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| To doctorate or not to doctorate, is that the question? |
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by David Mittman - March 17, 2009
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 Provided by Clinician1
As a PA or NP there are many situations we do not like, but choose to accept. Over the last five or six years one of those events is that many of the other health professionals that we work with are acquiring doctorates. Pharmacists, physical therapists, OTs and I believe audiologists, all will have the doctorate as their entry level educational requirement over the next few years. Then there are optometrists, chiropractors, podiatrists, psychologists and others who have had them for a number of years. That’s a whole bunch of doctors who are not “doctors”. That’s fine for those professions but it does put us NPs and PAs in a bit of a bind.
We NPs and PAs were always able to get doctorates in other areas; public health, education, and more. NPs also had nursing sciences. Those doctorates suited us well until the last few years when organized graduate nursing decided that they would institute the DNP degree and that degree would be required of all NEW NPs by 2015. Keep in mind that you do not have to be an NP to get a DNP. It means Doctor of Nursing Practice, Not Doctor of Nurse Practitioners. But on with the story. So the doctorate creeps into the NP world and with it comes the inevitable value that people put on your degree and what they all “think” it represents. It also puts stress on the PA educational world for parity. Here it goes again.
When it comes to wanting to be recognized as professionals on the same practice level as those professions that have instituted a doctorate, the doctorate is a good move. If we as PAs and NPs can write “orders” to other professionals who are doctorally trained, and we are not, it will become a bone of contention in the future. Sooner or later the other professions will ask why these NPs and PAs who are not trained at their doctorate level are making the decisions that these professions should be making. In other words, “How can you expect me, a DOCTOR of Pharmacy to take orders from these mere assistants and nurses?” So, yes, doctorates will have to be earned by some of us to keep up the status quo. Unfortunate but true. But back to the DNP. What is sad is that the DNP is not standardized, and in many educational programs it is not a clinical doctorate. It will cost NPs who are currently in practice $30-50,000 to acquire. and many, not all, but many of these programs will not make the NPs who enter them better clinicians. They will learn how to be better leaders and how to better impact the healthcare system. If they devote those new skills to making a difference, they will make nursing and patient care stronger, but in most cases will have not recieved the clinical eduction they expected. That’s the sad part.
What is also very sad to me personally as a PA who also loves the NP profession, is that both our professions have finally convinced people that our dream was accurate. For 35 years I have looked people in the eye and told them “You don’t have to be a doctor to provide high quality healthcare”. Then NPs and PAs went out and over the last thirty years proved what we all believed to be the truth, in fact, we proved it beyond the shadow of a doubt. So now that we have proven that you DO NOT have to be a “Doctor”, advanced practice nursing leadership (NOT most NPs) have now said “You DO need to be a doctor to provide primary care”. I understand the politics behind the decision but I wish it was done in a different way. It really undercuts what we have been saying for 30 years. On the other hand, 30 years ago many of the other healthcare professions were not at the doctorate level, and I understand that also. The question is, could we have done it better and could we have done it together?
I would have liked to see PAs and NPs team up and as many PAs do now (for no formal graduate credit) enter postgraduate residency programs. These programs are usually from one to two years in length and you learn on a resident level in a medical specialty while getting paid. At the end of your training you are very marketable and also know the specialty you trained in just about as well as a fourth year resident. Not bad. That is where I would like us to go for our doctorates if we want to practice clinically. Maybe now is the time to establish some joint postgraduate residencies and make that happen.
So, do I believe in the doctorate? Yes. I think PAs and NPs will be forced to have them. Do I think they are necessary-not really.
If we are going to go into these programs let’s make sure they prepare us clinically at the doctorate level so that we can assume the responsibility we want as compared to the other “doctors” in our healthcare system. To do it any other way might get us the title, but clearly will not make us the best clinicians we can be.
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| Rich (NH) |
on 30 Apr 2011 at 11:54 am |
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| I do think that it would be nice if PA\'s and NP\'s could find a common middle ground and combine their degree/ education and skills and create \"physician practitioner\" or something of the same. It is confusing haveing so many different people in so many different roles in the healthcare system to patients. I was just accepted to a DNP program and am very excited! My program has a dual focus Family and Psych. I think that when Im done I will go by Rich... Being called Dr. K..... can be reserved for my kids friends.... I do not want to confuse patients... |
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| Ann (Minnesota) |
on 15 Jun 2010 at 5:31 pm |
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I am an Adult Nurse Practitioner graduating in May 1990. I had the wonderful chance of working with an organization that saw military dependents and civilians in the Northern Virginia area. Unfortunately my former husband retired from the USMC and I was abandoned in my home state of Minnesota. My nursing degrees were from colleges on the East Coast - so was unable to break into the nursing field here I was told at interviews. While attempting to return to the East Coast I came down with what now appears by brain MRI's - Neuro Lyme Disease. My case was so mismanaged and non-treated that it was well established by the time I finally received antibiotics which was 8 plus years after the lab test CD-57 showed that I had no white blood cells left to fight the virus. The Western Blot showed that I had been exposed to the virus but was not in the active stage. The MRI's showed a lesion on the Caudate Nucleus, encephamalagia - scar tissue from untreated encephalitis, a 13mm lesion on the white periventricular area of the brain and chronic sequela. So after a weight loss of about 30 pounds (chronic wasting syndrome), chronic fatigue and visual changes - I am slowly coming back and hope to return to my love of Nursing as soon as I can find a refresher course that is affordable. I have been looking for a refresher course as an Adult Nurse Practitioner but have not found any. Also looked at the Phd programs in Nursing but the expense for all above after being unemployed for 14 years is unimaginable to meet. I am single, divorced (sadly) and no children and 59 years old. As a former USMC dependent I have no retirement and many of my social security points were lost as my former husband and I moved 11 times in 9 years both national and international moves. Currently my entire household storage is still with the USMC/ and private (me) paying monthly. It has been in storage since my husband arranged with the USMC his retirement plans and it was moved to storage and remains. This was over $20,000.00 (a course of 10 years while I have had Lyme) that it has been there. I will sadly be returning to the Washington DC area to have it removed and entirely sold or destroyed. This was my reward for being a wife of a USMC Lt Col and 22 years of marriage - with 18 active - so no military privileges after one year post divorce. The divorce was financially devastating - my former husband claimed he had no money and currently lives out of the country with wife no. 2 or 3 who knows. And this 59 year old lady is below poverty level living with her 86 year old mother and wishes to get back on board her professional after making it through all the above. I have always loved Nursing and wish to return to it and the new developments in patient care with computerization. So as one who worked with NP's and PA's both together and separately - I enjoy both and feel teamwork is important for excellent patient care. As one who worked as a civilian with the Navy Nurse Corps - I think that any personality differences, comparisons etc. on degrees, educational speciality, whatever - takes away from the important focus - excellent patient care - that is why God made Healthcare Providers - it is indeed a calling regardless of degrees. P.S. The deer tick lesion on my leg - is black in color with a white center. It is located on my right chin area. I will be so happy to get my energy level back up, get back into training and back to patient care as soon as possible. The deer tick will be history and hopefully the scar will be too. I was treated for Obsessive Compulsive Behavior since I was busy job hunting and trying to meet the expensives needed to
relocate both at that time myself and my husband. Then was treated for Delusional Psychosis/Schizophrenia for not getting to Mayo Clinic fast enough even though they wished for me to wait until the lesion had stopped draining and I could drive myself safely down there. My insurance covered only 5% of each appointment I incurred. So my medical bills have been unbelievable with no job or employer insurance to assist. And to date - no former husband either in contact for assistance or able to locate. I also lost my capability to read and that is now back. My entire case was abusive and it shows when you see me in person. |
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| Dan (Massachusetts) |
on 28 Feb 2010 at 10:32 pm |
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There are many reasons for exploding health care costs. One of the most serious is the practice of legislating prices through the roof. NP 's and PA 's should have the option of getting a doctorate, but it should most definitely not be required.
Let the principles of liberty and capitalism work and we will see most of the problems associated with this issue disolve. Limited choice (supply) is the largest issue behind the need for health care "reform". From my perspective it appears that high cost providers are afraid of competing with low cost providers. But the fact of the matter is that both are qualified for their respective fields already.
The only real way to sort this out is to let the market find the equilibrium of supply and demand. I include the government in this concept because our nation is in competition internationally.
Demand choice, demand liberty and demand sound economics. This is the only way to truly avert the health care and financial crisis that is beginning its inevitable swell. |
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| Anonymous |
on 14 Feb 2010 at 9:43 pm |
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| I AM ALL FOR PhD in Nursing. This DNP insanity is not organized. Pull up 10 programs and get 10 different "focuses" for the same title. DNP. I agree with the response that by the time you explain to your patient that you want to be called Doctor but you are not a Doctor of medicine they will have a migraine. They will probably want to start seeing a real physician at that point. This whole situation is very disturbing to me. It is deceit at its best. I think I would be better if you expected everyone else to call you doctor other than a pt. It is like changing the contents of a OTC but keeping the label the same. See wrong eh? Or sneaky... Have guys looked up the statistics on how DNP boards dont compare to MCATs and other tests? WE are NOT equal to physicians. They have more indepth training. We cannot take that from them and knock on a pt's door and say Hi, I am Doctor ***** We do not have the indepth knowledge that they posess. I am speaking of a good physician. I cant wait to see how this pans out. Some of these posts are eloquent ego trips!! We need to redesign the structure of our BS, master level, and I again totally applaud the nursing PhD and it rigor.. That DNP lacks rigor.. |
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| Anonymous |
on 14 Feb 2010 at 9:26 pm |
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| I am currently in the Pediatric NP master's program. Even after you introduce yourself as a Nurse Practitioner to the patients, some will still call you doctor. I DO NOT FEEL that we should introduce ourselves as Dr.s. yes it is an accomplishment but it is morally unfair to your patient popualation. I hope the AMA stands up and refuse to let this happen. These online programs have nothing on the education received by med students and residents. I do indeed believe that residency programs are much needed for NPs. We will NOT know what a (good) physician knows and should not be so d*m eager to say doctor. WE ARE NURSES!!! DONT STROKE YOUR EGO AT THE PATIENT"S EXPENSE. BE FAIR. DONT LET THEM CALL YOU DOCTOR. THE POOR NURSING WORLD IS VERY CONFUSED ON THIS ISSUE. I wish we would come together. Other professions are watching. The DNP requirement will help nursing to increase an already substantial shortage. Those potential students will go to medical school or DO school and I will gladly call them DOCTOR!! This ego trip is very embarassing to me as a NURSE. |
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| ARNP-Working on DNP (Florida) |
on 27 Nov 2009 at 6:42 pm |
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The above comments are interesting, but as a RN for 35 years and an ARNP for 16 years I have found there is not the relationship that you suggest among ARNPs and PAs.
I am proud to be an ARNP, that practices in the nursin model not a medical model. I work in a company that prefers ARNPs to PA's, as nurses have a different approach, most of us have done our time in the hospital, long term facilities, and home health, bring to our practice a different prespetive.
PA's do not know what it is like to push a med cart up and down the floor respond to a code, deal with family members and yes then deal with docs.
So yes there is a difference between us and I am pruoud that there is a difference, I am not a PA I am an ARNP. I am not the same and I explain that to my patients, that we are first and always nurses.
As I complete my DNP, I hope to continue with our nursing model and practice with scientific proven systems to improve health care to all citizens with measurable outcomes and increased mortality and quality of life.
There is enough room and patients for all, but please I hope that all remembers who we are and why we are in nursing to be nurses.
I would like to know if anyone has any numbers of clinics caring for the underserved and underprivelaged have PA's in comparison to ARNPs? |
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| Megatron PA-C (Cybertron) |
on 03 Apr 2009 at 5:43 pm |
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| Like Optimus Prime once said "Titles and thrones are for Decepticons. Besides I would rather roll out." |
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| Doug (Rochester MN) |
on 01 Apr 2009 at 4:42 pm |
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Unfortunately, the nurses in nursing are again cutting off their noses to spite their faces. My wife is an NP and a great one. She has more of a grasp on int med than mnay consultants. i kid you not. She is outraged by the decision of a bunch of people that want more letters behind their names so they can be doctors, too, are making the whole group spend this extra money for no additional clinical experience and no benefit to the patient, and most of all, no additional income.
Do you think it is wose to call your self a doctor and confuse patients in what is already alphabet soup? Do you think the AMA will let you call yourself doctors and ethically- SHOULD you expect that you will be able? I think not. AND- I think the best thing the PA schools can do to increase their numbers is to NOT go along. You don\'t need it, unless you agree to need it. I have a BS from a 4 year program, graduate in 1986. My experience alone is far more valuable than a masters level 2 year program and though I thought about it, i decided based on price, and \"what is in it for me\", that it was not worth the extra schooling unless I wanted to run a hospital, which I do not.
I personally think that the PA profession should make a stand here. how much schooling is necessary, really? if I am going to spend that much time in school, I would just be a doc! the money is much better. I think that with the NP decision they, and then we, will push many more people to be real doctors, and if the PA profession is realistic, we can have a LOT more PAs around because we do not require a doctorate. they will be well trained and good with their patients, just as we are now and have been since my mom graduated as a PA in 1975. Thank you for listening. |
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| Mary Campigotto (Washington University) |
on 01 Apr 2009 at 9:18 am |
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| I believe in continuing education. I think a Masters is a good starting point for an NP, but like all the Doctors, we need to specialize. I think NPs need more directed clinicals, just like Med Students and Residents, not to be told to just go find them on their own. If I wanted to be an MD, I would have gone to Med School. I think with the economy the way it is and the cost of education, requiring a DNP will decrease the number of DNPs in the future. |
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| Raphael (TX) |
on 31 Mar 2009 at 12:58 pm |
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PA's and NP's do not need doctorates. I have been practicing,teaching, and supervising " midlevels ( i hate this term) " for greater than 19 years as a PA-C, I can say I have seen PA's and NP's that should not be in the profession " in-spite" of their advanced degrees. Some I would never let touch me or my family.
We are missing the point of our mission as PA's if we " go along with " what every allied health profession is doing. Doctorates are BIG MONEY for colleges and universities. I think the PA's and NP's collectively have to stand up and say NO to the Doctorates and to those lobbying for this. The initials behind your name does not make you an excellent clinician or keep patients coming back to see you in a practice.
It took many years for patients to except our role in medicine, doctorates will just add wood to the fire amongst patients and physicians. If I wanted to be called Doctor I would get my M.D. or D.O. or PhD in non clinical areas. We need to squash this lobby that is pushing for this degree status.
My wife as a side note is a critical care diploma R.N. for 23 years and agrees with me. She has taught, supervised and worked with nurses that have advanced degrees but cannot do the most basic of nursing skills out of school..If we continue along this route we will see an implosion fo our professions since we will loose Physician support for PA's as dependent practitioners and R.N.'s as advance practice nurses..Thanks for reading.God bless you! |
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| Doc B (Deployed) |
on 31 Mar 2009 at 1:53 am |
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Simply put, We are mid-level providers.
It used to take four years to become a PA, now it is 5-6 for most programs. What has this done for patient access? What will an entry level Doctorate do for access in the future? While I agree with the Doctorate program, it should be as an option only. Even then, it should be a Doctorate as a result of good training, not a Doctorate just because. I started as a Bachelor PA-C, and honestly, my Master's didn't change my practice one bit. I am looking into a Doctorate program now, but only because it comes w/ the training. I would pursue the training regardless of it degree status.
We need to get a consensus voice and we need to do it now. There are dark days ahead for our economy. Reasonable, accessible healthcare will become more problematic as more providers retire or leave the system because of future rules and workload . Do we really want to price ourselves out of existance?
Doc B, PA-C |
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| Ms.Green FNP (Laguna Vista Texas ) |
on 30 Mar 2009 at 8:14 pm |
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Bravo!!! well written and quite true. I think a residency program is a must for all of us. We do not get enough clinical mentored training.
The only advantage for me to get my DNP at this stage in my career would be to be able to say this is Dr. Green when contacting another physician and get right through, cause it sure doesn\\\'t happen when I say nurse practitioner.
Have a great day. |
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| Psych NP not a psychiatrist lol (Arizona) |
on 30 Mar 2009 at 7:58 pm |
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I can't imagine introduing myself in my workplace as a doctorate in nursing but I am a Paych NP. Too much information for a patient who may not feel very patient right now. I agree that I fight everyday that I do not need to be a doctor to do this job. That in fact most doctors do not want to work in the county mental health system. Now I have to be a doctorate to practice the same psychiatry that I have for the past seven years. Oh boy what next? Do you know how many peope come in my office and disrespect me because I
I am not a MD. They act like it is seeing someone inept. I love what I do I just hate teh politics! |
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| 2nd Career (WA) |
on 25 Mar 2009 at 2:32 am |
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In the spirit of grace and collegiality, may I ask that we all take a deep breath?
There, I feel better already! (I hope you all are grinning)
The DNP is a good thing for advanced practice nurses. I presume that PAs will follow, or not, as is perceived to be best for the profession.
The world has changed and continues to change. Physicians cannot serve the healthcare needs all who need care, and it will take all of us working together to begin to accomplish the task.
When I am (finally) a DNP I will introduce myself to my patients in approximately the following manner: Hello, it is so nice to see you. I am Dr. Mary Morris.My doctoral degree is in Nursing Practice and I am also a Family Nurse Practitioner. Now I\'d love to hear more about that bad cough you\'ve been suffering.
We are professionals. We care and we will continue to do so. It is all in the attitude. |
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| Dr-NP (Canada) |
on 24 Mar 2009 at 12:00 pm |
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What a stimulating discourse on an important issue. Given the complexity of the issue, there are a couple of points worth re-stating and a couple of arguments to which I would like to respond.
FIRST, we have to find some measure of agreement about what constitutes a mid-level provider. For my part, this is an epistemic question which speaks to the nature of a discipline and NOT the things that any one provider DOES (i.e. the overt/obvious tasks of that provider). In this regard, "mcontrary, PA-C" argues that doctoral education, for both the PA and NP will exclude both practitioners from "mid level" practice: "we will no longer be "mid-level" practitioners.", presumably because we can call ourselves "doctor"
RESTATE: Epistemologically, and this is where the label "mid level provider" is born" in the construction of the argument that I make.
While, I fully realize that insurance companies may blanket PAs and NPs as mid-level providers for payment purposes, from a disciplinary perspective this label does not apply to nurses; it does apply to PAs. This get especially sticky when perceptions of POWER, PROFESSIONAL STATUS, MONEY etc come to the fore, as they have repeatedly in the posts below.
Let's keep in mind: The MD is a bachelor's degree in medicine .. it is a professional doctorate, not an academic doctorate. The DNP is a clinical doctorate, not an academic doctorate. Some PA programs are certificate, baccalaureate or master based programs. The variability in credentialing is a professional issue, not an epistemic issue.
RESTATE: PAs ROCK and ROLL and I can not wait to work with some of y'all.
NPs ROCK and ROLL.
Both roles are desperately necessary in BOTH the USA and Canada.
Both roles ought to work together and "mcontrary, PA-C" 's conspiracy theory that NPs are trying to strike the death blow to PAs is neither accurate nor helpful.
Again the argument I make is about the nature of what a mid level provider is and why doctoral education for the nurse is meaningful. Here is the epistemic breakdown in terms or "top" level and "mid' level and "bottom" level providers.
NURSING ------------------------------MEDICINE
1. NP/CNS/NA/NM --------------------Physician
2. no equivalent --------------------- PA
3. RN -----------------------------------EMT-Paramedic
4. LPN ---------------------------------EMT-Ambulance
5. no equivalent ----------------------EMResponder
6. NA/PCA/CA ------------------------no equivalent
The NP is not a mid level provider. The argument that the NP is trying to weed out PAs is ludicrous. Most American NPs I know would far rather work with a PA than a MD. The partnership between the NP and PA IS intact this very day ... it ought to be sacrosanct, not divisively argued. BOTH roles ought to be recognized for what they are .. and if the best we can do is to describe the NP as a top level provider and the PA as a mid level provider then neither the PA or the NP deserves to describe them self as a "master" of anything but their own ego.
Frankly, I see an AMAZING network of NP and PA clinics across the continent ... pay a MD to sign off on this and that .. WHATEVER ... let's get PAs and NPs working together in THEiR OWN practices for the health and wellness of all .. the money, the quality of work life will emerge on their own.
My 4 cents :-))
All good things to you all |
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| Michelle (NC) |
on 24 Mar 2009 at 9:37 am |
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| As a mere BSN, I have no skin in the game but do have an opinion. As an RN who has worked with and been taken care of by NPs and PAs, I fully endorse this "tier" of the medical machine. I have found the midlevel providor knowledgable, approachable, caring and COMPETENT. As others have commented, what is gained by (1) financial outlay that will most likely not be reimbursed in salary and (2) the time focusing on further degree study vs patient care which is what they were doing (well) in the 1st place. hmm I wonder what entity is behind this and it would prove youall well to investigate that. I think it would be extremely confusing to the patients and the endless explanations would get wearisome, fast! |
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| bezoar (kentucky) |
on 23 Mar 2009 at 11:49 pm |
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| I absolutely do not think that PA’s need doctorates. We have seen the nursing profession over educate themselves to the detriment of the profession. The BEST nurse came from the old three year schools. As soon as a BS of nursing was the thing to do, it was clear that they might have been smarter academically but inferior in patient care. Why would PA’s want to have a doctorate just to cover the empty wall space. Will it make us better practitioners? No proof of that. Doctorates only serve to pump up the ego. |
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| Jrod (Wisco) |
on 23 Mar 2009 at 8:32 pm |
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| You all forget or don't know that some PA program exist today as bachelor degrees confered. Some still give no degree confimation and only give a "certificate" to take the PANCE board exam as in Red Rocks Community College of Denver CO. Just food for thought on capable practicioners vs doctorate level degrees not offered to community college certificate owners who do so much for patients |
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| CO (IL) |
on 23 Mar 2009 at 5:23 pm |
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I am a NP with more than one specialty and certification. I have researched many DNP programs. If you have the money, you can get one.
I am disappointed that many NP programs now allow nurses in before they spend a single minute on he floor taking care of people. I even know of a prestigious program where ANY Bachelor degree will get you in. Then in 9 months you are a RN, and 9 more months you are a NP. I had one of the students as a NP Preceptor- I was shocked that she had NEVER even pulled medicine from a vial much less given a shot. How do I teach advance practice?
I do not believe the DNP is necessary. I believe it is another way to widen the space between us and continue this "who is better, smater, wiser" stuff we have been fighting for years. |
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| cs NP (mid-atlantic) |
on 23 Mar 2009 at 1:40 pm |
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| Some of the arguments are well thought out and very reasonable. I personally think the bottom line is that requiring a doctorate of any kind for NP practice is a bunch of crap and totally unnecessary. I agree with the above writer that post-masters residences would be better suited to improve the profession rather than a \"generic\" Doctor of Nursing. If nurses want to teach at the graduate level, do research or pursue upper level leadership positions in health care then a doctorate is reasonable requirement |
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| mcontrary, PA-C (Texas) |
on 23 Mar 2009 at 1:01 am |
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1) The real question is how MD physicians feel about us moving to a doctorate level (since our license is dependent on them.)
How will this affect us if they decide we are impinging on their practice?
2) I think it is unfortunate that the field of nursing feels it is necessary to offer the doctorate level. Of course the PA profession scrambles to keep up with the same credentialing as NPs, and inevitably we will probably follow suit (but to our detriment?) This is really a game of money & politics. Do NPs feel threatened by PAs? Is their decision to offer the DNP just a ploy to weed out PAs? "Melissa" mentioned her feelings that nurses in fact "have not been able to avail themselves to opportunities because of the lack of the doctorate." I believe moving to a doctorate level would be meaningless. Do you really think you would have more prestige or recognition? You most likely would not be paid any differently (which is proven with master's vs. bachelor degree PAs.) I personally have a master's degree in PA studies-- who cares! I guarantee you that I didn't learn one thing more (or different) than our friends with a bachelor's degree, nor would I get paid more. If people feel the need to be called "doctor" then go to medical school or check your ego at the door. I love my profession and chose to be a PA for all that it currently represents. I am proud of the PA's role and am proud of my knowledge of medicine. Just because someone calls you "doctor" doesn't make you any smarter-- there are plenty of ignorant doctors and there are plenty of smart PAs out there.
3) The purpose of our field's creation was to get a "quick" medical education, and further be trained by MDs. If we are tied up in school longer, how does this help broaden
patients' access to healthcare?
I also wonder what the doctorate curriculum would look like and if it would even be beneficial. Would it entail longer didactic or more clinical experience? Would they provide the last clinical year an opportunity to specialize? (which again would undermine the PA's original purpose).
I think this is a dangerous and sad game that could destroy the PA profession. The attraction to the PA profession by the prospective student is less time in school, nice salary for new grads, no required residency, versatile PA role, etc. etc. I think most would agree that the real learning comes with experience, and we could be better utilized in the field with on-the-job training.
4) Sorry I have to disagree with "Clare Voyance" and their comment that the difference with mid-levels is that we chose NOT to be in a leadership role. I believe that only a good PA must also be a good leader. Many of us lead teams, are preceptors to medical & PA students, act as board/ committee directors, and have a great deal of autonomy (thank you very much).
The bottom line is........remember why you chose this profession, your love of medicine, your love of patients. Remember Patch Adams? Everyone thought he was taking the "prestige" out of being a doctor because he wore a red clown nose and "got down on their level". He didn't care if anyone thought he was a doctor or not. In fact, he opened a hospital where the patients were ALSO called doctors to make the point that they, too, played an active role in their own healthcare.
If we continue to increase the entry-level credentials of PAs and NPs then by definition we will no longer be "mid-level" practitioners. We will have increased education requirements to such a high level that we will have taken the "mid" right out of our name. We as mid-level practitioners are important and necessary! |
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| Mary FNP-BC (MS) |
on 21 Mar 2009 at 10:39 pm |
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| I have worked as a NP for 13 years and love my profession. With the doctorate be front and center on everyone's mind, it is postulated that current NP's will be grandfathered. My concern is not with what letters are placed before or behind their name, but too many students are being allowed direct admission into doctorial programs without proper knowledge. They don't have the exposure to know what is normal much less know what is abnormal inorder to be effective mid-level providers. This is what will deface our educational status. It is of utmost importance that experience is in place prior to even entering the education track. I had 10 years of nursing and of this time all but 1 year was in critical care/ER and I became greatly aware of how much I still needed to learn. This is an urgent concern for our profession. As long as we can know what we know and provide the service in a professional and competent manner, we will be respected for what we bring to the health care system. |
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| Proud PA (New Mexico) |
on 20 Mar 2009 at 5:00 pm |
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What a conundrum. Doctorate levels only mean something to a practice if they add to clinical knowledge and standing. So far, a PA with a Master's Degree may or may not have much more clinical knowledge to apply to his/her practice or be that much better in practice than one of the "old school" PAs who have had a bachelor's degree and then a certificate PA program training plus years of experience. Currently, most PA schools are granting a master's degree after graduation from the PA program, so those of us PAs who have been in practice for over 20 years missed out on the automatic Master's Degree. However, due to the NCCPA education requirements, we've kept abreast of the changing faces of medicine and practice.
It would be prestigious, yes. But we are still not a Medical Doctor, and practice in partnership with MDs and NPs and RNs. It really won't make much difference in pay scales, either. We'd still be a PA, just one with new educational debt but a nice fancy title that will be confusing to patients. I've been fortunate to be in a family practice with urgent care and have had to keep skills and procedures sharp within this practice. The multiple CME's I go to yearly certainly update me well, as well as working with a number of MDs who share knowledge freely. I am sure that most practicing PAs and NPs have likewise honed their skills and abilities and CME certainly adds to this. As far as working within the community with a humanistic approach to medicine, PAs generally have good harmony with patients.
Will a doctorate add to the patient's appreciation of our skills? Will it really give us added clinical skills? Or simply more administrative skills? Or just prestige?
Could this all backfire on NPs and PAs? If Doctorate degrees become required, why not just go to medical school? Would it cut out those who don't want to or can't attend a long-term education that is expensive? Most of us couldn't afford it either in terms of time or expense. In short, will it eventually cut out the whole MID-Level profession? Would it lose people who could be serving the population as Mid-Levels because they would see that further degrees would be necessary and thus add to the primary health care provider shortage that is already critical?
I believe there is a vital role that PAs and NPs play in today's health care that will become more critical with time. I don't believe that doctoral degrees will count. Simply being a Mid-Level will. We need more providers giving health care, not administrators.
I started out as a PA at a time when I had to explain what a mid-level PA was to just about every patient and even to most MDs. I think our patients found out that we offered good medical whole patient care without the MD degree and that our mid-level specialties within the medical field meant they could get good medical care with caring. Will a doctorate degree improve that? |
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| Anna Davis, ARNP, MA (Los Angeles) |
on 20 Mar 2009 at 1:06 pm |
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I hold both psych and adult PC NP's, as well as an MA in clinical psych, and yes, I am still paying off student loans. I now work in psych research, but had a private practice in Seattle. The limitations on my scope of practice here in LA are maddening to me!
The best argument I can give for the quality of care I and other NP's in Washington give without MD oversight, is that my malpractice insurance from a national company, for full time private practice w/o MD oversight was ONLY $1,400/YR. A psychiatrist would have a hard time getting it for $14,000. Insurance agencies are niether charities or stupid---they know we are up to something good.
I do intend to do a DNP down the road because I want to know how to adminster programs to provide the high quality clinical care I was taught at the University of Washington to do. (Best program in the US.)
Still, I am glad that I didn't go to med school because of the differences in culture of practice. (With some exceptions...) MD's are taught to practice from a focus on thier own technical expertise, position of authority, and a rather linear expectations set. NP's practice collaboratively, with a focus on the patient's experience and outcomes. We LISTEN because IT'S ABOUT THE PATIENT, not about us. MD's generally haven't figured this out yet, so when things go wrong, the patients blame the MD who assumed all the power in the situation in the first place.
I am proud to be an NP because what I do makes a difference in people's lives---not only to fix the present problem, but empower them to be more well long after they've forgotten my name. There can be no better legacy than that. |
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| calvin pa-c (nevada) |
on 20 Mar 2009 at 12:10 pm |
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| All of the post graduate residencies should be doctoral programs like the emmergency medicine program run by the US Army and the Baylor school of medicine. A DScPA should not be required but offered as advanced training. |
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| Clair Voyance (GA) |
on 20 Mar 2009 at 8:54 am |
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I see no problem with all clinicians holding a doctorate level degree. You see patients, you treat them, and your resource of knowledge is vast. Podiatrists, chiropractors, physical therapists, etc all have enormous amounts of knowledge in their particular fields. They study for years, accrue debt, and aquire an abundance of scientific knowledge than was available even 10 years ago.
I think it is safe to say that some of the better mid-level programs produce practitioners that are smarter and better prepared than some of the worst medical schools. As a graduate of a PA school that has consistently been ranked in the top three, I experience this first hand everyday. One of the worst medical schools in the nation (by rank and admission criteria) is just down the street. Is it common for a PA student to teach a PGY3 how to manage rhabdomyolysis or a PGY2 how to do a lumbar puncture? It happened many, many times during my training. Yet these are \"doctors\".
As a mid-level who is married to a smart MD, I can understand the argument against mid-level practitioners getting advanced degrees. We have a defined role, and to get a doctorate could very well destroy that. However, she agrees that myself and most of the mid-levels she has worked with do patient care equally and occasionally better than her resident colleagues and deserve recognition for it.
That is the heart of the argument. Do we really just want more recognition. Dr. Keahey addresses herself as doctor and as a result causes confusion. In the end, does it matter what she calls herself? Is she delivering any worse care than a \"real doctor\". No. We as mid-levels are essentially life-long residents. We treat the same as a MD, we have the same outcomes, and the same knowledge base. The difference is that as mid-levels, have chosen to not be in a leadership role. If we wanted to be the leader of a team, we would have gone to med school.
In the end, I think we should come to a decision and then unify. Either have a uniform doctorate for all mid-levels or none at all.
One last thing (sorry Ive begun to ramble). The allied health professions need to all be on the same page in regards to licensing, education, and scope of practice. It makes no sense that chiropractors, podiatrists, physical therapists, and nurses all have separate governing bodies and get to decide what happens to their particular professions without thought of repurcussion. MD, DO, DMD, DDS, PA, orthotics, RT, ATC, and several others all are under the AMA governing board. So they come to consensus about what is most important for the allied health team as a whole, instead of what is best for an individual profession. |
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| Dian (Louisville KY) |
on 20 Mar 2009 at 8:39 am |
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| In reading Mr. Mittman's article I understand the need that society thinks that PA's and NP's may need the DNP to become equal (somewhat). I know that the patient's I see had rather see me than the doctor, and most doctors are intimated with this. I too spend several min. explaining that I am not a doctor, but most just don't understand. We bring to the NP role the role of the caregiver, I for one have not been able to turn off that switch. I take the time to explain test results, look them in the eye, etc. I educate as well as treat. The patients appreciate this so much. I myself had rather see my NP than my doctor. Sorry Doc. but back to the subject. I do not claim to know as much as the doctor, but in many ways I know more. When we were nurses we learned things the doctors were never taught, the human side of patient care. I would like to have a DNP, but at age 50 I don't want to go back to school, but I will if I have too. In order to pay my student loans to be a DNP would it be worth it? Will I do a better job. Will I treat the patient better than I do now? I would love to have had the resident experience, and I hope colleges get on board with more resident training. I would not want to be a better manager, I would want the knowledge of knowing the clinical. Which through the years I have learned on my own. I have learned what I needed to know, mind you it is not what the doctors know. With that said I have seem so many doctors that don't know squat and have been taken into the money machine and that is their only concern and not the patient. A particular group that I know wants a visit done in 5 min. my ethics will not allow me to perform in such a manner in order for the money machine to support all the owners which are 6. Many doctors have been forced into corporations because they can't make it on their own, they have to join the hospitals,hospitals are buying the doctors office's like crazy around here. In a large sense the insurance company and Medicare has forced this. It is terrible for them. I understand that they have a staff to pay for, malpractice and all the overheard, they just can't make it. Many are still paying on their student loans just like me and have to have a decent income to pay all of the bills. As a nurse for many years, like 90 + of you we worked in many arenas. I worked insurance for many years and I saw then 10 years ago where the future lies. NP's will be the gatekeeper and family practice and doctors are going to be forced to earn their degree's of practicing higher medicine. So will we need to be doctoral, I think so but I think we need the resident portion to be the best we can be. Think about it, as a payer of insurance, which would you prefer to pay, the rate of we are paid or the rate the doctor is paid. The insurance company has to make money too. So therefore we will be the sought after. Not the MD, he will be used for more complicated matters and a higher level of care, which I think is where they really belong in this day of change. For me I don't wan to go to any more school, but I would like to have a DNP with the residency. I figure I will be working and paying student loans until I die so I guess I will join the rest and become a DNP eventually, after all in my mind I am still 20 its my body that tells me I can't do those long hours, working full time, going to school and trying to find time for grandchildren. By the way I have an MBA as well so I have the business knowledge I don't need that, I can run a business and office but what NP has time? I just hope the DNP's are more thought out and evolve to reflect the demand of what is really needed. By the way the University of VA has a pretty interesting program. It is the best program I have looked at so far, 2nd is UAB. Just food for thought for those of you seeking and wanting to start soon on your quest. Good luck to all you young chickies. |
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| drkeahey (Texas) |
on 19 Mar 2009 at 10:51 pm |
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I am a FNP-BC with a DNP degree. Everyone has an opinion on the DNP degree. Some are for the degree and some are not. If we as NPs and PAs are going to stay alive as health care providers in the 21st century then we must band together, have a true understanding of the DNP role and support higher education levels for our upcomimg PEERS as more than likely they will be the ones caring for us older folks. If we can not stand tall with others in the health care team who hold doctorate degrees how will we survive?
Just for a little tidbit -- I went to the University of Tennessee Health Science Center Memphis for the DNP. I have to say the DNP Degree I received is a clinical doctorate. I had more clinical hours with this degree than I did with the Masters Degree.
This degree may not be the degree for all. It was hard and I would not of wanted it any other way. It's a doctorate degree for blank sakes. When one adds up all the years in college, working fulltime the whole time, all the home work and missed family time - yes the title of Doctor is warranted.
Dr. Diane Keahey, DNP, RN, FNP-BC |
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| Melissa (New York) |
on 19 Mar 2009 at 10:33 pm |
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It is a potentially divisive topic, but clearly the PA's have a role in medicine that the NP's do not and vice versa. Is there overlap, is there similarities of course but not one of the comments state that the roles exist and are appropriate. This is a period of growing pains and I do believe that there is enough room to find both common ground for both mid level practitioners.
During this transition, DNP are receiving a completion degree so of course there is far less clinical training, because it would be repetative. Future DNP's will have to study for approximately 6 years and have clinical experience which will be far beyond my initial clinical time for my masters degree.
Another issue is that many current DNP programs have yet to be accredited and they may accept students who are not clinically focused. This is yet to be decided and there may well be a decision to eliminate non clinical leaders to another doctoral program but not the DNP... I think that the decision will come to pass. But it is really too early to tell at the current time.
I know that Robert Morris University in Pittsburgh PA has officially decided to not accept applicants who do not have an clinical masters degree as Nurse practitioners, anesthatists and midwives, etc...this is the type of school which sees the value of the DNP and the need for clear focused education to benefit the healthcare professionals who are in practice, this strengthens the degree.
The mid level professional does not need mediocre degree with luke warm titles, this mr. mittleman was quite clear about. I fully support the education of my colleagues, but in this case at this point in time nurses must be able to move into the active role that they have refused to take for far too long. I eagerly await the nurse leader or the leader nurse. I feel that nurses have not had the opportunity to avail themselves to oppotunities because of the lack of the docotorate. I sincerely hope that all parties involved value the contribution of each type of practitioner but it is difficult for some nurses and pa's to accept that nursing is paving the way for the mid level --to -doctorate education. This may make NP's and PA's uncomfortable but it should not because you can move foreward on the path we take and this is the way professional growth and development occour. It is acceptable to persons to choose not to obtain a doctorate, this a not a mandate for current practitioners and should not be veiwed as a way to make some persons inferior. This is the growth and growing pains of a profession, pure and simple. |
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| Angry PA (So Cal) |
on 18 Mar 2009 at 2:19 pm |
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| For practical purposes Dr-NP you will end up spending 10 minutes just explaining to patients that you are not a Doctor but have a doctorate but still want to be called "doctor". That leaves you with just 5-10 minutes left for your exam and treatment plan. Mid-level efficiency just went out the window here. Moreover, the patient came in for a urinary tract infection but left with a huge migraine headache. Ha Ha |
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| Dr-NP (Canada) |
on 17 Mar 2009 at 7:16 pm |
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Both Mr Mittman and "Angry PA" miss the point, perhaps because neither of them possesses a doctorate, perhaps because both of them are mid-level providers for whom a doctorate is, as Mr Mittman makes clear, not really necessary. Or perhaps their position that a doctorate lacks clinical utility is rooted in the flawed argument that a doctorate is only useful if it positions its holder for a different [read: more highly paying] job.
From a nurse's perspective, the utility of doctoral work for the clinically focused nurse is to come to a more robust understanding/awareness of a distinct body of knowledge - Nursing. Trust me, there is no extra money that comes with a doctorate and the fees are not unsubstantial, as Mr Mittman accurately reports.
PAs practice within the discipline of medicine. Nursing is not the same as medicine, nor is it a subset of medicine. Some would argue this statement is divisive. It is not; it is simply the truth. As a nurse I effectively partner with MDs as I do the RD or the OT or Priests/Chaplains .. that NP and PAs operate from different paradigms is not divisive, it is self-evident.
A doctorate in nursing is meaningful as it allows nurses - whether they are practitioners or specialists - to more fully operationalize nursing's unique body of knowledge as a health care provider, distinct from the physician as primarily an illness care provider. Beyond being a health care provider, nurses are also key in ensuring the safe and efficient operation of the broader systems in which care (health or illness) is offered.
A nursing doctorate provides for an important research-based education reinforcing the relevance of knowledge translation and research utilization IN practice. Nurses are the largest part of any care system both north and south of the 49th parallel and will require doctoral-level education to address the tens of millions of Americans without access to adequate health care or the months and months of enduring painful ambulation faced by Canadian elders as they wait "patiently" for "elective" joint replacement.
It is for these purposes that doctoral work in nursing is important and ought to be actively pursued.
That "a horse is a horse of course of course" seems a reasonable professional argument ... well, this ought to be more than sufficient example of why a broader capacity to reason is so fundamentally important in the complexity of 21st century health and illness care systems.
It is not about partnerships: NPs and PAs will partner just fine thank you. It is not about confusing the PA or NP with the physician: that ALREADY happens as every NP and PA knows and still patients receive the care they require.
IT IS about becoming smart enough to solve the real problems that face Health and Illness care systems today before the USA & Canada can no longer afford health care, at all. |
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| Angry PA (So Cal) |
on 17 Mar 2009 at 1:56 pm |
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Funny scenario: "Hello Mr. Smith, I am a doctor but not really a Doctor. Do you understand what I am????" Ha Ha
The moral of this story: "A horse is a horse of course of course" |
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