Scope of practice

As NPs push for expanded practice rights, physicians push back

A vocal segment of nurse practitioners has relentlessly pursued practice autonomy and other practice rights despite having less training than physicians.


Of all the nonphysician clinicians seeking additional practice rights, nurse practitioners worry physicians the most, notes AOA 2nd Vice President Joseph M. Yasso Jr., DO, who chairs the AOA Bureau of State Government Affairs. Under appropriate physician supervision, NPs provide indispensable care to patients and help redress the worsening physician shortage, acknowledges Dr. Yasso, a family physician from Lee’s Summit, Mo. But a vocal segment of NPs has relentlessly and pervasively pursued practice autonomy and other expansions of practice rights despite having training unequal to that of physicians.

Outnumbering DOs 2-to-1, nurse practitioners have secured broad prescribing authority in most states. Many states allow NPs to have collaborative practice agreements with physicians rather than requiring physician oversight. And 12 states and the District of Columbia permit NPs to independently practice and prescribe.

Beyond their strength in numbers and pursuit of practice autonomy, NPs stir up concerns because of their likelihood of being mistaken for fully licensed physicians, points out Joel A. Kase, DO, MPH, the vice chairman of the Bureau of State Government Affairs.

Unlike naturopathic doctors, who typically work in alternative medicine clinics and offices, NPs work in conventional health care settings, Dr. Kase notes. “People who go to see naturopaths typically realize that they are seeing alternative medicine providers, whereas patients who are examined and treated by nurse practitioners—in medical offices, clinics and hospitals—are apt to assume that these NPs are physicians or have equivalent training to physicians,” he says.

“Every day I observe patients calling nurse practitioners ‘doctor,’ ” adds Dr. Kase, the president of the Maine Osteopathic Association and a family physician in Auburn, Maine. “Most people are not health care literate. They don’t understand the difference between physicians and physician extenders. Nurse practitioners have used this to their advantage.”

Apprehensions about nurse practitioners being confused with physicians—and taking their place in primary care—have become magnified with the growth of NP-staffed retail health clinics and the emergence of the doctor of nursing practice (DNP) degree, which will be required of all newly licensed NPs as of 2015.

Many DOs and MDs fear that DNP graduates, who now number in the hundreds, identify themselves as doctors when treating patients, exacerbating the public’s bewilderment over the credentials of various types of health care professionals, according to Dr. Yasso. In a study conducted by the Global Strategy Group in 2008, 38% of respondents hearing the title doctor of nursing practice inferred that this health care professional went to medical school. And when nurse practitioners say they are “doctors” without first clarifying that they were trained as NPs, the potential for confusion becomes all the greater, Dr. Yasso says.

The rise of the DNP degree is one of the main reasons the Bureau of State Government Affairs submitted Resolution 298 (A/2009)—on who has the right to be identified as a doctor or a physician—to the AOA House of Delegates last July in Chicago. Eventually approved as AOA policy, this resolution triggered an hour-long debate, marked by a series of amendments to amendments to amendments—the most extensive and heated discussion of the 2009 House.

Proposing that the resolution’s title be changed from “Use of the Term Doctor” to “Use of the Term Doctor As It Relates to Physicians,” Kentucky delegate Gail D. Feinberg, DO, successfully argued that the House cannot take away the right of individuals with doctorates to call themselves doctors but can oppose misleading uses of the term in advertising and in clinical settings.

New York delegate Robert B. Goldberg, DO, was among those calling for stronger language in the resolution. “Allied health professionals don’t use kid gloves when they attack our profession and take away our practice rights,” he declared.

As finally approved, Resolution 298 stipulates that the AOA opposes the misuse of doctor by nonphysician clinicians “because such use deceives the public by implying the nonphysician clinician’s education, training or credentialing is equivalent to a DO or MD.”

Squaring off

“The title doctor is not owned by physicians,” says Ellen Beth Daroszewski, PhD, the director of the DNP program at Western University of Health Sciences (WesternU) in Pomona, Calif., the parent institution of the College of Osteopathic Medicine of the Pacific. “I am a doctor because I have a PhD.” She contends that physicians’ desire to reserve doctor for themselves is “ego-driven.”

Dr. Daroszewski, a nurse practitioner whose doctorate is in nursing, refers to herself as doctor in both academic and clinical settings. “Patients usually call me Dr. Ellen or Dr. D,” she says.

Dr. Daroszewski notes that she always introduces herself as an NP and corrects anyone she hears referring to her as a physician, even though California is one of 33 states in which nurse practitioners with doctorates are not legally obligated to clarify that they are NPs when patients address them as “Dr.” While she believes that most patients at the NP-managed clinic she established in San Bernardino, Calif., know that she is a nurse practitioner with a doctorate, it wouldn’t surprise her if some patients assume she is a physician.

“Patients tend to call everyone in a clinical setting ‘Dr. So-and-so,’ whether addressing a male RN, a physician assistant or even a lab technician,” Dr. Daroszewski points out, noting that most clinicians will correct the patients. She says there is no evidence that such initial confusion on the part of patients causes harm as long as patients are receiving high-quality care.

If patients mistakenly believe that they are already being treated by fully trained and licensed physicians, they may fail to seek appropriate medical care when they become seriously ill, counters Dr. Kase.

Published by the American Journal for Nurse Practitioners (AJNP) in February 2009, the latest version of “The Pearson Report” contains passages and statistics that seem to validate physicians’ misgivings about NPs’ intentions. “NPs must continue to strive to remove statutory restrictions that prohibit NPs with earned doctorates from being addressed as ‘doctor,’ ” writes Linda J. Pearson, MSN, the report’s author and a consultant to the AJNP.

“The Pearson Report” gives each state and the District of Columbia a grade from A to F, with A signifying the most autonomy for NPs, based on whether NPs with doctorates can be addressed as “Dr.,” require physician involvement in any aspect of practice, have the authority to prescribe controlled substances, have hospital privileges, and satisfy more than a dozen additional criteria.

“To call oneself a doctor is a far cry from being a physician,” contends Dr. Goldberg, the dean of the Touro College of Osteopathic Medicine in New York City, as well as a former president of the Medical Society of the State of New York. “The health hazards posed to patients are great when people seek medical care from limited-practice individuals in the belief that such individuals are physicians.”

To thwart such arguments, “The Pearson Report” purports to demonstrate that NPs have much better patient-safety records than do DOs and MDs. The report draws on data from the National Practitioner Data Bank and the Healthcare Integrity and Protection Data Bank, which compile the number of accumulated malpractice judgments and adverse actions, licensure actions, civil judgments and criminal convictions levied against NPs, DOs and MDs. Pearson computed the ratio of the number of accumulated reported occurrences against NPs, DOs and MDs during the previous 18 years to the number of NPs, DOs and MDs who were in practice. When she applied this formula to malpractice judgments and adverse actions, the “overall national occurrence ratios” were 1 in 173 for NPs, 1 in 4 for DOs and 1 in 4 for MDs. Applying the same formula to adverse action reports, civil judgments and criminal convictions yielded the ratios of 1 in 226 for NPs, 1 in 13 for DOs and 1 in 23 for MDs.

“NPs must use these malpractice and malfeasance ratios and figures to show legislators that the rationale for physician supervision over NPs in unfounded,” Pearson emphasizes in her report.

But physicians shoulder more responsibility than NPs, perform riskier procedures, treat more seriously ill patients, and correct the errors of NPs under their supervision, Dr. Yasso argues. In addition, trial lawyers prefer to target physicians with malpractice lawsuits because they have more substantial professional liability insurance coverage than NPs typically have.

Dr. Daroszewski insists that nurse practitioners are forced to defend themselves against repeated attacks from physician organizations on NPs’ training, ability and patient-safety records. She also points out that dentists, podiatrists, clinical psychologists and other doctoral-level clinicians have long used Dr. titles in their practices without triggering the physician outcry that “doctor nurses” have.

Rising momentum

Coinciding with the establishment of Medicare and Medicaid, the first nurse practitioners were trained in 1965 to help relieve shortages of primary care physicians, particularly pediatricians.

To become NPs in the early years of the profession, registered nurses completed additional schooling that ranged from an intense four-month continuing education program at a university to a two-year nursing school master’s degree program. By 1986, NPs needed at least a master’s degree in nursing.

A key factor in nurse practitioners’ growing momentum, the Balanced Budget Act of 1996 gave NPs the authority to bill Medicare for their services anywhere in the country and in any practice setting allowed by state laws. Their numbers surging from approximately 250 NPs in 1970 to almost 90,000 in 2000 to more than 139,000 today, nurse practitioners have promoted themselves as both serving the underserved and providing lower-cost yet high-quality and safe health care.

While some nurse practitioners today do practice in physician shortage areas, the overall geographic dispersion of NPs resembles that of physicians, according to research by the American Medical Association.

Ronald H. Kienitz, DO, who practices occupational medicine in Honolulu, notes that in pushing to expand their practice rights state by state, nurse practitioners continue to insist that they will improve access to health care. “We have a word for this in Hawaii: shibai, meaning pure unadulterated b.s.,” says Dr. Kienitz, the immediate past president of the Hawaii Association of Osteopathic Physicians and Surgeons. “Nurse practitioners don’t tend to practice in physician shortage areas. They tend to practice in urban areas and compete with fully licensed physicians.”

The immediate past president of the Idaho Osteopathic Physicians Association, Kathleen M. Farrell, DO, dismisses NPs’ argument that they provide more cost-effective care than do physicians. While nurse practitioners draw lower salaries and charge lower fees on average than do physicians, they do not reduce the overall cost of health care, says Dr. Farrell, who practiced family medicine at Valley Family Health Care, a rural clinic in New Plymouth, Idaho, until February.

“Both nurse practitioners and physician assistants tend to increase the cost of medicine by ordering extra tests,” Dr. Farrell says, noting that she observed the work of NPs and supervised PAs during her four years at Valley Family Health Care. “They don’t have the training and experience to rule things out.”

DNP degree takes hold

The dean of the Columbia University School of Nursing in New York City from 1984 through 2009, Mary O’Neil Mundinger, DrPH, has been among the foremost champions of both the autonomous practice of NPs and doctoral level clinical nursing. In 2000, she organized the Council for the Advancement of Comprehensive Care (CACC), which describes itself as “a consortium of distinguished health policy leaders who are committed to assuring high standards of doctoral nursing practice.” Four years after the CACC’s formation, the American Association of Colleges of Nursing (AACN) mandated that by 2015 all entry-level NPs and other advanced practice nurses obtain DNP degrees.

Currently, 123 universities with nursing schools have DNP programs, according to the AACN. Among the parent institutions of osteopathic medical schools, three offer the DNP degree: Touro University at its campus in Henderson, Nev., and Ohio University in Athens, as well as WesternU.

Especially worrisome to the AOA, the AMA and other physician organizations, the CACC has partnered with the National Board of Medical Examiners (NBME) to develop a voluntary certification examination for DNPs that is based on the blueprint for Step 3 of the United States Medical Licensing Examination (USMLE). However, the examination is shorter than USMLE Step 3 and has different standards for passing.

Many osteopathic physicians question why the NBME is involved in an examination for certifying NPs, who are licensed and regulated by state nursing boards not state medical boards, notes John R. Gimpel, DO, the president of the National Board of Osteopathic Medical Examiners."The other concern has been the misrepresentation by the CACC that this examination is equivalent to the examinations taken by physicians," Dr. Gimpel says.

Indeed, many DOs suspect that the DNP degree and certification exam constitute a deliberate attempt to mislead the public into thinking that DNPs are equivalent to physicians, Dr. Yasso adds.

Dr. Mundinger seemed to corroborate such suspicions when she was quoted as follows in the Jan. 16, 2009, issue of the Chronicle of Higher Education: “If nurses can show they can pass the same test at the same level of competency [as physicians], there’s no rational argument for reimbursing them at a lower rate or giving them less authority in caring for patients.”

“If nurses want to be doctors, they should go to medical school,” Dr. Yasso contends.

“My students are training to be doctors of nursing practice—they don’t want to be physicians,” counters Dr. Daroszewski. The nursing model of doctoral level practice focuses on population health, disease prevention, and whole-person care, she explains, noting that students in DNP programs become skilled in information technology, health policy, professional collaboration, leadership, clinical inquiry and research translation, in addition to increasing their clinical practice knowledge.

In fact, Dr. Daroszewski objects to the NBME’s DNP examination, which she does not encourage WesternU DNP graduates to take, because it is based on an examination for physicians. “Although I have great respect for Mary Mundinger and what she has done for our profession, I disagree with her about the need for this exam,” Dr. Daroszewski says. “Mary argues that DNPs need the exam because as nurse practitioners, we are constantly pressured to prove ourselves, to prove what we can do. But we already have a credentialing process for our profession.”

The NBME’s DNP examination has been slow to catch on. In 2009, only 19 DNP graduates took the exam for the first time, with 57% of them passing, according to the American Board of Comprehensive Care, which was established by the CACC to oversee DNP certification.

Lawrence Edward Suess, DO, PhD, an AOA health policy fellow, completed his PhD in nursing in 1989, two years after earning his DO degree. A child and adolescent psychiatrist in Hanson, Ky., Dr. Suess asserts that it is important for physicians to understand that the nursing profession faces many of the same pressures that osteopathic and allopathic physicians confront. The DNP degree evolved in part because nursing has to keep up with a growing body of knowledge, he notes, as well as respond to the demand for safer, more cost-effective evidence-based health care, spurred by a series of reports by the National Academies’ Institute of Medicine, beginning with To Err Is Human: Building a Safer Health System in 1999.

Moreover, the nursing profession needed to counter criticism that NPs were educated only to the master’s degree level while other health care professions increasingly are requiring doctorates, Dr. Suess explains, citing the example of pharmacists now needing PharmD degrees to enter their profession.

Dr. Suess cautions physicians against ascribing deceitful motives to nurses obtaining DNP degrees. Most NPs are well-trained, he adds, urging his physician colleagues not to focus on a few “bad apples.”

Competing coalitions

In 2006, two years after the AACN announced its DNP mandate for advanced practice nurses, the AMA established the Scope of Practice Partnership (SOPP), a coalition of national, state and specialty medical associations dedicated to studying the qualifications of “limited licensure health care providers.” The AOA participates in the partnership and contributes to the SOPP-supported AMA Scope of Practice Data Series. This series, which includes a module on nurse practitioners, is intended to provide the data needed by medical associations and physicians to educate policymakers on the training disparities between nonphysician clinicians and fully licensed physicians.

In addition, the Scope of Practice Partnership strives to enact “truth in advertising” legislation that would require nonphysician clinicians to clarify that they are not MDs or DOs in all marketing communications. The SOPP also supports state medical associations and medical specialty societies in their battles to stop scope-of-practice advancements at the state level.

The partnership sparked immediate outrage from many nonphysician clinician organizations. The American Academy of Nurse Practitioners (AANP) spearheaded the formation of the Coalition for Patients’ Rights (CPR), which now consists of more than 35 organizations, including 26 national nursing organizations, as well as organizations representing naturopathic doctors, chiropractors, psychologists, occupational therapists, physical therapists, optometrists, and audiologists and speech pathologists.

“We call upon the SOPP member organizations to cease their divisive efforts,” urges the CPR’s position statement. “It is inappropriate for physician organizations to advise consumers, legislators, regulators or policymakers regarding the scope of practice of licensed health care professionals whose practice is authorized in statutes other than the medical practice acts.”

Issuing a draft of its nurse practitioner module in October 2009, the AMA solicited feedback from the NP community. “The document contains numerous factual misrepresentations and misleading conclusions,” 20 nursing organizations wrote back on Dec. 8, 2009. “We do not accept the AMA’s attempt to change the perceptions of NP practice as anything other than fully qualified professionals working within a legally established scope of practice.”

Team approach to care?

Despite the rancor engendered by both the Scope of Practice Partnership and the Coalition for Patients’ Rights, both sides express commitment to the team approach to care.

“Nurse practitioners have a lot of respect for physicians,” Dr. Daroszewski says. But because fewer physicians are entering primary care, NPs have to help fill that void, she notes.

AOA Trustee James J. Dearing, DO, agrees that nurse practitioners are a critical part of the nation’s health care system. With the gap between the demand for primary care services and the supply of primary care physicians widening, countering NPs’ scope-of-practice advancements has become increasingly difficult and even ethically ambiguous, acknowledges Dr. Dearing, who preceded Dr. Yasso as the chairman of the AOA Bureau of State Government Affairs. “This is not a black-or-white issue,” he says.

Dr. Dearing, who oversees nurse practitioners in his Phoenix family medicine practice, notes that NPs can become highly skilled in the tasks they perform repeatedly, whether taking patient histories, performing physical examinations, prescribing medications for routine ailments, or providing follow-up care. “There are a lot of things they can do as long as they are properly supervised,” he says.

But nurse practitioners sometimes “miss the subtleties” that physicians discern because of physicians’ more extensive training, Dr. Dearing maintains, noting that he periodically has to modify recommendations made by NPs on his staff.

Dr. Farrell has found NPs to be “too quick to jump on the bandwagon” when it comes to new drugs. She says that the nurse practitioners she has worked with lack the training to look at research studies critically and that they are more likely than physicians to accept without question the sales pitches of pharmaceutical representatives.

Dr. Suess, on the other hand, finds osteopathic physicians’ overall attitude toward NPs to be overly defensive. “We need to take the high road,” he urges. “Let’s worry about our own profession of osteopathic medicine. We must provide the best possible care based on research evidence that is replicable. We must produce clinical outcomes that prove we are worthy of our doctor title.”


    1. mike robe

      Why should anyone take the opinion of a Chiropractor possessing prescriptive authority seriously? manipulation?? definitely.
      Make an adjustment???. Change my oil while you’re at it?

    2. DNP

      DNP’s are educated and pass stringent boards prior to licensure. If one wanted to go to medical school then they would not have chosen to become a nurse.
      Also 100% of CRNA’s are certified. Not even anesthesiologists can say that.
      Healthcare is restructuring and reorganizing. The U.S. spends more GDP on healthcare than any other country, yet our outcomes do not reflect our expenditures.
      DNP’s are more affordable, provide safe, quality care. No supervision or direction required. Welcome to the future. Lets collaborate not dictate. Peace

  1. James Huang, DO

    The real mettle in medicine is saving someone’s life during life-threatening situations on a continual basis.

    After that, you are truly a DOCTOR.

    1. Jennifer Sells

      …And a regular ICU nurse with the right training have been doing that for decades. Anything one does, if they do it over and over they become an expert at it. I have worked in two of the world renowned hospital in their ICU, namely, Emory Hospital and the Hospital of the University of Pennsylvania and they have some darned good ICU nurses who knew more of what to do with the patient to save their lives then do the residents. Most of the time they asked the nurses what to do – the difference, registered nurses cannot write orders or performed certain procedures that physicians are trained to do, not because they don’t have the superior intelligence “like physician” to do it! What’s more, some of these very RN are the same ones who had gone on to become APN and they are as smart as most physicians. So, your statement implying that you are truly a doctor only after you’ve saved someone’s life during life-threatening situations on a continual basis is B.S. since nursing have been doing that all they lives. Nurses do this 24/7, 365 days. I know because I am one of them. APNs do the mundane tasks that physicians claimed are elementary. When they have difficulty to manage situation, they refer to specialty like other physicians. APN will never replace physicians, they need physicians just as physicians need them. I think you are afraid that since NP can do your job and do it just as well, then you will have to go to specialty school and you might not make the cut. Like the previous writer note – this is the future of health care in American and globally and neither you, the AMA and all the others like you cannot stop it. Get over it, and get over yourself. We work together, not against each other

      1. OrdinaryDO

        No one is jealous or scared of an APN takeover in the medical profession. What we are scared of is the limited scope of practice and knowledge these nurses have going into these online APN programs, which are now pushing for complete autonomy. There is no doubt that nurses have a plethora of experience and are very bright individuals, however, they were never trained to be doctors or primary care givers. They were trained to be nurses with very limited anatomical and physiological knowledge that physicians are required to take and they have a very limited amount of supervised training hours under a qualified preceptor. Medical students are trained under competent attending from their third year of medical school through AT LEAST an intern year and another two years of residency before we are ever given the opportunity to practice under our own license. It is nowhere near equal. An APN may be very knowledgeable in the field they have practiced in for so many years, but without a more broad scope of knowledge they will have no idea how to do things such as read diagnostic scans outside of their usual scope of practice, how to treat abnormal disease and prescribe medication. They were never meant to be primary providers, so they were never trained to do the job. You cannot take a few online courses and be good to go with a few years of experience.

      2. May Panelo, RN, MSN, FNP-C

        You couldn’t say it any better… from someone who’s worked in ICU settings, I knew I could do more; and hence, I went to APN school… and I am so glad I did! More power to APNs all across the globe!

      3. NPDO

        lol at saying most nurses are of equivalent intelligence as a physician. I do not see any other professions trying to do this take over of medicine. Why just nurses? They have one of the easiest schooling of all health professions. How do i know? I have done both DO and APN programs.

        If you want autonomy, take the MCAT, organic, get thru med school/residency. Then we will talk.

      4. CBlevins

        Well said! We are a team, if there were enough physicians to cover every underserved area life would be grand.
        Nurse Practitioners are hired based on whether a practice has had a good experience with them, and sometimes even because they need help in their practice and they cannot find someone who is a physician to work for them. I am not demeaning nurse practitioners I am just stating the facts I have observed.
        The practice where I work would love to find more physicians but our practice cannot compete with larger systems that pay more. I am grateful to work with the best doctors with character and a good work ethic who are mentoring to new nurse practitioners and available when I have a question, which is much rarer these days since I have been an NP for 17 years. Inversely they have asked me a few things from time to time. No one has an EGO about things we have the same goals: Give high quality care.
        I have my doctorate and by the way I always tell patients I am a nurse practitioner. My doctorate was very clinical and I feel I am a better NP as a result but know plenty of NPs without a DNP or PhD who are brilliant.
        Look at your history books, when the stethoscope was first invented only a doctor could use it. Now medical assistants and nurses aides use it and take blood pressures! Oh the horrors! Patients are not having adverse effects to that or being cared for by NPs. There are physicians and NPs who are not perfect, the beauty of working together is a marvelous thing! Underserved areas without a physician nearby could greatly benefit from an NP with experience to help provide care. Health care is changing. Thanks for listening!

  2. Christopher Haynes, DNP, MPH

    Let’s be honest. This is an argument about market share by the some physicians and not about patient care. I applaud the physicians who are willing to work collaboratively and see the larger picture and don’t simply jump on the bandwagon of their political lobbying organizations (AMA and AOA). The argument about who is a “doctor” is ridiculous. It is an academic title and physicians are not entitled to make the rules and decide that PhD’s, DC’s, DNP’s, DDS/DMD’s, DVM’s, DPT’s, OTD’s, OD’s, PsyD’s, AuD’s, PharmD’s, ND’s, DPAS’s. DMin.’s, DBA’s, and any other doctorally prepared individuals can not call themselves by their earned professional title.

    NP’s, CRNA’s and CNM’s are competent healthcare providers and there are hundreds of studies to validate that fact. Look at the evidence. It is even published in JAMA on more than one occasion for those of you who don’t want to look at non-physician journals. The inflammatory, slanderous, unfounded antidotal statements are unprofessional, unnecessary and possibly a point for legal intervention. It is simply the tactic of fear mongering and is harmful to all involved. The reality is that the healthcare system is in dire need of reform and a combination of care by providers is essential.

    Let’s stop wasting everyone’s time, resources, and energy arguing about this frivolous issue and focus on how we collaboratively provide patients with the healthcare they need.

  3. Tom Shields ARNP

    Thank you Dr Huang for your desire to call me DOCTOR. I have saved countless lives, many as an RN also. As kind as you are, I prefer the title Nurse Practitioner.

  4. hearing healthcare practices

    Knowing that taking up medicine is like investing but I hope by now doctors will focus on saving life as what their profession meant to be. Thanks for sharing your idea.

  5. Skeptical internist

    By all means-let the DNPs in the clinics
    be called “doctor.”

    Then the MDs/DOs, who actually went to
    medical school can just introduce themselves as
    the “REAL DOCTOR.”

  6. Kristin

    I am interested in a career in health care because I care about patient’s well being. This article/website really turns me off to becoming a DO. I thought DO’s were supposed to care about the whole person and provide a different approach to healing. Instead, comments made by DOs are outright arrogant, leading me to believe the “fear” discussed in the article is more about prestige than patients. There is more focus on creating a divide between health care practitioners than encouraging an open discussion for improving care and team work.

  7. Skeptical internist

    Reply to Kristin:

    Just want to make clear to Kristin what the NP movement is
    really all about- a power and money grab, as well as the
    theft of an honorary title by the mechanism of degree
    inflation. The evidence that NPs want a lot more than
    just to serve patients and increase access to primary care
    is present in two distinct places:

    1). In Iowa, the NPs are trying to establish the right to
    supervise RADIOLOGY procedures.

    Yet, nursing schools and the DNP do not even require one
    year of college physics. So, NPs demand this “right” and do
    not even understand basic electromagnetic radiation concepts!

    Evidence at AMA website under advocacy and scope of practice-
    the AMA has had to SUE Iowa Board of Nursing to prevent the
    utterly absurd from coming about.

    2). AT the University of South Florida the NPs are trying to
    establish a “residency” in DERMATOLOGY-far less rigorous and
    time-consuming than REAL residencies in Dermatology.

    Two EXCELLENT examples that put the LIE to the claims of the
    NP movement with its “DNP” degree- that is to” increase access” to

    General Statement: For ALL the licensed physicians in the United States,
    their medical license was earned with blood, sweat,
    and tears. Even the D.O. schools have been very
    selective in recent years with MCAT and GPA
    requirements at many now equal to several state
    MD schools- and acceptance rates among thousands
    of applicants of 5-10% at many D.O. schools.

    Following the intense hurdle to GET IN medical school,
    it takes enormous effort to graduate and get a good
    Residency- and pass USMLE/COMLEX- ALL THREE FULL
    STEPS- 5 1/2 days of testing in aggregate-and perhaps
    a thousand questions. { at the last book of STEP 2, I actually
    started to see the last 2 pages oscillate out of the plane-an
    illusion of mental fatigue}.

    Then: RESIDENCY with thousands of hours of work and call
    for 3 years minimum followed by: Another Exam.

    Now, most docs see their title as “teacher” BUT also as a
    respected honorific for all that work, debt and sacrifice.
    And so it has been for decades.

    Now, enter the NPs- what are their demands? What are their
    qualifications? With FAR LESS education and training they
    arrogantly demand equal status and full practice independence.
    They even invent a new “DNP” degree, just so they can be called

    As any economist will tell you, INFLATION cheapens the currency and
    amounts to THEFT by other means. The NPs seek to STEAL
    (by theft) the very honorific used in clinical settings that define
    who doctors are and what they had to accomplish to become

    And this is theft-by-inflation from those that actually earned the

    It is very much analogous to wearing military honors on your
    person never actually earned in Combat or in Service to your
    country- a thing which REAL soldiers and veterans despise and
    loath with good reason.

    NPs HIDE behind politically correct rhetoric while brazenly doing the
    same thing.

    So go right ahead-call yourself doctor so-and-so. Inflate the title.
    I will happily remind everyone who the REAL doctors are- and what
    they had to sacrifice to become so. WHY? BECAUSE I WILL NOT

  8. Skeptical internist

    The Wisdom of Socrates:

    At the end of his life in Athens, Socrates was attended by
    his followers and friends in an Athenian jail. Legend has
    it that as Socrates made his goodbyes, he had one request
    of his fellow Athenians:

    Socrates bade that his friends should severely CHASTISE his
    sons if ever they pretended to be MORE than they really were.

    For Socrates knew that the first step to wisdom was
    self-knowledge and intellectual honesty-even in
    the days of Socrates there were politicians and academicians
    who pretended to know and to be more than they really were.

    The NP movement vividly demonstrates that even today,
    in Century 21 America, the same phenomenon thrives.

    Consider, for example the NP argument that they provide care
    equal to the MDs- as proven in their “studies”.

    A little reflection demonstrates they have proved nothing of the
    kind. What they have shown AT MOST is only that NPs, when
    acting under supervision or in collaboration or with the
    ability to refer to physicians can THEN provide comparable care.
    That is, their care is equivalent ONLY when they are HOOKED INTO
    the medical care system-by one way or another. If they had NO
    physicians to consult or refer to- and no hospital to take care of
    patients-they could not possibly provide equivalent care.

    The D.O.s, on the other hand, BUILT their own hospitals and specialists-
    and over DECADES of hard work, GRADUALLY achieved equivalency with
    MDs. Now, of course, the D.O. system is very intertwined in the regular
    medical practice- in all fields-even neurosurgery and cardiac transplant, etc.

    A very far cry from the NPs.

    Kristin’s sharp post perhaps reflects the sting of the truth that
    Socrates pointed out- and that remains as true today as it was
    in the time of ancient Athens.

  9. Family Psychiatric NP enrolled in DNP Program


    I read your article with much enthusiasm and in my humble opinion as a Board Certified Family Psychiatric Nurse Practitioner practicing independently, although this is a wonderful example of marketing, in all likelihood this was designed to garner emotional responses and facilliate feedback for discussion.

    Suggesting as this article consistently documents you opinions versus evidenced-based practice material, consideration be given to referencing contrary or supportive journal literature or articles.

    Best Regards

  10. Skeptical internist

    The medical profession has been far too
    soft and politically correct in dealing with the NP movement.

    “Board-Certified ” family psych nurses!

    Going to take a short, watered-down version of the
    (easiest) step 3 of the Boards of NBME,
    OMIT the science-based tough parts, and then
    start calling themselves “doctors” based on
    the “DNP” degree in statistics and nursing theory.

    And there you have it- a nice brand new “board-certified”
    “family pysch” “doctor”- WHO IS REALLY A NURSE.

    This kind of blatant, in-your-face theft from the medical profession
    is allowed only because we are far too soft, will not take the tough
    decisions to fight this kind of arrogance.


    Who is Mudinger to tell all of us what qualifications are needed
    to practice primary care medicine?

    Is medicine really going to allow Mudinger to lead a revolution that
    forces all the docs to specialize just because she invents inflated degrees
    and phony titles and says that she and her gang can do the same job
    for less investment and training?

    If we strategize with the physician assistants and associates and
    work out, with the state legislatures,
    methods of allowing them to
    run their own (satellite) primary care offices with the docs in contact
    by tele-medicine/phone on a rotating basis, we CAN put these
    NPs OUT OF BUSINESS. One good general Internist can partner with
    4 or 5 physician associate practices and QUINTUPLE the patients and
    geographic areas served- WITH MD/DO referral and subspecialty care
    available very quickly.


    the nation is so strapped for money and resources that politicians
    will eagerly buy into the baloney put out there by the NP
    THEM TO DO SO- all under the guise of politically correct
    sounding PROPAGANDA.

  11. Skeptical Internist

    On yet another note:

    The recent stats out of the USMLE show that, for the 2008
    part 3 exam, BOTH the MD and DO passing rates were 95%


    Also the USMLE step 1 (basic sciences) passing rates were on the order of
    96% and 81% for MD and DO respectively.

    Kudos to the Osteopathic medical schools for producing
    physician graduates who, overall, are essentially the same as the
    regular LCME US MD graduates. Even the basic science difference is
    now quite small, so that the vast majority [>4/5] of D.O. physicians
    have the same academic training and accomplishments as their MD

    And the NPs? With the nice new “DNP” degree??

    Only 50% [FIFTY PERCENT} managed to pass the SHORTER,
    EASIER (different passing standards) version of the
    NBME step 3 using the “old, retired” question bank.

    More than anything else, this points out the VAST DIFFERENCE
    between fully-educated physicians and the NPs.

    And then, the docs have to take the ABIM certifying exam which
    makes the USMLE look like a high school exam.

    This data can easily be used to demonstrate that giving the NPs
    independent practice rights amounts to nothing other than creating
    a distinctly second class of “junior doctors” without the full training
    and qualifications of real physicians. This data should be presented right to
    the legislatures each and every time the Nurse lobby keeps pushing
    for independent practice.

    It is absolutely a weakening of standards to practice medicine.

  12. dnprn

    Why are there no mentions of PharmD or chiropractors, etc, who should not use the title doctor? Why is it just nurses who can not use the title doctor? Could it be that decades of talking down and looking down at nurses prevents them from looking at us as being highly educated. We do not want to replace physicians in any way, we are just another health care provider trying to care for patients. Advanced practice nurses know there roles and what there competencies are. Having a DNP does not increase pay or reimbursement rates in any way. I find physicians try and say that patient safety is their main concern when they discuss political issues, but that is just because it wouldn’t sound as effective to say ,”but that might make my salary or client base go down.” or ,”I am just jealous that someone I view as inferior and not under my direct control wants to provide some of the services I provide.”

    Just view the post earlier about pairing PA and medical schools together; not for patient safety but just to maintain control.

    Anyone with a doctoral degree has the right to use the title when introducing themselves. Although I do agree they would have to be very careful not to represent themselves as physicians. It might be confusing for a little bit, as it is with many changes. The public will get used to the idea of other advanced care providers that aren’t physicians. A nurse practitioner, anesthetist, or midwife who introduces themselves with the title doctor should follow up immdediately with their role. “I am Dr. SoAndSo and i am a nurse practioner.” If physicians don’t like this than they should introduce themselves the same way and state they are a physician.

    No one has the right to deny someone else a title they have earned, as long as that person is not trying to pass themself off as a physician.

    Finally, I would like to point out that I know of no DNP or DNP candidate that ever applied to medical school. I am tired of hearing that nurses who want a doctoral degree just want to be a doctor and couldn’t get into medical school. I am proud of being a nurse and never wanted to be a doctor, I am a CRNA.
    I have alot of respect for most physicians, but there lifestyle and schedules are aweful. I would never choose that for myself. That is just my opinion. I know my practice boundaries and can respect that they have a broader education than I do. Their broader education doesn’t make them any better at delivering anesthesia than me. Does spending extra time learning a little about pscychiatry, obstetrics, dermataology, etc. mean you can understand anesthesia better? I think not. I manage anesthetics, not diagnose and treat schizophrenia (or any other disease for that matter). It is enough to know how those drugs and disease states effect the anesthetic, I don’t have to be able to manage therapy for them.

    1. AmU

      You’re last statement (about not need exposure to other field due to practicing with anesthetics) is the exact problem with NP. You don’t know what you don’t know.

      Admittedly, there is a lot of exposure to other fields and knowledge not used on a daily basis. HOWEVER, when the rare patient has a complication that is outside the scope of your knowledge, a physician with more clinical reasoning (amassed only by the erroneous exposure you seem to degrade) will step and manage the patient.

      That is why they have “horrible” lifestyles. They are too busy supervising midlevels (like yourself) and learning way more information (that according to you, is unnecessary).

      I don’t doubt your soundness as a medical provider. However, never equate your overall knowledge & understanding with a physician. It is ignorant and insulting.

      1. L


        Why do you need to yell (HOWEVER) and use inflammatory language with negative connotations to make your point? Dnprn made some valid points and all you want to do is put this fellow medical provider back into place. Nurses begin practice 6 weeks into school– is that done by anyone else? Associate level nurses must complete 3-4 years of college to conquer electives and nursing school. How do I know; because I finished by biology degree and had to return to school when I decided nursing was my passion.

        To achieve a doctorate in nursing science requires clinical rotations while maintaining an unencumbered RN licensure, thus the patient care experience continues concurrently. Going to school while saving patients at work requires a metal spine that you seem to have no respect for.

        I personally know quite a few doctors who are masters of their specialties, and what they have over you and your rant is that their work ethic is impeccable and their humility intact. They never pause to share their specialized knowledge and do not have too much pride to ask me about patient care–my specialized knowledge.

        Interdiscipinary teams are awesome, give it a try. When the primary care physician or the hospitalist declines to place venous lines or intubate a patient, I do not judge them– because these individuals have not had to practice these skills for a long time. While they plan care, the other disciplines who can do it in their sleep jump in to make it happen. Stop spitting in the wind and think of the patients.

  13. Skeptical Internist


    Excepting federal service, chiropractors and PharmDs do not work in the same clinics and hospital setting the that the physicians do. There is no chance of confusion. They have very well-defined roles and, in my experience, they do them very well.

    The NP profession is an entirely different matter.

    The nurse practitioners are constantly lobbying the state legislatures for ever larger scope expansion, year after year, every year without fail. Those nurses are not genuinely attempting to add something new or better to medical practice except ONLY cheaper labor costs. Therefore, they make no effort to build science departments or medical schools to advance the practice of medicine itself.

    What a stark contrast to osteopathic medicine, which laboriously built its scientific base and its medical schools and hospitals to try to actually add a another dimension to standard medical practice. After most of a CENTURY of such improvements, ONLY THEN were they accepted into MD training programs and residencies. Thus, with no doubt in my mind, the “osteopaths” laboriously and MERITORIOUSLY EARNED the right to become PHYSICIANS. Today, for the most part, they are accepted by regular physicians as colleagues and partners.

    NOW come the nurses-first with NP “masters” programs and now the DNP (which has only a few clinical science components, no basic science, and far, far less hours and work than just bare medical school graduation).

    And what, in all honesty, are the objectives of this NP profession?

    I claim the objective is entirely to replace all primary care physicians with the cheaper alternative- the DNP-easy to grow them, easy to seed them, and now the cheap aspect can be a huge selling point to insurance companies and government. And that is the reason for endlessly pushing for independent practice.

    Worse- I feel certain that the NPs are fundamentally intellectually dishonest-

    How? In that they have attempted in many places to move health care practices that have always been labeled “medicine” by the several states TO the Nursing Board and then get those same practices RELABELED nursing.

    Mudinger herself makes the argument that primary care physicians are over- trained for what they practice- WHO IS SHE TO BE THE JUDGE OF THAT??

    The DNP is absolutely a cheap knock-off for a medical diploma, under the guise of greater access to medical care. With its far inferior academic standards, it is an absolute insult to the REAL doctors who had to sweat to get into and through medical school and residency to be called “doctor” when caring for sick human beings.

    In contrast, the DNP can even be earned on-line in some cases. If that is not a phony diploma-mill degree, I surely do not know what would so qualify.

    So NO, it is NOT about “control”-its all about honesty and recognition of one’s genuine limitations. And PLEASE do NOT expect me to ever believe that with a “doctorate” in “nursing practice” AND with a state license that is in REALITY a full, unrestricted license to practice medicine ( the DNP ulterior objective), that somehow the DNP will remember her actual knowledge base and when to seek help in diagnosis and treatment. They will certainly diminish the truth in practice and tell the world( as many already do) that “I am just like a doctor, except for the pay.”

    If the DNPs are allowed to achieve their ultimate objective, I cannot see how patients with unusual medical conditions masquerading as regular conditions (eg: Churg-Strauss prodrome appearing as simple allergic rhinitis), can possibly be safe in the hands of such “doctors.”

    The solution for medicine is to aggressively partner with PAs to meet the nations needs, NOT to aid and abet this DNP take-over- primary care agenda.

    I would even say that the PAs are better trained with more scientific knowledge of medicine than the NPs.

    One final point: that the DNPs are really stealing from the medical profession rather than adding something new or unique, can be seen NOT just in their new DNP degree (so they can get the title)- but even in calling their small post-graduate training programs “residencies”.

    So, whether we are willing to say so or not, the medical profession knows exactly what these nurses are pulling here- and the nurses should be ashamed of this behavior (DNP “dermatologists”) at USF.

    But what bothers me the most is that medicine is not standing up for itself with anything like the vigor and commitment it SHOULD stand up with to expose and abolish this kind of fakery. In part, this is because medicine seems to be engaged in countless battles with government and insurance companies and it has truly become a profession under constant siege.

  14. Cecelia L. Crawford, RN, MSN

    “Doctor” is Latin for “teacher,” coming from the word root of “docere,” which means “to teach.” It signifies a person of great learning; this person is recognized as having received a diploma of the highest degree in areas such as divinity, law, literature, medicine, nursing, etc. The doctorate originated in medieval Europe and was originally used by the Catholic Church to indicate persons authorized to teach the Bible. However, the University of Paris was granted permission in 1213 to expand this academic education to a universal license to teach, as in philosophy. One of the greatest early religious philosophers to come out of the University of Paris’ doctoral education system was Abelard. To restrict this word to only mean a medical doctor hijacks the original definition and hinders full understanding of a doctorate education and the various professionals who achieve this highest level of learning, such as DNPs. Rather than reacting in fear and anger, can we not collaborately educate the lay public and other professions in the use of this word? (Please note I am a DNP student and NOT a NP).

  15. Skeptical Internist

    No one is “restricting” the title of teacher [“doctor” ] to medical doctors.

    You bring a false charge.

    No one suggests that Ph.D.s in physics not be called “doctor” in
    schools-or, even better, professor.

    Neither the M.D., the D.O, (and certainly not the DNP) is
    considered the “highest” academic degree by Universities in the U.S.
    The Universities consider the highest degree to be the Ph.D.- a research degree.

    The argument here refers to use of the title “doctor” in CLINICAL settings, in
    seeing patients-where the term has long been reserved by tradition in the
    United States (and, for non-surgeon physicians in Europe) for physicians only.

    The demand by DNPs to be called “doctor” in the United States in CLINICAL
    settings therefore is tantamount to its logical equivalent- to be considered
    and recognized as a physician by patients, physicians, insurance HMOs,
    government and so forth. {Although disclaimers are issued concerning the
    true goal of the DNP movement, once it gets established, I believe those
    disclaimers will be conveniently ignored).

    Thus, your history lesson is quite irrelevant. Your appeal to emotionalism
    as rationalization for attempting to steal what others actually earned
    is in reality a great discredit to the DNP concept. My earlier post about the
    wisdom of Socrates applies- he strongly desired at the end of his life that,
    should his sons attempt to falsely represent themselves as (having accomplished)
    more than they really have, they should be severely rebuked by the ancient

    NPs with only masters’ degrees are even now often mistaken for fully trained
    physicians in clinical settings.

    There is no doubt in my mind at all that the rush to quick and cheap DNP degrees
    is a political movement with a nakedly political agenda-to displace primary
    care physicians- the real docs that actually went to med school-and replace them
    with “DNPs”. Mudinger’s own propaganda makes this apparent.

    You must ask yourself if your “DNP” program really meets the standards of
    intellectual integrity-as opposed to political posturing and propaganda
    in disguise.

    Although you may be willing to fool the public ( which is really tragic), you may
    well find that you cannot honestly fool yourself.

    You labor under a further misconception:

    The great Universities here and abroad firmly believe that no individual
    truly becomes a master of his/her discipline until they make a unique,
    substantial and worthy contribution to that discipline that is UNIQUELY
    THEIR OWN. Then, and only then, is the Ph.D. degree conferred.

    That process of unique and original contribution is what scholars and
    academicians consider to be “the highest level of learning.” It CANNOT be
    achieved by course work, or by passing ANY examination, including the
    USMLE, the ABIM, or even the rather silly “cheap and short” version of the
    Step III exam that the Nurse lobby recently conned the NBME into producing
    (where the NBME’s motive was profit, and who cares about the rest of the medical

    Medical degrees are considered to be “first professional” degrees.

    It is apparent that you believe that your DNP- degree -to -come will
    represent the “highest level of learning”.

    That is not even true for genuine medical degrees, in the manner that the
    great Universities define it. [One cannot get any degree from Yale without an
    original thesis, so great is their commitment to this ideal-I have an M.P.H. from
    Yale, besides a medical degree].

    So, with all your history lessons, learn also the truth-what the “highest level”
    of learning REALLY is considered to be-you will find it rather unrelated to
    the issues of professional practice, despite the propaganda put out by the
    Nursing lobby and agenda.

  16. skeptical DNP

    Skeptical internist….I do believe you have what we call “short-man’s syndrome”…. You’re DO/MD degree obviously defines WHO you are and not WHAT you are. The idea that I chose to further my education in nursing, does not give you or anyone else the right to down play my credentials. I make certain my patients know I am a NURSE, you do not need to fear!!! With the reputation “DOCTORS,” oops, I meant “REAL DOCTORS” have today in the healthcare industry, puh-LEASE call me a NURSE! :)

  17. Mike PA

    Skeptical Internist,

    I applaud your obvious skepticism of this attempted takeover of the Primary care marketplace. Its clear that this degree only seeks to serve the egos and pocketbooks of NPs, as well as the pocketbooks of the educational institutions conferring degrees, because we know: The more units you take, the better the universty does.

    Its unfortunate because this degree does little to advance the practice of medicine or to improve the quality of care provided to patients. You cant tell me that the NPs with Masters degrees will provide inferior care than that of a DNP, at least you cant make that argument based on the posted DNP cirriculums.

    While I am also skeptical of the production of this clinical Doctorate, I do believe that there is a real need for Physician Extender programs to have more Doctoral trained professors. In my opinion, this would improve the educational experience that PA/NP programs would get, especially from a research standpoint. Academically, a doctoral program is a good idea.

    Another area where I disagree with you is that NPs are clinically inferior to PAs. It is clear that PA education is superior, both with clinical rotation time and the academics mimicking that of the Physician medical model. However, NPs overcome this early obstacle in their career based upon real- life RN experience. We as providers have all known RNs that have taught us something or saved our behinds in some way…these are the nurses who go on to become NPs. After 3-5 years, PAs and NPs function at the same level, being excellent adjuncts to physicians who both provide quality and cost-effective care.

    The separation of PAs and NPs is simple, its a desire to expand and have independence in their practice rights. PAs want to be adjuncts to physicians. PAs responsibly fill the physician void and do not seek independence. If you want independence go to Medical school, get in substantial debt, and take on more malpractice risk. Deal with it, we have less training, thats ok, we can still provide a valuable service to our patients without a status title. MIDLEVELS-DONT LET YOUR EGO GET IN THE WAY OF WHAT YOU HAVE CHOSEN TO DO FOR YOUR PATIENTS.

    Unfortunately, In our competition based society, I believe PA education will follow the entry-level Doctoral path that PT/OT/DNP, etc has already taken. The argument will be, I am more highly trained and educated because I have a Doctorate. For many, this will be an effective argument. This has already sparked fierce debate among the PA community. Just look at the blogs! PA programs will compete for business by having a “higher status” than other programs, and so on and so on…Also the chance to increase the number of units taken will eventually prompt this change in degree conferred.

    So the title of doctor will become a mute point. The issue is how it is used in a clinical setting where patients can get confused.

    Seeking for further independent practice rights does not improve the quality of healthcare it only improves the billing rights of NPs, so this is a separate issue than degree title.

    I am a firm believer that PAs/NPs are imperative to the healthcare fields survival. As long as midlevels dont get overly-ambitious in their quest for a larger piece of the pie.

    1. mike robe

      PA…..associate? or just an assistant.

      Ironic 21, states and DC allow NPs to practice completely solo Must be some reason PAs have to be supervised. could it be arrogance or they enjoy being someone’s lap dog.
      I wonder if NPs get complete autonomy, would they be able to supervise PAs,,,would they want to?

  18. DNP

    Trying to get a derm residency started?? That USF program has been available since 2007. In addition, other residencies are available. Funny how MDs now own the term “residency”.
    If we are so substandard, why do patients come to us for care and why are we such a threat? Trying to deceive the public? Every patient calls me “doctor” and every one of them knows EXACTLY who I am. All patients get a bio telling them what my educaton/training consists of and many comment on how impressed they are that nurses can have this advanced training. Very sad all this bad behavior from people who perceive themselves as superior to us. What does Socrates say about that?

  19. Skeptical Internist

    According to “DNP”, the people who do NOT agree with her/his position all exhibit “bad behavior.”

    The skeptical DNP believes I have “short-man” syndrome, because I do not drink the cool-aid the Nurse lobby is pushing on this nation.

    All of these are forms of “argument ad hominem”- the logical fallacy of attacking the man who makes the argument, rather than the argument itself.

    Most forms of appeal to today’s “politically correct” “standards” are in fact a kind of ad hominem argumentation for not meeting the social standard of political correctness.

    The current generation of Nurse leadership fairly swims within vast pools of politically correct thought and virulently anti-physician propaganda.

    For many, many decades, the term “residency” in the clinical training of physicians was exclusively used, in the healthcare settings (hospitals) to refer to physicians undertaking required post-graduate training.

    Now, attempting to push political correctness to its logical extremes, “DNP” suggests that, in fact, physicians have never owned the term, and that DNPs now have the express right to use that term also.

    The bigger and more outrageous the lie, the greater the likelihood the public will believe it, as Nazi propagandists always understood.

    But “residency” is a term we use in our professional practice.

    No doubt the DNPs will start creating “fellowships” and “DNP fellows”.

    Also, the fact that “people come to us for care” demonstrates nothing- people once went to snake-oil salesmen for care also. People come for care because they are sick and in need of help.

    The chicanery and fraudulent behavior thus demonstrated will continue, unless and until state or federal statutes can be enacted to stop it.

    On another note, here is yet again further evidence of the debasing of medical practice in the United States- the frightful lowering of standards that the Nurse lobby is virulently and, in my opinion fraudulently, pushing on the public:

    1). Attorney John H. Fisher reports on Client “Z”, a 48 year old male with fever of unknown origin seen on several occasions by a nurse practitioner at his primary care physicians’ office, but never by the primary care physician.

    After three months of the same symptoms, Client “Z” succumbed to a massive stroke secondary to bacterial endocarditis.

    The nurse practitioner prescribed Motrin for his pain symptoms, apparently not recognizing subtle life threatening signs.

    Could a doctor have missed this also? Of course.

    But now the point: Was an internist AS LIKELY to have also missed it?

    Absolutely not. Internists are so used to life-threatening conditions from thousands of hours in hospital RESIDENCIES (the real ones), so that the odds are far less likely for an Internist to miss this.

    The same is true for the family physician, and for the same reasons.

    Mr. Fisher’ conclusion: ” This case illustrates the risks of expanding the role of nurse practitioners. Simply put, a nurse practitioner does not have the medical education, training or experience to handle complicated cases that should be handled by a physician. Unfortunately, many nurse practitioners believe that they are just as qualified as physicians and they see no reason to limit their patient care to uncomplicated or routine cases.”

    http:// practitioners-good-or-bad-for-patients.cfm

    2. A quick review of the DNP curriculum at UMDNJ reveals “foundational” courses like Information Technology and Healthcare Ethics for Nurse Leaders, and core courses of “health policy”, “health promotion across diverse cultures”, “interdisciplinary leadership, quality and collaboration”.

    Practically a “doctorate” of political correctness, whose students one suspects are anticipating equivalence with real doctors (physicians) in willful, gleeful ignorance. Without all that tough organic chemistry, biochemistry, gross human anatomy, those nasty USMLE steps one and two and three, and then that painful residency and board certification exam.

    Yes indeed! Equal pay for the “same work.”

    I re-iterate: the best solution for the medical profession is aggressive promotion of physician assistant and associate programs- with their scientifically based approach, as well as stressing the need to support primary care residency for family medicine physicians.

    Emphasis placed on physician associate programs will increase the science-based practice of medicine as well as increasing the pool of people who, IF THEY SO CHOOSE, would also make excellent primary care physicians if they then, later on, went to medical school themselves.

    Aggressively partnering with physician associates will also allow primary care physicians to maximally extend SCIENCE-based medical practice to the largest percentage possible of the population.

  20. Chris

    This knot comes untied when we look at it the other way. Do you see anyone suggesting that physicians LOWER their training standards because the NP standard is sufficient for patient care? Of course not. People do not seek the doctor who is just good enough. People also regularly sue for malpractice. I suggest that NP’s get equivalent training for equivalent privileges. THAT is what is in the patient’s best interest!

  21. DR. S

    I do not think the present standards for patient care is adequate for patient care. NP’s have 1 year of clinical rotations that may not require much reading. This places them near a third year medical student. I recently hired a NP. Although she is already an asset to my practice,and continues to improve clinically, she still requires a great deal of supervision.

  22. Sarah

    If nurse’s are pretending to be doctors I invite them to go to medical school and play the part to par. The sad reality for many medical graduates who will not match through ERAS or the scramble after wasting their youth in medical school and accumulating a heap of debt as a possible and very existing solution to this alleged doctor’s shortage in accommodation of inadequate care is given by folks who want to play doctor. Not every case that comes to the the GP is a URI and I hazard ask if the folks pushing for such a change would themselves like diagnosis and management by a nurse?

    I do wonder what the AMA is doing for us.

  23. Dawnmarie Risley, DO

    PA’s prescribe, NP’s prescribe, and now psychologists prescribe in New Mexico and Louisiana. Perhaps we should allow 3rd year medical students the “right” to prescribe. They have more education and training in medicine than any of the above. I have observed PA’s “practicing medicine” in a critical care setting and have been horrified. I have worked with a few sharp NP’s but mostly average to below average NP’s with very limited knowledge regarding medicine, caring for very ill patients. All of these disciplines cite malpractice claims as their measure for proving they practice safely. What they fail to tell you is, that when working collaboratively with a mid-level practitioner, the collaborator is responsible for the malpractice. Attorneys do not go after the NP, PA or “medical psychologist.” They sue the doctor in collaboration.

  24. Secure Physician

    This long-winded discussion is goofy! Look at yourselves arguing and presenting self-validated logic! Angry, frustrated, upset,worried,invalidated, paranoid? Stop this ridiculous discussion & go back to taking care of patients as you originally intended! If you are good at taking care of patients, they will know it, everyone else will know it, and most importantly YOU will know it! You will be secure in what you do! There are plenty of patients for all of us..we will all be fine. The saddest person in this string of commentators is “Skeptical Internist”. He or she is off base about a lot of his arguments, statistics, spends too much time trying to validate him or herself, especially in still holding onto the old “DOs are almost as good as MDs paradigm”. I work with numerous NPs & PAs and feel no threat. I know what I do and I know what they do, providing high quality care is the final product! If “Skeptical Internist” was as good a physician, and secure in his role as a physician as he should be, he wouldn’t have the time to write to this website as much as he has! He would be too busy taking care of patients! Obviously he has lots of free time, I suppose the practice ain’t doing too well? Time to get a life my friend!

  25. skeptical internist

    Dear “Secure Physician”:

    You really need to wake up to reality.

    The SOPP of AMA exists precisely because there is a problem.

    Dr. Goldberg (quoted above) is concerned because there IS a problem.

    Those same concerns are prevalent in the federal government, where
    federal law supersedes state law.

    It is physicians with their heads in the sand that are also part of the

    As to your ad-hominem attacks on me, they are worth precisely zero.

    If you want to analyze/discuss an argument, then attack the points made
    to support the argument, not display all the emotionalism in your

    If my “statistics” are off, then demonstrate this by proof by counter-example,
    NOT worthless ad-hominem attacks.

    Perhaps “secure physician”= DNP in disguise?

  26. skeptical internist

    One more point for “secure physician”:

    No one forces you to come to this site.

    If you consider this activity a waste of time, and the concerns
    demonstrated by the various national organizations to be without
    merit, you are free to ignore what is obviously occurring.

    What you have absolutely no business doing is
    arrogantly proclaiming that those of us who ARE concerned
    need to “get a life”.

    If you see no problem, then you are not needed in dealing with it.

    Leave it to those of us, and to the national physician organizations
    that are forced to take up these battles every year in the State
    legislatures to deal with it and just go your own way.

  27. JT DO

    As a first step towards gaining parity – NPs and DNPs can demonstrate their sincerity, by insisting they be accountable to the same oversight board to which PAs and physicians are accountable. In my state, NP/DNPs are accountable to a different board than PA/physician (i.e.Office of Professional Misconduct.) Every physician and physician organizations must contact their representative and demand this requirement. Sadly and for obvious reasons, nursing organizations are against this.

    As a second step NP/DNP training must change – After obtaining their undergraduate degree, working a few years as a nurse then completing only 36 hours of course work (WHICH CAN BE DONE ONLINE) and 850 hrs of clinicals, NP’s have the legal right to prescribe potent analgesics, psychotropics, antiarrhythmics, etc with minimal oversight. Strange that I had to complete thousands of hours of course work, clinical training and pass 3 comprehensive boards before I gained that legal right and before I felt competent enough to assume that right. So now the NP applies to the DNP program at Columbia University which indicates 40 credits are needed to completed its program (number of clinical hours is not disclosed on Columbia’s web site) and subsequently feels they should be allowed to practice INDEPENDENTLY. Any NP or DNP who feels they should be entitled to those rights does not understand the practice of medicine and presents as a danger to society.

  28. SFIII

    After working in an office for a short period of time with a Nurse practitioner and a Nurse Practitioner student, I quickly learned that much of what I have read in the previous paragraphs is true. Nurse practioners do see themselves as the future of Health Care. And what a sad and scary thought that is. I was quick to see that my approach to patients was very different to that of the NP. I am there to help patients become informed about their illness and hopefully see to it that they take care of themselves to either manage or eliminate the disease process. The NP I worked with seemed to care more about being liked by the patients and wouldn’t do anything to make a patient unhappy. I try to practice build and want a patient to come back, but I am not trying to run for office. I hope demonstrating my knowledge and approachability would speak for it self, I don’t worry about a popularity contest, but seem to do just fine anyway. The NP’s definetly cringe and become angry when they are categorized and Physician extenders. But the reality becomes apparant when they can not sign off on orders from Home Health Companies and other Durable Med benefits as a PA or NP. They also earn less than a Physician as they should. What angers me the most is the way they can be autonomous in their license to practice but the malpractice companies still seem to classify them as an Physician extender. For that reason their yearly malpractice premium is a mere fraction of what I pay. They have not been named in enough cases where they are held responsible since since traditionally they work under a doctor and the captain of the ship kicks in having the Physician liable in the end. As these clinics in grocery stores and the like hire NP’s to practice with out Physicians they will learn that they are responsible in the end for a patients well being and will go after them when they make a mistake. But until that happens they stand to make a fortune since they can practice medicine without paying high malpractice premiums and as they become licensed as a DNP they may even start earning a similar salary as a Physician which is a slap in the face to all of us who have incredible debt that follows us from all the education and certification fees we have had to pay and be responsible for. This article and the comments above made me smile, since I thought they were getting away with something and am so happy the DO’s are looking into this.

  29. MD concern

    I agree with SFII. The NP’s with whom I have worked don’t know their limits. They don’t acknowledge what they are incapable of managing. Often, I see them them actually calling other hospitals to inquire the “next step” because they’re embarrassed to actually be supervised by a physician who is way younger than them, but who outnumbers them in hours and rigor of training. Some NP’s will now dig their claws into these statements and say I’m probably not a good physician and that’s why they don’t come to me before calling for help..Um. Right. They avoid asking ANY of the physicians in the clinic, because they don’t want to consider themselves inadequate in any way. Just had an example recently involving a man having an MI in our clinic. A physician should have been notified in the facility first…before any calls were even made to an accepting a physician at another hospital.
    I recently even had an argument with one who refused to do a pelvic on a patient, arguing that the left lower quadrant pain in an otherwise healthy menstruating woman in her early 30’s did not require any type of pelvic exam, because her symptoms of diarrhea, nausea, and fever clearly were of GI origin on no basis. The pain was in the suprapubic and left lower abdomen. Right. That clearly means GI because it could not possibly be of pelvic origin and cause diarrhea….and that was their reasoning. Plus, we wouldn’t want to offend the patient and do a physical exam on them that seems to intrusive, right? They do come do a clinic and do want to be diagnosed, but let’s just skip exams that may make a patient uncomfortable or, for that matter, a provider uncomfortable.
    Should we really let them screw up patients first and then retract the priveleges we let them gain? A foreign doctor who has practiced 20 years can’t even practice under supervision temporarily to be eligible for a US license…they have to redo an entire residency just to practice in the US. Why in the world are we not limiting the autonomy of nurse practitioners before it is too late?

  30. Educated and secure

    Wow! I am flabbergasted! I am on graduate school and visited this site for a holistic health course. My primary provider is a homeopath. I can’t believe the immaturity if physicians/interns on this page.

    Thank you secure physician. You are poised and confident, I would choose you as a provider 20 times before seeing a DO so ignorant and arrogant as skeptical internist and some others. Skeptical internist is pompous! He/she will not display their name. Why don’t you let everyone on this site know who you are. SKEPTICAL INTERNIST IS A COWARD! I wonder what his/her upbringing was like, I fear for his/her patients. I (as do many others) disrespect physicians that are more interested in making a name for themselves. Jesus was known for his works and dealings. How will others remember you? A well-educated MD, pompous, high strung, miserable, and more concerned about who is called doctor than providing high quality care. I am so sorry that maybe how some of you will be remembered. You will be humbled in due time. Pride before fall haughtiness before crash. P.S. Many nurses hold Ph.D’s look at the DNP curriculum. A nurse has no problem saying they are a nurse. Respect others and they will respect you. Don’t feel so threatened.

  31. Educated and secure

    correction I am in grad school not on. Caring for my newborn while typing. Apologies for any other typos.

  32. skeptical internist

    We can all take note of the use of the
    descriptive pejoratives “pompous”:, “ignorant”
    “arrogant” and “coward” in Shirley Robert’s posting.
    Not to mention the religious reference, because
    certainly, God must be on Shirley’s side.

    As most of the posters here are aware, these are all
    trivially the “argument ad hominem” , abusive variant,
    well known to any college graduate who has intensively
    studied logic and philosophy. This “argument” is
    depressingly common in political discourse.

    To attack the man, not the arguments made by the man.

    For Shirley’s sake, I point out that, even when Adolf Hitler
    correctly argues the proof of the Pythagorean Theorem, we
    are all constrained to admit that Hitler (or Jesus) or whoever
    is correct, if the ARGUMENT made is correct.

    “skeptical internist” is used in open acknowledgment of the
    seminal work of a key physicist/chemist that was instrumental
    in turning Alchemy into the modern science of Chemistry:

    “The Sceptical Chymist or chymico-physical doubts and
    paradoxes, touching the spagyrist’s principles, commonly called
    hypostatical, as they are wont to be Propos’d and Defended by
    the Generality of ALCHYMISTS.”

    by the Honorable Robert Boyle, published in London and usually called
    the Skeptical Chemist, for short. In 1661.

    Now my argument is simple: To wit, that the Nurse Profession,
    with all of the trappings of political correctness, has introduced the
    “DNP” degree as a “practice doctorate”, specifically with the implied
    intention to replace/supplant family practice physicians with a cheaper
    and, according to them, more patient-friendly alternative.
    They introduce many studies to “demonstrate” the accuracy of their claims
    for equivalence, but a careful review of them demonstrates such claims are
    based only on the most commonly diagnosed and easily treated conditions
    prevalent in the general population.(diabetes,hypertension,asthma)

    Thus, in a very real manner, the Nursing profession is attempting to mislead
    and deceive the public by their actions.

    For the DNP to claim real equality with physicians, and so qualify for unsupervised
    medical licenses, they must prove equal knowledge of medical science and of
    clinical medicine.

    Here are two pieces of evidence that demonstrate that NPs/DNPs do NOT have anywhere
    near the medical science knowledge that physicians virtually universally have:

    1). DNP performance on USMLE part 3-the simpler, shorter and “dumbed down”
    version of the exam has a pass rate (set by NURSES themselves) that is only
    1/2 the rate at which real physicians pass this easiest of licensing exams. Even
    DNP cherry-picking and cherry-grading their exams demonstrates precisely the
    OPPOSITE of what they claim.

    Of course, DNPs will not even attempt STEP I in all its glory- they know they have
    not REALLY gone to medical school, don’t they.

    2). See the recent IOWA court decision preventing NPs from arrogantly presuming
    the qualifications to supervise fluoroscopy and other radiologic procedures
    in that state- the attachments appended by the Judge in the Court speak
    enormous volumes about the arrogance and political ambition of the nurses-
    and, as we all know, nursing programs require NO University Physics-let alone
    the study of ODEs or PDEs of Maxwell’s field equations that are really needed
    to understand radiation and its effects on matter. Of course, the nurses will
    tell you that none of that matters. Thank god for the Judge in Iowa who saw
    right through the baloney and prevented injury to Iowa patients and citizens.

    In the Iowa District for Polk County, Consolidated Case # CV8252.

    Finally- a review of the DNP degree curriculum demonstrates a “doctorate”
    in social and political correctness attempting to pass itself off as a scientific
    “practice” degree.

    Any legitimacy accorded the DNP represents a lowering of standards and will
    result in making medicine LESS scientific, not more so.

    We cannot convince the DNPs and NPs of the clear chicanery of their position
    in this discussion- theirs’ is a POLITICAL movement, not a search for truth.

    What we can do is to aggressively develop PA programs, which are actually
    based on medical SCIENCE, not Healthcare Political Correctness.

    I propose that the best way to maintain high standards of practice and sound,
    rigorous scientific training is to aggressively partner with PAs to give the best
    medical care possible to the greatest fraction of the US population that
    we can.

  33. NP, PhD

    I came to this website as I am a nurse practitioner and a psychologist. It is unfortunate that anyone would have to argue all of this, but suddenly I have nurses at work arguing that I should not be addressed as doctor.

    I make it crystal clear that I am a nurse practitioner for a number of reasons. In medicine we look at treating diseases, in nursing we treat how the patient responds to the treatment. I am proud to say I am well-rounded and versed in both, and a psychologist to boot. The argument over training is interesting as I work in addictions, which few Doctors are interested or trained in. I have worked in this field for 23 years and it is unlikely any schooling could have provided this expertise. I am constantly in training as theories, medicines etc evolve.

    So my complaint is this: I don’t believe for a second any nurse pracfitioner doesn’t introduce themselves as Dr. B, a nurse practitioner, because that is our selling point. We are the top of our profession and should be proud to be so. Yes, we practice medicine and yes we do so with an approach that differs from medical doctors, our training as nurses is rigorous and believe me does count toward patient care. While everyone was getting a Bachelors in some undergraduate specialty, we were fully studying patient care. With a two year associate degree, we spend another two (year round) years only to get a second associates degree, then two more years for a Baccalaureate. Then three more for a Master’s in Nursing and three more to become an NP. These all include clinical rotations. None of which are political.

    So, as we find out more about the human body It becomes clear we need this holistic approach. I did not do a rotation in surgery as a medical practitioner and this would not likely benefit my practice, but should you have an issue with addiction I suspect I deserve to be called my academically earned title of doctor.

    But here I am, still paying for my PhD student loan and actually having nurses argue over this point.

  34. JT DO

    NP PhD,
    Many of the NPs in my area are awarded their NP after only 4 yrs of UNDERGRADUATE training (college) then 30 credits obtained ONLINE and 850 hrs of clinical experience. This training does not come close to the breath or depth that a physician is required to obtain. Yet, with this paucity of training NPs are able to prescribe potent drugs and treat complicated diseases. Any NP who feels they can practice medicine with these credentials is a danger to their patients. And finally, just as I have no right to represent as a academician to students at a college or university (since I am a clinician), you have no right to represent yourself as physician which is the implication when you address yourself as doctor in a clinical environment.

  35. NP, PhD

    This is where I am confused with all of this. I have never said I am a physician, as I am not. I am ,however, a psychologist. I make it very clear I am a nurse practitioner and in the field I work we call psychologists “Dr.”. So i am gathering I do not acknowledge my PhD or that I am a psychologist because I am a nurse practitioner. This makes no sense. You are taking a leap saying “implication”. I think the only implication may be from those feeling threatened.

    There is no implication when we address ourselves as nurse practitioners. You see, if we say just nurse, then patients expect nursing. We practice medicine. According to studies, we do it well. And the reality is this is evidenced-based.

    Unless someone is out there calling themselves doctor who hasn’t earned the academic title, I don’t see this as a logical argument. I suspect the issue is that patient’s don’t understand that nps practice medicine and it has to be explained, hence the confusion.

    So when you speak at a college you clear it up with students that although you are a physician you are not a teacher, despite the latin “doctor” implication?

  36. Skeptical Internist

    For ” NP Ph.D.”:

    Truly a remarkable posting. As I read it, I cannot help
    but observe some glaring contradictions, while simultaneously you
    make statements that are honest in the sense of revealing what the NP
    movement is really all about.

    The honesty is refreshing.

    You must be aware, are you not, that all of the NP propaganda is that
    NPs practice “advanced practice NURSING” and NOT medicine. After all,
    where is your “Nursing Model” as opposed to the “Medical Model”?

    Yet you openly and honestly admit that you practice medicine.

    However, you are completely comfortable with the fact that you are NOT
    SOLELY regulated by your State Board of Medicine (I presume) and therefore,
    I assume you are comfortable with not being held to the same standards
    required to practice medicine that the physicians are held to.

    In short, if you practice MEDICINE, especially independently, you should
    be regulated by the State Board of Medicine (exclusively). The SAME standards
    should apply for the SAME privileges. ( How simple is that?)

    You also state that you are well-rounded and well versed in BOTH
    the professions of Medicine and Nursing. This claim is at least theoretically
    possible for any individual, but the problem is not one of isolated
    individuals or cases. The objective data from the USMLE is that 50% of new
    DNP grads fail the easier and shorter version of Step III, the longer and harder
    version of which all new physician grads pass (while INTERNS) at a 95% plus

    The conclusion cannot be escaped: even DNP nurses lack the basic
    knowledge of physicians before they even do their Residency. And Step 3
    is entirely CLINICAL.

    Would you care for a crack at Step I (Medical Science)? To be graded
    just as the physicians are graded, mind you. No special easier, shorter exam
    with NURSES setting the Pass/Fail standard instead of Doctors.

    How about a nice round of a two-day special called the
    Internal Medicine In-Training Exam?

    Sure, you are “well-versed” in Medicine.

    It is just that Physicians are a heck of a lot better versed in Medicine, and
    that is what it means to be held to a higher standard- a standard that begins
    in University and is maintained throughout medical school and residency.

    As far as Psychology goes- I have actually worked with my wife, a
    Psychiatrist, at a State rehab facility, and, if NPs know very little medical
    science, Psychology knows none. They incorrectly concluded, for
    example, that a patient with advanced hepatitis C and liver cirrhosis
    had an improvement in his mental functioning due to “talk” therapy.
    In fact, he improved on lactulose, which improved his hepatic encephalopathy
    leading to clearer mentation. Likewise, they do not recognize the mental and
    neurological impairments of advanced vitamin B-12 deficiency.

    Again, the “studies” cited (Mudinger et al and the like) invariably
    study only the most common acute and chronic illness invariably seen in
    adult medicine ( asthma, hypertension, diabetes). Essentially, NPs claim
    equivalence broadly based on management of a relatively small number of
    common diseases. Obviously, this does not mean that YOU as an individual
    do not have broader experience. But because NP programs and standards are
    so widely variable, one must examine the average status of NP training and
    standards. When this is done, the purported equality is readily seen to be
    political propaganda.

    But here is the REAL “kicker” in your posting:

    >” I work in addictions, which few Doctors are interested or trained in”<

    While this statement may be true, it ALSO reveals that you RECOGNIZE that
    you really are NOT a "Doctor" in the Clinical sense that the term has been used
    in for many, many decades in the Western world, despite the rest of your
    arguments. Of course, a Ph.D. is a "Doctor" in the academic sense.

    This tells me clearly that, whether you admit it or not, you recognize a great deal
    of truth in what the physicians have been saying all along. Obviously, not
    openly admitting this is the preferred course of action when attempting to
    obtain prescribing psychologist rights and independent NP rights by
    POLITICAL means-intensively lobbying State legislatures.

    I hope this clears up confusion. I also hope that the "nurses at work"
    understand my points as well.

    One further point: None of the above denigrates the wonderful contributions
    Nurses and Nursing makes to patient care, or the contributions Psychologists
    make to the care and improvement of personality disorders and other
    psychological disturbances in people.

    Unfortunately for Medicine and for Nursing, the NP movement has rolled out
    its DNP degree and wants NP "residencies" etc. This clearly qualifies as
    trying to be doctors, despite their propaganda to the contrary. Their actions
    speak far more loudly than their words- so loudly do their actions speak,
    that the NP verbiage and propaganda cannot be heard over the volume of
    their actions.

  37. RSConrad,DO

    I find it hard not to be defensive when the profession of medicine is politically being challenged…there is a true threat out there. However, let me say that as a former Hospital Corpsman, LPN, and RN I’ve had my share of “arragant doctors” to deal with, but they were few and far between and don’t count. The ones that do count are the hundreds of doctors (both MD and DO) that I have worked with over a 27 year period of time who I never felt inferior to, or degraded or demeaned while working with them. I respected them and were inspirred by them. I was a very good RN; I felt and knew I was making a valuable contribution and I knew I was an intelligent human being.
    Then, I decided to become a physician, and was willing to do anything I needed to do to make that happen. I wanted to continue developing mentally, emotionally and spiritually. I wanted the autonomy, the control, the mentally and emotionally challenging work, and the monetary compensation for the knowledge and skills I earned. And, I wanted the full responsibility and full accountabilitiy that goes along with it all, and the commitment to life long continuing education. Having a doctorate degree and being called “doctor” doesn’t make me a better person, but it does make me a different person, with a different set of societal responsibilities and accountability. And having been a nurse previously, I know the whole “battle of the sexes” that went on back then, and evidently still today.
    It’s going on in the medical profession as well, and in every other profession out there. It is the hugh spiritual challenge we all get to work on, no matter what profession we are in, or walk of life. The issue of practice rights and who gets to be called what will continue to be played out in the courts because I understand people will be people, and always want more and feel justified in pursing more. My prayer is that a Higher Intelligence gets the final say in the matter, and a Higher Justice will prevail. Meanwhile, I continue to create the life I love, and send love and light to everyone who’s intention is to relieve the suffering of others.

  38. JT DO

    NP,PhD, (this is in reference to your response quoted below)

    So when greeting your patients how do you introduce yourself? Do you say “I’m Dr Smith, nurse practitioner”, or “I’m nurse practitioner Dr Smith,” or “I’m Dr Smith, NP” or any number of other very confusing combinations. I am board certified in addiction medicine and medical director at 2 clinics, so I am acutely aware that many patients in the addiction treatment environment probably assume you are a physician if the designation doctor has ever been associated with your name by you or your staff (this is undeniably true if you also write for meds.) In all likelihood, this association has occurred since your staff probably books you with the following dialogue “Mr Jones we gave you an appointment with Dr Smith at 10am.” Even the way you refer to the people you treat can lead them to the wrong conclusion, since those in the medical field use the reference ‘patients’ whereas non medical (MSW, PhD, etc) use the reference ‘clients’. It would be interesting to know how you refer to them – as patients or as clients.

    In my opinion, unless you and your staff plainly and consistently convey to your clients in no uncertain terms, that you are not a physician, but a nurse with some specialized training, who holds a doctor of philosophy in psychology, you and your staff are by omission, misleading your clients. I doubt this can be accomplished in a plain and consistent manner. So that there is no misunderstanding let me state emphatically I am not attempting to minimize your PhD training which I understand is considerable but I respectfully suggest that in that clinical environment you refer to yourself as therapist Smith, PhD which is your proper designation and not Doctor Smith so as not to mislead your patients.

    Incidentally, I have never, nor do I intend to, teach at any university or college because I understand my limitations in that I have not been trained as a teacher but rather a clinician. Neither do I consider, or pass myself off, as a researcher since I also lack that training. You, on the other hand, may very well have that teacher/researcher training and thus would have every right to feel indignant if I breached your academic domain leaving that impression by omission .

    NP PhD wrote 4/2/11 –

    ” This is where I am confused with all of this. I have never said I am a physician, as I am not. I am ,however, a psychologist. I make it very clear I am a nurse practitioner and in the field I work we call psychologists “Dr.”. So i am gathering I do not acknowledge my PhD or that I am a psychologist because I am a nurse practitioner. This makes no sense. You are taking a leap saying “implication”. I think the only implication may be from those feeling threatened. There is no implication when we address ourselves as nurse practitioners. You see, if we say just nurse, then patients expect nursing. We practice medicine. According to studies, we do it well. And the reality is this is evidenced-based. Unless someone is out there calling themselves doctor who hasn’t earned the academic title, I don’t see this as a logical argument. I suspect the issue is that patient’s don’t understand that nps practice medicine and it has to be explained, hence the confusion. So when you speak at a college you clear it up with students that although you are a physician you are not a teacher, despite the latin “doctor” implication”

  39. Sonja Mast

    Dear Skeptic
    If NPs are skeptical physician extenders; are skeptical physicians NP extensions? Might we surmise then that a skeptical physician is akin to a snap-on-tool? Make no bones about it, my diagnosis is ubiquitus statusitsmyturficus related to anal retentive tendancies, paternalistic pathology, with excessive valsalva manouvering as evidenced by mechanistic dystonia and rabid verbosity. In the olden days a DRA and some paraldehyde might have done nicely but a second opinion in this era is certainly indicated.

    S. Mast NP
    Combinard, Ontario

  40. ONGYN Intern

    I did a little research on this topic just based on the number of hours training and it comes out to this

    MD/DO = 4yrs undergrad + 4yrs medical school + 3yrs residency (FP) + 3 National Board exams + 1 oral/written specialty exam (depending on specialty) = 11 yrs of training

    DNP = 4yrs undergrad + 5 years training with only 1000-2000 hours of supervised clinical experience required = 9 yrs. + 2 national tests

    Medical students typically do 6000 hours of clinical supervised training in just 2 years + countless more in residency about 9000-1000 for FP.

    It just feels wrong to say that with only 2000 hours DNPs should be able to practice unsupervised and that they should be able to say that they hold the title of doctor.

    All references of amount of time came for AAFP.

  41. Quixoticelixer

    Sounds like another case of “too many Chiefs and not enough Indians.”

    Stop arguing, roll up your sleeves, and get back to work. It’s something that we have a national shortage of healthcare providers when they are all arguing on a stupid website about something they ultimately don’t have any control over.

  42. Alan Berg, D.O.

    It is simple really to explain the difference. There are many people who have taken flying lessons and now take to the air in their single engine Cessna or other small plane. They are pilots. So given the current logic of the argument why not let them fly a 747? It’s the same thing, right? So how many of you who support this ridiculous notion of eeveryone being a doctor (even without medical school) are ready to get on board that 747 piloted by the weekend Cessna flyer? And please don’t try and tell me that this is “different”. Take your Cessna license and get hired by AA to fly the big planes and then I will accept everyone into the fold. No other industry would put up with this nonsense!

  43. robert migliorino,d.o.

    FYI,In Iowa,NP”s are NOT supervised nor regulated as are PA’s.When I inquired as to why,I was informed by a party in Des Moines that the State Legislature & Senate have proposed,written,or voted on any law covering this area.So,in Iowa,NP’s are quite independent & woe betide anyone trying to change the status quo.

  44. PhD, RN

    Funny, I hear many MD’s saying that DO’s went to DO school because they couldn’t get into a real medical school. So the name calling and false statements continue.

    Robert Migliorino: DNPs are independent in every state that I know of and have a much broader scope of practice and more education than a PA.

  45. PhD, RN

    “So how many of you who support this ridiculous notion of eeveryone being a doctor are ready to get on board that 747 piloted by the weekend Cessna flyer? ”

    I have a PhD; I have the right and the credentials to be called doctor. Physicians did not invent the word, nor do they own the word. DNP’s (or anyone else for that matter) are not calling themselves physicians, that would be unethical.

  46. robert migliorino,d.o.

    yes they can write well but ,thats practcal situations they are helpless.practcality was best exemplified by the diploma nurse.true you march first in the academic procession as a phd.why do np’s throw the complex cases to the physician? if they are so confident in their abilities,then they should pay the same premiums for malpractice that physicians do for the same procedures.also,do np’s work more than 8 hours per day or do a specialty residency for 3 or 4 years?of course not. Np’s & pa’s are cheap labor in a specialty wild field.

  47. robert migliorino,d.o.

    BTW,doctor means teacher.As far as DO school is concerned,many of us chose it for general practice,at a time when md schools were preaching specialties only.That is why i chose kirksville over others that i was selected for such as cornell-flower 5th avenue ,tufts,indiana,etc.

  48. Health Insurance Longmont

    I will right away take hold of your rss as I can not to find your email subscription hyperlink or e-newsletter service. Do you have any? Kindly permit me recognise so that I may subscribe. Thanks.

  49. JT DO

    Here we go again – PhD, RN writes:
    “I have a PhD; I have the right and the credentials to be called doctor. Physicians did not invent the word, nor do they own the word. DNP’s (or anyone else for that matter) are not calling themselves physicians, that would be unethical.”
    It is unethical and WRONG for you to call yourself doctor under circumstances wherein a patient would assume you are a physician. For instance, if you are working in a health facility as a nurse and you address your as doctor you are misleading the patient. At your own office, at an institution of learning, at social gatherings, etc call yourself whatever you want. So I hope you understand, you don’t have the right and the credentials to be called doctor under all circumstances.

  50. skeptical internist

    Just want to clarify on “DNP”:

    1. They are Nurses -“advanced practice” or not.
    2. They have the scope of practice defined by State law-usually the same as
    any other NP.
    3. They DO NOT have more education than a PA- IF the only thing that really
    counts is medical science and clinical practice- the DNP has very little
    medical science knowledge- as shown by exam performance and their
    politically correct course work for the DNP.

    4. The DNP is really a phony baloney “doctorate” in almost the same sense that
    middle school principles get phony “doctor of Education” degrees to
    puff up their academic qualifications in the most outrageous and absurd
    manner possible- so they can then be called “doctor” and grab more
    money and status for themselves.

    5. It is crucial that the docs (the real ones) keep calling out and exposing the
    conceits and phony non-sense that gets ENDLESSLY repeated in blogs and
    in the media. It is now the year 2011, and STILL it is the case that the
    it will be accepted as the received truth- “PROOF” by force of
    blaring, constant repetition.

  51. JT DO

    Several years ago at a state chapter meeting being visited by the president of the AOA, I offered that the biggest threat to primary care was not mounting malpractice premiums but the influx of, and expanding scope of practice of, nurse practitioners. The response I received from some influential members was that the “nurse’s union was too strong to fight.” At this point, I would be elated if the AOA and the AMA used their resources to insure that NP’s be scrutinized by the same oversight boards that oversee physicians and PAs. That would be a major step and I suspect it would be eye opening since NP malpractice erros is buried somewhere in never land

  52. Placebo

    Skeptical Internist – Wow,after reading your comments I am convinced to believe that you were breastfed by your father. You should be embarassed! If this is your biggest worry, you are obviously in the wrong profession. As a student in the healthcare field which I will not disclose, I am surprised I have not heard one word in the sense of COMPASSION or CARING. Healthcare is not a matter of money, who can be called “doctor”, or all ones political ideas; It is about taking the time to truly help someone that needs help, finding resources, and providing the best possible outcome for these people called patients.

  53. skeptical internist

    Response for “placebo”:

    I am not at all surprised by comments of this type.

    Nothing I have said has anything at all to do with compassion and caring for

    If anything, making certain that under qualified NPs are not allowed to
    practice without adequate supervision IS compassion and caring for patients.

    It is precisely the NPs who, using entirely inadequate “studies”, are the
    the ones playing political games-as their constant yearly treks to the State
    legislatures demonstrate.

    Using the buzz words of “compassion” and “caring” is just the sort of
    politically correct nonsense that passes for “reasoning” these days- just
    because you use buzzwords, you appear to believe everyone should accept
    whatever your position on the issues is.

    At least ATTEMPT to make logical and reasoned arguments, as opposed to
    impugning someone’s heritage.

  54. Placebo

    “Skeptical Internist” I am not attempting to or even suggesting to bash your “heritage”. Taking care of patients is no ones “hertiage” it is a privilage provided to you when you accepted and committed to The Hippocratic Oath. All I am saying, is that I know MANY (more that I would like to know) MEDICAL DOCTORS that practice using inadequate studies, they also have extremely high infection rates (surgical), poor treatment in regards to prevention not utilizing evidence base guidelines (primary care), and others ordering tests that are not needed on patient (mulitple specialities). When I see a 93 year old person getting a bone marrow biopsy to “start chemo” is that really realistic? So for one to say NP’s are doing this is ludicrous. I also notice that you suggest adequate supervision of NP’s, instead of adding to the problem by being so narrow minded out inadequately trained NPs, you should consider training a few. Just to let you conscience rest and you can feed your ego knowing there is that ONE NP doing exactly what YOU SAY (I am sure you can find just ONE that will tolerate this behavior)! When I use the “buzzwords” compassion and caring, I am not attempting to make people believe in any position, it is the basis of healthcare in my moral standing and the foundation of medice (well should be)!

  55. JW, FNP-C

    While reading these post I feel very defeated ad a Nurse Practitioner. I have a 2 year Associate Degree and practiced as a Registered Nurse for over 13 years. I decided to go back to school for my Bachelors degree after working in a Level one Trauma Unit in the Emergency helping Residents in the ER become the best that they could be. I was a Charge Nurse and became a Travel nurse, and a House Supervisor with my last job while I was going to Nurse Practitioner school. I chose to be trained by ER Doctors because I thought that I was going to be an NP in the ER. I loved the Doctor’s that trained me and I appreciate everything that they did teach me. I felt saddened as the Skeptical Internist kept putting everyone in one Melting pot as if all NP’s were bad. I do precept NP’s in the Independent practice that another NP and I run. I almost feel the same in that there needs to be some changes in the Colleges that if an RN enters into the NP Program they should have at least 5 years as an RN and also they should have at least 1 year of residency in the specific area of practice before being on their own. There should also be a 5 year of Supervision of an MD to at least have someone to inquire about different patient questions that should be needed. There are too many NP programs that are pushing out inexperienced Nurse Practitioners that are not ready to be on their own, but not all of us are like that. I am not a Physician and I do not have my DNP, and I tell all of my patients that I am a Nurse Practitioner and make sure that I am providing their care as a complete patient and not just one specific area that they are there for. I know that in being an ER nurse for so many years that it is easy to have a narrow focus and treat just one thing at a time, but since I have been in Family Practice I have learned to focus on the total healthcare of the patient. I DO NOT WANT TO BE A PHYSICIAN, but I want to be able to care for patients under the maximum of my scope of practice. I find it disheartening that there are people out there that do not want to accept that the Medical field is ever changing and focus on trying to change things instead of being on this specific site degrading a specific profession. I have dealt with too many ER Doctors that have looked down on the Nursing Profession and I have dealt with the best of ER Doctors that want to work together and band together as MD’s and NP’s to be able to care for our communities for improved and better patient care. I know where this one Physician is coming from and we as Nurse Practitioners need to make a change in our Education in order to bring us up to par with the acceptance in the Medical Society.

  56. raven,NP

    I’ve been a Nurse Practitioner for over 15 years, and work with a MD who has employed many NPs and CNMs over the years.When he first started doing this, it was not popular or well received in the community of Physicians, but over time, many area physicians have begun to utilize the help of NPs in their offices and in the ER. The physician I work for feels that the nurse practitioners can handle most of the yearly exams and common problems that present. He sees these patients too, but because the NPs see the low acuity patients, he has more time for those with acute problems or rare medical conditions, or those who have not responded to standard treatment. Speaking for myself, I have no interest in BEING a doctor, nor do I EVER let anyone refer to me as such. In my state, a collaborative agreement with a physician is required in order to practice, and the NP must practice within the scope of their specialty certification. All NPs learn when it is appropriate to consult or refer to their collaborating MD or DO. And they do this when the situation warrants it. Right now I am back in school for additional clinical specialty. Last week I spent clinical hours with an FNP in a college health care clinic. We saw about 20 -25 patients in the four hours I was there. The breakdown was something like 15 URIs, a couple UTIs, a couple of skin rashes and some probable STIs. These patients were all uncomfortable enough to be seen by a health care provider, without serious illness or emergent problems. Why not utilize the services of an NP for this? Dr. is available by phone, and the office/ hospital is 20 minutes away by car. And what MD or DO would take the time from his or her busy day to staff this clinic ? CLEARLY, there is room in the health care arena for BOTH NPs and MDs/DOs. WHY do we continue to have this debate? The physician I work with relies on his NPS to staff his office while he does surgery, attends meetings, goes on mission trips and supports community endeavors. He is in touch with staff daily if he is not in the office. Protocols developed by both MD and NPs guide NPs in decision making with regard to care and referral. There is room in health care for BOTH NPs and physicians for physicians who are smart enough to take advantage of the skills and services NPs have to offer. We ALL know excellent NPs and lousy doctors and vice versa. Lets just play nice, shall we? NOBODY disputes the MD or DO’s educational quality. This does not, however, diminish the quality of Nurse Practitioner education or NP ability to be a valuable and viable health care delivery partner.

  57. Male DNP

    I propose legislation requiring DOs to clarify that they are an inferior DO and NOT a MD when pts call them “(real)Doctor” in a clinical setting… just kidding.

    I wonder if the Nursing community were to mimic DO and MD education with the DNP, would the DO and MD community still insist that DNPs are not doctors? I suspect the answer is yes.

    Real or perceived, there is a primary care provider shortage. The government will attempt to fix this, with or without MDs and DOs. I think the most equitable solution is to increase the training requirements of DNP programs (but not to the extent of MD and DO programs, unless you want DNPs stepping in on you specialty territory as well) and keep masters level NP programs but limit there scope of practice to that of PAs.

    I doubt this solution will please many “Doctors” but I believe it is the most pragmatic solution.

  58. skeptical internist

    This response for “male dnp”:

    One of the essential elements as far as I am concerned is to never allow
    other professions, like nursing, to tell us what qualifies as, and
    what training is required for, medical practice.

    Physicians go to medical school to practice medicine.

    The NP “argument” for changing laws and standards for medical practice
    really amounts to nothing other than brazenly swiping areas of medical
    practice, and trying to use Nursing boards and State legislatures to
    RELABEL these areas as “nursing” or “advanced practice nursing”.
    This is, obviously, nonsense.

    What other profession puts up with these shenanigans?

    The DNP degree is NOT a medical degree
    It is not a scientific degree.
    It is a poltically-correct statement- an excuse for its holders to
    claim a title they have not really earned.

    Real doctors in clinical medicine go to medical school. That is a simple truth
    that will not change and that the public can understand.

    The public is not as foolish as “male DNP” believes: they can easily
    understand what fakery really is.

    As to the “shortage” of primary care:

    The number of medical schools is increasing, and the medical profession
    needs only to argue that family medicine and internal medicine programs
    need to increase-both to meet projected demands AND to maintain
    standards. I would add that we need more PA programs as well- so that
    primary care physicians can partner with several of them and thereby serve
    a very large number of patients.

    PAs are better trained in medical science anyway; they do not engage in anything
    like the political agenda that nursing does; and they often make excellent
    physicians themselves when they undertake medical school.

    Finally, last but not least, there has also been a shortage of bedside Nursing-
    foolishly letting “DNPs” practice medicine will merely exacerbate another
    shortage in another health profession- as well as lower standards.

    I stand by my conclusion that DNPs are not “real” doctors in clinical,
    medical and hospital organizations. They are Nurses. Period.

    Post-script: why is the fact that you are “male” important? Are you invoking
    the usual political correctness of the day? i.e, males do the DNP degree also,
    therefore it is “legitimate?”

  59. skeptical internist

    Other aspects:

    “Male DNP” also seeks obliquely to attack the medical profession
    by pointing to the fact that “inferior D.O.s” practice medicine.

    Once again, the osteopathic medical schools spent many decades
    under-going self-improvement and building their own systems of
    medical schools and hospitals. It took them decades to achieve a relative
    parity with the MD schools. They undertook this task because they genuinely
    believed they had additional aspects of therapy to bring to medical
    practice-“manual medicine”.

    It was the MD schools and residencies themselves that finally welcomed D.O. s
    into medicine-by opening their Residency programs/Certifying Boards and
    their complete and full Licensing exams.

    In this manner, the medical profession now has CONSISTENT and UNIFORMLY
    HIGH educational and training standards: SYSTEM-WIDE across medicine- BOTH
    for D.O.s and for M.D.s

    It is only the NPs who yammer about their incessant desire for “prescriptive
    authority”. This is because that is what they SEE physicians do, and what they seek
    to imitate.

    But to the primary care physician, the MOST important aspect of their practice
    is NOT writing prescriptions- it is to arrive at a careful and full differential
    diagnosis of a patient’s problems and to undertake steps required to secure a
    correct and accurate DIAGNOSIS.

    medical practice, not the trivial trappings of medical practice such as writing

    It is extremely telling that nurse practitioners keep up their endless din to
    legislatures about “prescriptive authority”- a term physicians never use.
    It clearly demonstrates that NPs in the forefront of their political movement
    really care about illusions such as the appearance of being a physician and
    their OWN “authority”- or relative level thereof.

    With perfect hypocrisy, they then turn-round 180 degrees and accuse real
    doctors of only caring about protecting their authority.

    And all the while, it is medical knowledge and training in diagnosis that is the
    key to good general medical practice- that which is NOT on trivial display, and
    therefore NOT the object of Nurse Practitioner envy/jealousy.

  60. Male DNP

    Skeptical internist:

    Your ego and lack of civility aside, I am as much a Clinical Doctor as any PhD prepared psychologist, physical therapist, occupational therapist, dentist, optometrist, or chiropractor. Especially in the case of the psychologist who is often found in hospitals, prisons, and offices with psychiatrist. When I introduce myself I always say, “hi I am Dr. Male, I am a Nurse Practitioner” the same as all of the psychologists I know. I know many MDs who still consider DOs second rate doctors. By the way my last name is Male, but I do happen to be a man.

    As far as my education goes I will be the first to tell you that my DNP program was hardly worthwhile. I am however more than qualified to do what I do, including full prescriptive rights in my state and a collaborative agreement that is little more than symbolic.

    I would like to see an improvement in DNP programs. The current curriculum at most institutions is worthless. It could be changed to add curriculum covered in MD / DO programs and even an abbreviated residency. Unlike MDs and DOs, nurses generally have an undergraduate degree in nursing, there would be little need for a DNP program identical to MD / DO programs. Nursing could offer a different Physician perspective much the same way DOs do.

    As far as the “nursing shortage” goes, it is largely a myth. There may be some areas in the US where RNs are in short supply but there are many where RNs are unemployed, especially new graduates.

  61. skeptical internist

    Reply to “Male DNP”

    Why this discussion is important:

    Leaving aside “Male DNP’s” personal attacks on my supposed lack of
    “civility” and my “ego” [ the fact that I am certain his arguments for
    his position are dead wrong, of course, has nothing to do with such
    attacks], this discussion is important for a few reasons:

    1. First, it highlights what the true motives and intent of the NP
    movement actually are, as opposed to the nonsense propaganda
    spewed forth by their political machinery and aggressive legislative

    As can be plainly seen, “Male DNP” wants very badly to be viewed as
    a Physician, and even states that “Nursing could offer a different
    Physician perspective much the same way DOs do.”

    So much for any pretense that they are NOT in fact trying to be

    They just want to do this NOT by adding any method or branch to Medicine,
    but just by having 1/10 the scientific background and far less rigorous
    clinical training.

    Of course, if they succeed, they will want equal pay and equal hospital

    2. Clearly demonstrated is Male DNP’s contempt for any oversight or
    supervisory arrangement, or to use their own “politically correct”
    language, “collaborative agreement”.

    NPs clearly believe they have earned the right to practice medicine,
    WITHOUT going to medical school ( even an “inferior” DO or
    ?foreign medical school). They believe they have earned this right
    regardless of the plain facts.

    This is why, in Iowa, the NPs wanted to supervise Radiology procedures,
    as if they were Radiologists, when their background does not even
    include one year of University-level Physics.

    The unbridled arrogance and egotism that was demonstrated elicited
    a Court injunction in Iowa to prevent this blatant and obvious risk
    to patient safety (a Court action that was successful).

    Now, for Male DNP himself:

    With breath-taking illogic, you assert yourself that your DNP
    program was hardly worthwhile [ not surprising, since a casual
    review of these programs reveals all fluff and management
    course work, and very little or zero medical science or clinical
    training]. You even admit that the current DNP curriculum at
    most institutions is worthless.

    You then proceed to claim that you are “more than qualified to do
    what you do” (practice medicine).

    You thereby prove my point that the DNP is a political degree and you are
    really claiming equivalence to other doctorally prepared health care
    providers and physicians based on your Master’s degree in Nursing.

    This obviously begs the question of why the DNP degree is needed as the
    “highest practice degree” in Nursing. [Ans: its needed for political
    reasons only, not “practice” reasons]
    Obviously, nothing here stands up to reason, logic or scrutiny.
    [feel free to start your ad-hominem attacks].

    Yes, some MDs still consider DOs their inferior.

    However, a great many MDs, in all specialties, do not.

    You need to be taught the rules of logic, reason and evidence.
    To wit:

    – The DOs now take the USMLE, all three parts, and score very
    closely to their MD counterparts, and BETTER than the foreign
    MD graduates. Indeed, their clinical science scores and pass rates are
    the same as US MD school graduates.

    – A great many DOs then do the same residencies and are Board Certified
    by the same Boards.

    So you see, Male DNP, there is a difference between evidence and reason,
    vs. prejudice.

    I can clearly point to OBJECTIVE EVIDENCE and STANDARDS for asserting
    that DOs and MDs are essentially equivalent ( and have been for many
    years now).

    HOWEVER, when the “DNPs” take their own SHORTENED and SIMPLIFIED
    ( you know Mr. Male DNP- EASIER) version of ONLY USMLE Part III:

    – 50 % FAIL their own lower standards, a result that is highly
    American Medical School standards.
    (in other words, it is not even close, like DO-MD).

    And for this nonsense, you want equal pay, same titles, equal
    privileges and so forth.

    Absurd, as PART of your post above actually recognizes.

    Last, but not least, the Nurse shortage is real according to the
    AACN. At the AACN website, one may look up a 2010 fact paper
    demonstrating the projected shortages-“NURSING SHORTAGE FACT SHEET”.

    A great many organizations and statistics are stated there. The shortages
    arise from the same factors producing the MD shortage- retirees from
    Nursing, Baby Boomers retiring, high burnout rates, difficulty of RN schools
    getting enough resources to increase and train more Nurses, etc.

    It seems this nation can ill-afford the arrogance and the self-serving
    propaganda of the NP movement, let alone the blithering pomposity of
    the DNP movement.

    But I do thank you for more fully revealing to the Physician community
    the true motives and purposes of the DNP degree, and all the “ugly”
    it really represents- this may serve to enlighten any unfortunate
    colleagues who may well have been “snowed” by the NP agenda.

  62. Student-FNP

    I agree with skepticalinternist. The DNP is absolutely a politically motivated power grab by the nurses associations. S-I : you’re a bit fiery but I think to some degree I’d feel the same way if I was in your shoes. There are a lot of passive physicians out there content to serve their patients and keep quiet. They probably don’t understand the damage they are doing on the fronts where they could still make a difference. I live in NY and go to a small private school. My FNP program is still a masters at this point, but they will be offering the DNP in the fall. The program is disappointing at best, and not challenging in the ways I find important.

    I tend to think in a scientific way, basics first- Outline the big picture first, and then fill in the fine colors. This is not the way we are taught. It is fact based, not understanding based as it should be. No surprise, it’s hard for people to remember these tangential facts with nothing to tie them together. I’m a bit of a scientific thinker so I heavily self study what I think is important, patho, fundamental sciences, anatomy and physiology. People laugh at me for this. They say why are you still reading patho and physiology books? Didn’t you take that before you went into nursing? They just don’t get it. They are so focused on the goal, not on the learning experience. I find myself more and more every day desiring everything medical school has to offer (except the bill). That fantastic residency, those core sciences, the challenge… ummmmmmmm…. delicious. I’m not saying there aren’t great NPs out there….. I just can’t understand how they end up that way.

  63. Student-FNP

    On another note it’s a little bothersome how many nursing students have the goal of becoming NP’s. I’m a nursing tutor at a community college, so I hear it all the time. What ever happened to wanting to be a bedside nurse?

    That caring touch, the humanistic love of your fellow man, that’s truly the caring spirit of the profession and nobody can argue it. I really don’t think NPs can accomplish this effectively as a provider. Its about being there, the every day grind, coming in early and leaving late. Time is no doubt the major problem. NP’s just don’t have the time to do this in the provider role. Maybe they possess the attitude, maybe they have it in them, or maybe they have felt that connection before, but what counts is being there. Those who can, do, right? All these students just care about the money and power of the role, these are the same attitudes driving the DNP. I am a hypocrite, I’m not going to argue it. I think its because of societal factors, my generation wants everything easy, the quick reward, and I do too but don’t think for a second I don’t see the problem with it. I’m trying to fight the urge but its tough. The NP is a troublesome imposition, not quite a “nurse” and not a “doctor”. Not quite caring, not medicine…..what are we?

  64. Student-FNP

    Mike PA- “We as providers have all known RNs that have taught us something or saved our behinds in some way…these are the nurses who go on to become NPs.”

    I think this is the most disturbing statement to me in the whole thread. Does anyone else see the tragedy here?

  65. Sweet Dick Willy

    I’ll preface by asserting that Nurse Practitioners are valuable healthcare professionals.

    Having said that, the DNP is a fluff degree that offers little if any contribution to clinical skills of practitioners over masters-prepared NP’s. Frankly, even if you don’t buy in to it being a politically motivated power grab, you’ve got to question it’s purpose. Why the push to make the DNP the entry degree for NPs? At best, it’s unnecessary.

    If nursing leadership is truly interested in furthering nursing education and insists on making the DNP the standard for NPs, and they are serious about wanting to be considered clinical equals to physicians, I suggest they go about it the right way:

    1. Be honest about the “nursing model” vs. “medical model” rhetoric. It is disingenuous to pretend that what NPs mean when they say “independent practice of advanced nursing” doesn’t mean, or at a minimum include practicing medicine.

    2. Hold themselves to a higher standard in terms of licensing requirements. Require NP students to pass exams on par with the USMLE or COMLEX exams, and set goals that NP students do so at a rate comparable to MD/DO programs.

    3. In order to meet those goals, radically alter the curriculum of DNP programs to equip students to do just that. This probably means cutting some of the fluff, adding rigorous science courses, and significantly increasing the clinical requirements.

    4. Either drop the rhetoric about NPs being essential to increase access to underserved areas and an answer to primary care shortages, or find a way to make it actually happen. The fact is that as it stands, NPs are geographically distributed in similarly to physicians. Underserved areas are still largely underserved. What is more is that NPs are moving more and more away from primary care and in to specialization.

  66. Boolah

    I’m an RN with 24-years bedside experience. I can tell you, there is a difference between book learning and practical experience. I have heard MD teachers state that they think the students coming out of med school are the stupidest they have ever had to deal with.

    I’ll leave the nuances of this fight to those with the degrees. My plea would be for the MDs, the so-called “real doctors,” to come to the bedside and talk to their patients. It’s a little disconcerting to hear a patient say that they have not seen or heard from a “doctor” in 4 days and “Please tell me what is wrong with me?” Of course, I know, but I am not allowed to discuss this with the patient because I am not the medical side. I have to refer the patient to the phantom doctor who comes to the bedside to visit the chart.

    At a certain point, patients will be happy to get to talk to anyone! I have taken the time to explain certain things to patients only to have them tell me, “Thank you! No one’s bothered to talk to me.” This is an absolute disgrace to the medical profession, and little respect will be given to your arguments unless you make it a priority to teach your students–no, require them–to talk to patients.

    Don’t tell me how great you are–I know what you do, and how patients are failed every day by great, learned docs who don’t have the time of day for sick people.

  67. Medical Student, MD/MPH

    I was trying to learn more about the debate between physicians and NPs. The article included both the physician and nursing views which was pretty good.

    I do think Skeptical Internist is being a bit unreasonable, short-tempered and verbally abusive. I’m pretty sure you’ll go on to attack my post next as well, but it’s alright, I’m probably not going to check back here over & over, like you have.

    I just want to state that I agree with many others:
    – 3rd year medical students are highly incompetent & will require help from nurses to become competent (so why are we attacking nurses so much?)
    – NPs do not have as much education/experience as physicians, but really, most medical students I know do not WANT to go into primary care- it is often a “fall back” residency & most people I know who get high scores on their USMLE exams will choose a specialty that has better work hours, pay, etc.
    -If physicians cannot fill the primary care shortage, then who are we suggesting? It is silly to do telemedicine with only PAs if patients want to actually be seen by a physician.
    -I agree with others that physicians don’t spend nearly enough time with patients. For my most recent checkup, I found the physician to be rude, dismissive of my concerns and she never gave me a chance to even ask her questions! I was very annoyed when I left & thought, “maybe I should have become a nurse if as a physician, I will only get to talk to my patient for 5 minutes while the nurse does everything else” But I do understand that some of that is the demands put on the physicians- they are expected to see some 40-50 patients in a day so of course time/patient is going to be short. I just wish physicians didn’t have to see so many patients every day.

    But that is not to say I’ve been impressed by the nurses I’ve met, either. I’ve met some great nurses, but there have also been some who were just bitter, rude, dismissive and mean to patients, especially at nursing homes. Of course there will be bad physicians and bad nurses, just as in all areas of life.

    Also, I am on the side of the doctors regarding the malpractice case studies- if NPs are being supervised, of course they will not get sued, it will be the physician and residents being sued. What are the statistics for INDEPENDENTLY practicing NPs?

    And the USMLE Step 3…if it’s a shorter & possibly easier test, then that cannot be said to be “equivalent” to an MD/DO. One of the hardest things about the Step exams is the duration of the test. You need to have the stamina & be able to maintain sanity to make it through 8 hours of testing!

    Also, my friend who is getting her master’s in nursing has told me that the whole reason hospitals and nurses want to make it mandatory for nurses to get a DNP over a master’s is that compensation for master’s is 80% of what physicians would get compensated while for DNP is 100%…so maybe $ is a bit of a motive?

    Overall, I don’t think NPs should practice independently because I feel like they need supervision from a physician to correct their errors, but I think there is nothing wrong with them using the term “Doctor” as long as they explain that they are NPs. Then if they are implicated in a malpractice lawsuit while practicing independently, patients will not think that physicians are the ones being sued.

  68. Medical Student, MD/MPH

    Also, skeptical intern, I feel like if you toned down your attacks a bit, it would all sound much more reasonable. As of now, it’s hard for anyone to trust what you are saying since you sound extremely biased & will turn what anyone says around to suit your needs. That’s not how reasonable, educated people argue their points and relentlessly attacking the other side will not win you any supporters.

  69. Skeptical

    The skeptical internist seems to have a lot of time on his hands. If he would practice medicine more then type on messages boards, he or she may actually accomplish something.

  70. Fixemup

    Medical Student MD/MPH…As for malpractice stats for NPs, check the Pearson Report for all those states allowing NPs to practice independently…I think you’ll be surprised.

    I am beyond words for expressing my distaste and embarrassment over the immaturity demonstrated on this site. Most of the behavior here is deplorable. I’ve recognized many behaviors seen in the APA DSM. Get some help!

  71. Allen T

    Medical education in the US is a but ridiculous. In most other countries in the world Medical Doctors only have Bachelor degrees in Medicine. Would American MD’s argue that they are the only REAL Doctors on the planet then? Since their foreign doctors did not go through the same years of schooling as they did. Honestly, why in the world would you need a bachelors degree prior to getting into a medical school? Do you really learn a lot of medicine in your undergrad? Those Med School prerequisites for admissions take no longer than two years to complete. Requirement to have a university degree before getting into a med school only exist in North America. And medical schools are no longer able to produce enough physicians for people. Something must change about the healthcare in this country. NP’s is a great alternative – they don’t study things that are not related to Medicine in their programs (I know doctors that did Music/Business (you name it) in their undergrads, that sure helps them to manage diseases. NP’s don’t go through the extra odd years of schooling, allowing them to have much less student debt. Having less debt means that you don’t need to make as much money as an MD, because you start working earlier with a much less debt. But since NP’s do the exact same thing as some physicians, why pay more to those with MD degrees? The country is in a huge debt, a lot because of healthcare. Thirty percent of government spendings goes towards healthcare.
    American Medical Association should attack foreign doctors for only having BS in Medicine. After that most of us will lose any access to primary care.

  72. do physician

    Allen T
    Without arguing the numerous false assumptions in your post, if we were to follow your argument/logic then the actual amount of post baccalaureate medical education an NP has accumulated is 30 class credits and 850 clinical hours. I doubt most patients would feel comfortable putting their health and life as well as their loved ones health and life in the hands of a physician with that meager amount of training yet it doesn’t seem to bother you.


    Nothing I’ve read here is as embarrassing as your statement which follows –

    “I am beyond words for expressing my distaste and embarrassment over the immaturity demonstrated on this site. Most of the behavior here is deplorable. I’ve recognized many behaviors seen in the APA DSM. Get some help!”

    Wow I find it amazing you can recognize and diagnosis from just a few statements found in a post. I have never met a physician who felt that that was adequate enough contact to come to a valid conclusion.

  73. Postbaccstudent, working Medic,

    MDs/DOs commit themselves to many years of student loans and hours of residency training.
    They’ve earned the privilege and right to be called “Doctor” of medicine and to practice medicine.
    A charge nurse with 25 years plus experience has valuable experience to offer and teach to future generation of residents, nursing students, health careprofessionals..

    I’m a full time paramedic In a very busy urban 911 system, soon to be post-bacc student with a bachelors in music.

    Now looking back, the Practice of brinigng the EMERGENCY Room ER acute emergency to the bedroom with about a year of training and formal education and the minimum qualifications of a high school equivalent degree is absurd.
    Granted access to the initial start of Patient care privelges for True emergencys from Recognizing STEMI’s, the LAD “widow makers”, Tight asthmatic, Acute Oulmonary Edema, diabetic and seizures, CVA, traumas, gynecology emergency etc.. And the routine alcohol and substance abuse to the common cold, psychiatric illness.

    For the most part the General public and especially indignant population do not know the difference or care as long as they get treated properly with dignity and respect.

    With all the skills and quick thinking clinical practice under a physicians license. A paramedic/EMT Never will all the experience equate to that of a fully educated and trained MD/DO.
    But In most cases the public does not know the difference from an EMT and a paramedic since practice do vary locally and by state.

    Modern times has Policy and Protocols changes, patient needs and situation changes, Hospital practice and working environment dynamics and corporate policy at times seem to work against each objectives and argument to reach the final goal of the medical professions.

    A Lack of solid base foundation in a rounded education promotes inflexibility and will only increase a work ethic and culture of self motivated incentives. Workplace drama and employee situations and territorial turf war over market share.

    Calling a mid-level practitioner a doctor will add much confusion to an already controlled chaotic profession.

    1. DNP

      DNP APN’s are not “mid-level providers” or “physician extenders”. Nursing is a vast and highly specialized area of study. Advance degrees such as CRNAs, Midwifery, CNS, and NP are rigorous programs requiring 7-8 years of study with thousands of hours of clinical rotations. DNP’s carry the same burden of sacrifice and financial debt. DNP’s are already filling primary care roles. The movement to fill care gaps with cost effective providers, within the U.S. is growing everyday. The real argument is physician groups who believe they “own” the term “doctor”. DNP’s and APN have a very long track record of safety. Studies or data to suggest that care outcomes are somehow decreased when care is provided by a DNP do not exist. As always one must base decisions on evidence and not how one “feels” about the evolving transition of healthcare. DNP’s are safe, cheaper, and offer exceptional care. It’s a difficult thing for some as we move towards patient centered care and away from physician centered care

  74. Average Joe

    I am an Average Joe, I don’t have a PhD, I am not a Republican or Democrat, I am an average consumer trying to make sense of this whole Affordable Care Act. I am reading as much info as I can and I am scared for myself and my family. I don’t know who is who-you guys all run around in long white coats and call yourself doctor. I live in Calif where I have now found out that the Lens Crafters optometrist and CVS pharmacist will be soon be allowed to prescribe blood pressure medications and diabetic medications and they call themselves doctor too. This is very confusing. Can you guys wear some kind of ID that lets me know who is a medical doctor and who not. Sometimes I am talking with someone in a long white coat and I think I am talking with a medical doctor and I am not, it’s all very confusing. I don’t understand why the Affordable Care Act means I have to get care from someone who isn’t a medical doctor. I was upset by reading the above disscussion about nurse practioners- that 1/2 failed the physician licensing test or that they don’t have the same amount of hours of training that a physician has or that they can take classes on line. I don’t like knowing the pharmacist are going to be treating some medical conditions or my eye glass doctor will give meds for diabetis. The other idea that is upseting me is reading the nurse practitioner above who said that he/she would not give a 93 year a chemo drug if they needed it. I am not into this die with dignity crap, I plan on going out fighting! That fried my butt to hear that! I am a triathlete and in a short time when I become 93 I hope that nurse practioners use better scientific reasoning than age discrimination to make discisions about health care. If that is the new type of reasoning which is part of the new nurse model thinking I don’t want it! If I find a nurse practitioner, CVS pharmacist or Lens Crafter doctor that denied me care, I will haunt them thru eternity for that deed!

    I don’t understand if there is a doctor shortage why not open up more doctor teaching places? There is a nursing shortage I understand, why can’t our nurses go to school be the great nurses that they are and let the medical doctors be doctors? I think we have great nurses, and if nurses want to go to medical school to become doctors, I am all for it.
    I just find it curious that when we don’t have enough medical care for the baby boomers that we resort to a Scrooge mentality of decreasing the surplus population by having lessor trained people treat the masses. People are going to be hurt by this plan. This is why as a consumer that I am scared.

  75. do physician

    Well said Average Joe. Spread the word far and wide for you and your family’s benefit as well as for every average Joe and Jill out there.

  76. DO with better things to worry about!

    I really cannot believe that a group of well-educated physicians are bickering about what a patient calls a person with an earned doctorate. The doctorate degree entitles that person to be called “Dr” if they so wish. There are no stipulations that come along with your “DO” that say you cannot be referred as “Dr” when you step into a University where the norm is a “PhD” or “Ed.D”. The list can go on and on…

    For the most part, people enter the profession to help others. Nurses are not trying to take over our role as a physician, it is now another option for patients (just like the option of a “DO” came along at one time instead of a “MD”). However, if we as a group do not start caring more for the patient instead of how many of them we can see, the nurses may just take over and we will not have anyone to blame but our self.

    Perhaps if you cared for the patient as deeply as you care about what they call you or your DNP counterpart then we would not even have a need for this conversation.

  77. MD,DO

    With the Rise of the DNP, well, perhaps DOs should change their degree to MD,DO now so that patients will know MD behind someones name means Medical Doctor. DO & DNP confuses patients. DOs : change your archaic degree title to MD,DO now.

  78. a patient

    I’m a patient & I see a DO. She told me that most likely the DO degree will be changed to MD, DO once the old stubborn current DO osteopaths retire from the AOA. Then, the new modern DOs will be in power and wull yhen change the DO degree to MD, DO.

  79. NPStudent

    Dear Skeptical Internist,

    Your hostility is downright appalling and I do not believe that energy is going to further your cause. You are crying a river about how rigorous path is to becoming a physician and you have yet to put yourself in other people’s shoes who have chosen other routes to achieve their profession as well. In my program there is a 30 year veteran to the field of nursing and an Army nurse who served our country in Iraq for a number of years. You forget that all those who are MSN-NPs or DNPs were nurses first and that not an easy career path either. We have years of experience bedside not to mention experience in taking care of your mistakes. While you see patients for 10-15 min each, we were by their side all along.

    You talk about hallucinating after studying, how about doing a double or triple shift with no downtime and have complete accuracy and still hold it together to respond to emergent situations if needed. If your program is too rigorous, you probably should take a semester off because I do not believe that a “hallucinator” could necessarily be considered a safe practitioner…

    Your complaints and insensitivity are so tired. Too bad the idea of a dermatology residency at USF (yes it actually exists already) for APRNS gets you heated because friends of mine have graduated from that program and are great at what they do and are LOVING their jobs. The purpose of an NP residency is to enhance learning in a specific field of choice not to become an “impostor” doctor. You have it so twisted!

    I guess we will have to wait and see what the repercussions of the ACA will have in store for us all. Autonomy for NPs nationwide will inevitably flourish due to the influx of patients so the system will need us even more. For that I am happy because I got into the health care profession to care for the underserved in our communities not to take your job or your “steal” your title. BTW there is no big deal with a DNP nurse wearing “Doctor of Nursing Practice” on their name badge. They earned it and who are you to downgrade that? They are not stating they are MD’s or DO’s and you of all people should understand (being so scholarly) how much pride they have in that accomplishment.

    Now please get back to your studies. You are wasting your valuable time trolling this thread.

  80. USANP

    I work with the best physician and PA in this world and know that I can out doctor many doctors in my community because of the training I have received from my mentors but also know when and where to go for help when I am in over my head, this is something many family DO’s do too late because they think they have to prove they are as good as MDs.

  81. Kurt Brickner D.O.

    Stumbling upon these commentaries regarding Nurse Practitioner status and whatever threat is being perceived by DOs and MDs has prompted me to weigh in from my perspective of 30 years as a hospital/clinic based internist.
    Firstly, so much of this reminds me of what the MDs spewed about our lack of training, inconsistencies, separate unverifiable boards and such in the early 80s. From this perspective, knee jerk hostility feels way to hypocritical to me; the degree of protest from Skeptical Internist, while spirited seems overboard to the point of perceived emasculation. My observations over the years regarding NPs is that the vast majority of them practice within their scope of knowledge, and because of that, naturally, from our perspective “over consult, and “over test”. But if you think about this, that is what a good NP has to do with their training base. What would be scary, and potentially harming to patients is a NP who did not understand their limitations and fail to recognize that a patient was indeed suffering from an illness unclear to the NP. What many physicians might say is that a person with limited training should never be placed in this position of responsibility. But our society has demanded it whether political or economical. So I say our best move as MDs or DOs is to provide collegial accessibility in order to optimize care for our patients.
    I have maintained this approach interacting with PAs and NPs in the community without actually employing one. I have been treated with utmost respect from them, many are now my patients, and they feel thankful and grateful to bounce things off me, send me complex cases before ordering another MRI, or a Nephrology consult for a GFR of 55, or a cardiology consult for a PVC. Yes, mistakes are made. Join the club. Ostracizing is counter productive. I have never seen a PA or NP upset at corrective guidance. I have seen doctors puff their chest out and rebel in the same situation though….
    I frankly don’t care whether or not a patiently mistakenly refers to them as a doctor or not. I know what I am, what my capabilities are, and how I got there. And so do they. Practicing medicine is rewarded individually and personally. Anything beyond that is meaningless. Harboring anger for allied care providers is as someone once said “like taking poison and waiting for the other person to die”. Utilize these providers as a resource, not as an enemy; demanding respect will never result in personal reward.

  82. Kurt Brickner D.O.

    Oh, and USNP (comment above)
    Your comment is sophomoric. Respect goes both ways. I’m so happy that you are able to out-doctor those dastardly quack DOs!

  83. Physician in Training

    I don’t mind the concept of expanding the role of NPs and PAs, but we need to clearly define what the term “doctor” signifies in a clinical scenario.

    A doctor is considered the final authority. Someone that; not only, has an understanding of how diseases manifests in a clinical setting, but also has an ability to explain to the patient the biomedical nature of what’s going on. And if we’re being absolute about what the word “doctor” signifies in westernized medicine, I would also state that the term “doctor” is an individual that can analyze scientific journals and also communicate in medical jargon with research institutes.

    Until a PA or NP can competently perform these tasks, the term “Doctor” is not appropriate. Just saying: I was talking to a first year PA student and they didn’t understand what a PCR was. In my biased and un-professional opinion this is not the kind of person that should be given the title of “doctor”. He or she is not an expert.

    Also, one last note I would like to make:imo studies that argue for the competency of PAs and NPs are worthless. You can take data and skew the results to fit whatever you want your conclusion to be. But let’s pretend that such a thing would NEVER happen ;).

  84. Shea

    Once upon a time the DO was not considered equal with MDs.
    Nursing is evolving and a DNP is well deserving of the title doctor with no explanation needed. I would also like to point out that many foreign doctors have less education than the DNP. Some countries only require 6 years before step 3. Those doctors than come practice in the U.S. Also, to become a DNP you must first be a RN, which takes about 4 years. That plus the time to get NP/DNP is about 8 years.

  85. NP Maloy, ex-MD

    Skeptical Internist seems pretty tightly wound (ad hominem). 50+ years of research shows that despite the differences in education, NP outcomes are the same or better than any physician.

    The constant barrage of opposition to NP’s has nothing to do with patient safety or outcomes. Every argument is “secretly” grounded in the fact that organized medicine wants to hold on to their rapidly shrinking piece of the money pie.

    Physicians’ “medical school” is closely related to a “fraternity” at the undergraduate level. The cronyism is hilarious, and if one doesn’t elect to traverse 4 years of “memorize/regurgitate” and then another 3 of “work for 40k and get treated poorly,” one isn’t a true “doctor.”

    The best part is that patient outcomes are no different. In other words, stop wasting your time.

    I obtained my MD in 1967, and went back to school 8 years ago. I am now a fully certified NP, and proud of it.

  86. NP Maloy, ex-MD

    The DO is still not considered equal to MDs. NP and MD are equal, DO is still considered inferior in many circles.

  87. What?

    @NP Maloy, I don’t know what circles you’re in besides AARP, but based on your argument “NP=MD” would quite certainly mean that DOs are less than NP’s. Maybe you typed it wrong, maybe you meant DO=MD, because I can assure you, no one in this nation, would agree with what you just said.

  88. Surprised101

    i’ve read every single last post on this webpage. The diagnosis is in: “you all are crazy.” case closed.

  89. How soon we forget

    The American Medical Association used to call Osteopathic medicine a cult. So having fought that long, hard battle of being recognized despite having a different perspective and philosophical foundation you just joined their club…

  90. DNP

    DNP’s will fill the gap as primary healthcare providers in the United States. Improving outcomes in clinical practice is a good thing. Increasing access and decreasing disparities by utilizing doctoral prepared Advance Practice Nurses is desirable. Nurse Anesthetists have been the primary sole providers of anesthesia for rural America for over 80 years almost 100% of the time. With the evolvement of the ACA which added millions of customers DNPs are the solution to provide quality, safe, effective care. Evidence to suggest that patient outcomes suffer when cared for by a DNP or APN does not exist. Quite the contrary. The rebuttal is always the same… Physician providers legislate to protect their monetary interest and stifle competition through anti commerce legislation. The momentum of DNP professionals is unstoppable and embedded in American healthcare. Battles for scope of practice rights are being won all across the country. Any argument in opposition should be based in evidence and not scare tactics. I know many NP’s and CRNA’s who work independently who I trust with my family’s care. DNP’s are highly educated, exceptionally skilled care providers. DNP’s do not seek to limit or replace physicians. Never have. It is in the best interest of the public to remove all restrictive barriers towards credentialing of DNP providers.

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  92. J kempton

    If you can prove to me that your attenuated education is equivalent to or better than the 20,000+ hours of training a BC derm gets, then I will cede all arguments.

    The problem is, you’re asking for something you did not earn, and it’s offensive to those of us who sacrificed so much to get where we are.

    An analogy would be a med assistant asking to be referred to as a nurse. She would claim that despite her having far less training, she still does 90% of what a nurse does. She cares for the patient just the same. Would this offend you, as a nurse? Would this cheapen the hard work you had put in to become a nurse? What if it wasn’t just one MA that was making these claims, but a whole group? And what if that group was lobbying to make themselves appear equal to nurses in the clinical setting? Would this offend you? Would this frighten you? It ought to. Would you wonder why they just didn’t go to nursing school if they wanted to have the rights and priviledges that go along with that title?

    And as a final note, I take no issue with DNP derm programs. Just, when you finish, refer to yourself by your earned title, that of DNP. To call yourself doctor, and leave it at that, purposely creates confusion.

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  95. Azalee Mcgeary

    I’m impressed, I must say. Seldom do I come across a blog that’s both equally educative and amusing, and let me tell you, you have hit the nail on the head. The issue is an issue that too few men and women are speaking intelligently about. I’m very happy that I came across this during my search for something regarding this.

  96. Jay

    As someone who has spent a majority of my adult life as a HC Administrator here is what I can tell you.

    Nurses are not Dr.’s. Period. Let’s start with education: The difference between the two is typically over 15,000 hours. And for Dr’s, 5 years of that is residency (Basic PCP) a NP does 1 year. NP’s are trained to continue existing care plans created and monitored by physicians that attended medical school, not evaluate or diagnose.

    NP’s simply do not have the background, education, or experience to evaluate conditions much more complex than a common cold. If NP’s want to be Dr.’s – GO TO MEDICAL SCHOOL!

    Along those lines, a Clinical Psychologist has to undergo double the hours an NP does to obtain a license. And all we do is talk to people. That being said, that doesn’t make us a psychiatrist. We can’t prescribe medication and thank God. You know why? Because we didn’t go to medical school.

    The nursing unions have been drunk with power since their walk out in the 60’s. NP’s have taken this to the extreme and are putting patients lives in jeopardy. They also refer patients to specialists at a much high rate than an MD’s so they certainly aren’t the answer to lowering HC costs.

    On a side note, nursing unions and their insistence on keeping nursing station paperweights on the payroll are one of the reasons I got out of the field. You wouldn’t believe some of the gross negligence that goes on behind the scenes.

    HC and ethics don’t go hand in hand.

    1. Gwen

      Jay, there is a bigger picture. When people quote the statistics for hours, they usually ignore all nursing experience. I have 8 years of nursing experience (4 on a medical floor & 4 in the ICU) that I spent caring for patients. Thousands of patients I should add. I spent the other half of that time in school, getting a second bachelor’s degree in nursing (I completed a Bachelor of Arts degree prior to that) and then a masters degree. To get where I am I’ve spent over 90 hours a week at work or school…for 10 years. Now I’m a nurse practitioner and have been for 2 years. I work in a teaching hospital doing the same job the residents do. Nurses are great at asking about things they aren’t sure about, as all medical professionals should be. I spend 75% of the day working independently and the other part looking up things I need to learn and talking to consultants or my attending physician. I’m being trained much like a physician at this point. I’ve also intubated patients, and placed central lines and chest tubes. In 4-5 years I don’t really see that there will be much of a difference between my training and medical school, and I would be willing to challenge the internal medicine boards at that point to prove it. Not that I will have the opportunity, because people think that it takes a medical degree to rule out an MI or a stroke. It doesn’t. It takes education and experience. I promise you there is more than one path to obtain that experience and education. I might add that I’m also quite good at picking out the patients with colds, and can usually guess the virus. EVERYONE is better at diagnosing the diseases they see routinely. If they weren’t, we wouldn’t need specialists. The goal is better access to care and standards. Saying nurse practitioners are less qualified because they spent time as nurses isn’t helpful (or accurate). At the end all that matters is that I can identify a critical illness and treat or refer appropriately or treat the minor ailment. Which I can do!

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