Dr. Toni Manougian has done it all. Starting as an RN diploma graduate, Dr. Manougian obtained her bachelor's in nursing, followed by a master's degree as a clinical nurse specialist and then a degree as a critical care nurse practitioner, before deciding to become a physician.
Dr. Manougian explains the differences in training between the professions and tells aspiring physicians that it's never too late to become a physician if that is your dream.
Transcript Patients at Risk podcast Season 1, Episode 21, MARCH 28, 2021 Rebekah Bernard MD 0:07
Welcome to "Patients at Risk," a discussion of the dangers that patients face when physicians are replaced with nonphysician practitioners. I'm your host, Dr. Rebekah Bernard and I am joined by my co-host, and the co-author of our book "Patients at risk, the rise of the nurse practitioner and physician assistant and healthcare," Dr. Niran Al-Agba.
Niran Al-Agba MD 0:25
Good evening.
Rebekah Bernard MD 0:26
When it comes to discussing the differences in education and training for physicians and nurse practitioners, there's really no one better to help us understand those differences than someone who went through both types of training. Today we are joined by Dr. Toni Manougian. She's an anesthesiologist who was a nurse practitioner prior to attending medical school to become a physician, Dr. Manougian, welcome to the show.
Toni Manougian MD 0:50
Thank you very much. Glad to be here.
Rebekah Bernard MD 0:52
Toni, you've worked as a registered nurse, a clinical nurse specialist, a critical care nurse practitioner, and a physician. Tell us about your journey.
Toni Manougian MD 1:01
Yeah, I know that sounds like a convoluted journey. But I started out as a critical care nurse mostly working in a burn / critical care. I loved what I did, I just always wanted to know more and learn more. And so I pursued the nursing journey. And I was encouraged to do that by my colleagues in nursing. And after starting out as a registered nurse through a diploma program, I then went and did a Bachelor's in nursing and then a Master's in nursing as a clinical nurse specialist. And that focus was primarily on clinical education of staff nurses. But I think my desire underneath it all was not only to educate staff but also to take excellent care of patients and to learn more about medicine. And so after maybe 12 or 15 years as a critical care nurse, I then went to a nurse practitioner program. I really quickly found out that that preparation was not going to be what I was looking for - that really just did not get to the thrust of medicine and the depth of understanding how to take care of patients.
Rebekah Bernard MD 2:10
Toni, you went through a diploma program to become a nurse. And that's actually the most common way that people graduate as a registered nurse - they go through a diploma program as compared to a bachelor's degree program. But the Institute of Medicine and some of the nurse practitioner nursing leaders have really been encouraging nurses to pursue that bachelor's degree, you have some thoughts about the differences. Tell us about that.
Toni Manougian MD 2:35
I remember when I did the diploma program and that was a very strong clinical focus. We were very much in charge of our patients and accountable for what we did after the introductory first semester. After that, we were really held accountable to what the standard of care for excellence in nursing was. You know, the baccalaureate programs that I completed and then the Master's in nursing after that - it was a lot of theoretical information. We had courses on nursing theory. Critical thinking was very much nonclinical in focus. I was thinking that the days of people being accountable and reliant on hospitals for their education for their jobs for their livelihood. I think that is what was driving nurses to encourage each other to get away from the hospitals so that they could perhaps branch out on their own or be more independent, have more options, and feel more secure in their livelihoods by having a baccalaureate degree just like any other profession, but I don't think that to me, it did not add any layer of excellence to understanding how to take care of patients.
Rebekah Bernard MD 3:48
Well, that's something that we uncovered in the book. Actually, there are some studies that say that a diploma program actually often prepares a nurse to right away get into the bedside to caring for patients better than a lot of bachelor degree programs. And because it is a quicker and less expensive route to become a nurse, it seems like it would make more sense to encourage nurses to enter into the field through a diploma program. But that's not the way the nursing organizations have really been structuring, nursing now. They're really encouraging nurses to go for a Bachelor's. And it doesn't really seem that practical because like you're saying, you can get a really good foundation and a good training with an associate's level. The only reason that a lot of people go bachelors is because I think they want to pursue advanced level like go into a nurse practitioner role.
Toni Manougian MD 4:38
Yes. I think that in terms of taking care of patients, it isn't really that much shorter to do a diploma program. I mean, at least when I did it, which was many years ago, it was full time studying for sure you could not do this part-time to have a bachelor's degree I mean, perhaps if the focus if your whole focus on going to nursing school is beyond the bedside, then I can see how that would make sense. But people in my class and in my day of training, we went into nursing school to be nurses to take care of people to be at the bedside. And we really didn't envision ourselves as being in administration or the C suite, or owning companies or doing private practice aesthetics or any of those other things. We were there to take care of patients. And so that made a lot of sense for us. And our clinical hours of training aside from classroom were - I was a full day towards the end, we were seniors in nursing school, we had classes probably two days a week, but then the other three days were at the bedside full eight hours, not including the preparation it took to get ready to understand our patients.
Niran Al-Agba MD 5:48
Toni, at one point, you then went back and did a clinical nurse specialist master's degree, is that right? So can you explain that to us?
Toni Manougian MD 5:57
I did that because, at the time, my options were to become a nurse anesthetist, to do nursing administration, or a nurse educator or clinical nurse specialist, which I thought was going to be the best of the worlds of education and clinical teaching and practice. And I always wanted to remain a clinician, which is why I did not go for a straight administration type of advanced degree. So I thought that clinical nurse specialists would be the best option for me. And I did that. And that was an accelerated program, because I had already had a bachelor's degree, and was a practicing intensive care nurse for many years. So I was offered the option to do this intensive training as a clinical nurse specialist and get a Master of Science in Nursing from Columbia University. And, you know, again, it was very little on clinical focus. It was mostly theoretical information, how to talk about nursing theory, how to lead staff how to design staffing patterns, and I was disappointed that was really not what I wanted. And when I graduated back in the 90s, there was really not that much role for clinical work like that.
Niran Al-Agba MD 7:10
Is that what you went on then to additional schooling to become a nurse practitioner?
Toni Manougian MD 7:14
Yes, I worked for another couple of years after that. I taught some, I even did an adjunct role in one of the well-known Ivy League institutions as a nursing instructor. And then I, after a couple of years did a nurse practitioner role because I heard that another university was offering a nurse practitioner program in critical care. And that was always my focus. So I thought, aha, I finally found it, this is going to be it for me. But I was - I was really disappointed because I think within the first semester, I realized this is not what I'm after. This is a little bit superficial, does not have the foundations and you know, understanding clinical medicine, there's little pharmacology - pharmacology was heavily based on outpatient management, because I think at the time, the nursing boards were all generic. And so I would have to understand how to also give outpatient type of care as well as critical care. And we did have some classes in ventilator management and some ICU-type things. It really was not what I was looking for which I decided that as soon as I could, I would start to figure out how to get into medical school.
Rebekah Bernard MD 8:29
So Toni, when you went through this critical care nurse practitioner program, theoretically, you were supposed to be then trained and qualified to take care of critically ill patients, right? I mean, that was the idea of this.
Toni Manougian MD 8:41
That was the idea. Yeah, you would, you would be working alongside the physicians in an ICU. And I think this was pretty innovative at the time, there really weren't many people who were doing this and it wasn't well accepted among the physicians that I tried to get employment from when I graduated because they were it wasn't standardized education. It was - you could have this curriculum at this university and a different one at another university. And they knew what PAs were trained to do, but they were not - they didn't really have anything standard for nurse practitioners. So it wasn't well accepted.
Rebekah Bernard MD 9:16
But we know that there are critical care nurse practitioners in a lot of states that are just running ICUs on their own having gone through that experience. And you know, having been certified as a critical care nurse practitioner, do you feel that you could have run an ICU or that you that the education that you were given qualified you to be able to care for these critically ill patients?
Toni Manougian MD 9:37
NO, and NO in no way was I qualified to do that at the time and I was an experienced critical care nurse for over a decade before I even tried to do this education as a nurse practitioner with a specific focus in critical care. I'm speaking for myself. No, I was not well prepared, because it is different. You know, I think that our education in NP was based on algorithms. What you saw before, you repeat, or you try to understand based on experiences that you've seen on rounds, or you commonly see admitted, but you don't have the understanding, or the background in medicine to understand when differences occur when things are not the routine. And that's really what is, you know, every patient deserves that you can't expect to treat people for the most part, 'okay enough.' Everybody deserves to have the best. And if you don't understand medicine, then you know, you really can't practice based on what you did before. Because every day is different, every patient is different.
Rebekah Bernard MD 10:42
We know the other thing is just the sheer number of hours. I know that doctors that get a critical care fellowship training that they're doing three to four years and getting up to like 20,000 hours of experience. But yet, I believe that last time I checked the number of minimum clinical hours that a nurse practitioner needed to be certified in critical care, I think it was like 500 for a master's degree. So 500 hours, and supposedly now you can work in some places independently in an intensive care setting. Whereas a physician would take 15 to 20,000 hours before they would be permitted to do that. So to me, it just isn't really logical. It doesn't make sense why it would take one professional all these hours and yet the other one supposedly can do it in just a fraction of the time.
Toni Manougian MD 11:24
Absolutely not. First of all, to address what you mean by certified in critical care as a nurse practitioner, I'm not sure I know what that means, because you can be certified as a family nurse practitioner and have a job in a critical care unit. And your nursing education in your NP training is in family care. And so I don't even know how that relates to an ICU environment. And people who do critical care fellowships have different requirements based on what their residences are. For example, I'm an anesthesiologist. So I did four years of training after medical school as an anesthesiologist, and our focus every single day of the week is essentially critical care. And then we do a year fellowship in critical care. And an internal medicine graduate would do three years of Internal Medicine and then two years as a critical care intensivist. Because perhaps their everyday life is not as intense as in anesthesia. So it's very different. And I for the life of me cannot understand how nurses who are essentially new grads come out of school, maybe work a year or two and are immediately enrolled in a nurse practitioner program, perhaps in family care, perhaps in acute care medicine, acute care nursing, pardon me, which is nothing like the rigors that we go through in residency, the accountability, just even the sheer dedication it takes to get in our residency programs and medical school. That's a whole other discussion here. If you're looking at nurse practitioner programs that have nearly 100% acceptance rate, where's the impetus to push and push to get really what you want to be and strive for that when it's handed to you?
Niran Al-Agba MD 13:08
Could you talk a little bit about what it was like when you were in your nurse practitioner program? Were you kind of told you would be an independent critical care person equivalent to the doctors? What's the prevailing kind of mantra, I guess, when you're doing a more specialized nurse practitioner program like that?
Toni Manougian MD 13:24
So from day one, it was many years ago, but from day one, we were told that we were going to be the leaders in health care. And we were as good as the doctors, if not better, and we did not need to be accountable the way physician's assistants are, we could work independently. And I was wide-eyed, sitting there in the chair thinking, how can this possibly be? How can I practice - I came to this program because I didn't understand what the doctors were doing. And now on day one, you're telling me that I'm just as good as the physicians? I didn't understand that I was looking at it, you know, with a critical eye, like I do everything, and didn't it didn't add up to me.
Rebekah Bernard MD 14:04
But you had the insight to realize that, you know, unfortunately, I think that there are probably some people maybe that don't have nursing experience like you did, and they hear all this and then they believe it. And I think then that is very dangerous because they're given this inflated sense of self-confidence. And that's when patients get hurt, unfortunately.
Toni Manougian MD 14:23
I think so. I can see that because I think I bought a little bit into this in the beginning until the ball was really in my court and I thought, okay, I'm the one putting my name on this prescription. I'm going to be accountable for this. Do I really have you know, the belief that I'm doing the right thing for the patients? And I didn't think I was well prepared enough with that kind of training. But in the beginning, I kind of bought that and, and my family will tell you that I used to spout that stuff and but when push came to shove, no, it's not the right level of training and still is I still strive every day to keep on top of my game. And there's no way you can come out of 18-month online program and be prepared.
Niran Al-Agba MD 15:09
Tell me a little bit more about your decision to go to medical school. You said you sort of decided in the first semester of NP school, but I guess I just want to hear more. And then maybe what you thought once you got into medical school and started the process?
Toni Manougian MD 15:21
Yeah, I mean, I went to the NP program, because I really wanted to understand why physicians made the decisions they did. I wanted to have that information and that knowledge. And so I went into that program. But then, as I said, I quickly realized that the kinds of courses I was taking in critical thinking nursing theory, and all this wasn't going to get me there. I wanted to drop out. My husband, who's an internist /endocrinologist - he advised me just finish the program and start applying to medical school. So that's what I started to do. Because I wanted to be an intensivist - I think I've always wanted to be an intensivist. And I worked in the burn unit most of my nursing career and I thought I was going to go be a burn surgeon, but I didn't like surgery enough, but I knew I wanted to do critical care. So it was a very hard journey to figure out how as a - you know, I was in my late 30s with two kids - how do I get into medical school? No one was advising me. I didn't have a college program helping me. I was just basically knocking on doors of Dean's of medical school saying, How do I do this? What do I do? I had to take all of my pre-medical courses, I had to take organic chemistry, physics one and two, and everything. You know, nursing, did not prepare me for that kind of basic science - no way. The sciences I took in nursing school where you know, a lot of statistics for nurses math for nurses, it was very different because you have to be ready to take the MCAT and then use organic chemistry and genetics in your basic sciences and medical school. So I did that. And it was a struggle to even get there to understand it. But I think that's another way that separates doctors from nurse practitioners is that nothing is handed to us. We need to fight to get a seat in medical school, we need to earn that place, earn our rankings on our seats of medical schools that we can get a good residency, and then take our step exams. It isn't just about what you can pass those exams, but it's to be well-enough prepared that you can get the best residency you can because let's say like myself, I wanted to be an anesthesiologist and I needed to live in the New York City area, you had to be pretty much on top of your game to get a seat there. It wasn't handed to you that I think trickles down to my daily care. What I see in daily practice is that people will call me as I'm on my way out the door at night and ask me a question or ask me to speak to a patient's family. And yeah, you take your coat off, and you just go do what you have to do. Your shift isn't over until it's over, that is built into the integrity that develops when you have to really struggle to get your seat and maintain your seat and have that level of commitment. It's reflective in everything you do as a physician.
Rebekah Bernard MD 18:14
I just want to tell you how inspired I am by your story because I hear from a lot of nurses and nurse practitioners and they tell me, you know, I really wanted to be a physician, but I just couldn't, or it wasn't something I knew how to proceed with. Or I had kids or I had all these different barriers that stop them. And you had every barrier. You were married, you had children, you were an older student for going to medical school, which, unfortunately, there is some ageism that we see in medical school that I've heard about recently. And so you had so many things that you had to fight against. And here you were, you didn't have to do any of that you were a nurse, you were a clinical nurse specialist and critical care nurse practitioner. But yet it was important enough to you that you fought to become a physician. And I think it's just so inspiring. And I'm so impressed with you. And I think it's really should be inspirational to anybody listening - that is really, just, well, I really, really - my heart really wants this, but I just don't know if I can do it. And here's an example of someone that did it. And to show that, yes, they can do that if this is what they want.
Toni Manougian MD 19:20
Thank you - I appreciate that. And yes, anybody can do it if they really, really want to. You know, I mean, I spent probably two years trying to figure out how to get into medical school and take the MCAT and retake the MCAT. And I just did it because it's really what I wanted to do. And if I could go back now that I see the easier path that nurse practitioners have, would I do it? I would still say no because I would not be as prepared. I just would not love what I do as much as I do every day when I go to work. And I think also that excellence for clinical care that was instilled in me in my diploma programs as a nurse and I'm not sure that that kind of education, that type of really compassionate care and drive for excellence is present in a lot of the fast track programs that we see for nurses today.
Niran Al-Agba MD 20:12
Well, and I was just gonna add to Rebekah's point, I've sat on the admissions committee now for about 25 years, we're where I'm at, you know, at the University of Washington, and we, as a whole would love students like you. So the reason I'm mentioning that is, I admire what you've done. And I think that anyone who's listening to this if they are a nurse, or nurse practitioner interested in going to medical school, you're sort of a natural fit, just because you already love clinical care. In general, you have experience with patients, you're what we call a mature student, which actually, for many med schools, they don't want the 19-year-old, fresh out of college, they really want somebody in their mid to late 20s, even early 30s, we have a student in our in her 40s in med school, who was tremendous. So it's really something that makes I think, a well-rounded physician, and I'm sure your patients appreciate the fact that you have this nursing background. I mean, it's just your breadth of experience is phenomenal.
Toni Manougian MD 21:06
Thank you, I think that comes across in my clinical care. But I have to say that people would have said to me in medical school, my classmates would say, well, you don't have to take all the classes, right? Because you were a nurse, like, No, I have to take everything because that type of pathophysiology, histology that's not covered in nursing. But why I could go in and talk to a family member and start an IV put an A-line, I could do those things very well. But the basic sciences, we don't have that. And honestly, you really do need that.
Rebekah Bernard MD 21:37
You know, I think you're totally right that medical schools would be very wise to look closely at candidates that are in a second career, especially considering that so many physicians are burning out and wanting to retire when they're in their mid-50s. So if you got a student that was in their 30s or even early 40s, you get just as much work out of them as you would as somebody who went straight through and then just says I can't do this anymore. So and some of the most dedicated physicians that I know, were second career physicians, and they just brought such a wealth of knowledge and experience that really helped them take care of patients really well.
Toni Manougian MD 22:14
I would like to say one more thing. And that was when I went to nursing school in a diploma program, we all went there because we wanted to take care of patients. And what I see now is so disheartening is a lot of young people are going even people in second careers going into nursing because they want to be nurse practitioners. And I see people coming to the bedside, and they're in and out. And as soon as they graduate, they're already in an NP program. And it's really a disservice to the bedside nurses who have put decades into that profession, that they're not somehow valued enough that whoever is deciding on salaries and career advancement is valuing the nurse practitioners, even if they've only been working for four years or five years, there is more value than all the staff nurses at the bedside, which is I think it's a real shame. It's a shame for the patients. And for me as as a working physician, needing to rely on you know, when a nurse comes up to me, and I know who that person is and their experience and they tell me something, I'm listening. And it's a whole different ball of wax when it's a new grad with very limited experience. And as a future patient one day, I want that experienced nurse who loves what they're doing.
Rebekah Bernard MD 23:29
You're so right. And what even studies are showing now is that the nurse practitioner role is driving nurses away from the bedside, many of them because they're just seeking to get away from nursing, but many because they're not even going to nursing school to become nurses. They want to just go straight through and be a nurse practitioner. And what's really unfortunate is this political agenda by some nursing leaders, is taking a toll on bedside nurses, which is really the bedrock of our healthcare system, I think and your points are really well made. And it's really disappointing to see that happening. My heart goes out to nurses, both my mom and my dad were registered nurses and went through diploma programs themselves. And I just have so much respect for anyone that stays at the bedside. That is really a tremendously difficult job to do, doesn't always get respect from hospital leaders and managers. And yet it's something that's so important. In fact, in speaking of nurse the nurse practitioner role, and how there's been this surge of diploma mills and drive to graduate more NPs. You were a nurse practitioner professor or a nursing professor?
Toni Manougian MD 24:37
I was an adjunct professor at a university that was a master's program that was an accelerated master's program in a critical care track.
Rebekah Bernard MD 24:45
Did you have any concerns about the quality of care for the nurses that were going through that program?
Toni Manougian MD 24:50
Yeah, you know, I myself went through that program for the master's degree when I was getting that clinical specialist, and some of my clinical courses really had nothing to do with the meat of taking care of critically ill patients. And I was a practicing nurse at the time, so sometimes I could just put clinical experience as part of those practicums as work I was already doing and I had colleagues become my preceptors. But when I was an adjunct Associate Professor, yeah, I was asked to pass one particular student. I mean, her work was, I think, very substandard, I do have high standards, but that was one person among the couple of dozen that were in the program. And I didn't want to pass her because I thought the work was really not up to a master's level of nursing. And I was told by the administration in that school to pass her.
Niran Al-Agba MD 25:46
So I guess, as we're, as we're running down in here, I guess my real question is, you've been everything. I mean, really, you've been absolutely everything from start to finish in medicine, in a way, and in nursing. So what is the solution to what's happening right now in this country? I mean, again, not that you necessarily have all the answers, I don't think any of us do. But because you have such a well-rounded breadth of background experience, and schooling, how would you like to see the system of team-based care work?
Toni Manougian MD 26:17
Well, first of all, I would like to maintain the presence of residents in our critical care units and on our medicine wards. I see those spots being dwindled down and replaced by nurse practitioners and nurse practitioner students. And that really kind of breaks my heart because I think the residents have, you know, they have a right to be there, they need to be there. They need to be respected when they're there. And I would hope that they continue to be trained by physicians, and not be trained by our allied health providers. And then as far as our nurse practitioners, and physician assistants, and nurse anesthetist, for that matter. I have worked with many, many over the years, and I enjoyed working with them. And I think overall, I have a good working relationship with them. I just do not envision them being the leaders of healthcare or having independent practice. I just think that the routine stuff, okay, stuff by algorithms, and what we do every day is fine. But there's just so much more that that is not what medicine is. So independent practice, no. Working alongside us and within teams? Absolutely. Do they have a value, of course? And I think we also really need to value our bedside nurses. And I think that there would not be such a drive into nurse practitioner schools if our bedside nurses were happy and valued and respected.
Rebekah Bernard MD 27:41
I think you're so right. In our last couple of minutes, Toni, you're just really amazing. Because on top of all of this, you're also just about to finish your MBA degree. And I just, it's amazing, tell us why you decided to pursue an MBA.
Toni Manougian MD 27:56
So I've been you know, I've just been, you know, looking and watching and seeing who is in our C suite, and why I can't get funding for one initiative or another or equipment and thinking, Well, you know, why not? Why not me, I see, you know, some even some nurses in our C suite with MBAs. And certainly, if anyone is going to be the drivers of healthcare, it should be the physicians because we truly are the ones who understand what it takes to take care of patients, and where we should be going in healthcare. And if that requires an MBA to be able to speak the financial language, the accounting language, you know, the managerial language, then, okay, fine, I'll do it. Because I've got a great cohort in my MBA program. It's an all MD MBA program. And there are a whole cadre of people just like me, who know that physicians to be the leaders in health care. And it isn't necessarily about the bottom line. Yeah, you need to be financially savvy to be able to hold your head above water. But as the doctors who understand how to take care of patients and what we need to do that I'm really thrilled to be a part of this MBA program.
Rebekah Bernard MD 29:11
Well, you really are truly the epitome of physician-led care and a physician leading care. So I want to thank you so much. Thank you, doctor, Dr. Toni Manougian, for joining us and telling us her story. I like to thank my co-host, Dr. Niran Al-Agba. And I'd like to encourage all of our listeners out there if you'd like to learn more about this issue, please get our book. It's called 'Patients at risk the rise of the nurse practitioner and physician assistant in healthcare.' It's available at amazon.com and at Barnes and noble.com. And we would encourage all physicians out there to join us at physicians for patient protection, our website physiciansforpatientprotection.org and of course, subscribe wherever you listen to podcasts and to our YouTube channel patients at risk. Thank you so much and we'll see you on the next show.
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