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    The problem with diploma mills in medicine

    Editor's Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Rebekah Bernard, MD, a family physician at Gulf Coast Direct Primary Care in Fort Myers, Florida. The views expressed in these blogs are those of their respective contributors and do not represent the views of Medical Economics or UBM Medica.


    In my last article, I discussed the trend of increasing non-physician healthcare providers, such as nurse practitioners (NP) and Physician Assistants (PA), as a way of easing the reported (and debated) physician shortage. 


    FURTHER READING: Top 6 resolutions for physicians in 2018


    Nursing organizations have been particularly effective in increasing the number and power of nurse practitioners. Through a combination of political action (nurses’ associations spent $5.3 million on lobbying and donated $2.1 million in 2016 to congressional candidates to promote unsupervised practice) and an aggressive multi-media campaign, NPs have been successful at achieving independent practice in 23 states, Washington DC and the Veteran’s Administration.Dr. Bernard

    But this increase in unsupervised nurse practice is worrisome in light of a new trend in nurse education:  the explosive growth of diploma mills, programs that graduate minimally trained nurses who are unprepared to care for patients independently. 

    Just type “NP online” into a Google search or your Facebook page and you will immediately see what I am referring to. Ads abound for nurse practitioner programs, with tag lines like “complete in 20 months,” “100 percent Doctor of Nursing Practice (DNP) online,” and “self-directed coursework.”

    There are dozens of direct to NP and DNP online programs, many of which boast a 100% acceptance rate.  There are schools that promote “as little as fifteen months from MSN to DNP,” or allow nurses to “use work hours to apply to your clinical training.” There are multiple accelerated programs that allow nursing school graduates who have not yet worked as a nurse to become a nurse practitioner. There are even direct entry programs that allow students with a non-nursing bachelor’s degree to become a registered nurse and a nurse practitioner simultaneously. This means that these NP graduates are legally permitted to practice “advanced” nursing before he or she has ever even worked one day as a bedside nurse.

    Once in attendance, coursework for these nurse practitioner programs may be 100 percent online. And while a certain number of clinical experience hours are required, they are often on the honor system and may involve simply shadowing a doctor or nurse, many of whom the students have to find themselves, sometimes by cold calling NPs listed online.  There are simply not enough clinical preceptors to train the volume of nurse practitioner students seeking clinical hours.

    Next: This should concern us

    Rebekah Bernard MD
    Dr Bernard was a National Health Care Scholar and served at a Federally Qualified Health Center in Immokalee, Florida for six years ...


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    • [email protected]
      I don't understand Dr. Bernard's objections: Firstly, just as physicians have to pass examinations in order to be licensed and relicensed, so nurse practitioners can be required to pass examinations. Secondly, the added tests which nurse practitioners order for patients is a plus!!! Most of my friends who live in states where nurse practitioners work claim that doctors are more concerned with getting bonuses by cutting costs for the HMO than ordering tests which would clarify the diagnoses or rule out serious diseases, whereas the nurse practitioners have the patients' interests at heart.
    • Anonymous
      It is mind bogging that somebody can state that Doctors practice with sole aim of getting bonuses. For the records, Doctors swear to an Oath; what oath do the NP, DNP etc swear to? I am further appalled that with 500 patient exposure hours and in some cases, no patient exposure hour ,we can expose an American life to such a "professional" This is disturbing. I do not really understand why someone cannot see the line of thinking of the author. It is well articulated and the figures are correct. I have mid levels in my practice and I find myself involved in teaching everyday, yet these have been licensed to practice independently.my panacea will be for Physicians to deny the Preceptorship of NP, ANP, DNP, students and by the time we have done this, we would have put some control and checks on this deluge of very minimally trained professionals into the art of Doctoring humanity. A nurse is always a Nurse and never a Doctor (Physician). One needs to go through that rigorous training to be a Physician. No short cut.
    • Anonymous
      Where is the evidence that adding unnecessary tests is a plus to patients or our healthcare system? Where is the evidence that doctors are somehow more concerned with getting bonuses (if you knew how much debt we graduate with compared to possible tiny bonuses, you'd see any argument that we are motivated by money quickly fall apart). But here is a fact: NPs from these diploma mills get about 3 percent of the training that an average physician does prior to completing residency. If that doesn't frighten you, you are drinking some pretty powerful Koolaid.
    • Anonymous
      The problem is they pass one exam one time for a general credential but then are allowed to self-identify as whatever specialty they choose to. Where I practice we have nurse practitioners that practice specialty areas in medicine without any specific training in those areas. Contrast that with residency and fellowship training for physicians and the ongoing requirement for recertification. There is no comparison. In 1910 the Flexner Report revolutionized physician training and took it from an apprenticeship model to the formal system we have today. ANP and DNP programs need to undergo this same scrutiny to ensure the quality of training is consistent. Finally, do you really think that ANPs that work for HMOs and health systems are not subject to the same pressures on testing and formulary compliance? Also thank you for inferring that physicians put dollars before patients - very classy comment.
    • Anonymous
      Saying that an NP can handle any medical issue that an MD can handle is like saying a Medical Assistant can handle anything an RN can. It simply is not true. We serve the patient best when we understand the scope of our knowledge, skills, experience and training. That is amassed through years of clinical training not months. I worked for years in primary care. We had both PA's and NP's. It not only drove me crazy, but it was a blatant misrepresentation of the training they had received every time they said they knew or could do everything the MD could do. If this were so, why weren't they a doctor? I'll tell you why, they didn't have the education, or clinical hours, most of them had roughly 500 (one NP had around 1500hrs) and none of them had done a residency. Now compare this to the education, minimum of 15,000 clinical hrs. and around 9,000 residency hrs. So, when someone starts the diatribe of all that doctors care about is "getting bonuses by cutting costs for the HMO than ordering tests which would clarify the diagnoses". I get a bit incensed. Doctors DO have patient's best interests at heart by NOT ordering unnecessary tests. We see MRI's being ordered by NP's for low back pain. Most often for overweight individuals which is completely attributable to myofasicial problems. The ordering of more test does not equal better medicine it just increases healthcare costs and bogs down the entire system.

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