Bioethics, government medicine, medical finance, Medicare, politics, professionalism, public health, public policy

>Dr. Nurse? Why not just Doctor?

>Get ready for Dr. Nurse, who will call himself/herself “Doctor,” but who, after 4 year bachelor’s degree in nursing, has gone to the Doctor of Nursing school for two years with a one year internship — that’s compared to the 4 years of college, 4 years of medical school, followed by at least 3 years of residency that Family Physicians, Pediatricians and Internal Medicine docs devote to training..

The Wall Street Journal reports
(please let me know if you can’t access this page) that the National Board of Medical Examiners will begin testing these “DrNP” candidates this fall.

From the Wall Street Journal:

As doctors face shrinking insurance reimbursements and rising malpractice-insurance costs, more medical students are forsaking primary care for specialty practices with higher incomes and more predictable hours. As a result, there could be a shortfall ranging from 85,000 to 200,000 primary-care physicians by 2020, according to various estimates.

So,the supposed reasoning behind the new doctorate is this shortage of primary care doctors. That shortage has been artificially encouraged by all sorts of federal interventions. For some reason, no one’s considered paying Family Doctors more!

Instead, there are schemes to divide and re-divide the Medicare “Pie.” There are the rural health clinics, which are paid more by Medicare and Medicaid than your local family doctor, pediatrician or internal medicine doc for seeing the same patients. In order to qualify, the clinic — get the distinction, there, not the doctor, but who ever it is that owns the clinic and contracts with doctors and hires the rest of the staff – must hire at least one “mid level practitioner” to see patients. They can’t hire a doctor to do the same work and/or for the same money — they must hire a Physician Assistant or Nurse Practitioner.

As the article notes, the main reason for the loss of primary care physicians, however, is the low pay for the thinking part of what we do, compared to the procedures of specialists, such as all the varieties of surgeons, urologists, gynecologists and gastroenterologists. We analyze, examine and determine treatment or treatment change, resulting in “Evaluation and Management” visits. Rather than the codes used for procedures, the E&M visits are divided into levels of payment based on a set of check lists and diagnoses. The money from Medicare – followed closely by the insurance companies – has consistently shifted from the office visits toward the procedures.

Needless to say, the smart medical students — or at least the ones more interested in money than in your family history, living arrangements and whether Junior ate his peas and carrots will become interventional sub-specialists, not a Family Physician or Pediatrician.

A few years ago, Medicare payments increased for home health agencies, which encouraged RN’s and LVN’s to leave the hospital. Medicare quit paying your family doc to “scrub in” with the general surgeon or orthopedist as an assistant during your gall bladder surgery, colon resection or hip replacement. But, they did pay the surgeon enough to justify the hiring of a nurse practitioner or physician assistant. And studies said there was no difference or even better outcomes, since the “team” worked better in the Operating room and the peri-surgery procedure became more efficient.

(Of course, the NP or PA won’t be available to your wife or kids for questions next week, and won’t watch the effect of your new level of activity on your blood pressure or diabetes. And your family doctor may no longer even know that she should, since she won’t even find out about the surgery until your next visit or hospitalization. But that has nothing to do with the outcome of the surgery, right?)

The increase of Federal funding for Nurse Practitioners has exacerbated the loss of good RN’s and LVN’s – leading to more of the Federal pie going to nursing schools. And the DrNP will probably have the same effect. The WSJ article mentions the lack of faculty in the nursing schools. The funding will have to come out of the Medicare and Federal “pie.”

However, what patients need to consider is whether the DrNP training can truly accomplish the same training in 3 years that our Medical Schools can do in 5 to 7 years. Some have said that mid levels can handle 80% of what doctors do.

It’s that 20% that is the difference between knowing what you don’t know and planning for the 2 AM crisis.

About bnuckols

Conservative Christian Family Doctor, promoting conservative news and views. (Hot Air under the right wing!)


12 thoughts on “>Dr. Nurse? Why not just Doctor?

  1. >I am a Nurse Practitioner and I not only have a 4 year bachelor degree, but 4 years of additional training in "Advance Practice Nursing". In addition, I also have over 10 years of experience! I have worked with residents in the ER and until their 3rd year, they consistantly have no idea what they are doing! So while they may have attended medical school, they haven't had the EXPERIENCE of putting it all together and the result is fragmented patient care. In addition, with the gaps in access to health care, the communitiy needs someone with a holistic approach and patient centered treatment versus insisting that if they were paid more, health care delivery would be better.

    Posted by Anonymous | July 9, 2008, 6:32 pm
  2. >Why not go to med school? We had nurses in my class. In fact, we had dentists who returned for training as oral surgeons, and had an abbreviated course, taking into account their experience and training.(I was a late bloomer, myself. Married in high school, college at 24, interrupted for a couple of years for a baby, then med school at 30, finishing my FP residency at 37.)I'm not objecting to nurses becoming doctors. I'm objecting to the shorter training period and plan to replace physicians with lower levels of training. (I like the "practice of medicine" better than the "practice of nursing," too. Although I've never quite been able to figure out the official difference between the two, there is something in the way we approach medical problems. I think like the doctors I know and have to translate when I precept nurse practitioners. And, by the way, Family Physicians are trained to see not only the disease process, but the whole person in the context of his family and culture.)You have pointed out that you have more years than the planned program, and seem to agree with me that the years of training make the difference.The money and energy would be better spent allowing nurses credit in training for their years of experience, rather than setting up a new pathway to train mid-level medical professionals.What happens after that 3rd year for the doctors in the Emergency Room, and what do you suppose the 3 years are for, if not to obtain the experience to go with the knowledge? Are there no differences between yourself and the attendings or the 4th year surgery fellow?For that matter, are you saying that you could replace 3rd year residents without a problem, And are you typical?Will there be the equivalent of supervision for the 3 years of residency for the Doctors of Nursing, or will they somehow not need the "EXPERIENCE"?There is a bit of a change over the last 10 years, since doctors are now trained with 12 hour days and 80-100 hour weeks. The old training made us more likely to think the case through to what could go wrong or what would worry the patient in the wee hours of the morning or after he went home. I'm seeing less of this in recent graduates.The point about pay is that the Federal training and Medicare schemes have worked to decrease primary care, encourage subspecialization, and have included multiple schemes that have taken the nurse from the hospital and doctor's office. Remember the home health care boom and what happened when Medicare clamped down on funding?The midlevels follow the subspecialists, and end up predominantly in urban and suburban settings, not in rural or health care shortage settings.

    Posted by | July 10, 2008, 8:05 am
  3. >Anonymous NP likely did not go to medical school because it would have taken longer than his/her nursing education did – 8 years compared to a minumum of 11 (4 years for undergraduate, 4 years for medical school and 3 years for residency.) And, at what point in Anonymous NP's career and 10 years of experience did he/she encounter these 3rd year residents who had "no idea what they were doing?" Right after he/she became a NP with no experience or after 5-6 years of experience? I would venture to say Anonymous NP was just as cluless as a new resident during their NP training…which is the point of training – "putting it all together."

    Posted by Anonymous | December 9, 2008, 4:52 pm
  4. >Worse, Dec 08 anon, the NP programs do not have a required year of internship on top of their schooling – they count part of their last year as "internship."They do have fellowships available that are similar to physician's residencies. We go on to fellowships *after* residency.

    Posted by | December 9, 2008, 5:35 pm
  5. >I don't understand particulary what "life ethics" means when they state "I like the practice of medicine better then the practice of nursing but am unable to figure the difference between the two." I mean there is a large difference in the roles of course but that comment seems condescending. As though we just can't understand the disease process because we are nurses. I have worked with numerous residents who have asked me out in the hallway what would be a typical POC with a pt just to repeat it verbatim to the pt in a very serious voice. They then go on to give me orders so they can look competent and belittle me as the subserviant nurse. Experience goes hand in hand with competence. I have seen doctors make it thru med school who are very dangerous and I have seen nurses in the field for 25 years who still don't know what they are doing. It is what you do with the information, education and experience that is going to help these pts. I think where there is a shortfall of FP's then we need to put people there NP's (after doctorate) and see what works. If the system is flawed then see what additional education is needed to fix it. I don't think all of these nurses need to do a 3 year term of residency like a med student because we have worked in the hospital setting (most of us) for years. I worked with many NP's and CRNA's and they are wonderful. For me they are easier to work with because it is a team effort to help the pt. I don't have to deal with their ego (like a doc)while my pt crashes and burns.

    Posted by Anonymous | March 18, 2009, 6:03 pm
  6. >To the latest Anon,"If the system is flawed," won't it hurt patients?Why not try for credit in medical school toward graduation for the years of experience and education, rather than invent a whole new track toward "doctor?"Why not stick with discussions about training and ability, rather than argue with divisive comments like your "that seems condescending" and "deal with their egos (like a doc)." Treatment of the patient is carried out as a team, there's no doubt – or should be none – about that. However, team members each have different roles and responsibilities.

    Posted by | March 22, 2009, 1:57 pm
  7. >The hardest thing for me to understand after nursing for years is why there is so many nurses in management. Is there even a need for a FNP, since Medical Doctors have PAs. I am starting to think every time I heare nursing shortage is the nursing profession seems to do it to themselves.Would it not make more since for nurses to do the job they were intended to do in the hospital.After working in nursing and seeing many FNPs, the thought process is not the same. Even simple procedures take longer with FNPs compared to a MD. Time wasted on the patients part and the nurse assisting.I have also seen many good nurses go on the medical school and some go to be FNPs. There is just things that doctors need to attend to and there are some things nurses should do.

    Posted by Anonymous | November 11, 2009, 1:47 am
  8. >Thanks, November 11 Anon. It does seem as though every government funding program concerning health care contains some way of encouraging nurses to move away from nursing care. And then, like the home health care push, they pull the rug out from under the business by removing the money.

    Posted by | November 11, 2009, 5:21 pm
  9. >I recently graduated from one of the top nursing schools in the country and I completely fell in love with nursing over the past four years. I want to give my patients the best nursing care possible. If that means going to school for an additional 4 years to earn a DNP then I'm going to do it. If I had to go to school for an additional 20 years I'd do that too. In no way do I want to take the place of a doctor…medical theory is just as important in a health care environment as nursing theory. I feel that it is my duty to provide my patients with the best nursing care possible and a part of that is receiving as much education as I can.

    Posted by Anonymous | December 22, 2009, 7:10 pm
  10. >Most nurses would see the comment of "Why don't you just be a doctor?" as insulting. There is a huge difference in what we do. We spend more time with patients-actively listening, assessing and observing. We know them. We care about what happens to them. They are not just a DX or a procedure to us. Can most doctors say the same? I think not. I, as well, have encountered the same issues with not only residents but physicians with years of experience. No one is infalible. No, really. MD's are not GOD, as much as they seem to think so. Nurses are not 2nd class citizens. In fact, some of us actually have a decent knowledge base. And, sometimes (said w/ much sarcasm) we catch the physicians mistakes.I am an MSN student with over 15 years experience (ER). Oh and btw, most DNPs are obtaining their MSN prior to DNP. So, add another 2-3 yrs to your equation and most programs will not accept you unless you have completed a role option in an advanced PRACTICE setting-thus clinical practice in your specialty. The idea is not Doctor but Doctor of NURSING PRACTICE. It means that they have gotten to the highest point in the profession of nursing. I honestly think disgruntled doctors are teaching the new ones and are perpetuating this BS.I believe there needs to be education about nurses-by nurses for physicians. I read a survey tonight that stated that 96% of nurses interviewed have heard a physician yell at or abuse another nurse. And, we wonder why nurses are racing out the door of the hospitals. How about some recognition and respect for what we do? Yes, we carry out orders. But, our work is difficult and laborious but it is the most rewarding thing I have ever done. I do not do it for the $…as most likely the reason that half the physicians are in their profession. I do it because I care and I make a difference by being a nurse. Research proves that good care by a nurse can be quite beneficial to patients. And, no…I would never want to be a doctor. I hold nurses in much higher esteem as does most of the country. In fact, another study revealed that while nurses are still held in high regards, that going to see an MD was considered lower than going to supermarket or a mechanic.

    Posted by Coleen | April 24, 2010, 8:04 am
  11. >Colleen, You are assuming a lot: about motives ($), listening/not listening, aggression against others. I can line up Family Physicians and Internal Medicine doctors that meet all your criteria. I only know about troubles communicating between doctors and NP, which seem philosophical rather than language or years of experience, the rate of referrals to sub-specialists compared to Family Physicians, and the problem that NP's are no more likely to move to underserved areas than physicians, are less likely to provide for 'round the clock call coverage for the patients seen in the office and that quite a few of them subspecialize and work for subspecialists.If it takes as long, and the training is equivalent, why the two degrees, why the two State Boards?

    Posted by | April 25, 2010, 4:39 am
  12. >Whenever i see the post like your's i feel that there are still helpful people who share information for the help of others, it must be helpful for other's. thanx and good job.Management Dissertation Proposal

    Posted by Management Dissertation Help | June 9, 2010, 5:16 pm

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