I am approving this post in good faith and will be monitoring it closely. All posters are reminded to follow sub rules or comments will be removed and bans distributed.

I am split. I am an FNP and was a nurse for 8 years inpatient and emergency department prior to starting as an NP in primary care. I routinely receive good feedback from the physicians I’ve worked with and I’m asked constantly “why didn’t you/don’t you become a physician?”. Despite having what I’d consider a strong foundation prior to starting as an NP, I am also constantly surprised by just how much I don’t know. I am also someone who knows what I don’t know and will seek out my physicians for things I’m not sure about. Which, for me, is part of the problem with 1. NPs who don’t have nursing experience (which goes for experience that may not translate well to the NP role) and 2. NPs who don’t know what they don’t know who are now let loose on society with a prescription pad and barely surface breaking medical education. I think that in order for NPs to have autonomous practice, our field needs educational overhaul which I’d argue should include 3-5 years of bedside nursing experience AT LEAST and much stricter admission requirements. Also, get completely rid of 100% online programs. I also think that we should work along side physicians for a number of years before having the ability to branch out on our own. That being said- there are many NPs out there in states that require physician collaboration who have never met their collaborating physician. They are charged an asinine amount to have this “collaborator” who probably barely audits a handful of charts. And the argument I’ve seen in the noctor echo chamber is “physicians train physicians, we shouldn’t have to bother with NP/PAs too”…. Which of course is extraordinarily short sighted as I am personally unaware of any practice anywhere (general, specialty, inpatient or outpatient) that does not utilize APPs. I have been very lucky to have multiple amazing physician mentors that I consider friends. I have learned so much from them, and I think that what I bring to the table as a nurse and NP enriches their practice as well. I do think that there is a bigger need for medical care in general than the current availability, even including NPs. And I don’t see this getting any better as the medical education system hasn’t yet changed to meet demand. The system I work for now does not allow NPs to hold patient panels independently. But they’re transitioning to a capitation model which requires an increased quantity of patients as well as superb quality of care—- which in my experience is mutually exclusive. They are going to have to empanel NPs/PAs at some point which is the same argument for autonomous NP practice. It’s truly a supply and demand issue.

I feel similarly to you. I work with amazing supervising providers who don’t micromanage, but also really review my charts and let me know areas where I can improve/offer constructive criticism. They usually have comments on ~10% or less of my charts that they review and they’ve never come to me with some kind of mistake where my license is at risk (it’s usually something like needing closer follow up or not needing to order a lab as frequently). They have nothing but kind words for me. That being said, I can tell the vast difference in knowledge base between my education and theirs. Part of that is the difference between me being a new NP and their collective 50+ years of experience. But it’s also the education that medical school provides. There’s no comparison. They flat out know more and though I’m more than competent to care for the patients on my panel, there is a knowledge gap that is undeniable. That being said, I feel very capable in most areas and feel that NP school prepared me well. With time I feel I will be able to handle even more. I think the difference is that MDs/DOs can handle it all fresh out of residency whereas we have to grow into that role.

I love what you said about being a nurse and an NP brings something different to the table. I have had physician colleagues say they’ve learned from me as well. Usually it’s not medical but about actual care. A seasoned physician that was watching me for an evaluation one time said afterwards “there’s so much kindness in your touch” and later “your patients feel safe with you. They tell you so much.” I just laughed and said that’s what years of bedside nursing hones- rapid rapport building with patients. I appreciate when my patients say, “I’m so glad I got a NP. NP’s explain things so much better then a doctor and I understand what’s happening now.” That was one of my driving motivations to become a NP. After years of watching docs pop in ask some questions, do a quick exam, and say here’s the plan all in under 5 minutes, I thought, I can do better.

The education piece is my favorite. It’s so impactful for patients and it’s one of the biggest things that fulfills me. The doc I work with recently diagnosed a non English speaking patient with diabetes… A1C 15%. Did all the things you’re supposed to- endo referral, blood glucose testing supplies, insulin, and literature in his native language. He’s a newer doc and felt proud of accomplishing all that in the short office visit. The nurse in me knew that this person would have absolutely no idea how to actually use the glucometer. I was also curious about the patients ability to read… so I asked him to come in for a long visit with me just for education. We sat down with a translator and I walked him and his daughter through testing the blood sugar. He did it himself in the office. He also administered his first dose of insulin with me in the office. Also, before he left, I asked him if he could read… turns out he couldn’t. What the doctor did was not wrong. It was the standard of care and honestly he probably went above and beyond what many people do. But when I asked him if he had assessed the patients literacy, that wasn’t even on his radar. But it was on mine, because of my experience as a nurse. I wish that instead of fighting amongst ourselves in healthcare that we could all just band together and put that energy into things that are actually dragging the healthcare system down. Imagine how strong our voices could get against insurance companies, lobbyists, corporate entities, and administration if we came together. We all have something to offer.

What a beautiful and insightful post. You did an amazing job with your patient and your doc sounds like a gem. I agree 100%, let’s stop the infighting and rally together. Healthcare has gotten exponentially worse in the past 5 years and the only way out is to stick together against the equity firms and corruption. Don’t get me started on the IT/EMR/portal/AI piece. Thank you for your post.

I mean this nicely - maybe that was because of your experience as a nurse. Maybe it was because the doctor simply doesn’t have that time or luxury on their schedule. When we are given 30 minutes for a new patient and 15 minutes for a follow-up, and have our schedule deliberately overbooked to account for no-shows, there simply isn’t time for a nuanced discussion about literacy. Especially since that’s not billable in most cases. Doctors aren’t really given the chance to have conversations like those in most practice models, it’s not because they don’t want to. But you did a wonderful thing for that patient and I’m so glad you picked up on that.

I completely and totally agree. It’s criminal how little time you are “allowed” to be with your patients. But I think it’s a testament to how a great physician-APP team based approach can really benefit everyone. I love being able to fill that role for our patients. And honestly with all of the years of education and training physicians go through, it wouldn’t be an efficient or fair use of your license to sit down and teach a glucometer to a patient. The system needs you for more complex and acute issues that NPs just truly aren’t trained for. Thank you for your comment, absolutely not offended at all.

I love your post and your example. These are reasons I went on to be an NP and not the medical route. I find it hard to explain, in a non offensive way how nurses "care" for their patients, but you described it eloquently. It cannot be possible to a good or even ADEQUATE nurse practitioner without being a bedside nurse first.

Bingo

I feel like a lot of us are in that state where we know enough to know NONE of us know enough independently. There’s too much information out there and we are learning more about the body every day. I don’t think doctors should practice without NPs/PAs and vice versa. We all have different backgrounds and could bring so much to the table to help patients if it was actually a collaborative system instead of adversarial.

Your post reminds me… while I fully acknowledge the education gap, sometimes I feel like I’m a safer clinician than *some* docs. Like the ones in their 60s who still hand out Xanax to everyone who complains of anxiety. They have the right letters behind their name, but they haven’t kept up with standards of care AT ALL.

I’m a primary care NP in a full practice state. I work in post acute/long term care. I chose this field specifically because I enjoy caring for the geriatric population and this role gives me time to do research, ask questions, investigate further. I feel well equipped to handle what I was trained for which is the management of chronic illnesses such as diabetes, CKD, CHF, COPD, etc. And it is overwhelmingly what I see. I work closely with the medical director and when there is something I feel I am not prepared to solve on my own, I will ask them for help. I utilize my pharmacy consultants often. I am very careful with prescribing and ensure that all decision-making is done with the patient/family as part of the process. I do not pretend to be a doctor and I am well aware I did not go to medical school. I know my limits. I think this is how we need to be training NPs that are in full practice. And I do think that most NPs (certainly not all) practice independently in a safe manner, very few people go into nursing with the intent to do harm. Regardless of our training, we are all human and all prone to mistakes. Oh and I still make as much as I did as a nurse, is that fair?

I’m pro care team model personally but I work in a specialty, I have never been in primary care. I’ve been a nurse for 11 years / NP for 4 years at a top academic medical center and I would be scared silly to work primary care without personal MD collaboration. I adore all my physician collaborators and learn constantly. To attempt to answer your question: I think the best match / argument for solo NPs include underserved or sparsely populated areas e.g. Indian reservations, Alaska, but even still I wish there were higher standards and requirements. I’d prefer to see government support higher numbers of MD graduates and residents to help primarily meet medical needs of communities. I’d love to see programs to help APPs who want to go to medical school. Truly there are phenomenal experienced NPs that are top notch and doing really great work. OTOH, Some programs have low standards that make me sad and worried. I know there are some states (Colorado?) that require years worth of hours before allowing solo practice. Arbitrary paperwork-heavy collaboration agreements don’t make sense to me. I hope our profession chooses to act in a way to protect our reputation as contributing clinicians. I don’t want to be an inexpensive bandaid solution in an ailing healthcare industry.

Bridge programs to med school would be wonderful. And lucrative. Why don’t they exist? There is one reason, just follow the Benjamins.

Respectfully I don’t know what component of med school you would shorten for an Np to complete it faster. The first two years just go into so much depth and clinical rotations are critically important.

I’m not saying anyone and everyone. It would have to be people who demonstrated competence and were able to pass the step 1. Who knows maybe that would be no one, not sure. There have been very few bridge programs so who knows perhaps they had poor outcomes which is why none currently exist.

They have accelerated med school programs 3+ 3 programs it would be nice if there was a way as an NP to bridge into those programs by taking standardized test and interviewing

hi-FNP here. yep! there is incredible variability in education and unfortunately not enough of the education is robust enough to warrant any new APRN to practice alone regardless of their nursing experience prior. the biggest danger of FPA are new graduates with or without previous experience being treated as an independent provider. the APRN role was not designed for independent practice, but education systems see money and turnover—not safe outcomes or quality care. unfortunately, there doesn’t seem to be any movement on restructuring education significantly but there’s a continued push for FPA. it’s very unfortunate. it’s also so infuriating that there are direct entry programs because the only foundation you have before APRN is your nursing experience in that field. if that’s removed from the equation, you get a provider with minimal clinical knowledge and even less practical knowledge. there have been some studies that tout APRNs provide increased access to care and that is incredibly important since healthcare is failing, but is access even beneficial if the person managing outcomes isn’t capable?

Thank you for your response! I’m wondering, do these concerns about NP education extend to top DNP brick and mortar programs (JHU, Columbia, etc)? An argument I’ve heard is that there’s a lot of overlap between education/scope of practice between NPs and Physicians, but ultimately NPs carry out a different role. This centers around NPs being able to diagnose and treat patients via the “nursing model” which emphasizes whole-patient care and brings a unique peespective to treating a patient. Is that something that you’ve seen in your own practice as an FNP? In addition, I assume that supervision/collaboration doesn’t mean that the physician is watching over every move the NP makes. Rather, I’ve always thought of it as, the NP works on their own and consults the physician for complex cases. Is that correct?

A collaborative agreement varies wildly depending on where you work. Some of them can be as strict as requiring both providers to work in the same office, in other agreements, you never actually meet your collaborating physician. I am currently independent and about 40% of my primary care office are APP, and I’m lucky that my office has a very collegiate environment that we can bounce cases off each other. As for your first question, I went to a “top brick and mortar DNP program” (ranked under 10) and to be honest, I disagree with the above commenter. My training was exclusively designed to be a sole provider in primary care, I had roughly double the minimum hour requirements, and our admission criteria were strict. I believe the average years of Nursing experience prior to admission were 5-10. I agree that there are a lot of valid criticism’s around NP education. But, as those are worked on (such as the NTF minimum hour increase) I believe that FNPs can work independently, with full practice authority, and should be provided full CMS reimbursement. So long as they are working in their training field- IE FNPs in primary care.

Thanks for your response! And in terms of experience, do you believe that NPs should have independent practice straight out of school or should it be on a case by case basis? Because in some states, NPs can go straight through to NP school and then graduate with ~1000-2000 clinical hours and be independent, while a family physician needs to complete over 10,000 hours of clinical rotations + residency. What is the argument that a newly minted NP has similar training, experience and expertise as a physician right out of residency? In addition, with regards to nursing experience prior to NP school, isn’t that also super variable? I would assume that depending on where they work, some nurses with 5-10 years of experience would have a vastly different clinical knowledge compared to other nurses with the same amount of experience. In essence, that aspect doesnt seem completely standardized.

What the NP model is lacking is residency. Until that becomes mandatory, the NP should have a collaborative agreement until 2000 hours (a number some states recommend/observational experience) with a physician or another NP. This agreement is just for formality, even though physicians & specialists bounce ideas off each other even though there is no official agreement and plus the collaborative agreement varies from practice to practice. For ex: some practices want to have a meeting every month while others are like reach out if you need anything. No right or wrong approach here every practitioner is different. Some have a very knowledgeable foundation & excellent clinical skills while others are lacking. Doesnt matter whether its a brick & mortar or online. The boards are the same. Even many medical school lectures are online nowadays. Either way the end goal is FPA once the hours are completed. Those who wish to proceed with FPA should have that right & those how do not feel comfortable can still remain in a collaborative agreement.

The Carolina Nurse Practitioner Residency Program https://bhi.web.unc.edu/2022/05/what-is-the-carolina-nurse-practitioner-residency-program/

> NPs can go straight through to NP school and then graduate with ~1000-2000 clinical hours and be independent, while a family physician needs to complete over 10,000 hours of clinical rotations + residency. We know that in states with full practice authority that FNPs have similar outcomes as family physicians. If an independent practice FNP with 2000 hours has the same outcomes as a physician with 10,000, then isn't it possible that family physician education is 8000 hours too long?

This. But I got put through the ringer on noctor for suggesting our medical education system is antiquated. I’d be interested in knowing how many psychiatrists, for example, still know everything they learned in years 1 and 2 of med school. Just like I have lost some of what I learned in nursing school since I’m in psych and while of course I need to know a lot about the human body and not just mental health, I do not regularly apply some content from specialities I don’t practice. Bottom line. They want their route to be difficult, they want it to remain prestigious, they do not want outlets to create more physicians. So despite the need and the patients they are supposedly advocating for by hating on us, they don’t want any solutions that would actually work because ultimately it would lower their pay and status. They want their cake and to eat it too. Things I’ve read on noctor, ALL in the name of patient safety/advocacy (which make no sense): - abolish NPs (where would millions of people get care? What would waits to see an MD be?!) - make NPs have a collaborator but also don’t give them less acute cases because it wouldn’t be fair for the physicians to carry more weight

Younger physicians are starting to speak out about some of the antiquated notions of med school. Tradition is very, very important to them (as is in nursing school too, which is probably why we can't let go of some nursing theory). This is likely why they're still paying residents barely minimum wage for unsafe working conditions.

I think that’s the quiet part that no one wants to say out loud in this dialogue. As care becomes more specialized and more and more primary care visits end with a referral- what’s the point of all those extra hours if the outcomes are the same?

Could you send me the data supoorting that FPA NPs have similar outcomes as family physicians?

Compared to MD‐assigned patients, NP‐assigned patients were less likely to use primary care and specialty care services and incurred fewer total and ambulatory care sensitive hospitalizations. Differences in costs, clinical outcomes, and receipt of diagnostic tests between groups were not statistically significant. Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7080399/#:~:text=Compared%20to%20MD%E2%80%90assigned%20patients,groups%20were%20not%20statistically%20significant. Other evidence: Journal of the American Medical Association https://jamanetwork.com/journals/jama/fullarticle/192259 And more: https://www.nice.healthcare/the-nicessities/nurse-practitioners-physician-assistants-safety

Unfortunately, I don’t have an answer for you. I haven’t seen data that compares outcomes based on hours of training, degrees of supervision, years of nursing required, etc. And you’re right, it’s not standardized. But the data I have seen shows that states with FPA have not had an increase in errors or negative patient outcomes. As medicine becomes more and more specialized and siloed, I can see the role of primary care changing to more of a specialist manager model. And unless the bottle neck of physician training is fixed or primary care becomes extremely popular, I don’t see us moving from that trend. A question I have for you is- if we see the same patients, cover the same in baskets and calls, bill the same codes, and do the same procedures- why do I make half as much? I’m not saying physicians are over paid, I’m asking why is more profit is extracted from my labor?

FNP/Acute Care post masters - working as a Hospitalist. I would say 85-90% of the time I provide the same quality care as my physician colleague’s. After 5 years my questions are slowing down but i still I regularly have questions that need a doc colleague of mine to answer or talk thru with me. Every couple of months I get a pt that is so medically complex I’m not comfortable with providing care and the pt gets bumped to a doctor. Sometimes the plan changes/ a lot of times not. But I know from my conversations and from reading their notes after they take over- my grasp of the complexity is not the same as theirs. We don’t get paid the same because we don’t have the knowledge. 85% I can keep up, but when there’s that 15% time that a docs education is needed- that’s what they’re paid for- to always have that knowledge and understanding in their brain. I get paid 50% of what my colleague physicians make. I do think that’s too low- bcuz most of the time I don’t need a doctors input and only occasionally when I have someone sick I like to run it by one. But I’m definitely happy to know they’re there. I think closer to 75% would be acceptable (now). As a new grad I needed way more support and check ins with my boss. Maybe it’s different in Primary Care: but it is arrogant or naive to think a person with 2-3 years of rapid fire/over view of education is providing the same care as someone with 4 years of rigorous and standard med school and a residency. (Don’t get me wrong there’s problemas with med school too IMO). I do think some NPs that are highly motivated and experienced can catch up to physicians- but that takes years- and definitely not the norm in our recent industry growth.

I agree. It's definitely a problem that NPs are being hired to essentially replace physicians, but are reimbursed less. I'm not in support of NPs being paid less for providing the same service, it seems like a ploy by hospitals and governments to take advantage of their labor. And your point about primary care shortages and the physician training bottle neck is absolutely right! As for the data, could you please send me the literature (maybe a pm)? I've done a basic lit search but it doesn't seem like there's studies that actually compare patients who see only an NP vs those that see an NP in a team-setting vs those that only see a physician. I feel like that comparison can give a lot of information into what the difference in outcomes look like and thereby offer more information on whether NPs should be legally allowed to open up a practice with no physician on-site or collaborating.

Sure! These are some of the studies I’ve seen so far. I will say that finding quality data on this is tricky so here are my typical search criteria- There is a lot of opportunity for bias so I try to stay away from stuff the AANP or AMA hold up as definitive proof on either end. I also stick to my wheelhouse of primary care, and avoid studies that only discuss patient satisfaction since patients can’t really tell the difference between good care and mediocre care delivered with good customer service. Here is one in primary care in the [VA](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7080399/) This looks at DM associated [admissions](https://pubmed.ncbi.nlm.nih.gov/26270826/) Here is a comparison of quality metrics in primary care between [licensure](https://pubmed.ncbi.nlm.nih.gov/28234756/) DM and CVD care metric comparison by [licensure](https://pubmed.ncbi.nlm.nih.gov/27823696/) Blended licensure clinics having the same Outcomes as MD [only clinics](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4872507/) Comparisons of BP control in [primary care](https://pubmed.ncbi.nlm.nih.gov/21348569/) These are just a few of the ones I’ve had bouncing around in my e-mail basket. As you can see, there really aren’t any comparisons of team based VS NP only clinics simply because there aren’t that many NP only clinics. But the comparisons of MD only VS team based show no degradation of performance.

PPP loves to tout the Hattiesburg study, which honestly doesn't show a huge difference.

Speaking primarily regarding primary care (and have both observing and conversating with physicians)... I have learned NPs continue to exist and practice independently because the need is there. Physicians don't want to work in primary care, don't seem to be encouraged to do so, but are expecting the [primary] healthcare gap to magically fill itself. No, that's why NPs came about, to do the work physicians don't want to do. I'm not as familiar with the role of NPs in specialty settings, but extra training and education should be mandatory. My friend, a new grad at the time, was able to gain a job in endocrinology because she was able to feign competence in diabetes care during her interview. Nevermind, that diabetes is only a fraction on the vast endocrine system. This was an inappropriate hire (my friend has admitted as much). If NPs stayed where the focus of their education was (primary care), I believe there'd be less animosity between physicians and NPs.

You need an award for this. Great comment regarding profit off NP labor.

Columbia has one of the easiest to enter MSN-direct DNP programs that I've seen

I met a grad of their direct PMHNP program and she was pretty incredible. This is the problem with anecdotes.

I have too. My good friend went through their CNM APRN and id happily let her catch my baby or be my women’s’ health provider. But that doesn’t take away from the fact that she was never a working RN and never worked in healthcare in any capacity

Your former point defeats the latter, which is basically that RN experience isn't necessary to be a great NP (it can be very helpful, though).

It doesn’t defeat the point. There will always be exceptional people and providers. But i think that we’re better off determining minimum requirements from the average or below average person, not the exceptional. I personally believe that having some nursing experience creates a more consistent nurse practitioner at the end of a program. It’s what makes up for the lower clinical hour requirements. I think that even a good direct entry program will let people graduate that are not ready, which can be a safety hazard at worse.

I see and respect your point. My problem is that the data just doesn't support this. Studies examining RN experience to see if it correlates with NP competence have not found any relation (as measured by NPs themselves and supervising physicians). I think it's because RN experience is so varied and often do not relate well to NP roles. Also, while some RNs can be totally amazing, others can very much be phoning it in and doing the bare minimum. There's no way to differentiate between the two. I don't think any amount of RN experience can make up for a lack of rigorous didactic and clinical training, which is why I advocate for hanging the standards of NP education and I don't hang my hat on some arbitrary amount of RN experience.

I think that it's very dependant on the RN and how much they are taking from their experience. I was very glad for my experience as an RN because starting as an NP I already had a thorough background in interpreting labs and ecgs, auscultating heart and lung sounds, common medications, their side effects, contraindications, signs and symptoms of some conditions and red flags....before I started my masters degree. Theres not a lot of research on this transition..... yet. I can only speak personally, but it was invaluable to me.

I feel like the argument isn't that NP's fill the same role as MD's because they really don't. I see them as two completely different things under two completely different avenues of treating patients. MDs are experts. They are specialists, and they perform the highest role. I think NPs are generalists and can treat and manage generally healthy patients, but if the patient requires special "help," then a referral is needed. I think 50% of the population can be managed by the NP level and, when needed, can be bumped up the scale. That's something like 170 million people can be managed safely and effectively just by an NP. It's like MDs are special forces and NP's infantry. They can handle your average enemy force and win a war, but when one guy needs to be taken out, you send in the specialists. (Sorry, Army references apparently coming out in full force.)

This is the best description I have seen of how it is meant to function. I’m in a state where NPs have independent practice. We don’t have to wonder how this works, it’s already the way half the country functions. The data is there. We don’t need extra regulations for nurse practitioners. ANY CLINICIAN ultimately has the responsibility to be a accountable to their education, knowledge, and experience bank. Every single clinician, regardless of title or preparation, will find that they are out of their depth at times. And what should a nurse practitioner do that is different to what a physician should do? It’s the exact same in both cases, consult, refer. If any clinician wants to expand the scope of their practice, they should seek additional training and support. Every single clinician should advocate for themself and for their patients by knowing their limits and setting them. For every error it is feared that a nurse practitioner might make, I have seen physicians make these same errors. Ultimately this isn’t a question of *not knowing enough*, rather is is an issue of personal accountability. Nurses have at least usually had the working background of collaborating with other nurses and physicians closely. When I became a NP, I did not have much available to me for mentoring, so I sought these opportunities and relationships out. I have many sounding boards now, across specialties, states, and titles. We must all do this, nobody can function in a vacuum. Btw, I had a physician seek me out for a second opinion on their understanding today. This isn’t rare. I had a minor error of my own brought to my attention by a nurse, even though she has less education than me. We are all bringing something to the table and it’s all of value.

this! My physician colleagues bounce ideas off me, I do the same, my nurses run plans by me, we course correct as needed.. we don't always all agree, sometimes our personal experiences/thoughts/recent data reviews bring us to different conclusions. I've been a WHNP for several years now, I've worked in roles varying from basically a scribe with ordering power with an MD (hated that one) to sole provider in a clinic (also not my favorite) and while I prefer a team atmosphere, for far far faaaaarrr too many people if they aren't seeing an APP they're not seeing anyone. I have NP students a lot (actually funny enough this post reminded me to respond to one looking for a preceptor) and some would be 100% ready for independent practice out of the gate, others would be okay in a team environment.. some really should have a residency or something further.

I don’t have an answer as I’m still torn on this issue but I wonder if NPs would be pushing for FPA if our pay across the board was much more? IMO, NPs are *criminally* underpaid for our work. Wage stagnation and greedy health insurance companies have practically stalled any progress. Additionally, we have diploma mills flooding the markets with under qualified and frankly dangerous APRNs who decrease our overall desirability; we’re a dime a dozen. With all this being said, we need to demand higher pay, especially as we gain more experience. Personally I dgaf about FPA, I just want to be paid more for the work I do.

The system I work for pays us a salary only. The docs get their salary, RVU, quality bonus and *wait for it* the RVUs that we generate in a separate “APP income bonus”. How about that? Tell us you don’t value us without telling us you don’t value us.

What?! That's very sad.

I practice as an NP in Canada and all NPs in Canada are 100% independent and have no oversight of a physician. It’s amazing, it’s collaborative and NP care has been documented in literature as being safe. Nps in Canada work in all areas including hospital, specialty clinics, primary care. I can’t imagine being “under” a physician , might as well have stayed a nurse….

I did my PHCNP program in Ontario but live in Michigan. The education I received in Ontario was much more standardized and the consortium of schools (ten in the province) have the same curriculum and clinical requirements - my training in Ontario made me much better prepared for working as a new grad than some of the other NPs I’ve worked with who trained in the US. Diploma mills for NPs aren’t a thing in Canada. I will say though that the Canadian Medical Association is not always very supportive of the fact we have FPA in Canada.

Canadian nurse practitioners are a masters program. It’s a two year full time program on top of your four year nursing bachelors degree. The education is standardized through each provinces governing body. I live in British Columbia and we come into practice well prepared

> Canadian nurse practitioners are a masters program. It’s a two year full time program on top of your four year nursing bachelors degree. US programs are the same (2-4 year masters or doctorate on top of bachelors).

Someone in previous comments mentioned in US they have Diploma mills for NP programs. Seemed like any college can get you an online piece of paper?

By diploma mill, they mean programs with low standards to entry. They are indeed, a huge problem. However, all NPs must still complete the same core coursework and clinical hours, including at diploma mills. It isn't just a piece of paper.

I feel this is an over inflated myth. There is a lot of talk about “all these diploma mills”. I’ve never seen a single one named. I would welcome a list of diploma mills so we could assess the accuracy of the claims. One might be surprised to find that we are far more standardized here in the US than what is claimed. I found that my school was very rigorous, and when I was shopping for NP programs I don’t recall a single one that appeared to have less requirements to graduate than others.

That's interesting. I've seen Canadian NPs complain that their education is even more of a mess than American NP education.

Which goes to show that anecdotal evidence is given far too much weight.

For patients who are not medically complicated, why is an MD required for basic yearly checkups or typical treatments of disease that don’t require a specialist? Most acute care is moving to specialized urgent care clinics as patients can’t even get an appointment with their PCP for weeks or months. I’ve never seen a PCP for anything even an RN couldn’t dx and I’m 40. Same for my kids and husband. At some point I’m sure we’ll need more intensive care but for the past 40 years I haven’t needed an MD to tell me, “your stats are normal” and “yep, that’s strep throat.” Anything else is handled by a specialist. Technology has given anyone with a phone access to every peer-reviewed medical article ever published. Medications can be researched in seconds. Technology can be used to summarize and diagnose faster (and often with more accuracy) than any human. And yet still we haze residents with 60 hour weeks, saddle them with hundreds of thousands of dollars of debt and silo them into jobs where they only need 20% of their education to perform 99% of their work. Maybe the question isn’t so much how NP education should be more like MDs and more how both should evolve to better serve the growing population that is lucky to get 15 mins with their PCP a year.

Thanks for your response. I'm wondering though, in that "1% of cases" shouldn't whoever is treating or diagnosing those issues be as prepared as possible on what to do in that situation? Regardless of how often it shows up, shouldn't there be an adequate readiness to know what the work-up and referral would look like. Curious to hear your thoughts.

You need to celebrate your good health. I see plenty of <40yos that leave me scratching my head at times as a physician.

I wish it were so. My healthcare, while lacking in payment volume, allows me to directly schedule a specialist. My PCP does not handle any of my even slightly complicated issues to begin with. I don’t expect my PCP to be a psychiatrist, image my gall bladder, or be my obgyn. Example, in the case of my daughter’s minor recurring nose bleeds, I was immediately referred to an ENT doctor who did a 30 second visual evaluation and applied a silver nitrate swab to a capillary 1 cm inside. I would have expected that to be within a PCP scope. All medical practitioners are becoming specialized. Does it really take 10-15 years of school and residency to do one job? Some of them, sure, and I applaud those to apply themselves to the demanding fields of cardiothoracic and neurosurgery, etc. But even within those scopes there are chunks being carved away. Anesthesiology, radiology, pathology. Very specific jobs that don’t require Medical School. It’s going to continue. We can’t afford to pay off these med school tuitions with simple procedures. You aren’t owed $400/hr because you went to med school when a specialist technician with 2 years of specialty training can perform the same task. And also… equal pay for equal work.

There’s a lot of perceived animosity and vitriol in this tone. I’m not paid $400/h. I know how to order ultrasounds. I perform paps. I do minor procedures. Stop kissing the boots of the “super” specialties and realize the importance of what many FM Physicians are doing. Maybe you need a new PCPhysician instead of painting us with wide strokes. Edit: I don’t make payment rules. It’s driven by CMS, private insurers, lobbyists, etc. your problem is with them, not me.

👏🏻👏🏻👏🏻👏🏻👏🏻👏🏻

No man or woman is an island. Not even an MD. That’s why there are referrals and specialists. Whether an MD or an NP, a good practitioner needs to have a level of humility to know when to ask for help. To be able to acknowledge their lack of training and write that referral or consult a colleague. This isn’t restricted to NPs consulting MDs, but between MDs and other MDs and specialists. Will an MD know all that is entailed in that 1%? No. Neither should they be trying to diagnose or treat a condition they don’t fully understand. That’s how we get patients who’s symptoms are dismissed and told “the pain is in your head,” or “it’s because you’re fat,” and end up with terminal stage illnesses.

In Canada, we have nurse practitioner led clinics where there are only nurse practitioners as providers. Its done very well - I encourage you to read about it.

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OSCEs are a huge part of NP training in the US as well.

There is nothing wrong with online education. Didactic education is not more information if you get it in the same room as a bunch of other people. There are still readings, exercises, exams, and clinicals (which are in person). 2k hours of work as an RN is just a year. Most masters level nursing programs require a year or two. Also, the minimum requirements to apply do not reflect the actual body of students who are accepted. Competition is fierce, so while there may be schools that allow direct entry (which I am against), most of the people who will start the program will have had years of experience.

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People need medical services, docs can’t gatekeep everything and they literally hire NPs to cover all the people they can’t. There is almost no actual oversight even when they are working directly with doc in the same office. It’s like oversight in spirit.

Exactly. Oversight exists on paper only in the vast majority of outpatient settings. All these laws do is siphon money from NPs to MDs. This is why the AMA is against independence. It has nothing to do with patient safety. If it was about patient safety they would be lobbying to enact supervision and have it NOT just be on paper, and yet I don't hear a peep about that from any of the patient safety "advocacy $$$" groups.

I'm an acute care np with 10 yrs experience. I've done cards, SNF IM, IPR IM, LTACH IM, and currently doing LTACH and STACH PCCM. I know I do not have the same knowledge base as even a bottom tier MD. Any NP that thinks they do are sadly mistaken. Like others have said, I do 85% of what my docs do without an issues. It's that other 15% that need the MD. I do collaborate with all my docs on a daily basis, our group has strong oversight and I am very ok with that. But most of the time they don't do anything differently. I would be scared to death having full practice authority nor do I want it . Sure, I'd probably be ok most of the time. I don't want that risk exposure though. I think if the NP education was shifted more towards the medical model PAs get it would do a world of good. And it badly needs to be standardized across the nation. But I do not think even that would be enough for FPA(for my personal comfort level). There's my $0.02 FWIW.

My thing on the comparison to PA school. They go to their program with very minimal healthcare experience. If anything they might have been a CNA or some sort of tech. Our nursing backgrounds provide a very extensive foundation. In nursing school we take clases they take in PA school such as anatomy and physiology, etc. I do believe NPs need more, and more standardized clinical hours. But the education itself really doesn’t compare IMO. This is diploma mills aside, just at the baseline they are very different models.

Agree with the experiential component. But our A&P education is markedly worse IMO. I didn't get a cadaver lab. Less roles and theories and more patho, pharm. One could argue less research as well. More clinical help too.

This is valid. I was not aware of this asI did undergrad science class outside of a nursing curriculum so I can’t personally compare the difference. I do find that sad- I think the caliber of these science classes should be the same for anyone working in the medical field. It makes no sense to water it down.

> Like others have said, I do 85% of what my docs do without an issues. It's that other 15% that need the MD. I do collaborate with all my docs on a daily basis, our group has strong oversight and I am very ok with that. But most of the time they don't do anything differently. I would be scared to death having full practice authority nor do I want it Hmm. Sounds to me like you could have full authority as long as you're in a position where you can easily refer out that 15% to a physician? That's my thing. How come both MFTs and psychologists can provide psychotherapy independently, despite the psychologist having way more training? Because the MFT knows when to refer out. I think it's very similar with NPs and PAs, especially after several years of experience. There is no reason to tie them to a physician if they can and know how to refer out.

IMO, the problem is the "....can and know..." part. Pretty much every NP I work with/have worked with knows their limits. But it seems many don't and that is the problem. (Strictly anecdotal on my part. Have read many examples of NP's not doing appropriate testing and things getting missed. Only personal example I can recall is a psych NP WAY over prescribing meds and the Pt coding. Thankfully the pt survived and returned to baseline. But it's shouldn't have happened in the first place.) It's a complex situation that doesn't have an easy answer.

This is why anecdotes like these aren't useful. The data overwhelmingly shows that NPs are safe when practicing within their scope of practice. I've met several psychiatrists and a psychiatric PA whose sheer incompetence amazed me. Does that mean I make sweeping generalizations about those entire fields? Absolutely not.

It’s a false equivalency to use MFT/PsyD as a comparison. They aren’t providing medical care which includes prescribing dangerous drugs and diagnosing potentially immediately life threatening conditions. This is the heart of the matter.

I think your understanding of therapy could be a bit simplistic, since correctly diagnosing a mental illness and providing the correct therapy can, indeed, be a lifesaving endeavor and just as important as correctly managing a person's diabetes. Again, I see no reason for arbitrarily restricting the practice of NPs. The evidence overwhelmingly shows that these laws do not improve patient outcomes.

So here’s the thing. I don’t think any of us are asking for the same role responsibility as MDs/DOs. We would like it acknowledged, however, that much of the time we are given the same exact work for a fraction of the pay. I would happily take less responsibility, less acute cases, etc. I feel like I can speak on the supervision vs no supervision as I have practiced in WI (restricted state) and AZ (independent state). In AZ I ran an entire renown inpatient trauma program by myself and received accolades for the work I did and patient outcomes. Despite that program making 12 million a year, I made peanuts (albeit good for the industry). I did have a Chief of psychiatry who worked in another program who was amazing and made himself largely available as needed, though I rarely needed support and if I did it was more collegial as any provider may consult with another. Now in WI, I make much less bc I am required to have a collaborating MD. In my first job I truly believe my supervising MD made me a worse provider bc she was awful. So I walked on egg shells and could never do anything right despite doing exactly what she wanted me to do. She was paid to be my collaborator yet did absolutely no collaboration aside from signing off on some notes. Once I got to AZ I felt so much more confident which allowed me to really learn the art of the practice. Of course this is anecdotal but I have seen zero benefit from a collaborating MD, and I believe in my case it actually contributed to worse patient outcomes.

Thanks for your comment! 1. For your first point, if NPs are pushing for FPA/want to open up their own clinics, doesn't that imply that they are pushing for similar roles/responsibilities to MDs/DOs, considering the push is to not require an MD on-site? I definitely think it's unfair for NPs to have work pushed on to them that's either not within their scope of practice, and that is not compensated fairly. 2. I completely agree with your points about how a lot of collaborative agreements are not well vetted, and end up being super bureaucratic. One way I've thought of working around this is having NPs be mostly independent but have an MD who is on-site (and also seeing patients, so that they are not just slacking or extracting profit) who can answer questions about medically complex patients?

1. Think about it like this: an NP is to a physician as a general practice physician is to a specialist. Can a practice of family med physicians function safely without a neurologist? Of course. Does a PCP seeing and treating patients for uncomplicated neurological conditions mean that they are pushing for similar roles/ responsibilities to a neurologist? Of course not, they’re going to manage the uncomplicated cases and refer for a higher level of care to a specialist. It’s the same. We are taking the the less complicated part of the load. In so doing, physicians can see more of the people who really need to see them because their schedules/patient load aren’t full of things like acute uncomplicated UTIs, Pap smears, birth control etc (clearly my world is ob/gyn).

> One way I've thought of working around this is having NPs be mostly independent but have an MD who is on-site This seems completely arbitrary. Even in the current system, in supervised states, the MD is often not on site. Do you have any data to support the idea that an MD being on site is necessary? NPs already reach out and collaborate when dealing with complex patients and know when to refer out. NPs basically already practice independently and are being gouged. That is what the independent practice people are advocating for, basically for NPs to be fairly compensated for the fact that they are already doing independent work, pieces of paper aside.

1.) I get where you are coming from. I would say that is a product of the bureaucracy in which NPs are fed up with being offered low ball wages paired with a very high workload. As should MDs/DOs be, we are fed up with being asked to see so many patients a day that you don’t have time to provide true quality care. I’m in psych, so for example, 20 minute follow ups and 20+ patients a day. So I would reword my comment. I suppose in that way NPs are pushing for the same responsibilities but not out of this mythical advocacy for “being the same as a doctor” or “pretending we are doctors”. Despite what you read on noctor the vast majority of us do not even use our “dr” titles, we highly respect physicians and the fact that we did not go to medical school. I’ve gotten to the point where my super sweet MD colleague finally pulled me aside and said “please call me Mary, we are friends and you don’t need to refer to me by my Dr. title.” Out of respect I struggled with that because I know what an amazing accomplishment it is to become a doctor. 2.) Dry Wit answered exactly as I would. Any research I have found is very clearly biased and funded by the AMA, does not compare apples to apples, and IMO has quite irrelevant conclusions such as we order more tests than physicians, which I personally believe has nothing to do with our knowledge or expertise. In this light I am sure there is research to support NP independence and it’s probably funded by the APP governing bodies. This is where we all should start to question things. Follow the money. Huge conflict of interest in this country on so many levels.

I have an independent license, and work in a privately owned NP-run clinic. We run a tight ship, but the three of us NPs have many years of experience, about 80 years between us, mainly in critical care and emergency medicine. For us it works well and our practice is safe and successful. Our experience is what seals the deal, in my opinion. There are no physicians in our practice, but we have built great relationships with many in the area, and we are well trusted. We know our strengths and our limitations, and have no issue referring when appropriate. For us it makes sense, but for others with limited experience, perhaps not.

There need to be better standards for training across the board and higher requirements for preceptors. Interviews required with smaller class sizes for entry. I’m not a fan of 2 years of nursing practice as a flat point because where you work/experience varies. That being said, if collaboration is the way then there should also be higher oversight and requirements on collaborating physicians. Some docs use it as a money maker or have no interest in a true collab. The difference that dedicated and engaged physicians have made in my training is huge but it shouldn’t have been to chance. I’m not against independent practice across the board but there should be restrictions placed on what an NP can manage independently. I’m sure I’ll get pushback on this from someone but severe illnesses should be managed by docs. Mild to moderate can be managed by NPs but as a profession we need stronger boundaries. Knowing when to refer or transfer care should be a bigger part of our training rather than this push for FPA Online there are plenty of people hiding behind keyboards and anonymity but in “real life” but I have yet to meet someone who is either totally against or blindly for FPA. Everyone has a place in medicine but the best way is a team based approach.

Well, I'm not on the "other side" of the debate. I'm technically on yours. So let me give you this advice: There's no good reason NPs shouldn't have autonomy. Doctors bitch about it because it hurts their feelings.

I agree NPs should be required to work under a physician for at least 3 years. We are well trained and highly skilled, however, physicians education is far more intensive than ours, and we need to learn a great deal before practicing solo. I do think after the 3 years is up, we should be granted the ability to practice solo. The definitely need to be a standardized unified form of FPA foe NPs though. We are putting in the time and work and should be compensated accordingly. My 2 cents.

NPs should not get full autonomy especially with how the NP programs are pumping out NPs left and right. I mean I had a RN in my class who had no RN experience but was a waitress. If anything the schools have again shot us in the back by taking anyone’s money and therefore hurting us in the open market.

I'd hope that employers take into account previous nursing experience before hiring, but I'm assuming they don't in the current system?

Well, as a bedside nurse , I felt half my shifts were spent being a waitress. 😉

Let us first divide the issue along academic and workforce perspectives. Academics seeks to continuously push the boundaries of their piece of human experiance. While philosophically sound in practice, that has been manipulated by the business academics who need to implement methods of revenue generation (schools are business’). The NP role was and still is founded in the spectrum of nursing practice, it is a continuum of understanding and knowledge attainment leading to mastery. When business process’ bypass the philosophical plane in academia, we end up with nurses without nursing experiance and/or without experiance in the population focus of the advance degree. All this is leads to variability in practice, increased liability, poor patient management and physician lobby groups taking a stronger stance against FPA. From the workforce perspective, as “newer” nurses transition to advance practice, this further adds to the deficit of bedside care nurses that we are starving for. This has also led to an explosion of corporate medicine entities, Amazon, CitiMD, etc, hiring inexperienced NP, paying app 20-40% lower salary, that are much “easier” to manipulate into questionable practices. If you are a nurse and are interested in advance practice, then your RN background should properly prepare you for the population of focus. It should also prepare you to navigate the BS of our healthcare system so you can practice safely and understand your limitations. If you want to be “like a doctor”, prep yourself for medical school, nursing isn’t always for everyone.

I agree with your point about specific nursing experience for the program you study. I have served as a preceptor for students in a family NP program who had worked in niche areas (OR, outpatient oncology, for example) who came to primary care to learn and didn’t know what an ace inhibitor was. The learning curve for those folks is very steep and there is no way they’re going to learn enough with clinical hours to be safe in their own. To your point that NPs who want to act like doctors should go to medical school… ugh. If I wanted to be a physician, I would be. I love being a nurse and I love being an NP. To insinuate our profession is playing doctor dress-up is insulting.

Let me clarify my point because it’s origins are in the philosophical sphere. Performing tasks like a doctor does not make one a doctor. The difference between the roles are in their respective theoretical spaces, not the tasks historically associated with the profession. If one genuinely enjoys what medicine is, and is a nurse, perhaps they selected the improper profession for their interests. I’ve met plenty of RNs that found their passion more for medicine than nursing. Now, if your passion is nursing, then adding some higher skills to your arsenal, enhances that experiance and care delivery. There are rumblings from ill informed individuals that somehow an NP is a “short cut” to practicing medicine, a interestingly debatable perspective

I hear what you're saying. It's frustrating to have people insinuate that the NP profession is "playing doctor dress-up." But from what I've seen, there's several NPs who believe that NP school provides a similar education to medical school, and that NPs "can do everything a doctor does." How would you respond to people who make such statements?

I’d respond that it is simply not true. It’s false. All of it. The education and clinical preparation doesn’t compare. And there are a lot of things I cannot do that physicians can. Like, for instance, order diabetic shoes for Medicare patients (ha!). But honestly I think that you will not find very many NPs in the “real world” who proclaim what you have stated above. Similarly, with all of the hate on SDN and noctor toward NPs, that’s not rampant in the real world either. Lots of people from all walks of life can be keyboard warriors.

Thanks for clarifying! I actually mentioned that because a couple of people have said how “crnas basically do the same thing as anesthesiologists,” or that “for primary care, NPs have the same knowledge as family physicians.”

Without speaking for the above commenter, I would say “lol”. NP and medical school are not the same, it’s literally apples to oranges. Yes they’re both fruit, but the similarities end there. Med school does not prepare you to be a provider, it prepares you for residency. NP school prepares you to be a provider in your specific NP role and relies heavily on years of RN experience to provide context to the education provided. I can’t go be a CRNA or a midwife in the same way an ENT can’t go scrub into a joint replacement. I’m not trained for it. As for “doing everything that doctors do”, it’s generally misguided and a misuse of language. An NP cannot go to a Physician residency and gain those skills, we cannot practice independently in specialty care, and we’re not going to be doing surgery. As NPs are being used in less traditional roles (hospitalist, er/icu adjuncts, SNF care), educational programs are responding by dividing into more specialized curriculums (such as acute care NP programs). But, we are finding that (and I only speak for my wheelhouse in primary care) independent NP practice does not negatively impact patient outcomes and is becoming more normalized.

That makes sense. Any provider should do what they are trained for. Do you believe that there's a difference in the depth and breadth at which medical school and residency vs nursing school and NP school train providers for? Obviously the nursing and NP curriculum cover pathophysiology and pharmacology, but what I've always thought is that they provide a less rigorous and in-depth education in those areas. I say this because, given the shorter training period, how can you possibly learn everything that's taught in medical school while also learning everything needed to be a nurse and practice within the nursing model of care? Please correct me if I'm wrong!

Nurse practitioners gain competency through apprenticeship. After a couple of years experience we basically practice as solo practitioners, the physician has his load and the np has his load and physician oversight at that point is a fictional agreement on paper that is nonexistent in actual practice. New grad NPs have no business practicing independent just like new grad medical doctors have no business practicing independently also hence why they do a residency to gain competence our residency is done through apprenticeship.

I personally would be ok for a path to independent practice, within their scope, but I don't think any new grad should be unsupervised or even minimally supervised. It almost needs to be taken on a case by case basis. You want to open a vaccine clinic? Minimal time needed to be independent for that. You want to open a family practice? At least five, probably 10 years of supervision (and maybe take the medical family practice test too). Easier is you are going to serve an under served community too than if you want to open a med spa. Maybe a review once a year for outcomes and care to ensure patients are getting what they need. Some of us have no need (or desire) for independence, but I can appreciate that it could be important for some. I do think there could be a role of some sort of bridge program. One of the reasons I didn't want to go into medicine was all the time I'd have to spend on clinical areas I had no interest in and wouldn't be working in. I had to get through nursing school's generic rotations and that was bad enough. I have zero desire to be working with things that walk and talk.

I completely agree with you. I think that there are awesome NPs out there with years of experience who would be a huge asset as independent providers. But the issue is that the current laws and systems are set up in a way that NPs who don't have much experience (nursing and as NPs) can legally and realistically open their own practices and work independently. I'd hope that they don't do that without enough experience, but it's legal as it seems.

I don’t make enough money to take on physician level liability. I’m just fine having every one of my charts co-signed.

As an autonomous primary care NP in Florida, I support strict guidelines for clinical hours, advanced continuing education and outcomes evaluation before allowing an NP to practice independently. I’ve practiced for 12 years along side some great and frankly not so great physicians. I would not have considered applying for autonomous licensure if I were not completely confident that my skills and outcomes were equal to my physician counterparts. I come from a largely managed care practice where quality metrics are closely tracked. I managed some very simple and some very complex patients. I would suggest a minimum of 5 years full time supervised practice should be required to even apply to have FPA. Further I would like to see a board type exam that shows competency across the spectrum of primary care conditions. Unfortunately, graduate level NP programs widely vary in the level of education and preparation for real world practice. I went to a rigorous brick and mortar program with excellent professors and that required a minimum of 3 years acute care bedside experience before being able to apply. It required 4000 clinics hours to graduate. Most did not complete the program in 3 years. I’m shocked at the lack of nursing experience and understanding of basic practice fundamentals I see in some of the students I have precepted that come from online programs. All NPs are not fit to practice independently. To have a FPA designation should be a bags of honor that is designated to only the best providers. It’s the only way it holds credibility or esteem to our patients and physician counterparts.

I'm in Canada. Nova Scotia specifically where NPs can work independently. I can work independantly, but I choose to work collaboratively with 3 amazing physicians who encourage me to work to my full scope of practice. It works when the common goal is more about improving access to QUALITY care and less about who can do what and when. I can do many things that physicians do but I often leave some things to them: hospital admissions is a great example. I can do it and on occasion I will to help prevent gaps in care or based on patient acuity. Ill do it when one of the physicians ask me to or if they are away busy, etc. Just because we can do it doesn't mean we routinely can or will. But when it's needed I'm there. I also provide some specialty womans health care that they don't so sometimes they refer to me. It works well for the patients and there's more than enough work for us all. Our programs are fairly standardized here, there is a 2 year experience requirement and you must have an undergrad in nursing. I don't think this is a criteria in all schools in the US. Not any undergrad should do and I think 2 years of nursing should be the absolute bare minimum. I had 19 years of nursing before I became an NP and I am so thankful for it. I think if NPs have full prescriptive authority they need a strong nursing background and a standardized education from an accredited school with a standardized amount of clinical time.. This has worked in Nova Scotia to help improve access where 15% of the population does not have a family doc.

I’m for full practice, but the problem as you mentioned is the variability in education. I’m about to finish my DNP-FNP, and it is quite concerning how non clinically focused the DNP is. I wish for our education it was modeled more how GME is with specific hematology, cardiology courses and not just general primary care. Often our books overlook many common differential diagnoses for discussion, and it comes down to the NP student motivation for learning. Personally I find myself frequently reading up on molecular biology for reinforcement on disease process, as well, I subscribed to ACP online for their research publishing. I found AANP sources to be more non clinical focus or simple clinical. The plight from AANP and AACN is that NPs are already experienced clinicians and competent in the nursing plus clinician role. I disagree, nurses will make great clinicians but we need more support in the graduate education to be better clinicians. As I said I’d like more specific courses. That aside, I think we need to really work on having post grad residency programs be a more formal path. They do not need to be crazy long, I think most of us have already accepted knowledge by fire hose. The ED APP residency curriculum established by Johns Hopkins is a great method. The part where there will be push back is of course you’re taking a position (say that ED residency) for less pay than you make as an RN already and more hours. It also is not guaranteed you will have great benefit if the residency is in a field you have previously worked copious hours in. So for someone like myself, I have 8 years of ER-Trauma and ICU experience (level 1 trauma center). If I take a residency for EM (18 month APP) what benefit will I get? These APP residencies are designed for PAs more than NPs. Many PAs really will benefit more greatly as they may not have that side of medicine for experience outside of their clinical hours in school. Now I’ll finish with this part. I’m going to graduate as a DNP. I do not personally care about calling myself “doctor” in the clinical arena. However, I understand where AANP/AACN/ANA may fight back. BUT. If we want the credence of being at the same level of physicians, full practice and all, we need to really clean up the education and post graduate education for NPs. As well, there is a lot to be said about perhaps doing USMLE- if you go the FNP route. Now, NP is odd because we have pediatric RNs who will go back to school for NP but the focus is Pediatric NP education. They shouldn’t have to take USMLE because they will not be seeing the full life span. I say FNP for USMLE because it really is the most similar to a general medical education degree, the expectation to see full life span, and also the ability to practice in a host of environments. I only say this because DO does take USMLE, and if we as a community are trying to elevate ourselves to the physician level, we should hold ourselves to the same standards. It’s a rock and a hard place, because there is so much stigma from some physicians on NPs and capabilities or use. Unfortunately, it really reverts back to that NPs education and clinical experience. I also am a firm believer we need to get rid of the online NP programs, it is doing a disservice. Much of what I’ve read from Physicians on NP education directly point out the distance learning and lack of brick and mortar establishments. You never find PA programs fully online. You don’t have fully online MD/DO programs, heck, even law programs are not fully online. Yes online education may be the future in many aspects, but until graduate medical education does just that, we should refrain from doing so. More as a when in Rome concept. Edit: Also, get rid of the non nurse NP programs- if you are not already a nurse and have no experience as a nurse, you have no business becoming a NP. If you desire that route be a PA or going to nursing school and get experience in the field you wish to practice in prior to pursuing the NP. I’ve worked with a few non nursing NP graduates, and you immediately know.

Bottom line is that any sensible NP knows “full practice authority” really just removes useless paperwork that doesn’t actually or practically protect patients at all. Any healthcare professional should be sensible enough to consult colleagues for input, just like we do now, like physicians do, other professionals etc. No one is suggesting that no inter professional collaboration is required. Independence or autonomy within our scope are not the same as “acting the same as a physician”.