Is anyone ready to listen yet?

[cinntsp]

Will DNPs really be able to supervise PAs? I thought we had to have a "supervising physician" not a "supervising doctorate degree holding clinician"? I understand they may hold leadership positions in hospital settings which may impact PA practice, but I don't think they'll ever be in a position the way our SPs are now...

 

Don't underestimate the nursing lobby. That'll end up being the straw that breaks the camel's back.

[chickitabanana]

I can tell you that is already happening. I worked in a local ER where the nurse manager who was a DNP routinely introduced herself as "doctor".

 

It happens in other professions, too. I have friends who graduated from pharmacy school and physical therapy school who say they "became a doctor." I know a PT who ran the Color Run last weekend and wrote "Dr. _____" on the back of her t-shirt along with her co-workers. As someone who has a lot of close friends in medical school/residency it is somewhat infuriating for these people to think they are at the same level and deserve to have the same title. I'm not saying that pharmacy, PT, DNP, etc. schools are not hard, but they cannot come close to what MDs or DOs go through. I'm sorry. How about a DNP can go through four years of medical school, an 8 hour long Step 1 exam, a 9 hour long Step 2 exam, a full day long Step 2CK exam and then 3+ years of an 80 hour work week residency while also taking Step 3 exam somewhere in there, then a board specialty exam, and THEN he/she can call themselves "doctor." Oh and while they're at it -- they can RETAKE boards every 10 years which they currently don't. I've always thought it was strange that NPs never have to re-take boards the way MDs, DOs, and PA-Cs do. I get that they have CME requirements, but it's not the same as proving you're still up to date/competent on the medicine you're practicing, IMO.

 

It's also very misleading for DNPs to introduce themselves as Doctors to patients. When I was a PA-S we were told we had to make sure we introduced ourselves as a student to our patients. Even then I was called "doctor" by some of my patients and I corrected them because it's just not right to pretend to be something you're not. If you're at a university and your professor introduces himself as "Dr. Smith" you know it means he has a PhD because it's clearly not a medical setting. If you're at a hospital/clinic and a PT, PharmD, DNP, etc. comes in and introduce him/herself as "Doctor Smith" you think they're your MD/DO. The average patient doesn't know as much about different healthcare professions as all of us on this forum so he/she assumes everyone in a long white coat is a doctor, right? How many times have PAs here been called "Doctor?" Then, you have these people who are not medical doctors introducing themselves as "doctor" and it's REALLY confusing to them. Even if you say "Hi I'm Dr. Smith, your nurse practitioner" all the patient hears is "doctor" and probably doesn't know what a nurse practitioner is and/or ignores it.

 

http://www.nytimes.com/2011/10/02/health/policy/02docs.html?pagewanted=all&_r=0

 

I don't think we should have to create a DPA program. If we create a 6 year DPA program right out of college then a lot of people will probably just choose to go to medical school. Why you would become a DPA and practice as a mid level when you could spend the same amount of time becoming an MD? It'll eliminate our profession as others have said. I don't understand why the nursing world even felt the need to create DNP. I understand it puts them in a better position to get administrative positions at hospitals, but who was getting them before when they had MSN degrees? People with PhDs in philosophy? No. PA-Cs with Master's degrees? Maybe. Actual Physicians? Probably. Do they think that if they have a doctorate and we only have Master's that they'll beat MPAs at everything? Also, won't they ask for higher salaries to go with their higher credentials? Seems to defeat the purpose of hiring mid-levels to save money instead of hiring physicians that cost more.

[coolbreeze]

I am also a little concerned about what Grinder has discussed here.

 

However, IMHO there is NO WAY a new grad/green PA should have complete autonomy- even if they do a 12 month post grad residency right after school. I truly believe an auto minus provider needs a lot of training and experience before you're there on an island.

 

My proposal would be a min. 3 years as a PA before applying for a 'doctorate residency' of some length which should confer a modified title of some sort and autonomy.

 

 

Pp

 

I agree, no way a new grad should be completely autonomous, but with your suggestion why wouldn't ppl go to med school then? 3 years of PA and then doctorate? meh still finishing up first year, just a thought.

[rcdavis]

(did not add to the dialectic)

[coolbreeze]

You all are posting some really scary stuff :( I'm just finishing up my first year of PA school and feel like my dream job/qol/ and other tiny dreams are going to be crushed soon.....

[Guest JMPA]

You all are posting some really scary stuff :( I'm just finishing up my first year of PA school and feel like my dream job/qol/ and other tiny dreams are going to be crushed soon.....

 

reality sucks, doesn't it?

There is no reason why the AMA should not be open to allowing bridge programs to go from PA to MD. This would show the sillyness of DNP, preserve the PA profession, and create more MDs. I could be created in a way to allow those PAs whom choose to advance further without hindering either profession. Contrary to popular belief the current bridge programs are not bridge programs but rather a new starting point that disregards previous education. How about a bridge exam with required # of years as a pa for pre-requisit?

[True Anomaly]

How about a DNP can go through four years of medical school, an 8 hour long Step 1 exam, a 9 hour long Step 2 exam, a full day long Step 2CK exam and then 3+ years of an 80 hour work week residency while also taking Step 3 exam somewhere in there, then a board specialty exam, and THEN he/she can call themselves "doctor."

 

Just as an aside...they're physicians the second they're handed their medical school diplomas. They have every right to be called "doctor" day 1 of residency.

 

But, I see your underlying point.

[Grinder993]

Okay, well, for starters it's not denial or anger. I rarely get angry about anything. It's a tempered realism. Here's a few questions to foster further debate:

 

1. DSc is NOT a clinical degree. It is a research degree and typically awarded in science domains such as engineering, epidemiology, biostatistics, etc. How does that help the practicing PA? Does being well versed in research methods or stats change how you practice?

 

2. How is this funded? I know that Baylor has one, but that is for the Army and is funded by the federal government. Setting up and getting funding for a residency for PAs is hard enough (I know, we are trying to do one now) how is the educational component funded? The awarding school will expect compensation or reimbursement for this, no? Funding for PA residencies is already tightening up and this would be considered a non-essential requirement, how would it be paid for?

 

3. You haven't addressed how having a non-clinical doctorate changes public perception or changes perception in the "marketing arena"? Does merely having the title confer some magical process by which you instantly have more respect? I can tell you, it does not. It has changed my career path in leadership and research tracks, but clinically? No one cares. It doesn't change the fact that I am a PA, and I am not a physician. Doctor or not.

 

4. You mention increased autonomy. How is that determined? Who determines that? Does it change pay? Does it change supervisory requirements at the state level? Graduation from current residency programs does not change your restrictions regarding autonomy and practice at the state level, how would adding a non-clinical doctorate change that? Would the FSMB suddenly change, and say..."OH, you mean you have a non-clinical doctorate?, well, we'll change the wording for that group of PAs" Would there be a different PANCE for those with the DSc? Would you be eligible to take physician specialty board exams? How would that work?

 

5. How many residencies would there be? Would this apply to every specialty? How is this accredited? Managed? Do you now create the need for DSc PA program directors? Where do they come from?

 

Not to be difficult, but this idea has so many questions, that it is difficult to take seriously......

Thank you for your reply. I am very dismayed by your last sentence. "This idea has so many questions, that it is difficult to take seriously". That is frighteningly self defeatist. You have posed logical questions that need to be answered. Instead of dismissing the problem because it is too hard to solve, start with your own list and let's try to answer them.

1 . DSc is the currently awarded degree from Baylor through the US Army upon completion of an 18 month residency which does entail a research component. This is an appropriate degree to award. Does this change how you practice? Maybe. Depends on what your research reveals. Furthermore. The DNP title does not change the clinical abilities of the NPs. It conveys a level of mastery of their trade that makes the case for autonomous practice. With the autonomy comes 100% reimbursement.

2.How is this funded? Tuition and working stipend. No different than a residency program now where you get a monthly stipend. The hospital gets cheap labor and you get a degree. 3. How does this change public perception? How did it change public perception for the DNP to be granted full autonomy in now 17 states and growing. Titles matter to the politicians that write and support the laws that dictate how and where you can practice. 4. How and who determines autonomy? Let's look at how the ANA did it. They lobbied for it and won. They have state and national level organizations that are backing the advancement of the DNP and supporting autonomy. We have to think outside of the box. But the first step is to have a national organization that supports the true advancement of our profession rather than maintaining the status quo and hoping for the best. 5. there would be as many residencies and the market supports and available in every specialty that the market has a need for. It could be accredited by existing organizations such as NCCPA if they were so inclined. In the end here you see, the best defense is a strong offense. To those of you who think that it is not a good idea because it just pushes people to go to medical school, I respectfully disagree. Med school plus residency is still 8 years. PA school plus DSc-PA residency would be less than 4 years.

[rcdavis]

Thank you for your reply. I am very dismayed by your last sentence. "This idea has so many questions, that it is difficult to take seriously". That is frighteningly self defeatist. You have posed logical questions that need to be answered. Instead of dismissing the problem because it is too hard to solve, start with your own list and let's try to answer them.

1 . DSc is the currently awarded degree from Baylor through the US Army upon completion of an 18 month residency which does entail a research component. This is an appropriate degree to award. Does this change how you practice? Maybe. Depends on what your research reveals. Furthermore. The DNP title does not change the clinical abilities of the NPs. It conveys a level of mastery of their trade that makes the case for autonomous practice. With the autonomy comes 100% reimbursement.

2.How is this funded? Tuition and working stipend. No different than a residency program now where you get a monthly stipend. The hospital gets cheap labor and you get a degree. 3. How does this change public perception? How did it change public perception for the DNP to be granted full autonomy in now 17 states and growing. Titles matter to the politicians that write and support the laws that dictate how and where you can practice. 4. How and who determines autonomy? Let's look at how the ANA did it. They lobbied for it and won. They have state and national level organizations that are backing the advancement of the DNP and supporting autonomy. We have to think outside of the box. But the first step is to have a national organization that supports the true advancement of our profession rather than maintaining the status quo and hoping for the best. 5. there would be as many residencies and the market supports and available in every specialty that the market has a need for. It could be accredited by existing organizations such as NCCPA if they were so inclined. In the end here you see, the best defense is a strong offense. To those of you who think that it is not a good idea because it just pushes people to go to medical school, I respectfully disagree. Med school plus residency is still 8 years. PA school plus DSc-PA residency would be less than 4 years.

 

grinder,

you sure are coming back in true form...

[Grinder993]

grinder,

you sure are coming back in true form...

 

Is that good or bad? :) LOL

[Deanj59]

Also, won't they ask for higher salaries to go with their higher credentials? Seems to defeat the purpose of hiring mid-levels to save money instead of hiring physicians that cost more.

 

Exactly. IMHO I would think at the end of the day money would be the ultimate motivator here. If the DNP expects close to a MD/DO salary then they lose their bargaining power. Isn't the draw that they able to act as "physician extenders" and see the increasing demand of mid-to-low acuity patients at a lower cost for the SP and or the hospital? What incentive is there then to hire a DNP that isn't already in place for the NP? NPs already practice with autonomy in many states. The prestige of a doctorate level education is nice, but I think the impact might be a bit exaggerated. Because the higher the minimum educational requirements, the higher the expected salary by the degree holder.

 

I would think the more concerning aspect would be the increasing impact of DNP or NP in administration and their impact to an organization. Their potential to limit PA scope of practice and or the hiring of PAs would be of more cause for concern for me personally.

[rcdavis]

good.. glad to see you back with a definite point of view, debating in good form, with points given and taken.

[physasst]

Thank you for your reply. I am very dismayed by your last sentence. "This idea has so many questions, that it is difficult to take seriously". That is frighteningly self defeatist. You have posed logical questions that need to be answered. Instead of dismissing the problem because it is too hard to solve, start with your own list and let's try to answer them.

1 . DSc is the currently awarded degree from Baylor through the US Army upon completion of an 18 month residency which does entail a research component. This is an appropriate degree to award. Does this change how you practice? Maybe. Depends on what your research reveals. Furthermore. The DNP title does not change the clinical abilities of the NPs. It conveys a level of mastery of their trade that makes the case for autonomous practice. With the autonomy comes 100% reimbursement.

2.How is this funded? Tuition and working stipend. No different than a residency program now where you get a monthly stipend. The hospital gets cheap labor and you get a degree. 3. How does this change public perception? How did it change public perception for the DNP to be granted full autonomy in now 17 states and growing. Titles matter to the politicians that write and support the laws that dictate how and where you can practice. 4. How and who determines autonomy? Let's look at how the ANA did it. They lobbied for it and won. They have state and national level organizations that are backing the advancement of the DNP and supporting autonomy. We have to think outside of the box. But the first step is to have a national organization that supports the true advancement of our profession rather than maintaining the status quo and hoping for the best. 5. there would be as many residencies and the market supports and available in every specialty that the market has a need for. It could be accredited by existing organizations such as NCCPA if they were so inclined. In the end here you see, the best defense is a strong offense. To those of you who think that it is not a good idea because it just pushes people to go to medical school, I respectfully disagree. Med school plus residency is still 8 years. PA school plus DSc-PA residency would be less than 4 years.

 

 

Back to number 2, a residency cannot confer a degree, only an accredited university can. How can that be paid for? I promise you that Baylor is getting money for the academic degree portion of the residency from the government. PA residencies do not typically receive money from ACGME. The degree is not free. No University in this country would even consider that. Also, the DSc is a research degree. You could just as easily say.....a PhD for all PAs who complete a residency.....I'm willing to bet that most PAs won't do that unless it dramatically changes their practice.

 

Agreed that the DNP did not change NP practice. It was never meant to. It was a political move. I would argue that they would have gotten autonomy in those states without the degree. Let's also be clear. Titles DO NOT matter one bit to politicians. Nursing is getting their way because they have over 3 million votes. The degree is not what is changing their political power. Only two things matter to politicians....money and votes. Anything else falls way down the list.

 

You have to remember, this is YOUR issue, this is your idea of advancement. It's rather egocentric to concede that this is the way the entire profession should feel. Many PAs do not agree with you. In fact, while a plurality polled supported a name change, the majority either did not, or were undecided. If you cannot get a majority of PAs to INSTANTLY agree with a name change, do you honestly think that they will clamor for this?

 

It still comes down to money (it always comes down to money). If you can find a way to fund the residency, which also includes an administrator, protected time for the director, as well as money for accreditation, etc. (which isn't cheap), then you still have to find money to pay for the DSc. Likely 50K plus per student.

[EMEDPA]

want to avoid being supervised by a DNP? refuse any job ion which that is a requirement.

docs(real docs) won't allow it and docs run emergency depts.

we are the preferred em non-physician provider and everyone knows it.

[rcdavis]

want to avoid being supervised by a DNP? refuse any job ion which that is a requirement.

docs(real docs) won't allow it and docs run emergency depts.

we are the preferred em non-physician provider and everyone knows it.

 

e, I know that you are right about that in PA centric states.. but what about those states which are more NP friendly (miss, ala, California, etc)?

[EMEDPA]

Do you think the doctorate for PAs (who are still dependent and supervised) will make a difference in your autonomy and the ability of PAs to be hired over DNPs in full-practice authority states? I'm all for PAs getting doctorates. I know yours is for a possible future in overseas work in public health and medicine.

no, autonomy is earned through clinical excellence, not high level of degree.

in the pa vs. np world a doctorate of any kind means some HR person who knows nothing about either will not say "well, the pa does not have a doctorate and the np does". that is nowhere near my primary reason for doing the doctorate but it's on the list.

I would stack my DHSc in terms of units and requirements against any DNP program. there are many ms trained rn's in my program and when I asked them why they are doing DHSC and not DNP they said the DNP was more like 40 units of a management ms level degree vs. our >60 units of learning about biostats, epidemiology, global health issues, research methodology, medical writing for publication, etc

[EMEDPA]

e, I know that you are right about that in PA centric states.. but what about those states which are more NP friendly (miss, ala, California, etc)?

don't know about miss. but in california for example there are pockets of pa preference. I would work in one of those. if it came down to moving or reporting to a DNP I would move.

I have moved for less before.

[Grinder993]

Back to number 2, a residency cannot confer a degree, only an accredited university can. How can that be paid for? I promise you that Baylor is getting money for the academic degree portion of the residency from the government. PA residencies do not typically receive money from ACGME. The degree is not free. No University in this country would even consider that. Also, the DSc is a research degree. You could just as easily say.....a PhD for all PAs who complete a residency.....I'm willing to bet that most PAs won't do that unless it dramatically changes their practice.

 

Agreed that the DNP did not change NP practice. It was never meant to. It was a political move. I would argue that they would have gotten autonomy in those states without the degree. Let's also be clear. Titles DO NOT matter one bit to politicians. Nursing is getting their way because they have over 3 million votes. The degree is not what is changing their political power. Only two things matter to politicians....money and votes. Anything else falls way down the list.

 

You have to remember, this is YOUR issue, this is your idea of advancement. It's rather egocentric to concede that this is the way the entire profession should feel. Many PAs do not agree with you. In fact, while a plurality polled supported a name change, the majority either did not, or were undecided. If you cannot get a majority of PAs to INSTANTLY agree with a name change, do you honestly think that they will clamor for this?

 

It still comes down to money (it always comes down to money). If you can find a way to fund the residency, which also includes an administrator, protected time for the director, as well as money for accreditation, etc. (which isn't cheap), then you still have to find money to pay for the DSc. Likely 50K plus per student.

 

You and I can certainly agree that does in fact always come down to money. And you are also correct that the ANA is getting it's way b/c of it's 3 million strong lobby. You're key question is how do we fund it? How does any DNP program fund there's? Here the University of TN awards a DNP, the program charges tuition. I disagree that this is MY issue or that I am egocentric. IMHO we are walking a road that is littered with landmines, many of which have been laid by our so called allies (MD/DO and NP). I am reminded of when Obama gave the speech about Obamacare back in 2009 (I think) the famous white coat speech in the rose garden. He specifically mentioned nurse practitioners (among others) as a solution to our looming medical shortage. Wanna guess who he did not mention?? Wanna guess why? Because someone from the ANA lobby made damn sure that NP's were specifically mentioned, did that same "ally" of ours make sure we were as well? Convenient amnesia?? I believe our profession should come out of the shadow of the past, it is time grow up and take charge of our own profession. Am I the only one it bothers that at any time on any whim the physicians on the state medical board can just decide to cut us off? Can decide without evidence or justification at any time to cut our scope of practice. It is happening all around us. It has happened here in TN and they are trying to push yet another bill through as we speak. Unfortunately, there just aren't enough PA's in the state of TN to make much of a lobbying impact. We are at their mercy, a place I do not like to be.

[Guest Paula]

I am also a little concerned about what Grinder has discussed here.

 

However, IMHO there is NO WAY a new grad/green PA should have complete autonomy- even if they do a 12 month post grad residency right after school. I truly believe an auto minus provider needs a lot of training and experience before you're there on an island.

 

My proposal would be a min. 3 years as a PA before applying for a 'doctorate residency' of some length which should confer a modified title of some sort and autonomy.

 

 

Pp

 

I would agree with that, too. Graduated autonomy after proving oneself and getting experience. The 3 years experience and then take a CAQ or additional certification for primary care/internal medicine and passing it gives one a license that is not dependent on a physicians.

[eddoc]

Grinder has made some great points and, unfortunately I already see the fruits of his points in my medical center - even amongst those who understand that the DNP isn't a "clinical degree." Case in point, we have both NPs and PAs in our ICU; when it came time to appoint a lead, the NP was chosen - not on the basis of her greater clinical experience, not on the basis of her leadership or management skills but purely on the basis of her DNP. If that were the only instance of this happening I would happily point to one person's misunderstanding of the contents of the DNP degree, but unfortunately, that is not the case. Politicians may tell you that they don't care about the degree, but I can tell you after testifying at their committees that they are telling you something very different than they are telling others. To the uninitiated the higher the degree, the greater the competence and we ignore that fact at our peril. Finally, there are several US med schools that are seriously entertaining reducing their curriculum to 3 years. When med school is as long as PA training, where will we be then?

[JoePino]

don't know about miss. but in california for example there are pockets of pa preference. I would work in one of those. if it came down to moving or reporting to a DNP I would move.

I have moved for less before.

 

What specifically are these pockets you speak of?

[EMEDPA]

What specifically are these pockets you speak of?

southern>northern

eastern/central valley >coastal

[UGoLong]

Ah, the famous pockets of PA domination! Once again, the retreating army is looking for a place to make a stand.

 

I am in a practice with a terrific NP who is about to become a DNP. She could already see patients when the doc is away (and I, on the other hand, lose all muscle tone when he is more than 60 minutes away). Now she will be a "doctor." To my SP, that carries weight; after all, he's a "doctor" too. Kind of like the respect between officers in different armies. They're not the same, but they both have terminal degrees. It won't affect me on the personal level because I'll still be "me", with all my skills and foibles. I love being a PA, no matter what happens.

 

I'm not sure there is an answer to all of this. And if there is, going through all 50 states yet again will be a huge undertaking, unless someone really big is on our side. I'm not sure who or what that is.

[MedicinePower]

DMP=Doctor of Medical Practice

 

It's time we formalize it. Require an MSPAS (or equivalent), 1 year coursework, 1 year residency.

 

Who's on board?

[MedicalRN]

DMP=Doctor of Medical Practice

 

It's time we formalize it. Require an MSPAS (or equivalent), 1 year coursework, 1 year residency.

 

Who's on board?

 

And that's different from an MD how?

 

I don't think a standard PA doctorate makes much sense because a PA essentially has a Masters Degree of medicine. PAs are taught the medical model, and a doctoral level degree in medical practice already exists, an MD. The DNP works because it is the terminal nursing degree, an entirely different field.

 

Furthermore, the purpose of the PA degree is to practice medicine without the sacrifice of medical school. Making a doctorate and requiring more residency hours, etc defeats the whole purpose of going to PA school in the first place. I, for one, am not a fan of degree creep.

 

also, as a possible future NP, I personally don't care for the DNP. It's essentially a management degree at MOST schools. Some schools, however, are doing it correctly and making the DNP a large increase in clinical hours and clinical related classes, with some schools even allowing DNP students to subspecialize (aka: an FNP does their DNP in cardiology). I think if all schools get on board with this strategy, yes, it would threaten PAs (imagine a cardiology practice choosing between a new grad general PA and a DNP who did their doctorate in cardiology?). Unfortunately, the accrediting body for Nursing schools has very low standards and will allow anyone, including for-profit online schools with no on site requirements to begin DNP programs. I think graduates from these schools will convince employers that DNP prepared nurses are no better than PAs (perhaps worse).

 

The two professions each have their issues, which is why it's so hard for me to choose NP vs PA and why one is not currently "better" than the other. One has much higher academic and clinical standards, but anemic legislative power...the other seems to wield incredible power in the political realm, yet has pathetic education standards. Whichever group is able to fix the Achilles heel first will likely destroy the other. Imagine PAs with the political power of nurses. Imagine NPs with the rigorous education standards and training of PAs.