Medical Practice

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 (@silverdalepeds) is a third-generation primary care physician in solo practice in an underserved area in Washington State

 

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71 replies »

  1. In every hospital I’ve ever heard of, all patients see an MD/DO doctor. You always see an attending physician, and any NPs are secondary. So if only a doctor and not an NP could pick up on this, how did the doctors in the hospital not see it? That would mean both physicians and NPs were incompetent.

  2. In this debate about whether nurses with a DPN measure up to a physician, just using the number of hours in training, whilst a good argument for physicians being superior, is a weak one. There are more important factors, which are even stronger arguments for nurse practitioners not being equivalents to physicians. Studies show that American nurse have an average IQ of 105, whilst American physicians average 120. Many overseas physicians average 130 IQ scores (my home country). The higher IQs of physicians reflect that it takes highest IQs to graduate from the toughest course at university. Furthermore it also concerns the curriculum content, the depth of information within the courses, and the depth to which the candidate is examined. You just ain’t a medical doctor unless you passed medical doctor exams, and met the other requirements too. To be equivalent to a medical doctor you have to be a medical doctor.
    Another point in this discussion, is that in all 1st world countries, except the USA, it is a crime to misrepresent yourself as a physician to a patient when you are not one. Saying “I am Dr. X” to a patient and not immediately elaborating that you are not a medical doctor will put you in jail. That should be American law too. The public need protection.
    If nurse wants to act as a physician, I think we should open the USMLE exams to nurses and require they also do a physician internship. If a nurse with a USMLE exams and internship wishes to advertise expertise in a sub-field of medicine I think we should open up registrar positions for them for training and give them access to the various America Medical Board exams too. All other first world countries in the world, by law, only permit a physician to advertise a specialty expertise, if they are appropriately certified as trained and examined in that field. A nurse claiming to be pediatric expert, and introducing them selves as “Doctor” without full clarification, would get 10 years in jail in non-American 1st world countries. It looks like quackery still exists in this country.

  3. Any pediatric nurse worth her salt should have been able to diagnose this baby with a CHD, much less a DNP. A good clinical history and an echo would have easily led to a diagnosis. This woman was just a crappy clinician, but not because she was a NP.

    We all have a responsibility as good practitioners of medicine to know our limitations and seek help when necessary. With that being said, there are a plethora of bad doctors out there, some from schools outside of the United States that likely function with little to no oversight.

    Besides, 20,000+ residency hours does not mean anything to me when a physician won’t answer my phone calls in the middle of the night when a patient is coding or when a doctor makes a medication error I have to catch or prescribes narcotics without a valid indication so they won’t be bothered. It’s all just anecdotes, and for every bad NP story you have, I can probably think of a bad doctor story.

  4. Good discussion.
    I just wanted to share my experience for educational purposes. In no way am I saying NPs are better than doctors. However, I am about to start a psychiatric nurse practitioner program after practicing as a registered nurse(BSN) for 10 years. My education consisted of anatomy and physiology, microbiology, chemistry, statistics, and the usual pre-reqs before applying to a RN program. Then in nursing school I had to take pharmacology, pathophysiology, medical surgical courses, and specialty courses. Then 120 hours of clinical practice under the supervision of an instructor.
    When I graduated the nursing board required an additional 120 hours of direct patient care before sitting for the NCLEX. I have practiced as a registered nurse in different settings, but my niche is psychiatric and addiction nursing. Thus, I started looking into psychiatric nurse practitioner programs.
    Psychiatric nurse practitioner programs require at least a year of experience in the specialty. (I have more than a year experience) Yet, before that experience is achieved medical surgical experience is needed before branching out into nursing specialties.
    Having said all of this, I just wanted to make it clear that nurse practitioners are not MD/DO replacements. Licensure, training and scope of practice is different. However my point of sharing experiences is to inform.
    Furthermore, I wish people in the health care field would be more respectful and kind. The bullying and demeaning needs to stop because it is contributing to burnout, mental illness and suicide. There should be more collaboration, communication and teamwork. It’s about the patients. Not our egos.

  5. 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 ask just any doctor to help me with a patient in transport- so there is a difference even amongst doctors they are not all the same. To be clear though- the level of training Doctors receive is unparalleled in the medical field. A fair comparison of training could be comparing a Navy Seal (MD) to a very good personal trainer (DNP or NP)- it’s just not the same. To have a DNP call themselves a Doctor is nauseating to me and I will elaborate.
    My critical care experience has served me very well over the years and I have the respect of Doctors and fellow nurses (as well as medics and techs who are smarter than me in many cases) alike. However, I am not the same nurse as a nurse you meet up on the floor, say on a med-surg floor or in a clinic. We have the same license but we are a very different species if you will. You would be hard pressed to hear a nurse from a clinic try to say he or she is the same as a nurse such as myself or other nurses who have been in the ER, Trauma and ICU trenches for 10 plus years (they are kind of afraid around critical care nurses). This is applicable to the DNP profession from a few perspectives.
    1: DNPs are far from Doctors they just can’t compare themselves and they should not try. There is no way a DNP would be viewed by me or others in the critical care world as the same as an intensivist or an ER Doctor. Its just like trying to compare a primary care MD to an intensivist- that would never happen nor would the PCP act like they are the same as an intensivist. But guess what- that PCP has had 10,000 plus hours of training- so why would a DNP try to compare themselves to a MD when they have had less than 1,000 hrs of training? It makes no logical sense and don’t get me started on the nuances and expertise it takes to be a great Pediatrician.
    2: This is a BIG one. The restrictions of experience for entrance to DNP or NP programs is based on years of licensure, not number of hours worked or where they were worked at. This means a RN with 2 years of outpatient clinic experience who worked part-time and saw 5 low acuity patients a shift is as eligible as a RN who has 13 years of full- or double-time experience, has seen 10-18 patients a shift of mixed acuity. Patient contact hours matter so do years of practice, but patient contact hours are not all the same nor are years spent in a low acuity setting compared to high acuity. This means there a lot of nurses going into NP and DNP programs with very few actual or real patient contact hours.
    3: This one is HUGE. Many of those RNs who have had zero critical care experience and were nurses in areas of healthcare that are not applicable to a provider role are now DNP- Professors at NP schools, because they went to school shortly after graduating RN school. Not all DNP educators fit this category, but I have not had one professor who has critical experience and they are all “Drs” as they insist, we call them in every communication. Their communications and “I had this one patient” examples read like a new grad nurse who just figured out how to treat a simple allergic reaction. It’s frightening that we have DNPs acting as if they are Doctors and they have zero critical care experience and they are teaching NP students to become DNPs and so on. The blind leading the blind online. Imagine how lost the general public is in all of this. This is not the case with medical school and not the case with residency programs for MDs. Their attendings have experience and they don’t have just one attending to learn from. If a resident has 3-4 years of residency, they have a pretty consistent amount of contact hours as another resident in another program has; in addition, they have attendings who have comparable resumes in regards to experience. My instructors are not at the top of their field nor are my preceptors and it shows. The best clinical experience I have ever had was with a 20-year veteran pediatrician who was a MD.
    The credibility of the NP profession is not lacking because of initials after one’s name. The NP profession also cannot gain credibility with the DNP by mastering the APA format. This is because the credibility of the NP profession lives and dies where patients live and die-THE BEDSIDE. The profession lacks credibility because there are not competent experienced nurses going into the NP profession and they are being taught by DNP instructors who were never in the trenches. If this profession wishes to rise to the status of “Doctor” than it must achieve credibility in the medical model where “Doctors” work. Nursing theory is not applicable to a provider role that is expected to function in the medical model. Any “Doctor” should know this- especially DNPs. This is the reality of it all, the “mokita” if you will.

  6. ” 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.

  7. 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?

  8. 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 every other DR. in the health care industry.

  9. 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?

  10. 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 described as tachypnea, sweaty, fatigue with feeding- these are never normal in 2 week old.
    All health providers need to listen to the concerns of their patients and families. Mothers know their children best and have mother intuition. This child and family were mistreated by numerous health care professionals. Thankfully, the mother trusted her intuition and went to a different provider which recognized the problem. An experience Pediatric Nurse Practitioner would have been able to recognize this babies symptoms and taken action.

  11. 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.

  12. 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 can. In my experience, there was never any expectation of taking responsibility for the broader knowledge of the physician specialist. Our lab coat embroidery reads, Firstname Lastname, DNP, FAMILY NURSE PRACTITIONER. I think that’s super important.

    In my clinic, the NPs and MDs very much work cohesively together. The NPs consult the MDs for things outside their training and expertise, and the MDs consult the NPs on things NPs *are* experts at-like patient care delivery. Having 17+ years at the bedside as an RN brought wonderful insight, and assisted me in the beginning of FNP training. But those RN years were *not* spent in the provider role-a COMPLETELY different role. By the end of my FNP training, my RN years actually wound up limiting my thinking in some ways.

    As one of my professors, who started out as an MD, then later got his NP/DNP also said, “NPs better be careful what they’re pushing for…they just might get it, and then some.” Meaning, ultimate responsibility is overwhelming, and NP training is not designed for that type burden.

    Super important to keep the dialogue open on this topic.

  13. So I will respond to your anonymous comment despite your fear to use your own name. First of all, you “Google” something, no plural necessary.

    As for your study, it gathered multiple studies together that met criteria as RCTs. 4/8 conducted in Netherlands, 2/8in England, 1in Canada and 1in the United States back in 2004. Zero evaluated care of children, which is what this case is about. Inclusion criteria were age > 15 or more for all studies reviewed.

    It appears Mid-levels are not trained in how to evaluate the applicability and weight of scientific evidence. Your study citation paradoxically backs up my assertion that no studies have been published in pediatric literature showing equivalent care from independent mid-level providers.

    If you assert my anecdote does not provide science (which is a fair point), then please post something that is scientifically appropriate in response. I am not sure where you work, so for reference, I practice in the US.

  14. Thank you for bringing balance to this discussion. We are going to see a lot more cases like this in the future.

  15. This is one case….this case is used to push a non-scientific backed thought of NIRAN AL-AGBA, MD. When we, our States, look towards the science, it indicates that NPs perform at the level of an MD in certain fields (even excel in others). I think both professions need to work together and learn from each other. Both have different training styles, is one “more correct” then the other? Well in certain fields no…http://www.mc.vanderbilt.edu/documents/nursingoap/files/Quality%20of%20Primary%20Care%20Advanced%20Practice%20Nurses.pdf

    I’m sure if I googles pediatrician harm I would get an article just as snazzy, give it a click-bait title, then throw my level VII evidence backed opinion on it, and proudly reply with “my experience answers”. *eye roll*….what happened to the scientific method people?

  16. Thank you for recognizing the coming storm. The lines are so blurred and the training happening is making DNP’s think they are physicians. I was a nurse before I went to Med school. The hours I spent and years i spent at the bedside did not contribute to my medical training in any way. The things I did as a nurse are NOT AT ALL related to the practice of medicine. The field as a whole has somehow become very good at advertising heroism in what they do. I went into med school with a fantastic GPA in nursing school. Top of my class. On the floors I was told “you should go to.med school”. Guess what…I couldn’t even pass the MCAT. Total flunk. I didn’t know the sciences. I had to retake them all at the University level. The college chem I took in nursing school was not adequate. None of medicine made sense without a firm understanding of the sciences. Yes, if the blood pressure is high, you start a blood pressure medicine. But you need to understand the complex mechanisms happening biochemically to make the blood pressure high and the way that the medicine you choose will impact those and other biochemical processes. The science is what saves lives, the science is what cures diseases, the science is what heals. The nurse practitioners should be fighting too. These online diploma Mills are going to ruin their reputation. No longer is experience required to be a NP. No longer are good grades required. With as little as 500 hours of observership, you can now be a nurse practitioner. And sadly, a few vocal people in each state will get these Independence laws passed, while these new NP’s who fully know their limitations and are afraid of independent practice hide because they don’t want anyone to know just how unprepared they are.

  17. Interestingly enough, Naturopaths tend to identify themselves as such quite readily. This is my larger point of concern. If someone owns a clinic, say Washington Pediatrics, then patients assume the “doctor” there is actually an MD/DO who completed training in pediatrics. Whereas, the “Natural Clinic” makes things a little more obvious that the “doctor” is not an MD/DO and likely a Naturopath. It is the same with most chiropractors, their business names are reflective of their specialty in general ie “Jones Chiropractic” so when a patient arrives they already realize they are seeing a Chiropractic Doctor. My real concern is transparency

  18. 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 pediatric expert. It is dishonest. BTW, it is Dentistry, not Dentestry.

  19. 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?

  20. Yes, it is possible. Their coverage does not cost the same as of yet, because traditionally they have been supervised by an MD/Do. I suspect as more states allow independent practice and some out-of-scope practice issues come to light, we will see cases develop. It will be interesting to watch over time and see what happens. The second issue about the level playing field is there is not exactly a Board Specialty exam for NP pertaining to specific specialties. Therefore, their insurance contracts and licensure is not tied to a maintenance of certification program. Physicians are forced to comply with some of these measures and should begin asking to be exempt from these additional regulations. Otherwise, insurance companies are discriminating against physicians specifically.

  21. I realize that this may be an entirely separate can of worms, but what about the practice rights in Washington state of naturopathic physicians? Naturopaths get to call themselves “doctor.” Eek.

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

  23. Malpractice concerns depend upon state law. In the states I am familiar with a nurse practitioner will require collaberation with a licensed physician. Therefore, their premiums are much less because the M.D. D.O. is also held liable and to a higher level of practice.

    Years ago one of our best surgeons retired, but wanted to assist in surgical operations. His premium was very high and he wanted a premium only to cover the level of an assistant nurse or nurse practitioner. He couldn’t get that lower coverage level.

    The playing field is not level for either side.

  24. Exactly. Malpractice issues with DNP and PAC are the great equalizers of this type of independent practice. Of course DNP and PACs require malpractice insurance, especially if they are ‘independently’ practicing. Think about that, if you feel injured because of negligence on the part of a independently practicing DNP or PAC, how much fun will the malpractice attorney have going over training/experience/”are you a doctor?” questions. All fun and games until that hammer falls. All the “bedside” experience will be put to test, along with certifications, testing, education, etc. How hard would it be to convince a jury that if it were a Board Certified MD that was the treating professional, that the negligence would not have occurred?

  25. 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.

  26. Is it possible for a patient to file a malpractice suit against a DNP?

    I assume it is. One would think paying for malpractice coverage would make practicing as a DNP economically challenging ….

    If it isn’t, this seems like a bit of an uneven playing field. As a patient, I’m not sure I’d be comfortable in situation where I didn’t have recourse / or the same level of recourse

    Any insights?

  27. 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, MD, DO etc. and #2 transparency is important regarding education. Those seem like reasonable suggestions.

    This piece did not generalize, it actually focused on one story and one particular practitioner. No one “dismissed” NP’s as an entire group in any way, shape or form. Why couldn’t this individual have asked for help? (from someone besides CPS) Why did he not realize he was out of his league?

  28. 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 pediatrics prior to independently practicing, and was not forthright about his educational background. Doesn’t that concern you? Would it concern you more if it were an MD/DO opening up a pediatric practice when they completed training in internal medicine?

  29. 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 standard of patient care. The focus should be on the patient and the outcome. We need to work together for the patient,collaboration has been shown to give the best outcomes. The model with the physician “in charge” dose not work well for the patient. Trying to insight fear and worry about names appears that focus is on someone beside the patient.

  30. 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 each other?

  31. 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).

  32. 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 that has the title of Dr. for those who have competed a doctoral degree in any setting the patients will begin to become educated and realize that the title Dr. is not only for medical Dr’s who as clarification have a doctorate in medicine.

    as time passes the patients will begin to associate the title of Dr. with someone who has achieve the highest degree in their perspective field and will learn to ask, read name tags to see what level of care they are receiving.

    i also want to add that the board of registered nursing has specific legal requirements that all nurses must have a name tag that clearly identifies in what capacity they are working.

    for example in the clinic i work dnp’s are given a nametag which clearly identifies their legal title Dr. name and underneath the capacity they work under in my case it clearly in bold letters has the words nurse practitioner.

    in our meetings we all address each other as Dr. in the clinical setting along with our name tags we call ourselves Dr. and add what capacity we work as.

    i assure you that there are no doctoral prepared nurses who want to pass themselves as a physician.

    also, as stated before, no one owns the title of Dr.and as a result cannot apply restricitons on how it is used.

    finally, we can all begin to educate patients what the title of Dr. signifies and as time passes the title of Dr. will simply mean what it is intended to mean… a person who has achieved the highest level of education in their particular field. the title of Dr. is not exclusive to medical doctors.

  33. Yep. You pretty much described my hours during residency minus the thoracic operations. Maybe CHOP had fewer hospitals to cover. 18 residents to cover 3 hospitals. University, children’s, and county hospital.

  34. Dude. Your math skills suck. Really, they absolutely suck. Granted, I have a near Putnam scholar as a son, and we love math in our house, but this is awful. Anyway, hours worked vary by residency. Some adhere closely to the 80 hours/week, some don’t. And, no one really takes sick days. In the old days when I trained we really did start elective cases after midnight, on days when you were not on call. We averaged a bit over 120 call days/year, and averaged well over 100 hours /week. In theory we had 2 weeks off per year. In reality you didn’t always get the second week. You worked post-call. (Did my first thoracic aneurysm after doing 48 hours straight of call, granted I did get a few (meaning 3 or 4) hours of sleep.) So, NIran’s claims are possible. (Though I don’t remember residents at CHOP putting in anything like those kinds of hours once they were out of internship, though their hours were much, much longer than the internal medicine guys. They actually had time to moonlight!)

  35. Thanks to our sharp eyed readers, we’ve recently uncovered a database bug that is causing some users to experience difficulty registering to use the site and/or leave comments on the site. If you’d like to leave a comment and are having issues or would prefer not to register, you can do so here:

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

  37. 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.

  38. 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.

  39. *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 weeks per year. We worked holidays, weekends and each month with a Saturday call we worked for 14 days straight. My longest stretch was 21 days without a single day off and that happened 3 times in three years. We did not attend out of town conferences; I missed my best friends wedding! If I was sick, I pulled an IV pole with fluids alongside me while pre-rounding on patients. I keep hearing non-physicians comment that the hours are unreasonable. Of course they were unreasonable! However, they were not illegal and therefore, this is not only possible, it is what most of us have actually done.

    This is fact, my dear boy, not fuzzy math. You can continue to use a single, narrow example such as anesthesia, however pediatrics (which this post is actually about) is one year of internship and two of residency — all involving children. A DNP is not a pediatrician. Again, straightforward and simple fact.

  40. Thank you for your support! Ah, yes, I am headed in the direction of elimination of Board certification requirements for physicians. I think it is something we should demand if there are other types of clinicians out there in independent practice without the same level of regulation. We should absolutely eliminate MOC on top of everything else.

  41. Dr. Nelson – We should all be humbled at every stage in health care period, from the CNA all the way through the ranks. That is not the point of this post. It really is about the importance of transparency. It is also a first step to asking the question of why DNP have independent practice rights and insurance contract abilities without MOC or other ridiculous regulation, for example. In Oregon, if they are going to pay the same rates for both, we should think about changing our designations as MD’s in order to side-step the MOC requirements after all. That is where I am heading with this….

  42. 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 also used by medical practitioners, regardless of whether or not they hold a doctoral-level degree.
    The primary meaning of Doctor in English has historically been with reference to the holder of a doctoral degree. These particularly referred to the ancient faculties of divinity, law and medicine, sometimes with the addition of music, which were the only doctoral degrees offered until the 19th century. During the 19th century, Ph.D.s became increasingly common in Britain, although to obtain the degree it was necessary to travel to continental Europe or (from 1861) to the United States, as the degree was not awarded in the UK until 1917.
    Regulation of the medical profession also took place in the United States in the latter half of the 19th century, preventing quacks from using the title of Doctor. However, medical usage of the title was far from exclusive, with it being acknowledged that other doctorate holders could use the title and that dentists and veterinarians frequently did. The Etiquette of To-day, published in 1913, recommended addressing letters to
    By the 1920s there were a great variety of doctorates in the US, many of them taking entrants directly from high school, and ranging from the Doctor of Chiropractic (DC), which (at the time) required only two or three years of college-level education, up to the PhD. All doctoral degree holders, with the exception of the JD, were customarily addressed as “Doctor”, but the title was also regularly used, without doctoral degrees, by pharmacists, ministers of religion, teachers and chiropodists, and sometimes by other professions such as beauty practitioners, patent medicine manufacturers, etc.
    The title of Dr. is a legal title given to an individual who has completed the highest level of education in their field. Furthermore, Throughout much of the academic world, the term “Doctor” refers to someone who has earned the highest degree from a university. This is normally the Doctor of Philosophy, abbreviated PhD (sometimes Ph.D. in North America) from the Latin Philosophiae Doctor or DPhil from its English name.
    To conclude no one owns the title of Dr. Also “doctor” is Latin for “teacher” and the title originally had no special connection with medicine. Instead, a doctor was anyone qualified to teach at a university (in medieval Europe teaching qualifications were typically determined by the church). The concept of a formal PhD degree came much later, but it continued this earlier terminology.

    Dr. Jorge L. Trujillo, DNP

  43. 1st year surgical internship 80 hr work week was a light week. ACGME rules are suggestions as anyone in medicine knows….. 20days off but worked 6am to 6pm post call. We did have an hour of lecture on Thursdays. I exceeded SRNA central line requirements at the end of the second month and also did a few trachs
    52wks*80hr*3yrs for the remaining years is greater than 12000hr. We had core lectures of approximately 2-4 hrs a week, usually be senior staff within the rotation. I also wrote a book chapter and published 4 articles, writing mostly at 2am oncall on down time.
    What is a sick day? Any time taken not as a scheduled vacation was either an extra 24 Saturday or tacked on at the end of residency. No exceptions.
    Don’t underestimate my work. Every bit counted. Internship was learning how to recognize crisis and utilize the chain of command. Hours outside of the OR were used to take histories and optimize patients.

  44. *SIGH* Always with the fuzzy math.

    ASA Claims of 12000-16000 hours of training and that CRNAs get an average of 1651 hours.

    Lets start with the ASA Claims of 12000-16000 hours

    So if they meant their residency in anesthesia that is only 3 years which is a total of 26,280 hours counting every hour in that 3 years.

    With their claim of 12000 hours that would mean they would have had to work 11 hours every single day for 3 years straight. (365 x 3 = 1095, 12000/1095 = 11/day)
    With their larger claim of 16000 hours they would have had to work 14.6 hours every day for 3 years straight. (365 x 3 = 1095, 16000/1095 = 14.6/day)

    Now if they consider the hours of their intern year (PGY 1) which has nothing to do with anesthesia it might be a little more possible but still outrageous.

    With their claim of 12000 hours that would mean they would have had to work 11 hours every single day for 3 years straight. (365 x 4 = 1460, 12000/1460 = 8.2/day)
    With their larger claim of 16000 hours they would have had to work 14.6 hours every day for 3 years straight. (365 x 4 = 1460, 16000/1460= 11/day)

    So when we review their clinical gross hours it is still quite unreasonable that they could possibly do 12000-16000 hours in either 3 OR 4 years (if we include the irrelevant intern scut monkey year). This would mean:

    · They never took vacation
    · They never took a day off for other educational opportunities (conferences, lectures etc)
    · They never had a SINGLE DAY OFF during residency and intern year.

    What we know is that the RULES say a resident cannot work more than 80 hours in a week. That is the rule. Therefore:

    3 years of residency straight through maxing the 80 hours a week would be a total of 12480 hours. (52 wks/year x 80 = 12480).
    This assumes no days off, no vacations, working an average of 11.4 hours PER DAY 7 days a week.

    Again this does not appear reasonable or possible.

    Per the UNC chapel hill residency program (https://www.med.unc.edu/anesthesiolo…y/copy_of_FAQ) here is what they say residents ACTUALLY do:

    · Average 55 hours/week
    · 2-3 weekends off a month
    · When not on call, residents are typically relieved from the OR by 4:30pm
    · 3 weeks off each year (15 working days) (weekend off before and after for 9 days off in a row)

    5 sick days/year
    5 days each year for attending national meetings and conferences

    · Each resident will far surpass the minimum number of cases required by the ACGME and can expect to do more than 1,200 cases during their three years of Anesthesiology training. THERE IS NO CASE MINIMUM.

    So now lets do the math with that information.

    · 365 days a year – 5 sick days = 360
    · 360 – 5 meeting days = 355
    · 355 – 15 weekdays of vacation = 340
    · 340 – 48 days (2 weekends a month off) = 292 or 340 – 72 (3 weekends off) = 268

    So what we see here is that a resident could only possibly work between 268-292 days in a year and that depends on how many weekends off they get per month (2 or 3). So to be fair we will average the 2 and call it 280 days worked a year. Now lets do that math.

    · 280 days per year worked / 7 days a week = 40 weeks worked a year
    · 40 x 55 hrs/week = 2200 hours worked per year.
    · 3 years x 2200 hours = 6600 hours worked during residency.

    What we see here is the REAL amount of clinical time gained during an anesthesia residency. This 6600 hours does not include all the time spent at M&M meetings, resident meetings etc. However, we will forgive that and pretend that a resident spends 6600 hours in anesthesia clinical time over 3 years. We are also not removing the hours which could be spent during residency doing an ICU rotation.

    What we now have to consider is how many cases residents do. The UNC program said more than 1200 cases in general for their ENTIRE residency. It is difficult to get exact numbers but the Stanford program does give averages which one can assume since most do not are higher than the average program. (http://med.stanford.edu/anesthesia/e…residency.html)

    · Stanford: 600 anesthetics in the first year, 400 cases in each of the next two years
    · That is a total of 1400 cases

    A resident has an average of 6600 clinical hours in their entire 3 years so then one must do the calculation to figure per case hours.

    If they counted hours like CRNAs do (time in the OR only) then the average case time would be 4.71 hours. (6600/1400 cases).
    Clearly this is not the case, so one must conclude the 6600 hours are simply hours IN the hospital as a resident not actually doing cases.

    So now lets look at CRNA education and do the same calculation.

    · CRNAs are required to have a min of 600 cases in their training period
    · Many Student CRNAs average 900 cases (like Stanford this is the higher end)
    · CRNA programs are 2.5-3 years in length

    Out of the 2.5-3 years of a CRNA program 1.5-2 years are spent in the OR doing cases, lets use the same numbers as UNC therefore:

    · 280 days per year worked / 7 days a week = 40 weeks worked a year
    · 40 x 55 hrs/week = 2200 hours worked per year
    · 1.5 – 2 years x 3300 – 4400 hours during a CRNA training program

    What are some caveats?

    CRNA programs do not rotate 1-2 months in ICU but residency programs count these hours.
    CRNAs come in with a minimum of 2080 hours of work experience (1 year full time) which would bring the “clinical hours” total up to 6080. The average CRNA has 2.5 years experience prior to anesthesia school which would push it to 5200 + 4400 = 9600 hours of ‘clinical hours’.
    CRNA programs currently ONLY count hours doing an anesthetic not the time you are waiting between cases or just being in the facility (the MDA programs count it all)
    It is clear that the ASA has chosen to count all the education from beginning of med school (and possibly pre med) to the end of residency (to reach 12000-16000 hours) and yet they do not count the same for CRNAs to minimize numbers
    These calculations do not include holidays where less providers are needed in the OR and therefore many residents and Student Nurse Anesthetists could be off.

    Conclusions:

    The ASA claims of 12000-16000 hours of anesthesia training are considerably exaggerated
    The ASA claim that CRNAs only get 1651 hours is impossible

    THIS is the masters program, there are more hours for the DNP.

  45. I have read a lot of People defend DNP, Nurse Practitioner education hours as the similar to Physician training. It clearly is not. I Have been an RN since 1989. Graduated Medical School in 2011. I went to medical school instead of Nurse Practitioner training simply because the course outlines and the training was not the same as Medical School.

    I strongly contest the notion that practicing as an RN gives me the same experience compared to a Medical Residency. Except for being in the same clinic and or hospital, there are vast differences between both. Nursing school did not prepare me for the level of practice of a physician. The course work in Nursing school is not the same as Medical school. Some of the subject matter is presented differently, from a nursing not a medical perspective. During Nursing School clinical time was a day an half a week not 24/7 during clerkships and not with physicians but nurses. We are taught care delivery not diagnosing and treatment. I practiced as a trauma nurse, ICU nurse and home care nurse during my career, non of this translated more than 50 to 60% into being a Physician for Patients, there was large gaps in my knowledge and experience despite the vast hours of working for 20 years gave me.

    I get emails every week telling me I can go straight into DNP as an RN online from such schools as University of Arizona
    http://www.nursing.arizona.edu/dnp

    You can enter the DNP as a post-Bachelor of Science in Nursing (BSN) student or a post-master’s (nursing) student. Part-time and full-time options are available. Nurse anesthetist students must attend full-time.

    The BSN-DNP curriculum is a 74-89 credits depending upon the practice specialty selected.
    The MS (Nursing)-DNP curriculum to become a nurse practitioner (NP) is 71-74 credits depending upon the practice specialty selected. Most students will be able to transfer coursework to reduce the total number of credits needed to complete degree requirements.
    The MS-DNP curriculum for those who already are NPs or CRNAs is a 43-credit program.”

    These programs are not similar to medical school and the idea that this “Short cut” into practicing medicine” with the expectation of Physician level practice equality is problematic.

    I see Nurse Practitioners as a vital part of the health care team. The push to be seen as equal to Physicians is misplaced in my opinion. Nurse practitioners should continue to put their efforts into working as part of the medical team, Physicians, Nurses, and pharmacists towards the goal of quality Patient care. WH RN MD.

  46. I suspect that Primary Healthcare will eventually be capitated with an associated all-other, stop-loss protected risk-pool. I wonder how many nurse-practitioners would be willing to take that on as an independent practice or even be allowed to participate. Medicaid support by the Federal government for state by state management of its Medicaid-eligible population might be the starting point. As a matter of professional priorities, I had a nurse practitioner as an associate for 20 years. Her nursing traditions kept us all “humble.”

  47. I think you have chosen two of the main points that should be addressed. It is misrepresenting oneself to patients to call oneself a “doctor” in a clinical (office or hospital) setting as most people will be expecting a physician if introduced as Doctor. Patients should be clearly informed that one is an Advanced Practice Nurse or Nurse Practitioner who has also earned a Doctorate in Nursing. Nurses are exceptional people and should be respected and regarded in high esteem (whether RN, BSN, MSN, DNP or LPN).
    Pharmacists have earned their Doctorate of Pharmacy for 20+ years and do not use the title doctor in the clinical setting as it is confusing to patients and staff. One on one, I will address the PharmD as Dr X out of respect and the title well earned.

    I know NP’s who because of their intellectual interest, acumen and years of practice under the supervision of physicians practicing excellent medicine can practice independently. They know a lot and care greatly plus they know what they don’t know. I have worked with many newly graduated NP’s who are self aware of their clinical training deficiencies (it is a shame schools will graduate by the hundreds but not care to pay preceptors or develop a post graduate training program). Independent NP’s should have similar rigorous requirements to meet such as years of experience or having their knowledge tested at the same level of physicians (for INDEPENDENT practice). If a Doctorate of NP can pass the Medical Boards of the specialty they are practicing, then they will have earned the right to be called Doctor in the clinical setting. (my opinion)
    If not the Medical Board then at least a standardized assessment for all NP’s in their field of choice before going out to practice independently. Otherwise, eliminate Board Certification requirements for physicians. Best statement to close with- Thank you, Niran for your thoughtful words.

  48. Good article. If we are going to have “patient choice” as our mantra for healthcare, then it makes sense to have transparency of training and knowledge so people can make informed decisions. If you want a doctor, you should be easily able to tell which providers are medical doctors and which are nurse practitioners.

    As a side note, I’m always curious why nurse practitioners include their nursing degree as part of their clinical training, since nursing is a completely different job than practicing medicine?

  49. The power of this argument derives from the discrepancy of minimum training requirements. While the profession competence of a nurse practitioner may by excellent, it is markedly less assured if the minimum training requirement is 1000 hours. In comparison, a physician has practiced 20,000 under the guidance of supervision, and competence is more robust.
    The Consense APRN model is a recognition of this problem, and identifies even more severe concerns. Training platforms are inconsistent between states as are licensing requirements. Within individual training programs, the students must fend for themselves to find training rotations, making the proliferation of online NP and DNP programs particularly concerning.
    I am concerned that the DNP is becoming a purchasable title rather than one acquired by diligent study.

  50. There’s another issue here – problem solving skill. Yes, some NPs are good, and some MDs aren’t so much, but if you overlapped the distribution, I think you’d see MDs would be more likely to be better on average. It’s partly, I think, because they are vetted for that on admission to medical school in the first place, and then that skill is honed from day one and throughout their training. Nurse training is heavier on learning procedures, protocols, response to an intervention, etc. Both skills are needed, but in evaluating a complicated situation, problem solving skills are essential. That’s just an observation from a non-M.D., non-nurse dietitian who worked in healthcare for a couple of decades.

  51. Thanks for your comments Elizabeth. I still don’t know why men always assume I am a he, but you are actually the first woman to do it. To the larger point, we should use the clinical hours of expertise for both careers, in fact. Some nurses have many clinical experience years in fields that prep them extremely well to become independently practicing NP’s. The best I have worked with have had time as flight nurses, ICU nurses, urgent care and ER settings. My point is exactly that those with many years in, should be considered more well prepared for independent practice. This particular “anecdote” is about one such situation where a nurse with very little clinical experience (1 year), went back to get his DNP, and after 1,000 shadowing hours, went out into independent practice calling himself a pediatric expert. This is something the NP societies should work to stop, in my opinion, because it is doing us all a disservice.
    I am absolutely in support of quantifying competency equally for MD, DO, and DNP. And I do not believe there is only one way to evaluate that. The medical societies have fallen into that trap and evaluation should be standardized across all disciplines.

  52. Elizabeth, thanks for your comments. Seem to me to be reasoned. The goal of the future of medical care may be, and I think it will be, to get rid of all definitions of the present, of MD, nurse, subspecialty, etc. We need new models for the new age. Information will be available on street corners, patients and the public will be trained in medical decision making, high school students are already practicing making medical decisions and interpreting information. Information management is burgeoning while our social change lags behind. Both MDs and DNPs are stuck in the present paradigm so don’t care which one keeps the crazy system going as it. The issue is, changing it. This debate of what type of person should practice is passé in my view. You are correct; what is good medical practice of the future? It sure ain’t what we now have. I am not a Luddite, but our principles and philosophies are changing, and they should. http://www.uncpress.unc.edu/browse/book_detail?title_id=3788

  53. The premise of this author’s argument is based on an incorrect comparison of clinical experience and the false assumption that time in clinical training translates to competence. He then supports his argument with an anecdote rather than a consideration of the literature. If we are to use hours that build clinical expertise outside of degree requirements (as the author does with residency), then we must consider those for doctorally-prepared nurses as well. The difficulty here is that nurses enter graduate school as licensed professionals with generalist training and often with subspecialty certifications. They may have years of professional practice under their belt and have been part of the team that trains medical residents before choosing to obtain a masters degree or clinical doctorate. It is a rare physcian who doesn’t have a memory of the nurse who stepped in and guided them when their inexperience left them indecisive or worse, unsafe, at the bedside. That is the nurse who typically enters graduate school and that nurse isn’t a blank slate like the average medical student. This is why the training programs look vastly different between medical school and graduate nursing programs. As for the DNP degree, which is the focus of this author’s contentions, these are usually post-masters programs and the nurses who enter them may not only have years of generalist experience but years of advanced practice/nurse practitioner experience as well. An hourly comparison of clinical experience, then, is problematic because it can’t be fully quantified for nurses and is fundmentally different than those required of physicians. On the other hand, competencies, which is the outcome of training, can be quantified. That leads us to the question, “What are the competencies of the MD, DO, DNP, and other doctorally-prepared clinicians and how are they measured?” The idea that there is only one route to competence is outdated and needs to be given up in favor of ensuring that competencies are clearly stated and accurately measured, not only at entry to practice, but throughout a clinician’s career.

  54. Anish, I’m with you 100% regarding site neutral payment, breaking up the large hospital systems and at least slowing down further consolidation among hospitals. The big cost drivers in the healthcare system are hospitals and specialty drugs though surgeons and anesthesiologists can bill at pretty astronomical rates too.

    Regarding NP’s, I think they’re fine for routine care but doctors are preferred for more complex cases obviously. As for rare conditions, everyone can get those wrong. I’ve heard it said that doctors are much more likely to see a rare presentation of a common condition than a textbook presentation of a rare condition. Finally, in some rural areas, NP’s might be the only clinicians who are available for a patient to see, at least at certain times.

    Finally, I think the medical education community could reduce confusion by changing the title of the Doctor of Nursing degree. Maybe they could call it an Advanced Practice NP degree or something like that. I agree with Niran that clinicians shouldn’t use the word doctor unless they have an MD or DO degree. For those with a PHD and destined to teach in an academic environment, Doctor is OK.

  55. No one is suggesting any individual knows everything. In fact, the only thing absolutely necessary to know would have been when to ask for help.

  56. Actually, the program for DNP is not after the masters, it is instead of. The DNP in this story had a bachelors of nursing and then ONLY three years for simultaneous masters and DNP. Considerable experience? 1,000 shadowing hours compared to 20,000? Again, you are free to choose whomever you wish. My point is that transparency is extremely important. This mother believed the primary care “doctor” to be an MD. Why are we not saying Dr. Nurse Jones and leading with honesty?

  57. Actually 80hrs/week x50 weeks = 4000/yr in year 3&4 med school. Internship and residency was 100 hrs/week x 50 weeks = 5000 per year x3. That is 20000 hrs in five years. Not sure how you got 10 but that’s ok. It isn’t ludicrous unfortunately; it is reality for what we have gone through to become physicians. No one is suggesting a professor with a PhD should not be called doctor, though how would you feel if your primary care doc had a PhD in philosophy and no MD? You are allowed to see whoever you want, my point is their educational background should be transparent. Why do you believe it should be a secret?

  58. Little training? A four year degree directly in nursing, BSN, a two year degree to be an NP, then three years for the DNP. All in nursing, all with considerable clinical experience. All graduate courses must adhere to normal grad school ideals ie two ‘C’s and you are out. An MD/DO can have a four year degree in anything, art history as my primary care does for example. Then four years med school, and they aren’t restricted to a B average minimum. As to the old adage: what do you call a med school grad with a “C” average? Doctor.

  59. 20000 hours is ten years. It is ludicrous to suggest you have that much more training etc. No practitioner can have knowledge or experience in every case. Secondly a doctorate cash be earned in many areas MD or IF are not the only ones allowed to be called doctor.

  60. Niran’s point is that some NPs may not know when to call for help. You have ~90 minutes to open up an occluded coronary artery -> findings can be subtle enough to be missed by an ER physician, and even cardiologists. Studies are generally poor at capturing rare, but highly significant events. But its your choice Barry – medicare currently pays 85% to see an NP – you can save the system some money by dropping the physician I know you’re very fond of and find an np to see?

    I think there are savings to be realized in large part from those that extract the lion’s share of the health care budget – large hospital systems that account for 1T of the 3T pie. Medicare could start by starting with site neutral payments that pay hospital outpatient practices the same as non hospital employed outpt facilities. They could then move to actively break up large hospital systems, and use existing anti-trust laws to disallow further consolidation. There are certainly physicians that deliver care at a unit cost that would seem to be very high – my approach would be to bring a dose of reality to hospital systems that operate in a land unplugged from reality (this would have your desired result of reducing physician income as well)

  61. Thanks Anish. It is a delicate topic, commenters may get a little fired up about this one. Rare diseases are difficult for us all, but I am not sure a DNP should be able to call themselves an expert in pediatrics with so little training and have the title “doctor” , which is very confusing for patients.

  62. Barry, this isn’t about all physicians being right or wrong or all NP’s being right or wrong. My piece focused on two main points. 1) It is misleading for patients to call yourself a “doctor” in a private office setting as they do not necessarily know the differences in training and when something does go wrong are not as quick to get a second opinion. 2) Independent NP’s should have some requirements to meet such as years of experience or having their knowledge assessed as physicians already do to ensure the clinical understanding is there or eliminate this requirement for physicians.

    Many NP’s have solid knowledge and years of experience and are excellent clinicians. Of course patients will be satisfied with their care. That point was never in question. I have no problem with them practicing independently either and think many do an excellent job. I am in no way expecting every patient encounter to involve and MD.

    The debate always seems to get boiled down to one versus the other. I am actually saying both are necessary and helpful, however regulations for NP’s should be standardized to assess for knowledge base in their field of choice before going out to practice independently. Otherwise, eliminate Board Certification requirements for physicians.

  63. Even the most renown senior doctors don’t always get it right and occasionally make mistakes. If an NP can provide care that is “good enough” the vast majority of the time at lower cost than an MD, it’s better from a system cost standpoint that they be allowed to do so. I once asked an NP in a retail store clinic what they do when they get a case that they can’t handle. Her answer: “we know how to call 911.” The failing in the case you described is that the NP didn’t now what he didn’t know or wasn’t willing to admit it and the mother didn’t follow her instincts to seek a second opinion soon enough, preferably from an MD, once she determined that the care her child was getting wasn’t good enough.

    I’ve received care from NP’s on numerous occasions and was highly satisfied with their knowledge and expertise. I don’t have any problem with allowing them to practice independently and at the top of their license. We can’t expect every patient encounter to involve an MD because there is a small chance that an NP might make a mistake. Doctors aren’t perfect either.

  64. Thanks for eating into a delicate topic Niran. Objective parties scream protectionism and cite mostly np driven studies showing no difference in care. Unfortunately, rare diseases is a good example where differences in care when it matters won’t be Sussed out in a trial.

    There is clearly a massive gap between minimum training required to become a physician compared to an np. I think the last thing generalists, already under great duress due to reimbursement schemes that don’t value them, need are schemes that devalue them further.

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