April 14th, 2017

Is There an NP on Board?

Elizabeth Donahue, RN, MSN, NP-C, practices adult primary care medicine in Boston, MA.

It was a moment I’d anticipated for nearly 7 years — not with excitement, but with dread. Two weeks ago, I boarded a plane, having won the lottery known as the standby list. Due to heavy wind, all flights were departing from a single runway and because of delays, the airline had thrown in a complimentary cocktail. Things seemed to be going smoothly. Then just before starting our descent, a female passenger fainted onto the floor of the aisle next to my seat.

As I jumped up to help, I had a few thoughts:

  1. Thank God I only had one drink.
  2. I’m on vacation – but here’s one more patient literally dropped at my feet.
  3. Oh shoot – it’s actually happening.

You see, I’ve had anxiety about just such a situation since 2006. One time, I was flying to a meeting in California with three outstanding physician colleagues when the pilot asked for medical assistance. They handled the emergency beautifully, of course. Since then, I’ve thought about my lack of emergency experience whenever I’m on a plane. Multiple times I’ve joked that if a fellow passenger is in need of diabetes education or has strep throat or any number of primary care complaints, I’ve got this under control. But a medical emergency at 30,000 feet? What could I contribute?

Turns out, more than I thought. First of all, my training of nearly a decade allowed me to remain calm and focused. My daily work and my international aid experience reinforced an ability to complete an assessment using the tools I have at my disposal, thereby garnering a lot of information. And the ability to quickly develop a differential diagnosis came in more handy than I ever thought it would – thanks to my teachers and preceptors! As medical emergencies go, this one was mild. It seemed a case of vasovagal syncope – the patient didn’t have a head injury and was awake within seconds. She had a pulse, a normal neuro exam (thanks to the makers of the iPhone for that flashlight), and appeared a reliable historian who knew her medical history. Not to mention, we were close to our destination and on the ground in no time.

After the adrenaline slowed, I started unpacking the experience and reflected on how it felt. The flight attendants were great teammates – getting what I needed almost as soon as I asked. And the patient behaved the same way – responsive and grateful, without questioning my decisions or experience. I was in charge completely even though I was doubting myself. Why did this feel different from my daily work?

As a nurse practitioner, I’m used to defending my practice. I explain my role to patients, which I am happy to do – some don’t know what an NP does; some have never seen one before. I consider it an opportunity for education and discussion. I’ve also had patients question an evidence-based plan of care, wondering if my credentials equipped me to make the decision alone or if we needed to check in with a physician. Again, I don’t take this personally – I can see it as a place to better understand a patient’s concern or a chance to explain something more clearly. Other conversations are less pleasant; one patient’s family member recently accused me of wearing my badge flipped over to hide my status as a non-physician and asked for a doctor, though he had confirmed the appointment with an NP earlier that day. This, also, I can understand – patients simply want what is best or most comfortable, while they may feel unwell, stressed or scared. I can empathize and do my best to reassure them. I can also involve physician colleagues for reassurance and often do.

What has been more troubling to me is observing similar reactions from healthcare colleagues. Last year, a physician testified before the Massachusetts legislature that nurse practitioners “aren’t even trained to diagnose ear infections” – an allegation without basis in reality. Physicians within my hospital have asked to speak to a doctor in my office about a patient of mine – either not understanding that an NP could be the primary care provider, or that speaking to the provider who had actually delivered the care would be best for the patient (even if they didn’t have the “better” credentials). Several physicians have weighed in on blogs here at In Practice with sharp comments like, and forgive me for paraphrasing, “PAs don’t practice medicine” or “everyone wants to be a doctor with only 6 years of college.” In fact, we are practicing and my graduate degree (much like yours) is simply not equal to a few extra years of “college.”

I have worked collegially with physicians across my career. I am educated on my role and scope of practice, and I don’t hope to practice outside of my license. Nor do I have any illusions that I can know everything or will never need help. I am aware of my strengths and I work collaboratively with physicians and other colleagues as needed. I have often seen that this is a two-way street. An intelligent and well-respected physician colleague often asks me questions about women’s health, in which she had minimal training and I have more experience as a family medicine practitioner.

I wonder; if there had been a doctor on that plane, would my skills or contribution have been questioned? What if that doctor was one with minimal experience in the chief complaint – say, a psychiatrist or an orthopedist? Would there have been a recognition that although I have different letters after my name, I may have been better suited to care for this patient? If there had been an EMT, an ICU nurse, or an ER doctor on the plane, I would have stepped aside without ego, in the best interest of the patient. To that end, I hope we as providers can begin to treat all situations as opportunities to work together as colleagues without unfairly judging each other’s credentials.

 

Register Now for more NEJM Journal Watch Content

62 Responses to “Is There an NP on Board?”

  1. Timothy E. Hohman CRNP, MP-C says:

    Elizabeth, I definitely understand your situation. I have been a nurse practitioner for five years and a critical care registered nurse for 25. What most people don’t understand is unlike Physicians the first four years of our training is dedicated to becoming a registered nurse. The first four years of becoming a physician or pre medicine has nothing to actually do with the practice. It is merely a weeding out process. As far as stressful situations about 10 years ago I had one of our house Physicians suffer a syncopal episode. Unexpectedly, three other positions for present and we’re just standing looking at their calling on the ground. I assessed him, placed him on the monitor and started an IV on him all the time his fellow Physicians stood in amazement. Because of our level of expertise as nurse practitioners Pennsylvania is considering passing Senate Bill 25 which will allow independent practice. For the past year I have run my own office and have several Physicians as patients who have stated on numerous occasions that they feel they get a more thorough office visit with me then with their physician counterparts. Nurse practitioners are not trying to replace Physicians. I have no interest in cutting into the human body or I would have went to medical school to be a surgeon. As a family nurse practitioner I have helped thousands of patients maintain and improve their overall health.

    • Mehrdad Saririan says:

      With all due respect to the nursing profession, becoming a nurse has *nothing* to do with the actual practice of medicine.

      What you fail to understand is that a 4 year medical school curriculum includes more *hands-on* clinical training than an NP gets during their entire clinical *observerships*. And while NPs end there, those new MD grads go on to complete a 3-year residency.

      Please never again compare the clinical training of nurses to that of physcians. It is foolish.

      • Kathryn Quinn says:

        DR. Saririan,

        Enjoyed reading your opinions. I am curious…
        (1) do you work with NPs? How do you utilize them?
        (2) how *should* NPs be utilized in the medical system in an ideal world?

        • Mehrdad Saririan says:

          I don’t directly work with NPs, but we have NPs in our health system and I have a colleagial working relation with all of them. They have access to a medical director who is available to assist them with questions.

          In an ideal world, there would be only one pathway to becoming a primary care provider. Are the number of years spent becoming a primary care MD/DO excessively long? Yes. Could it be shortened? Yes. Is current NP training sufficent? No. Should “online” NP degrees even be allowed? Absolutely not.

        • Nisha says:

          Agreed.

      • Stephanie says:

        Dear Mehrad – while you preface your statement by saying “all due respect to the nursing profession”, your response demonstrates a lack of collegiality and obvious lack of respect. As advanced practice nurses, we are NOT practicing medicine, we ARE practicing nursing. Further, you demonstrate a total lack of understanding of our education and training,referring to observerships is an obvious jab. There are over 40 years of peer reviewed data that support that our outcomes are as good as physician colleagues and at times, better…but importantly, we should all value/respect the contributions of our colleagues across roles and disciplines. The outcomes speak for themselves, and while nursing does not need external validation, the IOM, the National Governor’s Association, AARP, RWJ and many others have acknowledged this and are developing solutions to the nations access shortage around nursing. Finally, to expand your knowledge, please know that years of experience do not equate to better training or better care… you no doubt have peers who have completed medical training who have had poor outcomes, malpractice etc. Medicine, nursing and others are switching to competency based learning and including interprofessional learning/competencies. It’s time to work together and stop the insults…..patients needs us.

        • Mehrdad Saririan says:

          You state that you practice nursing and not medicine. How then do you explain the author presenting herself as “Elizabeth Donahue, RN, MSN, NP-C, practices adult primary care medicine in Boston, MA.”? Did the author not get your nursing practice memo?

          With respect to peer reviewed data looking at treatment of certain conditions that lend themselves to algorithmic care, then sure; advanced practice RNs do just as well. After all, anyone with minimum training should be able to follow an algorithm.

          Let’s not kid ourselves. There is absolutely ZERO data showing advanced practice RNs filling voids in underserved rural areas. That’s a ruse. NPs herd the same metroplitan and suburban centers as physicians. And while you lobby and legislate for your rights, we earn them.

          You are absolutely correct. There are many terrible physicians out there. An MD degree does not equate a good physician. But good bedside manners and a friendly smile does not equate good care either. You don’t know what you don’t know.

          The solution to a primary care physician shortage is not an explosion of NPs with now some degrees offered fully online. It is a fundamental restructuring of medical education for those wishing to commit themselves early to a primary care practice. That could take the form of an early admission (bypassing a complete 4 year undergraduate degree) into medical schools with curricul geared towards primary care. Another idea is to radically expand the number of primary care residency positions. The point here is to have conformity in education and standards, and not this hodge-podge of “providers”.

          I work with NPs. They are near universally excellent, though some of their requests for consults can be weak. As long as they are clear with patients that they practice nursing, as you suggest, and not medicine as the author suggests, we will get along.

        • Shannon Whitten says:

          I am one of those rural NPs that don’t exist in filling in the gaps. I’ve been in rural Ga for ten years 60 to 70 hour weeks and in rural communities with rare time away from direct care. I’m still working right now at 1015 pm with a pt in CHF. Each state determines what we can say we practice. In Ga I do perform medical acts in a delegated role in in my own office and I do act as my patient’s PCP. I provide care that uninsured pts would otherwise not have access. I see simple ear infections to CHF as I have critical care training. I read ECGs and ,yes, have found the DVT from the atrial fibrillation an ER resident missed last week. This isn’t an isolated event I might add. We need to work in teams for the interest if our patients. When any one of us thinks we can’t learn from another we become arrogant and dangerous. How would you characterize my removal of a sebaceous cyst today? I guess since I removed it its a nursing act but if performed in a similar manner by a physician it becomes a medical act. Do you see how absurd this sounds. Lets stop belittling the fact we each can add value to patient care. I don’t tell people in practicing medicine but lets face the facts much if what we do overlaps. I’m an NP proud to say it and will continue to serve the underserved. Its my calling and my gift. Lastly, I agree for NPs to show consistency in training we need in campus didactic and clinical training. I train NP students and the NP students in these online programs are not at the level those if us who trained on campus were at entry level care. If we want to be taken more seriously we need to make some changes in our training. I after 17 years of practice under physician supervision can say I do know how to treat complex problems. I’ve done my trauning.

      • GrannyRN says:

        With all possible respect, I have taught interns how to start an IV, administer an injection, etc. etc.
        And when I was called to see a patient over the Atlantic on my way to a vacation in Germany, the only MD on board worked for the CDC and stated that he ‘had not been in clinical setting since he was a resident’.
        The patient had suffered a TIA. She was German, 65 yo, postmenopausal and taking hormone replacement therapy.
        My considerable experience in Neuro and other ICUs led me to recognize the condition immediately and I performed a basic neuro exam while the Doctor observed. I offered the lady baby aspirin (4-81 mg. chewable tablets) and had the flight attendants give her water every 30 minutes to rehydrate and raise her blood pressure to an effective level.
        The Captain called back to the scene (back of the aircraft) and asked ME if he should divert the flight? (Answer: No. She is stable and the event is not likely to recur before we land in Germany). Should he have an ambulance waiting? Answer: No. A wheelchair will suffice.
        While I filled out the paperwork (never ends-even at 30K feet!) I noticed that the MD had started doing another neuro exam, having ‘remembered’ what he had seen me do a half hour before.
        I instructed the lady to see her own doctor ASAP and report the event and asked the flight attendants to continue to offer water and fluids every hour until we landed.
        When we landed I checked on the patient one more time, she grabbed my hand and thanked me over and over for helping her (in English fortunately!) and assured me that she would see her doctor that very day as she lives next door to his clinic.
        We all learn from each other, regardless of license and level of education.
        Only Pride, one of the 7 Deadly Sins, gets in the way of patient care when the Doctor vs. Nurse game is played.

        • Mehrdad Saririan says:

          I fully agree with you. Patient care requires a village. Physicians need nurses (and vise versa).

        • Paul says:

          I have nothing against NPs, but I would like to highlight Dr Saririan’s comment “You don’t know what you don’t know.” I think this fact is often overlooked by advanced practitioners.

          As an example, GrannyRN, you stated “I offered the lady baby aspirin (4-81 mg. chewable tablets) and had the flight attendants give her water every 30 minutes to rehydrate and raise her blood pressure to an effective level.”

          Water is a hypotonic solution that is evenly distributed amongst all body compartments (intracellular fluid, interstitial fluid, and intravascularly). The only component contributing to blood pressure is the intravascular space. So in this situation, the water would not have an effect on blood pressure by rehydrating the patient. This is why we use normal saline, an isotonic (for the most part) solution, for hypotension. A more appropriate choice would have been giving the patient a salty drink, such as V8 for instance, because salt is what increases the blood volume and hence pressure. Now, there is relatively new evidence that drinking very cold water can have a temporary pressor response and increase blood pressure, but that is secondary to activation of the sympathetic nervous system, and not from rehydration…and no airplane has water that cold.

          I know that was nitpicky and nerdy, but I was just trying to prove Dr. Saririan’s point that it is important to know what we do not know medically…and without a rigorous medical education that can be very difficult.

        • Mike says:

          I’d like to learn from your experience in neurology here. I know that standard of care and resources vary depending on the area. I also know that what looks like a stroke or TIA can actually be other things as well. As you know, depending on what study you read, your patient has something like a 15% chance of having a repeat TIA, major stroke, or ACS in the next year (if she had a TIA).

          Considering the importance of early intervention (just like I’d want to intervene early if I suspected someone was having cardiac ischemia, BEFORE he had a full-blown heart attack), do you feel like PCP follow-up, even same day, is the best choice here? I don’t know a lot about emergency care in Germany but I would imagine it is pretty advanced. Maybe they don’t admit TIAs in Germany like many hospitals do in the US.

      • Tamira D says:

        I am currently a nurse Practitioner student in the final stages of the program. I am on similar clinical rotations with medical students in 3rd and 4 th year and my nursing experience and training plus what I am currently learning has equipped me to stand out as more knowedge able than these medical students. If I wanted to be a doctor I could have gone to medical school but I chose to be a nurse Practitioner not because it was less than but because with it comes an opportunity not just to treat but to care. I think this is what intimidates medical doctors. The fact that most of the patients prefer to see the NP because we show care when we treat and there is fear that they will lose their respect. As a registered nurse midwife, i have taught interns how to do basic skills such as BP assessment, blood draws, giving injections and they are great full until they become senior officers and believe they are superior to the nurse. NP in my country have equal rights to care and prescribe without medical supervision and not once any nurse practioner has been charged for malpractice but for the medical doctors i cant say the same. I think this culture of comparing medicine with the work the NP does is not right. We are a team and if we are here for the patient and not for our ego we can do great things for our patients. We both are intelligent and smart but is there a level that NP cannot reach because she or he is a nurse?. No we are equipped to care and treat and I wish as colleagues we get the same respect and right that we extend to the medical fraternity.

      • Kris says:

        This 100% true! MD/DO should never be compared to NP, regardless of experience. I’m an MD and my gf is finishing up her NP studies in a year. I seen at first hand. The expertise is night and day when comparing MD/DO to NP. I totally concord that regardless of credentials we ought to work together as a team, but like every effective, each individual has a separate role, which he must plays well in order for the team to be successful.

    • I have been practicing for over forty years and started in combat while serving in Vietnam. I have intervened four times on flights and was always required to demonstrate by a card , evidence of my profession. My first save was enough to change Delta airlines guidelines. If they ask for a physician and no one responds in fifteen seconds, I am always going to respond and my NP colleagues would be just as fast. bob blumm

    • Jodi Galaydick says:

      I went to medical school, residency and two fellowships and I don’t cut people open either don’t assume the only people who go to medical school are surgeons. I work with NP and PAs and I respect their role in patient care, just as they respect mine we are a team. But guess who takes the fall if something goes wrong – me the MD, if NPs want independent practice be prepped to take full responsibility and liability.

    • Nisha says:

      I love how you equate medical school to a “weeding out ” process, truth is NP degrees are now being offered online. As physicians we simply have more training. I respect the fact that you had 25 years of experience prior to becoming an NP but this is not the case for every NP. I believe every NP needs to practice within their scope, which in my opinion isn’t independent. If you want to be a physician go to medical school.

  2. K R says:

    I use an NP as my PCP. I find her knowledge base excellent and her bedside manner vastly preferrable to some of the big ego MDs I’ve visited. I expect to continue seeking NPs or DOs out vs MDs for primary care.

    • Megan Radmer, DO says:

      You do realize that DO = MD? Unlike NPs, DOs are trained physicians that complete 4 years of medical education plus 3-7 years of residency training.

      • Shannon Whitten says:

        I’ve worked with a DO who completed 4 years if school no residency thank you. Its not always consistent.

        • Megan Radmer says:

          No, to be a fully licensed physician in any state you have to compete at least one year of internship and all three steps of your basic boards. You never worked with a U.S. trained DO that is practicing medicine without at least an internship.

        • Michelle says:

          Yes, it is. A DO or MD is not allowed to practice or be board certified without a residency. If you do one intern year (residency year) you can obtain a license and be a Moonlighter in an urgent care, but that is it. You can never be board certified. Lots of residents obtain this license after their intern year so that they can start paying back their student loans. Generally this work is in a group setting where there is another physician present.

    • Paul says:

      Easily the most insulting comment on this entire thread

    • Shannon Whitten says:

      Thank you for your validation. You state what we as NPs know. You are the reason we continue to practice under the current work environment. Its sad. We should all reexamine why we chose our professions. For me it is to hopefully be that person on someone’s worst day who can make a difference.

  3. Mehrdad Saririan says:

    I would venture to say psychiatrists and orthopedists would have been able to handle this simple situation quite adequetely. That the author assumes she is more capable is rather… dangerous.

    • Ed Aldine RPh says:

      I think because these types of doctors rarely deal with these situations. A psychiatrist who I socialize with, mixed up minocycline with monoxidil, claimed methadone was a partial agonist, said glucose was the currency of all cells. Another colleague of his declared false information on drug eluting stents. If one doesn’t revisit situations learned 20 years ago, the information often becomes forgotten, foggy or even wrong.

    • KDA says:

      Agreed. I expect anyone who can be MRP to manage basic syncope at the bedside.

    • Shannon Whitten says:

      Not so. Someone such as an acute care NP who can read an AED or ECG and who is ACLS certified and knows CPR can mean a good vs bad outcome.I Don’t know many psychiatrist who can run a code. Be reasonable please.

  4. John Goydos says:

    I think it’s a very fair article. But why does the last paragraph start with questioning the credentials of a psychiatrist/orthopedist while finishing with a statement about working together and respecting colleagues.

  5. Samuel Matos, MD MPH says:

    I do agree many NPs and PAs perform way better than some doctors in evaluating patients’ complaints. Actually, my PCP is a NP who conducts, in my view, a quite comprehensive anamnesis and physical exam. I am saying this as a patient and also a medical doctor with foreign training, and over 20 years of experience in internal medicine and critical care. While the emergence of auxiliary medical professions reflects a longstanding shortage of physicians in America, it is paramount to work collaboratively for the patients’ sake.

  6. Brittney K says:

    When comparing the eduction and experience of Doctors vs. NPs, the fact that you can become an NP entirely through online coursework says it all.

    • Tamira D says:

      Although the course work is online the practical training is done hands on in the clinical area. The nurse practitiner is also an experienced nurse before she is a NP. We have more experience than the intern after medical school. We even teach them how to perform basic skills.

      • Josh says:

        Basic skills that most doctors never do again. For example, placing an IV line, placing a urinary catheter, and drawing blood. These are all skills that in the future orders are placed and someone else performs. These are skills that will usually only need to be performed in in a low resource setting.

    • Nisha says:

      Agreed. We couldn’t obtain our medical degree online.

    • Adam Boyd says:

      Physicians keep repeating this and it’s purely false. While didactic coursework may be completed partially or totally in an online format, the same amount of precepts clinical time is required.

  7. Gina says:

    This article is very confusing to me. At first, I thought it was an article about a medical professional confronting their first emergency outside the hospital or clinic. Subsequently, I read the final paragraphs where it was clear the author’s goal was to highlight how her knowledge and skills have been unfairly slighted because she is an NP. The article highlights that she practices primary care medicine and she emphasizes that NPs “are practicing” ;however, she also states she does not want to practice outside the scope of her training. Which is it? Are you practicing medicine or practicing outside the scope of your training? I thought NPs practiced advanced practice nursing. I was taught that if I wanted to practice medicine that I needed to go to medical school so I did. 4 years of undergraduate work, 4 years of medical school, 4 years of residency, 200,000 + dollars in debt, years of missing holidays, weddings, and other important moments with my family. Now, still working long hours as an attending to pay off debt and missing many special moments with my daughter. I wonder why this author thinks doctors go to medical school. She must think we are not that intelligent or gluttons for punishment if we are willing to work that hard and sacrifice so much if ultimately we could take a less time consuming, less exhausting, less expensive route like she did and do the same work. Or, perhaps she thinks primary care medicine is within the scope of an NP’s training? Does she think that primary care does not require the skills and experience that one gains in medical school or residency? Because, primary care is one of the most difficult specialties and is the backbone of our medical system. Our primary care physicians are the ones that identify and stop disasters before they happen. We should be celebrating their expertise and not comparing their work to that of someone with less training and experience. I work with many great NPs and celebrate their contribution to my field. But, please do not try to diminish the significance of my training to elevate the importance of your own.

    • Theresa O says:

      Primary care is within the NP scope of practice. That is why they are called primary care NP. No one is discrediting the hardships and sacrifices of medical school training. The author was not in any way comparing her training to a primary care physician. She was simply describing an experience she had as an NP. Belittling the NP profession as a way to uphold medical doctors is counterproductive at best. You say you work with NPs but you seem to have very little knowledge of their scope of practice.

    • Shannon Whitten says:

      Primary care NPs in rural areas sacrifice. I got home at 10 pm tonight due to a usual office day. Finally called all my pts back to have them safely cared for. I miss family events most every school event. I also am on call 24/7 for my rural pts and I’m asked medical questions in church and the grocery store my free time. I have 12 years of college and now 17 years of primary care treating complex patients. You don’t get to say you work more , have a greater work ethic or care more. Its absurd. Teamwork. Arrogance and derogatory comments so not help

    • Shannon says:

      Studies do show NPs provide equal and in some areas better care than their primary care counter parts. Its an evidence based study too. I did go to college for 12 years and have now practiced for 17 years providing excellent primary even complex care daily for my patients. The only validation I need is they keep coming back. I too have debt have sacrificed and trained. I believe we should all work in teams to better serve our patients. No one physician or NP knows everything.

      • Kara Kimberly says:

        So if you believe these data to be true would you go out on a limb and state you would be capable of passing the same licensing examination? If you indeed are capable of providing similar or in what you’ve stated sometimes better care, should your knowledge of the basic sciences, medical pathology and treatments allow you to pass the licensing examinations for physicians? I took the NCCPA licensing exam when I was a PA. I never cracked a book and passed readily just by paying attention in classes and on rotations. I believe the content of NP Primary care examination are very similar to the NCCPA certification examination. My licensing examination for all three step examinations for MD licensure were grueling and agonizing and while I scored middle of the road on these tests, I studied for 12-15 hours per day for four years straight and did the same for 5 years of surgical residency to pass my board certification examination. It’s different. If you would go through both processes you would know. My husband is a board certified primary care provider and he is forever caring and everything NPs may claim is unique to them but he is also spreading the concept of evidence based medicine to all advanced care providers. Some get it, some do not. If you are wondering why physicians are pushing back, it is not because of insecurity, it is to get the truth of the situation to the NPs. It is not the same. It is not even close. Trust me I was a mid level and then I went back. It is vastly different.

    • Emily says:

      I agree fully. Primary care is challenging, complex, and requires astute physicians. Sadly, because it isn’t a high paying specialty and doesn’t get the same prestige of other fields, there have been huge shortages of physicians in primary care, which has opened the door for midlevels to “practice” rather independently. When one isn’t really as knowledgeable as he or she should be, (i.e. they haven’t had the years of training and experience to be in their “scope”‘ of practice), there are costs to us all. Patients with minor, simple things are often over-labbed, over-imaged, over-referred, which not only costs $$$, but clogs up the system and slows our specialists from seeing the really important consults. Alternatively, important red flags (or even common diagnoses!) are missed and patients suffer significant consequences or even death from poorly educated practitioners.

    • Kimberly T says:

      Well said.

  8. Michael Salvatore says:

    In my 40+ years of practice one of the things I have learned is that initially training can give a practitioner an edge but over time it is the kind of person you are that determines the kind of nurse or doctor you are.

  9. Michelle says:

    There are a lot of Comments on training above. I can say I have lived in both worlds. I was a registered nurse, and after evaluating both options, I decided to go to medical school. There were too many variations in the programs and experiences with the NP schools. Too many “online only” or “life experience” credits. I wanted to be prepared. My first smack in the face was the MCAT. I totally failed. The basic chemistry I had to take to get into nursing school was not enough to get me by, so I had to take all the major science courses and then I was able to pass. Still in my head I thought I had something that put me above the others. The truth was that I was no more prepared for medical school than anyone else. Yes, I could check a blood pressure and put in IV’s , but that did not count for anything. I knew some of the medications, but not the details that were important for medical school. I am very glad I made the decision that I did. I am also happy to work with other members of the health care team. I find it so offensive when one physician specialty is put down. Psychiatrists and orthopedists are trained to handle emergencies just as well as anyone else!

    • Tamira D says:

      I am confused as to the comparisons made. I did college chemistry just like my friends who went to do medicine and I went into nursing. Some of which did not complete medicine and i did. The training of the NP is totally different to traing for a registered nurse. The level of knowledge and training is at an advanced level. History taking and physical assessment taught is no different to that of medical students. Pharmacology and prescribing medication, prescription writing is no different. Please get the facts before comparing because registered nurses are not taught at the indepth level that NP are taught. I have experienced both worlds.

  10. Reading all of this brings up thoughts of how anyone in the medical field needs to realize they are not proficient 100% at everything and maybe instead of criticizing other medical professionals and commenting that NP’s are not competent Mehrad Saririan, why don’t you focus on the fact that you do not know everything. While you may think you do, you don’t. None of us do. And while we have our specialties, I can accept that others do things better than me. I am a Certified Wound Specialist & when I see the incompetence of some physicians ordering dry gauze for wounds, dakins, wet to dry dressings it makes me question why they think they are doing the right thing for patients. So, how about we all start working together & stop the criticizing. We all have a place in the medical arena, like it or not. Glad you were there Elizabeth to help out.

    • Mehrdad Saririan says:

      Please re-read my posts. Don’t assign statements to me. I did not say nurses are incompetent.

      On the contrary, the author made the broad generalization that she is more competent in dealing with syncope than psychiatrists and orthopedists. It’s this attitude that I abhor.

      With respect to wound care, we need people like you. No argument there. Physicians depend on nurses. But also know that there are burn and wound care physicians who know more than both of us combined, and you more than likely received your training from their research and contributions to the field, if not directly.

      • Stephanie says:

        Mehrdad,
        I’m hesitant to reply because I suspect you are not really interested in learning what NPs do or what kind of training we go through. Alas, as a proud NP I can’t help but be sucked in by this. A few points for you to think about, if you are interested in more than just petty turf wars:
        1) In the second week of my nursing program, while you were probably studying for your medical anthropology class (or something equally relevant to patient care), I was doing compressions on a patient in the cardiac step down unit
        2) By the time I finished my bachelors, I had logged 800+ clinical hours, this of course doesn’t count any of the time spent on coursework like pharmacology 1,2 and 3, critical care, evidence based practice, child health, pathophysiology, etc.

        – Did this prepare me for my current role as an NP? – no, so I went on for more training, including many more hours of clinical rotations – not “observerships”. My BSN however was certainly a stronger foundation for my future role than the bachelors programs that precede medical school. I could go on to talk about the knowledge I gained working as a surgical/trauma and burn ICU nurse, about the thousands of head to toe assessments I did before I even started my advanced degree program, but the real point I would like you to consider is that our training is simply different. Not better, not worse. I am not trained to deliver babies, or perform surgeries. I can’t intubate a patient. I’m not claiming to have had all of the same experiences a medical student/resident has had, and I’m not claiming to be better. But similarly the medical student/resident has not had all the experiences I have had, and they are not better simply because of the letters behind their name. I am exceptionally proud to be a nurse and an NP and I provide high level, evidence based, primary care to my patients. Please respect your colleagues, they probably have kept you from killing a patient at some point when you were a resident and didn’t know any better.

        • Josh says:

          all of the things that you stated above is the reason why you might be a much better nurse practitioner then your colleagues. However, nurse practitioner training and prior experience is not standardized. At the very least to become a physician you require four years of medical school and X number of years of residency. Every Doctor No matter the specialty, must take step one, step two, and step three. Which means that they all have a basic minimum level of knowledge and skills.

      • Olga Amusina says:

        Just an FYI, as a pulmonary/ critical care NP I have completed 9 years of education and received a DNP degree to practice medicine within a specific / state limited independent practice. I am grateful to all my collaborating physicians for the mentoring I received from them over the years. I have always respected the difference in training and there were several reasons for me not to go to medical school ( none related to lack of intellectual abilities) …I also think that if you work directly with a competent NP in a practice that allows top of the license practice , you will be shocked to learn how competent and knowledgable a non MD can be. This dialogue here could never convince you and it would not convince me if I was on a physician side!!!

      • Bram Hengeveld says:

        No. She (specifically) did not say she IS more competent.

        ”I wonder; if there had been a doctor on that plane, would my skills or contribution have been questioned? What if that doctor was one with minimal experience in the chief complaint – say, a psychiatrist or an orthopedist? Would there have been a recognition that although I have different letters after my name, I may have been better suited to care for this patient?”

        That part is at the heart of the issue she is adressing and you are pretty much totally goobering it up.

    • Shannon Whitten says:

      Well stated thank you

    • Tamira D says:

      Agree 100%

  11. Jayc says:

    I am a nurse and I find this article offensive. It reveals the critical spirit in which clearly other colleagues (doctors) are being compared to elevate this NP’s “credential”, “competency”. But read it well, she doesn’t seem to know well her basis enough (7 years in nursing? using iPhone app for neuro score?)

    No wonder some are furious reading this

  12. Faren Clum says:

    As a relatively new physician, I find the majority of comments from physicians on this thread to be incredibly dismissive of other health professions, over-confident about the value of our own and truly embarrassing. I work with NPs daily both in and outpatient who generously teach me a variety of clinical skills and knowledge. I also do not think the author was making any specific dig at psychiatrists or orthopedists, just observing that those are among the specialties that may not see a whole lot of clinic patients for syncope – just because they dealt with it in residency 20 years ago doesn’t mean they would be as comfortable evaluating the patient as someone like the author who sees it daily. The point is that experience matters and that we all become experts in the type of work we do daily. She is pointing out that there is nothing about an MD that makes you automatically better than all other practitioners at all aspects of medicine as has been implied above. Also, all the suffering we go through to become board certified physicians is hardly required to become a good provider of healthcare; it’s a broken system and just because we’re bitter about it doesn’t mean we should take it out on other people.

  13. Lisa says:

    NPs can be a great addition to a team and I personally have learned a great deal from many. These were veteran NPs with years of experience. The problem is as stated in one of the comments above, the training is incredibly variable and now, one can become a NP without ever have been a beside nurse. One of the strengths a NP carries is the bedside experience he or she brings. Additionally, the minimum of seven years of medical school and residency combined provides is no way comparable to lesser amount of training a NP undergoes, time is time and there is no substitute for that. Bottom line, NPs are not MDs and MDs are not NPs.

  14. Anand Dave says:

    I wish people would take a step back and look at what the professions (MD vs NP) are based on.

    An MD is a Physician. They practice medicine. They are governed by the Medical Boards of their respective states.

    An NP is an Advanced Nurse. They practice advanced nursing. They are governed by the Nursing Boards of their respective states.

    Some may argue that “advanced nursing” is actually the de-facto practice of “medicine.” The author of this piece suggests that she is equal to or better than an MD.

    So why not push to be governed by the Medical Boards? Why not submit to the same standards as those who practice Medicine?

    There’s no alternative to being an MD or their international equivalent.

  15. Lynley says:

    I feel a bit disheartened reading these replys. I am an NP and am sure as other NPs have felt when you are finally accredited and begin officially practising you realise how much more you need to learn. How lack of understanding has made us defensive and always having to explain ourselves. We fit into the health care system similar to a jigsaw puzzle nestled beside other health practitioners all providing essential support and knowledge to complete the big picture. Yes as said by a previous author we do have to constantly explain our scope of practise. Doctors have had years of public acceptance and publicity so the public have an instant trust and acceptance of there guidance whether warranted or not. As an NP we are constantly being challenged questioned and second guessed by clients and other medical and allied health professionals. I work with some excellent medical fraternity but also have other less professional “collegues” that I have to work alongside. It would make our profession more enjoyable if other members of the health team would just give the respect earned by our qualification freely without judgement as it is so freely given to the medical team. Clients will pick up lack of respect without realising it and further denigrate our profession. Also perhaps some of the readers could review some of the statistics comming out of Canada for NP run clinics for data they were looking for.

  16. NA says:

    There is truth to the fact that 4 years Med school and 3 plus yes residency followed by2 or more years of fellowship – all hands on experience ; cannot compare to the observership rotations of NP and APP training. The goals are different and roles are different.
    Perhaps the training ducation system needs to improve and cater to the goals, and possibly include residencies for APPs too

  17. NA says:

    I must say that a NP or APP who does ” just orthopedics or psychiatry” would probably not like to with syncope.

    And who’s to say only doctors can manage syncope ? Agreed NPs can, so can RNs, EMTs. It’s group effort and team work.

    The point I’m making is compare yourself to a physician who is in the field you chose. Just like you wouldn’t want to compare your skills at diagnosing bipolar or operating on a broken shoulder with them.

    There should be a willingness to accept roles.

    If you want the title of MD or DO- then there’s no short cut to it. And no replacement . NP is not an equivalent degree.

    As is there no replacement for NP. And MD or DO is not a replacement degree.

    Let’s respect that.

Leave a Reply

Note: This is a moderated forum. By clicking on the "Submit Comment" button below, you agree to abide by the NEJM Journal Watch Terms of Use.

Our physician bloggers cannot respond to requests for personal medical advice, and recommend patients discuss health issues with their individual physicians.

NP/PA Bloggers

NP/PA Bloggers

Elizabeth Donahue, RN, MSN, NP‑C
Alexandra Godfrey, BSc PT, MS PA‑C
Emily F. Moore, RN, MSN, CPNP‑PC, CCRN
Harrison Reed, PA‑C

Advanced practice clinicians treating patients in a variety of settings and specialties

Learn more about In Practice: Reflections from NPs and PAs.