OP-ED

MD vs. DNP: Why 20,000 Hours of Training and Experience Matters

As southern states entertain legislation granting nurse practitioners independent practice rights, there are some finer details which deserve careful deliberation. While nurse practitioners are intelligent, capable, and contribute much to our healthcare system, they are not physicians and lack the same training and knowledge base. They should not identify themselves as “doctors” despite having a Doctor of Nursing Practice (DNP) degree. It is misleading to patients, as most do not realize the difference in education necessary for an MD or DO compared to a DNP. Furthermore, until they are required to pass the same rigorous board certification exams as physicians, they should refrain from asserting they are “doctors” in a society which equates that title with being a physician.

After residency, a physician has accrued a minimum of 20,000 or more hours of clinical experience, while a DNP only needs 1,000 patient contact hours to graduate. As healthcare reform focuses on cost containment, the notion of independent nurse practitioners resulting in lower healthcare spending overall should be revisited. While mid-level providers cost less on the front end; the care they deliver may ultimately cost more when all is said and done.

Nurse Practitioners already have independent practice rights in Washington State. In my community, one independent NP has had 20 years of clinical experience working with a physician prior to going out on her own. Her knowledge is broad and she knows her limits (as should we all); she prominently displays her name and degree clearly on her website. This level of transparency, honesty, and integrity are essential requirements for working in healthcare. Below is a cautionary tale of an independent DNP elsewhere whose education, experience, and care leave much to be desired. I thank this courageous mother for coming forward with her story.

After a healthy pregnancy, a first-time mother delivered a beautiful baby girl. She was referred to “Dr. Jones,” who had owned and operated a pediatric practice focused on the “whole child” for about a year.   This infant had difficulty feeding right from the start. She had not regained her birthweight by the standard 2 weeks of age and mom observed sweating, increased respiratory rate, and fatigue with feedings. Mom instinctively felt something was wrong, and sought advice from her pediatric provider, but he was not helpful. This mother said “basically I was playing doctor,” as she searched in vain for ways to help her child gain weight and grow.

By 2 months of age, the baby was admitted to the hospital for failure to thrive. A feeding tube was placed to increase caloric intake and improve growth. I have spent many hours talking with parents of children with special needs who struggle with this agonizing decision. It is never easy. A nurse from the insurance company called to collect information about the supplies, such as formula, required for supplemental nutrition. Mom was so distressed about her daughters’ condition, she could not coherently answer her questions. As a result, the nurse mistakenly reported her to CPS for neglect and a caseworker was assigned to the family.

Once the tube was in place, the baby grew and gained weight over the next three months. At 5 months of age, mom wanted to collaborate with a tube weaning program to assist her daughter with eating normally again. A 10% weight loss was considered acceptable because oral re-training can often be quite challenging. As this infant weaned off the tube, no weight loss occurred over the next two months, though little was gained. She continued to have sweating with feeds and associated fatigue. On three separate occasions mom specifically inquired if something might be wrong with her daughters’ heart and all three times “Dr. Jones” reassured her “nothing was wrong with her heart.”

However, “Dr. Jones” grew concerned about the slowed pace of weight gain while weaning off the feeding tube. Not possessing the adequate knowledge to recognize the signs and symptoms of congestive heart failure in infants, he mistakenly contacted CPS instead. After being reported for neglect a second time, this mother felt as if she “was doing something wrong because her child could not gain weight.” This ended up being a blessing in disguise, however, because the same CPS worker was assigned and recommended seeking a second opinion from a local pediatrician.

On the first visit to the pediatrician, mom felt she was “more knowledgeable, reassuring, and did not ignore my concerns.” The physician listened to the medical history and upon examination, heard a heart murmur. A chest x-ray was ordered revealing a right-shifted cardiac silhouette, a rather unusual finding. An echocardiogram discovered two septal defects and a condition known as Total Anomalous Pulmonary Venous Return (TAPVR), where the blood vessels from the lungs are bringing oxygenated blood back to the wrong side of the heart, an abnormality in need of operative repair.

During surgery, the path of the abnormal vessels led to a definitive diagnosis of Scimitar Syndrome, which explains the abnormal growth, feeding difficulties, and failure to thrive. This particular diagnosis was a memorable test question from my rigorous 16-hour board certification exam, administered by the American Board of Pediatrics. If one is going to identify themselves as a specialist in pediatrics, they should be required to pass the same arduous test and have spent an equivalent time treating sick children as I did (15,000 hours, to be exact.)

A second take away point is to emphasize the importance of transparency. This mother was referred to a pediatric “doctor” for her newborn. His website identifies him as a “doctor” and his staff refers to him as “the doctor.” His DNP degree required three years of post-graduate education and 1,000 patient contact hours, all of which were not entirely pediatric in focus. His claim to have expertise in the treatment of ill children is disingenuous; it is absolutely dishonest to identify as a pediatrician without actually having obtained a Medical Degree.

The practice of pediatrics can be deceptive as the majority of children are healthy, yet this field is far from easy. Pediatricians are responsible for the care of not only the child we see before us, but also the adult they endeavor to become. Our clinical decision making affects our young patients for a lifetime; therefore it is our responsibility to have the best possible clinical training and knowledge base. Acquiring the aptitude to identify congenital cardiac abnormalities is essential for pediatricians, as delays in diagnosis may result in long-term sequelae such as pulmonary hypertension which carry with it a shortened life expectancy.

Nurse practitioners have definite value in many clinical settings. However, they should be required to demonstrate clinical proficiency in their field of choice before being granted independent practice rights, whether through years of experience or formal testing. In addition, the educational background of the individual treating your sick child should be more transparent.

Raising our children is the most extraordinary undertaking of our entire lives. Parting advice from this resolute mother is to “trust your gut instinct, and no matter what, keep fighting for your child.” Choosing a pediatrician is one of the most significant decisions a parent will make. This child faced more obstacles than necessary as a result of the limited knowledge base of her mid-level provider. A newly practicing pediatrician has 15 times more hours of clinical experience treating children than a newly minted DNP.   When something goes wrong, that stark contrast in knowledge, experience, and training really matters. There should be no ambiguity when identifying oneself as a “doctor” in a clinical setting; it could be the difference between life or death.

When it comes to the practice of medicine, the knowledge and experience required are so vast that even the very best in their field continue learning for a lifetime.

Some graduating nurse practitioners believe they are equally as prepared as newly trained physicians to care for their patients. The numbers, however, in hours of hands-on training and experience, simply do not back up that assertion. Physicians have at least 11 years of education after high school. By the time we set off to practice independently, we have had a minimum of 20,000 supervised patient contact hours. Depending on the type of training and school attended, a nurse practitioner has had a minimum of 500-1,000 supervised patient contact hours.

Niran Al-Agba, MD

 

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NPWheelsOutdoorsDouglasKatieAJLaurie Walshpseuzieq Recent comment authors
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NPWheels
Member
NPWheels

I believe this is a very good discussion and topic. I am nearly a FNP. I have over 13 years of ER, Trauma, ICU and Flight/CCT experience as a RN. The achieved status the term “Doctor” means to me is beyond what can be stated as I have seen so many Doctors do so many unbelievable things under enormous pressure. Just has I have seen plenty of Doctors do some very stupid things in situations that do not have room for stupidity. It’s quite clear that in many situations Doctors shine and other they do not. However, I would not… Read more »

OutdoorsDouglas
Member

” they should refrain from asserting they are “doctors” in a society which equates that title with being a physician.”

I think every one whose ever graduated with a PhD and works in academia may take issue with that broad and clearly erroneous statement.

KatieAJ
Member
KatieAJ

Also I think I think if there are people out there who actively seek out someone with a PhD in alternative medicine, chiropractors or others who are also typically referred to as doctor, but are able to make the distinction between that and an MD, then they should also be able to make the distinction between a Dr of medicine and a Dr of advanced practice nursing. They are not the same as an MD, their focus is on a holistic approach to treatment just as the focus of the chiropractor is different, and the focus of a dentist, and… Read more »

Niran Al-Agba
Member

Fair enough. I cannot say I disagree.

KatieAJ
Member
KatieAJ

My issue is that the main standpoint of this argument is that it doesnt really matter that they both go to school to earn a PhD, but that it is the experience that makes DNP’s less capable the MD’s. But by that logic, couldn’t a DNP become equally qualified after working an equivalent 6-7 years to that of an MD’s residency? So as long as they’ve had almost a decade of practice under the supervision of a MD, shouldn’t they be just as qualified and a new doctor out of residency?

Niran Al-Agba
Member

Ah, now that is the million dollar question. Medicine used to be an apprenticeship profession, handed down to the next generation in time with experience. You question is a good one. I do believe NPs with many years of experience in the role of independent clinician working directly with an MD, are absolutely more qualified to go out on their own. Now, when are we going to set some boundaries about this?

Laurie Walsh
Member

I am a PNP in a 4 provider practice of 3 pediatricians and myself. We all consult each other all the time. It makes the most sense for excellent patient care. My question is if this baby was admitted to the hospital for failure to thrive at 2 months of age , weren’t the cause of this failure to thrive investigated them? Her cardiac defects should be been found at that admission and work up! It sounds like this was over looked at this time also. The provider at 2 weeks of age should have been concerned about the symptoms… Read more »

pseuzieq
Member

Super interesting discussion. I just graduated a FNP/DNP program, but the culture of the program didn’t necessarily promote the idea of pretending to be on par with MDs/DOs. In fact, lots of us advocated for a residency or fellowship process. Unfortunately, there is rarely financial or university backing for establishing one. The program I was in and the clinical sites I did rotations in simply supported us to do what we *can* do, to the best of our ability. Meaning, if we hadn’t been thoroughly trained to do a procedure or make a certain diagnosis, we defer to those who… Read more »

Niran Al-Agba
Member

Thank you so much for your insightful comments. This is exactly the kind of dialogue we should be engaging in. It would be ideal to collaborate and work together. We all should know our limits for the sake of patient safety. I think your MD/NP is right on. He knows enough to be worried, so am I.

William Vitale,APRN-CNP,MSN
Member

Physicians seem to forget that DNP has had hours and hours of practice at the bedside as RNs Prior to the additional hours in advanced practice education . RNs are not taught to diagnosis but still learn pathology,anatomy,treatment of disease,pharmacology as well as rotation in several areas; pediatric.obstetrics,psychology,internal medicine and others. Nurses are also taught to focus on the whole patient not just the disease.Can you explain to your readers why outcomes of patients who are cared for by advanced practice nurses have just as good outcomes or in some cases better. NP and MDs are held to the same… Read more »

Niran Al-Agba
Member

No one is forgetting the fact that some ARNP’s or DNP’s have had hours of bedside experience, while others have not. What this post is pointing out is #1, they should have that experience prior to going out independently and #2, they should be honest about their educational background. I do not think those are unreasonable suggestions. No one is trying to incite (not insight, btw) fear. The focus should absolutely be on the patient and the outcome. To that end, in this particular case, the DNP did not have many hours of bedside experience, did not specialize specifically in… Read more »

Elizabeth Denver
Member

I think that the DNP did not practice good medicine period. As a new PNP I would have realized something was wrong and gotten to the bottom of it asap. There was no critical thinking done on the specific part of this DNP. It was not about level of education or experience-it was lack of critical thinking. I know plenty of doctors with 20000 hours of clinical experience that still do things like this and I do not think that degree makes a difference.

Allan
Member
Allan

Are you trying to say that a DNP is as likely as a physician to be able to adequately treat all patients?

Niran Al-Agba
Member

You are correct this is an example of not practicing good medicine period. I have been surprised that more PNP’s have not jumped up and down about this. He was not as qualified as a PNP to be managing pediatric patients. Isn’t that the whole point of becoming a PNP, so you can work in pediatrics?

survivormomRN
Member

I am also soon to be NP and have had ~40,000 hours hands-on patient care – way more than any physician. And physician’s 20,000 hrs of “training” are not even comparable to hands-on care of a patient at the bedside, learning subtle cues and trusting your gut when something isn’t right. The MD or DO “training” isn’t the same. There are terrible NPs, PAs, MDs and DOs, and there are also exceptional ones in every field. Don’t generalize. To be dismissed this way is ridiculous – why can’t we all collaborate to fulfill the increasing demand for providers and support… Read more »

Niran Al-Agba
Member

40,000 hours of patient care at 60 hours per week is equal to almost 13 years of practice. I believe you are making my point for me. I am not sure it is more than all physicians as you said, being that many had 20K in training plus have been in practice for 2-4 decades on top of that. However, the larger point is someone with clinical experience at the bedside, examining, diagnosing, and making treatment decisions is a good candidate for independent practice. The point of the piece is #1 bedside experience matters whether that be as an RN,… Read more »

concernedcitizen
Member
concernedcitizen

In the modern age (in which we live, now), the term Doctor is a clinical title, when used in a clinical setting. When someone says, “I finally went to see my doctor this morning about my knee pain,” it’s understood that she isn’t referring to the academic PhD who lives down the street. It’s disingenuous to suggest otherwise, and the only people who are suggesting that “Doctor” in the clinical setting should be obscured are people who do not hold a medical doctorate and are trying to trick patients into thinking that they do.

Niran Al-Agba
Member

Concerned citizen, I couldn’t have said it any better than that! Exactly correct.

jorge512
Member
jorge512

I have yet to meet a doctoral prepare nurse who wants to pretend to be a doctor or to suggest they are one. once we realize that the title Dr. is a legal term given to those who have earned the highest educational degree in their perspective field the territorial concerns will be significantly diminished. as i have stated before no one owns the title of Dr. and no one can stipulate how it is used. now the thing is that over many years the term Dr. has been associated with medical doctor but if we begin to address everyone… Read more »

William Vitale,APRN-CNP,MSN
Member

The term is physician

Niran Al-Agba
Member

*Sigh* So my response to Michael is the discussion is about DNP’s practicing independently in a private clinic setting. It is suggesting transparency be important for patients when choosing a private practice and that there is a significant difference in hours of experience prior to earning the ability to be independent. Maybe you are too young to remember back when many of us trained, but we easily worked 100 hours per week on average, meaning many weeks we put in longer hours than that. Yes, we received 2 weeks vacation per year, so the calculation is correct multiplying by 50… Read more »

jorge512
Member
jorge512

Doctor is an academic title that originates from the Latin word of the same spelling and meaning. The word is originally an agentive noun of the Latin verb docēre [dɔˈkeːrɛ] ‘to teach’. It has been used as an academic title in Europe since the 13th century, when the first doctorates were awarded at the University of Bologna and the University of Paris. This use spread around the world with European universities. Contracted “Dr” or “Dr.”, it is used as a designation for a person who has obtained a research doctorate (e.g. Ph.D.). In many parts of the world it is… Read more »

Niran Al-Agba
Member

Absolutely agree the term is an academic title when in an academic setting. In a private clinic setting, it does not seem to be about teaching; otherwise patients would be informed about the difference between different educational backgrounds of “doctors.” The DNP in this story was not teaching at a university; he was calling CPS on a mother while missing the case of heart failure due to congenital heart disease sitting in front of him.

jorge512
Member
jorge512

the are two issues in the story: one is a concern of who uses the title of Dr. and secondly someone misrepresenting themselves as a medical Dr. anyone who misrepresents themselves should be prosecuted to the fullest extend of the law.

correction Dr. is not an academic title. Dr. is a legal title given to a person who has achieved the highest level of education in their given field (e.g. doctor of dentestry, doctor of veterinary medicine, doctor of education, doctor of medicine, etc).

Niran Al-Agba
Member

Doctor is an academic title denoting level of education. The legalities of using it are variable dependent upon in which country one lives. The point of this piece is that one was misrepresenting themselves as a medical doctor and not clarifying they were a nurse practitioner. There really isn’t a concern about who uses the title if they have a doctoral degree; it is more about the setting in which they are using it without clarification. The second issue in this story is that someone who completes a DNP in general family medicine should not be billing themselves as a… Read more »