I like the emphasis on being a “team” and complimenting each other abilities.

ACP has produced a reasonable and fair comment on NP and PA practice within the healthcare milieu. It is certainly an improvement in that it is no longer completely physician-centric, and acknowledges that non-physician providers have an important role to play.

Same old, same old. I do not see anything progressive here. Practicing independently means practicing within one’s scope of practice, collaborating, referring appropriately, etc. Why the hang up on independence and establishing uniformity within the US for practice? I’ve practiced in 4 states with the same skills but grossly different practice parameters. Does that make sense?

Risa Denenberg ARNP

Hmmm. On one hand, “Today, no one clinician should practice independently of other clinicians.” On the other hand, physicians should still be the captain of the ship, it seems. I do wish they’d stay evidenced-based in their intimations about patient-care quality being harmed by NPs and PAs as PCPs.

Overall, not as bad as previous turf statements. But not as realistic nor unafraid as the editorial on collaborative practice in the recent Female Patient journal, which I thought was quite positive. http://www.femalepatient.com/html/arc/edi/articles/1010.asp

If physicians and/or internists were patient centered, and delivered comprehensive care as they describe there would not be such a void in the healthcare delivery today. While negotiating the healthcare system on behalf of my aging parents, I cannot find one physician speciality to be an advoate for them. They just want to say, “that is not my responsiblity” and turf them off to the next specialty physician. The general feeling we get as a consumer of the health care system of today is that no one cares about my parents, they are not concerned if their needs are being met, and it is up to the family to coordinate thier care. I wish I could find a PCP practice, or internist practice that had an advanced practice nurse that could be the “coordinator of care, and foster collaboration among health care providers” because to date we have yet been able to find a physician that is interested in doing so.

Recommendation #1 is pivitol. They are willing to open the door just enough to let in as many as they (desparately) need. But its good! The journey of a thousand miles begins with a single step…

Sorry, I never proofread my blogs. Above should read, “to let in as many of us (NPs & PA’s) as they (MD’s) need.

Whoever wrote this talked and talked but didn’t really say anything...or anything new or interesting or significant or of any value, etc etc.  The health profession crackes me up with all the rhetoric, regulations, worry over who has a doctorate, but yet continues on more or less the same path.  No I don’t have a solution, except to tell everyone to stop being egotistical, lazy, and/or greedy.  And no, I’m not talkiing about the government, but them too!!

Funny how they go on and on about the MD education and hours of training but have no clue about NPs that have designated clinical hours, rotations, BSN (4 years first) then 3 years full time for Masters.  Our training does advanced education in anatomy, physiology, patho, diagnosis, treatment, medications, primary care and much more.  They need to realize that we do a lot of hours also.

The ACP statement is overall quite reasonable in advocating a team approach with the physician as leader of the team.  After all, physicians do have more training than either Physician Assistants or Nurse Practitioners/Advanced Practice Nurses.  What is more bothersome is the need for the statement at all.  Nurses and PAs accrue significant expertise through both training & practice.  As professionals, we naturally want to expand our practice as our skills & knowlege increase.  The medical training establishment has consistently refused to acknowlege this. Therefore, any midlevel provider who wants to practice medicine independently faces the same 7 or more years of training as any newly minted college grad headed to medical school.

I’m still bugged about the statement that

“The use of the prefix “Dr.” or “Doctor” by nurses who have obtained the DNP degree could lead to confusion and misconceptions by patients.”

I don’t have a doctoral degree (yet...), but if and when I do, I expect to use the title “Dr. Anderson.” That being said, I will always follow that with ..."I’m a Nurse Practitioner” I’m proud of being a nurse.  I like the mode of thinking that I was taught in nursing school, which is fundamentally different from that taught in medical school.  I have no desire to be confused with a physician (even though because I’m male, wear a white coat and carry a stethoscope, I’m called “doctor” on a daily basis).  To me this smacks of petty turf battles - “Yes, you have a doctorate, but you didn’t go through residency, which means you’re not a *real* doctor, so we’re not going to let you use the title, because you might “confuse” the patients.” No.  If I earned a doctorate level degree, I’m a real doctor, just not a *medical* doctor.  My wife has an earned Ph.D in american history.  You never hear anyone tell her she can’t call herself doctor.

Using the title Doctor in a clinical setting identifies oneself as a physician.  If your practice is nursing, calling yourself Dr in such a setting is, however unintentionally, misleading.  If I have a PhD in Engineering, I can call myself Dr at an engineering firm or in academia. Using the title in a hospital would not be appropriate. When you finish your doctorate, please use the title at nursing school, but not on the ward.

The ACP still tries to get their zings in there.  There are subjective BS statements in there, such as “Advanced practice nursing cannot substitute for nor replace primary care medical practice as provided by general internists, family physicians, pediatricians and other physicians.” Yet no clinician should practice independently?  Of course none of us can do all specialties.  We just want the BS laws off the books so we aren’t subject to mandatory laws that says we have to write a bunch of crap down in a binder and keep it on the cob web shelf to practice. 

I’m with DJM225; the article was a bunch of rambling crap that has been regurgitated - although I suppose a bunch of nonsense is better than an all-out assault.

Doctor is not owned by physicians. There are some NPs and PAs that do not agree with that, but as NPkeith says, after that you have to say EXACTLY who you are.
I see all kinds of people who do not identify themselves.
I have a bunch of PA friends who are “doctors” and identify themselves as such and in the same breath say they are PAs. OK.  If PHYSICIANS don’t like it, tough.

I think the ACP statement tone is vastly different. Really comes closer than ever to saying we are all in this together. If you expect them to say, NPs and PAs are great and we want to be their partners, they won’t directly. They went farther than ever before.
Change is incremental.
Dave

I am a AANP National Board Certified Advanced Registered Nurse Practitioner. I’m not proud of this because I have to be, it’s because I earned the right to be. My clinical specialty is Internal Medicine and Cardiology. I was trained by physicians and surgeons. When I’m at the bedside, my skills are expected to be at the same level as the M.D. evaluating and treating the same disease process. In Florida, I will collaborate with my physician of record, but it is understood that’s the extent...collaboration. If I disagree with his recommendation, I can refuse it. However, it’s also understood, I must be willing to accept the SAME level of accountability as the M.D. once I write that order. 
I will be earning my DNP (Doctor of Science in Nursing Practice) within the next couple of years. My title at the bedside will RIGHTFULLY be, “Doctor” ...I will introduce myself as “Dr. A ...Advanced Registered Nurse Practitioner”. It is the PATIENT’S right to refuse services of an NP if they do not feel my skills/credentials will provide the same if not superior results as their physician.  In practice, I’ve had only 1% of patient’s ask me to refer them to a physician for treatment. The other 99% of patients...came from physicians that caused them greater harm or the patient didn’t know they had a choice of medical provider beyond the physician. Note: Most patients have told me if they had known earlier that an NP had similar clinical authority and ability to treat them like the physician, they would have come to me a long time ago. The main reason...our nursing skills in addition to our ADVANCED medical training seem to provide them a sense that we are able to give a more holistic approach to their care. Not to mention, I have a higher compliance ratio compared to many of my physician colleagues. I wonder why

I also train third and fourth year medical students. I tell them to consider three things if they want to shadow me. 1) Leave your ego at the door and bring your training to the bedside, 2) NONE of us are superior to our patients, we only have superior responsibilities. 3) We’ve ALL been invited to the same “party” we just came thru different doors and the PATIENT is our HOST.
It doesn’t matter what your background, M.D, PA, ARNP....if you are not in practice solely for the patient benefit...you have no place in this profession.

I work alone when I’m the only one that cares...I’m a team player, when I know you’re standing next to me for the SAME reason.

Best wishes to all of my colleagues on this site. Wishing you and yours a safe holiday season...that includes your patients

David A., PMC, ARNP, NP-C, CHt, LNC

I still say this whole article is just a bunch of blah blah blah.  Going to work on wall street maybe.

The “doctor” title argument is a joke at least in the outpatient setting.  When you go to the optometrist, chiropractor, or dentist, do you hear them say, “Hi, I’m Optometrist Bob”, or “Good afternoon, I’m Dentist Gary”, etc etc.  No - so when it comes down to it, it really screams turf war as someone mentioned because they’re only bitching about those of us who really do the same thing they do - not someone who isn’t a real threat.

Why would an individual want to introduce her or himself as Dr ---- to a patient unless they were an MD or DO?  Really, what’s the motive?

dfscaggs:  Many want to be recognized for earning a doctorate, like all the others (ie dentist, physician, optometrist, chiro, etc etc).  Many want patients to listen to them and feel that introduction saves them from having to explain for the millionth time what they are and what they did to get there.  Many just want the perceived power. 

I personally want everyone to call me “your majesty”.  (kidding… :o)

It’s a matter of respect.  By telling doctorate-prepared, non-physician providers that they cannot use the title that they earned by hard work, the physician establisment is belittling those providers.  They are effectively saying “Your doctorate is not as good as my doctorate.” I’m sorry, but a doctorate is a terminal degree- you have reached the pinnacle of education *in your field*.  That demands respect.

Ask the PT that saw me recently or the PharmD that I met at a meeting.
Let’s stop the volleying about the “doctor” moniker. It is too late and for too long physicians thought they owned a degree. They do own Doctor of Medicne or Physician. Although in NJ now, optometrists are Optometric Physicians, Chiropractors are chiropractic physicians. And to make matters worse their “assistants” say they are “physicians assistants”. If we want to argue about people calling us something, let’ s drop the assistant and turn to associate. OK, again another post.

Those that earn it can use it, jst like any other degree.
Dave

NP Keith -

What is your doctorate degree?  If you earned the D in Philosophy or D in Nursing Sciences then you have earned every right to be called doctor in the academic setting or any other non clinical setting. When you earned your degree to practice as an NP you reached the pinnacle of your career clinically. The PhD for NP’s as well as PA’s does not change our practice.  We have no more authority or less restrictions on our practice. If you received a D in American Literature yet still practiced as a NP would you still want to be called doctor in your clinic?

Funny home some people have such a hard-on for this doctorate thing.  At any time in history a PA could have gone ahead an gotten a doctorate; maybe not in PA (studies - whatever), but certainly could and some did obtain another degree.  However, the degree was probably is something diverse that made them more marketable, such as education, so they could advance their careers in a deverse way, not ANOTHER PA degree just so they can keeps up with the “competition” (not really competition).  Just ask the PharmD or PT what???  Are you really in competition with those professions?  I don’t plan to mix my own IVABX or put someone in traction!!And my guess is they’re in no hurry to do H & Ps or do rectal exams either!!  Also, who says physicians “owned” the degree??  What degree are you talking about??  They still “own” the doctor of medicine degree, and never did own a doctorate unless they got a phd.  So should we be called physician assistant physicians in NJ?  They were DOCTORS of Chiropractic Medicine and DOCTORS of Optometry before they were called xyz physicians.  They were not DOCTORATES of xyz.  Also, saying “your docorate is not as good as my doctorate” is moot.  A doctorate is a doctor of philosophy, aka Ph.D. (aka piled high and deep).  Different from a Doctor of Medicine.  Syntax makes them confusing to the general public.

Got news for you all folks - whether your called a physician assistant or physician associate or you have doctorate, and you’re now a Dr. PA, you’re still going to be asked what’s a physician (asst or assoc. - you fill it in), and your still going to be looked at as a PA.  Your still going to do what you have been doing, and you’re still going to earn what you have earned.

As long as there’s a grandfather clause most folks won’t give a flying fig anyway.

Npkeith do you really think a patient cares if you have a PhD?  All they care about is that your training & experience is sufficient to treat them.  Patients equate that training, licensure etc. with referring to you as
“doctor “ of medicine.  Few PhD’s refer to themselves as doctor in anyplace but their respective fields where confusion would not cause misunderstanding or potential harm.  It would be easier if we all take pride in what we provide to our patients, and not obsess about what we title we have.  Let the MD’s have their rightful title, they earned it.

I must first respond that you didn’t include the clinical hours that nurses have to have.  I had 5 years at Northeastern University where I spend 2 and half years on coop experiences/internships.  I then spend the next 10 years in high risk labor and delivery and also in management then I went back to school to become a Women’s Health Nurse Practitioner.  I have had quite a bit of clinical experience.  I have always worked full time when I was in college on my coop’s not including our clinical time in school I logged 5200 hours, again not including my scheduled clinical time.

Then the next 10 years I logged 20,800 hours.  For my ARNP clinical practice I had to log 1000 hours of gyn time and 1000 hours of ob time, not including my clinicals. 

I have been in practice for 12 years which gives me 24, 960 hours.  So I am pretty sure I have logged plenty of clinical time to do what i do. 

I do not wish to replace physicians we do work as a team.  There are things that I have expertise that some of my physician collegues talk to me about and ther are things I go to them about.  There is enough people for us to see.  I could care less if I have a doctorate.  I honestly do not think after all my years of clinical experience will add anything else to me professional other than a title.

My patients come to me year after year because of my compassion, my competance and my clinical expertise.  I don’t think they care what initials are after my name.  Lets get out of the alphabet soup and just see patients and take care of them as that is my vocation and is what most of us went into do.

The more pressing things are the fact that insurance premiums are going up, we are paying more as the insured and we are getting paid less as the providers.  This is something we should focus on not who has what degree.

The Doctor of Science in Nursing Practice (DNP) is the clinical equivalent to the M.D. Want to know why? Upon completion of the DNP, the NP now has the authorization to sit for the USMLE Step 3 exam authorized by the USMLE testing authority and administered by the American Board of Comprehensive Care. The Step 3 as most of you know is required to be completed by graduating physician residents in order to become licensed to practice.
If the DNP/NP passes the ABCC Step 3 exam they earn the clinical designation, “Diplomat” of the ABCC. The AMA is having fits about this new authorization for NP’s but they have no enforcement authority over the USMLE testing authority or nursing.  If you don’t believe me that this test exists for DNP/NP’s go to http://www.abcc.dnpcert.org/

In reference to my comment above about the ABCC DNP exam.

“After a careful review of three proposals from test developers, CACC established collaboration with the National Board of Medical Examiners (NBME) to develop the ABCC DNP Examination, which is comparable in content, similar in format and measures the same set of competencies and applies similar performance standards as Step 3 of the United States Medical Licensing Examination (USMLE)
DNP Conference Hilton H”

Interesting discussion!  I think as with all things, money speaks loudest and supply and demand.  SO they HAVE to acknowledge us as there is no other logical answer to the primary care crisis.  And we are very well poised to take on the challenge but the key is to communicate professionally and amicably with our colleagues to effect positive change.  It’s all about the patient and if we all just focus on them, the fighting should stop.  But we all know it won’t!

I agree with Dave Mittman; change is incremental. Like I said earlier, I like the emphasis on being a “team” and complimenting each other abilities. Things are certainly not going to change overnight. Any progress, no matter how small, is a positive thing. I certainly have worked with many physicians who treated me as an equal and a scattered few that chose not to. Maybe I have been fortunate to be be treated as an equal or maybe my nature commands it. It never even occurred to me through life that I wasn’t equal to a man and perhaps this has carried over in to my career. Regardless, fighting about it does not result in a forward progression; only acknowledgment and respect will do so.

Change takes time and is very difficult for many.  The statement gives a step in the right direction.  Sure they haven’t come full circle and still want to be the “charge”, but after thirty years as a nurse...there are definite signs of a more positive mind change.  I also have worked with many physicians that appreciate me as a team member.  Be patient...the full circle will come.
And, as far as being called doctor...if you achieve it, you should be it!  Many of my patients call me doctor, a title which i have not yet earned.  I immediately let them know I am a nurse practitioner.  As a DNP, you should let your patients know it is a doctorate for nursing practice.  This does not mean you are justifying your position, but it gives identity to the role.

To really mess rhis up....say a PA, sits for the DNP part of the test...since we already do the 100hrs every 2 yrs of CME. take a test every 6 yrs, or whatever the NCCPA comes up with, not wothstanding the new subspecilty exmas...and then pass the DNP exam are you then a “DR”? PA should have that right to set for that exam...and I don’t want to hear you are not “trained as well”.....BS…

It’s not that the PA isn’t trained as well. The PA does not qualify to complete the DNP exam. You have to first follow the ranks of Bachelor/Masters/DNP as an RN/ARNP. Very few PA’s have nursing expertise going into their PA programs. An RN can’t even qualify to enter an ARNP program till they have shown a minimum of two to four years CLINICAL WORK experience as an RN.

Most entering students for MD and PA programs aren’t required to have any previous clinical experience, only “preferred”. I’m speaking of most Florida based schools. I know this first hand, because our clinic gets calls from MD and PA applicants wanting to shadow for one month so they can tell the interviewing board they “exposed” themselves to the profession before completing their entrance exams. 

In Florida, an ARNP can own and operate a sole clinical practice with just a collaborative physician “on record”. The M.D. never has to enter the clinic. As a matter of fact, the ARNP can collaborate with a physician living and practicing out of state as long as the MD has an active Florida license.

A PA can not operate their own clinic. What many PA’s will do, is pay an M.D. to have their name on the door and business license, and the PA operates/mans the clinic behind the scenes. 

Most PA schools in Florida are Associate and Bachelor level degrees. Some schools are extending their PA programs to Master’s level. At this time, in Florida, there is NO PA school program at the Doctorate level. The ARNP Master’s programs are being eliminated and qualified nursing applicants will transition from the Bachelor directly to the DNP. I understand this will become a mandatory requirement to graduate as an ARNP by 2015.

If the PA schools in Florida are planning anything similar, nothing has been made public at this time. Perhaps the PA could focus on a PhD in Health Sciences? It still won’t qualify the PA for the DNP graduate exam, but you’ll have the “doctor” title

Can we stick to the ACP Statement? There is too much “Us against them” on this one.
For the record, PAs “supervision” in many states is less restrictive than NP collaboration. PAs can operate their own clinic with the physician never setting foot in it. In NY we do not even have to tell the state who that physician is! Also over 85% of PA programs are now MAsters programs, they have always been extensive and hard with long hours and a full one year internship. Also 75 % of all PAs are women and many come from nursing. There are also postgraduate residencies that are for both NPs and PAs. There are two PA programs that also offer the FNP if you are an RN so they are “both” programs.
Lastly, there are two doctoral granting clinical programs for PAs and when the people graduate they like other professions can be
called “doctor”. Whether they are or not is a personal choice.

I think the ACP Statement was positive and a real step in the right direction between us and physicians.

I agree with Dave!

I’ve worked in rehab units, both PM&R;and Chemical dependency, and the psychologists always introduced themselves as “Dr, Blank, I’m a psychologist.” NEVER A PROBLEM.

We’ll never be “ real “ Doctors , we’ll always ride in the back of the bus and there is no Rosa Parks for us.
There are far to many PAs that see themselves as subservient practitioners as I have learned from posts on this board.
In order to make this work for those people that truly want an “ independent “ practice, minds have to change.
I continue to be an advocate of an integrated medical education system in which there is an entry level requirement for some period of time doing primary care designated as physician. Those that want to continue would go on to become physician and surgeon. Those that would be interested in sub-specialty work could then do a fellowship as is the current practice.
The people currently practicing could be grandfathered in at the physician level.
This would end the “ turf “ wars and answer the primary care shortage issue.
These things can be legislated , for instance DOs in California are licensed as MDs and can advertise themselves as such .

Dave...my reference was according to Florida standards...all you did was continue the argument for NY based operations.
What I care about is not the title, but who shows the competency and ACCOUNTABILITY in caring for the patient at the bedside. Like someone else quoted in a previous post, it is difficult to find PCP’s willing to be patient advocate and provide the comprehensive care needed...especially for the disabled and elderly. ARNP’s come from a nursing base that is patient focused from day one.

If you find “women” who are previously RN’s in a PA program it’s because they either didn’t qualify to become ARNP graduate students, there were no ARNP programs in their area, they’re trying to take a short-cut to their training.

Most female PA students I train in Florida, have no medical background and don’t even know how to complete a proper medical examination coming into their clinical rotations.

I have physicians tell me in confidence they would rather have an RN/ARNP at bedside or in ER over a PA because we have the training and sense to know when a patient is going to crash. Most PA’s are trained to react once the patient has already crashed. This told to me by the medical director of a local Florida ER.

I feel the article posting at this site only serves to patronize those in the industry. In Florida, it is easier to get a job as a PA over ARNP because the physicians are afraid the ARNP will steal their patients. The PA must answer to the physician, so the physician maintains a “psychological control” over the medical practitioner.

I’m not saying any of this is right or wrong. I believe we need a NATIONAL standard as to scope of practice for PA and ARNP. We’re not going away and the public will demand more of us once they know what we’re capable of doing for them.

npcharmer: “Most female PA students I train in Florida, have no medical background and don’t even know how to complete a proper medical examination coming into their clinical rotations.

I have physicians tell me in confidence they would rather have an RN/ARNP at bedside or in ER over a PA because we have the training and sense to know when a patient is going to crash. Most PA’s are trained to react once the patient has already crashed. This told to me by the medical director of a local Florida ER...”

Wow. What a divisive set of comments! Apparently you are an NP who knows more about PAs than they know about themselves. For that matter I’m sure you know more about medical (nursing) practice than just about anyone else does. You also seem to feel you have the capability to see into the future and predict the “crash” before any of the lowly, poorly-trained PAs that you have “taught”. Amazing arrogance. I certainly would not want you working on my team.

DNP can sit for the USMLE?  That’s new to me… Guess I can tell KU never mind on the bridge to MD.  If that is really true, I’ll sign up for the (in my opinion, rediculous) DNP program.  I’ve already went to one and the content was more of the same fluff that the MSN had in it.  But I’ll happily write their stupid papers if it means I get to practice with an MD without any restrictions or collaborative BS requirements and suddenly get a 200% pay raise.  What’s crazy about it is I’ll do exactly the same thing as I do now.  My guess is the “too good to be true” postulate applies here.  But if it’s true, for Gods sake, let PAs do it too.  The training is different for all of us, but after a few years out of school, we all look and act the same.  I think we’d all be better off if nursing went to the BSN, then the “nursing” title was dropped from there and a masters was a masters in family practice and a doctorate was a doctorate in primary care or family practice or whatever.

DNP can sit for the USMLE?  That’s new to me… Guess I can tell KU never mind on the bridge to MD.  If that is really true, I’ll sign up for the (in my opinion, rediculous) DNP program.  I’ve already went to one and the content was more of the same fluff that the MSN had in it.  But I’ll happily write their stupid papers if it means I get to practice with an MD without any restrictions or collaborative BS requirements and suddenly get a 200% pay raise.  What’s crazy about it is I’ll do exactly the same thing as I do now.  My guess is the “too good to be true” postulate applies here.  But if it’s true, for Gods sake, let PAs do it too.  The training is different for all of us, but after a few years out of school, we all look and act the same.  I think we’d all be better off if nursing went to the BSN, then the “nursing” title was dropped from there and a masters was a masters in family practice and a doctorate was a doctorate in primary care or family practice or whatever.

Agree about the Florida comments.
To say that RNs who become PAs (and there are many)
made that choice because they could not get into an NP program or there was not one near them, is truly absurd. Please try to learn more about NPs and PAs-all of us before we say things. They only make the writer look silly.
Also I have never heard that the DNP graduates can take the med boards. Don’t forget the DNP is not a clinical doctorate today as any master’s prepared nurse can go to a DNP program. It is not Doctor of Nurse Practitioner (which in my opinion with great clinical content would be utterly fantastic) but Doctor of Nursing Practice which is open to all nurses.
Anyway, please let’s stay on the ACP statement issues.
We have to learn more about each other’s professions.
Dave

Dave, thanks for trying to keep this post on task. The ACP statement is certainly an improvement over the past approach this organization has had toward advanced practice providers.

We will do ourselves a huge favor by focusing on what we can do with this information rather than quibbling over qualifications and turf.

The debate about titles will work itself out over the next several years as more advanced practice providers achieve a doctorate in their clinical areas. Until then, it is a useless rabbit trail.

Hey SHS: Keep posting. I like your style.
And let’s all keep working together and building a better healthcare system that includes us all functioning as the ACP says to the highest level of our training and competence.
Dave

I agree with Dave, lets just stick to the statement. 
Although, I must say, I am an NP and have worked with many PAs who are excellent clinicians.  I am proud to work side by side with each and everyone of them.  We must all realize that we are part of a team...no one better than the other, just different mindsets towards the same goal.  We assess, diagnose and treat all according to standards.  So, please keep your biases to yourself...it is not a representation of the practitioners I know.
If we must all argue against each other, its no wonder we are in this position.

Anyone who has earned a doctoral level of education has rightfully earned the title “Doctor” and it does not matter whether the degree is in Nursing or English.  I am very much against the title allied health professional to address NPs and PAs.  The health care should let go of the word Physician and adopt the word “providers”.  I have been fighting for this at my work place and the results have been slow due to some very old fashioned internal medicine providers.

The American College of Clinicians who are a think tank of NP and PA leaders had agreed to adopt the term “Advanced Practice Clinician” (APC) to describe PAs and NPs.
Dave

Well Dave the question is: how do you get the AMA, ACP, and most work places to adopt aforementioned term? How can we legislatively make changes to the system?  What can we do to get the credit that NPs and PAs do and not just a pat on the back but also right reimbursements?
Nurses and NPs can do the best work and be the most effective leader of the organization yet it is not reflected in how they are paid.  We have a long way to go and we are only going to achieve by uniting and getting congress behind us.
Thanks for your time.

If you were in the service you know that APC stands for All Purpose Capsule

Thanks Dave,

Like many in our shared professions, I’ve been at this long enough to know that we are much stronger together than apart.

There was a study done through the VA in 2005 by Hooker, Sipher and Sekscenski that was published in the Journal of Clinical Outcomes titled : Patient Satisfaction with Physician Assistant, Nurse Practitioner, and Physician Care: A NAtional Survey of Medicare Beneficiaries.

The Conclusion: “Medicare beneficiaries are generally satisfied with their medical care and do not distinguish preferences based on type of provider. Non-physician clinicians and physicians in primary care seemed to be viewed similarly regardless of patient characteristics.” The patients see and use doctor as a functional rather than an educational title.

As long as we keep the patient the focus of what we do, they really do not care what we call ourselves.
This really is freeing if you think about it. We certainly need to be absolutely the best trained/educated/prepared providers of health care that we can be. But where the rubber meets the road is in the exam room or bedside.

By the way, APCs both in the military and not, we a combo pain pill-OTC Aspirin, Phenecetin, and Caffeine.
I remember them as a kid. They were gone when I got in the AF.

As to how to get people to use APC, use PA and NP first when appropriate and when you hear MIDLEVEL, EXTENDER, NON-PHYSICIAN PROVIDERS step out and correct them and tell them the new term. Check out some of my past blogs on this if they are still up there.
Dave

The push is for Patient Centered Medical Care, and for that to be successful everyone has to play nice in the sandbox. This response is a great start and does a good job representing the strengths an APN brings to the PCMH team, and as an independent provider. To meet the needs of the aging baby boomers, me included, it will take a coordinated effort, teamwork, and respect for what everyone brings to the team. Lisa

I am a PA, in Head & Neck Surgery.  I’ve been in practice with 2 MD’s for about 10 years.  I have the benefit of working with surgeon’s that have attended top 5 ENT residencies, whom could not be more supportive of my position.  I find that people (MD’s, DO’s, ARNP’s and others) can be very critical of my PA-C, when refering patients to our office.  However, I find I am pretty much loved by all when I show up in the ER to address the exsanguinating patient’s nosebleed.
There is great merit in degrees and I am by no means belittling any of them.  However, I firmly believe the job we do and the quality of the care we render comes down to one thing, experience.  Experience you can only gain by doing the job.  As my mentor has put it many times, “it doesn’t matter the letters after your name, what matters is that you know what the @&%^* your doing. You can read about anaplastic thyroid cancer 100 times, but I promise you see one, once and youll never forget it. 
Experience, it’s the reason we don’t allow 1st year residents to do brain surgery without an attending, even if they have a PhD.

KPrater:  Precisely.
There seems to be little comment anywhere about the rather broad variation in experience among PA’s and NP’s preceding their respective educational backgrounds.  My father, grandfather, and great-grandfather were all highly accomplished MD’s.  The townhall in Poseyville, Indiana is not only dedicated to my grandfather (locally “Doc Paul town hall") but bears his likeness donning stethoscope in a metal plaque in the foundation.  I used to carry his large medical bag on scheduled housecalls after church for 4-6 hours mostly to little old ladies who no longer drove (the little old men were largely dead) to check BP’s and blood sugars.  My father was the retired psychiatrist-in-chief of the oldest, largest, and top-five ranked psych hospitals in the country and for the bulk of his career ran the residency program.  At 7 years old I was wheeled out at resident-training parties in our home to do things like recite the basal ganglia (caudate, pteutamin, clausdrum and globus paladus - at that time which was DSM II -these have changed several times since then) to help prove to the various classes/students that “of course they learn do it.  This wasn’t an isolated factoid rote memorized:  I did not cards with my father on long road-trips to maternal side 2x/year for HIS board exams.

I spent a decade working for Pfizer pharmaceutical at increasingly high levels ultimately talking to department chairs at teaching hospitals about new products in infectious disease, cardiology, psychiatry and endocrinology with a knowledge-base that included all competing products and extensive knowledge about the disease processes these meds treated.  The university I attended for PA school had the third-ranked pharmacy program in the country and our class was taught by the pharmD chair of the program.  I routinely corrected erroneous questions on exams citing things like “the correct answer isn’t offered - what you want is...” and to the gross irritation of classmates when I left the exam the professor stated:  “the remainder of the exam appears to be okay… Boren’s done.” Everyone was irritated but I usually gave them 3-4 correct answers to complicated k-question multiple choice in correcting the exams. 

In one of my longer clinical positions I worked directly with a triple-boarded (geriatric, internal medicine and pediatrics) Harvard faculty MD and he routinely referred pharmaceutical, infectious disease, immunology, psychiatric, and endocrinology questions to me.  “Ask Boren, he’s a walking PDR” - that sort of thing.  I’ve also endured four increasingly complex cervical spine surgeries and the latter three were spurred by my insistence on obtaining further w/u - “let’s go old school here and get a myelogram to highlight the areas around the hardware” revealing a posterior screw dinking the R C6 nerve root, the symptoms of which were written off by several MD’s as “arthritis - what do you expect, you’ve had 3 surgeries?” and, for that matter, actually ordering the original MRI due to bilateral radicular symptoms in upper extremities with no trauma in my 30’s.  “No accident? No work injury?  Oh, you’re fine.  Welcome to adulthood… you have a stiff neck.” Wrong. Listen to your patient:  persistent bilateral radicular symptoms.  R/O cord compression you nitwit.  Result of initial MRI:  70% cord compression at C5-6 with stenosis so tight that no CSF was even getting by the lesion.  Or how about the bilateral double hernia surgeries where the surgeon was playing with Marlex when it was new and put way too much in and sewed it down like a patch on jeans - you’re supposed to only tie the “corners” which in this case were triangulated and let it fibrose-in.  “Yer sewn up tighter than a drum.... we could start a baggy factory with you post-mortem.” Result, finally, 2 years, three MD’s and my insistence that something was horribly wrong (post op notes here):  “Entire superior border of the marlex is essentially ripped off the rectus abdominus resulting in overt re-herniation with massive concrete-type adhesions.  Several branches of the ilio-inguinal nerve are entrapped and traumatized to the degree that it was felt it was better to just divide the nerves proximally.” Etc. Etc.

Sound like just bragging?  I know.  But my point is MD’s are just people.  See one, do one, teach one.  I can say with absolutely extraordinary comfort that I would rather see ME as a patient than literally 99% of the MD’s I have ever known.  With dad, grandfather, g. grandfather, 10 years of calling on sometimes 20 MD’s/day, my own bizarre medical history with dozens of providers involved, working in 9 practices over two decades, etc. there are few humans in this country who have known more MD’s. Complexity?  You need an internal medicine doc?  No you don’t.  You need a real clinician with a broad and deep knowledge-base AND experience base.  Period.  And ALL of us need to know most intimately and MOST IMPORTANTLY - get your damn ego out of the way - FREELY ADMIT when you’re out of your league and need specialty referral.

Bottom Line: I’ll take a smart PA or NP with 10 years’ experience who continues to put patient advocacy and education first and foremost and, oh yeah, who insists on actually DOING the H&P;and actually LISTENING to the patient over the vast majority of practicing “MD’s” in a New York nanocsecond.

Dear colleagues...just because you claim not to know about medical board testing for DNP’s doesn’t mean it’s not true...I posted the link to confirm the same for you nay sayers...but apparently you missed it.
Once again...my comments are based on my direct exposure to NP’s and PA’s in Florida. If there are a different set of standards and/or training demands in other states, that is not my concern. I care about those that claim to be trained, stand next to me and have the potential to kill or heal the patient.
Just ask yourself next time you’re at the bedside...which one are you?

This is a very slanted piece - slanted against - not in favor of NPs.  It implies that NPs are without the proper training, that they are unworthy of working in an independent practice.  Much of it is pure balderdash.

NPCharmer - Why not read and learn.  Quit competing.  Most of the many, many physicians I have worked with in three states have stated that when they worked with NP’s they felt like they were working with nurses and when they worked with PA’s with clinical practice they felt more like they were working with MD colleagues.  The reason for that is that all PA programs for 30 years (now there are more) were ALL at schools with medical schools associated and the clinical requirements - course work, text books, and content - were taken from the EXACT coursework for 3rd and 4th (yes, 3rd and 4th, not 2nd and 3rd) years of medical school in the corresponding medical school.  Additionally, we were required to take 19 and 20 semester hours (there were no “part time” programs ANYWHERE - this has changed) very specifically because of the MEDICAL school notion that anyone involved in taking care of patients should be able to handle constant high stress loads.  NP schools typically and historically (much has changed in the past 5 years) had lighter loads more spread out.
Furthemore - and this is quite amusing and obviously reflects your complete lack of knowledge about the PA profession much to your chagrin - the history of the PA profession is that it evolved in the 1960’s when specialization of MD’s began to be widespread and there began to a serious absence of primary care providers esp. in classically underserved areaa which tended to be very rural or very urban and there was a corresponding abundance of military corpsmen who had done an awful lot more than most nurses (don’t fret deary, my mother, grandmother and older sister are all nurses and I have great respect for them) i.e., suturing up severe trauma in the field.  And yet they had no civilian training and could not even function as an MA.  A Duke MD came up with the idea of taking the very best and brightest corpsmen, making sure they had at least a Bachelor’s degree, and putting them into very intense, MD 3rd and 4th years and having them work closely with MD’s for their first 2-3 years.

Now then, sweetie, read this and weep:  the concern of “competition” from the AMA led to the blanket and continuous promise from our profession that we would NEVER try to hang out our own shingles as we were viewed as an extension of primary care to those in need.  That continues to be the mission statement of our profession and continues to be the political position.  Note that many states - incl. Florida when I got out of school - allowed NP’s to hang out their own shingle but NOT to Rx narcotics which PA’s could do.  The reason NP’s weren’t allowed to Rx narcotics was very clearly because of fierce opposition from:  Florida MD’s. 

Read my earlier piece.  Note that it WAS NOT competitive, but rather about what is important:  quality patient care and clinical competence.  Finally, let me add, that my choice for PCP is a CFNP who is very bright, exceptionally patient-oriented, and ethical.  Let me add that my little sister, in whose shoes I followed, spent the first 10 years of practice in CT and then neurosurgery at a clinic associated with Harvard; when I met her doc’s in the neurosurg practice they confirmed what she had told me (and why she didn’t want me coming there for my 4th c-spine surgery):  she has the best hands they had ever seen and had been doing most of the “close work” in the practice for years.  As she very reluctantly stated when I inquired about coming to her:  “I’m the best cutter in the practice and I’m not cutting on you.”

I can tell you one thing for damn sure:  YOU are not the one I’d want standing beside me in any medical scenario.  Do some research outside your own profession if you want to editorialize.  Clearly your NP profession in Florida didn’t instill in you the core values of my profession.  And since you want to compete - really I hate to put it this way but… my daddy is way, way bigger than yours.

Oh yeah, I should have added, my little sister is a PA and has been for twenty years.

Oh yeah, I should have added, my little sister is a PA and has been for twenty years.

Finally, NPCharmless, the NCCPA board questions come directly - randomized computer - from the board exams for MD/DO’s in primary care (and other).  There aren’t “PA” questions nor are the questions chosen as “easier” ones.  Historically from my rather vast exposure to medical providers - including calling on both NP’s and PA’s for a decade, I have found that NP’s sound more like nurses.

Again, read ‘em and weep.  I have chosen an NP to be MY PCP.  My little sister is a better cutter than the four MD neurosurgeons she works with.  She is a PA-C.  My father was the psychiatrist-in-chief and medical director of the Institute of Living in Hartford, CT and was Yale faculty, UConn faculty, Dartmouth associated in his retirement; he was also a senior board examiner for 18 years running at every board exam for the boards in psychiatry and neurology. He was American College of Psychiatry (the only one at a high level institution with 400 associated psychiatrists) and also served as Secrectary of the American Association of Directors of Psychiatric Residency Training Programs.  My grandfather and great-grandfather were highly accomplished MD’s and all went to Washington University School of Medicine in St. Louis. I have lived, breathed and died medicine since I was in utero.  Do you really want to compete here?  Okay, I graduated valedictorian, co-valedictorian, summa cum laude, magna cum laude, Phi Beta Kappa over three degrees in three separate colleges and universities including one ranked in the top 5% of all liberal arts institutions.

Quit competing and start taking care of patients.

Geez, I forgot one thing.  In 1995 the NCCPA board exams were given once per year in October - didn’t matter where you went to school, Yale, Stanford, Duke, you took the exam in October and either passed or failed.  Almost 3000 took the exam on the same date (did you guys do any statistics down there in Florida?  I did a lot working for the largest pharmaceutical company in the world for a decade - this number is statistically significantFYI).  The raw scores ranged from 200-700 with 700 reflecting the 96th percentile and each 20 points on raw score reflected between 3-6% on the percentile ranks.  I scored 720.  Do the math.

Don’t compete sweety - see how it looks and sounds?  Pretty obnoxious, huh?  Sorry, fellow PA’s - I had to do this to make a point.

FYI, in my many clinical practices in family practice, internal medicine, pain management, and urgent care I have worked with many, many PA’s and NP’s (good ones, not-so-good, and poor on both sides with the same experience with MD’s).  We are and should be COLLEAGUES in providing high quality patient care.  End of discussion/competition.

Associates degree for PA’s?  Huh?  We all had at least Bachelor’s degrees to even get in - the course work in semester hours is the same for PA’s as NP’s it’s just that we had to get them (93 semester hours for my program including sitting in the same A&P;class as the doc’s) in two years rather than three.  NP’s got to take it a bit slower.  A fair amount slower.  Most PA programs are now master’s degree programs.  Personally, I have two completely independent degrees - the first in English literature. All-in-all I have 273 undergraduate and graduate semester hours.  That’s more than two 4 year degrees. 

Sorry, we stopped competing, right?  I just read a couple more of charmless-nurse’s posts.

Struggling with fundamental insecurity honey?

“Don’t compete sweety - see how it looks and sounds?  Pretty obnoxious, huh?  Sorry, fellow PA’s - I had to do this to make a point. “

Personally, I think you had to do it that way because you have yet to learn a better way.

Competing with fellow providers is not the way to go.  We must need a common goal and that is patient centered care- a team oriented approach which not only strengthens all of us but also a safe way to practice medicine.  We must abide by decency and professionalism toward each other respect our differences for the sake of our patients.

No, it was because those posts were patronizing and condescending - physics.  NP’s post more obnoxious, competitive-oriented garbage rather consistently.  I’m sick of reading them - this is probably the second post I’ve ever made re: important issues that are hi-jacked by non-physician providers.  The other one had to do with interleukin-6 levels in chronic fatigue and immune dysfunction patients.  90+% of the “mid-level” provider (I really couldn’t care less what the acronym is or whatever ludicrous semantics are going on) posts that are “competitive” are NP’s stating that because they were nurses and took 7 years to do what PA’s did in 6 they are “better” and more competent.  Sorry, I fianlly needed to call BS on this.

NP Sexton-
My comments were made in precisely the same spirit as nurse charmless’ were.  Those comments were quite -t-r-a-n-s-p-a-r-e-n-t-l-y histrionic and competitive and quite clearly in direct contrast to the spirit of Mr. Mittman’s numerous, consistent, professional pieces regarding what is, and I really can’t emphasize this enough, our most important duty:  quality patient care.  When nurse charmless writes:  “ just ask yourself who you’d rather have at your side if it’s kill the patient or help them survive.” Good christ almighty what an insignificant twit he or she must be.  If you don’t see or understand the satire offered - except that my credentials are not only as above but include many, many not even remotely offered up here - in my posting them in such a patronizing, belittling way, then you didn’t read all of nurse charmless’ posts or perhaps you were coming from an NP perspective.  Nurse charmless needs to do a bit more research on the “competing” profession or get a god damn grip on what matters.
Does Florida let NP’s Rx narcotics yet?

Where are you NP charmless:  “the potential to kill or heal the patient...”
What’s the area under the curve of glipizide at 4 hours post-dose in a patient with a creatinine clearance of 2.4?

Kill or heal the patient… come on now nurse charmless, what do you do?

What is the mechanism of resistance of pseudomonoas maltophilia and why is it important?  What is the most common vector?  Why are you an idiot if you think that prescribing a beta-lactamase inhibitor will help you here?

Tell me why pharmaceutical grade co-q-10 (ubiquinonne) is considered an absolute necessity and has been for 15 years when prescribing statins in Japan.  Why don’t we do it here in the US of A?  For that matter, what is the mechanism of action of statins?

Why is it important to know the difference in coagulopathies instigated by broad-spectrum antibiotics i.e., what is the difference between de-riguer suppression of vitamin-k producing probiotics in the gut which occurs with all gram-negative enteric antimicroials (which can be rapidly addressed by 50 mg of vitaimin K -any route) vs. the more significant coagulopathies requiring immediate administration of fresh-frozen plasma?  What are these mechanisms - specifically?

What’s scary here sweetie?  What’s scary is that I’ve always practiced in strictly office milieus… and YOU think you’re a hospital “provider?” Answer one question.  Any of them.  Tonight.  And you even have the internet.

Come on, now, you go girl!!!

Jon , I would be interested in your and your sisters’ ideas for treatment of Spontaneous Spinal CSF leak leading to intractable headache.You can contact me at
PS Don’t worry about that NP she’s obviously young and inexperienced.

Actually, I was only coming from a human perspective, not that of an NP or PA. I’m for working together as a team. I did read all the posting but frankly most of it is Boren.

OK. I am cutting this off. We need to hold comments on this thread. As I have said before, we all need to learn about each other’s professions more than we have. We have managed to stay away from “We P.A.s Are better than you NPs” and “We NPs are better than you. PAs” until this post which I guess brought some new people out of the woodwork.
Please let’s act like the professionals we are. If you can’t, we can deal with that also.
Dave

Thanks Dave for stepping in.  We must act with utmost professionalism to gain the trust and confidence of our patients.  Impressing each other and competing against other health care professionals only frightens the patients and we loose their confidence.  Let’s unite together for a betterment of health care system by teaching, educating and supporting each other.

pkquick - always what I’ve done, and, as stated above before the competitive remarks, so have 4 generations of my family.  Never had a single discussion at any of my offices with NP’s or PA’s about the “competition” among us nor has any pt. of mine ever had even the remotest inkling of my personal state - in pain with c-spine, stressed out from work or homelife.  Not once.
My point here was to get the obviously young, inexperienced, or insecure NP to shut up about his/her credentials and how much more able he/she felt they were “vs” entire categories of providers about whom he/she knows very, very little.  Anyway, simply not the point. 

roblorane - spontaneous CSF leak leading to intractable HA:  confirm etiology i.e., if they lie down and it goes away c/w dx as provided then locate leak, assess etiology, do all protocol w/u i.e., labs and imaging and if small and csf pressures okay watchful waiting, if not patch.  F/U as dictated by w/u vis-a-vis other etiologies.  Again, I’m strictly a medical guy and sis is out of town and not answering cell.

Jon,
Thanks for your message.  Your point well noted.  Good luck with your health and do keep educating new PA’s and NP’s each moment you get.  I truly admire your passion for the profession and your knowledge.  Once again my best regards to you.

Touche PK.  Patient advocacy, education, and care in what has been a hostile environment for some time remains the sole core of what we should be about.  We are all colleagues in this endeavor.  Learn from each other, teach each other, never lose sight of what we do and why we do it - despite whatever milieu and what the bean-counters remind us in so many ways - we are in an honorable profession with - at all times, please - honorable intentions.

Jon: This is closed. I am the guy that decides such things.
If you want to speak to me about it email me.
Dave