are reimbursing us up to 50% less and Medicare reimburses us 15% less for the exact same work. It’s ridiculous – if they’re going to reimburse us 50% less than physicians, then physicians should be reimbursed 50% less for their NPs/PAs visits. It’s going to happen.

      • NPPCP

        One in two FNPs go into primary care. How about physicians?

    • NPPCP

      Again respectfully, this sounds snide, no intention for it to sound that way: our societies would like nothing better than for you to stop precepting and teaching us and hiring us. That is our fastest way to practicing as we are educated on a national level. It would be an iron clad way for us to “gain independence”. I hate that phrase

  • Mengles

    “Many commenters (both physicians and other readers) cite anecdotes, perhaps unwittingly overlooking the canon of research demonstrating equal or better patient outcomes between physicians and nurse practitioners.”
    Really? Please list them with their links that AREN’T advocacy pieces by politicians (who have something to gain with increased political contributions) and Nursing deans (who gain by increased student tuition), and whose outcomes aren’t limited to meaningless time intervals like 6 months

    • Allie

      I agree. We don’t “overlook it.” We critically assess it for its value. I have found that the studies from emergency medicine generally compare NPs to residents where both are being supervised by attendings. The studies from primary care generally identify a few common markers in easily diagnosable diseases to compare NPs and Drs. All of the articles I have read have supported a belief that NPs have a role in supervised care of common illnesses. But, that isn’t what they are being touted as by people with a pro-NP unsupervised agenda.

  • Jason Simpson

    If John Schumann and Anna Reisman really believed what they have wrote, they would immediately resign their positions and let nurse practitioners take over their jobs.

    After all, isnt an NP just as good as they are? Why is the University of Oklahoma paying John Schumann 100k+ in compensation when he openly admits that an NP is just as good as him and will work for far less? Why is Anna Reisman on the faculty of a medical school when she has claimed that she is no better than a nurse with 1/2 of the training?

    Why are we paying these doctors bloated salaries when they have made it plainly obvious that we’re not getting any extra value for their ridiculously high levels of compensation?

  • Mengles

    Wait, was Matthew Freeman’s blog post one in which he missed a FREAKIN’ MELANOMA? And was proud of that fact?

  • pbat

    Here’s a thought–in order for physicians to begin independently practicing/prescribing they must take USMLE step 3. If NPs want to be the equivalent of physicians and practice independently, have them also take this exam prior to being able to do that…..

  • Kaya5255

    Nurse Practitioners and Physician Assistants have a role in healthcare, just not as independents. Their education and training can not be compared to that which physicians receive. NP’s and PA’s should only be permitted to practice under the guidance and supervision of a licensed physician.
    If you want to “practice as a physician”, then you need to go to medical school and get the degree and the license.

    • NPPCP

      Thank you for your opinion. Where I practice and own a clinic, the prevailing opinion and attitude differs. But I respect how you feel.

  • eddy

    Ho hum . . . old news old story. This topic’s come and gone. NPs are on their way to replacing primary care docs. Like it or not, done/s done.

  • http://www.myheartsisters.org/ Carolyn Thomas

    I wonder if any of you commenting here are yet aware that this post is now being followed/shared online – not because of the topic (a valid discussion subject) but because of the sad irony clear to all (except those trolls participating here) of a post about “civil discourse” whose comments are disintegrating into censored replies, intolerance, and cheap insults.

    I’m just sayin’ . . .

  • https://www.facebook.com/arobert6 Alice Robertson

    One other tip before Kevin gets busy deleting is to get a Disqus digest because all the comments are delivered even the deleted ones daily.

  • https://www.facebook.com/arobert6 Alice Robertson

    Because so many people get these posts in your emails I have had contact with Disqus and it’s an abuse what happened yesterday. So get a screenshot and report the abuse (not of the deleted comments…that’s no big deal) Then you can use the screenshot to show the abuse and have something if you desire to go beyond here with postings about the abuses where not just comments are deleted…you can publicly post anywhere like Wikipedia, etc. Okay….this post will expire as soon as one certain doctor’s fingers can put Kevin on high alert to delete…quickly delete…before the public gets informed…omg…..

  • http://www.kevinmd.com kevinmd

    For those who are wondering how comments are moderated, here is my comment policy:
    http://www.kevinmd.com/blog/terms-of-use-agreement

    “Comments to individual posts are encouraged. This is a moderated forum, meaning comments from unverified email addresses are reviewed before they are posted.

    The Site will also not publish comments that, in the Author’s sole opinion, fall under the following categories:

    snarky, off-topic, libelous, defamatory, abusive, harassing, threatening, profane, pornographic, offensive, false, misleading, or which otherwise violates or encourages others to violate the Author’s sense of decorum and civility or any law, including intellectual property laws

    “spam,” i.e., an attempt to advertise, solicit, or otherwise promote goods and services

    make the same point repeatedly

    The Author reserves the right to delete any comment, for any reason, at any time. The First Amendment gives you the right to express your opinions on your blog, not the Author’s.

    Comments that receive a certain number of flags from the readership are automatically deleted.”

  • Morgan

    Nurse practitioners are highly educated health care providers. The nursing model of care is similar to the medical model and includes assessment, diagnosis, outcomes identification, planning, implementation, and outcome analysis. The educational preparation of an NP begins at an undergraduate level and continues throughout their educational and professional careers.

    I have posted below the “core courses” in the ACNP curriculum. Not included below is the admissions examinations for undergraduate consideration in basic sciences and math (ATI TEAS or NET), the requirement for all students to achieve a B or better to maintain enrollment in nursing school, the two sets of boards/licensing exams, and the specialty certifications NPs obtain throughout their training. I just wanted to emphasize that, while NPs approach patients from a holistic viewpoint, their education and practice is not entirely different from their MD peers. They have a grounded science foundation which prepares them for the second step of being a student..their experience as a new clinician. I do not believe any new graduate NP or MD student is experienced enough to practice autonomously, but I do believe there should be an endpoint to both their proctored/guided experience followed by a supported transition into collaborative (not supervised) practice.

    The Nurse Practitioner Pathway: Adult Acute Care

    1. Prerequisites- BSN Admissions: (GPA must be >3.5 in prerequisites)

    Biology, Chemistry, Organic Chemistry, Biochemistry, Statistics, Nutrition, Psychology, Sociology, Cultural Anthropology, Developmental Psych, Life-Span Human Growth and Development, Human Anatomy & Lab, Human Physiology & Lab.

    2. BSN (4 years):

    Clinical Microbiology & Lab, Genomics, Med/Surg Didactic & Clinical, Health Assessment & Lab, Med/Surg Didactic II & Clinical , Clinical Lab, Human Pathophysiology, Pharmacology, OB Didactic & Clinical, Pediatric Didactic & Clinical, Adult Health/Gero I Didactic & Clinical, Psych/Mental Didactic & Clinical, Research, Adult Health/Gero II Didactic & Clinical, Community Health Didactic & Clinical, Ethics

    3. MSN ANCP Courses: (2-3 years)

    Adult Acute Care Theory I, Strategy & Healthcare, Advanced Pharmacology (P695 & P660), Policy & Healthcare, Graduate Research, Graduate Statistics, Advanced Physiology & Pathophysiology, Advanced Health Assessment Lab/Lab Models, APRN Role/Negotiating, Adult/Gero Acute Care Didactic I & Clinical, Adult/Gero Acute Care Didactic II & Clinical, Adult/Gero Acute Care Didactic III & Clinical, Acute/Critical Care Lab (chest tube placement, central lines, LPs, ECG/Dx imaging interpretation, etc), 699 Thesis Project

    4. DNP Courses: (1-2 years)

    Graduate Statistics (800), Epidemiology (802), Scientific Foundations, Health Informatics, Clinical Leadership, Quality & Safety Improvement, Policy Analysis, Thesis/Capstone Defense, Implementation Science (N900), DNP Residency, DNP Capstone

  • Julz7777777

    I agree wholeheartedly with the post. I enjoy reading Kevin MD and I sometimes comment on blogs from my NP perspective. The unfortunate aspect of this site is the outrageously rude and inconsiderate behaviors
    between adults (professionals mind you). It is a shame professional adults need pointers on how to behave appropriately. Maybe instead of competing to see who can dish out the most trash, why don’t we see who can show the most class?

  • Mary Zorzanello

    As an NP, I value the collaborative relationship I have with my physician colleagues in our university-based medical practice. We each respect one another’s experience and abilities, and recognize that we have complimentary skills. We are a team, the goal is excellent patient care within the confines of our current health care system. In addition, I have the highest regard and respect for Anna Reisman, having had personal experience with her outstanding patient centered care.

  • ambrozia web

    Primary care MDs treat patients when specialist and sub-specialists have more education and experience (and volume) to know more. And the specialist (sometimes privately) complain about them too. Same goes for the NP/MD debate, IMHO. NPs do have the knowledge for family practice and with specialty follow-ups. I don’t want to see an NP for the initial diagnosis in a specialist office, that belies the reason I went to a specialist, but for follow-ups and general it works. I believe NPs will dominated family practice as time progresses. And they will work in specialty offices for follow-up care. MDs have always tried to control all the healthcare rules, but I doubt that will work any longer. It might have made sense in the early days of healthcare but many other professions now have a valid education.