Nurse practitioner training has changed

[Anonymous]

Anonymous wrote:I really don’t understand physicians assistants and nurse practitioners. Why do they keep coming up with terms? I think most patients don’t know what they mean. Patients know what an RN is and a doctor.

My parent is an OB and midwives have a similar issue. Most patients don’t know what the education of a midwife is an assume it’s more like a doula.

Sounds like a personal problem.

[Anonymous]

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.

[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 am currently an NP with many years of bedside nursing starting in General Medicine, then ICU.

I cannot imagine a better job than being a nurse.

There is something sacred about a profession present at the first breath and the last breath, and through all sorts of challenges in the middle. A nurse is who will teach you how to take your medicines, clean you up when you need it, talk to your family members, cry with you or your family members and sit with someone who is dying. That is why someone goes into nursing. There is no profession like it.

For the entirety of my career, starting in the late 80s, nurses have always moved from Med-Surg to ICU to NP. Back then, there were nurses with minimal to no bedside experience becoming NPs. That was a problem then and continues to be a problem- but on a larger scale now- just due to sheer numbers.

As for the rest of the comments- I guess I am an “old school” NP, with a lot of experience. IMO- you have to be able to walk in a room and tell if someone is sick, immediately. That is a skill cultivated over time. Once you figure out they are sick, you need to figure out why. That takes a lot of time with patients and understanding of normals and abnormals, as mentioned.

As an NP, I know what I don’t know and am quick to ask for assistance and guidance. As a member of the team, caring for a population of patients, it is critical of PAs and NPs to have doctors available to consult. I am lucky, in my current position, to have that.

One thing I would like to mention, is that everyone needs guidance and training, including doctors. In the ICU, in my experience, the nurses are the ones that are going to be the first to notice a change in a critically ill patient. The nurse will tell the doctor. That nurse will anticipate what needs to be done and will be ready to implement what is ordered. It is not rare, that a nurse will guide the intern or resident in a management strategy. A nurse with several years of ICU experience has seen most of these scenarios, many many time. The new intern or resident? Not as much. It is a team, always. Do some doctors not respect nurses? Sure. There is nothing to do with that except continue to take the best care of patients that you can.

In my current role, I do so much that is similar to bedside nursing. Talking to patients about their life, their habits, their stressors, their medicines, their wellness. I am not a doctor, nor do I wish to be one. I truly believe I have the best job out there. I think NPs and PAs have a role to play in the care of patients, to the benefit of a population. I do agree that more time at the bedside is a benefit to all.

[Anonymous]

Anonymous wrote:

Anonymous wrote:https://onlinelibrary.wiley.com/doi/10.1111/1475-6773.13246

https://www.healthaffairs.org/doi/10.1377/hlthaff.2019.00014

A list of studies... https://www.nice.healthcare/the-nicessities/nurse-practitioners-physician-assistants-safety

Most studies to date show better health outcomes / better health management for NP seen patients in primary care vs MD.

This is important info, but two issues here:

1) The individual articles you posted are from 2019 and 2020, and the proliferation of essentially untrained NPs is more recent.

2) The NPs that people are worried about the most are ones practicing in specialties and not primary care.


I am fine with an NP, even in a specialty, but the training needs to be waaaaay better than it is.

I am the one who posted the links and I agree with you. NPs need experience and they need to be properly trained for the role they are doing. This thread had gone down the road of seeing an NP = poor health care, so that was more what I was responding to. The research doesn't support that.

[Anonymous]

Anonymous wrote:https://onlinelibrary.wiley.com/doi/10.1111/1475-6773.13246

https://www.healthaffairs.org/doi/10.1377/hlthaff.2019.00014

A list of studies... https://www.nice.healthcare/the-nicessities/nurse-practitioners-physician-assistants-safety

Most studies to date show better health outcomes / better health management for NP seen patients in primary care vs MD.

Sorry, old data. You need to stay up to date on the research literature.

[Anonymous]

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

[Anonymous]

Anonymous wrote:https://onlinelibrary.wiley.com/doi/10.1111/1475-6773.13246

https://www.healthaffairs.org/doi/10.1377/hlthaff.2019.00014

A list of studies... https://www.nice.healthcare/the-nicessities/nurse-practitioners-physician-assistants-safety

Most studies to date show better health outcomes / better health management for NP seen patients in primary care vs MD.

No, you need to look at the up to date research.

[Anonymous]

When an NP or PA asks a doctor for guidance, it benefits the patient and future patients. Training people takes time and effort. Doctors confer with each other frequently too, and take more time in discussion about th case, in my experience, than with the NP or PA

[Anonymous]

Anonymous wrote:

Anonymous wrote:https://onlinelibrary.wiley.com/doi/10.1111/1475-6773.13246

https://www.healthaffairs.org/doi/10.1377/hlthaff.2019.00014

A list of studies... https://www.nice.healthcare/the-nicessities/nurse-practitioners-physician-assistants-safety

Most studies to date show better health outcomes / better health management for NP seen patients in primary care vs MD.

No, you need to look at the up to date research.

Second comment on this post. Why don’t you add the links?

[Anonymous]

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.

[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

You could make the same comment about teaching or other helping occupations. People don't go into them for $ (I know that is a foreign concept on DCUM where everyone is a lawyer, etc)

I deliberately left a higher earning career for nursing along with assumption of loan bills. Zero regrets, I love working in healthcare even though it's hard. There is definitely job stability as nurses are always needed and in chronic short supply.

[Anonymous]

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!!

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:https://onlinelibrary.wiley.com/doi/10.1111/1475-6773.13246

https://www.healthaffairs.org/doi/10.1377/hlthaff.2019.00014

A list of studies... https://www.nice.healthcare/the-nicessities/nurse-practitioners-physician-assistants-safety

Most studies to date show better health outcomes / better health management for NP seen patients in primary care vs MD.

No, you need to look at the up to date research.

Second comment on this post. Why don’t you add the links?

Sure. Start with https://www.nber.org/papers/w30608 , from the National Bureau of Economic Research (2002, revised in 2024).

Look, there are great NPs. There is a wonderful example just above in this thread who is passionate about her work and is, I suspect, damn good at the job. The problem is that private equity and insurance companies see profit without caring about the actual training. You have many nurses who are incredibly burned out from the last 5 years of hell in this country, and they are trying to find a way to work that they find tenable. Many new nurses are not interested in being the front line for abuse from patients, and (frankly) doctors, and everyone else under the sun.

It's a perfect storm for errors. People don't understand what is really require for a thorough education to do diagnostic clinical work and management. You get away with too little training, until you don't. Then it gets really ugly really fast. That's a problem.

I get that nobody cares what I think. I'm just one anonymous poster on a pretty busy forum, and that's fine. You can disagree with me all you want. I do think it would behoove all of us to watch these outcomes as the story progresses. I'm concerned -- not because of money (I work salaried and can do this as long as I want, no matter to me), but because I care about what happens to patients. We all should.

[Anonymous]

^^Sorry, should be "2022, revised 2024". Widespread look at VA.

[Anonymous]

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.