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
Categories: Uncategorized
I have noticed that you are quick to correct the grammar and spelling of others. I wouldn’t normally do this, but now I feel compelled to point out that your last comment should read “ARNPs or DNPs.” The practice of adding unneeded apostrophes to acronyms and abbreviations when pluralizing them is common but is nonetheless incorrect.
Its a shame that you feel the need to lie.
20,000 hours divided by 3 years
128 per week for 3 years straight. No vacations.
20,000 hours divided by 5 years. (Giving you credit for your last two years of med school where you do a few weeks rotations in various specialties. You actually don’t get to do very much except watch.
77 hours per week without a single vacation.
You see how easy it was to prove you are a liar? You stated CLINICAL experience. We know the first two years of medical school is all didactic and no clinical.
You’re not really factoring in all the hours of bedside experience that nurses have to have to even get into an MSN-FNP or DNP program. Two years is the minimum for most, so if you’re working full time 4 days on per week (12 hour shifts) for a minimum of two years that’s around 5,000 hours before entering a DNP program. Let’s say the DNP program is 3 years, and since money doesn’t grow on trees you work part time during that, 2 days on per week (12 hour shifts) for 3 years, bringing you to around 4,000 hours. Adding the 5,000 hours of bedside experience before the program, 4,000 hours of bedside experience during the program, and the 1,000 hours of clinical experience required by program, and you end up with 10,000 hours. That’s half of 20,000. Fine. Most people in DNP programs don’t just work as a nurse for the minimum two years before. Let’s say a nurse works full time for 5 years instead of two years, bringing the nurse to 12,000 hours of experience before even entering the program. Let’s assume they also work during grad school, bringing the total to 16,000 hours of bedside experience, and then adding the 1,000 hours brings us to 17,000 hours of bedside patient care experience. You’re also not including the hours of clinical spent to obtain a BSN. You do not get clinical hours of bedside experience from a pre-med undergrad program, but you do from a BSN undergrad program. If you’re going to include all the clinical experience time for MD, then you need to include it for DNP. While pre med students are learning about fish and physics, nursing students are in the hospital. Most programs are 3 years, and all have multiple clinical rotations. Let’s take the main clinicals for example: Foundations, Med Surg I, Med Surg II, Obstetrics, Pediatrics, Psychiatry, Community (specializing in prisons, geriatrics, home care, etc.), and Critical Care. Each one was about 9 hours once a week for 8 weeks on average, coming out to be around 600 hours. In these clinicals you are learning the pathophysiology, etiology, manifestations, diagnostics, medical treatments (e.g. what medications, why, how they work in the specific disorder/disease process, proper dosages, etc.), complications, and nursing specialized bedside care. It also doesn’t include the hours spent outside of the hospital with the patient information learning and creating plans of care expected from physicians and from nurses- I remember one time spending around 7 hours just with one patient’s information one week and being happy it didn’t take so long, but just to count actual clinical bedside experience hours let’s not count those. So undergrad itself adds another 600. Rounding that up to 1,000, considering some programs require more clinical hours, that brings the previous hours to 11,000 minimum, or the more likely 18,000 hours. But even though the most novice nurse has an almost 1,000 hour head start on the new medical student, let’s not factor in those hours, let’s take 1,000 hours off, because this crowd doesn’t seem like one to see the actual value of those hours.
How many of those 20,000 hours are actually spent at the bedside, assessing the patient, physically taking care of the patient, observing and becoming familiar with the gross observations of diseases and disorders? Not as many as the minimum 11,000 hours or much more likely 18,000+ hours have been. Does that mean one is more superior to the other? No. It means just like MD vs DO, a DNP is also specialized, but equivalent and uniquely valuable.
This story is sad, but it’s rare, and shouldn’t speak for all NPs/DNPs. There are of course many problems with DNP and NP programs, but that doesn’t mean there isn’t an equal amount of issues with MD and DO programs. The amount of times nurses have caught crucial assessment findings that doctors have missed, caught mistakes that doctors have made, and have advocated for alternate plans that turned out to be more beneficial than the ones originally ordered by doctors is comical. It’s a joke in the nursing community how often nurses have to correct these mistakes. It doesn’t mean anything is wrong with doctors, it just means that they do not have the bedside experience that nurses have had. They pop in during rounds for 10 minutes, they are not with the patient for a good part of 12+ hours a day. Neither situation is better than the other, they’re just different. And, those are just nurses with BSNs catching those mistakes and advocating for different evidence based practice plans, not even NPs/DNPs yet.
I have heard countless stories in my training from NPs and DNPs who had to fight with MDs and DOs to advocate for their patients. These stories always end up with the NP/DNP winning and the patient surviving, or the NP/DNP losing and the patient declining or dying. Of course they are the ones telling the stories, but they often have evidence as they are using these examples for their lessons. In my own experience working on a Med/Surg and PCU/TCU overflow unit, I have seen this countless times.
Yes there are issues with NP/DNP programs, there are also issues with MD/DO programs. Both need to be fixed. Insisting that just because a MD/DO program requires 20,000 clinical hours while an NP/DNP program only requires 1,000 means it is inferior and dangerous to patients is an unfair and unprofessional argument, completely ignoring the other 17,000 hours spent at the bedside (not just there on rounds for 10 minutes at a time). Despite the valid points that DNP programs, just like MD and DO programs, need improvements, it is obvious that the author has extreme bias and distaste toward DNPs. This is not only evidenced by their unprofessional highlight of this story to represent DNPs and the issues surrounding their training, but also their ignorance to the many holes in their arguments.
Here’s the real important thing: we all need to work together. We need to stop assuming that someone has less experience than us because of their degree or title. Do you know how many times I have heard an experienced CNA call a diagnosis way before anyone with a degree even thought of it or ran any tests? They didn’t have 20,000 hours of MD/DO experience, they didn’t have 11,000-18,000+ hours of specialized nursing experience. What they did have was their own specialized knowledge and experience- that none of us with degrees had. We didn’t have their specialized training and experience that led to them to build their intuition and specialized knowledge. We all need to work together and listen to each other if we actually want to improve patient care. There is no harm in listening, but there is harm in not listening, especially not listening to someone because we believe their credentials are inferior to ours.
First of all, I feel terrible for the family and am so sorry they had to go through this ordeal. As a health care provider, I truly believe we all are trying to do the best for our patients.
I think that it is not acceptable to misrepresent yourself as a healthcare provider, and I think that is what the author is trying to convey in this article??
With that in mind, I feel like this article really missed the mark on trying to get that message across…
The patient was admitted to the hospital at 2 months – and would have been seen by many doctors (on a very regular basis, all the hospitals I have worked in have residents and attending see the patients at least daily, if not more). And a pediatrician would definitely have been consulted (and hopefully would have seen the client – it feels negligent if they didn’t). And nothing was diagnosed or noted at this time?
Further, how come none of the MDs in the hospital (or nurses or social workers) recommended a consulation/follow-up with a pediatrician? They should have recognized that this ‘doctor’ was not actually a pediatrician, and did not have the expertise to follow a child that was this complex. We cannot expect our patients to know the difference, but we should.
He definitely misrepresented himself as a doctor, and that is not okay – I think that is the true purpose of the article.
It’s unfortunate that the message gets lost in a story that actually makes the MDs seem more imcompetent (as I imagine the baby would have been seen by multiple MDs while in hospital, vs one primary care provider).
Maybe I am missing something though?
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.
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.
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.
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.
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.
” 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.
Fair enough. I cannot say I disagree.
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?
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.
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?
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.
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.
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.
Hmmmm…. Mike, it’s good to know this information. Puts your comments into better context. https://forums.studentdoctor.net/threads/rn-to-do-comments-suggestions.214665/
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.
Thank you for bringing balance to this discussion. We are going to see a lot more cases like this in the future.
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?
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.
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
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.
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?
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.
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.
Are you trying to say that a DNP is as likely as a physician to be able to adequately treat all patients?
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.
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?
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.
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?
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 realiz