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    The problem with diploma mills in medicine


    Unfortunately, this lower quality of training and clinical experience is beginning to become apparent. New studies are demonstrating that removing standardized curriculum and physician supervision from nurse practitioner training and practice is impacting the quality of patient care, including poorer quality referrals[i] to specialists compared to primary care physicians, more unnecessary skin biopsies[ii] than physicians, increased diagnostic imaging,[iii] increased prescriptions[iv] including increased antibiotic prescribing[v] and higher opioid prescribing shown in the states of Connecticut and New Hampshire. Payouts for malpractice claims against NPs are also on the rise, as are claims for the improper prescribing and management of controlled substances. With training programs churning out NPs at a rate of 23,000 per year, compared to about 19,000 physicians graduating from medical school per year, we may see these trends grow.


    POPULAR ON OUR SITE: DPC is here to stay


    As physicians and patient advocates, this should concern us. As we know, doctors receive 20,000 minimum hours of training before we are permitted to practice independently, and yet we often remain fearful of being unprepared or missing something. Nurse practitioners require only 500 clinical hours to sit for their boards, and are now permitted to practice without supervision in almost half the states in the union. Perhaps it is easier to feel confident when you “don’t know what you don’t know.”  Unfortunately, this is not something that can be learned online.


    Rebekah Bernard, MD, is the daughter of two Registered Nurses and a Family Physician in Fort Myers, Florida. She is the author of “How to Be a Rock Star Doctor.”  She can be reached at RebekahBernard.com.




    [i] Comparison of the Quality of Patient Referrals From Physicians, Physician Assistants, and Nurse Practitioners Lohr, Robert H. et al. Mayo Clinic Proceedings , Volume 88 , Issue 11 , 1266 - 1271

    [ii] JAMA Dermatol. 2015;151(8):899-902. doi:10.1001/jamadermatol.2015.0173

    [iii] JAMA Intern Med. 2015;175(1):101-107. doi:10.1001/jamainternmed.2014.6349

    [iv] Prescribing Practices by Nurse Practitioners and Primary Care Physicians: A Descriptive Analysis of Medicare Beneficiaries Muench, UlrikePerloff, JenniferThomas, Cindy ParksBuerhaus, Peter I. et al.Journal of Nursing Regulation , Volume 8 , Issue 1 , 21 - 30


    [v] Open Forum Infect Dis. 2016 Sep; 3(3): ofw168.

    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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