[NPInfo] DO vs MD and NP clinical training

[Carla Anderson]

I would rather have had a year of internship/residency any day in my training program than more theory.  I would have liked more extensive training in biopsies, laceration repair, and orthopedics ask well as EKG interpretation. I would have liked much more OB training and GYN procedures. I do think additional training in business, writing publications and tracking evidence based practice outcomes would also have been helpful. 

Stephanie Walker <stephanie2u at optonline.net> wrote:  I've been out of school for a long time, though I've talked with new 
grads and also have done some precepting.

My impression is that the NP programs (Master's, DNP, what have you) 
do not have the resources (expert clinicians to teach new NP's 
because the compensation is so poor), or facilities in which to do 
residencies. Most new grads do not seem satisfied with their state of 
readiness.

The people I precepted did not have very challenging requirements. 
They did not have to manage any patients. They weren't around enough 
hours in the week to get much done anyway. One student was obviously 
bored by or afraid of pediatrics (this was a private peds practice) 
and would refuse to even examine a patient. She shadowed me and 
watched me do everything. The faculty member supposedly in charge of 
these students never asked me what the students actually did.

Preceptorships don't force NPs to handle situations as interns while 
mentored by residents, as MD programs do. Of course, I think that 
Medicare is funding a lot of the MD internship and residency programs 
because these folks get paid a salary and the internship programs are 
highly stable. NP's are left out in the cold because we don't get in 
on this funding.

That is why NPs emerge from their training at the bottom of a steep 
learning curve. But I don't see where a DNP program is going to 
address this deficiency.

If it provides the same mediocre clinical training everyone always 
complains of, from the same inexperienced academic people (some of 
the DNP faculty teaching the fluff may even be PhD in nursing with no 
RN), then it is nothing but pie in the sky.

The people outside our profession who harp on the training issue will 
still harp. They want everyone to be MD's. No previous nursing 
doctorate dreamed up by academia has ever even appeared on the radar. 
Why should this one?

Stephanie Walker, FNP


On Dec 2, 2007, at 8:10 AM, Marilyn Dean wrote:

> Hi Lisa,
> I will weigh in. I would have liked to have worked on a cadavar, 
> had more
> procedures, definately more pathophysiology. I would have liked to 
> have had
> a class dedicated to EKG's. Yes, and I think a clinical residency 
> would be a
> good way to increase skills and have NP's up and running. Luckily, 
> the three
> physicians I worked with initially considered my first few years as 
> the
> equivalent of residency and were extremely informative and helpful. I
> practice in an independent state, but participate in a practice with 2
> physicians and another NP. I know I am very lucky to be in this 
> situation.
> Unfortunately I didn't see anything in the DNP program that I 
> looked at that
> I thought would increase my clinical skills.
> Marilyn Dean
> -----Original Message-----
> From: npinfo-bounces at nurse.net [mailto:npinfo-bounces at nurse.net]On
> Behalf Of Lisa Meyer
> Sent: Saturday, December 01, 2007 9:46 PM
> To: NP Info
> Subject: Re: [NPInfo] DO vs MD (was Mary Mundinger)
>
>
> After reading Dena's post, I will agree that the current 2 year NP 
> program
> is NOT long enough to teach everything one needs to know to 
> practice. BUT:
> my program had plenty of theory, role preparation and research. 
> What was
> lacking was enough clinical content. I would love to hear from 
> other people
> what they thought might have been lacking from their programs-- 
> perhaps mine
> was very unusual? Did you have lots of clinical content and 
> practice hours,
> but yearned for more research and role prep? Please weigh in.
>
> Lisa
>
> ----- Original Message -----
> From: "Dena" 
> To: "'NP Info'" 
> Sent: Saturday, December 01, 2007 3:33 PM
> Subject: RE: [NPInfo] DO vs MD (was Mary Mundinger)
>
>
>> Dave--
>> I think you are missing a big point about DNP programs... one of 
>> the main
>> reasons for the DNP degree in the first place was that the 
>> traditional 2
>> yr
>> NP degree programs have been found to not be long enough to 
>> include all
>> one
>> now needs to know in order to practice after graduation. The programs
>> would
>> have to be longer to provide the newest in evidence-based practice 
>> as well
>> as adding on a clinical residency to the already established 
>> curriculum of
>> basic clinical courses, theory, research, role transition, etc. 
>> Add that
>> extra time on to the current two year NP program and you would be 
>> looking
>> at
>> a 3-4 year program-- way more time, credit, and effort than needed 
>> for a
>> MSN
>> degree. So, in keeping up with the amount of time it takes to earn a
>> PharmD,
>> PT doctorate, and 4 years of post-grad Med school, the nursing 
>> faculty
>> group
>> decided to expand the NP program in length and make it a doctoral 
>> degree
>> instead. Why should we put in 3-4 yrs of post-grad education for a 
>> MSN
>> when
>> other professions were coming out with "doctors"???
>>
>> There will be TWO types of DNP programs available. What we are 
>> seeing now
>> is
>> the 2 yr MSN-to-DNP program for the MSN prepared NP who wants to 
>> go back
>> and
>> get the extra degree. Those will be the "experienced NP" with the
>> doctorate
>> degrees. There is no clinical component to those programs because 
>> we have
>> already had that part in our MSN programs and, supposedly, have 
>> developed
>> our clinical skills already in our years of practice. What can 
>> they teach
>> us
>> at this point when it comes to clinical stuff?
>>
>> Then there will be the 4 yr (or whatever) DNP programs that will be
>> post-Bachelors (hopefully BSN but I have little faith in the 
>> integrity of
>> nursing schools ) programs for those who want to BECOME NPs. This
>> program
>> SHOULD include the basic clinical stuff that we currently receive 
>> in our
>> MSN
>> NP programs as well as all the extra non-clinical stuff of the 
>> current
>> post-NP DNP program and, hopefully, allow for a clinical 
>> residency. The 2
>> yr
>> MSN programs for NPs will become obsolete.
>>
>> I agree that it's going to take a whole hell of a lot more than a 
>> piece of
>> paper that says I'm a "doctor" to make the medical community sit up
>> straighter, look me in the eyes, and clasps me to their bosom as 
>> an equal
>> and valued colleague. That is a LONG way from happening-- if ever! I
>> personally never plan to use the title "Dr", the DNP degree will not
>> change
>> my clinical practice at all, I live in the "collaborative" state 
>> of CA so
>> I
>> won't be immediately awarded independent practice (if ever 
>> ), but
>> rumor has it I might make a two-step pay increase at my job in the 
>> VA--
>> although then I'm maxed out with no further increases possible 
>> . So
>> what
>> will I gain?????? As for the words of encouragement "So many 
>> doors will
>> open up to you once you have your DNP" I'd just like to say that, 
>> at my
>> age
>> and this point in my career, that unless those doors open to a 
>> retirement
>> Shangri-La or to a huge secret bank vault with my name on tax-free
>> millions,
>> I just as soon keep the doors shut.
>>
>> Dena Galler
>>
>>
>>
>>
>>
>> -----Original Message-----
>> From: npinfo-bounces at nurse.net [mailto:npinfo-bounces at nurse.net] 
>> On Behalf
>> Of David Mittman
>> Sent: Saturday, December 01, 2007 11:39 AM
>> To: NPinfo
>> Subject: Re: [NPInfo] DO vs MD (was Mary Mundinger)
>>
>>
>> Judy:
>>
>> Just to know you better, what state do you practice in?
>> I have so many thoughts. Being in state and national medical 
>> politics for
>> over 30 years has made me think (a pleasant surprise). This is 
>> long post
>> and
>> I hope it will further the conversation.
>>
>> I believe it will be harder to get independent practice in many 
>> states
>> exactly because that article in Forbes said that the DNP is 
>> equivalent
>> training to physicians. Let me explain why as I think there are a 
>> number
>> of
>> reasons that come to mind. I know a few people in DNP programs and 
>> it is
>> generally not clinical at all. So where are these people getting the
>> equivalent training? No one said anything about outcomes not being 
>> similar
>> (we still need more studies on that, but most people believe it) 
>> it was
>> education being equivalent, remember it's the hours put into the 
>> years of
>> clerkship, internship and residency that some are now saying is 
>> equal.
>> Dos set up the exact same training, same hours, same classes from 
>> the day
>> you make DO school until the day you practice. As you said because 
>> of this
>> the degrees are now interchanable.
>>
>> Why do you think the nurses who go into the DNP programs will be
>> experienced NPs with years of experience? As the months turn into 
>> years,
>> if
>> they succeed to any degree, they will get applicants who want to be
>> doctors
>> right out of BSN programs (just like NP programs now do). Even in 
>> 2008
>> would
>> most graduates use the title doctor when they graduate unless 
>> prohibited
>> by
>> legislation? Your not using the title is personal but I expect 
>> that as
>> time
>> goes on almost all will. One has to accept some confusion and patient
>> misunderstandings and sword rattling from many of the other 
>> professions
>> (but
>> that in itself is OK and the price to pay for change).
>> The larger more ominous question is what's going to happen in NY,
>> California, Florida and North Carolina
>> (which has 35% of all NPs in the nation) when you open up the 
>> practice
>> acts
>> for NP practice to reflect the independent practice DNPs MUST by it's
>> professional definition have? Those 4 states are all collaborative
>> practice
>> states where there would be huge, expensive, drag out
>> fights for this type of revolutionary change. Has anyone consulted 
>> with
>> the
>> state orgs on how they feel this opening and clearly ensuing 
>> legislative
>> battle would effect the "regular" NPs.? Will they want to pay for 
>> these?
>> If
>> not, who will? I fear things could slide backward very quickly. Don't
>> forget
>> NPs have never before said things like they have equivalent 
>> training to
>> physicians. That will make them fight much harder as they have 
>> much more
>> to
>> lose. If org. medicine can show this is untrue, it could backfire. 
>> Don't
>> forget saying things like that are now public record from a pretty 
>> high up
>> nursing leader (and it can't be taken back).
>> We have always said that our training (PAs also) was MUCH more than
>> adequate
>> to do what we were doing and we all have made the argument that 
>> MDs are
>> over
>> trained to provide primary care. Let's not forget people 
>> understood that.
>> Remember the old
>> "you don't have to learn how to be an astronaut to fly a plane". 
>> People
>> understood that. That is why NPs and PAs have flourished, because we
>> proved
>> beyond a shadow of a doubt that US regular pilots had the training 
>> it took
>> to fly the plane.
>> Now it seems nursing is saying that being the astronaut is the 
>> only way to
>> go and, yes, the pilots were inadequately trained. Or else why the 
>> need
>> for
>> the mass exodus to the doctorate? Can anyone show this? If not, is 
>> it just
>> professional ego? Don't forget the docs don't much care about the 
>> PTs,
>> OTs,
>> and PharmDs as they are no threat to their daily practice.
>> Is there any evidence based research that shows DNP grads are
>> significantly
>> better than Masters prepared NPs (or for that matter, certificate 
>> prepared
>> NPs)? Those are serious questions that will be asked by the health 
>> policy
>> makers (especially in legislative circles), when you say your 
>> training is
>> equivalent.
>> Also NPs and PAs were allowed to practice and to be very
>> autonomous/independent because our training was shorter, less 
>> expensive,
>> and
>> most importantly
>> we could get clinicians to specialties and geographic areas of 
>> need that a
>> State region or specialty might have. Legislators heard that and
>> understood
>> it. Employers heard that and understood that. The whole retail 
>> clinic idea
>> is based on NOT NEEDEDING A DOCTOR LEVEL; CLLINICIAN on site. Will
>> doctorate
>> level trained people who are at the "level of a physician" be happy
>> working
>> at CVS? If the doctorate prepares
>> one for policy and research, it will also be much harder to do 
>> those tasks
>> when you are in a town of 1,500. Will there be the same problems 
>> the docs
>> face about few going to inner city and especially rural areas 
>> (again a
>> place
>> we already shine)?
>> I think there also has to be the recognition that NPs (and again 
>> PAs) feel
>> the frustration of having many of the skills that physicians have 
>> but not
>> being recognized as "physicians". Being a DNP won't make you a 
>> physician,
>> so
>> might these frustrations even multiply?
>> I would rather see a full year of 80 hour a week residency (yes, 
>> quit your
>> job and mirror the physician residency) added to a few didactic 
>> classes
>> and
>> one could then be a Doctor and graduate with a clinical doctorate 
>> that
>> might
>> be a step up from the Master's prepared NP and PA and might have a 
>> new
>> name
>> (Health or Medical Practitioner) who goes out and establishes a new
>> professional pathway. The only Dr. PA program from Baylor will 
>> require at
>> least a one year residency solely in Emergency Medicine after ER 
>> practice
>> for a number of years. Was that model considered for the DNP? That 
>> would
>> make more sense and still not deny those who believe that you 
>> don't have
>> to
>> be an astronaut to be a pilot-which I still think is the saving 
>> grace of
>> both professions.
>> Just my thoughts on an obviously very complicated situation. Do 
>> not mean
>> to
>> denigrate anyone or their beliefs and actions.
>> Dave
>>
>> On 12/1/07 12:28 PM, "jabphd83 at aol.com" wrote:
>>
>>>
>>> I introduce myself as Judy Jones, nurse practitioner.? I sign my 
>>> records
>> "Judy
>>> Jones APN,C, PhD."
>>> My cards, which I give to all my patients, state these 
>>> credentials.? I
>> want my
>>> patients to know that they have received excellent care from a 
>>> NURSE.? I
>> want
>>> to leave them with the impression of what a NURSE can do. Like you
>> Stephanie,
>>> I have been working as an NP for a very long time and have lived 
>>> through
>> many
>>> changes in nursing, some good and some not so good. I believe we, 
>>> as a
>>> profession,?have gained momentum and I want to? help move "us" in
>> a?forward
>>> direction toward independent practice.?
>>>
>>> You are so right about $$$ and lobbyists.? That is why we ALL 
>>> need to
>>> join
>> our
>>> professional associations and professional PAC groups and support 
>>> nursing
>>> lobbyists to espouse our credentials and expertise where it 
>>> counts --- to
>>> those determining where health care dollars are spent.
>>>
>>> Thanks for the spirited dialogue.?
>>>
>>> Judy
>>>
>>> -----Original Message-----
>>> From: Stephanie Walker 
>>> To: NP Info 
>>> Sent: Fri, 30 Nov 2007 10:24 pm
>>> Subject: Re: [NPInfo] DNP and R*E*S*P*E*C*T
>>>
>>>
>>> Judy, I don't know what your last name is, but let's say it's 
>>> Jones. Are
>> you
>>> calling yourself Dr. Judy Jones? Are you patients saying their 
>>> primary
>> care
>>> provider is Dr. Jones? (I am looking at your statement "Many 
>>> legislators,
>> TV
>>> commentators, consumers etc?won't go to "just a nurse" for advice 
>>> when
>> they
>>> can go to a DOCTOR. This term connotates authority and 
>>> knowledge.? But if
>> the
>>> Nurse?also had a Doctorate in their chosen field, then maybe the 
>>> public
>> will
>>> begin to believe that both professions have expertise."?
>>> ?
>>> I don't think the answer is to start calling ourselves Dr. That 
>>> seems
>> almost
>>> like carrying out a deception. Nor are we RN nurses. We're nurse
>>> practitioners.?
>>> ?
>>> I've been an NP for 25 years. I find that many more people know 
>>> what an
>>> NP
>> is
>>> today than did even 10 years ago. But--whether the public knows 
>>> about NPs
>> is a
>>> completely separate issue from our practice issues and our 
>>> legislative
>>> issues.?
>>> ?
>>> The public perception is irrelevant when we are talking about 
>>> funding,
>> money,
>>> political power, practice legislation, etc. The public doesn't 
>>> have any
>> role,
>>> or any power, in these areas. If all your patients wrote a letter 
>>> telling
>> your
>>> legislator how wonderful you are, it would not make any difference,
>>> unless
>>> they threatened to not vote for him/her the next election and 
>>> there were
>>> enough of them to change the outcome by so doing. Legislators are 
>>> not
>>> "the
>>> public." They are politicians who are paid off by the AMA and state
>> medical
>>> groups to act in their interests, and willingly do so.?
>>> ?
>>> Stephanie Walker, FNP?
>>> ?
>>> On Nov 30, 2007, at 2:53 PM, jabphd83 at aol.com wrote:?
>>> ?
>>>> ?
>>>> Stephanie, I agree that $$$$? speaks volumnes and the?AMA has 
>>>> lots >
>>>> more
>>>> money than the ANA, yet there are MANY more RNs than MDs in > 
>>>> the US.?
>> MDs
>>>> join their national and state associations and support > them so 
>>>> that
>> they
>>>> can lobby the issues that may come up that could > eat into the MDs
>> pocket,
>>>> such as NP and PA practice.?? RNs need to > learn that they will 
>>>> never
>> get
>>>> far on legislative issues unless we > support our organizations 
>>>> to lobby
>> for
>>>> our needs.?
>>>> ?
>>>> The doctorate in nursing will help?negate the AMA's argument 
>>>> that?> MDs
>> are
>>>> better educated and trained than NPs. We do not need to get > this
>>>> degree
>> to
>>>> impress anyone.? We need a doctoral degree as a > terminal 
>>>> degree to
>>>> help?equal the health care playing field.? Many > legislators, TV
>>>> commentators, consumers etc?won't go to "just a > nurse" for 
>>>> advice when
>> they
>>>> can go to a DOCTOR. This term > connotates authority and 
>>>> knowledge.? But
>> if
>>>> the Nu On 12/1/07 12:45 PM, "jabphd83 at aol.com" 
>>>> wrote:
>>
>>>
>>> Shelby,
>>> Thanks for the history. In my state our professional organization
>> threatened
>>> a "restraint of trade" suit against the administration of a hospital
>> medical
>>> staff. The medical staff board told their members that they would 
>>> not
>> support
>>> their practice in a lawsuit if they utilized NPs hired by the 
>>> hospital to
>> do
>>> admitting H & Ps when pts were admitted and the MD was not coming in
>>> immediately to do the H&P. The medical staff administration 
>>> backed down
>> and
>>> now those MDs that want to use the NPs, do so.
>>>
>>> $$$ and legal action make people take notice.
>>> Judy
>>>
>>>
>>> -----Original Message-----
>>> From: Shelby Havens 
>>> To: NP Info 
>>> Sent: Sat, 1 Dec 2007 7:39 am
>>> Subject: [NPInfo] DO vs MD (was Mary Mundinger)
>>>
>>>
>>>
>>>
>>> tephanie:
>>>
>>> he osteopaths filed a class action lawsuit against the MDs, alleging
>>> anti-trust
>>> r restraint of trade. They won the battle but lost the way, so to 
>>> speak.
>> They
>>> ad to agree to fulfill the same educational requirements as the 
>>> MDs. They
>> have
>>> o complete the exact same residency programs as MDs. So 
>>> essentially, they
>> are
>>> Ds but with different letters after their names (DO). They are MD 
>>> clones.
>>>
>>> est Regards,
>>>
>>> helby Havens, ARNP
>>> Love is an act of endless forgiveness.~ -- Peter Ustinov No trees 
>>> were
>> harmed
>>> n the sending of this message and a very large number of 
>>> electrons were
>> asked
>>> heir permission to be terribly inconvenienced. And a party was 
>>> thrown for
>> them
>>> fterwards for being really cool about it. > Date: Fri, 30 Nov 2007
>> 22:04:27
>>> 0500> From: stephanie2u at optonline.net> Subject: Re: [NPInfo] Mary
>> Mundinger>
>>> o: npinfo at nurse.net> > Can you give a more detailed history of 
>>> what the
>> turf
>>> ar was, and > how it was resolved? Was there really any 
>>> similarity to our
>>> ituation > as nurse practitioners?> > As far as I know, 

=== message truncated ===


Carla R. Anderson, FNP-C
  Healing Presence Family Practice, PC  
  carla_rayne at yahoo.com
  503 819 9726