“A mule that had made twenty campaigns under Caesar, would still be but a mule. Experience alone does not make a General……………………..”
Maurice de Saxe, Marshall General of France (1696-1750)
Just when I thought things could not get stranger………………………………..
For generations, the traditional model for delivery of medical care has been unchanged. Physicians diagnosed patients, ordered treatment, and performed procedures. Nurses provided ongoing patient care and an invaluable personal connection with their patients, something busy physicians often did not have time to do. Physicians have always been the pinnacle of the medical care pyramid. I include both allopathic (MD) and osteopathic (DO) physicians because they have the greatest level of education and training. For years, nurses have been pushing to expand their scope of practice to include provision of independent primary care, unsupervised by physicians. The battle lines have been drawn; what once was a partnership has become an adversarial relationship.
It is partly physicians’ fault. Busy physicians have been quick to adopt advanced, so-called ‘mid-level’ providers, such as physician assistants and nurse practitioners, to relieve them of some of the burden of patient care and extend their ability to care for ever more, and sicker, patients. It should come as no surprise that, over time, these physician extenders began to champ at the bit to become more autonomous. After all, how hard can medical practice be? You take a history, hold a hand, prescribe a medication, provide some counsel and the patient leaves happy and, arguably, better.
Now, into the fray steps Big Daddy, or Big Momma, as the case may be: the Doctor of Nursing Practice (DNP). DNP’s want nothing less than equivalency with physicians. In fact, they claim, and present studies to back this up, that their patients are treated as well or better than those of physicians, and are happier as well. Their ‘metrics’, such as control of blood sugar, blood pressure, and lipids, reduction of asthmatic attacks, etc. seem to be as good or better than that of their physician counterparts.
Physicians who have pushed back against this tide have been accused of professional jealousy, trying to protect their hallowed turf, trying to protect their income, or been called traditionalists or dinosaurs who resist the advance of medical practice. I understand the latter; I am a sort of dinosaur myself. At 65, I still see every patient who comes to me, I still use paper charts, and, unbelievably, my office computer system is MS-DOS based. One can argue that I don’t have a dog in this particular fight. After all, I am a specialist. I receive referrals from both primary physicians and mid-levels because I do things they cannot do. On the other hand, I will someday be a patient myself, as will my wife. Who do I want to care for us?
Let’s look at some facts. DNP’s claim that they are just as well educated and receive as much, or more, clinical experience as physicians. To become a DNP, you must have a bachelor’s degree in nursing. This means four years of college instead of the usual three typically required to become a registered nurse. Then, they must study for two more years to obtain certification as a nurse practitioner, the equivalent of a masters degree. To become a DNP involves studying another two years. While work experience on top of that formal training is nice, it is not required. DNP’s claim they get more clinical experience than medical students.
Physicians must have a baccalaureate degree before they ever start medical school. Regardless of the subject they major in, they must take certain requisite courses: organic and inorganic chemistry, biology, physiology, physics, calculus and biochemistry. Nursing students take some, not all, of these as well but there the similarity stops. The courses in nursing school are much more basic, so much so that they cannot be substituted for the requisite pre-medical studies. I know this because my daughter, now a medical doctor, started in nursing school and later transferred to pre-med. She told me how much harder and in depth the pre-med courses were than those in nursing school. It cost her (and me) an extra year of college.
In terms of education, a DNP, “qualified” to go into independent private practice has significantly less education than a newly graduated medical student. The medical student, despite his or her MD or DO degree, cannot go into practice until they have had intense, and I mean intense, residency training for a minimum of another three years. Only then are they considered qualified to treat patients independently.
So much for education. What about comparative clinical experience?
I think it is disingenuous to consider the clinical experience of nurses as equivalent to that of medical students. Today, medical students begin to see patients from year one, so nurses cannot say they get the jump on them in that regard. What’s more important is the type of experience. From the start, medical students are being trained to recognize and diagnose increasingly complex medical conditions, to establish a list of possible diagnoses, make a coherent plan of testing to establish the correct diagnosis, and initiate a treatment program. The experience of nursing students is completely different. They are presented with patients with known diagnoses and taught how to carry out the treatment plan formulated by a physician. One year, or ten years, of nursing experience does not qualify one to be a physician, not without the necessary education and training. The rest of Maurice de Saxe’s quote above is: “Experience……must have been improved by practice, and intense study.”
I am not saying that one is better than the other. The roles are totally different so the education is as well. Some DNP’s claim they get all the training they need ‘on the job’. That seems to me to be a frightening way to learn medicine. At least medical residents are supervised continuously throughout their residency years, by experienced, senior physicians. My training in surgery was one of graded, progressively increasing responsibility. I was not turned out into the community and told to learn as I went.
Even in my limited scope of practice I have seen multiple instances where the limited education and training of nurse practitioners resulted in what I consider to be suboptimal care. While they may be great at managing patients with known conditions, such as diabetes or hypertension, they do not do so well in physical diagnosis and initiating treatment plans. Because of their limited fund of knowledge, they often miss the mark in patients who are more complicated than they appear. Theirs is a classic example of the Dunning-Kruger Effect in action. Their limited education makes them unable to appreciate how little they know.
I am not against nurse practitioners, mind you. I think they can function very well but should be under the supervision of a physician. The concept of Team Care involves a physician working closely with a team of medical assistants and has been shown to provide high level medical care, very efficiently and cost effectively, and with high satisfaction rates for both patients and the medical team. What I am not in favor of is nurse practitioners, even DNP’s presenting themselves to patients as fully qualified physicians. I think this is dangerously misleading.
I recently learned of the recently established American College of Cathopathic Physicians, the brain child of founder Michael L. Arnold, DNP. Its goal is to provide a professional society for DNP’s who wish to be fully autonomous and want to be called physicians as well. Its position regarding physicians can be summed up as “anything you can do, we can do better”. Arnold clearly has a chip on his shoulder regarding physicians. Perhaps he could not get into medical school……
I worry for the future of patients who cannot tell physicians and DNP’s apart. I worry for the future of my own medical care and that of my wife.