Another doc who understands PAs/NPs

[deleted6669]

nice article:
http://www.beliefnet.com/columnists...ts-and-nurse-practitioners.html#ixzz2moq3BeRW

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[sarjasy]

Hey, emed. Can of worms here, I know, but I'm curious as to your (and others) opinion. You seem to be well-versed on medical education and have a lot of experience, so you are the one to ask. The article you posted hints at the idea that the PA/NP is bascially in perpetual residency, but that the NP/PA can achieve a very high level of knowledge and expertise with experience (just as you have done).

Can the PA/NP achieve physician level ability in a given specialty without med school and residency, given the right person and the right amount of "real world" experience? I ask in part because there was once a time in which physician education was largely an apprenticeship model.

 

[deleted6669]

Can the PA/NP achieve physician level ability in a given specialty without med school and residency, given the right person and the right amount of "real world" experience? I ask in part because there was once a time in which physician education was largely an apprenticeship model.

I think a highly motivated PA in a primary care specialty( or EM) can work at the level of an "avg" attending after many years. at some point docs forget the stuff they don't need and a PA learns all the stuff they do need and their skill sets overlap quite closely. I know guys who have been fp, em, and critical care pas for almost 40 yrs who run circles around many physicians because they have seen hundreds of thousands of patients and pick up atypical presentations of uncommon problems because they have both seen them many times before and stay up to date on recent advances in the specialty. a friend of mine is such a pa. he taught the doc who is now his chief when he was a medical student how to do LPs, central lines, chest tubes, etc. I have had several of my former students become my "supervisor of record" in the ER and most of them still defer to me on certain issues and ask my opinion regarding certain patients.
funny that you mention physician apprenticeship. I come from a long line of docs including one over 100 years ago who never attended medical school but learned on the job from his physician father over 6 years. he followed him around with gradual increases in responsibility between the ages of 15 and 21. one day his dad said " you're ready" and he hung out his own shingle. he later taught at harvard medical school and has a disease named after him.

 

[sarjasy]

I'll overlook the fact that you only mentioned highly motivated PA's (and not NP's).

Here's what I don't understand, and maybe it's just my ignorance (seriously). You mention FP, EM, and critical care PA's with 40-ish years of experience being equivalent or better. Does 1-2 years of med school didactic and 3 years of residency trump, say, 5-10 years of on the job training/experience for a PA? Does it take decades to overcome the lack of 1-2 years of med school didactics and residency? Serious question.

Perhaps a better way to put it. How many years of experience does it take for a PA (for example), to overcome the lack of 1-2 years of didactic and residency in say, a primary care specialty? Or can it even be done?

 

[deleted6669]

How many years of experience does it take for a PA (for example), to overcome the lack of 1-2 years of didactic and residency in say, a primary care specialty? Or can it even be done?

for outpatient family practice I'm guessing 10 years. right out of school a PA can in theory do 80-90% of outpt fp and peds. that remaining 10-20% requires a lot of self study and seeing lots of pts. with a mentor who can point out differentials that the pa might not consider on their own. I think inpatient management really requires a residency or full time employment in that setting. a PA who worked as a hospitalist seeing all levels of acuity would be pretty good after 10 years but not up to par on the outpt stuff.
on the job training is not as high yield as a residency as it is not directed learning. in a residency you have to do off service rotations to see many different types of pts. At a job it might take much longer to see those same types of folks just because you are not seeing them in a structured prearranged fashion. I think the future for both PAs and NPs will likely involve required postgrad training for at least 1 year followed by passage of a specialty exam like the new nccpa caqs(certificates of advanced qualification).

 

[swamprat]

for outpatient family practice I'm guessing 10 years. right out of school a PA can in theory do 80-90% of outpt fp and peds. that remaining 10-20% requires a lot of self study and seeing lots of pts. with a mentor who can point out differentials that the pa might not consider on their own. I think inpatient management really requires a residency or full time employment in that setting. a PA who worked as a hospitalist seeing all levels of acuity would be pretty good after 10 years but not up to par on the outpt stuff.
on the job training is not as high yield as a residency as it is not directed learning. in a residency you have to do off service rotations to see many different types of pts. At a job it might take much longer to see those same types of folks just because you are not seeing them in a structured prearranged fashion. I think the future for both PAs and NPs will likely involve required postgrad training for at least 1 year followed by passage of a specialty exam like the new nccpa caqs(certificates of advanced qualification).

I think your too far out of school to realize how little newly minted pas know. Like I've said previously I'm at the end of medical school and no way do I think I can handle 80-90% of out patient fp and peds. Do u know how many guidelines there are? And the whole idea of clinical gestalte that a freshly minted pa (or md for that matter) doesn't have. I mean I can't say I disagree that a pa like yourself with 26 years of working in EM knows a ton but I say your the exception then the rule most pas I've met on the coast have no desire for more autonomy or to learn more they are happy at their level most didn't want to become a dr so they knew what they were getting into. my one friend works in ENT she just does out patient been doing it for 10 years never sees the OR but works 30 hrs a week makes 6 figures. Also I think that this makes it very hard to say oh we should let mid levels do more or this or that..even after years not everyone has the drive or the ability to get to where you are at in your career. Just because someone has worked 10 years in EM as a pa .. Maybe they were fast track never saw the main ED who knows( I know you are not I'm just saying there's no baseline).

 

[deleted6669]

I agree with your points to some extent which is why I referenced motivated PAs, not avg PAs. a motivated PA with initiative to do more and learn more has their nose in a book between patients, goes to procedural cmes to learn new techniques, reads all the journals in their specialty, goes to grand rounds at the hospital every month, seeks out opportunities to go to the o.r. to intubate, etc, etc.
I'm also not talking about those PAs who switch specialties every few years but folks who dedicate themselves to one field for years. I know a derm pa who does full scope derm including MOHS and transflaps for example. he is on the faculty of a physician derm residency program and writes journal articles every month.

 

[swamprat]

I agree with your points to some extent which is why I referenced motivated PAs, not avg PAs. a motivated PA with initiative to do more and learn more has their nose in a book between patients, goes to procedural cmes to learn new techniques, reads all the journals in their specialty, goes to grand rounds at the hospital every month, seeks out opportunities to go to the o.r. to intubate, etc, etc.
I'm also not talking about those PAs who switch specialties every few years but folks who dedicate themselves to one field for years. I know a derm pa who does full scope derm including MOHS and transflaps for example. he is on the faculty of a physician derm residency program and writes journal articles every month.

Yeah all I was saying is that you guys are the exception not the rule and lack of standardization and credentialing doesn't help your cause. I also wonder how prospective pa applicants would feel if lateral mobility was lost and there were required 1 year residencies after and could only switch fields if they did another residency.

 

[deleted6669]

I think lateral mobility is going away as hospital credentialing committees require more and more every year and the joint commission and similar entities push that as well. I think the future for the pa profession is 3 yr programs with required 1 yr internships and specialty exams upon completion. the docs went that route 100 years ago. it's our turn. some PAs will applaud this trend. most will hate it. gotta pay your dues if you want to play with the big boys and use the big toys.

 

[Makati2008]

I think lateral mobility is going away as hospital credentialing committees require more and more every year and the joint commission and similar entities push that as well. I think the future for the pa profession is 3 yr programs with required 1 yr internships and specialty exams upon completion. the docs went that route 100 years ago. it's our turn. some PAs will applaud this trend. most will hate it. gotta pay your dues if you want to play with the big boys and use the big toys.

I honestly hate the increase in schooling and a possible residency. If that is the case why not just go to one of the accelerated MD/DO program, do a tri, and practice in a rural ED( I know of several doctors doing this back in Texas. Two of them are pretty young as well and making 250+)

 

[princekc]

I think lateral mobility is going away as hospital credentialing committees require more and more every year and the joint commission and similar entities push that as well. I think the future for the pa profession is 3 yr programs with required 1 yr internships and specialty exams upon completion. the docs went that route 100 years ago. it's our turn. some PAs will applaud this trend. most will hate it. gotta pay your dues if you want to play with the big boys and use the big toys.

^^^Agreed! The landscape has change. PA graduate this days are so young with very little prior HCE.

 

[Nasrudin]

Yeah I agree the landscape has changed. I can say honestly that I would be honored to have the opportunity to rotate as a resident under the training of someone like emedpa. But that's because awesome is awesome. My mother is an NP of the original sort, replete with decades of nursing experience in the ED, OB, peds, surgery, and ICU before she became a clinician. She's also a helpless nerd who gets excited when she can go to a conference and learn cutting edge stuff.

I couldn't agree more that with the IDEAL circumstance and personality, that within a decade the clinical training of NP/PA's has the POTENTIAL to match and even surpass a physician's if the force of one's personality were directed at expertise and mastery.

But what has changed, as the previous poster indicated, is that these routes that were designed to utilize experience and unique systems based common sense built over time in another profession, has become lifestyle oriented short cuts, which neither encourage or demand the sort of personal characteristics that would create an emedpa prototype.

As such it is a dangerous assumption that they are producing the clinicians they were designed to originally. And I would also say that if you are motivated towards excellence to take the hard road and become a physician. All....all...of the individuals motivated by excellence who have taken other clinical courses of training that I know....wish they had gone to medical school.

I can only recommend short cuts for those that want to work a carefree straight 8 and go home to do other things. And there's absolutely nothing wrong with that. But doing that and wanting the fruits of the tree of knowledge without effort is obscene and blasphemous and only cheaply acceptable in the court of opinion that weighs seriously the goings on of Kim Kardashian's sex life.

 

[deleted6669]

But what has changed, as the previous poster indicated, is that these routes that were designed to utilize experience and unique systems based common sense built over time in another profession, has become lifestyle oriented short cuts...
As such it is a dangerous assumption that they are producing the clinicians they were designed to originally. And I would also say that if you are motivated towards excellence to take the hard road and become a physician. All....all...of the individuals motivated by excellence who have taken other clinical courses of training that I know....wish they had gone to medical school.
I can only recommend short cuts for those that want to work a carefree straight 8 and go home to do other things. And there's absolutely nothing wrong with that. But doing that and wanting the fruits of the tree of knowledge without effort is obscene and blasphemous and only cheaply acceptable in the court of opinion that weighs seriously the goings on of Kim Kardashian's sex life.

AGREE. PA/NP should only be a path for those with significant prior experience. all others should strongly consider medschool.

 

[fab4fan]

It's exasperating to read posts from people who haven't even finished nursing school and plan to immediately start a NP program. While working as an RN doesn't teach you how to be a clinician, you do learn a lot about working with patients and colleagues. There's no replacing hands on experience.

 

[Makati2008]

It's exasperating to read posts from people who haven't even finished nursing school and plan to immediately start a NP program. While working as an RN doesn't teach you how to be a clinician, you do learn a lot about working with patients and colleagues. There's no replacing hands on experience.

I totally agree. Also it irks me that folks that couldn't get into med school(the lazy folks like the ones who don't take the Mcat serious) that take a seat out of a PA/NP program from a more worthy applicant

 

[sarjasy]

Also it irks me that folks that couldn't get into med school(the lazy folks like the ones who don't take the Mcat serious) that take a seat out of a PA/NP program from a more worthy applicant

Do you really think that those that don't "take the MCAT serious" end up going NP/PA? As if either are a bail out/back up option? BTW, it's "take the MCAT seriously" not "take the MCAT serious."

 

[Makati2008]

Do you really think that those that don't "take the MCAT serious" end up going NP/PA? As if either are a bail out/back up option? BTW, it's "take the MCAT seriously" not "take the MCAT serious."

I know of five people that went this route. My best friend will be the sixth from what he has recently stated to me.

The one that bugs me the most was accepted into a combined BS/MD program and dropped out over someone of the opposite sex. That person went on to take the mcat several times, enrolled into a postbac, and now is a nurse enrolled into NP school.

Also thank you for correcting my grammar but your suggestions in that department are not needed. It's safe to assume there will be errors present.

 

[fab4fan]

Do you really think that those that don't "take the MCAT serious" end up going NP/PA? As if either are a bail out/back up option? BTW, it's "take the MCAT seriously" not "take the MCAT serious."

I have read many posts over the years here of people who say they want to do just that.

 

[sarjasy]

I know of five people that went this route. My best friend will be the sixth from what he has recently stated to me.

Your anectdotes aside, perhaps I am interpreting your original statement too literally. I fail to see how someone who blows off the MCAT would have enough drive, dedication, or desire to earn a BSN/MSN or to get through PA school after earning the requisite HCE. It makes no sense to me.

Again, perhaps I am taking your statement too literally, but your post history (esp. before becoming a mod) subtly suggests a belief that those that go NP/PA aren't willing to put forth the effort to become an MD (and yes, I know you are a PA in med school), and now you provide anecdotal evidence to support that view -- a view your post history suggests you have held for some time. Given that, your lament that these "lazy" folks are taking seats from "more qualified applicants" is tempting to interpret as a proverbial throwing of a bone to NP's/PA's while simultaneously insulting them -- a textbook passive-aggressive maneuver. As you surely know, reasons for becoming an NP/PA are far more diverse and complex than that. Perhaps my interpretation of your statement is wrong, if so, I apologize.

 

[Makati2008]

Your anectdotes aside, perhaps I am interpreting your original statement too literally. I fail to see how someone who blows off the MCAT would have enough drive, dedication, or desire to earn a BSN/MSN or to get through PA school after earning the requisite HCE. It makes no sense to me.

Again, perhaps I am taking your statement too literally, but your post history (esp. before becoming a mod) subtly suggests a belief that those that go NP/PA aren't willing to put forth the effort to become an MD (and yes, I know you are a PA in med school), and now you provide anecdotal evidence to support that view -- a view your post history suggests you have held for some time. Given that, your lament that these "lazy" folks are taking seats from "more qualified applicants" is tempting to interpret as a proverbial throwing of a bone to NP's/PA's while simultaneously insulting them -- a textbook passive-aggressive maneuver. As you surely know, reasons for becoming an NP/PA are far more diverse and complex than that. Perhaps my interpretation of your statement is wrong, if so, I apologize.

l don't have an issue with people going NP/PA in general. It's more so the newer generation that seems to be taking an easier route which bothers me. Now those that become midlevels due to age , $ cost(which I understand all too well), or other extenuating circumstances I can understand but lately I have been seeing people use my previous career as a fallback and it bothers me.

Also I have a problem with NP/PA independence without a residency(md level) because medicine is so broad that a midlevel needs a safety valve of sorts and I think this is why you might see me as a little harsh? Also if a person is younger then I tend to challenge him or her to go to medical school unless they have an extenuating circumstance.

Maybe this might give you more insight into what I think about both our professions as a whole. At one of my audition rotation sites they currently have PA/NPs but I was told they are letting them go and this was to have a place for residents to moonlight internally. It went from my top three to not being ranked at all. I'm still a big advocate for MLP rights (both professions) although people may feel my posts here may not reflect that at all times.

 

[fab4fan]

l don't have an issue with people going NP/PA in general. It's more so the newer generation that seems to be taking an easier route which bothers me. Now those that become midlevels due to age , $ cost(which I understand all too well), or other extenuating circumstances I can understand but lately I have been seeing people use my previous career as a fallback and it bothers me.

Also I have a problem with NP/PA independence without a residency(md level) because medicine is so broad that a midlevel needs a safety valve of sorts and I think this is why you might see me as a little harsh? Also if a person is younger then I tend to challenge him or her to go to medical school unless they have an extenuating circumstance.

Maybe this might give you more insight into what I think about both our professions as a whole. At one of my audition rotation sites they currently have PA/NPs but I was told they are letting them go and this was to have a place for residents to moonlight internally. It went from my top three to not being ranked at all. I'm still a big advocate for MLP rights (both professions) although people may feel my posts here may not reflect that at all times.

It makes my eyes want to bleed when I read posts from "pre-nursing students," nursing students and new grads who want to know what's the fastest and easiest route to become an NP/CRNA.

I don't think you should pick a profession as a fall back. If you want to be an NP/PA, do it because that's what you really want to do, not because it's your second choice because you couldn't cut it in med school. If you're doing it because you're "settling," you'll never be happy.

Makati, I think that says a lot about your character that you crossed off that program from your list.

 

[Makati2008]

It makes my eyes want to bleed when I read posts from "pre-nursing students," nursing students and new grads who want to know what's the fastest and easiest route to become an NP/CRNA.

I don't think you should pick a profession as a fall back. If you want to be an NP/PA, do it because that's what you really want to do, not because it's your second choice because you couldn't cut it in med school. If you're doing it because you're "settling," you'll never be happy.

Makati, I think that says a lot about your character that you crossed off that program from your list.

Thank you fab.