Nurse practitioner training has changed

[Anonymous]

Anonymous wrote:Just want to raise my hand here as a health policy nut, and not and not a NP who sees these threads come up repeatedly…these are totally being seeded by the medical society (of Virginia?)

I have had both positive and negative interactions with NPs. More negative with ads overall, but admit that is probably due to seeking out MDs. So, it makes sense if I see predominantly MDs the opportunity for poor interactions is higher. I have also
had poor interactions with an NP. but I haven’t written them off altogether.

OP. You are missing the point. I’ve worked with plenty of NPs over my career. Some of them have been great clinicians who are fully competent to do their jobs. But without exception these were the old model of NP - had many years of experience as a nurse first before going back to school in a “real” NP program, not a diploma mill. Also nearly without exception, every patient I have gotten coming from one of the new model of NP training (online, they have to find their own training placements, very minimal clinical experience) has been mismanaged in some way, often dangerously. These diploma mill schools are churning out thousands and thousands of new NPs yearly - it’s not like this is a small niche issue. They will quickly outnumber physicians and the old style NPs.

[Anonymous]

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.

[Anonymous]

Anonymous wrote:

Anonymous wrote:I’m not sure how to add an image here, but you can see a graphic showing the differences in training here: https://www.patientsatrisk.com/differences

I am not sure what medical programs have 6000 clinical hours by year 4. Certainly not the med school affiliated with my university.

I don't think the issue is that being an MD makes you an excellent clinical and being an NP makes you a bad one. We all know terrible primary care doctors and amazing NPs. The issue is when any discipline allows shortcuts and doesn't require sufficient training and experience to do the job well. There should be a minimum hours of clinical work requirement to gain admission to an NP program.

You may be wrong in your estimation.

[NP students] must obtain 500 clinical hours to graduate. That’s less than 5% of the amount required of medical doctors before they can practice medicine ...

https://www.bloomberg.com/news/features/2024-07-24/is-the-nurse-practitioner-job-boom-putting-us-health-care-at-risk?leadSource=reddit_wall

500 is 5% of 10,000.

[Anonymous]

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.

So after the “new-school” NPs will be OK once they have enough experience? A lot of us have been treated by super-new medical residents (MDs) whose inexperience was palpable, so I would only be worried if the NP was also unseasoned.

[Anonymous]

Anonymous wrote:That’s still one year longer than PA school..

It’s my understanding that a certain amount of clinical hours are required prior to even applying to PA school; many have been EMTs, etc. I work in a hospital and the PAs tend to be very good, at least anecdotally.

I did not realize this about NPs; I’ve had very good experiences with them in the past.

[Anonymous]

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.

So after the “new-school” NPs will be OK once they have enough experience? A lot of us have been treated by super-new medical residents (MDs) whose inexperience was palpable, so I would only be worried if the NP was also unseasoned.

The medical school model is built to accommodate for new residents. Interns are supervised by a senior resident who is supervised by a fellow or an attending. There are required conferences. Required exams throughout. Board exams. And frequent check ins to make sure you are on track.

an NP/PA can just graduate and start prescribing. It’s very alarming. I was working with a new Doctor in Nursing. She did have several years as a nurse and just got her PhD and now she can prescribe independently. She admitted she was scared and was nervous to even prescribe an aspirin. Well I would be too! She didn’t have any residency to help her slowly build independence. How is that okay? How would she know when to hold aspirin with some patients and when to start aspirin for secondary prevention without a rigorous training? And all these organizations don’t care about you or your health! Np and pa are cheaper. They finish faster and can prescribe immediately so you’ll see more and more of them.

[Anonymous]

Anonymous wrote:

Anonymous wrote:I am finding it hard to find a PCP who is not a NP.

My longtime PCP is retiring in September. The few MDs nearby are not accepting new patients. If I increase the distance from me to 30-40 miles, I can find one, but who wants to drive that distance each time they have a minor ailment, you know?

My doctor relative said that most are fine with having their care overseen by a NP if they are generally healthy and/or see a specialist regularly for any issues they have.

I am a T1D and see my endocrinologist every 3 months, so my relative said I will be fine having my PCP be a NP. I have my first new patient appointment in a few weeks so I'll see how it goes.

But what happens when issues come up even if you are generally healthy? Our child was completely healthy for 12 years. Well visits only. We took them to their 12 year old well visit with the NP and found out they had low iron. No big deal - we put them on a iron supplement. A couple months and their iron levels weren't rising. Some intermittent nausea started. Went back to the PA this time from the ped group. Again viewed as minor issue. We went home and tried to adjust with diet. Then one night our child woke up shaking and pain on their right side. We went to the ER to check for appendicitis and found stage 4 cancer with a bone lesion. That is what the NP & PA missed for us. I have no idea if an MD would have put together the pieces earlier, but it has changed my view of what is routine. We all now see an MD PCP (an our child is in remission and healthy).

In support of NPs I had an amazing NP midwife. So experienced and knowledgeable. But I think she had a long bedside nursing background and then many years as an NP before I saw her.

Yep anemia is super challenging, there are so many different types. Though the most common is iron deficiency you really need to be aware of how to dissect the lab results. In internal medicine residency we rotate through various specialities including oncology where we learn how important this can be. We are drilled on these various anemias on board exams. an NP does not have any of this training so it’s borderline unfair to expect them to underhand how to interpret these things. This was not the intention of their role.

[Anonymous]

This was such a disturbing article!

Some of my favorite medical professionals have been nurse practitioners, and I used to reassure people that nurse practitioners were great. But I had these experiences a long time ago. What a shame that things have changed so much.

[Anonymous]

Anonymous wrote:

Anonymous wrote:That’s still one year longer than PA school..

It’s my understanding that a certain amount of clinical hours are required prior to even applying to PA school; many have been EMTs, etc. I work in a hospital and the PAs tend to be very good, at least anecdotally.

I did not realize this about NPs; I’ve had very good experiences with them in the past.

Not all PA schools require clinical hours and the ones that do, those can be a very wide range of things that are not going to provide high level learning. Since they aren’t certified to anything related to actually caring for patient, those clinical hours are typically things like being a scribe, medical assistant or CNA (if they get certified). And don’t think EMT training is all that amazing. It isn’t. The vast majority of their time is spent sitting in parking lots or dealing with non emergency BS calls from mobile home parks.

I’d much rather have an NP that worked as an actual bedside nurse for years before going to NP school. WAY better education and well-rounded provider. But since now this isn’t the case with all of them as the OP points out, that does create a dilemma.

[Anonymous]

Also, I think this is a result of so much private equity controlling healthcare. They are squeezing every bit of profit out of healthcare practice, and what incentive do finance bros have to ensure people don't die due to poor healthcare training? A settlement of 75K is absolutely nothing to them, and that's for a wrongful death(!!).

I think we need government legislation on this. I really don't understand how it's okay for an entity solely interested in profits to control healthcare decisions. They should not be able to buy medical practices, even if one morally corrupt doctor rubber stamps their decisions.

[Anonymous]

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

[Anonymous]

The push for career advancement in nursing also seems to lead to the sentiment that it isn't ok for an RN to stay an RN for their career. We still deal with a nursing shortage, but it is made worse, in a way, by the push for career options. It is very rare for a new nurse to stay in med surge for more than a year or two. By the time you train them, they want to move to ICU or a specialty area (and then get their NP degree) and now you're spinning wheels trying to hire and train new med surge RNs.

On the other hand, med surge nursing is also completely brutal and it seems the only way to make it any easier is mandated nursing ratios... Which hospitals hate.

Maybe there should be tuition incentives - work in med surge nursing for 5 years, the hospital will cover some significant x percent of your NP degree

[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

I actually made a mid life career change to be an RN. I used to work in marketing. Zero regrets. I now work in a sort of niche RN position and earn nearly as much as my husband who works in a senior mid tier marketing position.

There is such an ongoing desperate nursing shortage that you can find hospitals that will pay most of your tuition in exchange for a work commitment. I had 65 percent of my tuition covered in exchange for a 3 year work commitment at a local city hospital.

There are young nurses who make bank nowadays through agency and travel work stints...

There are a lot of options once you get an RN degree, especially if you are young and willing to go the agency/travel route.

Unfortunately, this still means we are bleeding med surge RNs. There are older RNs who did med surge for their careers, but as they retire, the retention issue will get horribly worse.

[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

I actually made a mid life career change to be an RN. I used to work in marketing. Zero regrets. I now work in a sort of niche RN position and earn nearly as much as my husband who works in a senior mid tier marketing position.

There is such an ongoing desperate nursing shortage that you can find hospitals that will pay most of your tuition in exchange for a work commitment. I had 65 percent of my tuition covered in exchange for a 3 year work commitment at a local city hospital.

There are young nurses who make bank nowadays through agency and travel work stints...

There are a lot of options once you get an RN degree, especially if you are young and willing to go the agency/travel route.

Unfortunately, this still means we are bleeding med surge RNs. There are older RNs who did med surge for their careers, but as they retire, the retention issue will get horribly worse.

Obviously the nurses working as travel work stints do so because salary as a full time employee is low
By the time you have a family the travel stints become very difficult so you are stuck in full time employment at a hospital where even the doctors do not respect you.

You could give it all up and work as a case worker for the insurance companies, monitor doctors who are going above and beyond in cancer treatments and not standardizing care

[Anonymous]

Anonymous wrote:I also try to not see NPs or PAs. But recent experience example - had to cancel a gyn appointment as I have irregular cycles and it started and is too heavy for exam. I was told I can see next available dr in four months or PA in three weeks. So I have to either delay my mammo and Pap smear four months or see a less trained professional. I have family histories that make a four month delay - assuming it even happens then since I’m irregular - very concerning. I feel forced into seeing a less trained professional.

I feel pretty good about the nurse-midwives I’ve seen for well-woman checkups at my OB GYN. (Less happy about the ones who did my delivery but that’s a different thread…)