On the one hand, far too many people are completely unaware that doctoral degrees exist or that people with Ph.D.s have the right to use the title of doctor. On the other hand, medical doctors are notorious for trying to protect their turf, power and exorbitant incomes. If physician assistants can examine and diagnose patients, then nurses with advanced degrees should be able to so the same. However, some very specific guidelines need to be developed regarding titles and making certain that patients are fully understand that the nurse who calls herself doctor is not a medical doctor.

MD's are "notorious for trying to protect their turf, power and exorbitant (SIC) incomes"? What group of professionals isn't? Not terribly long ago, people could hang a shingle and call themselves a "doctor" with little to no education. This was stopped decades ago. PA's, NP's, and Dr. Nurses all have good uses and are very good at their jobs. I know lots of them and many of them are considered by patients to deliver "better care" than many doctors. There are numerous reasons for this: time constraints, education, level of experience (many NP's have more experience than a new physician). When it comes down to a bad situation, who will you want? Dr. Nurse or Dr. Doctor. That depends on society's opinion of good care and bad health...

People just looooovvvve capitalism until competition comes along. Ever notice how many people fight it while at the same time claiming to support it?

That said, I don't who can do the job as long as they can do it and don't misrepresent what it is they are capable of.

Capitalism will kick in when the new "Dr.s" find out that there's more to medicine as a business than just treating patients. When they find out that they go broke and can't support their employees or families, we'll see what happens. Most will work for other businesses or hospitals and watch as the government and market ratchet down their income while increasing their workload. Then, we'll see about this Dr./Doctor stuff.

I can see where this is definitely a tricky issue. The word doctor in antiquity basically meant "teacher, scholar, or keeper of the church". Over time that transitioned into terminal degrees in basic fields of study (scientists, literary scholars, anthropologists, etc). Using the word doctor to refer to medical professional is something of a new phenomenon (past few centuries). In fact, to this day, surgeons in London think it's odd that physicans took the word from the scholars and refuse to use it, so your surgeon there would be Mr. or Ms. so and so. I can see where this might be bad for the patient when someone walks in and introduces themselves as a doctor.

On the other hand, there is the reverse problem. Sometimes physicians use the title doctor to make themselves sound scientifically credible. It's no great secret that a lot of grant money is wasted every year on scientific studies where a few MDs didn't bother inviting an actual scientist along (a PhD). I fully support collaboration between the two, but the term is getting out of hand. In fact, I find most MDs are not scientifically literate, and know less about the mechanism of how a medicine works than I do. It's kinda funny that physicians don't see scientists as real doctors, and scientists role their eyes when physicians use the term to give them authority during a scientific conference.

One last fun food for thought: lawyers have been recently demanding the title too. (As in Juris Doctor). So the next time your physician gets sued for malpractice, he or she can call up their doctor to represent them. Maybe we should just do away with the word altogether.

Sounds good to me. I have great respect for scientists. It comes from medicine being part science (using information to diagnose and then treat the problem) and art (interacting with sick people and deliver the news and treatment with respect and sensitivity that they need). No title is needed for any of that. Just make sure that people should know what they are talking about.

If I'm paying to see a doctor, it better be an MD. Many in the teaching profession who have PhDs insist on being called doctor. I make sure I always call him or her Mr. or Ms.

That's funny, too. Teachers were the original doctors (used as a professional title), but have lost that title today. The PhDs (who rarely become teachers), are generally the ones doing the research the MDs study during medical school. On the other hand, some scientists take it too far, and only consider researchers to be doctors (and yes, some of them actually are petty enough to call others Mr. or Ms.). This isn't far, though. If someone in another field contributed an original piece of work to advance our knowledge on some field, that's enough to be a doctor.

One really neat proposal recently has been to extend medical school to make them do research, and give them a joint degree, so then there wouldn't be much debate at all, would there. Given that medical school is only four years, and research doctorates are more like 6 or 7, it might be possible to make some kind of hybrid program.

Many in the teaching profession who have PhDs insist on being called doctor. I make sure I always call him or her Mr. or Ms.

Why, Kitti? Their Doctor of Philosophy degrees should certainly have earned them some respect.

Kitti, they have earned the title. Anyone who has earned a PhD in any field is properly addressed as "Dr.". If you went to college, did you call your professors with PhD's "Mr." or "Mrs."?

I agree that there should be more information for patients. For instance, the person who identifies themselves as a Doctor could be the first year intern. Or an MD not board certified to practice the specialty claimed.

More doctors are fleeing primary care. And except for surgery, a Nurse Practitioner is quite able to function as my primary care provider.

I think that in a clinical setting the term doctor should be restricted to actual MDs. To do otherwise would create unnecessary confusion. If they want to use the title outside a clinical setting fine, but for a nurse to call themselves doctor in a clinical setting is asking for confusion and designed to do nothing more than feed their egos and mislead people.

Supposedly, anyone with an MD degree should be equipped to conduct research as well as as treat patients.  This issue was touched on in novels, such as Arrowsmith and Dr. Zhivago, both set in the early twentieth century.

I myself have a research doctorate (Ph.D.) in a technological field, and my professor has a different research doctorate (D.E.S.).  I am familiar with a medical practice where two of the nurse practitioners have earned Ph.D. degrees, and their &ldqo;boss&rdqo;, an MD without a research doctorate (although she is noted for her research), encourages everyone to refer to them as &ldqo;Dr.&rdqo;.

The title of doctor for MD is honorary only. The original title of doctor was intended for PhDs as it was intended historically to indicate a person who had carried out extensive research. MDs may have successfully incorporated the title to reflect their profession with the argument that they are capable of research but it is only an honorary one.

nonsense.

Everyone thinks of physician when they hear the word doctor. Not to say that PhDs arent doctors, they most certainly are

But to claim it was "stolen" because of what the custom was 200 years ago is ridiculous

This subject is much, much more complicated than this article suggests.

In traditional academics (going back to the 1100's and earlier), there are three levels of degrees --- Bachelors, Masters, and Doctorate.

The Bachelors Degree is supposed to signify that a person has studied a field enough to perform substantial work with little supervision. Usually, all that is required is a course of study. It is called a Bachelors Degree because in academics in the past a person with a Bachelors Degree would generally not be capable of earning enough of a living to marry and support a family.

The Masters Degree is supposed to show mastery of the field. This is demonstrated by not only course work but by a thesis, assigned and supervised by PhD's. The object of the Masters Thesis is to show that a person has sufficiently "mastered" the field to the point that they can work without supervision and supervise others with lesser education. The emphasis of the coursework is on methodology --- the processes of the field.

A Doctorate, or PhD, is supposed to show, by the completion of a Doctoral Thesis that the person is prepared to make a substantial independent contribution to their field. A Doctoral Thesis (in addition to course work) is the primary focus of the degree and usually takes years to complete. The emphasis of the course work is not just knowledge, but has heavy emphasis on critical thinking and the rigor that research and instruction require.

And then, something that most people forget, an academic PhD does post-doctoral work, usually at very low pay, and for very little credit. It is this post-doctoral work that defines a PhD in their chosen field and hones very specific knowledge sets. Post-doctoral work can last as long as 20 years.

n.b. A PhD can teach any class in any subject in a college or university. My wife is a PhD (a research psychologist) but has taught classes in law, business, pharmacy, medicine, and biology as well as psychology.

In modern times, vocational "doctorates" were added, primarily through political pressure. Vocational degrees are far less rigorous than academic doctorate programs and do not require a thesis or any contribution to the field. Both MD's (medical doctors) and JD's (juris doctors) are of this category. They both have emphasis on practicum rather than on critical thinking. The education is narrowly focused and much of it is OJT. In terms of education, both physicians and lawyers have identical educational levels.

If you look at strict etiquette, "Doctor" becomes a part of a persons name ) just as Jr., or III) for a PhD. It is not an honorific title because it has been earned. It is proper to address a PhD as "Doctor" in any setting, public and private. Physicians and lawyers, however, are not in the same category. A lawyer is called "Doctor" only when testifying in open court about a point of law or when teaching in a law school. Likewise, a physician is supposed to be called "Doctor" only in the clinical setting.

When a person calls himself "Doctor" outside of his professional practice, he is claiming to have a PhD and misrepresenting his educational status. There are no countries that refer to a lawyer routinely as "Doctor." And there are only 5 or 6 countries that routinely refer to physicians as "Doctor." For example, in Britain, a physician is referred to as "Practitioner" and usually addressed by his first name. A specialist physician is referred to as "Mister." Referring to your physician in England as "Mr. Smith" would indicate that he is a specialist such as a cardiologist.

To make it even more complicated, many schools (but no colleges or universities) have created classwork-only "doctorate" programs. These are also vocational degrees and do not require a thesis. Usually the only additional requirement is two additional semesters of "advanced" study with all the classes in the person's field. An example would be a PharmD (which holds absolutely no relationship to PhD in Pharmacy.) Strictly speaking, in proper etiquette, a person with such a vocational doctorate are addressed as "Doctor" only in actual

End even more complicated is the issue of "specialist" Doctorates. These are earned doctorates because they require a thesis that demonstrates the ability to contribute independent knowledge to the field, but their classwork focus is much more on the field rather than on the ability to think critically. Most people consider that a vocational degree of this category should should be treated the same as an earned PhD and that "Doctor" becomes part of the person's legal name. An example of this is Dr. Bill Cosby who has an EdD from Temple. He completed the same coursework and thesis requirements that a PhD doctoral candidate would have completed.

n.b. A person with only a vocational degree, such as a MD, JD, or PharmD can only teach in school in their field --- such as a law school, a medical school, or a school of pharmacy. They have exactly zero qualifications to teach in a college or university.

You will notice that people with an unearned doctorate are usually graduates of a "school" versus a college or university. This is because schools teach narrow focused curricula rather than the broader (and more difficult) disciplines of a college or university.

Most physicians and many lawyers do not have an earned degree of any kind, even a Bachelor's degree. (This is usually referred to as an intercallated degree.)

The last real category of advanced degrees is an "honorary" doctorate. If the Doctorate (such as a Doctorate in Humane Letters) is conferred on an individual in recognition of a lifetime of contribution to a field, it is considered to be a higher degree than a PhD. If it is conferred on a politician, for example, it is usually meaningless and a cheap way to get commencement speakers.

I am not down on physicians and lawyers. It's just that a PhD has worked hard for many years and jumped through in numerable hoops to earn the right to be called Doctor. Physicians and lawyers and others who have not taken the time or effort or even have the skills are not in the same category.

My suggestion for physicians who want to be called "Doctor" is to go back to school, get a PhD then talk about. To say that a nurse who has an earned doctorate in Nursing should not be called "Doctor" is demeaning to both the physician and the nurse and to the field of medicine in general.

I can't say I read your post..rather skimmed it. But one thing stuck out-almost all physicians have a bachelors. Its a requirement for med school

Most physicians and many lawyers do not have an earned degree of any kind, even a Bachelor's degree. (This is usually referred to as an intercallated degree.)

Wrong. One must have a bachelor's degree, at minimum, to get accepted into medical school. Now, medical schools will accept some candidates who are projected to complete their bachelor's degree before they matriculate into medical school. However, if you do not complete the bachelor's degree, you will not be allowed to matriculate.

In fact, due to the increasing competitive nature of getting accepted to medical school, more and more successful applicants (those accepted) have earned a master's degree or higher.

There are a few programs out there that are 6 year programs (though these are in the minority). These programs admit the person to undergrad and medical school at the same time. These students spend the first 3 years in undergraduate classes, then transition to medical school classes. They are awarded their bachelor's degree at the same time as they are awarded their medical degree.

There are a few programs that are considered "early admission" programs. In these cases, a specific medical school will have an agreement with a specific undergrad school. The medical school agrees to accept up to a certain number of students (though they can accept no students in any given year) at the end of the students junior year of undergrad. At the successful completion of the first year of medical school, the student will be granted their undergraduate degree from their undergraduate university.

In any case, a physician will have at least a bachelor's degree in addition to their medical degree. More and more physicians have degrees beyond their bachelor's degree in addition to their medical degree.

Chris 749391, you are wildly wrong. So wrong it is too time-consuming to even point out the various problems. Summer points out a few key ones. Thanks, Summer.

Thank you and you're welcome sadmoronsvote2 (like your nickname, lol)

Sorry Nurses, even undergrad pre-med is harder than undergrad nursing school. Take one simple class: Pre-meds end up with a minor in Chemistry while Nursing chemistry is very basic. Their "organic chemistry" is a little above high school level.

Nursing PhD programs are no Medical School plain and simple! Nurses also are not responsible for the insurance, mal practice and the complete responsibility that weighs heavily on doctors shoulders daily. Introduce yourself as Nurse Doctorate or Nurse PhD.....not Doctor! Lawyers don't walk around saying I am a doctor of law.

I should have also added that i am forever indebted to great nurses ! About half the nurses I know are true professionals with clear minds and an attention to detail. They are compassionate and save lives each and every day. The other half I am not even sure where they got their degree, their homes lives are a wreck and they bring that mess into work and their bad attitudes bring down morale and actually may endanger patients. Nurses need to be kind, organized, smart, non-judgemental and caring ----it is one of the toughest jobs on earth.

If a nurse (or anyone else) wants to be called 'doctor' in the medical profession, he/she should go to school and earn a proper medical degree equal to that of a "medical" doctor. Patients shouldn't be mislead by someone claiming to be a medical doctor, simply because a nurse, pharmacist or physical therapist got some additional schooling. Sorry folks, no matter how you slice it, you are not medical doctors and do not have the right to charge me as such if you treat me.

Talk about driving up medical costs! This is ridiculous.

Post-doctoral work can last as long as 20 years... A PhD can teach any class in any subject in a college or university.

Chris - I don't know where you found your information, but most of it is questionable or outright incorrect. I have a Ph.D. in chemistry. To earn that degree required four years of undergraduate work to earn a Bachelor of Science degree, followed by four years to earn the doctorate. Both degrees were earned at major, well-known universities, not some "college" located in a strip mall. The university from which I earned my doctorate is rated in the top 10 in the nation for my specialty. Most post docs in my field last one to two years. No one spends 20 years working on a post doc.

As for Ph.D.s teaching any class in any subject in a college or university...that is certainly not standard practice. How can someone with a Ph.D. in English teach a class in calculus? My chemistry department is not going to hire someone with a Ph.D. in anthropology to teach undergraduate physical chemistry. People go to school to earn doctorates because they want to specialize in a specific area in a particular field. That doesn't not qualify them to teach everything under the sun.

Most physicians and many lawyers do not have an earned degree of any kind, even a Bachelor's degree.

That's news to me, as the vast majority of medical schools require an undergraduate degree for admission to medical school.

The above examples cover just a few of your errors. There are too many others to make it worth anyone's time to enumerate.

I have a few suggestions for Doctors

"I am a real doctor" or "I am a doctor doctor"

WHOA! Kallie.

I earned my BSN in 1971. I took Psychologh, General Chemistry, Organic Chemistry, Bacteriology, Immunology and a few other science courses at the same state University that the pre-med students were taking. I took the same general courses, English, languages, history also. These were the same courses. Not all pre-med students took courses strong in sciences. They also had electives. My Nursing program had trouble accepting some of my Home Economics courses in Family Economics, Family Relations and Nutrition, but those have been some of the most helpful courses in working with families in both a public health/community health nursing and a primary care nurse practitioner role. Those courses also broadened my world view and I could work better with clients.

I agree with other comments. If I pay for a doctor, that's who I want to see. On the other hand, I've come across M.D.'s over the years who shouldn't have been practicing in any capacity. In the example in the article, the woman introduced herself as, "Dr. so-n-so, I'm your nurse." What's not clear about that? Since M.D.'s all to often think the initials stand for Medical Deity, how about they identify themselves with a halo as opposed to the old-fashioned nurse's cap. A halo with a dollar sign for the most illustrous of them.

The facts are clear. Nurses are not doctors. Period. I can't tell you how many nurses have decided to give up the "bedpans" for the easy life of "medical transcriptionist," only to back to nursing because they couldn't handle the transcription work. That means that they are used to the area that they deal with and the specific work that they deal with. Quite frankly, I'd rather have a medical transcriptionist treat me than rely on a nurse.

But, the idea that a nurse would refer to themselves as a "doctor" to the patient is obscene. We've all heard stories through the years of people stopping at scenes of accidents and administering whatever care they can, and have referred to themselves as "doctor" so-and-so. Usually, if something goes wrong, they end up in trouble. I'd never dream of passing myself off as a doctor, Doctor of Jurisprudence degree notwithstanding.

If a nurse tries to tell me that they are a doctor the first thing I'd ask is why they aren't doctoring. I'd be very suspicious and wouldn't trust anything that they say as they are obviously bloviating.

Witchrunner -- The nurse in the article was not at all bloviating (fun word, doc!). She clearly stated she was a nurse. Like you, she holds a doctorate. She worked for it, so she can use the title. As an attorney, you don't need to pass yourself off as a doctor; you make enough money as is--at least some of you do. (Allow me this bit of humor)

A nurse with a doctorate in French literature should not say she is a doctor in a medical building.

My poodle wants to be called Alsatian.

Susi-Oh: She said “Hi. I’m Dr. Patti McCarver, and I’m your nurse,....”That's clear? Especially in light of the fact that she "proceeded to prescribe her medicine." If that's so clear, then is she saying that she is a "doctor" but is so incompetent that she can't get a job as a doctor, so she is working as a nurse? Or, is the nurse a doctor who has a medical practice and is moonlighting as a nurse to make extra money? So, that is clearly not clear to the patient. Quite frankly it could just as easily mean I'm a doctor in ventriloquy, but I'm working as a nurse to make extra money. Or, if this is not clear enough: A duck is a duck is a duck. If it's not a duck, it's not a duck! In other words, the only reason for a nurse to mention she is a doctor is to mislead the patient into believing she is a doctor, qualifier of "nurse" be damned.

The nurse in the article was not at all bloviating (fun word, doc!). She clearly stated she was a nurse.

Susi-Oh - There is no question that the nurse in the article clearly stated that she is a nurse. The problem is that most laypeople do not understand the distinction between medical doctor and doctor of philosophy. That is why guidelines must be developed that clearly define the difference to the patient.

BTW, do you even know the definition of "bloviate"? It means "to speak or write verbosely and windily" or " talk at length, esp. in an inflated or empty way". How is the simple statement "I am Dr. So-and-so, and I am your nurse" verbose (wordy)?

Witchrunner, the nurse in this article is a nurse practictioner...she first went to nursing school for four years and obtained her BSN, she then went on another year or two for her MSN...she then had to take 12 mths of training as a "Nurse Practitioner" and she became licensed in her state to see patients, ( have her own patients in a Dr.'s office) she is allowed to write most prescriptions, and she can make referrals to specialists. If you are trully a lawyer as you say, then you should have known that. She is not practicing as a doctor, she is practicing as "nurse practitioner" in the legal scope of practice that the state has licensed her to practice as. The PhD. is something she went BACK to school for, and has rightfully obtained. She CAN legally call herself Dr. SO AND SO!!! The fact that she plainly said," I am DR so and so, I am your NURSE. " made it crystal clear what her position was!!!

sandi,

you obviously know a great deal about nursing training and scope of practice. I think the major issue is that many patients don't know all that. Even if she has a doctorate, and even if she is practicing within her defined scope, when people hear "doctor", they think MD. Whether this is right or wrong, it is simply the way it is

I think the concern most people have is that this nurse doctorate can confuse patients in the clinical setting

Too many people hung up on titles.

She's a nurse so she's in the medical field. She's just specialized in one aspect of the medical field, she is still in the medical field.

I don't care if she has a doctorate in First responder first aid.

The fact that she's studied in great depth in the field of medicine makes her an asset not matter where she's standing on earth. She still has more knowledge in medicine than an Intern.

Even medical doctors are mostly specialized in a certain field of medicine.

If I were standing in a shopping mall and saw a medical emergency and I yelled "Is there a doctor in around" and she approached and said I'm a doctor in nursing, that's good enough for me, I think this guy is having a stroke.

If someone walks up and says "I'm doctor" and I say "Good, I think this guy is having a stroke" and he says "Oh I'm not that kind of doctor, I have a PHd in Engineering." Then I say "Well then you're pretty much useless then aren't you?"

When she comes up to you and says she's doctor so-n-so and I'm your nurse, you can rest assured she's only going to perform within the boundries of her training. If something falls outside her area of expertise she's going to refer you to someone that is in that area of expertise. A General Physician is going to refer you to a heart specialist when it concerns your heart.

If she's a nurse and she's prescribing medications, it's because she's had the professional training to do so and that is good enough for any of you. She's qualified. If you have a problem with that, then it's your problem, you're hung up on traditional roles.

I know a nurse that likes to be called "Doctor".

But only during sex, and I have to be wearing fireman boots.

eric-2573068

"I can't say I read your post..rather skimmed it. But one thing stuck out-almost all physicians have a bachelors. Its a requirement for med school" (no punctuation from you...)

Wherever you go, there I (PhD) am.... And, WHOA, "I can't say I read your post.."

Keep on keepin' on, Mr,"MD." Again, I say you are a TROLL.

Cyberstalking? Pathetic, and much more akin to trolling than anything eric is doing.

Because its confusing in the clinical setting. She very well may possess a doctorate degree, but in a patient care environment, people assume doctor equals MD. That confusion can lead to bad patient care

Dont worry,in many cases these people are already claiming the title of "Dr."I was a follow up patient being treated for "terminal"lung cancer with the only current treatment being daily courses of opiate pain killers . When the "on-call" RN working for my Oncologist decided to transfer my treatment to my PCP "Welfare Dr Sarvassy, at INTERFAITH MEDICAL HEALTH CENTER in Bellingham WA. Despite the fact that there was no Dr. in consult at either end of this transaction( Ocologist, Dr. Nestor, Peace Health services, St. Joseph Hospital, Bellingham, WA on vacation/Dr. Sarrvassy, GP, Welfare Dr. for INTERFAITH HEALTH CARE SERVICES, also on vacation

Between the two unsupervised nurses and a PAC they were able to transfer my lung cancer treatment from my Oncologist/ Dr. Nestor to the Welfare Dr. Dr. Sarvassy. This PAC (Physicians Assistant) was able to provide care after never having any contact with the patient (me) at all. Her extreme collection of healthcare knowledge was deemed sufficient in her mind and apparently to the managment of INTERFAITH HEALTH CARE SERVICES for her to not only perscribe Class II narcotics( 2 different deliverery methods for morphine) and the lesser pain killer, Vicodin.To show her caution in her methods of patient assessment she took 3-4 times over 2-3 days to get my prescription correct, strike that, the problem with the presciption was ignored untill the actual Dr. showed up. She didn't even have to waste the time that might have been involved by taking so drastic step as maybe contacting the patient or heaven forbid perhaps contacting the Oncologist's office.

Her actions endagered my health and showed you can get the arrogance you pay for in a real Dr. without having to pay the premium that comes with Dr's who have actually recieved the training.

And to top it all off PAC (Physician's Assistant) Rebbacca Hale PA10001215 of INTERFAITH MEDICAL CENTER in Bellingham, WA is still able to act like a Dr. and and is perfectly capable of signing her scrips Dr. Rebecca Hale

See, no problem at all

haha, clearly you don't have an axe to grind

If that comment about ax to grind is about me, fine. That changes the validity of my comment not at all! I have spent more than ten years in medicine and untill I was diagnosed with cancer I had been activly working toward my LPN (Licenced Practicle Nurse) while also taking all of the pre-reqs for the RN (Registered Nurse) I have worked in several different fields in medicine starting at Registered Caregiver up to and including being responsible for more that 25 patients and leagaly and professionally liable for the actions for 5-10 caregivers. My observations are documented and valid. The investigations taking place at this time have shown nothing except that my reportage was accurate and that there was obvious cause to investigate. Who would you prefer look into this problem? Someone with no skin in the game at all?

If I survive my cancer I am uncertain that I will even continue my studies in medicine. I find myself ashamed that people of that low quality are my professional equals and that we share a vocation.

I am so sorry about your illness. The best of luck to you

Dear tired of pirates -- it sounds like you met some bad apples and hope that you ended up getting the treatment you deserve. Don't give up on your studies. We need good, ethical people in every profession.

And all this doesn't even touch on the travesty that is Chiropractors (DO's) getting board certified, and becoming primary care physicians. My mother had one. She correctly self-diagnosed herself with gallstones when she started experiencing abdominal pain. Her "doctor" ignored her and kept forcing acid-reflux meds on her even though she had never had heartburn in her life.

Six months of agony later, she finally took my advice, dumped the idiot, got a real MD, and got the problem fixed.

My advice for people is to check the credentials of your primary care physicians. If you don't see MD, dump the pretender.

Faust: A DO is NOT a chiropractor. A DO is a doctor of osteopathic medicine and attend medical school just like an MD does. A chiropractor is a DC, they do not go to medical school.

Tired of Pirates - I'm sorry you had a bad experience, and I'm sorry for the unimaginable physical pain and mental anguish you are going through. But for every horror story, someone else has a wonderful experience. I have an auto-immune disease. I have never once seen the Rheumatologist whose office I receive care from. I have a great relationship of over 7 years with 'My Rheumy", the practice's Physicians Assistant. I have had several people gasp when they find out that, egads, I've never even seen the REAL DOCTOR! I don't need to. The PA takes good care of me, and I always feel like I'm in good hands. And the "real Doctor" must trust her enough to allow her to see patients. So, they're not all like that, is what I'm trying to say.

Nurses carry a pretty significant level of responsibilty that our title nor our pay reflects. We have to learn in 2-4 years what MD's get 10+ years to learn. Maybe we don't do the volume of clinical rotations that they do, but we have to know what they are doing, why and what it means when the patient reacts to the treatment (for better or worse). Not to mention what we are supposed to do as part of our job description. Nurses can be sued for malpractice just as any doctor can, but the real stinker is that a doctor won't get in trouble for me doing something wrong. And it's total sh** that doctors are the front line in healthcare, Nurses are! Before you ever see a doctor a nurse talks with you about your problem and breaks it down for the MD. Pt care bgins and ends with nurses!

A lot of med school training is simply hazing at it's finest. Doctors are quick to point to med school as being their key qualification to being the overlords of healthcare and yet study after study shows that the long hours and chronic fatigue bring nothing but poor outcomes for pts. Not to mention sleep deprivation has been documented as the equivalent of being legallly intoxicated so what would they be learning let alone the provision of safe, competent care. Yet they are still quick to defend it because, "dammit, I had to do it and they should too." The only common thread I see with Md's is the tendency to being narcissistic jerks.

What makes NP and ND's good at practicing medicine and delivering pt care is that they are typically expected to work as nurses while in school (that also include clinical rotations in specialties studied each quarter) and then are quickly put into practice effectively creating an emersion apprenticeship. They spend their training on the floor working with real pts rather than in a lab or writing papers and aren't burdened by the "publish or parish" mantra.

Md's are no more capable of spotting oddities than nurses and, let's face it, that's why there are specialists in medicine. The dominance of specialists and lack of generalists is the exact problem in healthcare and it's insulting to the human capacity for intellect to presume that only a few are capable of understanding and anticepating the needs of the human mind/body that requires an exact number of years of schooling to know them.

This has nothing to do with title and everything to with money and prestige. Healthcare is not called "Doctoring", because you see healthcare providers and not just doctors alone, but there's not enough money to pay all healthcare providers anywhere near what MD's make and they're certainly not going to share the glory of saving lives or delivering babies. The tasks they have already willingly farmed out are not surprisingly the less glamorous stuff like taking blood pressures (nurses use to be considered to dumb to be doing such important tasks), but everyone remembers the guy that sewed them up like a new quilt or told them they have cancer and pays them handsomely for it.

you think you learn THE SAME MATERIAL in 2-4 years that doctors "get 10 years to learn"??

Honestly, the worst kind of ignorance is not knowing what you don't know

missrn wrote, "Md's are no more capable of spotting oddities than nurses."

This shows the underlying problem to your entire argument. In fact, it belies the most important distinction between doctors and nurses. Nurses are trained to spot problems, physicians are trained to diagnose. Nurses alert doctors, doctors figure out the cause and treat it. So much of my medical education in internal medicine was spent learning how to develop differential diagnoses, looking for the most dangerous and the most common, and excluding extraneous possibilities. My sister is nearing the completion of her DNP. She is a sharp cookie and knows a lot about medicine. But I know for a fact that her diagnostic skills are not the same as a physician's. The focus in training is not the same. Can a DNP do basic medicine? Sure. But how do you know when something looks like basic medicine and it is really something serious?

I love my sister, I respect what she does, but I want to see a doctor.

Agreed 100%

I tried to use a similiar logic in response to the fact that NPs were only going to treat "minor" illnesses, but the other poster got mad

Im glad I'm not the only person who recognizes this issue

Stop the sanity!

PS LMAO

The problem with that solution is that a lot of patients may be unaware that there is such a thing as a "Doctorate of Nursing" degree, and wouldn't know to ask. If the degree were more widely known, yes, that would be a good solution.

Most states require as part of obtaining a professional license to practice that a professional identify themselves clearly to a patient and inform the patient why they are there.

That's the most effective way of stopping medical errors and clarifying patient misconceptions.

Sandy, you can get a doctorate in just about anything, I would assume even basket weaving (would probably be called Fine Arts or something along those lines). The few times I was in a hospital, I always checked the person's name tag to see whom I was dealing with. Hospitals should make sure that personnel wear identifying tags; they should also make sure that every employee knows his/her role in the patient-care business.

I know, but most patients in a medical setting assume that someone who introduces him/herself as "doctor" is an MD or DO, not an English PhD. To be honest, I was unaware until a few years ago that a Doctorate of Nursing degree even existed, and would never have thought to ask "doctor of what?" of my health care provider. I'm sure I was not alone in my ignorance.

I've worked in a hospital setting for years and have found very few patients have an issue IF someone properly introduces themselves and answers any questions a patient may have openly and honestly.

America. a M.D.

America

M.D. in MO is a dick doctor

So, all doctor's have a "God complex"? There are some, I'll admit, but most are not. Being a nurse is a calling. It's a rough job. But then again, any profession is a calling, esp. when dealing with the ill. Most MD's have to see >30-40 people/day as specialist or >50-60 as PCP in some studies, to pay for nursing staff, office staff, billing staff, lab staff, medical supplies, computers, professional fees and licenses, inspections, etc. Many are essentially small business owners whose income is essentially dictated to them by the government. How many other businesses are run that way? If you go to a lawyer to get a will done, if you can't pay what they want, you are shown the door. Medical care is not done that way for the vast majority of physicians.

A PhD is and has always been called Dr. If the MD's have a problem, perhaps they should start introducing themselves as MD Smith. I am sick of MDs and the AMA trying to protect salaries and turfs. It is ego pure and simple. I much prefer a nurse practitioner for my care as compared to an MD.

. Ask if the nurse is a medical doctor the moment he introduces himself as 'Doctor so-and-so'.

In the example given, she CLEARLY identified herself as a nurse. Works for me.

Studies have shown that nurses with master’s level training offer care in many primary care settings that is as good as and sometimes better than care given by physicians

I'd much rather be seen by a nurse practitioner than a doctor. They have more time and are much more empathetic. They also seem to be more willing to try remedies that are not as drug dependent as doctors. Perhaps the big pharma companies haven't gotten to them yet.

Its very popular these days to say nurses are more caring, and take more time than doctors. This may very well be true.

But don't mistake the appearance of good care with actual medical care. they are very different. And nurses have not yet proven they are capable of delivering the level of care that is needed

I would rather be treated by dr house than mary poppins any day of the week

I don't care if it's "popular" -- in my experience, it's true. And any good nurse practitioner can diagnose and treat the majority of minor illnesses, and handle the majority of screenings, that are required for basic health care.

But here is a biggie. They LISTEN to you. Thus people are more willing to talk to them. That's huge when diagnosing illness. Then if it is past the NP's ability, it is sent to a physician.

This works. A physician doesn't NEED to treat the flu or take care of a healthy woman's pre-natal needs. This frees up him/her for the more serious cases.

and in my experience nurses are not as friendly OR knowledgable. See where comparing anecdotes gets us?

Your claim about nurse practioners is simply untrue. Is there anyway to prove this? Sure, have them take a BASIC test that all physicians take to show they are capable of not killing people

In fact, DNPs already tried this. They took a watered down version of step 3, which is a licensing exam given to all doctors. Its a joke of a test. And they failed. Miserably

http://www.ama-assn.org/amednews/2009/06/08/prl10608.htm

50% failed. And these are DNPs, not just plain NPs. Supposedly the cream of the crop

The test is a joke. The pass rate for docs is well north of 90%

Im glad you are satisfied with your care from nurses. By all means, keep seeing them if you want.

but keep in mind your opinion is one thing, fact is another

How are you going to determine that you are asking the question you propose to a nurse, or are you going to ask EVERYONE who introduces themselves as a doctor if they have an M.D.?

There is a ton of research out there showing that patient outcomes are just as good if not better when comparing care provided by nurse practitioners to physicians. Your opinion does not negate the true facts of the research results. The evidence shows that nurse practitioners provide safe quality care that keeps patients healthy.

SHOW ME THE RESEARCH!!

They failed a basic test that most doctors pass WITH EASE. ITs not opinion, its FACT.

Eric --

I never said that NP's can treat everything. I said the MINOR illnesses that make up BASIC health care, thus leaving the MD's for the more serious cases. You obviously choose to read what you want into my posts to prove some sort of point.

As to your link ... what do you expect? Sure, there is a lower passage rate on that test, but NPs are NOT doctors and I never said that they were. They aren't passing themselves off as doctors either.

As to the quality of care ...

In an ambulatory care situation in which patients were randomly assigned to either nurse practitioners or physicians, and where nurse practitioners had the same authority, responsibilities, productivity and administrative requirements, and patient population as primary care physicians, patients' outcomes were comparable.

http://jama.ama-assn.org/content/283/1/59.full

So ... I'll keep my OPINION (which obviously DOES have basis in fact), thank you very much. If I'm sick enough to need a doc, I'll go. My NP is very good about that. But if it's not necessary, there is not the need.

Im going to be a little snippy here, and I apologize in advance

But for starters, how do you define "minor" Is that heart murmur benign, or does the patient need cardiac evaluation? Is that fever and fatigue a viral illness, or the b symptoms of malignancy?

Thats the problem with limiting yourself to "minor problems" They may turn out to be not so minor

Also, the purpose of citing that test wasn't only to show that nurses arent doctors. I showed it to prove that they do not possess the eductation needed to TREAT PATIENTS independently

Furthermore, I have commented on that study numerous times. for your own knowledge, posting just the conclusions of a study is an amateur move. I don't care what the authors thought of their own study, I want to see the data. Ill repost my thoughts on it below

Ive read it. Its a pile of garbage. It compares outcomes in a primary care setting over the time of 6 months.

6 months is not nearly long enough to show a difference in outcomes, especially with the low event rate in a stable outpatient population

Its like following 2 people for a week to see whats more common--avalanches or getting hit by a car. Neither happen, so you claim they are equally likely. No. Its called underpowering a study, and is admitted to by the authors in the paper

But you have latched onto what you wanted to believe, and nothing can change your mind. Not even facts

Eric -- we can post competing studies all day long.

But again .. you are reading things into my posts that are not there ... and frankly I'm tired of it.

So .. take the last word which is obviously so important to you ... I've better things to do.

ok. Im sorry if you felt I was reading things into your posts. I tried to directly quote you when possible

I also did not mean to make you feel antagonized. I was actually enjoying our discussion

Eric - Due to your conciliatory post, I'll return.

It's remarks like this that made me feel antagonized:

But you have latched onto what you wanted to believe, and nothing can change your mind. Not even facts

Also, apologizing in advance for being "snippy" doesn't excuse it. If you recognize it for that, don't do it.

And I did feel you were reading things in ... like INDEPENDENT NPs. I never said they should practice "independently" ... mine does not, nor do any of the others I know. If fact, if you were to read anything in, it was that they did NOT practice independently. But that would not have made your point.

I've been in the medical field .. and left it. I recognize good medical care when I receive it. The NP gives good BASIC care. I don't feel like posting my medical history, but suffice to say, when it was a mild problem, she treated it well. She was also experienced enough to know when it was NOT a mild problem, and I saw the doctor ... which was not always a great experience.

Fair enough...honestly, that part you quoted was a copy and paste job in another post to someone else who wasn't as friendly. I shoulda left it out. My apologies

But your first post insinuated that nurses provided better care and were not as beholden to drug companies. Thats just false

I'm always suprised when people think drs are "owned" by pharm companies. Just because they agree to see reps, it doesn't mean they take everything they say as law. Most listen, and then research for themselves

I agree with you regarding independent practice. Unfortunately, that's what this nursing doctorate is about.

Im sure there are many cases where NPs provide good treatment, especially in routine cases. With the push for a broader scope of practice, however, I think the limitations in their treatment abilities will become clear

Just know that your experiences aren't necessarily the norm. I try and rely on large studies and broad research whenever possible to avoid this size bias.

I still believe in many ways they DO provide better care. Not necessarily diagnostically, but emotionally. Perhaps this is a gender issue, but I've seen many patients "hide" their symptoms from doctors (go figure) but they will open up to the nurses. I think it's because the nurses take the time to connect in a way that many doctors these days don't.

As to the drugs, I do believe there are a significant number of physicians on both sides of this.

Perhaps *MY* experiences aren't the norm, but I know that NPs are very prevalent in my area of the country -- most every medical practice has one or two -- and most have good experiences with them.

Gender issue? That assumes that all physicians are male, and all nurses female. While I admit that male nurses are fairly rare, female physicians are not.

studies have seemed to confirm your experience that patients feel more connected to nurses rather than doctors

However, most of these studies had nurses with a significantly lighter workload than doctors, so hard to really compare

But I probably agree with you...on the whole, nursing tends to attract more emotional individuals than medicine

Does this equal better care? Im sure there are benefits (patient compliance, education, etc)

But Im not sold that outweighs the knowledge deficits

Time will tell though, I guess

Thanks for giving me a second chance!

Gender issue? That assumes that all physicians are male, and all nurses female. While I admit that male nurses are fairly rare, female physicians are not.

@sandy -- I meant the PATIENT.

@ Eric -- I think the issue is, the doctor can't diagnose what the patient doesn't tell him. I don't know about studies, just experience. Patients tell NPs more than doctors. Especially female patients.

The key is using ALL medical professionals. I do believe that NPs are definitely capable of more than just "standard" RNs. Perhaps think of it more of a triage type situation. The NP treats the things he/she can and refers on what they can't ... but with much more background than the lesser educated RN.

I don't think we're all that far apart, we just think about it in different manners.

(& YW)

Misunderstood, but I'm still not sure I agree. My experience has been that female patients will generally discuss symptoms in more detail with health care providers in general. In college, I had a summer job as a receptionist in a medical office, and some of the female patients would tell ME all their symptoms, over the phone while making their appointment. Male patients are more reticent with providers of either gender, unless their symptoms are severe. As women tend to visit health care providers more often than men, I think they are more comfortable in that setting, and also don't feel the need to "tough it out", as men are expected to do.

How did I miss this discussion....? :)

your post is nonsense

kickbacks from drug companies are a figment of your imagination.

Patients are brought back for routine evaluations because drugs alter the way your body functions, sometimes in dramatic ways, and its necessary to monitor those effects

In fact, that could be role NPs might serve well--under a doctors supervision

But seeing new patients, diagnosing illness, and prescribing treatment plans is something they are not qualified to do

Its not a greed or money issue primarily. Its a patient safety issue

The "would be" doctors that are only in it for the almighty buck drop out of medical school to attend law school, where the real money is. And they don't assume nearly the liability that doctors take on.

"patiences"?

If this were about patient safety, nurse to patient ratios would be a nonissue. The AMA and all of the other big medical associations and lobby groups would be all over whatever regulatory body they needed to. If that were to happen though, it would invariably cut into physician salaries. It's common place for nurses and other healthcare personnel to get laid off when their salaries start to take up too much of the budget.

what does this have to do with nurse patient ratios?

It is a patient safety issue

Wow,

Overpaid technicians? REally? Im sorry, but statements like that show a complete ignorance of the complexity of modern medicine.

Im glad you have a wonderful team of nurses that care about your health. But its rude to disregard the input of physicians as technicians

You are full of shiit. I live close to Canada - I have friends in Canada. None of them have ever waited weeks for care. They show a card, sit down in the waiting room (just like us) and see the doctor that day. They get good, immediate care for practically nothing. They keep telling me how stupid and crazy Americans are for not wanting universal care. I agree. By the way, doctors in Canada make good money -- just not as much as our overpaid technicians, living in million dollar homes and driving BMW's. I thought doctors went into the medical field to help people, not make big bucks. But in our capitalistic system, even doctors are corrupted by the almighty buck.

Google "wait times for doctor appointments in canada". Educate yourself. It'll feel good.

Socialized medicine works great until you need something that is both elective (not an emergency) and expensive. This is true for things like joint surgery (expensive and waiting won't kill you) and other forms of surgery. Also, newer medications may be lacking. It depends on Big Pharma to work it out with the government. Since Canada has a large population, it has great clout to bargain. Most insurances in America do not have enough bargaining power. If there is not enough profit for Pharma, they won't get the drug. This is especially true for the horrid expensive cancer medications. You probably won't get the newest, most expensive versions.

macrulz makes excellent points

Socialized care is very good for routine office visits and common problems, in addition to preventative care

But heaven forbid if you ever need expensive cancer or cardiac treatment. It aint happening

Where do you idiots get your facts? Fox Noise? In Britain and other universal care countries, people are not turned down for cardiac or cancer care, but given that care as urgently as needed. The wait time for seeing a doctor in Canada is, I repeat, is no more or less than in the states.

I know you won't read this because you're delusioned with the greatness of someone else paying for your medical insurance but here is one of many sites that document that Canada has weight times for health care.

I know you won't research anything that would bust your delusion so in an effort, probably fruitless on my part, I present to you one of many websites that indicate Canada has wait times for health care. Click it if you dare...

http://www.usnews.com/opinion/blogs/peter-roff/2009/07/28/statistics-show-canada-healthcare-is-inferior-to-american-system

Since I doubt that you'll click the link, here is a sample of what you would find if you did.

For example, the median clinically reasonable wait time before receiving neurosurgery is 5.8 weeks. In Canada in 2008 it was 31.7 weeks. For gynecology it's 5.6 weeks v. 16.1 weeks. And for internal medicine is 3.3 weeks v. 12.5 weeks. Fraser's hospital waiting list survey measures median waiting times to document the extent to which waiting times for visits to specialists and for diagnostic and surgical procedures are used to control health care expenditures. The report measures the wait times between seeing a general practitioner and a specialist, the time between seeing the specialist and receiving treatment, and the total wait time.

So who's the idiot?

jeff,

then why did the CAnadian supreme court rule in 2005 that wait times were endangering patients?

Another bit of text to educate:

The Fraser Institute’s twentieth annual waiting list survey finds that province-wide wait times for surgical and other therapeutic treatments have increased in 2010. The total waiting time between referral from a general practitioner and delivery of elective treatment by a specialist, averaged across all 12 specialties and 10 provinces surveyed, has risen from 16.1 weeks in 2009 to 18.2 weeks in 2010. Compared to 1993, the total waiting time in 2010 is 96 percent longer. Patients in Ontario experience the shortest wait (14.0 weeks) followed by Manitoba (17.5 weeks), and British Columbia and Quebec (18.8 weeks). Canadians wait nearly 3 weeks longer than what physicians believe is “reasonable” for elective treatment after an appointment with a specialist. Throughout the provinces, in 2010 people are waiting for an estimated 825,827 procedures.

http://www.fraserinstitute.org/research-news/display.aspx?id=17068

jeff,

I was in another Newsvine conversation with a Canadian who said that in rural areas of Canada, it can be a 5 year wait period to see a primary care doc. Patients end up going to urgent care clinics instead, even for non-urgent problems. Granted, it is unlikely to be the same in urban areas, but there are an awful lot of rural areas in Canada.

So, I guess y'all love our system, eh? Maybe y'all have great coverage, but most don't. Folks are dying all over because they're not covered. The fact is - we have a cruel, capitalistic healthcare system that's causing folks to choose between paying medical bills or the mortgage, even groceries. You can arm yourselves with all the bullshiit right-wing facts you want, but millions are now choosing between paying stacks of healtcare bills or feeding / housing their families. You can believe what you want -- you might be the fortunate few that are well-covered, but you are the minority. Obamacare is not the answer, but a government insurance program that competes against the ruthless private insurance companies is the answer for most Americans, especially those with health issues. Wish y'all good health -- you might need it, if you lose your cadiallac coverage. Most of us aren't that fortunate.

"bullshiit right-wing facts"

Mamma was right... you can't fix stupid.

I wish you good health too Jeff.

The Us has wait times! What's the big deal about Canada here? Some part of Canada may have long waits, but other parts may not, like in the US.

The US has long wait times for routine care, particularly for the uninsured, and this causes minor illnesses to escalate. Any US citizen can be seen in the emergency room for more urgent care, and that usually involves a wait too.

waits in the ER are on the order of hours, not weeks

It is tough seeing a doctor if you are uninsured, but there are many safety net programs that address the problem, leaving a minority of US citizens voluntarily uninsured

In Canada, no matter what, no matter your financial status, or often your health status, you are subject to a wait

Freedom and equality are often at odds, but I'll take freedom in this case

In a few urban areas in Texas, there are community and charity clinics. Many people who have always worked and lose their jobs don't know about them, though.

Around Dallas and Houston, nearby upper middle counties don't want to tax their citizens appropriately and let dump on the Dallas County and Harris County Hospital Districts.

Very isolated rural areas, where I don't live, like in West Texas, probably have emergency rooms that treat most everybody.

In practice, emergency rooms in the large Texas municipalities do treat minor illnesses.

The wait for routine care in my huge state is probably a big problem for the many towns in between the large municipalities and the isolated rural area.

Though nothing's perfect, in Texas they still don't wait for weeks. See post 9.7 and 9.9.

Obama, a failed experiment -- Your ignorance is overwhelming. I have family in Canada, Europe and well as some other continents. Those in Canada and Europe as getting excellent care and do not have to worry about ever running out of care due to lack of money. I can cite one example of a relative in Europe who was diagnosed with a rather uncommon cancer. She was in surgery within a week of the diagnosis. Her very involved treatment lasted a year and included everything from cosmetic surgery to home care. Because she required such specialized treatment, she was sent to the best hospital available. Her care, in her words, was superb. At one point in time she asked the doctors if all that treatment was worth it considering she's in her 80's. Their response, if there is any chance at all to save a life, they will do it. Other than her affordable monthly premium, it cost her nothing. How can that be so bad?

why does no one ever respond when I cite the 2005 Canadian supreme court decision?

what country in europe? Some have more money in their health care system because of obscenely high taxes and a relatively healthy population

RE: waits in Texas. The biggie county hospital in my city wants people to take out health insurance if they employer has it. So, I heard of someone who had an early skin cancer, but had not taken out health insurance on his low hourly wage.

And that the county hospital claimed they could not help him, since he had not taken out health insurance.

This is anecdotal, but not an uncommon situation.

If the person did stuff like squawk to politicians, the county surely would have treated him anyway.

Yes, people wait months in Texas for treatment for routine illnesses like diabetes, which is highly treatable.

In at least Dallas, Bexar (San Antonio), and Harris (Houston) counties, the country hospital districts will provide routine treatment on a sliding scale to county residents. Yet, they go through tears where they demand larger payments and turn people away from their appointments if they don't have them.

A diabetic who needs insulin and doesn't get will either die or end up in the emergency room with a serious problem.

Okay, let's say you live in a rich county like Fort Bend near Harris County or Collin near Dallas County.

Once you had a $70,000 a year job. You got laid off, spent all your 401Ks, can't afford COBRA, and you are unemployment or your unemployment ran out. You need $1000 a month medicine.

Your county won't cover your medicine. Harris and Dallas don't like to provide uncompensated routine care to nonresidents. They will take anyone in an emergency.

So you go without your medicine 4 months in Fort Bend County and then you end up at Ben Taub Hospital in Houston with costly complications.

If you showed up at Ben Taub or at Parkland in Dallas with a breast lump, they'll probably be glad to aggressively screen it cause it helps then train students. But, if your illness is not beneficial to their teaching program, you are going to wait a long time!

Keep in mind that I am discussing hypothetical for someone who lives NEAR one of the major county hospital districts.

You could easily at first see an NP or PA at Ben Taub or Parkland, but you'd probably be real glad to see anyone, regardless of what title he or she uses.

Eric -- I'm paying twice as much in taxes as Warren Buffett and, in my opinion, get very little for it. Wouldn't it be better if at least some of the taxes I'm paying went for better healthcare instead of war?

i could not agree with you more susi

Technically, to complete a doctoral program, you need to contribute an original piece of research to add to our knowledge on some subject. Seeing as this doesn't happen in medical school, the term is mostly honorary for physicians and is more of a job title than anything.

Technically, this is not true for medical school. They do not require original research to award an MD. HOwever, most residents and young physicians actively participate in research

In fact, most fellowships require a research project as part of the ACGME curriculum. Since this is a de facto part of medical education, I would say practically speaking, you are incorrect

You are citing the exception, not the rule. Even in those cases however, there generally has to be a scientist in charge (since you need their lab space anyway). I'm married to one of those MDs, and we agree on this point. Division of labor is a good thing, but I'm starting to think this term is too silly to keep. Let's get rid of it.

As I stated, MOST residents participate in research

As I stated, this is an ACGME REQUIREMENT

not exception, rule. Im happy to discuss this topic with you, but i ask you to at least read my posts if you respond to them

The "scientist" in charge of the lab is usually an MD. Often, its an MD/PhD though

Oh, don't get me started on that one. Don't get me wrong, if they want both degrees more power to them, but we shouldn't use tax dollars to pay for it (nearly all MSTP programs are funded by the federal government). Most of them end up in administration, some practice medicine only, and a rare few end up doing what they were subsidized to do: be a bridge between the two.

As for the other bit, in many cases fellowships are not needed.......after residency my spouse will look for a job directly. Still, I'm curious, where do the findings from those studies get published? Are they patient studies or what? It's always good for me to learn new things.

I published in circulation. JACC is another that has a basic science bias

Only 25% of physicians go on to fellowship and MOST medical schools (DO or MD) do not require any research (1). The big schools do, Duke, Harvard, Yale, etc. That's what sets them apart from the rest. They accomplish their "research year" during their 3rd year while still accomplishing all other tasks that 3rd years accomplish.

The article mentioned that medical doctors training is almost twice as long as the other practice doctorates. This is also incorrect. I am a subject matter expert in this subject (NP working toward DNP) and my wife is a PharmD (Doctor of Pharmacy). My wife received her undergraduate degree then her PharmD degree, 4+4=8. By 2015, the talk is that pharmacists will have to complete a residency of 1-2 years to practice as a clinical pharmacist 2 more years = 9-10. I completed my undergraduate degree then my masters 4+2 (24 months full time unlike 12-16 months reported in the article)=6 then will complete another 24 months for my DNP at Duke = 8 years of academic education. Now take into the fact that I accomplished a 1 year ER and ICU residency and worked as an ER RN for years prior to working as a NP in the ER. Thi is the "norm" for most NPs as they have many more years of patient contact than the majority of newly board certified physicians. How many chest tubes, intubations, central lines, etc. did I assist on as an ER RN prior to learning in my advanced education and being allowed to accomplish these on my own. I am a Licensed Independent Practitioner (LIP) and have NO physician over site have better outcomes than most of my physician counterparts and consult when needed just like my physician colleagues (licensed to practice and prescribe in Colorado). My ER Physician colleagues have 4 years undergrad and 4 years medical school with 3 years of residency, 4+4+3 = 11. What is always missing is the fact that the last 2 years of my undergraduate degree was strictly nursing. This equates to 2 years undergrad, 2 years grad, 2 years doctorate = 6 years nursing. The first 2 years where all when prerequisite courses where accomplished such as chemistry, anatomy and physiology, biology, etc. The medical doctor starts to receive medical studies after they have the required 90 credit hours completed of chem, o-chem, physics, calculus, etc and have a bachelors degree even though it is technically not required, 4 years med school (where they learn anatomy and physiology, etc.) and 3 years residency (paid) = 7 years of medicine. Now what most do not understand is that the internal medicine, family practice, pediatrician, and emergency physician all only need the 3 years of residency. These physicians make up the largest portion of the physician workforce. There are actually some general practice physicians out there that only have the single internship year that is required to practice medicine which equates to 5 years of medical training.

In other countries the physician is called just that, physician and not doctor. Maybe that is how it should be in America, especially if all other practice doctorates are doing the same which I am 100% for. I want people to know that they are being seen by a Nurse Practitioner, Physician, Physician Assistant, Clinical Pharmacist, or Physical Therapist. This is how it is now for my practice and how it will be after I receive my doctorate.

1.

The fallacy in your argument is that work experience = residency. That is wrong for numerous reasons

1) Hours

Most residents work 70-80 hours a week. Most nurses work about 40 hours a week. So even if your erroneous assumption about an equivalent amount of YEARS spent is true, then you are still "out-experienced" by a factor of 2

2) Didactics

Residents are required to attend 5 hours of conference EVERY WEEK. These talks are extremely helpful, and are part of the continuing education after med school.

3) Responsibility

Residents work in the same units as nurses for years. Does that mean they are equipped to perform even basic nursing tasks? Of course not. If you asked a doctor to start an IV, or dress a wound, he would fumble around much more than a nurse. Likewise, working around doctors does not make you one, or give you the experience of one

4) Uniformity

I don't know what your experience was like. You may have worked in an extremely busy hospital, giving you exposure to a wide variety of patients. Or you may have worked in a hospital in east BFE with very low acuity. There's no way to know. ON the other hand, residencies are evaluated every 5 years by the ACGME which looks to make sure the exposure of residents is sufficient

Eric, I was not equating the residency factor alone which you chose to discuss first. Physicians receive a "generalist" medicine degree during their 4 years. NPs, Nurse Anesthetists, and Nurse Midwives all focus on their specialty after accomplishing the undergraduate portion (includes "generalist" nurse training), have at least 1-2 years of experience prior to acceptance in their advanced degree path then the years for the degree. When discussing my education with my physician colleagues, I continue to hear that they do not use a majority of what they have learned from medical school and that it was pointless. They understand our model of learning what the specialty that is being entered into; family, pediatrics, GYN, Anesthesia.

Not all residency programs are equal as much as you try to play the "uniformity" card. During my ER/ICU residency I worked along side FP residents from 3 different programs who where sub-par to say the least. The greater majority came from foreign medical schools, had no interpersonal skills, and where poor diagnosticians. All of these residents graduated and entered the workforce. Some are currently struggling due to never grasping the patient centered model.

The point that you missed in your responsibility paragraph is that I mentioned years of patient contact. That is invaluable. The outcomes of the NP and physician have been studied head to head and has even been put to the test in a study that looked at intensivist NPs and physicians in an intensive unit. The NPs outcomes where better than those of the physician. Point is what does all the education equate to if the outcomes are the same as pr better than. I think that medical school should be revamped and that speciality tracks should be included all medical schools (there are limited schools that do this) and require less residency. This would put physicians out in the workforce quicker and limit the amount of education that is not needed or used later in practice.

Getting back to the point at hand, physicians are physicians, nurse practitioners are nurse practitioners. One is not trying to become the other. Both are necessary to help fill the primary care gap and need to get on the same side and stop bickering. I enjoy working with my physician colleagues and believe they feel the same way. The NP is not trying to take over the DO/MD role, just want to care and treat the patient in the best capacity possible. As far as my background, I work in a ACS Level 1 trauma center where I see both emergent and urgent patients. Even though I have worked on many traumas as an RN, I will take them as a NP if the physician is unable and will hand them over or consult them through it. I will see all medical emergencies regardless of their nature independently. I make less than half as much as my EM physician colleagues and feel that I make a very good living. My RVUs are higher than most of my ER colleagues and have superior patient satisfaction scores compared to them. To repeat, this is while working in an ED. I currently work with 2 other NPs who are both pillars in the ED.

Not all medical, nursing schools, or residency programs are equal, regardless of accreditation and revaluation. All people that have received a practice doctorate should be titled doctor in the practice setting. All practice doctors should be required to state what they are.

i've read the study you mention about NPs and intensivist

NPs were not superior in that study to the best of my recollection

Plus, the patients in the NP group were managed by resident physicians overnight, so it wasn't much of a "head to head" comparison. Plus, the NPs had ATTENDING physicians in their cohort as I remember, so it really wasn't head to head at all

As for the uniformity, I never said they were equal. There are much better programs, and not so good ones. But they all meet a basic requirement that work experience does not have to meet

The rest of your post is mostly opinion, which I cannot really prove incorrect

But I would love to hear your thoughts on the fact that half of DNPs failed step 3, which is honestly a joke of a test that >90% of physicians pass

yeah, here's a link to the study I think you're talking about

http://ajcc.aacnjournals.org/content/14/2/121.full.pdf

I think you better read it again, its not at all what you claimed. My memory of it was pretty good

At most, it shows that fully trained NPs are as good as doctors-in-training in following their boss's orders.

Big deal

Eric, I first thought that you may be a physician but now I do not know. I also realize that you have difficulty in reading scientific literature as you are incorrect in your 2 previous comments which also makes a clinician status suspect. The study actually looks at physician fellows, which are physicians that have completed residency in internal medicine and where board certified in internal medicine. The Acute Care Nurse Practitioner had 15 years experience as a critical care RN but only 6 months of experience in the Nurse Practitioner role prior to the beginning of the study. This goes back to my point of being an ER RN prior to working as an Emergency NP gained me experience with patient contact and medicine that was invaluable which I am sure translated to this NPs practice and the practice of the vast majority of NPs. Yes, both had attending physicians but the ACNP team had higher daily census and patients with a greater number of comorbid conditions than those in the fellows team. The outcomes of this study were similar but this was not the study that I was mentioning in my previous post. The study that I was writing about does look at the NP versus the resident led teams.

As far as the USMLE part 3 goes, the test that is administered to DNP graduates is similar in blueprint to the USMLE part 3 but has been revamped by the NBME. Yes, the part 3 is considered the easiest portion of the USMLE to complete but I question that if we are not taking the part 3 and in fact are taking a newly designed test by NBME then we cannot compare the two. As a matter of fact, the American Academy of Nurse Practitioners and the American College of Nurse Practitioners do not endorse this test or the credentialing body. That is probably why only 95 DNPs have taken the test since its start in 2008 and with thousands of DNP graduates in the work force, this test is considered to be not important. We all have to take a board certification in our field which is what is required by the state boards. This board certification is in advanced nursing and not in medicine like the ABCC (NBME) test is designed.

Look, we CAN and should all get along and, except for in posts like this, do get along on a daily basis. Lets put the patient first and stop trying to devalue each others degrees and titles.

i think its pretty funny that you lecture me about fellowship when I am currently a fellow. I think I know about the training involved

That being said, you are absolutely right that they were fellows in the study I posted. I looked at multiple studies, and the one I ended up posting had fellows--the majority compare NPs to residents.

Anyway, that's a fairly minor issue, don't you think?

The nurses, as you point out, only had little experience in the unit. Fine, then find me a study comparing outcomes of more experienced nurses

The test administered to the DNPs used old questions from previous step 3 exams, but was "watered down" ie, easier questions with a lower passing threshold. The fact that many could not pass this test is very telling

can you pass nursing boards? Well, I hope so. But that proves you to be competent to be a nurse.

Step 3 tests your ability to diagnose and manage common diseases.

Look, it comes down to the fact that this article is about nurses who call themselves "doctor", see patients independently, and prescribe treatment plans. This was all the previous domain of MDs

If you want the territory, then at least take some of the same certifying exams. I think the failure of DNPs in terms of step 3 shows the extreme knowledge gap between NPs and MDs, and reiterates the point that NPs are not ready for this role they want to play

Speaking as a primary care MD, I would love nothing more than to have the kind of relationships with my patients you describe. In fact 25 years ago I did. In the interim, reinbursements have been cut nearly every year for my work, while my rent, bills, malpractice insurance, staffing costs, nursing costs, ect. have all gone up every year. That leads to seeing more patients everyday to try (and fail) to make up the difference. The rise in health care costs have not gone to doctors, they have gone to drug companies and device makers (hips, knees, imaging equipment, ect.). I highly doubt this is what society really wanted.

No that is not what society wanted. They wanted everything: Better medicine, better care, longer life, less responsibility/personal accountability, and especially less cost for care. That turned into insurance. Now I have to rush through appts and important technical discussions just to make sure that my check-in assistant, check-out assistant, medical assistant, registered nurse, billing staff, various practice managers can get paid a reasonable salary and medical insurance/401K program and still have something left for my family to make the time and stress of it all worth it. When the focus in our society became money and consumerism, something in the medical relationship was lost. It won't be coming back soon...

Hey Peter, in spite of all the so-called rising expenses you face, would you share with us what kind of house and car you have? Most doctors around in my area have $300,000 to $500,000 homes.

Perhaps if so many American doctors weren't living extravagant lifestyles, you'd face less criticism.

If you'll read, "The Millionaire Next Door," you'll find that a lot of millionaires live rather frugally, like in a $150,000 home and send their kids to public schools

I live in a 2 bedroom apartment. I'd live like a queen in a $150,000 home. I took me forever to upgrade to a 2 bedroom apartment.

However, I spend most of my time in bed or sitting cross-legged on the floor at my computer. I've always sat on the floor and eat by the computer most of the time on the floor.

So how much home do you really need?.

tof - There is a huge difference in reimbursement rates between Primary Care Physicians and Specialists.

Dear Second that - of course I know specialists get paid more, and I want the PCPS's paid more!

A DO vs MD is more of a matter of approach to medicine. The DO term is not limited to Chiropractors. In fact, there are entire medical schools where the doctors that graduate are DOs and not MDs.

DOs are "licensed to practice the full scope of medicine and surgery in all 50 states, equivalent to their MD counterparts."

In short, a DO is a Doctor just as an MD is a Doctor.

Osteopathic Medicine Doctors go to full medical school and are trained alongside MDs. They are legally entitled in the U.S. to the full ability to practice medicine. Their professional training is essentially the same as an MD.

My father, an MD and retired USAF flight surgeon, said he would have no problem being treated by a DO.

DO's go to full DO medical school and MD's to MD medical school. It all washes out in the residency programs where MD's and DO's are trained together. I know great DO's and weak MD's and vice versa.

DOs are not the degree given to chiropracters. That is a DC

DOs have a slightly different viewpoint that has become closer to allopathic medicine in recent years.

However, my personal opinion, and one that may anger DOs, is that it is a backdoor into medicine as the average gpa requirement of DO schools is lower than MDs

Outside of everything posted by JRS & TFJ, I would add DC is a Doctor of Chiropractic.

Too late. Talk to the chiropractors that have D.O. after their name, not M.D. and yet they're doctors.

The big problem with your statement is that chiropractors and DO's are NOT the same thing and don't go to the same school. A chiropractor obtains a "Doctor of Chiropractic" degree. It is not equal to an MD or a DO degree, both of those which are granted the same rights and privileges of practice.

A Doctor of Osteopathy is a Medical Doctor who may also perform chiropractics. But a chiropractor is not a Medical Doctor.

Nope, a D.O. does not perform chiropractic manipulation, which is supposed to be limited to the spine.

A D.O. might perform osteopathic manipulation, which does not have to be limited to the spine. The D.O. is qualified to use other methods, like pills and surgery, to treat any part of the body, just like an M.D.

Osteopathic medicine also tends to be more interested in general medicine, though there are osteopathic specialists.

Specialists in either type of medicine tend to be overeducated idiots to my eye! With them a little bit of knowledge is dangerous! Yes, I use a few specialist, but I generally prefer a general practitioner with less training.

The whole point of the difference of DO vs MD vs DNP are there are different ways to provide healthcare that are equally valid. MDs fought DOs very very hard as well.

There have been plenty of studies in the NICU about the performance of NNPs vs MDs. And NNPs have consistantly been shown to be equal or better, to the point that most NICUs of repute are not allowing residents, or they are mentored by NNPs.

wow, just wow.

That post is is a complete work of fiction. Its honestly mindblowing. The studies you claim do not exist. Period.

Just think about what you are saying for one second. If NICUs stopped allowing residents, where are we going to train future pediatricians?

How on earth can you think that your post makes sense?

literature review on NPs in critical care roles. Comparable outcomes.

NP vs medical led resuscitations at birth - faster intubations, surf delivery, higher temps at admission.

secondary source, but with good citations.

And most pediatricians have nothing to do with NICUs. What do you think pediatricians do in the office? That's why they aren't allowing them in the NICU, or they need to be paired with NNPs. The reduction of allowed resident hours also contributes to this. Smaller NICUs that are Lvl I or II can care for ill babies without the worsening of outcomes on larger services. I know for a fact that Stanford (Lucile Packard, ranked #6 in the nation for Neo) highly limits what sorts of babies their residents can care for - no cardiac, only basic surgery, no micropreemies. Other hospitals allow residents to do more, as long as they have an NNP working with them.

It may not make sense to you, but this is what I've seen, going to many of the top ranked NICUs in the US. They need to protect the infants more than educate the residents. Residents do not have to be caring for the sickest of the sick, especially when they have no interest in neonatalogy, or even pediatrics.

Crud, my links got cut out. go to pubmed and start looking, you'll find lots.

What???

Most pediatricians have nothing to do with NICUs? REally? REally?

Show me ONE NICU that does not have a pediatrician as the director.

Heres info from stanford about their peds residency

http://med.stanford.edu/pedsres/education.html

The hospital and clinics are vital elements in contributing to the breadth and depth of the training experience for our pediatric residents through their cutting-edge treatments and world-class clinicians.

Nowhere does it state that residents are limited or "not allowed" in the NICU. It makes a point of stating that the rotate through the NICU

Neonatologist Robert Castro, MD is the Medical Director of the NICU at Stanford.

NOT an NP

the only study I could find on pubmed was this

http://archpedi.ama-assn.org/cgi/content/full/154/11/1123

basically, it compared a team of residents with a team of NPs, and showed equal outcomes.

BUT BOTH TEAMS HAD AN ATTENDING MD

not only that, but the NPs had years of experience in the NICU compared with DRS IN TRAINING

great, so youve proved that experienced NPs are no better than medical trainees, even with the supervision of an MD.

And that is supossed to prove your point?

Again, NICUs are staffed by pediatricians. These are MDs that went through residencies that trained them....in the NICU!

Im not trying to be mean, but its difficult arguing with you because you lack the fundamental knowledge of medicine and apparently human logic

How can you have an attending MD run a NICU if he's not allowed there as a resident?

Because its a lie. Its fiction. Its not true

Correct, but they are limited, whether they put it on the website or not. I've been on rounds there, seen how they run things. They give the residents limited experience, but do not allow them to compromise patient outcomes.

And yes, most pediatricians do have nothing to do with the NICU. They work in offices, or with older children. Neonatalogy is a very small subset of pediatrics. While all neos are peds, not all peds are neos, can you understand this concept?

And residents are doctors, they have the MD after their name. One of the strengths of NNPs is the fact that they have way more experience than the residents.

I undestand the concept, its not difficult

I think you may misunderstand the simple fact that ALL NICUs are run by pediatricians. Where are they going to get their training if not residency???

As for your experience....so you are telling me that residents are "limited" but NPs are not? And you want to generalize your personal anecdote to ALL NICUs based on what?? A guess? Or your bias, most likely. How do you know that one resident wasn't very green? Or that particular attending was very controlling (ive had a few like that) Im sure you'll tell me it was a pattern you witnessed over and over again with many attendings and many residents. I hate to say I doubt it, but...

And please comment on the fact that NO study shows NP superiority, nor does any study show full NP independence WITHOUT MD supervision, which negates your point that NPs are better at providing care than MDs

Not to mention the fact that drs in training are just as good as EXPERIENCED NPs at managing patients. Imagine what they'll be like after they finish training....

If they have experience, why can't they pass STEP 3?????

I don't know what step 3 is, and just because you love it and think it is the end-all, be-all for medical knowledge, it is not necessarily true. It's a test for the medical school students and I'm sure they are prepared for it. Is it a test solely on the specialty of the student?

Step 3 is NOT a test for medical students. It's given to residents. Steps 1 & 2 care given to medical students (and if the person is a DO medical student, so is the PE boards). I can't speak to what is specifically covered on step 3 because I have not taken it yet (I will be taking step 1 in June).

step 3 is a test for physicians. It tests basic diagnosis and management of conditions across a range of specialties. Its fairly easy, with a >90% pass rate for first time takers

50% of DNPs failed. That's scary

Because it is not specialized. I have no idea of the content on the test specifically, but I'm not sure how to say in any other way except for specialization.

if you want a specialized test, then take boards in the specialty areas like MDs. I took the ABIMs, and I'll tell you, it was a heck of a lot tougher than step 3. Be careful what you wish for there.

We do take boards.....They aren't your boards, because we use a different model than you, but they are boards. You don't pass your boards, you don't get a job, no matter what the master's degree says. You are not an APN until you pass boards.

right, but they test on historically nursing concepts

With APN, you are moving into a territory of diagnose and treat

Why not take an exam that tests your ability to do just that?

Actually, our boards do test on that as well. Reading XRays, interpreting labs, prescribing medications, procedures...all covered in boards.

must be at a very elementary level if DNPs can't even pass step 3, which is pretty basic (which is generous)

Bravo!!! Very well put!!!

Yes, in context it is misleading and confusing. Use your doctor title anywhere else, but not in a medical practice before patients if you are not a medical doctor.

agreed. You have nailed the crux of the argument nicely

Agreed. And she did that in the article.

Use your doctor title anywhere else, but not in a medical practice before patients if you are not a medical doctor

I disagree. They are just as entitled to use it there as anywhere -- perhaps more so. But the position of the person does need to be clarified. An appropriate greeting would be "Hello, I'm Dr. Smith, your nurse (or fill in the blank)." Another great way to do it would be a name tag: Dr. Sue Smith, Nurse Practitioner.

I refuse to call anyone Doctor if he or she is not an MD. Why feed the ego of some who have a lesser degree.

Considering one of my research advisors spent 6 years in graduate school and made a discovery that every medical student in the country now has to learn about, I have to ask myself what you mean by "lesser" or "greater" degrees.

I think kitti is referring to DNPs, possibly

I completely agree with you that PhDs are some of the smartest individuals I have ever met, and are very, very deserving of the title doctor.

No, Kitti thinks that PhD's in education don't deserve their proper title, either. She insists on addressing them as "Mr." or "Mrs.", according to an earlier post.

I refuse to call anyone Doctor if he or she is not an MD

I'm sure that breaks their heart ... but what do you call your dentist? Your vet (if you have a pet)? Your professors in college (if you went)? I'm guessiing "doctor" all! If not, it's a breach of etiquette and you are simply showing you're rude.

thanks sandy, i stand corrected

Then she is clearly wrong as PhDs definetely deserve the title "doctor"

By the way, I think i remember you from previous threads...youre a dentist, right?

Yes, we've been in discussions on several threads, and I'm a dentist.

hey, well I always enjoy reading your posts...they are insightful and well written!

Thank you. The feeling is mutual.

Wow,

so med school is 4 years, not three. Get that straight first

They CANNOT go into practice straight from school. They need to do a little thing called residency, which is 3 years MINIMUM. EVEN IF they go into primary care, family medicine, etc.

Fellowships are for specialization in cardiology, pulmonology, etc. NOT obgyn or internal medicine (those are both residencies)

Nurses are NOT as qualified as physicians to provide primary care. The lack of education is the key thing. Look at your post--you don't even understand medical training let alone possess it

Saying you have "no animosity towards physicians" given the tone of your first few sentences sounds a little unlikely. Let me correct your misunderstanding about MD education. Most follow path #1-- 4 years undergrad +4 years medical school + 3-5 years basic residency= >11 years commitment to becoming a new physician (which is more than 8). Path #2--Specialized undergrad + MD programs 6-7 yrs + 3-5 yrs residency= 9-10 years if you have that open to you. There is no law requiring resindency, but no malpractice insurance provider will cover an MD out of school without resident training. That hasn't existed in >30 years to any sig. degree.

Many MD's choose not to go into primary care for numerous reasons; not the least of which is long hours with too much work, stress, time away from family for relatively low pay compared to other specialties. Should it be this way, no, but that is how the current reimbursement scheme is.

In all fairness (and not trying to be rude, just food for thought) there were a few different times in my life when I had to go to a scientist to figure out what was wrong with me. They have a lot more specialized knowledge of WHY things happen in the body that MDs do. Remember, medicine is an outcome based profession, and you don't have to know why a drug works to get it passed the FDA, and therefore medical students don't have to learn how it works.

And as far as the numbers game goes to get a science PhD: 4 undergrad, 6 grad, 3-4 postdoc = 13 or more years.

Medical school is four years, not three. I understand that you would want to be called doctor after earning a doctorate but in the clinical setting, you should make sure that the patient understands you're not an MD or DO. To do otherwise would mislead the patient. I have a JD which is a doctorate but I am not called Doctor here in the US.

Post-docs are not required to work, just improve knowledge and capability of landing a better position. No one is comparing MD physician to PhD scientist. Roles of both are completely different and not judged here.

Long and short, PhD's, NP's, PA's, and other non-MD/DO care providers have responsibility that stops at the exit of the building. Some take call, but most do not. Many work hard, but none are on-the-hook for complex situations that have no easy answer other than not to get fired. While NPs and PAs may need insurance, it is typically much less expensive and much less used than physician malpractice.

I was referring to residencies when I wrote internal medicine, etc. Having worked in a teaching hospital for many years, I'm quite aware of the difference between residencies (OBGYN) and fellowships (OBGYN-Maternal Fetal Medicine for example). My apologies if I was mistaken about the four years versus three years or if I came across as hostile, I really am not. I am hostile to the idea that when a, say, academic PhD's call themselves doctors, nobody has a problem with it, but nurses who have doctorates calling themselves doctors is completely unacceptable. I don't agree with the idea that nurses should represent themselves as MDs, but they are not doing that, they are clearly representing themselves as doctors of nursing practice. Doctorate level nurses are trained in a different model of medical care than physicians in which they specialize in a particular patient group from the beginning of their graduate training. For example, my specialization is midwifery and women's health. After four years of grad school, I will be well-qualified to provide care to this population of patients, although, like physicians in residency, I will not go from grad school to independent practice, but will complete the first few years under the guidance and training of highly experienced preceptors. I will NOT be qualified to care for high-risk OB patients, for patients needing Caesarean section, maternal-fetal medicine, etc and I'm well aware of that. But I will actually be very well-trained to care for a large population of women that doesn't need specialized, high-tech care, the kind of care that is responsible for a lot of problems and bad maternal and fetal outcomes. I worked in OBGYN in a teaching hospital for an Ivy League school - we had a large pool of highly qualified nurse midwives who treated the bulk of standard, low-risk obstetrical patients. The idea of being a doctorate level nurse is, in my mind and training, not to replace physicians, but to fill the gaps in treatment to save costs, provide exemplary care and free up physicians to deal with the high need populations they were trained to teach.

Yes, physicians are required to go to residency because of the reality of the medical system as it exists now. But the second those med school graduates (and I'll fully admit to being wrong about the length of med school, I was under the impression that it was 3 years med school, 4 years residency, 3 years fellowship, obviously I was wrong) enter the hospital as residents, they are fully licensed, practicing doctors afforded the rights and privileges of the position as they train in their specialities. They work under attending physicians and faculty, but they also practice at a highly independent level and they are qualified to do so, I'm not for a moment discounting that.

Macrulz - I agree, many physicians don't do primary care for all the reasons you listed, but it's also important to point out that "relatively low pay" means in the range of $80-$120K, depending on where you practice as opposed to $200-$500K or more depending on your experience, training and specialty. The point is, nurses trained at a doctorate level are well-qualified to pick up the slack left by doctors who want to make more money in specialities.

Last time I checked Medical School MD or DO was FOUR years, and if you want to legally hang a shingle as a physician you need a minimum of 1 year residency training. Many states require 2 or more years of residency prior to licensure. The extra years in residency are standard for the majority of physicians. Very few physicians would feel comfortable practicing without residency training, and rightly so.

In time, the actuary will tell. When that sweet NP who introduced herself as Doctor is sued by the patient who brought her cookies...

If the patient and their care is the focus, why would any "caring" person do something to confuse them? Especially considering the large population of patients who live under the paradigm that only old white men are physicians?

They go to four years of undergrad and three years of med school.

Wrong. It's 4 years of undergrad, followed by 4 years of medical school. Due to the competitive nature of getting into medical school, most of my classmates went to undergrad, then got at least one master's degree (many of them have 2 or more) before getting into medical school. A few of my classmates actually have their Pharm.D before coming into medical school. One of them has a JD. Basically - anymore, most medical students and younger physicians have much more education than just a bachelor's degree and medical school.

Medical school is divided into two sections (essentially) - the first two years are pre-clinical education. Depending on the medical school, this is done as core sciences followed by systems based pre-clinical education (which is what mine is like); others are systems based from day one; yet others are somewhere in between. At the end of pre-clinical education, we take the first board exam to ensure we have the basics down before we enter clinical education. The last two years are clinical education. During this time we are on rotations. Depending on the medical school, rotations are typically 1 month each, and we have several rotations in various areas. Osteopathic medical school typically require more primary care rotations than do allopathic medical schools. At the end of 4th year, we have to take the second board exam. A medical student going to an osteopathic school also has to take an additional board exam at this time called physical examination boards.

Once we graduate from school, we are called "doctor", even during residency. Residency can last 3+ years depending on the field one is going into. Three year residencies have typically been family practice and some internal medicine residencies - though many of these are expanding to 4 year residencies. During residency we take the third board exam that is in our area.

After residency, we can chose to either enter private practice, join a practice or a hospital as an attending or we can go on for a fellowship. Fellowships can be 1 - 4 years depending on the area we are going into.

I am interested in either emergency medicine (which will be a 4 year residency after medical school), ob/gyn with a fellowship in fetal/maternal medicine to specialize in high risk pregnancies (which will be a 4 year residency + a 3 year fellowship), or infectious disease (which is a 3 year internal medicine residency followed by a 2 - 3 year infectious disease residency).

Most doctors have no interest in primary care at this point because it is the least lucrative and you make far more money going into a specialty.

There is some truth in this statement. Another important factor in this is the amount of crap a PCP has to deal with. There is actually more that a PCP has to deal with than many specialists have to deal with that isn't directly related to patient care.

As of 2014, all nurse practitioners will have to be doctorate trained, as they should be, and at that point, they are just as qualified to provide primary care as any physician coming out of med school

The vast majority of doctorate level NP programs are geared toward administrative duties. This certainly doesn't make them just as qualified as a physician to provide primary care. Of course, there are doctorate NP programs out there that aren't geared toward administrative duties. I am well aware of the NP programs because when I was in undergrad (after my divorce as a single parent), I was trying to decide if I wanted to go the NP route or go the DO/MD route. I opted to go to medical school because it suited my goals better.

Medical school is 4 years. To treat patients you must pass a series of 3 "step" board exams to get a medical license after medical school, plus 3-4 years of residency depending on your chosen field.

Including college that is at least 11 (sometimes 12) years of education. A fellowship is an additional 1-4 years depending on your field. Followed by a final board exam in your chosen specialty and a recertification exam at a set period of time throughout your career. (that would be 12-15 years of training with a fellowship just to practice and treat patients).

I do not take away from the education that nursing/pharmacy must complete in the course of their career. But please do not belittle the time, effort, blood, sweat, and tears put in by physicians to reach their endpoint. Most people have no idea of the training that goes behind a career in medicine. I know of no other fields (besides astronauts...maybe) that has that many years of training, with an expectation of perfection on a daily basis while being required to see more patients and deal with the "medical decisions" of insurance companies who are determining care more and more for patients.

If you want to complain about compensation of doctors, first think about the amount of commitment and training that goes into this profession, combined with a debt of about 250,000 dollars to pay for that education when it's all said and done. MDs deserve compensation more than most careers out there (lawyers go to school for 3 years and make more than a lot of pediatricians will ever make in their first year out b/c they can).

Please do not confuse medical school and it's associated required residency training as something easily mimicked by other types of programs. If you were qualified to prescribe all medications, diagnose all diseases, and deal with the complications of such problems and treatment...I would say good that's great! That program already exists. It's called medical school. if you want the same abilities as MDs you should go to medical school and not take short cuts. there is a need for nurse practitioners, etc. But that doesn't mean they are trained for everything for which they want privileges.

I should add, I agree that NPs have a very good role to play - they are a great asset to any medical team. They can provide mid-level services and should be considered a valuable part of the team.

University of Chicago,

Med students do have to take biochemistry and pharmacology, which focus on "why drugs work".

Please check your facts before posting something like this. Physicians complete a 4-year undergraduate degree, then 4 years of medical school. In order to practice ANY kind of medicine, a residency is required, even for primary care, and an additional 3 years is the minimum. I have worked with some wonderful nurse practitioners, but I do find that many presume to be just as qualified as an MD. While they may have better interpersonal skills at times, and have the luxury of spending more time with patients, their training is NOT the same. Nurse practioners are trained to treat the normal and common things, so their role in primary care for wellness checks makes a lot of sense. However, nurse practitioners do not know what they don't know, many times, and that is where we physicians become concerned about patient safety if all medical care is left in the hands of practitioners who have less extensive training. I agree with many of the other posters on this board who believe it may be time for a new "title" for physcians, other than "Doctor", since I do believe that if one puts in the time to earn a doctorate degree, they deserve the title. Until a new designation becomes commonplace, however, it is very confusing for anyone other than MDs to use the term.

Ok, I was wrong and I got to look like an idiot - always a fun time. However, my original point stands - physicians have 12 years of training (4 years undergrad, 4 years medical school, 4 years residency). However, they are considered doctors (MDs) after the first 8 years. DNPs have at least eight, sometimes nine years of training and some do post-doc as do physicians. The article suggested that physicians have double the training of DNPs, which isn't necessarily the case.

I don't remotely discount the role of physicians and I agree with many who have posted on here that master's trained NP's are not remotely at the same level nor are they qualified for independent practice as diagnosticians. I also was not complaining about physician salaries, simply pointing out that a difference between a low level and high level of pay starts at a pretty high level.

Physicians, NPs, DNPs, RN's, PA's etc all have a very important role to play in healthcare. As a healthcare access advocate and advocate of cutting costs and improving outcomes, especially in my chosen field of midwifery and women's health, DNPs have a very important role to play, both as independent practitioners and in supportive roles to OB's, who are specialists trained to deal with high-risk and complicated pregnancies and who are surgeons.

However, I do have a problem with physicians trying to deny DNPs the right to call themselves doctors. They ARE doctors and have a right to represent themselves as such. The proposition that DNPs will mislead patients (which is illegal), denigrates the ethics, integrity and education of DNPs. The proposition that patients are so stupid that they will be so confused, underestimates patients - they don't seem to have a problem figuring out the difference between other types of medical specialist who are not MDs but call themselves doctors.

see my above post about trying to compare years nursing with years of medicine

residents routinely work 70-80 hours per week. nurses work 40. So now your difference of 4 years is more like 8.

Eric, the point is not in anyway to argue that DNPs are at the same level as physicians. We aren't surgeons, we aren't qualified to diagnose at a specialized level. Nobody is arguing that - or at least, I certainly am not arguing it. But nurses at a doctorate level have the right to call themselves doctors.

I am hostile to the idea that when a, say, academic PhD's call themselves doctors, nobody has a problem with it, but nurses who have doctorates calling themselves doctors is completely unacceptable. I don't agree with the idea that nurses should represent themselves as MDs, but they are not doing that, they are clearly representing themselves as doctors of nursing practice.

The problem with your reasoning is that these PhD's are representing themselves as "doctors" in an entirely different context and environment. This does not create confusion with patients, as a DNP calling themselves "doctor" in a healthcare setting would.

breesus,

I just think it comes back to patient safety. If one calls themself a doctor in front of a patient, he/she is going to assume MD. As you agree, nurses have far less training than physicians. Thus, its misleading

We have different training than an MD, and I challenge you to find a study that says NP care is not safe and effective in the US. It is a different path to care.

It is a clinical doctorate, like the medical doctorate. No, we don't go through years of learning about areas that we aren't specializing in. I don't think MDs should either. It ratchets up their loans and does not demonstrably improve care for most specialties.

Show me so evidence and we'll talk.

I challenge you to find a study that says kindergarteners are not safe or effective at providing care.

Some things aren't studied because frankly they don't need to be

In addition, a study of this magnitude would literally be impossible to carry out. To show a difference in a primary care setting, you would need HUNDREDS of ThOUSANDS of patients for adequate power as your hard clinical endpoints are going to be rare. You would also need about 20 years of follow up AT LEAST because thats how long it takes for primary care diseases to show HARD clinical endpoints

Anything less than that is certainly worth a look, but hardly convincing

I think you see now why any study demonstrating this is not going to be forthcoming.

IN the absence of evidence, I think you need to rely on judgement

50% of DNPs FAILED a watered down version of step 3--a test I can tell you is a joke, designed only to evaluate for the most basic of diagnostic and mgmt skills.

Further, an average DNP has maybe 500-1000 clinical hours...while a residency trained physician has TENS of THOUSANDS.

Again, in the absence of RCT data, I find those facts persuasive

We have evidence to show safe, effective care. Not to the scope that you prefer, but at that point, we don't have that for physicians either. Nor do we have evidence to show that their education promotes better care and outcomes.

Your average resident has that many hours....and how many were spent sleeping? I know our residents tend to sleep all night if at all possible. They avoid doing anything at night in general. And great, you had a bunch of additional hours in disciplines totally unrelated to your specialty. Doesn't help you practice in your specialty.

Your average DNP has between 700-1000 hours to get the DNP. on top of the 700-1000 hours to get her masters. And then the required 2 years as a bedside nurse full time in a level III NICU. (because I can only speak to neonatal) So you're looking at nearly 5k hours SOLELY in that specialty. And that's coming out the door. No, she can't pactice in adult medicine or even in general peds, but she'll know her neos.

what???

I was awake on average for 27 of the 30 hour shifts I had working. If your residents are not doing that, then theyre not the norm. Again, you can't generalize your personal anecdotes to the entire world just because you feel like it.

Why do you think the work restriction hours were passed by the federal govt in the first place?? Because residents were making mistakes based on FATIGUE. If they were sleeping, why the concern?

Further, a residency is IN YOUR SPECIALTY OF CHOICE BY DEFINITION. A surgeon doesn't do a residency in family practice....he does it in surgery

Your lack of understanding of medical education is probably what is contributing to your misconceptions of physicians

So 5000 hours. Lets put aside that most of that is in NURSING, which qualifies her to be a NURSE, not someone who is charge of diagnosing and treating.

80hrs week x 50 weeks/year means I did almost that many hours MY INTERN YEAR.

Im currently a PGY-5 IN MY SPECIALTY. Im not the best at math, but that's a lot more than your friend

as for evidence of physician led safety of care? REally?

lets study and see if architects are really the ones we want designing houses, if lawyers are really the best at practicing law

Youve got to be kidding

I'm a bit concerned by the idea that physicians or NP's should have limited education outside of their specialty. If NP's are going to tout their "holistic" model of medicine (as one poster on this forum did), then they should recognize the importance of a thorough knowledge of all the body's organ systems.

eric's a cardiologist, but I'm sure he needs to have a fairly good grasp of the mechanisms and complications of diabetes and renal failure (among other conditions), as they impact on the cardiovascular system. My focus is teeth and gums, but I have to know how they are impacted by diabetes, autoimmune diseases, nutritional deficiencies, osteoporosis, medications, etc.

Tunnel vision is never in the best interest of the patient.

But that is all focused on teeth and oral health, and it is important to know how all possible systems can impact your specialty of choice. I know about alzheimers in that it relates to Trisomy 21 in expected outcomes to talk to families about. Specialization doesn't mean you know nothing about anything else, but it does mean that my focus is neonates and if you want to talk to me about gerentological issues, I will need to look things up and will not have much insight.

Perhaps it is a better descriptor to say that although they aren't actually getting sleep, there is much pursuit of it and so they avoid things in the attempt of sleep.

No, there aren't studies at this point that show superiority (and I've not argued superiority) but that they can be comisurate in level of care. Residents are still doctors. They still call themselves doctors. And I'll admit, I do not know the details of how every school of medicine handles residencies, I have no desire to practice in the medical model. I want to practice in the nursing model. Both are valid forms of care given.

Would it make you feel better to give attendings different titles so people can recognize that they are a higher level? NPs are not trying to compete with the attendings or say they have no use, but NPs are a safe and effective method of providing health care.

And I believe that not having much insight could be dangerous in many cases. If I were to consult eric about a cardiovascular concern, and mention that my family health history includes quite a few diabetics, I would expect him to perk up and listen, and perhaps investigate further, because I know that diabetes adversely affects the cardiovascular system. I understand the mechanisms, and I expect him to understand them as well. I also expect my Ob/Gyn to understand them, as diabetes can adversely affect pregnancy outcome. And I expect them to have a pretty damn good grasp of the information. Not just a passing familiarity.

Granted, neonatology and gerontology have little impact on each other, but most other specialties are not so isolated from each other in their focus. Kidney failure can lead to heart failure. Treatments for autoimmune diseases can cause diabetes, which can lead to cardiovascular disease. All organ systems can impact other organ systems, and health care providers need a working knowledge of all of it.

What you are talking about is all part of the same specialty. While he might perk up at the mention of diabetes, that doesn't mean he is going to be able to provide comprehensive diabetic care. He knows how diabetes interacts with his specialty. He will know that anorexics and bulemics are prone to heart trouble, but would not be the one to treat the underlying anorexia or bulemia.

Specialized training involves knowing how every other system crosses with yours. I can't provide diabetic care to an adult, but I do know how types I, II, III and CFRD relate to pregnancy, the problems it causes in the developing fetus, the likely sequelae to the neonate and how to treat them. That's what I mean by specialization. I even know that oral health has been linked to preterm labor and birth and there are some salivary markers they check for to see if preterm birth is imminent, though the sensitivity of that test isn't great.

I think your education is more generalized than you're recommending it should be, which I think is a good thing. I wouldn't expect eric to treat my diabetes, if I were diabetic (I'm not), but I would expect him to have a good grasp of the pathology. I would expect my primary care physician to treat it, unless I could not control it under her care. And SHE needs a pretty good knowledge of it, my heart condition, my family history of breast and colon cancers, etc. My point is that education in areas other than your own specialty is not wasted.

I'm not arguing against general education, I'm saying there are benefits to specialization. You have to have a certain base level of knowledge before specialization is possible.

And that's what med students are obtaining, before they specialize.

interesting slant this discussion took...

specialization is important after general concepts have been learned. I don't mess with diabetes treatment much anymore, but could if I had to

I re-read some of the discussion earlier regarding residents and NPs in a NICU. I think I understand now what is going on. I bet when fresh, green interns start in the NICU the attending might not allow them to care solely, or even at all, for the sickest infants. And would very correctly mandate that a experienced NP be that patients primary caregiver.

However, I think as the residents get more experience, by their 2nd or 3rd year, they probably would require less and then maybe no supervision or assistance from the NPs.

I learned plenty from NPs and PAs during my training in this manner. I specifically remember one PA who basically taught me central lines.

But I think looking at the above scenario and concluding residents are being "forced out of NICUs" by NPs is a bit ridiculous.

They are being forced out of the nicus, by and large, by fellows and attendings who don't want their outcomes to look bad. Interns are rarely allowed in our unit, though I know other units allow them. Many times the residents have little supervision, if the NNPs aren't watching them.

In our particular hospital, residents are not allowed to take surgical babies. (while I know at other hospitals those are the babies they are allowed to have, but they can't have cardiac, which they can in our hospital.) The reason they can't take surgical babies is because the surgeons refuse to allow them to care for them. That is completely serious, the surgeons have mandated that only NNPs may care for patients in their service. And other places, CT surg or neurosurg or whoever has made the same demands.

I have a friend currently in med school and he is learning a ton of stuff, absolutely. But the memorization of the multitude of incredibly rare diseases I would argue is less necessary for most practitioners because there are a plethora of resources to look up the necessary information if needed. More important is the ability to recognize and assess the situation correctly.

My friend will be a great doctor when he's done (and he's almost into residency) but I guess to illustrate best, we were watching a "mystery diagnosis" type shows. I knew what system was malfunctioning, but needed to look up information for details. He was able to come up with the correct, incredibly rare diagnosis.

But when I asked him an incredibly basic neonatal question (that most 2 year veteran RNs in the NICU could answer) he was absolutely stumped. Question: 3 day old infant with an unremarkable birth history comes in seizing, what's your management and diagnosis? He had a bajillion rare things and could cast a very wide net, but while he had 45 different inborn errors of metabolism memorized, once he got to the point of knowing it was an IEM, he didn't know the 8 most likely to present emergently prior to newborn screen results being processed.

That memorization of 45 different IEMs are unlikely to significantly assist him, even if he ever did specialize in Neo (which he isn't). There's a lot of focus on the details and the minutiae, which I don't think is absolutely necessary to the level it is taken in general medical education. I agree with someone who likened it to hazing.

i really think youre generalizing your experience to all nicus without any reason to suspect that is the case

I can't speak as to your unit or hospital, but there is no reason to suspect this is going on at a national level

Again, think of the absurdity of your logic. Denying trainees exposure to these patients means that in 10 years we will have no doctors that will be able to take care of these patients

Thats nonsense

As for your anecdote regarding the resident, I don't know what to tell you. N=1 studies are worthless

There is reason to suspect it based on the large teaching hospitals from coast to coast and in the midwest changing their policies, and it is a challenge, because we want to keep producing neonatal attendings, but need to find a safer way to do it. In the meanwhile, patient safety has to be paramount. I think in the future that it will just be that residents and NNPs will work as a team, as opposed to most units where the residents have a team of babies and the NNPs have a team.

Perhaps residents should be called practitioners as well? There would be NNPs and NMPs? (again, I can't speak really for any other specialty, because big people are....big.) As you rightly pointed out, they are still in their training period, so are not anywhere near the level of most attendings.

So how are NNP's trained? Is there not a period in their training when they are just as inexperienced as a medical resident?

It is illogical to assume that an inexperienced NP is any safer in a NICU than an inexperienced, but more highly educated resident.

Actually, NPs tend to be more closely mentored. Residents, in my experience, are often expected to just "go" - they check in with their attending during rounds and if they feel they are unsure. There is not an experienced attending working with them every step of the way.

Preceptorships and orientation for NNPs (and other NP positions) involve another, highly experienced NNP whose sole job it is that day is to mentor you. The new APN takes care of the patients while being very closely observed and taught. They are encouraged to be asking their preceptor, as frequently as they need, questions about care, quality improvement and evidence based practice. Clinicals are about a year, orientation lasts from 3-6 months most places, and even when you are out of orientation, you are typically not alone and solely responsible for the patients, you have someone else working with you to provide support and assistance in emergencies.

Additionally, there is the experience as a bedside nurse requirement. While that does not fully train by any means, it does acclimate the person better about ranges of normal, what typical interventions are, which work better than others, familiarity with typical medications etc.

again, i call shenanigans

You have ZERO evidence to support this is going on "coast to coast"

Residents are not being "forced out of nicus"

Are the newest interns more closely supervised, sometimes by experienced NPs?--certainly

Is this correct--certainly

is it what you are saying? NO!!

Show me one SHRED of evidence to suggest residents are being forced out of nicus

Again, for the last time, I call attention to the utter absurdity of your logic

1)ALL NICUS are run by pediatricians

2)Pediatricians get trained in residency

3)Residents need access to nicus

There is no way around that. Its been done safely ever since doctors started training, there is NO reason to suspect that has changed recently

Your "experience" of residents is meaningless since you never were one. You can't even stay internally consistent. In one post you claim safety is such a concern that residents are not allowed in nicus, and the next post you are saying residents essentially have little or no supervision

Which is it?

Again, I'm not sure what's so difficult to understand. There are currently residents in the NICUs. They are not providing the level of care desired because they do not have as much experience nor are they as mentored. So, the NICUs are severely limiting what they can and cannot do in the NICU because patient safety and outcomes are important. They are still there, but they are being limited. As I stated, there is a real challenge because we do want to produce attendings, but we do not want to do so at the expense of the patients. Again, the mentoring relationship with an NNP looks to be the way many of the units are going.

No, this is not for just interns, it is for residents. One month in a NICU every year does not make them competent in the NICU. They need to be watched very carefully the whole time. There are always exceptions, usually those who have an interest in neonatology (though not always those particular residents).

And the point is, it is not being done safely, the patients have suffered, and they are seeking to remedy it. Neonatology is a newer discipline within medicine, and we are constantly reviewing our outcomes to better provide care.

I do have evidence about how it is being handled coast to coast. John's Hopkins, Boston Children's, Rainbow Babies, Texas Children's, Cincinnati Children's, Lucille Packard, Riley Children's, Rush Medical, Maine Medical, Seattle Children's, Rady Children's,Nationwide Children's, Mattel Children's, these NICUs all are changing and limiting their residents. You have no evidence or experience that it is not happening.

so listing the names of hospitals is not evidence

Im going to completely give away my identity. I am credentialed at Riley's, and your statements are blatantly untrue. Ive walked into their nicus with a good friend of mine whos a pediatric fellow there, and she has full run of the place

Honestly, there's no other way to say this but that you are lying, or at the very least severely misrepresenting yourself

Its not that its difficult to understand, but you just repeat, and repeat the same thing over again without ever opening your eyes to logic

Why the change now all of the sudden? Why only nicus? Where was the concern years ago? Medical education hasn't changed

I worked in adult MICUs and had the run of the place overnight, and called my fellow or attending when I needed it. I discussed patients during the day, and made plans as a team

Again, listing places is not evidence. And since you listed the place I worked, now I know you are greatly exaggerating (which is being kind)

In my opinion, if it is true, it flies in the face of NP's repeated reassurances that they don't want to be physicians. In this case, not only are they fulfilling the role of physicians, but they are participating in and advocating a system that prevents physicians from fulfilling the role of physicians and prevents the training of future physician specialists in neonatology. This would leave NP's as the only fully trained specialists in the field.

Hmmmm.

right sandy?

I mean, this poster refuses to accept the facts that her arguments make no sense

They are being forced out of the nicus, by and large

If that were true, we would soon have no MD neonatologists!!

Its like saying, youre going to get rid of all apple seeds, but expect to eat apple pie forever

She brings up issues of patient safety--this is nothing new, and has been a priority of medical training since day 1. Why you think this is a novelty, and a reason peds residents are "forced out of nicus" now... makes...no....sense

Just go over your plan with your attending, do procedures while supervised, and don't do anything youre not comfortable with. Its always the way its been done out of necessity for future docs, and everyone understands that

The nicu may be more restriced than a MICU per se, but saying residents are NOT ALLOWED is fibbing

This appears to be another instance of not letting the facts get in the way of an AGENDA.

I did not mean they were not allowed period, end of story. I clarified my statements many times, but you are intent on holding onto anything that can allow you to ignore the rest of what I am saying.

You have your own skewed version of what residents are like, I have my own skewed version. It changes because every year we learn more. Every year we try and find better ways of doing things that are better for the patient.

There is no evidence to support the medical method of education is the only way to get quality care, and some to support the idea that there are other ways (by showing equal or better outcomes by NPs). You can't just say that it's obvious it works, because it hasn't been studied and investigated thoroughly. Many things that people thought were no brainers in medicine, when they were actually studied, whoops, it turns out we were wrong and it didn't work like that. So we adjust, improve, change.

I personally think that the whole medical education process should be overhauled, because it is hasn't been studied and shown to be effective, in fact it has in many ways been shown to be dangerous to patient care (see the increasing regulation over resident hours because of safety concerns) I think in the end, a long way down the road, the disciplines will merge, like DOs/MDs essentially have, and that all disciplines will be better for it.

Many patients complain about the way doctors relate (or don't) to them, that there isn't enough caring, that it is just about their disease, not them. Well, medicine is about their disease first, the person second. Nursing is about the person first, disease second. I think they will eventually come together to a middle ground.

Again, how about we leave the doctor title for Attendings and call residents practitioners?

1)You made extreme statements, then backed off when confronted with the absurdity of them

2)You have never shown BETTER outcomes by NPs. The studies showing equivalence always had physician team leaders (didn't I explain this to you aleady?)

3) How are you going to study whether or not doctors provide the best care? You need a gold standard to compare them to. They are the gold standard. Just suggest to me a trial design.

Not only that, but a little bit of education regarding a term you are not wholly familiar with. That term is GENERALIZABILITY. Its trying to apply specific trial findings to a larger population. Its ok to do, as long as your data is robust

Now you really think you can say NPs and MDs provide equal care based of a study of 2 teams at one institution??? Or 5K patients at another institution??

No. Thats insufficient data to make that claim. It is a HUGE leap in logic. You could say that NPs provide equal care to residents when each are directed by an attending. Or in stable outpatients with known diagnoses can be treated equally as poorly (look at the a1cs in that trial)

But to blow up those specific scenarios to equal care ACROSS THE BOARD in ALL situations? Especially when the studies compared NPs to TRAINEES but your bias starts to throw all MDs into the mix? That smacks of an agenda

4)Residents have earned an MD, and deseve a doctor title as much as anyone.

If you want the same responsibilites, try to pass the same tests as residents. Exams that test your ability to diagnose and manage disease (like step 3, which DNPs failed)

Until then, I think its obvious that the knowledge gap is why the public sees MDs as true doctors, and DNPs as confusing

Your argument assumes that MDs are the only people with a doctorate who are currently called doctors, which is completely untrue. Anybody with a PhD or other doctorate can call themselves "doctor" at any time. As a nursing student who intends to get my DNP, I find your opinion of nursing students somewhat laughable and it highlights the weird competitive rift between PA and NP students, a rift that baffles me. I want to independently practice primary care (my chosen specialty is midwifery and women's health). For that, I feel I should be trained at a doctorate level, but I don't feel that for average birth, I needed to go be an OBGYN because I have no desire to be a surgeon. It has nothing to do with "proving" myself or not wanting to stay in my "rightful" place (an antiquated an argument as you could possibly find) - it has to do with what it is I actually want to do and the training that is adequate to fill that role.

I am happy that you are happy with a master's degree, but I want to fill a different role than you want to fill, which is fine for both of us. And while I will never represent myself as an MD, I will be a Doctor of Nursing Practice and intend to represent myself honestly to patients and colleagues as such. This is not dishonest or "fooling" a patient any more than a dentist fools patients by calling herself a Doctor of Dentistry.

I agree with Linds

The point is not whether DNPs have a doctorate or not. They apparently do, even though, as the article claims, much of the extra coursework is in epidemiology and NOT diagnosing or treating disease.

The point is that in a clinical setting it confuses people. The term doctor in a clinical setting makes people think MD, like it or not

I think you need a better understanding of the role of NPs in the health care setting. As a PA student, you are being trained in a medical model. Nurses and NPs are educating in a completely different model of care. To be quite honest, your comment about "mid-level providers" is really strange, because I have absolutely no idea what a "mid-level provider" is. PAs are not wanting to get doctorate degrees, because their scope of practice is different. You have a medical model way of thinking. I highly recommend you broaden your scope of knowledge pertaining to models of care. It will benefit you once you are caring for clients with multiple and complex problems.

If you don't know what a mid-level provider is, then you don't seem to know what the role of NP or PA's in medical care is. Their role has physician extenders or equivalents has expanded over the years for time and budgetary restraints. Most NP's I've met were great nurses and went on to become great NPs. PAs I've met have typically been high-quality. Each have different training and can be slated for different purposes by hospitals, medical practices, or other businesses. As mentioned in the article, how much better does patient care get going from NP to DNP? What is the actual purpose?

And stop trying to fool patients. At the end of the day, you didn't go to medical school. Just because you have a doctorate degree does not mean your training is equivalent to that of a doctor's.

I've been treated by NP's who are "doctors" by virtue of their degree. This gave me confidence in their education -- but no one was trying to "fool me" into thinking they were a physician. BTW: That's illegal, so I doubt you see much "fooling" going on.

I understand those with a PhD can be called doctor. I have no problem with this. I was simply speaking only in terms of those with a doctorate in the medical profession.

But those with PhDs in a field other than medicine who call themselves doctor are probably not confusing anyone they introduce themselves to that they are an MD. If an NP introduces themselves as "Doctor," they may confuse a patient. In the medical setting, I think the term "doctor" should be reserved only for those who have an actual MD.

I don't think getting a doctorate is bad for NPs, as you seem to think. This is fine, though I question the necessity. If one wants to independently practice primary care, I think one should be a doctor. I have serious questions as to why NPs are allowed to practice independently, even with their training.

I never said you had a "rightful" place. I do, however, feel that no matter your degree, you still will be a mid-level practitioner. To want to be more than that, is really asking to be an MD without going to medical school. This is not antiquated. There are tiers in the medical profession for a reason.

I don't believed in a structure to health care providers. I believe in team approaches to care. The physician (MD), NP, Nurse, Pharmacist, PT, OT, and dietician should all work in tandem. No one's job is more important than the other. There is no mid-level provider, just like I would not label someone a low-level provider. People need to realize that people, other than MDs, can provide quality care.

jimcg,

I agree that everyone can provide quality care. And its a team approach. But if the fullback all of the sudden insisted on taking the snap and throwing the ball, he would need to be set straight

Medicine works best as a team approach. The most important member of the team is the patient. One big problem nowadays is that people have removed themselves from the equation. People smoke, drink too much, eat too much, don't exercise, and participate in other risky behavior then expect to be fixed when their body breaks. When they find out that the treatment isn't all that great for many things, they blame doctors and the government for not enough "preventative" care.

Who is the most important member of the team is a matter of perspective? Using the football analogy above, the coach would be the most important person on the field as he/she directs all of players to do what needs to be done to win the game. Just as it happens with games, sometimes you lose even if everyone did their jobs right.

Part of the problem with the health care system, using your football analogy, is that health insurance companies ultimately become the coach. The quarterback is the physician, but even physicians are limited in their care by what the client can afford.

jim

I agree with that 100%. Even taking it a step further, they are like the owner who insists on interefering with the game. Like cameron diaz in any given sunday

Very true... Ultimately, $$ controls the level of treatment. Currently, that is the insurance company or the government. That's not ideal, but that's how the world turns. I really wish I didn't have to fight insurance companies or medicare for things I think are necessary. On the other hand, I hate ordering tests I don't think are necessary because I have to. New treatments are expensive. There's no denying that. Most are better though. Medical care costs have risen greatly for last few decades, but some diseases are better treated. We have seen life-expectancy rise from low-60's to high-70's over the past century. New census data may even put that into low-80's. However, everything has it's price. That sucks, but it's true...

Linds I agree that I will be a midlevel practitioner of medicine and I have no designs on being a physician or taking their role from them. But I'm not sure how that denies me the right to my earned title of Doctor of Nursing Practice. I'm not misleading anybody and I will be highly trained for a specific level of care to a particular population.

What about DOs? Are they allowed to be drs in your world?

@jjmcg - good for you & good luck!

I have to say for most things, I'd trust a nurse WAY before a doctor! (well, except an Army doctor - tie then)

Too much schooling, ego-strokes & not enough real life intuition

i think that's an unfair generalization with NO evidence to back it up

Which statement are you referring to?

If an NP is getting paid less than an RN in a hospital, then that was by choice. There is more to medical care as a business than treating patients. As you get more experienced, you will become wiser and have fewer starry-eyed comments. Some provider-patient relationships are partnerships, many are more one-sided than you imply. NP's cannot bill directly for care rendered. This still needs to be done by physician. This is why most NP's are on a salary. Let me hear from you when you have hire several people to fight for the fees that are owed by people who can pay. It turns out that no one will work very hard for free for very long. Good luck finding that out one day....

Macrulz,

And what exactly is your job in the health care field?

jim

sorry for the confusion. I wasn't referring to your post--i was talking about JRs statement:

Too much schooling, ego-strokes & not enough real life intuition

I think that's a bit unfair

I agree! I think physicians are very important too! They work very hard and do deserve respect. I just think NPs are a great alternative, especially to primary care. I don't work in an acute care setting. I leave that to the MDs. However, I know NPs who have received extra training to work in the acute care setting.

jjmcg

I am a relatively young post-residency physician, surgical specialty.

Show me these "studies"

I hope you don't pull out the one by mundinger at columbia. That "study" is a pile of dung.

If they could "easily" have been MDs, then by all means let them go to medical school, then residency if they want to diagnose and prescribe.

Im pretty sure they are called dr overseas

Few drs care what you call them. The point is not fooling patients by calling yourself one which most people infer as MD

I was informed in no uncertain terms that in England at least they do NOT call medical practitioners "doctor."

Right, the surgeons in London are Mr. and Ms. But the Irish see things differently.

yeah, i seem to recall surgeons not being called "physicians" as that title is reserved for internists. Im not sure about dr though. Honestly, I really don't know, and I'll take your word for it

Miker -- England is an exception -- somewhat -- you are only partially correct. It depends upon the level of education. I believe they are called "doctors" until they reach the level of "Surgical Fellow", and then are Mr., Miss (or whatever is appropriate).

Most other European countries call their MD's "Doctor" (or the equivalent in their language).

For example, in Austria and Switzerland, it's "Doktor" (Although Artzer is the word for physician when referring to one.)

In France, it's "docteur".

I was also informed that PhDs had claimed the term "doctor" long before the medical profession. . . But, since I have neither a PhD nor a medical degree, I only know what I've heard.

And, I still stand by my original position that anyone who insists on being called by their title rather than their name is a pompous ass.

And, I still stand by my original position that anyone who insists on being called by their title rather than their name is a pompous ass.

LOL -- outside of a professional setting, I totally agree!

How would you know? Do you have either a MD or PhD?

I have both an MD and a PhD in Biochemistry. Frankly speaking, my PhD was a joke compared to my medical education.

At the end of the day these nurses have as much of a right to call themselves doctors as lawyers carrying JDs do.

I say let these nurses call themselves whatever the hell they want to. You can only treat so many melanomas with antifungals (true story), or lung cancer with antibiotics (also true story) - until the public wakes up.

JDs, the original doctorates, refused to call themselves doctors, and in my experience, don't do it today. It's been the physicians who are the Johnny-come-latelies, and who, by in large, are profoundly ignorant of the academic tradition of the doctoral degree. Why nurses, who have substantially less training than an M.D., should be allowed to dilute the meaning of the degree even further, is beyond me. As for your Ph.D. being a "joke," well . . ., something about a shoe fitting seems apropos here.

Bill, I did not mean to offend. I may have misspoken when I said "joke". I was trying to be a smartass. The truth is that I was done with my PhD requirements in 3.5 years. On the other hand, my MD, along with my specialty and subspecialty took me a total of 11 years (I'm not counting my 4 years of undergraduate education here, which was required to get into medical school). I'm sure you can understand where I am coming from.

Length of time, yes, I can appreciate that, especially as a "muddy boots" ecologist whose Ph.D. didn't happen in 3.5 years - - try almost twice that. There is (or at least should be) something different about doing a dissertation vs. the length of time required to master a technical skill. Of course all this is moot because anyone can get a doctorate in just about anything these days and not know "it-shay" from the proverbial Shinola. So, my training took the better part of 11 years post-baccalureate and I get paid an eighth of what you make. All I can do is laugh -- good naturedly. No hard feelings, Kiddoc.