Rebekah Bernard MD
The United States is facing a looming physician shortage. While efforts to increase physician training programs (including H.R. 2267 and S.1301) slog through the political process, some groups have embraced the idea of fixing the doctor shortage by replacing physicians with nurses.
Nurse-As-Doctor Origins
The nurse-as-doctor agenda made its debut in the Institute of Medicine’s 2011 Future of Nursing report, which called for a radical change to the nursing structure in the United States, including a push towards higher levels of education and a plan to achieve “full” nurse partnership with physicians. Nursing organizations eagerly responded with a goal of doubling the number of nurses with a doctorate degree, or “Doctor of Nursing Practice (DNP),” by 2020.
Nurses’ Aggressive Marketing Campaign
To advance independent nurse practice, the American Association of Nurse Practitioners (AANP) invested in an aggressive multi-media campaign, including a recent onslaught of television commercials promoting nurse practice in states like Pennsylvania, which is currently debating scope of practice laws. Nurses’ associations also spent over 5.3 million dollars on lobbying and donated 2.1 million dollars in 2016 to congressional candidates to promote unsupervised practice.
This public relations campaign and lobbying has reaped benefits for nurse practitioners (NPs). The Veteran’s Administration, for example, recently granted full practice authority to advance practice nurses, allowing veterans to receive medical care from nurses without physician supervision. In addition, twenty-three states and Washington DC allow nurses to practice independently, with ongoing political battles in other states.
Unfortunately, this agenda of increasing nursing scope of practice has led to two very dangerous consequences. First, a decline in bedside nurses, one of the most critical components of our health care system, and second, the growth of diploma mills.
Consequences: Decline in Bedside Nursing and Nurse Educators
The decline in bedside nurses is happening in several ways. First, as nursing programs encourage masters level and doctorate programs, fewer students are entering associate level training, a shorter and less expensive track for becoming a nurse.
Secondly, the rapid expansion of BSN to NP programs is causing critical shortages in essential nursing care, as nurses leave the bedside to practice “advanced” nursing. As nurse Brie Gowan puts it in an article on why nurses are leaving the bedside, “fewer nurses are staying in the trenches” and instead are “pursuing higher education off the bat.”
Finally, we are also seeing a shortage in nurse educators. Doctoral nurses are more likely to enter clinical practice than academia, a far less lucrative career track, which is leading to a decrease in the training of bedside nurses.
Consequence: NP Diploma Mills
The second dangerous trend in promoting nurse practitioner autonomy is the recent tremendous growth of diploma mills, programs that “graduate” minimally trained nurses who are nowhere near ready to care for patients independently.
I’m referring to the dozens of direct to DNP programs, many of which boast a 100% acceptance rate. I’m talking about programs that promote “as little as fifteen months from MSN to DNP,” or “use work hours to apply to your clinical training.” There are multiple accelerated programs that allow students who have never even worked one hour as a nurse to become a nurse practitioner, and also direct entry programs that allow students with a non-nursing bachelor’s degree to become a registered nurse and a nurse practitioner “seamlessly.”
Once in attendance, coursework for these nursing programs may be 100% online. And while a certain number of clinical experience hours are required, they are often on the honor system and often involve simply shadowing a doctor or nurse, many of whom the students have to find themselves. There are simply not enough clinical preceptors to train nurse practitioner students, and the number of preceptors can only be expected to decline as the number of students seeking training increases.
Consequences: Poor Practice Patterns
And unfortunately, this lower quality of clinical experience is beginning to become apparent. While early studies showed that NPs working under physician supervision were able to produce similar outcomes in the management of already diagnosed chronic conditions, these NPs were mostly trained at brick and mortar schools, with a high level of clinical experience in nursing before advancing their career.
Newer studies are demonstrating that removing standardized curriculum and physician supervision from nurse practitioner training and practice is impacting the quality of patient care, including poorer quality referrals to specialists compared to primary care physicians, more unnecessary skin biopsies than physicians, increased diagnostic imaging, increased prescriptions including increased antibiotic prescribing and higher opioid prescribing shown in the states of Connecticut and New Hampshire.
Payouts for malpractice claims against NPs are also on the rise, as are claims for the improper prescribing and management of controlled substances. As training programs continue to churn out NPs at a rate of 23,000 per year, compared to about 19,000 physicians graduating from medical school per year, these trends are likely to continue.
NPs SHOULD Care
If you are a NP reading this, you should be outraged. Your profession is being diluted and abused by your leadership and your teaching institutions. Ultimately, the nurse-as-doctor agenda will backfire as the market becomes saturated with diploma mill grads, and as patients realize that their lives are being sold to the lowest bidder to hospital and organizations who employ new nurse grads ill-prepared to care for them.
Physicians Should Care
If you are a physician, you should be outraged. Your years of work and sacrifice are being alarmingly devalued as you are replaced by an online graduate. There is no online medical school. There is no “honor system” in med school – no one graduates without passing a rigorous evaluation process. There are no shortcuts to the 20,000 hours minimum of clinical experience that physicians receive during training. And yet you will rarely meet a physician with complete confidence, because even with all this training, most realize that there is so much they don’t know.
Politicians Should Care
NPs are Not Filling a Void in Primary Care
If you are a politician, you should be outraged. And worried. Because your constituents will see that you have fallen for the lobbyist lines. NPs lobby that they will enter primary care practice to ease the shortage of physicians, but this has proven to be untrue. CMS data from 2012 showed that NPs are moving more and more into subspecialty practice, where they are practicing independently having received little to no supervised practice in that specialty. Because unlike physicians, who must complete a separate residency of at least three years to change specialty, NPs can jump from one field to another without any additional formal training.
The Rural Access Fallacy
You have also fallen for the hype that NPs will provide care in rural areas, where physicians supposedly “won’t” go. Also, untrue. In Arizona, where NPs have been unsupervised since 2001, only 11% of all non-physicians (NPs, PAs, CNMs) work in rural areas, and serve only 15% of Arizona’s rural population.
The Financial Advantage Fallacy
And if you have believed the line that NPs save money, well, you may not have seen that the goal of the American Association of Nurse Practitioners is pay parity1 – that NPs be paid the same as physicians – a goal which was achieved legislatively in Oregon in 2013. Not to mention that NPs may cost the system more, with a rigorous ten-year study showing that unsupervised CRNA practice in rural areas was more expensive than hiring physician anesthesiologists.
Patients Should Care
If you are a patient, you should be outraged. And scared. But also, hopeful. Because physicians like me really do care about you. I am part of a group called Physicians for Patient Protection (PPP). We recently traveled to Washington DC on our own dime to talk to legislators about our concerns for the future.
For most of us, it’s not about the money. If I wanted to be rich, I wouldn’t have chosen Family Medicine. I wouldn’t have worked in an underserved area for years. And I wouldn’t have opened a low cost Direct Primary Care practice.
It’s also not about a turf war. There are many, many jobs out there for good docs.
It really and truly is about patient safety. We worry about our own health and that of our family. We want the best care for our future too.
What Can You Do?
Join me in this discussion and this fight. Physicians, JOIN US. Patients, ask your “provider” about their training and credentials. Demand a physician or physician-supervised practitioner for your care. It’s not too late.
1. Reference linked may now be hidden behind member-only paywall on AANP site.
Rebekah Bernard MD is the daughter of two Registered Nurses and a Family Physician in Fort Myers, Florida. She is the author of “How to Be a Rock Star Doctor” and a member of Physicians for Patient Protection. She can be reached at RebekahBernard.com.
I am a retired Physician Assistant (PA-C) after 36.5 years in practice with 30 years with the Veterans Administration Hospital. I have long stated that the PA snd especially the NP should have a supervising physician in-house readily available and neither the NP nor the PA should be an independent practitioner. I naturally am biased in favor of the Physician Assistant’s training verses the Nurse Practitioner’s minimal training.
In my years of practice I have noticed the lack of background knowledge of many Nurse Practitioners. Of course I know there are exceptions but the NP nor the PA were ever meant to replace the MD. The originally proposed job of the Physician Assistant (as established by Eugene Anson Stead Jr., MD, at Duke University in 1965) was to supplement the MD and not replace the MD. As for the Nurse Practitioner the very strong American Nursing Association is flooding America with ill-prepared individuals stating “I choose a Nurse Practitioner” on their TV commercials.
I am willing to help your organization in anyway I can. This takeover of our medical practices must be stopped!
Donald Edward Fleener, PA-C, Retired
I’d like to support the need for a collaborating physician for both NPs and PAs. However, in FL there is a 3000 hour requirement prior to FNPs practice independently. This is obviously a far cry from the “20,000” hours a physician is expected to endure. I’d like to understand how you decided NPs have less of an education than a PA? The other value most NPs have is their years of experience as RNs carrying out the orders physicians prescribe and then assessing the patient’s outcomes. Many NPs are very comfortable assessing the patients holistically and not only focusing on one area. This experience I believe is a value PAs do not have.
Because they don’t, PA programs follow the medical model, that focuses on multi-disciplinary medical subjects, both with intensive classroom instruction then completing a series of clinical clerkships to prepare PA’s to practice medicine as licensed medical providers working under the general supervision of a physician. Historically, most PA’s worked in a healthcare role before attending PA programs which are highly competitive for admission and require many (if not most) of the same science prerequisites required to apply for medical school. For example, I was a paramedic for 7 years before applying to my program. Biology, Chemistry, Biochemistry, Physics, Microbiology, as well as all the typical Liberal arts and such. The PA program, Gross human anatomy w/Cadaver dissection (1 sem.), Medical Physiology(1 sem.), Clinical Laboratory medicine (1 sem.), General Clinical Medicine (3 sem.), Psychiatry (1 sem.), Pediatrics (1 sem.), OB/Gyn (1 sem.), Emergency medicine and Surgical care (1 sem.), Pharmacology (2 sem.), Elective (1 sem.) and Preventative medicine (1 sem.). Beyond the didactic education, we completed nine (9) 5-week clinical clerkships in General medicine, Pediatrics, OB/GYN, Psychiatry, Emergency medicine, Surgery, Family Medicine, an Elective 5 weeks (radiology for me), and a final preceptorship (Pediatric ER for me). So at graduation, I had 1800 hours of clinical training before I touch my first patient after training. I’m not knocking NPs. I’ve work with a lot of NPs and have many good friends who are NPs and they do a great job and I would never denigrate anyone for being an NP, but the training of a PA and an NP are not equivalent. That’s doesn’t have anything to do with the job they do (and do well), but the training of an PA is geared towards medical practice (still under supervision), but medical practice none-the-less. NPs practice advanced practice nursing, and while there is some overlap, it’s not precisely the same, and that’s why PA programs are more comprehensive than NP programs, even the DNP programs. Regardless of the titles, physicians remain the leaders in practice, and rightfully no non-physician practitioner (PA or NP), should be granted unrestricted independent without a requirement for physician collaboration.
As a last note, when I submitted my post I barely caught the previous comment that NP assess patient “holistically,” implying that PA specifically and I would assume the commenter would say the same of physicians. This is patently not true. I work in the ED where we are often confronted with an acute presenting the event, but we don’t “miss the forest looking at the tree.” I read this kind of stuff all the time and I’m sure that I am not the only one that would challenge that baseless assertion. That we probably spend less time with the patient than the nursing staff does, that cannot be extrapolated to assert that NPs are more holistic that any other practitioner, especially when we are performing in similar roles.
I too am a retired PA after 42 years of practice. I agree wholeheartedly with Mr. Fleener’s comments regarding the use of NPs in replacing physicians or practicing completely independently. I would think that the NP training mills that have sprung up would aggressively be disapproved of by the ANA, as it significantly harms the credibility of their profession, whether or not they are in supervised practices or independent practices.
Tom Kasbeer
I am currently a masters direct entry/seamless Doctor of Nursing Practice Psych NP student at a top rated Ivy League university. Very much brick and mortar. I also am a former foreign medical student (reached MS4). So I have a little bit more foundation in basic medical sciences and clinical knowledge than most PA or NP students because of this. There are also many foreign physicians that have for whatever life reason become PAs or NPs. Why is this? Why would physicians choose either pathway? I’ve talked to many and its because they can continue to practice medicine one way or the other. Definitely NPs, even though under the guise of the nursing model, are: producing differential diagnoses, ordering and interpreting lab work and diagnostic imaging, using Semiology, using ICD coding and estsbilished algorithms developed by physicians….if that isn’t practicing medicine…then what is it? I do personally believe in stricter guidelines, increased academic rigor, and regulation.
I wanted to say that even though I don’t agree with EVERYTHING you have said, I do agree that NP education should not be coming from online-only programs. This is seriously destroying the reputation of the academics involved in NP education. Please know not all schools are like this. You can’t say Walden, Cappella is the same as Yale, Johns Hopkins, Columbia, Upenn, etc. I do believe online education is the future and many medical schools offer coursework online in a blended format. But certainly not CLINICAL COURSEWORK.
As a person who has gone through both I am uniquely capable of making the following statement:
1) There should absolutely be more clinical hours required in NP programs (minimum of 2,000-3,000).
2) Include some more basic sciences in there, it would go a long way
3) Independent practice (this will not go away, its the new real)should be contingent on:
a) A post-graduate NP “residency”/fellowship. This would serve as a safety-net for new grads. I personally plan on doing one that plans an intensive year long didactic/clinical program alongside Psychiatry residents.
B) A minimum requirement of documented “supervision”/“collaboration” with a physician or group that is at minimum 3-5 years. Who then recommends the clinician to a state board as an eligibility requirement.
C) A licensing examination that is jointly created by NPs and MDs that evidences minimum competency in independent, supervision-free practice.
These conversations are important, but not when their purpose is to denigrate, destroy, or potentially damage a profession that will never go away, is here to stay, and has fought tooth and nail for its rights as hard as that pill is to swallow. But building bridges, removing ego, and coming to the table amicably for the betterment of patient care at-large should be the end-goal…and this is where it all kinda breaks down…it just becomes a crapshoot of name-calling, finger pointing, and of who “has the biggest”…you fill the rest of that out.
Unfortunately, not all of us are able to attend brick and mortar schools and the only opportunity for us to complete a NP degree is from an online school. I attended the University of Delaware for my BA in Psychology and Thomas Jefferson University for my BS in Nursing. Thomas Jefferson University just so happens to be a medical school as well. Online schools do not have professors physically present but they are still available to answer questions students may have. In addition, we are still required to complete mandatory practicum hours at various locations which is only one of the many items allowing the school to be accredited. The experience I had at Thomas Jefferson University was outstanding but I found the online approach to education just as demanding. All of the Ivy League schools you list are great; however, not everyone can afford to attend an Ivy League school or is able to work full-time while attending school. Online schools provide an opportunity for those who are just as qualified as any other NP candidate but may have more obstacles placed on them to attend and graduate from an accredited NP school. The bottom line is I passed the Boards and I am very comfortable with my knowledge and my experience. I also work with some amazing physicians who appreciate the qualities I bring to their team. They look at my performance and not the schools I graduated from.
I am a registered critical care nurse currently in school for a Master’s degree to become an acute adult nurse practitioner.
I essentially spent my first semester teaching myself through YouTube and medical school textbooks borrowed from a friend, to supplement my lacking education.
Never in a million years would I want to practice independently.
Now would I like to be part of a strong team where each discipline’s opinion is heard and respected and included in decision making in patient care?
Foolproof win on that bet.
And do I see why bedside nurses leave the bedside so often and so quickly ? Absolutely.
But diploma mills schools undermine absolutely everything that nurses should stand for at their core: fierce patient protection. Additionally is the failure to gain the respect of other healthcare professionals that by and large are educated at higher levels than nurses across the board.
How can nurses be expected to be full partners when the regulations of our education cut some serious corners, our entry-level programs lack any extensive medical science education, and the people that lobby on our behalf continue to allow these things to happen?
I hate that what is going on is furthering the divide between APRNs and PAs, DOs, and MDs. It only allows the animosity to grow on both sides instead of learning from one another and respecting our individual roles.
I wonder if there are any other APRNs that have formally expressed these concerns. If any did, maybe they were simply shunned by their fellow colleagues instead of trying to understand differing insights.
Great analysis of the issues.
Here is a scary statement: “Data from the American Association of Colleges of Nursing show that 175 of 376 nurse practitioner programs are offered mainly online and 52 are completely online.”
Long time nurse first-time reader. I am going to disagree with you on several points. One nurses are leaving the bedside at an alarming rate due to a multitude of reasons higher education is not the top of that list. Nurses are not staying at the bedside. 33% are leaving less than 2 years into their career. They are moving to management, education, informatics, or just out of nursing. Nurses leave the bedside and or the profession due to workload, emotional toll, physical injury, and work environment. Women can work in another field ie computers make more money with less education, stress, and the burnout that is so prevalent with today’s nursing. There are many careers that women may be accepted in and make more equivalent income to male counterparts in 2020 versus even 2000, with at least half the stress. The balance a hospital makes between profit and care is 99% of the time determined by how much a nurse can work, work for less, and take on one more patient.
In Current Evidence and Controversies: Advanced Practice Providers in Healthcare
August 15, 2019
Erin Sarzynski, MD, MS , Henry Barry, MD, MS “a retrospective study of 30 million patient visits to community health centers found that APPs cared for similar patient populations as physicians and achieved equivalent or better results on quality metrics (eg, smoking cessation, depression treatment, statin therapy) and utilization (eg, physical exams, education/counseling, imaging, medication use, return visits, referrals).” Your information that you refer to is a study is representative of 160 cases of the advanced nurse in 2010 and perhaps stronger evidence for your argument of a care deficit could be found.
The world is changing and medicine must change with it. We must better accommodate the growing number of people who need care at the least amount of financial burden. You have been a doctor for many years. Nursing practice has been expanding to accommodate the decrease in MDs working in hospitals for several years this in some way is a progression of that. The amount of NP working with Medicaid medicare is steadily increasing, the amount of NP working in rural areas and Medicaid Medicare populations increasing at a greater rate than physicians in these areas.
While I agree that NP schools should be careful as to who they include and I think that NP candidates should have a number of years as an RN prior to graduation, I do have concerns with some of the articles you cited. Some were no longer available, some combined both NP and PA, and some looked at NPs in a specialty (I blame the specialists more than the training of the NPs because the specialists should have more oversight in the NP’s practice in a specialty). As an NP in Family Medicine, I value my physician’s input, however I feel that I provide standard care to my patients
In a meeting recently, while introducing ourselves, a nurse rose and proclaimed, “I always wanted to be a doctor, but I could only get into and afford a nursing doctorate program. I’m so happy to be a doctor now.”
I am an NP and found this thread by searching, “NP and DNP saturation.” I’m married to a physician and often have this discussion about his experiences with bedside nurses (I left the bedside years ago). He recently overheard a nurse introduce herself to a patient, “Hi, I’m Dr. XXXXX, how can I help you today?” He wasn’t pleased and let her know it’s misleading (and I agree).
Interestingly, I recall a faculty member (about a decade ago) telling me, “I can’t be a tenure professor with a DNP.” Checking today, I see she’s a full time tenure faculty member with a practice doctorate in nursing.
Standards are changing.
But ultimately…….drum roll…..I think we all know why so many institutions love the DNP. As a nursing PhD program director recently told me, “we make all our money from our online 18 month DNP program. We can’t get rid of it now.”