Why you should be a nurse practitioner (and NOT a doctor or PA)

Be a nurse practitioner
Ethan Stuart, RN, sent me this email.  I’m publishing (with permission) exactly the way I responded.
 
Ethan: Hi Pamela, I have a question about my future career choice, and even though it is more complex than what I will write here, I will try to hit the main points. You seem like a smart, understanding, and compassionate person.
 
Pamela: I AM! 🙂
 
Ethan: So I thought I would send you an email. 
 
Pamela: YAY!
 
Ethan: Basically, my struggle is this: I am a current RN and would like to do primary care in the future (family medicine). However, I am torn as to whether I should try to become a family physician or become a family nurse practitioner. 
 
Pamela:  My first thought is NP right off the bat.
 
Ethan: Here are the things that attract me to becoming a family MD/DO: #1 = Autonomy 
 
Pamela: You can have autonomy as an NP – in your own practice. Listen to this interview I did with the happiest NP in Alaska. (Note: PAs actually can not practice with autonomy and require a collaborating physician so that makes the NP degree much more valuable in my opinion—especially if you want to launch your own independent practice one day!).
 
Ethan: #2 = Knowing that I became the best that I could be and didn’t settle because it was hard (probably the main reason).
 
Pamela: There are NPs who are better than doctors. DEFINITELY less abused and have more self-confidence as NPs.
 
Ethan: #3 = The opportunity to acquire a deeper and wider knowledge base (probably the next main reason).
 
Pamela: Your knowledge base is directly related to your level of curiosity and your dedication to being a lifetime learner.
 
Ethan: #4 = Ability to practice internationally.
 
Pamela: Not sure about this one.
 
Ethan:  Here the things that attract me to becoming an FNP: #1 = Better work-life balance.
 
Pamela: YES.
 
Ethan: #2 = Faster/cheaper More flexible should my interests change I can work and go to school part time I can directly choose to study what I am interested in (rather than have to go through many rotations in medical school that I might not be interested in).
 
Pamela: YES.
 
Ethan: #3 = I must say, too, I am a person who does not want to train/work in a toxic environment, and I know medicine seems to have plenty of that. I see it daily as a nurse. I also have anxiety that can flare up pretty severely and tend to get burned out if I have to go through a demanding schedule for too long, as I naturally give a lot to people and have to have time to care for myself. If I could get down to the bottom of my indecisiveness, the thing that causes me the most uncertainty/anxiety, I think it would be this: I would like to pursue medicine because I prefer the medical model more and because I would like to be the best I can be, even if it is more difficult. But I am very worried about the price I would pay to get there and the toll it would take on me and my family—I am married now, and my wife will likely have kids by the time I would be in my training.
 
Pamela:  YOUR MENTAL HEALTH & OVERALL HEALTH will be WAY better as an NP.
 
Ethan: As you know, you can’t help anyone if you can’t help yourself. I don’t mind becoming an FNP, as I think my dedication to learning will make me a great provider regardless. But I also am not sure I am philosophically on board with the nursing model per se, and it is mainly attractive me for PRACTICAL purposes, not intellectual ones.
 
Pamela: Your intellect can take you anywhere you want to go. Degree really doesn’t matter. It’s your initiative.
 
Ethan: The rub is I don’t want to pursue being an FNP (or an MD/DO, for that matter) for the wrong reasons. Lastly, I also have many hobbies, and though I would enjoy the knowledge base that physicians have and the autonomy, I am not sure I would like the stress and any longer hours that comes with it. 
 
Pamela: NOT worth all the extra training. You could get an NP in an 12-18 month accelerated program for 10% the cost of getting an MD/DO. AND you can earn MORE than a doctor!! (see above video).
 
Ethan: And I realize one may not be able to have one without the other. I may just have to accept that there will be trade offs either way. What do you think? 
 
Pamela: I think you should design your dream clinic/practice FIRST—then reverse engineer the steps to get there choosing the fastest, least costly method to get there.
 
Ethan: Based on your personal experience as a family MD, what would you advise me to do?
 
Pamela: Go for your NP degree.
 
Ethan: THANK YOU for your time and for all your wonderful work. No doubt you are such a treasure to many. Most sincerely, Ethan
 

Pamela: Can I publish this on my blog as I think lots of people would like to know the answers to these questions. Also after you read what I suggest tell me what you decide. I’m not attached either way.

Ethan: Thank you for the quick response and specific answers. I honestly have known which path would be better for me personally for a while, but there has been that small part of me that doesn’t want to completely rule out medicine because of the reasons I listed. Be that as it may, I want to be healthy and happy and do what’s best for me and my family—which will make me a better provider and family member. 
 
And, of course you can publish this on your blog. I’m honored! You can even leave my name if you feel inclined, although I don’t think it’ll make me an overnight sensation. *:P tongue
 
Will keep following all your great work. I just have to say—I really, really admire your courage. Thanks for leading the way—hopefully the rest of us can follow suit. 🙂 
 
What do you think? NP? MD? DO? PA? Other?
Want to fast track your dream? Join our teleseminar or retreat (or jump on the fast track here).
 
Physician Retreat - Join Us!
 
 
ADDENDUM 11/29: This is my advice for Ethan. My advice for you may be totally different based on your life circumstances. I love doctors. I love being a doctor. I loved my residency and the last 2 years of medical school. I am the happiest I’ve ever been in my life practicing medicine in our community-designed ideal clinic (solo doc for 12+ years). My greatest joy is helping all health professionals find their joy no matter what the “official degree.” We are all valuable.
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157 comments on “Why you should be a nurse practitioner (and NOT a doctor or PA)
  1. Nicole Alu-Parks says:

    Wow. How disturbing.

    • Vanessa says:

      I do appreciate Pamela’s addendum. She was personalizing the responses to him. I hate that this article seems to have generated such divisiveness after review of the comments. For Ethan here, becoming a doctor may “NOT [be] worth all the extra training” as he’s looking for something “Faster/cheaper More flexible” and not have to “go through a demanding schedule for too long.” I would suggest that the author reword the title of the article to make it seem not so generalized as she herself added that this advice is for Ethan specifically. I would also recommend that she leave the PA part out as he didn’t even ask about PA-ship. Accordingly, a more appropriate title would be “Why he should be a nurse practitioner (and NOT a doctor)” or even leave that last part out to avoid inviting division. I share her belief that all – no matter what letters are behind your name – are valuable!

  2. Emily says:

    Pam! What happened?! I have championed your efforts in the past to avoid physician burnout and prevent suicide. What is this? I’m very surprised and disappointed to read this. I kept thinking you were about to reveal the punchline of a cynical joke. I think we all know the training isn’t even close to being comparable. And to say “Degree really doesn’t matter?” Are you feeling some burnout? I am worried about you now.

  3. Tatiana Arolli, DO says:

    I appreciate everything you do however I disagree with this article. As a physician, I am perplexed you would recommend becoming an NP. Education is NOT the same, the foundation is NOT the same. The medical knowledge is complex and requires YEARS of mastering that cannot be done in 12-18 months of NP school. I also disagree you can master it by being a “life-long learner”. While it’s extremely important, it cannot be done without a proper foundation.

  4. Dara says:

    I was a Nurse Practitioner before I went to medical school. While there are valid reasons to choose becoming NP over MD/DO, rest assured the education and preparation is NOT equivalent. Medical school was a HUGE wake up call, as I was repeatedly made aware of things that I had not even realized I didn’t know as a nurse practitioner- things that were critical to patient care. There were several instanced in medical school, when I’d be reminded of a patient I saw as a NP- and realize that I had not done the right thing. I wasn’t stupid. I wasn’t malicious. I simply didn’t have the proper knowledge base to take the correct action. Fortunately, I am unaware of any harm done to a patient (after all, and error or incorrect act does not always result in harm).

    There is a growing body of evidence that NPs and PAs order more tests, write more inappropriate antibiotic prescriptions, and make more unclear/inappropriate referrals when compared to MD and DO. Again, this is not a sign of lack of intelligence or lack of caring. It’s a sign of lack of depth of education. The differences between MD and DO education vs. NP and PA are vast and meaningful. I’ve attached a document outlining the differences

    I’m sorry that your medical school experience was so abusive that you feel compelled to turn people away from the profession. There are many doctors who did not have an abusive experience.

    • Pamela Wible MD says:

      My recommendation to Ethan had nothing to do with an abusive med school experience.

      ADDENDUM 11/29: This is my advice for Ethan. My advice for you may be totally different based on your life circumstances. I love doctors. I love being a doctor. I loved my residency and the last 2 years of medical school. I am the happiest I’ve ever been in my life practicing medicine in our community-designed ideal clinic (solo doc for 12+ years). My greatest joy is helping all health professionals find their joy no matter what the “official degree.” We are all valuable.

      • Vanessa says:

        Hi Pam! I have read through the comments along with your replies. I agree that this advice is individualized. Perhaps you should change your title to “why Ethan should be an NP?” I think that is the crux of the miscommunication here. People who reply are worried that you mean to generalize this advice. Good luck!

    • Roxana, FNP-C says:

      You mentioned here that NPs and PAs are responsible for the opioid crisis and antibiotics resistance. I beg to pardon here… I think it is just the opposite. Patients have been trained by their physicians that a Z-pack will treat their “upper respiratory”. I have seen this thousands of times and have been bashed by patients because I did not prescribe their Z-pack which “they always get when they see their doctor”. There may be fewer and in between NPs or PAs out there who may be too lenient with antibiotics but that is because they have been trained by their “supervising” physician to do so. It only takes 30 seconds to write a script to where it takes 20-30 minutes to educate a patient. Time is money and our schedules feel up just as much as yours. More so we are dumped with the “hard, difficult, non-compliant patients” because the physicians do not want to deal with them. In terms of the opioid crisis, from what I have read in mass media, the over prescribers are actually medical groups of anesthesiologist, psychiatrists, surgeons, and so on who have been indicted and more so committed fraud. NPs and PAs in their offices were just collateral damages and by no means the “heads” of the operation. So, throwing the blame on us is to say the least that is incorrect, unfair, and completely dishonest.

    • Jeff says:

      I can’t get this link to work. 🙁

  5. There are many things to take into consideration to make a degree/career choice. It depends on what you want to do. NP’s may make a similar income as physicians in certain areas such as psychiatric and primary care but not many others. There are many scope of practice limitations for specialties and independence as a NP depends on the state. At this moment, as a NP, I could not move to California or Florida (I want sun) and easily start my own practice. It is complicated and can be costly paying a physician to supervise. I also cannot independently prescribe schedule 2 drugs in those states.

    The pay for physicians in almost all the specialties is significantly higher and rightly so. If you want to be a surgeon then you need to pursue a MD route. In cardiology, you have to be a physician to perform the surgeries, ablations etc.

    I am a psychiatric NP practicing independently. My scope of practice is limited to psychiatry. I cannot perform ECT or surgical procedures/implants.

    I am lucky to practice in Washington State and regularly collaborate with some of the most amazing physicians and NP’s and feel very supported. I love my job…until I have to do a prior authorization.
    Good luck with your decision.

  6. Nicole M Johnson, MD says:

    Dr. Wible, the only thing I agree with is the lifestyle may be better for NPs due to burn out rates of physicians. However, the rest I disagree with 100%. If you truly understood the educational model of nursing you would not think NPs are better than physicians. Nursing education of the practice of medicine is very basic. They are not fully taught how to diagnose and treat. In depth pathophysiology and pharmacology is absent frequently. There is no standard for NP certification and there is about 20,000 hours difference in classroom and clinical education. The current NP and DNP mills are churning out these practitioners while they are still wet behind the ears from nursing. The best NPs were trained under a physician and not granted autonomous practice without a thorough clinical experience.

    Additionally, primary care NPs refer patients to specialists more without a basic workup a physician knows to do. They also prescribe antibiotics and opioids more often than physicians. With increasing antibiotic resistance, the current opiod crisis, and the rising cost of healthcare on the consumer, I wouldn’t count any of this care being better than what physicians provide. Patients may be “satisfied” because they get what they want, but this doesn’t equate with quality patient care.

    It is very irresponsible of you to use your platform to push your opinion on this subject without knowing all of the facts.

    • Roxana, FNP-C says:

      There is plenty of advanced anatomy and pathophysiology as well as pharmacology in FNP training. It is true that we do not dissect corpses. Has that helped you tremendously in your family practice as an MD? In terms of FNP certification, we do have to pass a national certification exam but we have two options: AANP or AANC. A FNP-C means certified with AANP and FNP-BC means certified with AANC. These are very similar exams testing same knowledge. I think they will be unified in future. I hope this clarifies your confusion about FNP training and certification.

    • Roxana, FNP-C says:

      NPs, PAs, MDs, and DOs follow a different training path, I agree. Medical schools have more hours of training. In my training, I did not spend any hours dissecting corpses. I agree that I did not have as many rotations as medical students do. But nonetheless, I went thru a 3 yrs long training program and received a solid knowledge base. I narrowed my focus to Family Practice. I did not go thru neurosurgery or neonatology or any other areas which I had no interest in. I do not pretend to know everything and I have made mistakes. But who doesn’t? Can you say wholeheartedly that you know everything that there is to know and you keep up with everything that is published or that you have never made a mistake? I am not God and I do not pretend to be. Nor should you… You consult with specialists. You ask for help too when something does not add up. You know your limits too.

      If you are worried about our training… We are the first ones to know our limits. The learning does not stop after graduation… I would like to see residencies and fellowship programs offered to NPs and PAs and I can assure you they would be filled with post-graduate NPs. But all the space was taken by medical students and residents. So, don’t think for a moment that we are not capable to learn or better ourselves in our profession… I do advocate that every FNP program should be followed by at least one year program residency in Family Medicine. But I know of none out there.

      I do believe that collaboration is necessary with all members of a team. I have seen great NPs whom I would trust my child’s care to and some of whom I thought they were in the wrong profession. I have also seen and worked with many MDs who were the brightest and best at what they do, really caring and compassionate human beings… but I have worked with lots of butchers and an army of very rude, demeaning, disrespectful, awful physicians, and just very disgraceful human beings …

      You are speaking so loudly in favor of supervision… I can tell you that collaboration is the correct term to be used. I my FNP career I have worked in 4 different settings thus far… and I was let loose after the first couple of weeks of “shadowing” the MD. I had a full schedule and I was expected to perform well. I was thrown to the wolves and I had to learn quickly what I did not know. None of my physicians have looked over my shoulders to “supervise” me but they were available for my questions and I greatly appreciated so. So, “supervising” is incorrect to use. Collaboration is what is happening in real world. Welcome to it!

      • Pamela Wible MD says:

        Medicine is an apprenticeship profession and we all need to apprentice under someone for a period of time to hone the craft of the profession we choose. NDs would love the opportunity to have additional residency training, as would NPs, and all the unmatched qualified MDs and DOs. There are too few residency slots even for doctors (thus leading to unemployable MDs who may have more training than NPs depending on the length of NP program online/offine etc). An end result is the recent suicide of Robert Chu MD—an unmatched physician. WE need to completely revamp medical education so that it serves the best interests of the bright and brilliant people who chose to pursue the healing arts.

  7. Tarina says:

    Pamela – Why did you become a doctor if you are telling others to go the NP route? And why would anyone become a primary care physician after reading this?

  8. rjmnar says:

    Dr. Wible, I used to admire you. Now I have lost all respect for you after you threw your own colleagues under the bus. I am a female MD and never once have I regretted my decision to become a physician. I have never wished I had taken the “easy” way and become an NP or PA. These mid level providers are not and never will be the equivalent of a physician when it comes to knowledge and educational background. The biggest and scariest problem with mid levels is they don’t know how much they really don’t know. Ask any NP or PA who decided to go to medical school and they will ALL tell you the same thing. This proliferation of online degree NPs is a big social experiment that is going to fail miserably and the citizens of this country are going to pay the price literally with their lives.

    • Roxana, FNP-C says:

      I have great admiration for anyone advancing their education. Kudos to any NP and PA becoming an MD. Having NP or PA background will make medical school a breeze and will make them the best compassionate, kind and caring physicians. Please, do not think that NPs are “wanna be” MDs. We are nurses first, trained and educated in the nursing profession model, who have worked hard at bedside for years before deciding we want to know more and do more for our patients. We have a calling and our own path. Next time, when you MDs and DOs are rounding your patients, take a very good look at the nurse caring for your patient… because that nurse one day may be your FNP to whom you will entrust your patients with and you would be very grateful for the care she has provided to your patients and for the extra income she added to your pockets. More so, we are fully aware of our limits and know when to ask for a second opinion, when something does not add up or we just don’t know it. We all need sometimes an extra pair of eyes or ears or hands to confirm our diagnoses. That is why we collaborate with specialists and all others involved in patients’ care.
      I do agree that the proliferation on online programs is detrimental to NP profession. But what can I say, it is all about money and business… I do wish that there would be more oversight and a limit to these programs.

      Also, please do not call us mid-levels. Call us what we are, what we have achieved thru hard work and education. Call us NPs or PAs. Mid-level is a derogatory term. On my diploma, next to my name, it does not say “mid-level”. There is nothing mid-level about us. We are highly trained, experienced and skilled clinicians. We do not want to be called other than what we have earned. I did not go to “mid-level” school but rather to graduate nursing school where I have earned a Master in the Science of Nursing as a Family Nurse Practitioner. So, please, call me a Family Nurse Practitioner, or in your office, kindly “my nurse practitioner” or “my physician assistant”. I promise you that we will go above and beyond to provide the best care to OUR patients coming in and we will always ask for your help and collaboration when need be.

      • Pamela Wible MD says:

        I absolutely despise the mid-level term. Makes me feel like I’m trapped between floors in an elevator at a crappy hotel.

        Also: Don’t say PROVIDER. A provider is a person who provides something. How nebulous. In medicine, a provider is an economic term used to lump all the revenue-generators together into one pile (often to see how much more money can be squeezed out of them). It’s a dehumanizing word that lacks precision and, honestly, it’s offensive to the people who have spent so many years of their lives to achieve mastery in their chosen profession. Use proper terminology. Say NURSE PRACTITIONER, MIDWIFE, PHYSICIAN. If you must use a collective term, say HEALTH PROFESSIONALS. Sometimes, I say HEALERS.

        MIDLEVEL is a word used by health care administrators to describe revenue generators who are somewhere halfway between a nurse and a doctor (I think). Use proper terminology. Say PHYSICIAN ASSISTANT or NURSE PRACTITIONER.

        (above excerpted from the article: 7 Shaming words to stop saying now)

  9. Pamela says:

    Ever consider crna?

  10. Taz says:

    Hi Pamela,

    I’ve admired you for your commitment to the issue of physician suicide as well as the toxic environments some of us may train/work in. I love your dedication and compassion. However, this article is a disappointment. In my opinion, you are minimizing the contribution and expertise of our physician colleagues in Family Medicine. I am a member of a group who is adamantly against the unsupervised practice of nurse practitioners and physician assistants. It is offensive to me when you state that some NP’s are better than docs. No one is better than anyone. What we are is different. Nurses are trained under a nursing model and physicians under a medical model. The depth of knowledge involved in each practice is profoundly different. Physicians have an intricate understanding of medical pathophysiology and pharmacological management as a result of both our didactic and clinical training in medicine. And there is no doubt this is necessary to manage patients with complex illnesses requiring sophisticated management. One has to have the ability to develop a differential diagnosis which can be limited by one’s training. We do carry a huge burden that we willingly accepted when we decided to become physicians. To then have a colleague state that one can become the same by becoming an NP is wrong. A 12-18 month accelerated program can hardly be compared to the 3-7 years of residency required for a particular specialty in medicine. NP’s in neurosurgery are not neurosurgeons. NP’s in pediatrics are not pediatricians. And NP’s in Family Medicine do not equate to Family Practice physicians. My organization has compiled data and statistics related to liability claims of unsupervised NP’s from 2009-2017. We have evidence that it is not safe because the knowledge is lacking. A first year resident cannot practice on a patient unsupervised and you condone a NP with an 18 month degree can? That is ludicrous.

    Despite what you may think, I do believe that NP’s/PA’s are a vital part of the health care team, there skills are invaluable. Over the 22 years I have practiced emergency medicine, I have worked with hundreds. And it has been a symbiotic relationship for the most part–everyone respects each other’s roles. But there is a reason these teams have been traditionally physician-led. Because physicians have the most training and expertise. That is not arrogance, that is a fact. It is not fair to the patient to blur the roles of each member of the team–they have a right to know who is caring for them and their level of training. And for you to equate FM and FNP as one and the same is misleading and dishonest and frankly, disrespectful to our physician colleagues.

    There is no question that there is room for improvement in the toxic environments in which many of us train and work. But not all of us have had those experiences. My EM program, although difficult, was supportive and I did not feel abused. I’ve worked in unhealthy environments and subsequently left those positions. But those environments are made up of people and it is the people in them who make it toxic. Physicians are not and should not be the lone bearers of this dysfunction. Nurses, administrators and other medical staff contribute as well. Your article suggests that the nurse should go to NP school because they are happier and healthier. I say it depends on where you practice. Some of these NP’s abuse residents just as physicians do. It really is about the individual and their internal environment. Misery loves company.

    Ultimately, I believe one’s education is what one makes of it. You get the most out of what you bring to it. We must work on improving the training environment of our physicians, but never would I discourage someone dream to be a physician because of my own personal experience. I give them the pros and cons and allow them to make their own educated decision. It is still an honorable profession in my eyes.

    • Pamela Wible MD says:

      1) “I am a member of a group who is adamantly against the unsupervised practice of nurse practitioners and physician assistants.” I do not subscribe to your philosophy.

      2) “It is offensive to me when you state that some NP’s are better than docs. No one is better than anyone.” You are correct. For some certain degrees are better for their financial and emotional health. And they can have fulfilling wonderful careers in any number of healing arts specialties.

      3) Do you have a problem with NPs treating UTIs, Strep throat, doing Paps and physicals unsupervised? Just curious. I think they are skilled to do these things without a collaborating physician.

      4) If Ethan wants to do what I listed in #3, why should he have to go through 4 years of med school and 3 years of residency?

      5) “A first year resident cannot practice on a patient unsupervised and you condone a NP with an 18 month degree can? That is ludicrous.” I believe (as many states already allow) that docs with just an internship should be allowed to practice outpatient primary care. NPs are already doing outpatient primary care and are licensed in states to practice independently. Do you have a problem with my friend Christine Sagan NP practicing independently in Alaska? Did you watch the video of her –> http://www.idealmedicalcare.org/blog/meet-happiest-nurse-practitioner-alaska/

      6) “FM and FNP” patients absolutely deserve to know who is treating them. If patients choose to see Christine Sagan NP rather than me that is fine. She is giving them great care as an independent NP. If they prefer an MD or they want me to be their family doc, that is their decision. I would absolutely go to an NP or my health care. Again, Pro-NP does not mean anti-MD. I love all health professionals who practice ethical and safe medicine within the scope of their training. I know when to refer when I’m not comfortable as does Christine Sagan.

      • Taz says:

        I’m not quite sure why you are asking me if I have a problem with NP’s when I clearly state that they are a vital part of the health care team and that I have worked with them for many years. In my opinion, they must remain supervised. The fact that 22 states allow some form of unsupervised practice does not necessarily indicate it was a good decision. After attending the Health Care Policy meeting in Washington, D.C a few weeks ago, it became painfully apparent to me that many legislators do not understand the difference between nurse practitioners, physician assistants and physicians. That ignorance may be part of the reason the laws were passed. “Forgive them, for they know not what they do.” The American Association of Nurse Practitioners(AANP) is a powerful lobby and as we all know, lobbies influence politicians. Even when the decisions are poor.

        The scope of practice of NP’s remains undefined. Therefore, stating that as long as they practice ethically and safely “within their scope of practice” is meaningless. Much is left open to interpretation; that is unacceptable when patients may suffer the consequences of of one practicing beyond their skill set. That is, if one does not recognize the limitations of their knowledge in their practice, it is a disaster waiting to happen. Physicians can certainly make mistakes and we pay a severe price for those mistakes because we are held to a higher standard–as we should be. NP’s are not held to that same standard because they do not answer to the Medical Board. They fall under the auspices of the nursing board which is a bit more lenient. Yet they want full-practice authority. One cannot pick and choose. If one desires to practice like a physician, then one should be held accountable just as a physician would. What may appear to be a simple physical, UTI or Strep throat to you may, in fact, hide an occult prostate cancer, an appendicitis masquerading as a UTI or retropharyngeal abscess. So I will reiterate, I do not believe and never will believe that NP’s or PA’s should practice unsupervised. Ever.

    • Roxana, FNP-C says:

      I do agree that we all NPs, PAs, MDs or DOs have a learning curve once out of school. It is great that medical school graduates have the opportunity to go thru residency. I wished that NP schools would have this too. That first year after graduation is critical to shape you into the clinician you will become. But you see, all space for teaching has been taken by medical residents. There is no accommodation for graduate NPs and I do not know of any such residencies offered to NPs or PAs for that matter. I do think however, that after 1-2 years in family practice, an FNP can function independently very well depending on their training and experience.
      You mentioned statistics about safety… I would be very curious to read what your organization came up with… from what I know, it is just the opposite. ER NPs and PAs run by themselves Urgent Care and free standing ERs, more so in rural areas. It all comes down to each individual’s training and experience. In big hospitals, in big cities, I am sure that teams are physicians led. However, in small cities and rural hospitals, all eyes turn to NPs and PAs… so, when the going gets tough, the tough get going and NPs and PAs step up to the plate. Same “sophisticated management” and complex patients you manage in big ERs, in a small ER in the middle of nowhere and middle of the night, the NP or PA working that shift will lead the care of these patients.
      I do agree with you that a 12-18 months program may not be enough. I have gone thru 3 years in my training. So, we are not all the same and our training and knowledge may vary depending on schools and prior nursing experience.

  11. HospitalistMD says:

    As a physician, I am so disappointed in your responses. From my limited past knowledge of your work, I thought you helped other physicians fight burn out (which is a great cause). But this is just insulting and an attitude that contributes to physician burn out.
    The training that an NP receives is 1/10th that of a physician and any rational person who is familiar with the current NP degree mills that churn out ill prepared NPs with 100% online education and 600 hours (equivalent to basically 2 months) of shadowing (not training) for their clinical experience. Training does in fact matter. They do not know what they do not know and in many cases are harming patients. I have witnessed this first hand.
    In an environment where physicians are constantly asked to do more and be more, blamed for everything that is wrong with healthcare, and constantly devalued, this is the cherry on top of the bullshit pie we are forced to eat every day. In this article you have just devalued everyone of your physician colleagues years of sacrifice and hard work. Shame on you. I would have expected more, much more from a fellow physician.

    • Pamela Wible MD says:

      1) “From my limited past knowledge of your work, I thought you helped other physicians fight burn out.” I don’t do this. I do not subscribe to even using the word ‘burnout” which is a victim blaming & shaming term. Using this word prolongs physician captivity and victimization. I suggest you stop using it too. I’ve been prolific on this topic: http://www.idealmedicalcare.org/blog/how-the-word-burnout-perpetuates-medicines-cycle-of-abuse/

      2) “Training does in fact matter.” I totally agree. And if your goal is to do outpatient primary care, NPs are skilled enough to do this. And in a low-overhead model where they can spend 30-60 minutes with a patient NPs may give higher value than a doc locked in a big-box assembly-line clinic in a 7 minute visit. Practice model matters. Degree matters. My advice for anyone in particular is based on THEIR goal. I could have been happily an NP in a outpatient practice provide safe care for my patients. I would say that a good 75% of what I do in my practice is just simple bread-and-butter type primary care that I could easily do as an NP (minus MD). The other 25% certainly the extra training has helped but what has helped more than anything or any degree is my relentless search for the truth in partnership with my patient in 30-60 minute visits where I can get to the bottom of their issues. No degree guarantees that you will practice ethical, safe, accessible medicine for your patients. Your internal motivation has a lot to do with how you eventually practice.

      3) “They do not know what they do not know and in many cases are harming patients. I have witnessed this first hand.” And I have witnessed many MDs and DOs and naturopaths and chiropracters harm patients too. Not unique to any degree.

      Again, I love being a family doc. I also love many NPs I’ve met. My love for NPs and my recommendation for Ethan does not mean I love my profession any less. Do you not like NPs? Do you not see their value?

      Pro-NP does not equal anti-MD.

      • HospitalistMD says:

        I work with great NPs everyday. They are a vital part of healthcare teams. However, they do not have the training or the knowledge to replace primary care physicians as you suggest above. If there is any place for our brightest, most intelligent, well trained physicians, it is in rural primar care. Unfortunately, our system does not incentivize the best and bright to become primary care. Let’s fix that problem! Not devalue those primary care physicians that are dedicating their lives to good health care by telling them they can be replaced by nurses with much lower education and training. If you don’t see how your statements would be offensive to your physician colleagues, you are obviously part of the problem.
        Oh and I agree with the statement that we should get rid of the term physician burnout. But you advocating for this change does not make your other comments any less egregious. You have shown your true colors and thousand of physicians out there now know what you are about. And you are obviously not about fixing or elevating the practice of medicine, nor about protecting patients.

      • AThac says:

        There are hundreds of former NP/Paa physicians out there who are outspoken on this topic and disagree with your assessment that they had adequate training as NPs to practice medicine autonomously in any setting, including outpatient.

  12. A sad physician says:

    For someone who proclaims to fight for physicians and help with burnout and physician suicide, with this article you have single-handedly done more to destroy physicians and add to the toxicity of our profession. Why Dr. Wible? Put yourself in our shoes. Some of us are happy in our profession and want to fight to defend it and make it better.

    • Pamela Wible MD says:

      Oh I am so happy as a physician and I spend my life helping other docs fins their joy and happiness. My one recommendation to Ethan (which I stand by) does not negate my life’s work to help and heal physicians.

  13. SBB says:

    Dr Wible: Generally I respect the light you have brought to physician burnout, suicidality,etc, however, I feel this piece may be showing your burnout. I’m hurt for our physician colleagues as I feel you are equating an NP to an MD/DO. Know your worth. Sincerely, SBB, MD

    • Pamela Wible MD says:

      I am not “burned out” and in fact I am full of more energy, hope, and idealism than I have ever had in my career which I LOVE. “Burnout”btw is a smokescreen for human rights violations: http://www.idealmedicalcare.org/blog/a-smokescreen-for-human-rights-abuse/

      I’m not equating an MD/DO with an NP. In this particular case I feel it is the best route potentially for this man’s goal. It will certainly be a better financial choice and also better for his mental health. I’m looking out for HIS future. My answer was for him and for people in his position. We have many more options than following a traditional meded trajectory if we want to be healers on this planet. Everyone should choose what makes sense for them.

      • AThac says:

        This NOT good for patients and at the end of the day patients are human beings, not just a source of income for his “finaincal choice”.

      • SBB, MD says:

        Unfortunately, your title and much of your discussion is equating to or even elevating NP over MD. Maybe this is the right choice for this person who wrote to you. I understand that point. However, it’s also demeaning to the path you and your colleagues chose. Continue to bolster us.

  14. Danielle Manalo says:

    I admire your work and passion for physician wellness. But this makes my heart sad, angry, and disappointed. There are still physicians out there who do not let burnout get the best of them, and are still able to maintain a healthy life-work equilibrium. I’m not hating on those that leave traditional medicine, but I do take offense when they subsequently try to extinguish us altogether.

    • Pamela Wible MD says:

      I absolutely LOVE physicians. What I recommend to this nurse in his unique situation does not reflect a lack of love for my own profession.

  15. Julie Hicks says:

    I am shocked. You just advised someone to take peoples’ lives into their hands with less education. I have to say that I strongly disagree with you on this.

    • Pamela Wible MD says:

      There are NPs with lesser education taking people’s lives into their own hands all across the Unites States right now. Do you have a problem with NPs?

      • EMC says:

        We have a problem with NPs practicing MEDICINE UNSUPERVISED with NURSING training. It is about PATIENT SAFETY, not about who is better or smarter. It’s literally comparing apples to oranges. First Do No Harm. With this post you singlehandedly are promoting harm to patients and your physician colleagues.

        • Pamela Wible MD says:

          I would totally entrust my routine health care to an NP. An unsupervised NP.

          • Tarina says:

            If you were a passenger on an airplane, would you rather have the hostess fly the plane than the pilot? Because that is an incredibly similar situation you are promoting here. Please answer my question.

          • Pamela Wible MD says:

            Totally ridiculous question. Hostess has zero training.

            Do you want an NP or a MD to treat your UTI? If you don’t want an NP then tell me why.

  16. Astrid Herard, M.D. says:

    I am so disappointed in this response, Dr. Wible. So disappointed. I have come to see you as a respectable advocate for physician well-being. Why would you steer this young man, who clearly wants to be a physician (just read his words), in the direction of taking what you describe as the easy way out? That’s not how life works! We need more people to enter the medical profession, fill the physician gap, and help change an abusive and malfunctioning system together. Running away is not the answer. I am angry beyond words!

    • Pamela Wible MD says:

      I lovebeing a physician. I adore physicians. I spend most of my waking hours helping docs create the live they always dreamed of. I am one for fast, effective, and cheap options when one exists to get to your goal. IF you want to drive cross country you could go in a Rolls Royce or a Prius and still get to your destination. Everything depends on the end goal of the person. Then the next question is what is the best way to get there. I do not across the board believe an MD/DO is the best route for everyone. I also believe that folks who have mental health issues that could experience YEARS of instability should potentially choose another career altogether. Informed consent is essential. AND it is lacking in medicine. Medicine has covered up it’s suicide crisis for > 100 years. I absolutely feel that those pursuing medicine need to know all their options including naturopathic medical school. There is no one way that is right for everyone.

      • Tarina says:

        If you drive cross country in a Rolls vs Prius, you get to the same destination BUT which is more safe for others? This is a completely selfish answer where you are only thinking of the “shortcut” easiest and cheapest way to get to the same destination but what about the patients whose lives they will have in their hands? Don’t the patients deserve a far more educated professional, aka a physician?

        • Pamela Wible MD says:

          Patients deserve medical care from someone who is accessible, affordable, and practicing within their scope of expertise. That could be any number of people. Given the shortages of health professionals we should spend less time infighting and more time collaborating. Being an NP may be the perfect choice for Ethan. I don’t need a “more educated” person to do my Pap, physical or treat my UTI or strep throat or many, many other things . . . I need someone practicing good medicine within their scope of expertise (and referring when appropriate)

          • Tarina says:

            However the NPs are certainly not practicing within their “scope of expertise,” that is the problem. They do not have the education or training to be able to practice unsupervised, that is the problem. Sure they can do the pap or treat the UTI but they most definitely need to have a supervising physician. I am sorry this is so difficult for you to understand but we will keep working to educate you on this.

  17. Mary Ann Maurer says:

    I’m sorry. This is awful advice. Ethan, if you want the best training, go to medical school and pursue a residency. I promise that not all are malignant. Dr Wible, I know that you have seen some of the worst of the worst. Please reconsider some of the advice that you’ve given. NP does not equal MD / DO, not by a long shot. “Initiative” does not make up for several semesters of anatomy, pathology, and physiology, not for years of clinical rotations.
    Signed,
    Happy to Be a Family *Doctor*

    • Pamela Wible MD says:

      I am also extremely happy to be a family doctor and had I done it again I would do it the same way; however, if I were an RN I would ABSOLUTELY go the route of NP as the fastest and cheapest way to get to my goal of having an ideal community-designed clinic. I stand wholeheartedly by my advice to Ethan.

      Of interest, I do feel like much of what I was taught was financially-influenced indoctrination. Examples:

      1) Murdering docs as medical education. I protested this. Now all med schools have stopped at least this form of cruelty. More here: http://www.idealmedicalcare.org/blog/bambi-syndrome/

      2) FORCING women to take Premarin and other HRT. Got into some pretty huge arguments with one particular faculty member about giving ALL postmenopausal women estrogen like it was some harmless vitamin. I did my OWN research to discover much of what I was never ever taught (plus later found out our residency was one of the sites for Premarin testing on women). Man did I get hell for thinking independently and clearly (and my approach was supported by literature)

      3) Throughout my education in medicine, I have been belittled for not only my compassion, but also my eating whole foods plant-based diet. I had to learn INDEPENDENTLY the value of nutrition which was not taught in med school. (Later attendings have written me apologizing for belittling me for what science how now proven was correct all along)

      4) I will say that much of what I learned that was most valuable came from a few attendings that I adored and from primarily (90%) my own MOTIVATION and relentlessly INQUISITIVE nature.

      If I were Ethan and my goal is to open an ideal clinic in my neighborhood in the next year or two he should absolutely pursue an NP degree,

      • AThac says:

        In the next year or two? Sadly that is actually as long as it takes to become an NP. You don’t see a problem with someone attempting to learn to practice Medicine in less than two years and then working alone in a practice?

  18. Maneesha Agarwal says:

    Dear Ethan,
    First, I’m thrilled that a thoughtful person such as yourself is interested in primary care. It’s a field where we need bright, compassionate, articulate individuals.

    Dr. Wible have given you her opinions, but I hope you are seeking out other input.

    As an MD myself (but in pediatric subspecialty practice), I had a few thoughts:
    – I love that you want to be the best you can be! And frankly, while there are certainly varying degrees of excellence in all fields of medicine, the average MD/DO is more knowledgable than the average NP.
    – Part of it is the breadth of learning. While you say that you are not interested in many rotations that you may not be interested in, in family medicine, you NEED to learn about everything! Pediatrics, internal medicine, family medicine, ob-gyn, surgery, and psychiatry – the standard clinical rotations in medical school – are all integral to being a great family medicine doctor.
    – Part of it is also the depth of learning. Both an NP and a physician know that steroids are important in the management of an asthma exacerbation. But the physician will have learned in medical school that steroids work via a variety of important mechanisms. Both will know (hopefully) that codeine is contraindicated in children. But the physician will have learned that this is due to specific genetic polymorphisms that have impacts on multiple medications. There are multiple other examples like this.
    – Any field in medicine requires lifelong learning as things are constantly changing. However, you also have to look at the FOUNDATION that you are building this learning on. As an MD/DO student, you will develop a much larger, more sound foundation to continue learning over time.
    – Above, it is stated that “degree really doesn’t matter.” This is sometimes true, sometimes not. An MD can start independent practice in any state. An NP has independent practice in SOME states, but not others, and it’s not clear what will happen regarding NP practice nationally. Additionally, you have to think about what skill set you want to have. Usually, a physician will be credentialed to do more procedures than an NP. In my ED mindset, I think of it this way – as an MD, I am the one caring for the most critically ill patient. Any patient can be my patient. But as an NP in the ED, care is going to be passed off to a physician and there will be limits in what they are allowed to do (ex: take care of coding patient, etc).
    – I do understand your concerns about work-life balance and/or a toxic environment. But things are better than they used to be. You have to look closely and carefully at the schools and training programs. I did not feel abused as a medical student or a trainee. Sure, I didn’t have as much free time as I did before. But I still pursued what was important to me – movies with friends, cooking, skiing, etc. Yes, I missed some holidays and weddings, but it’s a sacrifice that I was willing to make.
    – It will be challenging whatever route you take. I see many of our fabulous ED RNs go onto NP school. They continue to work full time AND take classes AND do clinicals at the same time. They are incredible super-women, and to me, seem busier than I was as a medical student and some of my trainee rotations.
    – Also, training is time-limited. You won’t be a student/resident forever. Once you’re done with training, you have a lot more control over what you want your life to be like. Work one day a week, take locums in different places every few months, etc.
    – And obviously, patients don’t always care about our schedules. Regardless of what degree you go for, if you have to give a patient bad news and it goes past closing time, you WILL sacrifice a bit of your personal life for that patient – because you care.

    There isn’t one right answer about the best degree for you. Keep exploring and thinking about it. Based on what you wrote, I’m sure you’ll be a great clinician. Just think of your dream, focus on it, and go for it.

    Best of luck!

    • Pamela Wible MD says:

      Also want to add that obviously if you want to pursue something like neonatology or transplant surgery than MD/DO degree is the way to go. Whatever you do, QUESTION everything. Never lose your independent thinking and inquisitive nature—even if it threatens your attendings or the entire medical establishment. Not everything you learn in school turns out to be the truth.

      • Runningdoc says:

        I think it is dangerous for them to be practicing without any physician supervision in any setting and I’m happy to share any one of the hundreds of stories I’ve collected–including my own–which may help you understand why I feel this way. Just bc they are practicing primary care unsupervised doesn’t mean people aren’t getting hurt. Patients are, in fact, being harmed all over the country and reports to the board of nursing–who is suppose to be overseeing these NPs–are going ignored. No one is against NPs, but for you to encourage a “cheap and easy” route to the independent practice of medicine is just wrong. It’s all good until someone you know and love is hurt by the “provider” who chose the cheaper and easier route to practicing medicine independently.

      • AThac says:

        … but if you want to be in primary care where you literally have to know everything, then by all means do that the shortest way humanly possible. Is that REALLY your message here? Do you even know there are NP programs 100% online with almost no clinical training at all? Does patient safety matter to you?

    • Ethan says:

      Dr. Agarwal,

      Thank you for your thoughtful and insightful response! I think many of the points you make are valid, as perhaps are many of the other commenters’, too.

      I really liked your example of steroids and the asthma exacerbation. And this is where I am sensitive to what many physicians say about the knowledge base difference, all the way down to genetics, as you described. And I think that my inquisitive nature would really like the way physicians are trained to think and their strong science base.

      I do think that (based on the brain’s capacity to retain only a certain amount of information for so long), most of this scientific knowledge is forgotten (at least I know I constantly have to go back and review fundamental scientific/pharmacological concepts from nursing school), and from what I have observed so far much of medicine (whether one is a doc or an NP/PA) is algorithmic. I work at a teaching hospital and I have listened in on the thinking process of residents and attendings, and, to be sure, even though they definitely think critically, there seems to be lines of thinking that everyone draws upon to formulate a diagnosis. However, I think as a whole physicians are more adept at thinking beyond those algorithms and catching the finer details in care and building on the foundations they have. I think NPs/PAs can do this, too, but by and large I presume that physicians do this more consistently.

      I also appreciate your mentioning about looking closely at medical schools and residency programs. Even though my temperament is definitely on the more sensitive and compassionate side, I can still take a lot–I have to in my job consistently. But I just worry that being under the stress, long hours, and exhaustion that is required to become a physician (perhaps it is only really bad AT TIMES), that it would simply be too much for me, especially with the added responsibility of a family. But I do read about inspiring stories of people making it through–I think the key would be just surrounding myself with as much support as possible to help out. But thank you for the encouragement, and I will definitely keep this in mind.

      And to the comment about learning about ALL the subjects in medical school to be a good provider–I totally agree. And I am interested in learning them! I really do love being a jack-of-all-trades. The rub for me, as I explained, is if the extra time spent in medical school/residency would be worth what I think I want to do–which is primarily outpatient primary care–teaching patients, getting to know them over time, being able to care for them as a whole. But then again, I may end up wanting to work in another capacity later in my career, such as hospital medicine or something else (you have many options in family medicine!). And with an MD/DO degree, I might look back and be thankful that I pursued that extra training so that I could enjoy the many options I would have at that point with the autonomy.

      Man, it’s just a tough decision. So many scenarios…I read in The Med School Confidential that an informed decision is a good decision, and I think when the time comes when I decide which route to take, I will have peace about it. At least I hope so. 😉

      Thanks again for your insight. I need the guidance of doctors like you in a similar field I am interested in.

      Best wishes to you,
      Ethan

    • Ethan says:

      Also, Dr. Agarwal, would it be ok if I got your email address, in case I have any future questions? What do you think?

      Ethan

  19. Joy says:

    You can’t have your cake and eat it too. Less training, less burnout, more free time = less knowledge, less expertise. And it should be also less authority and autonomy. To be an expert Hou have to bust your hump. That’s not a philosophy, it’s a fact.

  20. SEE says:

    Your lack of respect and support for your fellow physicians is appalling. You should be ashamed of yourself. Quick, easy and cheap does NOT = better or even equivalent care to a physician. Glad to know where you stand, however.

  21. ProudMD says:

    You obviously have little insight into your own beliefs and the damage that this does to the physician profession. You are negating any positive work you perceive you are doing regarding physician burnout and suicide if you think promoting the undercutting of our profession is ok. Self centered and narcissistic may be a better way to look at your recommendations since it appears you are only attempting to expand your audience now to the support of APCs. And no, he cannot “follow suit” as an APC. As a promoter of this you are contributing to physician burnout and suicide and “Dr.” Wible, blood doesn’t wash off easily.

  22. HappydocMD says:

    Dr Wible,
    I have to say that this article rendered me speechless. I cannot believe that someone who claims to be an advocate for physicians would write something like this. Your arguements make no sense and you know it. This is about $$$$ for you isn’t it? You know what you are doing, writing this in this day and age when NPs are lobbying for independence and trying to replace physicians. You are NOT a physician advocate. You have shown your true colors. Carry on.

  23. AThac says:

    As a resident who very much appreciates and respects the training I have received and the need for the rigor involved, this article disgusts me. What a shame to discourage someone from the practice of medicine and in such a disrespectful way. I was a nursing student once and I chose medicine because I wanted to be the best I can be. I would not be prepared for the autonomous practice of medicine with an advanced nursing degree – and if I had gone straight from BSN to an NP program, I probably wouldn’t even be ready to practice nursing. What is going on with you that you place so little value in your own education and experience and in that of your colleagues? When did you move from fighting for us to being one of “them” and dumping on us? Shame on you, doctor.

  24. TM says:

    So you are “America’s leading voice for ideal health care”? I don’t think so. Please don’t lead my health care Pamela. I am shocked at your comments. What are you talking about? There are NPs better than MDs? Holy Cow.
    To advocate NP instead of medical training, calling the latter “not worth it” is irresponsible. Unless you intend to do away with medical training all together and have everyones healthcare delivered by mid levels, trained by mid levels- medical school certainly IS worth it. Medical training and residency is hard and expensive. The work and hours are demanding, we all know this. BUT YOUR ALTERNATIVE, online certification, long distance learning, a quickie drive through approach frankly wont do for me or my family. Yes, the NP lifestyle is “healthier”. That is bc there is a physician out there who is bearing the brunt of the responsibility. NPs can walk alway cant they, and while the ultimate burden is on the medical doctor that signs off on their decisions. If you like Dr Wible, you get your care at the NP office. Ill stick with an internist, if they continue to exist.

  25. Erica Bowen says:

    Dear Ethan,

    I am a third year family medicine resident, mom of 2 children (5 yo and 1 yo), and wife of a full time ICU nurse. I greatly appreciate that you are thinking critically about your future training to best care for patients and balance your own well being as well. I won’t lie to you, this is a long, exhausting, exhilarating, draining, crazy adventure. I have accrued a significant amount of student debt on my journey to be the best family medicine physician I can be.

    There have been times I have asked myself the same question… Was all this time, debt, strain on family, and exhaustion worth it? Should I have gone the midlevel route instead? I can honestly say that I have been envious of friends who started PA school after me, finished their training before me, live in a nice house, and drive a nice car, while I am working near 80 hour weeks and sacrificing so much. If a midlevel education is sufficient for practicing medicine, then why in the world does anybody go through this process.

    I can also honestly say as I near the end of my training, I am confident I chose the right pathway. As someone training in primary care, all of those rotations through specialty clinics are essential to gaining a broad base of knowledge, to learn what primary care can adequately manage, and to learn when patients are better served by the specialists. I do firmly believe that family medicine can manage the bulk of patient concerns, so developing that knowledge and skill set is essential. This doesn’t happen overnight. Even though I worked very hard in medical school, my first days as a resident were difficult. Book knowledge doesn’t easily convert to real world medicine. The ongoing intensive apprenticeship with attending physicians and emphasis on evidence based medicine is vital to developing skills as a proficient family medicine physician.

    You mention concerns about work life balance and starting a family. Again, I won’t pretend it is easy. But it is doable. It is vitally important to have a strong relationship with your significant other, always be supportive of each other, and build of a strong web of support. The phrase “it takes a village to raise a child” is especially true in medicine. Regarding personal wellness, remember that medical training is a marathon and not a sprint. You will learn best and retain information if you have sufficient sleep, a healthy diet, and take time to exercise.

    Lastly, I think it is important to think about the big picture. What is the point of all this training? The point is to provide the best care you can for the patient in front of you. Retrospectively, I strongly believe this requires the rigorous training of a physician, especially in the field of primary care.

    If toxic environments and insufficient time with patients is the main deterrent for becoming an MD/DO, then join us and help be a force of change to better the environment for patients and physicians alike. Be thoughtful of what schools you interview at and which residencies you pursue. I feel that I have had pretty good experiences.

    Best wishes as you proceed with your training.

    ERB, DO

    • Pamela Wible MD says:

      Great advice Erica! Thanks for chiming in.

    • Ethan says:

      Dr. Bowen,

      Thank you for your insight and thoughtfulness. Seriously, hats off to you for being able to be a mom, student/resident, and wife at the same time. I truly think that is amazing and takes so much strength.

      I think I agree with everything you have said. Knowing myself I think I would clearly be able to see all of the advantages of the rigorous training that physicians go through. That may seem rather obvious, but when you think about it below the surface I would imagine that it becomes even more apparent. A big key for me, as you touched on, is being able to take care of myself. Diet, exercise, sleep–totally agree. I try to practice that now. I think it is a fact that any provider will be better when he or she is healthy. And I know physician training is long, hard, and exhausting, but no doubt rewarding in many ways. I guess it’s just about knowing yourself and your strengths and abilities, what is best for YOU, knowing how to take reasonable risks (and for the right reasons) and knowing when to be humble and step back. And I think with physician training, you acquire more knowledge and autonomy, but with that comes other sacrifices, as you mentioned. I guess you just realize that many decisions in life require trade-offs, and career choice is one of them.

      So happy you have found success and resolve on your own journey. Stranger to stranger–proud of you! 🙂 And nothing but the best as you begin your career as an attending–finally! 🙂

      Warmest regards,
      Ethan

      • Ethan says:

        Also, Dr. Bowen, if it isn’t too much to ask, it would be great to have your e-mail address, as I could have someone else to contact who works in family medicine when I have specific questions.

        What do you think?

        Ethan

      • EMC says:

        Ethan, you clearly are really taking the time to make an informed decision and honestly that is the most important trait to have as a physician or NP. We always need to be thinking below the surface so we don’t miss things that can be harmful. That’s what we learn in residency. I am now 13 years out from graduating medical school. The longer I do this the more I realize what I don’t know. I hear some NPs say they hardly ever ask their supervising physician questions. For me as a Hospitalist there is not a work day that goes by that I don’t run something by my colleagues. Humility is the key. Can’t be afraid to put ourselves out there, question others, stay late, etc. All of that is for the safety of our patients and not for ourselves. Yes medicine can be demanding and “burnout” is huge. However, burnout is not due to the actual practice of medicine, it’s due to the excessive administrative, insurance and government burden preventing us from being the physicians we want to be. This is not unique to physicians because NPs have to follow the same guidelines. I think we will see changes in medicine to help those issues but it will take time. I’m already seeing lots of physicians that are speaking out. Personally based on your eloquence, interest and truly thinking about all the pros and cons tells me that you would most likely make an excellent physician.
        I wish you well with whatever you decide to do!

        • Ethan says:

          Thank you, EMC. It’s good to hear “humility is the key” coming from a physician. Very encouraging. And I think any good provider, as a lifelong learner, will continuously realize how much he/she doesn’t know or how much he/she must go back and review to be the safest/most effective provider possible. Thanks so much, again!

  26. Brooke says:

    While I was not a NP, I worked as a floor RN for about 5 years working alongside NPs, and I understand their role well. Now, I am in my third year of medical school (not doctor yet, but close). With these experiences, I may be able to offer a little more firsthand insight into the difference between the nursing vs medicine path as it stands. Both nurses and physicians play a critical role in making sure the patients have best outcomes.

    I personally opted to pursue medicine instead of becoming a NP after working as a nurse because I found myself working in rural areas internationally and didn’t feel comfortable enough with my knowledge base to practice in rural areas and provide the care to the extent I wished I could. I also wanted to play more of the role of final decision-maker in the patient’s care. Lastly, many countries don’t recognize a nurse practitioner license, and being able to work internationally using the full extent of my knowledge base was (and still is) important to me. A nurse’s scope of practice can vary widely between countries.

    While career paths vary within both NP and medicine worlds, I think it could be valuable for you to shadow at least a few NPs, DOs, and MDs to explore their workflow, lifestyle, schedule, and their specific roles on the health care team to see what kind of role you wish to play in the patient’s care.

    It’s my opinion that your decision can come from what kind of role you want to play when caring for the patient.

    I would be happy to talk to you more about this if you care to send an email!

    • Pamela Wible MD says:

      Excellent advice Brooke. Much appreciated. How can Ethan reach you?

    • Ethan says:

      Brooke,

      Would love to talk more, especially because we share a nursing background in common. My wife being Brazilian, international practice is attractive to me, as who knows if later in life I will have the opportunity to practice there, or anywhere else where there is opportunity.

      Will be in touch! Thanks so much for reaching out!

      Ethan

  27. Deborah says:

    As a happy NP who has worked in primary care for many years I would like to add my two cents:
    It took me a while to understand my worth as an NP, but I worked through many feelings of inferiority and now know clewrly that the holistic, listening approach I learned toward patients as a nurse is immensely valuable in primary care, not to mention some clinical skills that MDs weren’t taught very well. (Giving IM or SQ injections, placing IVs, setting up an infusion, patient teaching, etc.)
    Are there things I don’t know, that my training was lacking in? Absolutely. Can I typically find them out by doing research on my own? Yes. Do I typically recommend working as part of a team initially as a new to practice NP? Yes!
    Do I think that experienced NPs are intrinsically less well suited to providing primary care than MDs? No.

    I agree with Pamela’s advice to this RN in this situation. And I recognize the dilemma that Ethan identifies: MD or Dao training is more comprehensive and deep than typical NP training. Yet the course of study to become an MD or DO may not be healthiest for Ethan. And ultimately if providing high quality primary care is Ethan’s goal, (not becoming a surgeon or specialist), a nurse practitioner can very well provide that. It does take personal initiative and finding a good program of study will help, not to mention humility enough to know ones’ limits. However it sounds like Ethan is making this decision with his eyes wide open and I am confident he’ll find his way, whether to become an NP or an MD.

    *Side note: MDs may certainly find themselves cleaning up some messes caused by incompetent NPs. I’ll just mention that nurses have their fair share of cleaning up after MDs every day, whether as RNs or NPs. It goes both ways.

    • Andrewe Hansen says:

      Working under interventional cardiologist, I often find myself cleaning up messes left by incompetent hospitalists/intensivists: NPs/PAs/MDs/DOs alike. The training is huge component, but we all know you can walk away from any amount of training still very ignorant. Just today I walked in to the ICU to a patient with a troponin trend of 0.29, 1.5, 4.2, 5.9 and T wave inversion x10 hours. No anticoagulant since admission 24 hours prior. But by god they did that bronch and and biopsied that lung mass they were positive was causing her chest discomfort. Nobody is perfect. No training will ever separate you from anyone else unless you absorb the training, put it to use and continue to build on that knowledge every day. Complacency is fatal in our industry, and I will NEVER just automatically trust any provider based on the letters behind their name. Prove that you’re worth your salt.

    • Ethan says:

      Deborah,

      Thanks so much for your comment. I agree with your line of thinking, too. For an FNP, especially when new, I think it is smart (and probably should be mandated) that he/she work with a physician for a few years in the area of their specialty before going solo. I think that is just common sense, really.

      I wonder, too, when one considers the broad evidence out there, if it is not really a stretch that experienced FNPs can provide independent care, WITHIN THE SCOPE OF THEIR PRACTICE. Admittedly, I am not up to date on all the current literature about NP independent practice and patient outcomes, but I have seen that there is quite a bit of evidence in the past suggesting that it is positive.

      I really like your honesty here, too. I know that if I become an NP that there will be many things I am ignorant of, especially when comparing new NPs to physicians fresh out of residency. And that is why I would WANT to work with a physician for a few years in my specialty before branching out. But I do have a hunch that Pamela is right when she says the quality of provider you are starts with your own drive and determination to be excellent. And I also think that after adequate training for NPs in the scope of their practice, if evidence shows that it is safe, then perhaps NPs should be able to practice independently. But, I could be wrong. That’s where I think with all things fairly considered the evidence should speak for itself.

      And I appreciate your honesty about fighting feelings of inferiority. I know I would have to do that myself, too. I’m sure it passes with time, though, and there are other things in life that are far more important.

      All the best to you,

      Ethan

  28. Debi Wong says:

    You are certainly one of the most enlightened physicians I have encountered, I would have loved to have worked for you when I first graduated. I became a NP entering from a totally different profession (City Planning) at age 45, a journey that spanned from 1996-now. I entered a RN to MSN program at Mass General which took 3 years under a National Health Service Scholarship program. It took me 5 years to “pay back” the 3-year scholarship (poor fit, general downsizing due to the clinic having to reimburse Medicare about $1.3 million back).

    I did find my place as a hospitalist and have been doing this since late-2011. I have made good income, actually have not taken a “real” vacation since 2012, find this field challenging and interesting.

    But if you ask me if I would do this again, I am not sure I would. I came into the profession when medical care was and still is undergoing big transformations, not sure for the better. As an NP, I feel as though I am always having to justify who I am to patient’s, RNs, and MDs. Administration seems to get it oddly enough.

    As I look to retiring in about 6 years, I don’t regret the change in careers, just wished it had been a little more stable and without as many moves, coming from someone who was previously with the same employer for 13 years and the same position for 10.

    Debi

  29. Lawanda Mann says:

    An an NP myself, I obviously agree with your advice. M.D.’s seem to experience burn out much quicker, I love the nursing model when compared to that of physicians. I have autonomy (Arizona got something right) and my own clinic.

  30. EAB says:

    I have to say that I completely agree with you Dr. Wible. For Ethan’s circumstance, becoming an NP is an excellent decision. It may not be right for everyone, and I agree that NP’s are not MD/DOs, but as an NP you can still help people, have autonomy, and have a life without debt. My decision to become an NP has never been stronger after completing your teleconferences. I actually had no idea the extent of abuse physicians went through or that their profession is number 1 in suicides. Physicians spend several years enduring this, only to leave $100,000 ++ in debt and get a bad job where they are again abused. This information was so eye opening for me, but also so horrible to hear. I have great respect for physicians and still as an NP hold them in the highest regards, but I would not take that same path unless things change. Thank God for you and realizing this terrible problem and doing something about it.
    As far as Ethan, he is already an RN, married and wanting to start a family soon. If he wants to have time to spend with his family, have the option to work part time and go to school so that his debt doesn’t wrack up majorly, and also be able to have autonomy, NP is the way to go for HIM. As far as starting his own practice, I do think he would need several years experience before making that leap, but it is definitely possible.

  31. Ethan,

    We’re lucky to live in a time where you have options and my .02 cents is to become a physician. Burnout, physician abuse, workplace anxiety…they are all born from financial greed mixed with narcissistic injury (not inherent to the practice of medicine itself). While I (a psychiatrist in private practice) can’t fix the latter for everyone, I’m working on fixing the former. Our health finance paradigm needs to change, so I’ve made a new one: http://www.changehealth.today

    You mentioned autonomy multiple times in your post and I’m here to shoot you straight: the ONLY way to true professional autonomy is to be the master of your craft IN YOUR OWN COMPANY. I didn’t find happiness (and Pamela can attest) until I quit corporate medicine and started my own practice. It’s a ton of work but my quality of life (and patient care) is better than ever.

    Physicians are the master craftspeople of medicine. Sure, you can try to do that as an NP, but as Pamela pointed out to you, 10% of the training is 90% less mastery. NPs are not master craftspeople of medicine, i.e. you will never had the mastery you’d need to be fully autonomous.

    Lastly, regardless of what you choose, I advocate for professional accountability. I believe that all NPs should pay malpractice rates of 100% commiserate to the physician they collaborate with and if they go unsupervised, their rates should be( 100 + 90 = 190%) of the commiserate specialty’ed physician. After all, rates are based on risk (not earning potential) and if I train 90% harder to protect patient safety, either I deserve an insurance break or NPs deserve to pay more.

    In a nutshell, decrease risk for your patients and become a physician. Take business classes so you can start a private practice as soon as you’re done with residency and have a fantastic autonomous life for you and your family.

  32. Ziba Rezaee says:

    Are you serious!? I suggest you leave your soap box and reliquish your MD and go become an NP. I have no words or respect for you as a physician. I refuse to call you a colleague as you undermine sand disrespect the profession that you so did not deserve to be a part of. I am appalled by your article and would recommend you work on your sense of reality and judgment prior to writing ignorant articles like this.

  33. Melissa G. Pearce, D.O. says:

    Reverse engineering your dream practice is the best part of this. For me, DO all the way. Best application of healing in full scope practice I can dream of

  34. Andrewe Hansen says:

    There exists a plethora of variables when considering your terminal career goal. PA vs NP vs MD/DO is a huge decision.
    One significant factor to consider is where you wish to practice. Currently only 18 states have independent full practice authority for nurse practitioners. The remaining states all require an agreement with a supervising physician at minimum. In some of these states, an NP is not even able to place clients on services such as home health, or hospice. In addition to these restrictions, the states without full practice authority often have a reduced formulary, restricting the type or quantity of drugs they can prescribe.
    Another important factor to consider is that the age-old adage about the versatility of the NP being able to easily change specialties is coming to a end. The National Council of the State Boards of Nursing (NCSBN) working with multiple other organizations, including the American Association of Nurse Practitioners, American Nurses Credentialing Center, and several specialty organizations published the Advanced Practice Registered Nurse Consensus Model. While this model advocates for NPs being permitted to practice to the full extent of their education and training, it also cites fairly stringent boundaries concerning this. The Consensus Model states that an APRN must have a population focus ( family, neonatal, pediatric, adult/gero, womens health, psych) and a specialty (primary vs acute). For the sake of time I will leave out CNS, CNM, and CRNA. Family Nurse Practitioners (FNP) are trained in primary care, as an acute care track does not exist at this time. Therefore FNPs should practice in the primary care setting, and remain in that boundary, according the Model. Several hospitals utilize FNPs in acute care roles, even in critical care environments. The Consensus Model may strain the NP versatility as it continues to gain momentum.
    Be sure if you choose the nursing route that you do NP, as NP is the only APRN credential that is at least recognized in all states.
    One final thing to consider is that licensure endorsement requirements state by state vary tremendously, and that the nurse licensure compact (NLC) and the eNLC do not cover advanced practice licensure, and that transferring an advanced nursing license can be tremendously taxing, or impossible in certain circumstances, based on education and background.
    The NP role can be an amazing path, if you’re lucky enough to live in a state that truly embraces their potential. If you don’t, you may have to become a physician just to ensure you can provide the breadth of services your community needs.

    Side note: NPs are not trained in the biomedical model of care. We are taught to utilize medical modalities in treating our clients, however our practice is that of nursing, not medicine. The education focuses on holism (mind, body, spirit, emotion) and all advanced practice nursing theories focus on the core tenants of the the nursing metaparadigm (Nurse, patient, environment, health). NPs are not nurses who are taught some medicine. It remains the practice of nursing at an advanced level, where we have more tools to manage the care of our clients.
    Inversely the practice of medicine appears to be moving in the same direction also, as far as holism and care partnership goes. DOs have embraced holistic care in their formal education for a long time, and now many MD programs have this component as well. All good providers practice holistically. You’re treating a person, not just a disease contracted by a sentient sack of meat; there’s a human soul in there.

    Please remember that whatever path you take, never shirk the importance of collaboration and consultation with other care providers. It’s okay to refer or to collaborate with other providers MD/DO, PA, and NP alike. None of us know everything, and it’s better to swallow pride than to risk a life.

    My advice: if you plan on residing in a state where you can accomplish all of your goals in providing care independently, go for your NP. Perhaps in. Your ideal clinic, you may not even need this full independence. Like Dr. Wible said, set your practice goal and reverse engineer a path to it from there!

  35. Vanessa says:

    I actually agree that Ethan would be better suited to pursue an NP degree. I applaud him on knowing his limitations. He notes that he is prone to anxiety and would get “burned out” if put through a “demanding schedule for too long.” As a physician, I would recommend RNs just pursue an NP degree. RNs are typically used to doing shift work with time on and type off. I remember taking overnight calls even as a medical student and definitely as a resident. I have worked with several very intelligent NPs. I agree that initiative or drive may be the deciding factor. The design your dream clinic advice is key for Ethan. I would add that he may want to limit to just clinic or just hospital work as crossover would definitely create a more demanding schedule. I don’t necessarily love the “stress and longer hours” associated with being a physician, but I do love what I do and am thankful for the road that I took. There are also intangibles that accompany being a physician. I love flashbacking to some seemingly obscure fact that I learned in medical school that actually made me not miss a certain diagnosis. I do feel like my specialists converse with me differently than an NP bc can draw on our shared medical experience as medical schools and residency programs basics tend to be pretty uniform. It’s also quite neat that I have access to a variety of specialists not in my community in the form of friends from school/training. I wish Ethan the very best in his medical career!

    • Ethan says:

      Hey Vanessa,

      Thanks for your advice. My gut is that NP is likely a better choice for me; I just trying to stay open-minded until I make a decision, which why I am seeking out the advice from physicians, too.

      I think that’s cool that you can flashback to things you learned back in school, which is why I also want to have a good foundation, so I can hopefully do the same. I once heard an orthopedic surgeon recall some obscure fact he learned in med school that was relevant to what he was doing, and I thought that was pretty neat. So glad you are happy in your career, and I wish you the very best, too!

  36. I LOVE the fact that one size does not fit all. What you have proven to me, yet again, through this blog is that you are willing to really listen to what is being asked and answer honestly. The present shortage of medical professionals from physicians to nurses means there is plenty of work for EVERYONE. Thank you for your answer!

    • Pamela Wible MD says:

      Thanks Sydney. It’s been a wild day unrelated to this blog. I almost didn’t publish this because I thought nobody much would read it. Wow! Was I wrong!!!!

  37. Sharon Karn says:

    Hi Pamela……
    I love that you are honest and honestly you didn’t say anything to be
    attacked……I’m a 40 year Nurse and an NP since 1984 and everything you shared I would say the same thing. Try being a nurse since 1972 and a psychiatric NP since 1984 only because I had 5 physicians blow smoke in my face and tell me at my interview into med school I needed to go home and become a nurse…… it was so hard to take back then and now it was the best choice I ever made because bottom line is our AANP association advocates for us, they support us and they have worked to advance us as human beings…..med school can’t even stop the hazing and abuse much less the suicides from it……you can tell anyone that I agree with everything you have said and I’m one of the “old” girls that helped roll that boulder uphill so that NP’s can practice autonomously…. we stay with the sickest of the sick in the hospital, we call and give observations and we are trusted to care for physicians sick patients around the clock……..to me that makes nursing better than being an MD you can care for a patient as well and make a difference. There are more than enough patients for all of us so trying to stay in a space to not be burned out and leave the profession to survive is the answer. I am my own boss….I do everything a psychiatrist does with the exception of ECT which most psychiatrist don’t do either only my philosophy is pills and skills or skills and no pills but you always need skills and that what nursing school taught me how to give my patients the skills to get better not just pass out pills. I cannot tell you how many times a patient has said to me “ I have never had any shrink treat me as kindly as you have or spend time with me”
    That is so pathetic but then I think they don’t even care for their own residents so why would a patient be different.
    Don’t let it bother you being honest comes sometimes with angst because being honest is hard for some to hear so they attack. I think I have enough years to say to you that I loved who you were from the day we talked and being brave and speaking the truth doesn’t mean it’s easy.
    I find it so fascinating that those that attack others for a view that differs from theirs don’t even realize that THE ABUSED has become the abuser…….
    You are the best…… HUGS
    Sharon Karn
    509.202.2200

    and anyone is free to call my “ideal practice” and discuss anything with me……my office # is 503-951-2376
    Huge hug……
    Sharon

  38. I think we all have a calling. I think there are many ways to help people and many more ways to reach people today than in the past. All persons participating in medicine are important and have an impact. The ANP training is based on the medical model. There is research on outcomes of care from ANP vs MD and it is found in family practice that is is the same or better. I find most of my knowledge came as time progressed with experience, reading, conferences and personal growth. ANP can be very fulfilling career. I loved my schooling. I felt it was it easy transition from hospital care to the ANP training. I had a good foundation for patient care. I would recommend starting with ANP and see what you think of medicine. The ANP is now a doctorate (DNP). It is an efficient system. DNP can become board certified in a wide range of sub-specialities. If for some reason it is not satisfying, a person can do a bridge program from DNP to MD in the future. For me, it doesn’t matter esp. in family practice. Billing is the same (except for Medicaid/Medicare). The laws are different by state but there is great autonomy esp. in the west coast. I agree with Pamela that most of this comes from your curiosity and attitude. It is important to have a vision so you are aligned. This will allow you to be fulfilled no matter what you choose.

    • Pamela Wible MD says:

      For those of you who have not “met” Christine Sagan in the video I recommended above, here she is (really worth watching): The happiest nurse practitioner in Alaska

    • EMC says:

      The research you reference is actually SUPERVISED NPs in primary care vs physicians. Those outcomes are similar. But the research on unsupervised NPs compared to physicians is lacking.

      I fully appreciate the role NPs play in healthcare and have worked with many awesome ones. The difference between those and the ones that scare me is humility. Recognizing that one doesn’t know everything and is willing to ask for help.

  39. Patti Robertson says:

    I have one correction for Ethan pertaining to his preference for the medical vs nursing model. NP practice does follow the medical model and not nursing. NPs are held to the same standards and guidelines as MD.

    • EMC says:

      This is not correct. NPs are regulated by the Board of Nursing not the Board of Medicine and the BOM has much higher standards than BON in regards to the practice of Medicine. I have heard numerous stories of blatant malpractice by NPs that BON ignores. If that is the case with a physician that docs license would be suspended in a heartbeat and investigation performed.

  40. NP who learned a lot from this post says:

    Wow. As always Pamela, thank you for your blunt and radical opinions. As a NP I am surprised at how riled up I also feel from these posts and the venom from some of the MDs – even though I absolutely agree that the educational foundation is not comparable, that we need our doctors, that online DNP degree mills are a looming problem for the profession, that NPs should have some fellowship period, that MDs should make much more than NPs and sorry Pamela, but I do not at all agree with that equation at the top of the article, for me NP does not equal MD/DO. I have had no problem accepting the hierarchy of medicine with MDs higher than NP/PAs although I think the comments here may have forever changed the teamwork model of patient care I have developed, as I will wonder what doctors have the more angry underlying attitudes expressed here.

    Yes, I do think NPs are capable of treating UTIs, strep etc autonomously and work on the same red flags that MDs do. As I see the EMR charts of all providers and progression of care in a large medical group, I can tell you absolutely I am cleaning up the mess left by some MDs – although I never thought to compile it as one of the physicians above is doing – and I never throw those physicians under the bus, because that is the sad, scary fact of our profession that we all make mistakes, occasionally things go in unexpected ways and you can do all the “right” things and a situation still turns out badly. I feel this job is hard enough and that the least I can do is bring some professional collegiality and respect to each other, which this article has almost made me question. Someone brings out NPs order more tests vs. article showing same outcomes for MDs/NPs vs. compilation of mistakes NPs have made vs. the mistakes that MDs make. Sorry, to one of the MDs above, but I see physicians prescribing codeine to children, doing paps under age 21, ordering unnecessary tests and prescribing inappropriate antibiotics all the time, leaving me with the problem of explaining why I am not prescribing an antibiotic to the person with two days of nasal congestion when their PCP always does. And to another one above, boy you would have loved it if it was a NP who prescribed a Zpak to that Ebola patient in Texas, but no, it was a MD.

    Its laughable to me to call the AANP a powerful lobby when I think of the AMA and their recent comments on NPs, even though it recalls to me their 170 year turf war against anyone besides MDs, DOs included. Do I want my hospitalist to be a MD? Yes. Do I want an experienced hospitalist NP to talk to also? Yes. Should critically ill patients be passed off to MDs? Yes. Should NPs pay the same liability insurance? Hmm, but the fact is that their rates are much lower because we are sued much less due to many factors including our more limited scope of practice (which I am very clear what it is thank you very much). But it is clear and sad to me how sick, tired, stressed and deeply unhealthy American culture is today and I think it calls for a range of health care providers. Thank you Pamela for calling attention to how deeply unhealthy medical training and practice can be, I hope you don’t lose followers because of this, because doctors need you. And we need our doctors.

    • Pamela Wible MD says:

      “equation at the top of the article, for me NP does not equal MD/DO.” I did not equate with equal signs. I used vs. for versus. Versus means in contrast to. So weighing each degrees in contrast to each other I felt the right way to guide Ethan might be NP. This is advice to one person based on his mental health, finances, desire to start a family soon, etc. . . I do not believe all these degrees are equal or interchangeable. They all have pros and cons. Each individual should obviously make their own choice about what health profession is right from them and there are SO many to choose from.

      Sometimes the right choice is social work or psychology and not MD med school. Sometimes the choice is rerouting to naturopathic school. Often DO or MD is the best choice. It all depends on many, many factors that an often young premed must weigh for themselves without proper guidance. I do think some of the 661+ doctor suicides on my registry may have been prevented had another more appropriate (even non-medical) career been selected. Some are pressured into medicine by parents. We all must follow our own dreams to become self-actualized.

      We all come from different experiences and backgrounds. As for me I’ve been on the phone with many many parents who have lost their children (sometimes their only child) to suicide during medical school or residency or beyond. I absolutely want to prevent others from losing their lives over their desire to help and heal others. Suicide is an occupational hazard in medicine. It does not appear to be nearly as high in nursing.

    • Patients have a right to choose their care and be compensated for deviations from standards of care. It’s strange when I hear NPs rationalize their lower malpractice rates by saying their scope of practice is “less” than ours. The same antibiotic and Prozac you prescribe is the same that I prescribe. The risk to the patient is (at minimum) the same. Thus it’s most safe for NPs to have rates AT LEAST equal to physicians.

      I advocate for them to actually be more. Think of it like car insurance rates. Those with higher risk (and less experience) pay more than those with lower risk (and more experience.) Are NPs willing to admit this?

      • Pamela Wible MD says:

        Seems to me the rates should not be lower. Rates should also be based on how many patients one sees per day/hour. If one doc is practicing assembly-line medicine is 7-minute increments and another is seeing patients q 30 minutes then obviously those with higher throughput and larger patient panels in shorter visits are higher risk. There are SO many factors that should be assessed in determining the premium (that don’t seem to factor in at all).

    • Anonymous NP says:

      Agree with all of this. So funny, I’m also feeling riled by the physician anger and yet, at the same time I agree with most of their arguments! My education left me with much to desire and reading the comments here, all of which are arguments I have read many time before (you’re luck to have not come across these rants before – I find them in every online medical forum), has still been able to re-shake my confidence. But what should I do? Lay down and give up? Go back to medical school where I am highly suspicious that I would drop out or commit suicide because I have endured altogether too much abuse in one lifetime? No, I think my patients need me as I am – stable, healthy, empathetic as all get out because of the abuse I’ve experienced, and capable of asking for help whenever I think there might be something that I’m missing.

  41. INP says:

    I appreciate your honesty. I too have similar thoughts, but do not speak them it loud due to the backlash you are receiving

    • Pamela Wible MD says:

      “I love conflict. It’s apathy that kills me.” I’m glad we’re having this conversation. Remaining silent is never the solution. I, for one, am open minded and always willing to learn something new. Nobody has all the answers. I’m thrilled that Ethan is getting so much input from so many well-meaning people who want to help him decide what route is best for his future. So thank you all.

  42. NPs may practice independently in some states, but in those states where collaborative arrangements are required, the abuse prevails. Impeding quality of work life and life in general. We should all move to Alaska!

  43. Michael Lionson says:

    For NP’s to treat something that is simple, they will have to have plausibly ruled out all that is not simple, but appears simple.
    But you can’t do that without a basic knowledge of all of medicine.
    NP’s don’t know what they don’t know after 18-months of online training. You must know that.
    And all strep throat is not just strep throat.

  44. Candi says:

    Thank you so much for your insight & your champion of NPs! You are so right, education in any scope is merely what you make of it. Going to medical school does not automatically make you a wonderful provider just like going to NP school doesn’t automatically make you a subpar provider. We all strive to keep learning and growing throughout our careers. I am so proud of being a nurse practitioner and I love all of my colleagues and strive to work together with them all for the betterment of my patients. Great article!

  45. LeeMossNp says:

    As background, I’ve been a nurse for over 30 years and a NP for over 23 of those years. My wife is a RN. My daughter is a ED Physician and my PCP, who I love is a family medicine physician.

    My thoughts: First, NPs do not practice medicine, we practice advanced practice nursing. This overlaps with medicine in the same way that osteopathy overlaps with medicine. In fact it took many years for MDs to accept DOs as colleagues and some still don’t!

    Second: NPs are not “mid-level providers” or “physician extenders”. We are held to the same standard of care as physicians.

    Third: yes, our educational track is different than physicians but not inferior. I was in ICU nurse for seven years before becoming an NP and helped train surgical residents. That work experience was part of my NP education!

    Fourth: Safety, over 40 years of research data shows that NPs provide safe care with patient outcomes that are equal to and sometimes better than physicians (patient satisfaction). Currently, there are 22 states and the District of Columbia that allow for full and direct access to nurse practitioner care without statutorily required physician collaboration or supervision. If physician supervision or collaboration are required for safe care then these states should have poorer patient outcomes from NPs but they don’t!

    Fifth: The AMA has been fighting a “turf war“ with all nonphysician healthcare providers for years to protect their “piece of the action“! Well, if more physicians went into primary care instead of lucrative subspecialties, there would likely be fewer NPs but there are plenty of patients out there that need excellent care from all of us!

    I didn’t choose to be an NP because I didn’t think I could become a physician. I chose to become a NP because I’m a nurse first and that is how I can best care for my patients!
    Ethan, choose the path that’s best for you, choose your passion, either way, you’re in for an awesome journey!

    • EMC says:

      Your training as an NP is NOT inferior but it is in fact very different than the training for physicians.

      The articles you reference about outcomes are very flawed, are sponsored by nursing associations and published in nursing journals. For every article you have that shows they are equal there are articles that show they aren’t.

      Nursing training is different than medical training. Indisputable fact.

      Also please explain to me what the difference is in practicing nursing to full scope is from practicing medicine. As an NP what do you see as the difference? For me nurses are trained in assessment of patients, education, non-medicine related treatments. Physicians are trained in diagnosis and treatment of disease. How is an NP diagnosing, treating a disease in addition to nursing training without supervision NOT practicing medicine? The “scope of nursing” is frequently stated as “practicing to full extent of our training”. But if you ask for clarification on what that means there is either no answer or vague answer. That’s where the problem lies in the NP vs physician issue.
      We are all important to health care but how is an NP who owns their own clinic and diagnosing and treating patients NOT practicing medicine?

    • Lynn Cronin says:

      Patient satisfaction scores are NOT a surrogate for good medical outcomes. In fact some data suggest quite the opposite.

      You may have seven years’ experience as a nurse, but there is nothing stopping a fresh graduate from doing on line courses and hanging out a shingle and you want me to send my family to see that provider with the confidence that he/she has the requisite chops? I was an athletic trainer and PT assistant for 6 years before medical school. I don’t put that on my CV as “experience”; it is helpful background knowledge for sure but does not make me more qualified in my specialty. Would you fly in an airplane that was engineered to the very minimum standard, built as quickly as possible and on the smallest allowable budget? That seems to be what this author is saying—the shortest, cheapest, least difficult route is “best”. I say BS to that.

  46. Pamela Wible MD says:

    Just got this email and answering for all who may be wondering:

    1) “Hello, sister-doc. I wonder if you can clarify the current level of respect that you have for our profession.”

    I have little respect for the abusive ways that medical system treats it’s own students and how corp med treats physicians. We should be honored for our contributions and after all the training doctors have we do not deserve to be micromanaged like bad kindergarteners. I love the field of medicine and have devoted nearly every waking moment that last 5 years to saving the lives of wounded healers. A labor of love.

    2 “Do you really think that a physician extender has the same abilities as a physician?”

    Nope. We all have a different scope of practice depending on our training.

    3. “How would that be possible? Our training is longer and more intense. We are not choosing what courses to study based on what we might “like”-we are being prepared to save someone’s life in the future.”

    I think out training needs to be less one-size-fits-all and more personalized. I should never have had to do so many months in the NICU as I had no interest in delivering babies or caring for preemies in my future practice. Those rotations would have been best for an FP+OB or someone who wants to pursue neonatology or peds.

    4. “Also, everyone does not have the ability to successfully work independently. So regardless of the title of the provider (NP, PA.MD) anyone can potentially be a part of a toxic environment if they are working in a hospital or clinic system (as most are).”

    You are right. Neonatologist and radiologists are unlikely to launch their own outpatient practices. For primary care, most can (especially those who are entrepreneurial or want to be business owners—and they should be taught business strategy in med school and residency, not left to flounder as employees in toxic work environments with no way out but suicide (that’s how some think!).

    5. “So, I would ask that you give a more even set of advice when someone comes to you with this question re what type of provider should I be.”

    I do when I’m on the phone with people I give very specific advice based on their interests, their finances, their desire to practice in a certain specialty, region, their interest in being an employee, a business owner, or entrepreneur. See this:

    6. “The answer may be “none”, depending on what one wants to get from the situation.”

    Exactly right.

    7.”Sticking with a RN lifestyle might be the best choice for that individual or any future patients.”

    Absolutely. RN may be the best answer for some.

    8. “Not everyone is mentally or spiritually ready to be the last decision maker when it comes to maintaining a life.”

    TRUE.

    9. “Everyone has a bias with this topic. As you have given yourself a national platform, I would just ask that you recognize yours and give advice accordingly.”

    Thanks for writing. I give much more comprehensive advice when I have time to speak with someone. This blog was a quick email correspondence.

    10. “By the way, are you still seeing patients?”

    Absolutely. I love seeing patients. I love being a doctor. And I’ve never turned anyone away for lack of money in 12+ years. I still take insurance. I submit my own claims. I have no staff. I am a solo-solo doc and I have never been happier.

  47. Anonymous NP says:

    Pamela,

    I initially responded with my thoughts on NP vs MD but deleted it when I saw the hostility you were getting from MD’s. It reminded me why I have problems with doctors.

    I have been an RN since 1980. Throughout my years I have been bullied an harassed by MD’s on a regular basis. We knew who we could call without being chewed out or being chastised in front of others, yelled at. The MD’s treat the nurses like they were treated in medical school. Not always but usually. The attitude is evident in the hostile responses you got from them in your blog.

    I wanted to be a doctor. I was accepted to an overseas medical program and could not get financing, additionally I was told I would have difficulty getting into a residency program.

    I am happy I did not go to medical school for many reasons but it was really a financial decision. I did not know about the terrible treatment the students have to endure. It is a blessing that I did not have to suffer that.

    Of course NP’s are not trained like doctors. The MD’s are reporting NP’s refer to specialist more. Of course we do, we are not trained to manage complex medical problems. We are also not trained to see a patient every 7 minutes.

    I agree with you Pamela, the RN should consider becoming an NP instead. First of all, you have to take extra chemistry and physics classes and normally you have to retake some basic classes due to the length of time the initial classes were taken. Then you have at least 6-8 or more years of school (assuming the RN has a bachelor’s degree and not an associate degree. An RN with a bachelors degree can take the NP class in 2 years. We also have a scope of practice established by the Board of Nursing. Each state determines the scope of practice.

    NP’s are not recognized internationally. I wanted to move to Israel and they do not recognize NP’s. Some countries do, I think Australia does. There is an international NP group that could help the RN find out which countries accept NP practice.

    The MD’s have tried to stop non physical providers for many years like the chiropractors, DO’s (yes I remember when they were not recognized), acupuncturist, naturopathic providers etc. We were trained that the MD is like the “captain of the ship” and the other providers are under the MD. Well this has changed but until we all work as a team without the bullying in health care, there will be a divide between MD’s and NP’s.

    Loretta Ford is the one who founded the NP programs and was a pioneer in advanced practice for nursing. The program started due to a lack of services in rural, poor areas. Recently she issued a statement about collaboration with MD’s due to their strong opposition. The AMA has been a strong opponent of NP’s fighting prescriptive authority, insurance reimbursement and putting up a lot of barriers to practice. The affordable care act changed that and it allowed NP’s to practice within their scope of practice. 20 years ago when I wanted to open a private practice, the insurance companies would not allow me to be a primary care provider, that was exclusive to an MD so I would have had to hire an MD to bill under.

    There is plenty of research that supports NP practice as being more affordable, safe and effective. There is also a lot of research that indicates NP’s have high patient satisfaction scores.

    How terrible the divide still exists.

    Sorry to be so long winded, it is really sad that NP’s are still thought of as second class citizens in the health care arena

    • Roxana, FNP-C says:

      I agree, these comments by MDs were filled with hatred. It is too bad that this turf war between NPs and MDs is never ending. MDs also fight DOs and NDs. As you said, the “captain of the ship” syndrome and complete disregard and disrespect towards other healthcare professionals. But not all MDs are the same. I know lots who are very appreciative and respectful of our profession.
      For those so adamant speaking against NPs and PAs, I sure hope that they do not employ NPs because that would only speak volumes to their hypocrisy. NPs and PAs are employed by MDs because the value, knowledge and skills they bring to their practice. It we are so poorly trained, unsafe and incompetent, why do they hire us?

      To those who do not know, becoming a registered nurse and then a FNP is a long and hard path to follow. Look into your local nursing schools and see how long the waiting lists are before being admitted into their programs. It is highly competitive to be admitted and even more challenging to complete the program and pass the nursing boards. So, do not think for a moment that becoming a registered nurse and then an advanced practice nurse in whichever area is something anyone can do or that our degrees and licenses are handed to us on a gold plate because that is farther than the truth. Our regulatory boards are very tough and they do not protect us but the public we serve. Not same can be said about Medical Boards. I advocate that every nursing and medical school program should have cross training. That way we can better learn, respect, and appreciate each other.

      Patients love us because nurses are very compassionate, caring, astute, dedicated and hardworking individuals. Because of great nursing care, our patients go on with their lives and return to MDs offices. This profession is highly regarded for a good reason. We have gained the trust of our patients. Why do you think that is? I see patients everyday coming to me because they feel heard and cared for. They have left their physician because “the care was not there”. So, please, as smart and educated MDs think they might me above NPs and PAs, do not make the mistake to disregard what we do for OUR patients.

      • Pamela Wible MD says:

        Infighting and turf wars between health professionals are totally counterproductive. I’d love to see a conference where we all come together and diffuse this tension that has existed for way too long. Happy that I can bring NPs, NDs, RNs, MDs, DOs, and even veterinarians and LMTs together at my retreats. I have so much love and respect for you all.

        • Erica says:

          Yeah! This is what we’re working on in our little corner of Austin!!
          First, I know you don’t need a champion Pamela, but I’m going to chime in because you’ve done so much for us healers for more than a decade. It seems silly that so many people will abandon ship, break off from following your mission based on an opinion you expressed for one person’s situation, it may be why our culture is the way it is. Online courage is very different from an in-person scenario. If we’re unable to let someone speak their mind and share their voice, we’re f’d as a society. I went to an emotionally charged meeting of docs the other day and one of them said “please don’t get stuck on my words and opinions because it’s going to prevent me from using my voice”. And that’s what happens, particularly online. I know we could never stifle Pamela, thank goodness, but others are not so strong. For a second reading this, as a PA, I was offended, but then I let my ego go and recognized the ridiculousness of my response. She was talking to Ethan, not me. My energy is better focused elsewhere; to patients, to my family, to living a life that I want to live, allowing others to live theirs and minding my own business. Plus this is Pamela’s venue, she’s courageous enough each and everyday to have an opinion and open herself up to criticism and comments. Healthy healers (and teachers) equal a healthy world. We have to be able to have a friendly banter without vitriol and insults. We are the ones who help set the stage for a society, creating a ripple effect to the masses. I know trauma NP’s who run codes more safely, efficiently and with better patient outcomes than docs and PA’s. I know a PA who is the chief scientific director and vice president of a neurosurgery center and oversees docs. I know PA, docs and NPs who simply clock in for a paycheck and insurance. We’re humans, not titles. We’re called to collaborate not compete. We’re never going to be able to heal our healthcare system if we’re not able to get past our differences with kindness and compassion. To define the ‘Physician Guardian Angel’ by an individual response is just plain wrong. It’s like defining our patients as ‘drug seekers’ or ‘non-compliant’ and not recognizing the whole person. We’re not giving honor to the story and complexity of the human being. This is my philosophical response, it always goes to spirit for me. If you’re so passionate about giving advice about your chosen profession, start your own site, create your own tribe, tell your story, do you. Then maybe you can gain some compassion, understanding and acceptance for people who are constantly championing for a greater good.

          • Pamela Wible MD says:

            Reactivity and polarization make it quite challenging (if not damn impossible) to thoughtfully discuss complex topics.

      • Anonymous RN says:

        Thank you for your comments Roxana. I’ll leave it with just this….I quess the docs responding perceive NP’s as a threat. That’s the only reason I can think of for their angry responses. I have worked with great NP’s and lousy NP’s. I have worked with great doctors and lousy doctors. Sorry, it’s not a hierarchy. Could you run that Ultrasound machine yourself and interpret the results? Any diagnosis you make is because of the team working with you. Lab, radiology, nursing and especially the patient. You are not the captain of the ship. And stop acting like it. Leave your ego at the door. Healthcare is collaborative, and the best docs I’ve worked with had respect for all members of the team.

  48. Pamela Wible MD says:

    Comment #100: “And, of course you can publish this on your blog. I’m honored! You can even leave my name if you feel inclined, although I don’t think it’ll make me an overnight sensation.”

    Looks like Ethan became an overnight sensation.

    Thank you all for giving him more advice than he ever thought he would get on his future career choice.

  49. Roxana, FNP-C says:

    Ethan,
    It is great that you want to pursue further education. Whatever you will decide to do, I am sure you will do best. Your nursing background will serve you well. I would suggest to narrow down your interests. If you want to become a surgeon, by all means medical school is the best way to go. If you want to practice Family Medicine, I would suggest you to follow a FNP for a while and then follow an MD in the same practice setting. Then, you judge for yourself what differences and similarities are related to the way we practice and training. I am a FNP and I can tell you that FNP schooling is not easy but it is all worth it and very rewarding. You will make a difference in your patients’ lives. Your training will be just as good as you’ll seek out to be. Put yourself out there and do not hesitate to learn and ask questions, take initiative and do not be afraid to make mistakes. This is how we all learn… but remember, patient’s safety first and when in doubt, always ask for help.
    After you will became certified as a FNP, you will start your first job. I can assure you that it will not be your last. You will doubt, question and second guess yourself a lot in the first year of practice. That’s ok. Ask your collaborating physician or your peers for help. There is no stupid question. Keep your learning going for lifetime! No one knows everything except God! You will move on and go thru few jobs until you will find your niche, your perfect job. One day, you may want to open your own clinic. That time will come and Dr. Wible will be there for you:)
    One more thing… NPs are not immune to burnout because of the abusive healthcare system we all work in. MDs, DOs, NPs and PAs are all in it. You will work long hours, be oncall, and start all over again the next day for as long as you stay in that system. Recognize the symptoms and seek ways to heal yourself, use your creativity to follow your dreams, and move on with your career. You will be taken for granted, overworked and underpaid, used and abused… but you will get over it because at the end of the day, patients will appreciate you. Continue learning and challenge yourself professionally, do not get stuck. When your gut’s feeling tells you that you are in the wrong place surrounded by the wrong people, take a leap of faith and move on. Be kind and grateful on your chosen path! Wish you the best on your career!

    • Pamela Wible MD says:

      Excellent advice and sorry I did not mention before the value of shadowing docs and NPs. I can certainly help you set up a rotation in Oregon where you can potentially get elective school credit while training under both NPs and MD/DOs. Do let me knwo if you want to purse this and I will help you set it up. Ethan, I’m so glad we made our conversation public. So much we can learn from discussing various educational tracks. You will really need to keep up informed of your decision. I think e are all on the edge of our seats waiting to see what you do now!!!

      • Ethan says:

        So glad we made it public, too! Definitely some thoughtful insight on this thread. It will always be a point of reference until I end up deciding, and I’m grateful for that! And will keep you updated!

  50. Anna says:

    I’m disappointed. I’ve always supported your message until now because while medical school and residency was stressful and not always pretty, I went to a school that was not toxic and trained in an environment that that was incredibly supportive.
    Additionally, any NP is going to be dealing with a lot of the same administrative, insurance, EMR garbage, so why not be well trained and better capable of taking care of the patients? I feel that you have now ended up on the opposite end of the spectrum and become what you have been fighting against, someone who derides and puts down what is a very special calling for me and many others. Very sad and disappointing

    • Pamela Wible MD says:

      Medicine is a special calling no matter what field you choose. All this anti-NP sentiment has really been shocking to read. A sad state of affairs that we can’t honor each other for all of our unique contributions to medicine.

    • Anonymous NP says:

      Why not be well trained? Like, oh, why not grab a seltzer water for me while you’re up at the fridge? What not! No big deal! That “why not” is like… the entire reason for the rest of Pamela’s blog here. The cost in dollars, time, mental health, physical health, and the lives of caregivers is the price that is being paid for being “well-trained”, not to mention selecting for and rewarding those that have a tendency towards being unfeeling zombies. Capable can and should be measured in multiple ways. There is a safer way to answering a calling and becoming a healer – being an NP that continues to learn beyond their formal education.

      • Pamela Wible MD says:

        I have been very shocked and sad to see the toll that medical education has taken on physician mental health. I have been on the phone with so many family members who have lost their children, spouses, siblings to suicide in medical school. NEVER have I been on the phone with any family member who has lost a loved one to suicide in NP school. From my retreats I am always saddened to see how fragile many of the docs are in regard to mental health Many of them require ongoing therapy to heal from the wounds of their medical training before they can ever plan to launch an independent clinic. However, the NPs who I meet are much more psychologically stable as a group and just lack the business strategy that we teach at the retreats. Does it piss me off the amount of distress the meded has cause my physician peers? You bet is does. I’m appalled that such truly brilliant and compassionate doctors have been left so traumatized by our training and toxic work environments. Are their great residencies that are not so abusive? Of course. Mine was awesome! And I am still heartbroken for my colleagues who have sustained such deep wounds from training. Do I think Ethan will emerge with less mental health struggles as an NP? YES! One of the reasons I suggested he pursue an NP rather than an MD/DO. Make sense?

  51. The only downside to this advice is that half the states in the U.S. do NOT have independent practice for FNPs. I live in Arkansas, where independent practice for FNPs was voted down by the legislature last year. I graduate with my MSN FNP in May 2018, and should NPs not gain independent practice here in the next few years, I’ll probably leave the state for one that does allow it.

  52. As for people think that physicians and med school are being maligned in this blog post, this generation of physicians is the first who are telling their own kids not to go to med school.

    A financial writer for CBS wrote: “It… takes between 11 and 14 years of higher education to become a physician. That means the typical doctor doesn’t earn a full-time salary until 10 years after the typical college graduate starts making money. That lost decade of work costs a cool half-million dollars, if you assume this individual could have earned just $50,000 annually, and the typical medical school candidate is smart and successful enough to earn considerably more. Add in the time and cost it takes to pay off medical school debt and a dissatisfied physician may well consider pursuing medicine a $1 million mistake. (This assumes the average $166,750 medical school debt takes 30 years to repay at 7.5 percent interest — a total cost of $419,738.)”
    (Source: https://www.cbsnews.com/news/1-million-mistake-becoming-a-doctor/).

    Also, Ethan can be an NP in 2-3 years (if he has a BSN). He might even be able to continue working as an RN through most of it and have little or no student loan debt.

    In addition, male physicians in the U.S. have a suicide rate “1.41 times higher than the general male population” and female physicians have a suicide rate “2.27 times greater than the general female population.” We lose a disastrous 300-400 physicians to suicide each year (Source: https://afsp.org/our-work/education/physician-medical-student-depression-suicide-prevention/)

    Given Ethan’s admitted challenge of anxiety and needing a lot of downtime to recharge, med school seems like a terrible choice for him.

    Side note for those who don’t like NPs practicing independently:
    #1 – Multiple research studies have shown that NPs are as effective and safe in primary care as physicians. This is the data our lawmakers are going by to make decisions regarding the independence of healthcare practitioners.

    #2 – If physicians would go practice in areas that need them, like rural areas, or reservations, or other places that might not necessarily be the nicest to live, then our nations wouldn’t need independently practicing NPs.

    Heck, if there were even enough physicians to take care of the population of the US, we wouldn’t need independent NPs. The fact of the matter is that NPs serve populations that really need them because few others will. People can want collaboration and supervision, but if you’re 200 miles away from your NP, the reality is that the NP is practicing independently so they might as well have it legally, too.

  53. Chris M says:

    As a trained family Nurse Practitioner, I work in a specialty clinic at an academic medical center. My physician colleagues are extremely supportive and always willing to answer my questions. Many of these posts now have me wondering what they really think of me.

    Anyway, I am considered a peer by my physician colleagues and they poke fun at me when I address them as Dr. xyz instead of by their first names. I feel very lucky to work in such a supportive environment.

    I see very challenging patients and am acutely aware of my knowledge deficits. I ask questions constantly and look things up for every patient, every single day. I see many patients who are getting a “2nd, 3rd, or 4th” opinion. Often times these patients have been seen by all or mostly MD’s prior to me. Many local MD’s refer patients to me by name, not just my specific practice. In many cases, these are very complex patients that the docs wouldn’t want handle because of the extensive amount of time required. Digging thru sometimes hundreds of pages of medical records, etc.

    In situations where I end up with a patient who would be better suited seeing a different provider, I am able to gather data and document a detailed H&P for them to have available when they see the patient. In reality, NP’s manage a lot of the visits the docs don’t want to see or don’t have time to see.

    In regard to the whole malpractice insurance argument…. historically NPs are sued less often with lower average pay outs. That is probably a large factor in terms of premiums. Additionally, many NPs couldn’t afford the premiums our physician collegues are responsible because our pay is significantly less. If I made “Doctor money”, I’d be in a better position to do that. To me, it doesn’t make sense that I am ultimately independently held to the same standard yet paid significantly less AND many of the physicians here feel NPs should also pay the same or MORE for insurance.

    After all my rambling (forgive me, it is 1am), I have a few conclusions. NP’s are another valued part of the health care team. We all have something to contribute to the setting in which we practice to ultimately provide the best patient outcomes. I am very fortunate that I work with so many physicians that value my hardwork and dedication to my patients and that are so willing to help if I need them.

    PS: In a previous life as a ICU nurse, I have had to run more codes than I can count because a physician (sometimes fellows) forgot ACLS or were panicking in the moment. As a nurse on the hospital code team this was common when responding to codes on the floor and often the residents and other doctors would say “I’m so glad you’re here”. That is what real teamwork is and I hope these negative views of NPs and nurses in general diminish and disappear over time.

    • Pamela Wible MD says:

      You make some excellent points. Regarding malpractice premiums, most in primary care can get them down below 10K/year. Mine is 2K/year. Never paid more than $3800/yr in the last 13 years. I wonder how much lower mine would be as an NP? I think my premiums are pretty cheap. For those who are interested, here’s how I saved 86% on my premiums and you can too.

  54. Anonymous New Grad NP says:

    Hi Ethan! An overnight success you have become, indeed! Surprise!

    I wanted to throw my experience in the mix here because I feel like I was going through the exact same thing as you were and it wasn’t until a year into my program, when every other day I was either elated to have chosen to become an NP or crying and devastated that I had not gone to medical school, that I finally came to the ridiculously simple conclusion that there is no perfect choice. They both have their strengths and their drawbacks and I wish that this was the discussion that was had more often instead of which one is “better”. Constantly I found myself thinking in nursing school, THIS is the stuff that the physicians need to learn, and as I studied with my medical school friends I thought, THIS is the stuff that I need to learn!(Has anyone ever considered that it might actually be more feasible to save NP education by adding in the medical foundation than it is to save medical education by taking out the abuse?? But I digress…) Overall, it’s usually a combination of both that heals people. So, you’re not going to win here and make the right choice because I don’t think there really is one! You’ll be missing half of the picture no matter what and I think you just have to pick which half you’re willing to pay for and which half you’re willing to fill in on your own. This attitude of “This is what I was taught in my training and is therefore how I practice. My competence cannot be questioned, see my degree over there?” is absolutely ridiculous and it’s killing people all the time. None of us know jack in the grand scheme and no one can truly be competent when we consider the millions and billions of things that we don’t even know yet (or all the things we think we know, but we don’t actually know because it turns out that while this “evidenced based medicine” idea is a very nice sounding, the evidence is easily manipulated and we, the clinicians, are easily manipulated as a result). No matter what path you take, just remember that you still don’t know jack, then you’ll never lose you motivation to keep learning and searching for the truth, which is what I believe is the defining factor in a good clinician, not the letters behind their name.

    Overall, I’m very glad that I made the choice that I made. I left my nursing program healthier and more whole than I have ever been. I am much better at taking care of myself and as a result, I believe I am also much better at taking care of my patients. I also considered myself to have issues with anxiety before going to school (though I have since found that this goes much deeper than that and is something that I have been able to diagnose and figure out on my own after eventually giving up on “medicine” as I couldn’t get a physician to listen to me) but instead of this feeling like a drawback to my personality and my ability to practice, it instead was a strength. Surprise! Most patients are pretty darn anxious and having the ability to empathize and help them work through it is a skill worth its weight in gold. You also mentioned you weren’t really down with the philosophy of nursing, so I can just about guarantee that NP school is going to drive you up the wall, but I have to say, as much as I hated (and I mean really hated, I was so angry…) all of the “fluff” classes in nursing school
    at the time because I felt like our time would be better spent on pathophysiology and pharmacology, that nursing fluff did turn out to be my foundation. In primary care, you can know everything there is to know about medicine, but if you aren’t able to really connect with that person in front of you – listen, empathize with them, help them understand, build their trust, be healthy and present for them – it’s practically impossible to figure out what’s going on and the most perfect treatment plan in the world will be pointless because they aren’t going to do it anyways (or they’re going to do it wrong, or partways, or they’ll just stop after a while because it didn’t seem that important…). This is what I believe I, as an NP, provide to patients and why I think it is accurate when we say that NP’s practice “nursing” and physicians practice “medicine” – this is why I believe that they are different. The diagnosis and treatment plan (which I fully admit, I am ill equipped to accurately and efficiently come to after my disappointing NP education, so in the mean time, as I work to rebuild my foundation for this – not so ironically, one built on anatomy, physiology, and pathophysiology through the never-ending online and in person education resources out there for physicians and medical students – consults and referrals for everyone!) is where I feel my work begins, not ends. I help patients figure out how to change their behavior so that they can manage and reverse their chronic conditions and live happy, healthy lives.

    Now, with that being said, this type of care is what I always wanted to do, so it stands to reason that I’m happy with my decision. I wanted to do relationship-based, preventative primary care where I have a small panel and spend a lot of time getting to know my patients. If I couldn’t stand listening to people complaining and I just wanted to be able to treat and street in <10 minutes, I don't think I'd be a happy camper as an NP. I think our education leaves us grossly unequipped for this type of care and I fully agree with the enraged physicians above who feel it is unsafe and inappropriate for new grad NP's to be in these types of jobs. But if you want to take your time, ask a lot of questions to everyone, and look a lot of stuff up, NP's the way to go! So I suppose it all comes back to that ingenious idea of "reverse engineering" your future. Who are you and what do you want to provide to healthcare? That will tell you what to do next.

    Good luck! It's going to suck and be absolutely amazing at the same time either way!

    • Pamela Wible MD says:

      Love many of the things you brought up. I do think its dangerous for docs (even the super-brilliant one at the top of their game) to be in 5-minute quickie assembly-line visits. I think anyone who has been in primary care knows, most patients need more time and attention.

    • Ethan says:

      Anonymous New Grad NP,

      LOVE THIS COMMENT! I totally relate to fickleness of wanting to choose one path one day and then the other the next. Part of the reason for this is that I do not have enough information yet (aka, shadowing and seeing what family physicians/FNPs do in their practice). I keep telling myself I will have more clarity once I reach that point, but in the meantime it is difficult not to think about it because I am such a planner! Ha.

      I think you are absolutely right when you say there is no perfect choice. I am sure if I was to become a physician, I could end up regretting the toll it would take on me to get there (what I fear most) and then end up despairing after going too far down the road (financially) to turn back. I read comments from sad physicians who are in this exact position, and my heart breaks for them. I can also see myself as an NP working some day and end up being frustrated by my lack of knowledge and possible dissatisfaction with my training when working around other doctor. The kicker is, though, I think it is much better to be in THIS position than the aforementioned one…know what I mean?

      If you don’t mind my asking, what aspects of your training were you disappointed with? Do you think it was just the school, the training itself, or both? I know there are probably sub-par NP programs out there, but I know there are very good ones, too (I am thinking Columbia, Vanderbilt, University of Illinois–well known state/private schools). I think if I was able to get into a reputable program like one of those with a solid curriculum, I could be satisfied with that kind of training/foundation and then be happy to keep learning and learning from there.

      Anyway, would love to read your response! To answer your question about who I am and what I want to provide to healthcare, I think I am someone who would ideally (no pun intended, Pamela 🙂 like to be in a relationship-based practice setting primarily and have time to think thoroughly and get to the bottom of patient’s problems, as well as use skills to help them make real change, to try to help alter their behaviors/habits so that they can live healthy lives. I think this is where I am the most gifted. Second, I like the intellectual stimulation of inpatient medicine and treating patients when they are sicker and more vulnerable in the hospital, but by no means would I want to do this full time. Too much time at computers and with charting, too impersonal. Ideally I could do both, and I am sure it is possible to do so! But what I don’t want is to be spread too thin and not have time for myself. Sometimes I think, “Well, maybe I could live with the extra hours.” But then knowing myself now, where as I have gotten older have grown to appreciate down time as a way to stay balanced, it seems that I wouldn’t like that scenario. But how can I know for sure unless I try? Ultimately, it’s a risk either way–a risk of at the end of my training not thinking that the extra time and training of becoming a physician was worth it, and at the end of my NP training not thinking that I had enough of it. But I also tell myself this: If I was to become an NP and be dissatisfied, I could always go back to school. Maybe more inconvenient later, yes, but it’s doable and people do it. But what I CAN’T DO is after all my training to become a physician, go back in time and get those years back. And that is why I think I am leaning more toward NP. Just trying to stay informed (but not think too much!–a challenge…haha) until it’s time for me to decide.

      Thanks again for your great comment!

      Ethan

  55. Marybeth Rizzo Moore, CRNP says:

    Hello Dr. Wible,
    Wow, what a lively discussion….I am not sure I can add much more to this thread! I can only relate my experiences, and I have so many! I was a nurse for 19 years before I became a FNP. I worked in major trauma centers almost my whole career and primarily in solid organ transplant (kidney, liver, pancreas). I spent all my time with patients and administered every conceivable medication, monitored telemetry, did bedside peritoneal dialysis and so much more! So, I believe it was this training that set me up very well to take care of patients as an NP. I worked with surgeons, nephrologists (one of which became a very good friend and mentor), and every other medical specialist. I can’t say that one of them every discouraged me from becoming an NP. In fact, they encouraged me to learn as much as possible and they were my best teachers. I have so much respect for physicians. If I had a different life and could do it all over, I would become a physician, maybe a surgeon, but that was not in the cards for me. I thank you for encouraging this RN to become what is best for him. I believe you have the right idea with your approach to his question. I read some unfortunate replies to your interview.
    My patients call me “doctora” and I say “no, enfermera especialista” because there is no “nurse practitioner” description in espanol. I collaborate with three incredible physicians, we work in an underserved area at an FQHC and believe me we are all needed to run this ship! I have learned so much there and thankfully have the support of these three docs, one midwife, and three other NP’s. It’s all good Dr. Wible! You totally get that message and it comes through in your posts!!!!
    Best to you!

  56. While this conversation looks seemingly generalized, it appears to be mostly targeted towards one party (Ethan). Intellect trumps degree but the degree will get you through the door- it is why we needs license verification(degrees) for most professions to get you THROUGH the door and then you can wow them with your intellect!

    • Pamela Wible MD says:

      I’ve found that (beyond degree) intellect, relentless curiosity and determination, and proper business model are prerequisites to good medical care. I’ve known many health professional (of all degrees) who may dangerous to their patients when left in toxic work environments, sleep deprived, hypoglycemic, emotionally distressed and with 5-minute assembly-line appointment slots. Recipe for disaster for all.

  57. VS says:

    Dear Pamela,

    Wow! I’m dismayed at the way you were attacked by physicians who took your comments as a sort of betrayal. Geeze, who peed on their cinnamon toast?? How dare you have your own opinion!

    How did your comments to Ethan hurt any one of them??

    I have worked with many physicians who seemed to me to be developmentally arrested by the unhealthy environment of their medical school training. To me it’s similar to how children who have major illnesses do not always meet their developmental milestones–the “circuits are busy” dealing with the immediate dangers and all the self-actualizing tasks are moved to the back burner.

    There is no question that medical school is completely different from advanced practice nursing education but some of the MD/DO responses foolishly underestimate NP dedication to patient safety, seemingly assuming they are the sole keepers of positive patient outcomes.

    I’ve been a family nurse practitioner for 10 years and I’ve saved an M.D. colleague`s rear on more than one occasion by seeing a situation from a different perspective and throwing in my 2 cents worth. The reverse has also been true- and that’s the beauty of healthy collaboration– we are working together to provide safe, effective patient CARE.

    I have more words, but these are only ones I can let out right now because I have 60 unfinished notes haunting me.

    Thank you for offering me a life preserver today. I have been waiting for the Universe to show me a way to deliver patient care MY WAY. I`m an NP so I can help people, not to be a cog in a sick, greedy corporate game that is sucking the life out of me.

    I am grateful for you today.

    • Pamela Wible MD says:

      We really all need to band together and help one another for the good of the patients. Many of us (NPs, PAs, MDs DOs) are being victimized by unethical employers in toxic “health” systems that are imploding. The sooner we all practice in alignment with our highest values the better. Often this means taking your autonomy back and serving the patient off the assembly line. I commend all who are practicing medicine with kindness, compassion, dedication, and skill (as well as asking for help when cases are outside of your scope of practice). We literally are all in this—TOGETHER.

  58. Pamela Wible MD says:

    Just got this message from a med student: “Dr Wible, I did not want to post publicly but I wanted to tell you how shocked I was to read the comments to your article NP vs MD/DO. I am currently a post 4th year medical student, and I wish someone had given me that advice before I started down this road. My hopes of practicing medicine are rapidly disintegrating. All I wanted to do was help people and be the provider I wish I could find for myself. Instead I have amassed a large debt to be demeaned by the school and establishment that I sought to join. I think you absolutely have Ethan good advice for a reasonable path to helping people as he desired.”

    We deserve FULL transparency of ALL risks and benefits of our educational programs.

  59. HF says:

    Dr. Wible, I have been following your post about Nurse Ethan. First, I think your advice was genuine and fair. I can’t say that I was shocked by the reaction of your physician colleagues. I perceive that physicians have a unspoken fraternal oath which is why I believe your peers accused you of treason. I wanted to give you an honest opinion because your were kind enough to offer Ethan the same. I think there some “bad apple” physicians that are making it horrible for all. Unfortunately, most of my experiences with physicians have been dismal until recently. Why do NP’s feel like they can/should practice independently? Because many of us have non-existent physician supervisors already. As a new grad NP, my “supervising physician” was either on the beach in Florida or at home relaxing. He couldn’t be bothered if I had a question or concern. If NP’s want to be independent then why don’t they go to medical school? I suspect many of us would consider a program that “bridged” us to MD/DO. I know I would consider it. There’s only one program that offers this option and it is in Somoa. Ive heard most people have trouble getting placed into a residency after completion. Some people forget where they come from. There was a time not too long ago where DO’s were considered “quacks”. They were refused hospital privileges as well so much so that they had to open their own hospital in our area to follow their patients who were hospitalized. Years later, they are now accepted and all is well. Organized medical groups should work together to establish more programs that offer residencies for NP’s if NP’s are such a “threat to humanity”. Why would people choose a NP vs a physician? Various reasons. I can tell you that most physicians in my area do not accept Medicaid or CHIP for low income kids. These are typically “unwanted” patients by physicians. I just found it disappointing that you have done so much advocacy for physicians and when you wrote ONE supportive article to ONE nurse, it was considered treason. I agree that NP training needs more work. I’ve been fair in my criticism to my own profession. My criticism was viewed a treason and offensive as well. My point is that I think the US healthcare system is so broken and backwards. It’s infiltrated with variables that shouldn’t even matter. We should spend more time solving the issues than fighting amongst each other.

    • Pamela Wible MD says:

      If we spent half our energy truly collaborating with one another instead of
      fighting a turf war, we would have real health care. We all have so much
      to learn by having this conversation.

      • C2s says:

        Pam, no need to defend yourself from so many reactions of people either envious of the NP freedom or those preferentially MD with all the privilege and hiding places. I’m In the industry machine and not MD and these reactions are predictable given the head space MDs are taught to embody… “We all know MD is not DO, those second tier wanna’s.” The ego maniacal MD reactions here are predictable. Fierce world on the inside. I suggests full non-ego inquiry before choosing MD over NP. Save yourself the hell ride and treat grateful people where you don’t have to be omnipotent and grandiose all day, which has to be exhausting (well, I do see a lot of docs energized by that kind of head space). Lots of NP work out there!!!! Boy is there! You could EAsily have an ideal practice as NP… Refer when you have to but my god, be a learner and a healer and enjoy your practice!!!!!!

  60. Pamela Wible MD says:

    ALL health professionals are invited to our retreats. Whether you are an NP, PA, MD, DO, EMT, RN, DVM. No matter your special initials, we welcome you to this healing adventure so that you can practice medicine the way you always intended.

    Click here for monthly coastal retreats

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    Join in the fun!

  61. E. Watts, MSW, LSW says:

    Hello Ethan. I’ve read your email and subsequent comments by Dr. Wible and others.Thank you for sharing your feelings and concerns. I’ve listened carefully to the conversation without interruption of thought. Afterward, the sensible part of my brain exercised control over the emotional part of my brain to say this:
    First and foremost, here is a (hug) for going through a “struggle, rub, and feeling torn.” Once you make a decision, your first action step, those negatives will go.

    I’ve written out two lists of your likes and dislikes to help walk along side you in your
    quest for a future career choice. I’ll rename the two lists interests and disinterests. You are interested in: Family Medicine, Autonomy, Being the Best, Don’t Settle, Deep/Wide Knowldge, International Practice, Better Work/Life Balance, Faster/Cheaper/flexible Training, Non-Toxic Environment, Medical Model, Part-Time Training/Full-Time Work, Hobbies, and being the best, healthy, and happy husband and father you can be.

    You are disinterested in Stress, Longer Hours, Paying a Higher Price (personally), Philosophically Not on Board Nuring Model, Worried, and Too Hard.

    You have known which is the best choice for you for awhile – family medicine nurse practitioner. I call knowing that a “gut instinct.” Sounds like you have listened to your “gut” in the past and made a great education and career choice to become an RN. Kudos. What is keeping you from listening to your instinct again? Ultimately, you aspire to become both best healer and best, happy, healthy family man. Look beyond the horizon of your life now to see who and what you absolutely cannot live without. Answer this: When you wake up tomorrow morning, what will your perfect life look like? If your answer matches your “gut instinct” therein lies your answer to your question. With warmest regards, Evelyn

    • E. Watts, MSW, LSW says:

      PS – All comments contain thoughts, opinions, and ideas based on beliefs and values, but not all comments are angry responses. Dr. Wible, your responses and comments are thoughtful, considerate, empathic, professional, and insightful. Should you feel a need to clarify a comment in your original response to Ethan’s email, do so. Should you discover a need to make an apology to anyone in particular or your profession, do so immediately and sincerely. Should you think that all your comments support your original physican suicide burn-out movement stand strong, stay resilient, stay relentless, and stay unshakeable. Your profession NEEDS your VOICE to speak-up for those unable or unwilling to speak at this time.

      • Pamela Wible MD says:

        Love your thoughtful and comprehensive response Evelyn. My only other response is to please stop associating me with the word “burnout” which is a victim blaming and shaming term that deflects attention from the system that perpetuates human rights violations against our brothers and sisters in medicine. I’ve written extensively on the dangers of using this term. Archived articles here: http://www.idealmedicalcare.org/blog/category/physician-burnout/

        • E. Watts, MSW, LSW says:

          Dr. Wible. Thank you for your kind correction. What do I call your movement? I’ve not followed you for quite sometime. The loop that I stepped away from caused me to forget some very important information.

          • Pamela Wible MD says:

            Ideal Medical Care Movement has been the most frequent term I’ve used. I do so many things that I’m not sure what to call them all. There may not be a unifying phrase that integrates my work in community-designed ideal clinics, med student/doc suicide prevention, human rights violation in medicine, and all the other stuff I do! If you think of a word let me know. By all means do not use the word burnout!!

  62. I LOVED this! Thank you for sharing it. The truth is there is plenty of room for healthy, happy health professionals — no matter what initials they place behind their names.

    One of the huge challenges I see, and have for many decades, in the health care world is the lack of true collegiality, respect and teamwork.

    This response to this exchange would suggest we are still a long way from this. What an opportunity for all of us to make health care healthier!

  63. ABB says:

    Dr. Wible.

    Frequent reader; big fan of your enlightened, supportive, open-mindedness; first time writer. I just could not resist adding to this thread a couple points I thought salient. And my apologies ahead of time to Ethan, who’s future aspirations we have co-opted in turning this into a mud-slinging contest. Now, time for some NP-style mud-slinging.

    1. As I read through the comments what became clearer and clearer was the idea “where you stand is a function of where you sit.” Other than yourself, precious few M.D.’s offered thoughtful, insightful, well-reasoned, solutions-based, or (sadly) collaborative-based comments. It was: Dammit, we’re smarter, we have bigger and better degrees, and we’re doctors (foot stomping heard).

    2. Why so much generalizing? Why “NPs this,” and “NPs that?” There are OUTSTANDING individual NPs and OUTSTANDING individual M.D.’s in the singular (insert individual name here), just as there are poor individual NPs and poor individual M.D.’s (I’m sorry, but it’s true). By your nonsensical reasoning, the worst M.D. is better than the best NP? Can we please stop generalizing?!? Don’t you dare ASSUME bc I’m an NP that I can’t treat patients in a safe, accurate, and comprehensive manner. You don’t know me, and you damn sure don’t know what it is that my education, experience, and innate level of knowledge-seeking has allowed me to know.

    3. A brief digression if I may. How many of you holier-than-thou M.D.’s who expressed so much anger, disappointment, and vitriol at the audacity of Dr. Wible to be supportive of NPs have EVER worn a US Military uniform? If you haven’t, then may I suggest you recognize you have not accomplished all that much bc you had the academic chops to navigate medical school (and avoid serving in harms way) like I have! Next….

    4. A brief football analogy. There are several accomplished NFL and college football coaches who played very little or no football themselves. Bill Belichick (multiple Super Bowls), Nick Saban, and Urban Meyer (both “played” but I’d hardly call it relevant or significant). My point is that one can breeze through (bc apparently it’s not at all demanding) NP school, and still become a GREAT practitioner.

    5. Did an M.D. on this thread really suggest NPs refer too much? Really? Let me reverse-engineer this argument. Your ego is so damn big such that you can solve any medical issue, treat any medical problem, that you don’t refer enough. (Danger Will Robinson!)

    6. For all the M.D.’s who have stood up on this DB, jumped up and down, and pounded their collective chests about how great they are, and how NPs should not be permitted to practice independently, allow me to ask this: Where are all the family practice providers in rural, underserved areas? So you’d rather these patient populations receive (A.) NO care than (B.) SOME care? News flash! With option (A.) they get worse every. single. time. With option (B.) they get better a lot! And if we can’t help them, we refer to someone who can (bc we are taught in our little, insignificant NP curricula) to stay in our lane.

    7. Many of the M.D.s who “contributed in a collegial way” (NOT!) to this DB sound like architects. Can you still lay bricks? You sound like Generals. Can you still climb down in the foxhole? You sound like Principals. Can you still teach?

    I sincerely apologize for the negative tone of this post, particularly to my NP colleagues who have done a wonderful job of taking the high-road and remaining polite and respectful despite the temper-tantrums thrown by our M.D. “colleagues.” Dr. Wible, thanks for advocating for all your colleagues. Providing for our patients is difficult no matter what, or how many, acronyms are behind ones name.

    • Pamela Wible MD says:

      Degrees have a perceived status. People become highly reactive if you lower their status by ever suggesting that their degree is not always better than others perceived as lesser degrees. People spend their lives amassing material goods, education, etc . . . to showcase their success to the world. Interestingly, some people really care more about how others perceive them (I am not one of these people by the way) and their status in the eyes of the world that any potential threat to their status (even giving advice to one RN to choose to be an NP) can lead to quite impassioned responses!

  64. Ethan,

    First, from what I have read, you are already a phenomenal healer and I applaud your intellectual curiosity and desire to expand your knowledge and skill set. Let me muddy the water a bit and toss out the idea of also shadowing a PA.

    The reason I am asking you to consider the PA route is because we are educated and trained to practice medicine and you would have the best of both worlds. You will always have your nursing education and experience to enhance your practice and you also will have a medical education.

    I was fortunate to be mentored by Dr. Eugene Stead, Jr., the creator of the PA profession, and by my father, one of the early PAs. Dr. Stead created the PA profession to extend access to medical care and to free up doctors for more complex care. We were never meant to take the place of doctors. Being a PA is always being part of a medical team.

    PA school can be really tough. We spent the first year, 4 semesters, with six to eight hours of lecture, five days a week, and three to four exams each week which meant that every other day was finals. During our clinical year, we were frequently on teams with medical students, residents and attending doctors. It was exhausting and exhilarating. I did get some of the hazing and harassment that medical students and residents endure because I was at Duke and the environment can be toxic, but not all of my clinical rotations were there, so I did have some great experiences.

    I have practiced Psych prescribing for 8 years and had excellent on-the-job training by my former supervising doctor. I tell my patients that we are on a team consisting of the themselves, my supervising doctor, and me and that they are the captain of their team because it is their bodies and their lives that we’re treating and that they have the final decision on what happens. I do make it clear that I will not always tell them what they want to hear, but that I will offer the best medical advice I can and it will ultimately be their decision whether or not they follow my advice.

    I have a part-time Psychiatric prescribing practice which is my Ideal Clinic. I did have to hire a supervising doctor, and I must say that I am fully aware of what I don’t know and am grateful to lean on my doctor for guidance when I am not 100% certain in my decision making. I want to keep my patients safe and protect my doctor and myself from liability. It really doesn’t bother me not to be 100% autonomous.

    I love that I have the time to connect with my patients and dig deep to find out what is really going on with them. I love that I can say, “I don’t know or I’m not sure. Let me look this up or let me run this by my supervising doctor.”

    To me, you would get the best of both worlds by spending two years on the PA route. Just a thought. : )

  65. Alene Nitzky says:

    After reading this I am perplexed as to why there was such an uproar. I certainly did not read it as Dr. Wible denigrating physicians, she was simply giving an individual advice when he asked for it directly. I can see that the entire range of healthcare professionals have similar fallibilities- no more willing to accept someone’s opinion without taking it personally than the average layperson. In order to make the healthcare professions more nurturing and less toxic, we all need to take a good look at ourselves, how volatile our responses are, and take a step back to examine our own values. I left traditional nursing myself because of this sort of infighting and toxicity. Let’s accept each other for who we are, and stop the attacks. Dr. Wible has contributed the effort and dedication to save our lives while we try to save others’ lives. I don’t think she deserves this kind of vitriol.

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