Nurse practitioner training has changed

[Anonymous]

Anonymous wrote:One general concept overlooked here...

NPs are really not nurses. They are providers. They are not even housed in the nursing dept in a hospital. They may have worked as a nurse but I do not think of them as nurses whatsoever- and I am a nurse!!

Yeah, you are a nurse. That's why you don't think of them as nurses. I assure you -- they are nurses.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

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Anonymous wrote:

Anonymous wrote:My training was explicit that you had to see tens of thousands of normal to recognize abnormal reliably. Rashes don't often look textbook, and there is so much variation in presentation of the same diagnosis.

Without that large clinical database in your own mind, you can't reliably tell when to worry. Anemia that is not microcytic and hypochromic, or that doesn't respond as expected to treatment (as per PP)? Dig further. On the other hand, you don't order labs or antifungal treatment for pityriasis rosea when you can recognize it, even on the many varieties of skin type.

NPs can be fantastic. Old school NPs with many bedside years under the belt, or NPs who are well-trained in a narrow scope with good oversight (e.g., L&D) are more likely to be fantastic than others.

And you still need to see tens of thousands of normal before you can reliably pick out abnormal.

This is so important. You are going to have trouble hearing a murmur if you haven't heard a lot of hearts without one. Even something simple like distinguishing wheezing from rhonchi requires experience. I had a NP at a Minute Clinic listen to my lungs and tell me I had pneumonia and she gave me antibiotics. That seemed serious so I got in with my pcp the next day who sighed and said "You don't have pneumonia -- so those antibiotics aren't going to do anything and they shouldn't have been prescribed." The NP thought she heard rhonchi and panicked.

Medicine isn’t as simple as normal vs abnormal. Good practioners have to have an advanced understanding of pathology, pathophysiology, and pharmacology. This cannot be done in a 2 yr PA crash course. NPs are slightly better because they get some of this in nursing school, then again in NP school, but still no where near as in depth and complete as the education a MD receives in 4 yrs medical school, plus residency, plus fellowship. Their depth of knowledge is not even comparable and goes way way beyond normal vs abnormal. They are dealing with people with complex issues involving multiple organ systems, on multiple meds, and each situation is slightly unique and individual. There needs to be critical thinking happening and that cannot happen if you don’t have the solid foundation of knowledge

Well, yes, but did you really expect a full medical school training in a single post? That's silly.

Normal vs abnormal is the heart of it. I'd challenge you to propose a medical problem that doesn't rest on that distinction at the core -- and medical school training plus residency plus (hopefully) working in a supportive learning environment for the first few years is what gets you there, minimally.

But it’s not helpful or cost effective to have an NP decide something is abnormal and then turf it to the MD because they aren’t really sure how to manage it. And this is what happens A LOT. They just make more work for the physician instead of less

I think you missed the point of the post. NPs coming through diploma mills are NOT the old school NPs with tones of experience, and they cannot reliably distinguish normal from abnormal. That's why the stories of poor care are mounting.

Furthermore, you cannot just declare medical schools must now have a 10% increase in admissions, or whatever. Those slots need to come with clinical placements with skilled practitioners. Many, many current NP students are not in a structured clinical training, if they even are getting any clinical time -- they are having to go out and find people to "supervise" them, with little to no oversight. If you start expecting medical students to do that, you'll see their trainign tank, too.

No, I didn’t miss the point. Per the OP, the fast tract for an NP, has students that already have a bachelor’s degree in another field able to get complete an NP program in 3 years. I’m not seeing how this is any worse than all the PA programs, which are only 2 years, in addition to various bachelor’s degrees. And don’t bring up “the clinical hours” covered to get into PA school. They are not required at all programs and are BS anyhow. They aren’t significant medical experience.

What are you arguing against, exactly? That PAs and NPs don't have enough clinical training time to practice independently, at least without a long stretch of on the job training?

If that's what you think you are disagreeing with here, it's a figment of your imagination. You are yelling into a void, not arguing with the post that was quoted. You missed it.

Not that PP... Why is length of clinical training/experience questioned more for NPs but as much for PAs?

It’s because NPs are typically women..

The PA programs are almost all women as well.

[Anonymous]

This rapid proliferation of NP and PA schools is driving down wages. At the same time it has been decided that if you see a NP or PA as a consumer you pay the same price? I don't understand how this is possible? Where is the uproar that you get charged the same?

Who is getting this extra money? Is it insurance companies or is it providers who aren't paying NP/PA the same so the owners of the medical practice are getting more money?

I recently broke my ankle. Minor fracture and saw and orthopedist. The practice mandates that follow up care is done by a PA. I never went back because I didn't see the point. I asked if another x-ray was going to be taken and the orthopedist said no. I absolutely would have gone back if I were going to see an orthopedist but I realized the PA had recently finished training.

So again- Who is getting the extra money from patients being charged the same price regardless if a MD or PA/NP is seen?

[Anonymous]

Anonymous wrote:So the shortest NP programs are still a year longer than all PA programs. Yet OP wants to call out NPs specifically as being undertrained. I’m sure it is just a coincidence that NPs tend to be higher percentage female (86%). PAs are predominantly female too (66%), but double the men working as PAs.

PAs aren't working independently. In every US state, they require some level of supervision.

NPs, in contrast, can practice completely independently in 26 states. That means they have no oversight required whatsoever. One year is not enough preparation for that, especially when NP students are going begging for clinical practicums which themselves are mostly unregulated.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:My training was explicit that you had to see tens of thousands of normal to recognize abnormal reliably. Rashes don't often look textbook, and there is so much variation in presentation of the same diagnosis.

Without that large clinical database in your own mind, you can't reliably tell when to worry. Anemia that is not microcytic and hypochromic, or that doesn't respond as expected to treatment (as per PP)? Dig further. On the other hand, you don't order labs or antifungal treatment for pityriasis rosea when you can recognize it, even on the many varieties of skin type.

NPs can be fantastic. Old school NPs with many bedside years under the belt, or NPs who are well-trained in a narrow scope with good oversight (e.g., L&D) are more likely to be fantastic than others.

And you still need to see tens of thousands of normal before you can reliably pick out abnormal.

This is so important. You are going to have trouble hearing a murmur if you haven't heard a lot of hearts without one. Even something simple like distinguishing wheezing from rhonchi requires experience. I had a NP at a Minute Clinic listen to my lungs and tell me I had pneumonia and she gave me antibiotics. That seemed serious so I got in with my pcp the next day who sighed and said "You don't have pneumonia -- so those antibiotics aren't going to do anything and they shouldn't have been prescribed." The NP thought she heard rhonchi and panicked.

Medicine isn’t as simple as normal vs abnormal. Good practioners have to have an advanced understanding of pathology, pathophysiology, and pharmacology. This cannot be done in a 2 yr PA crash course. NPs are slightly better because they get some of this in nursing school, then again in NP school, but still no where near as in depth and complete as the education a MD receives in 4 yrs medical school, plus residency, plus fellowship. Their depth of knowledge is not even comparable and goes way way beyond normal vs abnormal. They are dealing with people with complex issues involving multiple organ systems, on multiple meds, and each situation is slightly unique and individual. There needs to be critical thinking happening and that cannot happen if you don’t have the solid foundation of knowledge

Well, yes, but did you really expect a full medical school training in a single post? That's silly.

Normal vs abnormal is the heart of it. I'd challenge you to propose a medical problem that doesn't rest on that distinction at the core -- and medical school training plus residency plus (hopefully) working in a supportive learning environment for the first few years is what gets you there, minimally.

But it’s not helpful or cost effective to have an NP decide something is abnormal and then turf it to the MD because they aren’t really sure how to manage it. And this is what happens A LOT. They just make more work for the physician instead of less

I think you missed the point of the post. NPs coming through diploma mills are NOT the old school NPs with tones of experience, and they cannot reliably distinguish normal from abnormal. That's why the stories of poor care are mounting.

Furthermore, you cannot just declare medical schools must now have a 10% increase in admissions, or whatever. Those slots need to come with clinical placements with skilled practitioners. Many, many current NP students are not in a structured clinical training, if they even are getting any clinical time -- they are having to go out and find people to "supervise" them, with little to no oversight. If you start expecting medical students to do that, you'll see their trainign tank, too.

No, I didn’t miss the point. Per the OP, the fast tract for an NP, has students that already have a bachelor’s degree in another field able to get complete an NP program in 3 years. I’m not seeing how this is any worse than all the PA programs, which are only 2 years, in addition to various bachelor’s degrees. And don’t bring up “the clinical hours” covered to get into PA school. They are not required at all programs and are BS anyhow. They aren’t significant medical experience.

What are you arguing against, exactly? That PAs and NPs don't have enough clinical training time to practice independently, at least without a long stretch of on the job training?

If that's what you think you are disagreeing with here, it's a figment of your imagination. You are yelling into a void, not arguing with the post that was quoted. You missed it.

You seem to only have a problem with NPs. You are angry that now there are now programs where training is 3 yrs with no prior RN experience. Whereas PA programs have always been no prior medical experience and their program is and has been always only 2 yrs. So what is your problem with NPs exactly?

I'm not angry about anything, other than patients suffering poor care. And that anger is directed at a system, not a person. Sorry.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:My training was explicit that you had to see tens of thousands of normal to recognize abnormal reliably. Rashes don't often look textbook, and there is so much variation in presentation of the same diagnosis.

Without that large clinical database in your own mind, you can't reliably tell when to worry. Anemia that is not microcytic and hypochromic, or that doesn't respond as expected to treatment (as per PP)? Dig further. On the other hand, you don't order labs or antifungal treatment for pityriasis rosea when you can recognize it, even on the many varieties of skin type.

NPs can be fantastic. Old school NPs with many bedside years under the belt, or NPs who are well-trained in a narrow scope with good oversight (e.g., L&D) are more likely to be fantastic than others.

And you still need to see tens of thousands of normal before you can reliably pick out abnormal.

This is so important. You are going to have trouble hearing a murmur if you haven't heard a lot of hearts without one. Even something simple like distinguishing wheezing from rhonchi requires experience. I had a NP at a Minute Clinic listen to my lungs and tell me I had pneumonia and she gave me antibiotics. That seemed serious so I got in with my pcp the next day who sighed and said "You don't have pneumonia -- so those antibiotics aren't going to do anything and they shouldn't have been prescribed." The NP thought she heard rhonchi and panicked.

Medicine isn’t as simple as normal vs abnormal. Good practioners have to have an advanced understanding of pathology, pathophysiology, and pharmacology. This cannot be done in a 2 yr PA crash course. NPs are slightly better because they get some of this in nursing school, then again in NP school, but still no where near as in depth and complete as the education a MD receives in 4 yrs medical school, plus residency, plus fellowship. Their depth of knowledge is not even comparable and goes way way beyond normal vs abnormal. They are dealing with people with complex issues involving multiple organ systems, on multiple meds, and each situation is slightly unique and individual. There needs to be critical thinking happening and that cannot happen if you don’t have the solid foundation of knowledge

Well, yes, but did you really expect a full medical school training in a single post? That's silly.

Normal vs abnormal is the heart of it. I'd challenge you to propose a medical problem that doesn't rest on that distinction at the core -- and medical school training plus residency plus (hopefully) working in a supportive learning environment for the first few years is what gets you there, minimally.

But it’s not helpful or cost effective to have an NP decide something is abnormal and then turf it to the MD because they aren’t really sure how to manage it. And this is what happens A LOT. They just make more work for the physician instead of less

I think you missed the point of the post. NPs coming through diploma mills are NOT the old school NPs with tones of experience, and they cannot reliably distinguish normal from abnormal. That's why the stories of poor care are mounting.

Furthermore, you cannot just declare medical schools must now have a 10% increase in admissions, or whatever. Those slots need to come with clinical placements with skilled practitioners. Many, many current NP students are not in a structured clinical training, if they even are getting any clinical time -- they are having to go out and find people to "supervise" them, with little to no oversight. If you start expecting medical students to do that, you'll see their trainign tank, too.

No, I didn’t miss the point. Per the OP, the fast tract for an NP, has students that already have a bachelor’s degree in another field able to get complete an NP program in 3 years. I’m not seeing how this is any worse than all the PA programs, which are only 2 years, in addition to various bachelor’s degrees. And don’t bring up “the clinical hours” covered to get into PA school. They are not required at all programs and are BS anyhow. They aren’t significant medical experience.

What are you arguing against, exactly? That PAs and NPs don't have enough clinical training time to practice independently, at least without a long stretch of on the job training?

If that's what you think you are disagreeing with here, it's a figment of your imagination. You are yelling into a void, not arguing with the post that was quoted. You missed it.

Not that PP... Why is length of clinical training/experience questioned more for NPs but as much for PAs?

Independent practice without oversight or adequate training. That should scare you, both as a patient and as an NP, if you are one.

[Anonymous]

Anonymous wrote:This rapid proliferation of NP and PA schools is driving down wages. At the same time it has been decided that if you see a NP or PA as a consumer you pay the same price? I don't understand how this is possible? Where is the uproar that you get charged the same?

Who is getting this extra money? Is it insurance companies or is it providers who aren't paying NP/PA the same so the owners of the medical practice are getting more money?

I recently broke my ankle. Minor fracture and saw and orthopedist. The practice mandates that follow up care is done by a PA. I never went back because I didn't see the point. I asked if another x-ray was going to be taken and the orthopedist said no. I absolutely would have gone back if I were going to see an orthopedist but I realized the PA had recently finished training.

So again- Who is getting the extra money from patients being charged the same price regardless if a MD or PA/NP is seen?

Hospital corporations, health management systems, private equity, and other corporate structures, for the most part. About 80% of physicians are employees working for other people. The wealth profits don't go to them -- it rises to the owners and executive suites.

https://www.beckersphysicianleadership.com/independent-practice/nearly-80-of-physicians-are-now-employed-study.html

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:My training was explicit that you had to see tens of thousands of normal to recognize abnormal reliably. Rashes don't often look textbook, and there is so much variation in presentation of the same diagnosis.

Without that large clinical database in your own mind, you can't reliably tell when to worry. Anemia that is not microcytic and hypochromic, or that doesn't respond as expected to treatment (as per PP)? Dig further. On the other hand, you don't order labs or antifungal treatment for pityriasis rosea when you can recognize it, even on the many varieties of skin type.

NPs can be fantastic. Old school NPs with many bedside years under the belt, or NPs who are well-trained in a narrow scope with good oversight (e.g., L&D) are more likely to be fantastic than others.

And you still need to see tens of thousands of normal before you can reliably pick out abnormal.

This is so important. You are going to have trouble hearing a murmur if you haven't heard a lot of hearts without one. Even something simple like distinguishing wheezing from rhonchi requires experience. I had a NP at a Minute Clinic listen to my lungs and tell me I had pneumonia and she gave me antibiotics. That seemed serious so I got in with my pcp the next day who sighed and said "You don't have pneumonia -- so those antibiotics aren't going to do anything and they shouldn't have been prescribed." The NP thought she heard rhonchi and panicked.

Medicine isn’t as simple as normal vs abnormal. Good practioners have to have an advanced understanding of pathology, pathophysiology, and pharmacology. This cannot be done in a 2 yr PA crash course. NPs are slightly better because they get some of this in nursing school, then again in NP school, but still no where near as in depth and complete as the education a MD receives in 4 yrs medical school, plus residency, plus fellowship. Their depth of knowledge is not even comparable and goes way way beyond normal vs abnormal. They are dealing with people with complex issues involving multiple organ systems, on multiple meds, and each situation is slightly unique and individual. There needs to be critical thinking happening and that cannot happen if you don’t have the solid foundation of knowledge

Well, yes, but did you really expect a full medical school training in a single post? That's silly.

Normal vs abnormal is the heart of it. I'd challenge you to propose a medical problem that doesn't rest on that distinction at the core -- and medical school training plus residency plus (hopefully) working in a supportive learning environment for the first few years is what gets you there, minimally.

But it’s not helpful or cost effective to have an NP decide something is abnormal and then turf it to the MD because they aren’t really sure how to manage it. And this is what happens A LOT. They just make more work for the physician instead of less

I think you missed the point of the post. NPs coming through diploma mills are NOT the old school NPs with tones of experience, and they cannot reliably distinguish normal from abnormal. That's why the stories of poor care are mounting.

Furthermore, you cannot just declare medical schools must now have a 10% increase in admissions, or whatever. Those slots need to come with clinical placements with skilled practitioners. Many, many current NP students are not in a structured clinical training, if they even are getting any clinical time -- they are having to go out and find people to "supervise" them, with little to no oversight. If you start expecting medical students to do that, you'll see their trainign tank, too.

No, I didn’t miss the point. Per the OP, the fast tract for an NP, has students that already have a bachelor’s degree in another field able to get complete an NP program in 3 years. I’m not seeing how this is any worse than all the PA programs, which are only 2 years, in addition to various bachelor’s degrees. And don’t bring up “the clinical hours” covered to get into PA school. They are not required at all programs and are BS anyhow. They aren’t significant medical experience.

What are you arguing against, exactly? That PAs and NPs don't have enough clinical training time to practice independently, at least without a long stretch of on the job training?

If that's what you think you are disagreeing with here, it's a figment of your imagination. You are yelling into a void, not arguing with the post that was quoted. You missed it.

Not that PP... Why is length of clinical training/experience questioned more for NPs but as much for PAs?

Independent practice without oversight or adequate training. That should scare you, both as a patient and as an NP, if you are one.

+1

[Anonymous]

Anonymous wrote:This rapid proliferation of NP and PA schools is driving down wages. At the same time it has been decided that if you see a NP or PA as a consumer you pay the same price? I don't understand how this is possible? Where is the uproar that you get charged the same?

Who is getting this extra money? Is it insurance companies or is it providers who aren't paying NP/PA the same so the owners of the medical practice are getting more money?

I recently broke my ankle. Minor fracture and saw and orthopedist. The practice mandates that follow up care is done by a PA. I never went back because I didn't see the point. I asked if another x-ray was going to be taken and the orthopedist said no. I absolutely would have gone back if I were going to see an orthopedist but I realized the PA had recently finished training.

So again- Who is getting the extra money from patients being charged the same price regardless if a MD or PA/NP is seen?

Yes! Keep asking these questions. So the hospital system / PE firm gets the money. NP can charges 80% of what doctors make. They make a lot less than doctors so the amount that the hospital makes of them is huge!! But yes you still pay the same copay.

[Anonymous]

Anonymous wrote:

Anonymous wrote:So the shortest NP programs are still a year longer than all PA programs. Yet OP wants to call out NPs specifically as being undertrained. I’m sure it is just a coincidence that NPs tend to be higher percentage female (86%). PAs are predominantly female too (66%), but double the men working as PAs.

PAs aren't working independently. In every US state, they require some level of supervision.

NPs, in contrast, can practice completely independently in 26 states. That means they have no oversight required whatsoever. One year is not enough preparation for that, especially when NP students are going begging for clinical practicums which themselves are mostly unregulated.

PAs want independence. As a doctor I think they should give it to them mostly to really show what is going on. For many pa and nps, they are only supervised in name only. A health system may pay a doctor in another state to “review” their charts but really they act independent. I think if a system is using them in this way then they need to just be independent fully and we can deal with the consequences of this vs this false security they they are being supervised. One thing I’d love for the lawyers to comment on is liability. Apparently NPs have low liability than doctors because they are held to the standard of their training, meaning since they have less training - they are held to a lower standard even though they are “independent”. If that’s true then even better for the hospital. Make more money on them and lower liability.

[Anonymous]

Anonymous wrote:Why would somebody choose a low paying profession like nursing?
You will always be a low income earner and it will take years to pay back your student loans. Unless you have family money and get a free ride from your parents, that is the worst choice

There are other options

2nd Career Nurse chiming in here - yes, nursing can be a tough road. With a few years experience, many options open up, however, including care navigation (aftercare planning) and work-at-home jobs, including utilization review.

[Anonymous]

Nurses represent a wealth of knowledge and passion for advocacy for their patients. They can navigate many areas of healthcare that people without their training simply cannot do as well, if at all, including care navigation and utilization review, as noted about.

There is nothing "just a nurse" about this. As one of the physicians posting in this thread, I have the highest respect for my nurse colleagues. The training is different for nurses than physicians, especially around the tool of differential diagnosis, but it isn't lesser -- it's a different focus of expertise. I can't do what the nurses I work with do.

Can a nurse go through the additional training to work in the area of diagnosis and management? Sure. I've known a few nurses that went through medical school as well, and I've worked with some very experienced and well-trained NPs. But I don't think the NP training you see now is, for the most part, adequate to bridge that difference safely.

[Anonymous]

^^Sorry, "as noted above"

[Anonymous]

Anonymous wrote:

Anonymous wrote:Why would somebody choose a low paying profession like nursing?
You will always be a low income earner and it will take years to pay back your student loans. Unless you have family money and get a free ride from your parents, that is the worst choice

There are other options

2nd Career Nurse chiming in here - yes, nursing can be a tough road. With a few years experience, many options open up, however, including care navigation (aftercare planning) and work-at-home jobs, including utilization review.

Yes, but these are 80K jobs. They do not pay well at all. I know, I've worked in this field for years. You need a number of years of nursing experience to get the jobs and then they pay $80K, maybe $90K if you are really, really lucky. I was just offered $70K for a full time job doing care management/utilization review in the DC area. I didn't take it because that is insanity.

[Anonymous]

80k is not a good paying job??