DPM or nursing?

[DrShoegal]

I've been accepted to both DPM and an accelerated BSN program. I graduated with a BA in 2010. If I go the BSN route, I am interested in pursuing CRNA or NP but I have heard it is very difficult to get accepted into those programs. I am leaning towards DPM, but I am worried about the future of the profession.. decreasing reimbursement rates, and I would love to open my own practice but a few doctors that I've shadowed said it is getting more and more difficult to keep up with the expenses and more are going towards group practice, hospital settings. I am also worried about malpractice and the possibility of getting sued whereas in nursing you are basically covered. I know they are 2 completely different fields and I don't know if I could see myself being a nurse but I would love to become a NP but if I couldn't get accepted to a program I think I would regret not going to pod school. I am in my mid twenties and sometimes I dread the fact that I will be in school for 4 years plus 3 years of residency compared to the BSN program that is only 11 months..I really don't know what career to choose..Like I said I am leaning towards podiatry but nursing would be nice since it would only take me a year but I am worried I will regret not becoming a doctor. Also, the podiatrist I am shadowing really doesn't know if she would go through with podiatry again if she had the chance so that also worries me..Any suggestions are great! I am down to 1 week to decide! Thanks in advance

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[benny32311]

Well, it sounds like you want to be a podiatrist.

 

[DrShoegal]

I think youre right..I am also worried about the amount of debt I will have if I choose podiatry school. I dont have any debt now but if I choose podiatry I will have around 150, 000 which will take me years to payoff which means waiting longer to have a family. And nursing will be a lot less. The pay is good in both fields. I just want to be happy with my choice and not have to worry about finances.
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[pamac]

I think youre right..I am also worried about the amount of debt I will have if I choose podiatry school. I dont have any debt now but if I choose podiatry I will have around 150, 000 which will take me years to payoff which means waiting longer to have a family. And nursing will be a lot less. The pay is good in both fields. I just want to be happy with my choice and not have to worry about finances.
Sent from my SCH-I535 using SDN Mobile

I thought about podiatry years ago. Had a long conversation with a well established local podiatrist. What you said about group practice was in line with what he told me,, although he managed to successfully operate his own practice. He said it was incredibly difficult to be independent, and those that join groups are often taken advantage of. He was throwing out numbers like 30k take home wage for the first few years as a new grad after residency. I though that was a joke. But it really didn't take much research to see that podiatry was a mixed bag, which puts it in a strange category given all the debt and effort that can go into becoming one. You compete with ortho MDs, and I'm not sure I'd want to be in that position. And 150k for pod training actually sounds low to me. I'm not in any way implying that podiatry isn't legitimate, but the more I looked at it, the more quirky everything about it seemed, from the super lax entry requirements (visit the pod forums and see how folks with ultra weak stats are told they are golden to get in somewhere), to the fact that every pod school is private.... It all seems to operate more on the margins of medicine than from core. Don't mistake my take on this as equating them with chiropractice, or naturopathic quackery, but just that for the expense and effort that goes into it, it seems that there are too many variables in what you are guaranteed to get out of it. So like when I meet a dentist, it's a good bet that they at least have a decent cash flow (despite maybe being in debt up to their eyeballs), the same cant really be said of podiatrists. There's always a few that rake in great money, but if I'm going to fork over 7years of my life, I want some good odds of making more than a PA or NP, and not having my overhead and insurance benefits eat up my income to the point where I take home what I would as a nurse.

But... I didn't have my heart set I being a pod, and I enjoy nursing. That can make the difference between what it takes to be a successful podiatrist. If you live doing it, I'm of the opinion you are in a good position to thrive at it despite the possible drawbacks I mentioned. You might find out that group podiatrist practice works out great because by pooling resources, you take home a good wage and don't have to work like mad.

There's virtue in evaluating what the future of podiatry will be like, but I wouldn't become focused on the drawbacks and assume that you would be associated with the losers in the field. If you want to succeed, there's ways for you to excel. Assume that you could potentially be a successful NP or Podiatrist, and then try to imagine which field youd rather be practicing in for 25 years or more.

 

[dudestheman90]

[

 

[pamac]

I'd say nursing. Here's why...Less Debt, finish quicker, solid and well known career, unlimited amount of specialty areas you can work in, even in non-clinical positions, high income potential, and many opportunities for advancement such as DNP/NP, CNS, PHD, CRNA, ect...Podiatry has a high attrition rate and a residency shortage. Podiatry school will cost 200k + interest, your actually looking at 250k to 300k in debt. At least if you fail NP school, you at least have a BSN/RN to fall back on. Plus being male is a huge bonus, you can potentially move up into management/leadership roles quicker and make more money. In nursing, you get paid by the hour, not by how many patients you see, which means overtime, bonuses, holiday and weekend pay on top of what your making. You can do much better, income wise then a podiatrist, esp if you work in biotech or pharmaceutical sales which is an option many RN's explore, even public health or military nursing. Really nursing is such a vast field and is unlimited. As a Podiatrist, your limited to working with feet, most of the time is clipping toenails, i shadowed a pod, it wasnt appealing. Id much rather work in onology or a surgical specialty, or psychiatry, that seems a lot more interesting and rewarding than gross feet.

I agree with all of that, and that kind of information played into my decision to do nursing over the other options available. The one (!) thing podiatry seemed to have going for it was potential income.... But even that was a toss up, and maybe worse than that when you factor in debt and overhead involved. Too much variability in the outcome, and too little variety in opportunity for the price and time involved. I don't know a degree out there that provides as many opportunities as nursing.

 

[dudestheman90]

[

 

[pamac]

I really do feel your income potential is very good in nursing, you can become very wealthy in this profession. With the the many different specialty areas to work in, research/teaching opportunities, graduate programs, non-clinical areas such as sales/marketing and nursing informatics, as well as management and leadership roles, the sky is really the limit! Nursing is a very powerful organization within the healthcare system and under obamacare, nurses role will only expand and become more vital. That's why the profession moved towards a clinical doctorate degree besides a phd. In podiatry, the schooling is expensive, your income can range from very low to high, and you have to be a competent foot surgeon, otherwise your not going to make much money and possibly lose your license.You have to also like surgery or you won't last long in this field. Not to mention the residency shortage they have and the high attrition rates,

Nursing does seem to have their fingers in every pie imaginable... You find them everywhere... Employee health, schools, public health, consulting, military, prisons, government, administration, research, academia, insurance industry, home health, rehab, CEO's, law..... It's amazing. I moved into nursing as a detour from pursuing PA school, and I'm a lot more excited about the options there than I was with any other career path. I have a lab science degree as well, so putting both nursing and lab backgrounds together seems kind of unique among nurses. I'm interested to see how that will work for me when I graduate soon. Even if I stay in one area in nursing, I still am more comfortable with some other cool avenues available to me. Not to mention the lack of debt.

 

[dudestheman90]

[

 

[badasshairday]

So do I, worked in a lab with a bio degree for a short time, didnt really like it all that much, the pay wasn't great, so now went onto nursing. I thought about pursuing PA but i feel becoming an NP is the much better route in the long run. Here's why. In nursing and as an NP, you practice underneath your own license, for the most part your autonomous and your responsible for your own actions. As a PA, you practice underneath an MD license. Your basically going to do al the grunt work. You can obtain your clinical doctorate degree as an NP as opposed to a Masters in PA and could never call yourself a doctor. As a PA, i feel at some point your going to feel limited, as a 60-Yr old PA working for a 32 year old doctor fresh out of residency. In NP school, you can still work part or fulltime as a practicing RN while pursuing your NP license which means cost or debt wont be an issue. PA is 2-3 years of schooling and you wont be able to work thus accruing debt. Those reasons steered me towards nursing!

Just to clarify. >96% of NP's do not practice independently despite legislation.

So essentially becoming a PA is the same if not better.

 

[AnnoyedByFreud]

Nursing does seem to have their fingers in every pie imaginable... You find them everywhere... Employee health, schools, public health, consulting, military, prisons, government, administration, research, academia, insurance industry, home health, rehab, CEO's, law..... It's amazing. I moved into nursing as a detour from pursuing PA school, and I'm a lot more excited about the options there than I was with any other career path. I have a lab science degree as well, so putting both nursing and lab backgrounds together seems kind of unique among nurses. I'm interested to see how that will work for me when I graduate soon. Even if I stay in one area in nursing, I still am more comfortable with some other cool avenues available to me. Not to mention the lack of debt.

I agree. The opportunities in nursing dwarf any other career I've looked at. Even now, in the midst of my accelerated RN, I see nurses everywhere making great money (granted I'm in an area of the country that pays nurses very well). A girl ahead of me in the program is currently working part-time as a RN (making 45-50$/hr) while earning her MSN to become a psych NP. Also, the scholarship opportunities are immense. At my university many of the health science students recently attended an information session on different loan repayment programs (it was a mix of nursing, medicine, pharm, etc. students) and they went through 3-4 loan repayment/scholarship programs that are exclusive to nursing only (much to the dismay of the students in the other fields). This is a field that is ripe with opportunity, especially if you can go to a top school that can help you network and form connections, you can be eased into a leadership role, etc. It seems like once you have RN after your name, doors come flooding open. Most unhappy nurses I've seen are the ones who feel stuck at the bedside and because of life circumstances can't pursue higher education (MSN, doctorate, whatever) to move to a better paying (and less back-breaking) part of the field. That's why I'd advise people to start with a BSN and get their MSN/DNP/whatever higher degree in nursing sooner, rather than later. Or if you already have a bachelors then just enter at the MSN level. As more and more hospitals seek out "magnet" status, it's the smart thing to do.

 

[AnnoyedByFreud]

Just to clarify. >96% of NP's do not practice independently despite legislation.

So essentially becoming a PA is the same if not better.

Do you have any citation for that statistic? I ask because I lived in an independent practice state previously and there were many NPs with their own practices. The psych NPs in private practice made absolute bank (no physician or facility to take a cut) and were not accepting new patients. Hell, even in non-independent practice states many NPs have their own practice and only have a "collaborative agreement" with physicians that basically states "I'll come to you if I have a question". It seems like many PAs do not enjoy the same type of freedom, and although it varies from state-to-state, overall I would argue that it is not the same between NPs and PAs, at all. I have spoken with PAs who are very frustrated by the limitations that the physician supervision requirement causes, and many talk about taking a lead from the NP field and pursuing more freedom. Isn't there a PA group (PAs for tomorrow, I think) that is arguing for autonomy?

And I'm sorry, but in nursing there are far more opportunities to go into leadership, management, policy, research, teaching, work abroad, etc. The positives for PA (IMO) are if you want to practice EM or surgery (though I'd probably just go to med school if I wanted to do that) and the ability to switch specialties at the drop of a hat. In nursing you have to go back to school, though it's not too bad (most post-masters cert programs are 9-12 months and you can work while you do it).

 

[deleted307836]

Do you have any citation for that statistic? I ask because I lived in an independent practice state previously and there were many NPs with their own practices. The psych NPs in private practice made absolute bank (no physician or facility to take a cut) and were not accepting new patients. Hell, even in non-independent practice states many NPs have their own practice and only have a "collaborative agreement" with physicians that basically states "I'll come to you if I have a question". It seems like many PAs do not enjoy the same type of freedom, and although it varies from state-to-state, overall I would argue that it is not the same between NPs and PAs, at all. I have spoken with PAs who are very frustrated by the limitations that the physician supervision requirement causes, and many talk about taking a lead from the NP field and pursuing more freedom. Isn't there a PA group (PAs for tomorrow, I think) that is arguing for autonomy?

And I'm sorry, but in nursing there are far more opportunities to go into leadership, management, policy, research, teaching, work abroad, etc. The positives for PA (IMO) are if you want to practice EM or surgery (though I'd probably just go to med school if I wanted to do that) and the ability to switch specialties at the drop of a hat. In nursing you have to go back to school, though it's not too bad (most post-masters cert programs are 9-12 months and you can work while you do it).

I would guess that these NPs are included in that 96% statistic - it's hard to call someone truly independent when they have a "collaborative agreement" with a physician. Just a guess, though.

 

[deleted307836]

You can obtain your clinical doctorate degree as an NP as opposed to a Masters in PA and could never call yourself a doctor.

I don't mean to revive a tired SDN debate, but please don't do this in a clinical setting. The majority of patients equate "doctor" with "physician." Many probably don't even know what a physician is (some type of physicist? ) I have a lot of respect for nurses and nursing, which may not seem to be the SDN norm most of the time, but steering away from the "Dr" label just seems like the smartest thing for NP's to do.

 

[dudestheman90]

k

 

[AnnoyedByFreud]

I would guess that these NPs are included in that 96% statistic - it's hard to call someone truly independent when they have a "collaborative agreement" with a physician. Just a guess, though.

~17 states allow complete independent practice, another ~10 allow for a vague agreement. I believe. Facilities can have their own policies that are more restrictive sometimes. Anyway, that's why the 96% statistic thrown around seems highly inaccurate to me. The south is very restrictive as far as I can tell, but I have zero interest in practicing there.

 

[AnnoyedByFreud]

I don't mean to revive a tired SDN debate, but please don't do this in a clinical setting. The majority of patients equate "doctor" with "physician." Many probably don't even know what a physician is (some type of physicist? ) I have a lot of respect for nurses and nursing, which may not seem to be the SDN norm most of the time, but steering away from the "Dr" label just seems like the smartest thing for NP's to do.

Psychologists, pharmacists, dentists, PTs, optometrists, podiatrists, etc, etc. are all people who earn doctoral degrees and work around physicians. I do not care if people call themselves doctor or not (assuming they have a doctorate degree in the field of their practice) AS LONG AS the person is crystal clear about their role. Like, "I'm Dr. X, your psychologist", "I'm Dr. Y, the clinical pharmacist", etc.

No one complains about these other fields using their titles. I don't understand why the world explodes and suddenly we're all very concerned that patients may get "confused" when a nurse earns a doctoral degree, but apparently it's a huge problem.

This is coming from someone with no plans for a doctoral degree in nursing and will most likely go by my first name.

 

[dudestheman90]

^

 

[AnnoyedByFreud]

^ see my link/post above. its actually 18 states and the district of Columbia allow for complete autonomy Also as time goes on this list will only get larger.

Thanks for the correction! I recently read that Minnesota might try for independent practice this year...

 

[deleted307836]

~17 states allow complete independent practice, another ~10 allow for a vague agreement. I believe. Facilities can have their own policies that are more restrictive sometimes. Anyway, that's why the 96% statistic thrown around seems highly inaccurate to me. The south is very restrictive as far as I can tell, but I have zero interest in practicing there.

I know you're in psych -- I would think that many more psych NPs practice independently than NPs in other specialties due to the ease of setting up a private practice in psych. Maybe NPs who work in settings like the ER, ICU, etc. bring this number up?

Psychologists, pharmacists, dentists, PTs, optometrists, podiatrists, etc, etc. are all people who earn doctoral degrees and work around physicians. I do not care if people call themselves doctor or not (assuming they have a doctorate degree in the field of their practice) AS LONG AS the person is crystal clear about their role. Like, "I'm Dr. X, your psychologist", "I'm Dr. Y, the clinical pharmacist", etc.

No one complains about these other fields using their titles. I don't understand why the world explodes and suddenly we're all very concerned that patients may get "confused" when a nurse earns a doctoral degree, but apparently it's a huge problem.

Dentists, optometrists, physicians, and podiatrists all share a roughly similar educational background of four years of professional school which lead to a defined role in the clinical setting. Likewise with NPs, I don't see it as a good idea for pharmacists and PTs to refer to themselves as doctors in front of patients. Psychologists I can also understand since they practice in a setting where their role is more clearly defined. That's a good point though - I concede the issue is not completely black and white and I totally understand why disagreements occur here.

 

[AnnoyedByFreud]

I know you're in psych -- I would think that many more psych NPs practice independently than NPs in other specialties due to the ease of setting up a private practice in psych. Maybe NPs who work in settings like the ER, ICU, etc. bring this number up?



Dentists, optometrists, physicians, and podiatrists all share a roughly similar educational background of four years of professional school which lead to a defined role in the clinical setting. Likewise with NPs, I don't see it as a good idea for pharmacists and PTs to refer to themselves as doctors in front of patients. Psychologists I can also understand since they practice in a setting where their role is more clearly defined. That's a good point though - I concede the issue is not completely black and white and I totally understand why disagreements occur here.

I'm not sure if it's unique to psych or not. I know of a FNP who works for an organization where all the "providers" (MDs/DOs/NPs) are considered independently practicing employees... no one's supervising anyone. I think many clinics function that way in independent practice states, though I'm not certain.

meh, I'd argue that a PhD psychologist's background surpasses that of a MD regarding appropriate use of the word "doctor". It's all a big "mine's bigger than yours" fight. As long as people clarify their role, I do not care if a person uses the word doctor if they have a doctorate degree in their field of practice. Arguments like this are petty and don't play well with the public (they buy into the idea that docs are arrogant, entitled, etc.) My point is that people seem disproportionately upset with nurses using the title. Most people have no clue what the difference is between a psychologist and psychiatrist, yet both call themselves doctor in a clinical setting, and no one is screaming about patient confusion, for example.

 

[deleted307836]

I'm not sure if it's unique to psych or not. I know of a FNP who works for an organization where all the "providers" (MDs/DOs/NPs) are considered independently practicing employees... no one's supervising anyone. I think many clinics function that way in independent practice states, though I'm not certain.

meh, I'd argue that a PhD psychologist's background surpasses that of a MD regarding appropriate use of the word "doctor". It's all a big "mine's bigger than yours" fight. As long as people clarify their role, I do not care if a person uses the word doctor if they have a doctorate degree in their field of practice. Arguments like this are petty and don't play well with the public (they buy into the idea that docs are arrogant, entitled, etc.) My point is that people seem disproportionately upset with nurses using the title. Most people have no clue what the difference is between a psychologist and psychiatrist, yet both call themselves doctor in a clinical setting, and no one is screaming about patient confusion, for example.

I guess what I'm getting at is that patients can expect a certain level of standardization of education and professional responsibilities among those categories of "doctors" I listed above -- but they cannot for NP's, whose roles vary by legislation and from a wide range in quality of educational programs (from what I understand). Likewise, PTs and pharmacists lack the responsibilities that those four groups of professionals have, which include prescribing as a result of their own diagnosis - so introducing the term "doctor" IMO has the potential to be very misleading in terms of expectations from patients. I agree with you though that nurses are targeted disproportionately in this debate, which I would guess partly comes from the recent introduction of the DNP degree.

I like your point about making ones role clear even if they do introduce themselves by their professional title. (Dr. ____, pharmacist, NP, etc). That is probably a good compromise, though I suspect as more health professionals creep towards a doctoral degree that hospitals may make their own policies on this.

 

[dudestheman90]

[

 

[Textbookversion]

"Hello, I'm Dr. X, your nurse."

"Sorry, could you repeat that."

"I'm Dr. X, your nurse."

"I must be really out of it Doc, I keep hearing you say you are my nurse."

"I'm am your nurse."

"But you said you were a doctor?"

"I'm a a doctor nurse. A nurse doctor."

"I... what.... you can't be... what?"

"I have a doctorate in nurse practice"

"Doesn't that make you like a super nurse, not a doctor?"

"No I'm your doctor, who is a nurse."

"I think I feel a headache coming on."

 

[deleted307836]

I know you post that in jest, but it really does get to the heart of the issue with regard to the potential for confusion.

 

[dudestheman90]

l

 

[deleted307836]

technically nurses and np's do take medically related course work to medical students. Pharmacology taken once in undergrad, and again in Np school. Pathophysiology is taken 3 times, once in undergrad and 2 courses in NP school, health assessment once in undergrad and again in NP school and so on.

I can't speak from experience, but I am extremely doubtful that an undergraduate nursing course in pharmacology comes even close to the level of rigor in an analogous medical school course... and same thing for other courses such as pathophys and physical exam. The focuses of the two professions are different - how could you even expect them to be comparable? Even at the NP vs medical level I doubt most courses are at the same level.

This also doesnt include the 2+ years of nursing experience you get as an RN that your exposed to in which you gain and build medical knowledge before entering NP school.

This isn't standard, though.

Even while in NP school, your learning more and are able to work at the same time and apply that knowledge as an RN. It's a pretty cool way to learn. All NP's must do a residency in order to graduate as well, so your really getting a lot of clinical experience at the RN and NP level.

 

[badasshairday]

"Supervision" and "collaboration" are interchangeable terms for PA's. I know PA's in primary care practices. In fact when I was in medical school I was at a FP practice with two PA's and one doc. The PA's saw there own panel of patients, the doc saw his own panel. So that is collaboration I guess. Same thing if would be true if they are NP's.

Second if you truly think you are ready for independent practice fresh out of NP school, you are in for a shock.

Again, maybe primary care and pych after many years of experience it is possible. But NP's working in ICU, ER, hospitalist, surgical subspecialties, medical subspecialties, radiology, are all "supervised" by physicians. This is what brings the number to ~96%.

 

[badasshairday]

Its a prestige war. Physicians need to stop thinking their ontop of the ladder. Respect and treat eachother equally, too many physicians have this idea that they are the best and every1 is below them. You go to school to memorize a bunch of info. just like a car mechanic, he memorizes a lot of info and spits it back out, being good at what he does. Even as a future NP, i am not better than a janitor, and the janitor is no better than a doctor. Every1 chooses their own path and becomes skilled at what they do. Engineers can make excellent doctors, they just choose not to go into medicine. In fact i believe their schooling and content is a lot more difficult than anything else.

Thanks for the lack of respect. Hope you don't try to learn anything from us "car mechanic" types during your educational training and career. And actually a lot of my friends did do engineering and undergrad and decided to pursue medicine after.

Hmm and about the prestige thing. I don't know, maybe it is because it is the physicians who are calling all the shots and making the big decisions in patient care.

For example, an ER doc or neurologist making the decision on giving tPA to an acute stroke. To an interventional cardiologist deciding to take a patient to cath. Or a surgery to take a person to the OR or not for there belly pain. Or the radiologist calling the brain MRI as no ischemic findings and allowing the treating doc to treat a bells palsy over an acute CVA. Do you know what it is like to take full responsibility and liability for every medical imaging scan you read? Do you know how much time it takes to develop these skills? This takes the skills and expertise of a board certified physician. And to get to that point takes a lot of hard work and sacrifice.

No short cuts.

 

[badasshairday]

http://www.tafp.org/news/stories/11.04.21/capitol-update

A 2004 survey of practicing nurse practitioners published in the Journal of the American Academy of Nurse Practitioners reported that in the area of pharmacology, 46 percent reported they were not "generally or well prepared" by their education. The authors wrote: "In no uncertain terms, respondents indicated that they desired and needed more out of their clinical education, in terms of content, clinical experience, and competency testing."

Nurse practitioners testifying before the group argued that independent practice for APRNs would reduce health care costs, but a study published in Efficient Clinical Practice comparing utilization rates among physicians, medical residents, and nurse practitioners in the same setting showed that utilization of medical services was higher for patients assigned to nurse practitioners than for patients assigned to the residents and the physicians. Hospital admissions were 41 percent higher among the patients of nurse practitioners, and specialty visits were 25 percent higher in the nurse practitioner group.

"In our residency program, our residents complete three years and must be supervised for the entire three-year duration," Elliott said. "They must pass multiple standard rotations, be evaluated along six core competencies, and undergo 100 percent chart review for the duration of their residency in preparation for practice. Only at the end of these three years, when they have met all of their requirements and competencies, and after completing almost 16,000 — that is 16,000 — clinical hours from medical school to residency, do I as their residency director summarize their experiences and declare them in writing fully competent and able to practice independently."

No such standard exists for the education of nurse practitioners, she said, adding that nurse practitioners experience between 500 and 1,500 hours of clinical training while pursuing their degrees.

 

[dudestheman90]

j

 

[Textbookversion]

Honestly it's the fact that the NP's feel they are ready to practice independently right out of school that worries me the most.

I am fully cognizant of how stupid I am and how little I know. I know I need the supervision and training of a residency program.

If I was a NP you'd find me lining up for a job with lots of supervision and educational opportunities.

 

[Textbookversion]

Your not counting the 2 years of clinical experience that's undertaken at the undergraduate level, it's usually the last 2 years of a BSN program. The NP programs I'm looking at require a minimum of two years of experience as an RN. Also most RN's work while their in NP school so that's even additional clinical experience. Not to mention hospitals do give scholarships to RN's looking to move up, so some go to school for free. Then residency is about 1000 clinical hours for most programs, so thats even more clinical experience. It adds up. Im not saying RN's should take over as a physician, not at all, but the trend i see is that 18 states allow independent practice and more states are likely to follow suit in the near future.

Clinical experience as an RN really has nothing to do with being a physician. Totally different responsibilities.

 

[AnnoyedByFreud]

"Hello, I'm Dr. X, your nurse."

"Sorry, could you repeat that."

"I'm Dr. X, your nurse."

"I must be really out of it Doc, I keep hearing you say you are my nurse."

"I'm am your nurse."

"But you said you were a doctor?"

"I'm a a doctor nurse. A nurse doctor."

"I... what.... you can't be... what?"

"I have a doctorate in nurse practice"

"Doesn't that make you like a super nurse, not a doctor?"

"No I'm your doctor, who is a nurse."

"I think I feel a headache coming on."

Honestly, I really think this is poor form and plain silly. If a patient can't wrap their minds around the fact that a nurse can have a doctorate then I think we can just give up. And no one says "I'm a doctor nurse", I'm sure they'd say "I'm a nurse with a doctorate in nursing, doctorate refers to the level of training". Like I said, psychologists and other allied health professionals call themselves doctor all the time (even in the presence of psychiatrists, OMG how does the patient not get so confused?!??!?!). Anyway, I think the DNP as entry to practice is silly and stupid and I have no interest in earning one. However I also think the argument that a nurse using their appropriate title is somehow "misleading" the patient is utter horse****.

 

[AnnoyedByFreud]

"Supervision" and "collaboration" are interchangeable terms for PA's. I know PA's in primary care practices. In fact when I was in medical school I was at a FP practice with two PA's and one doc. The PA's saw there own panel of patients, the doc saw his own panel. So that is collaboration I guess. Same thing if would be true if they are NP's.

Second if you truly think you are ready for independent practice fresh out of NP school, you are in for a shock.

Again, maybe primary care and pych after many years of experience it is possible. But NP's working in ICU, ER, hospitalist, surgical subspecialties, medical subspecialties, radiology, are all "supervised" by physicians. This is what brings the number to ~96%.

Still waiting on that citation, because I've seen differently (and not just psych NPs, but primary care NPs as well). And PA practice seems to vary wildly by state (just like NP practice). I know a PA who had to quit their job because their physician supervisor decided to retire. I'm curious what you think about the PAs for tomorrow groups that are fighting for autonomy (like NPs have done).

 

[dudestheman90]

k

 

[pamac]

lol who cares about the title. if a patient wants to call me doctor fine, but i think you can say, hi my name is dr. X, im your nurse practitioner, how can i help you today? technically nurses and np's do take medically related course work to medical students. Pharmacology taken once in undergrad, and again in Np school. Pathophysiology is taken 3 times, once in undergrad and 2 courses in NP school, health assessment once in undergrad and again in NP school and so on. This also doesnt include the 2+ years of nursing experience you get as an RN that your exposed to in which you gain and build medical knowledge before entering NP school. Even while in NP school, your learning more and are able to work at the same time and apply that knowledge as an RN. It's a pretty cool way to learn. All NP's must do a residency in order to graduate as well, so your really getting a lot of clinical experience at the RN and NP level. Combining nursing theory with medical knowledge, i think that is whats needed in patient care.

My hope is to become an NP at a point in the future, so I'm excited about the notion of having plenty of latitude in my career. I feel that moves towards NP independence provide bargaining latitude, and can only help NPs gain voice in how they will be treated by potential employers. There are plenty of stories out there that demonstrate that being linked at the hip to a doctor like a PA is statutorily can be difficult for a lot of reasons.

I diverge from the notion that the training an NP gets is equivalent to a MD. I feel like there is a way for me to fit into the NP role and thrive, but from the perspective of someone who is in RN training with folks who aren't steeped in biology background, its clear how that lack holds the nursing world back from being able to claim parity with MDs. There are so many ways someone can tear the notion of parity to pieces, and I'm not sure how you can compare the two and not realize they just aren't the same. I sit in lectures taught by experienced and very competent nursing instructors that don't know as much as I do from a biology standpoint (although for the most part that bio knowledge is absolutely unnecessary to the care provided at hand). However, that knowledge isn't necessary until the moment it is, and at that point it's vital to the patient. Doctors not only have a unique insight, they have big picture knowledge. I don't see a compelling case for ignoring that across the board. As a patient, that's what I want for the final word. I guess since that's the case, then that is what I should want as a professional. Every situation may not warrant a physicians involvement, but i dont want to take them out of the equation. This doesn't just apply to the NP/physician comparison, but also the physician/specialist aspect of my care. Clearly there's a point where more expertise is needed, and its just reality that there is a hierarchy that exists. It probably should remain in the professional sphere and not dominate other kinds of social interaction, but that's up to individuals how ignorant they want their character to seem among fellow humans.

In my job or as a patient, when I walk into a room to talk with the lead provider, I want to know who I'm dealing with.... Not to bow down or to scorn them for their education level, but so I know where they are coming from. The last word doesn't have to come from a doctor, but i do think that we should have our roles laid out in a manner thats not confusing to the patient. Like it or not, when a person is called "doctor" and they are in an exam room dealing with us, we either assume they are MDs or equivalents. Patients shouldn't have to face any risk in misunderstanding who they are dealing with so I can have a feather in my cap. The respect or disrespect aspect doesn't come to mind for me in that process.... A provider gets the same respect from me regardless of being an NP,PA, or MD/DO (incidentally, I've received the best treatment so far from physicians compared with non-physician providers at this point in my career, so maybe I'm seeing how some of the complaining about titles and arrogance can often come from folks who want the prestige without putting in the effort). It might be chance that I only run into physicians that are jerks rarely, and nurses and other staff that are "on one" more often than I can count.

As far as statute is concerned, I think that nonphysician providers should have some liberty from physicians to the extent that they aren't beholden to them like PAs are. I don't think that requires being labeled as equivalent, but it seems to involve being regarded as individually accountable. In my neck of the woods, emergency med groups are moving away from PAs and towards NPs because NPs licensure and independence leaves them off the hook. No headaches, paperwork, signatures, liability, chart review, etc... It falls on the NP to be held accountable for their judgement, and hopefully that judgement includes knowing when to consult with a physician, but its on them rather than the physician or organization. My understanding is that it works well, and wise decisions are made. NPs seem to feel like they aren't at the mercy of arranging relationships with supervising physicians, and documentation is brisk.

I think PAs are really well trained and should have NP style latitude, but I doubt the PA world will get it unless its handed to them in some form by either the needs/wants of physicians/boards of medicine, or unless hospitals or the insurance industry (aka the secretary of HHS) decide to provide it. The latter is probably the only hope they have because the face of PAs, the AAPA, isn't broadly interested in rocking the boat. But the clout that the nursing lobby has is momentous, which puts them at the table WITH doctors in dividing up the spoils of healthcare. The relationship PAs have with physicians prevents them from advocating aggressively for themselves like nurses can.

 

[deleted307836]

Nice post, pamac.

 

[badasshairday]

It is hard to find the stats. Finally found it.

http://nurse-practitioners-and-phys...wnloads/2010/010410/NP010110_SalarySurvey.pdf

Third page, under the section in which they talk about practice owners. So that >96% number comes from the fact that ~3% of NP's run their own independent practice.

 

[badasshairday]

I know a PA who had to quit their job because their physician supervisor decided to retire. I'm curious what you think about the PAs for tomorrow groups that are fighting for autonomy (like NPs have done).

Honestly, I see NP's all the time in so many different fields, autonomy is really just a political thing. IN reality in >95% of the hospitals and clinic settings NP's and PA's function in the same role. In the ED, the active life threatening emergencies goes to the physicians, and the midlevels work on the other patients and run things by the doc's when they have questions. In surgery, the midlevels run the floors and help the clinic move along efficiently, both NP's and PA's. In interventional radiology, both NP's and PA's do a lot of consults and basic procedures while this frees up time for the IR to do high end interventions. Same thing in GI, they do consults, floor work, and do a lot of clinic work.
They are extremely good at what they do too.

NP's and PA's play a very essential role in healthcare today, but to state that NP's are better off than PA's because they have this "independent practice" ability is misleading. 97% of the time it doesn't make any difference... unless you are that elite 3% running a solo practice in primary care or psych.

 

[pamac]

The PA profession is relatively new and not well-known. The nursing profession is very powerful and has a strong lobbying group in D.C. That's why our profession has grown so much over the last years, converting to a clinical doctoral degree, independent practice with more states to follow suit, ect...A PA student goes into school knowing he's going to be a physician "Assistant" and that he/she has to practice under a MD/DO license. I personally feel that shouldn't change, that supervision needs to remain, that's why its called PA school. An NP is different since he/she operates under a different model of care and practice under our own license.

PAs are well trained. I'd be fine with them approaching parity with NPs. Name change, on the other hand, is an ego issue. The same folks that insist that being called a physician assistant is demeaning and inaccurate point to patient confusion with regard to their skill level as providers. Where I'm at, PAs are widely recognized, and the folks who demand to be seen by a doctor are usually folks who would chafe at being seen by anyone other than a physician regardless of the severity of the ailment afflicting them at that given moment. For these folks,neither nurse, PA, NP, or resident will do (unless the resident is assumed to be a doctor). Many of the name changers also concern themselves with how to parlay their past health care experience into an introduction to their patients so as to enhance their resume, which betrays their feelings of being slighted. To me that's not a legit reason to throw out the name they took upon themselves by their own efforts. If the profession wants to call new grads "provider associates" or "practitioner associates" without grandfathering in the folks who practice as physician assistants, I think that would be reasonable. But good luck getting most name changers to swap out "physician" from the moniker, because that brings with it prestige. Change the laws that say PAs are physician extenders, then change the name to reflect the new reality, then grandfather in physician assistants to the new name if they want to. Seems the best route to me. I agree that they went into it knowing that they would be linked to physicians and called physician assistant. I've also heard NPs frustrated at having "nurse" in the title, and thought it to be just as weak to push to change that. But when I hear "physician associate" I can't help but think the speaker of that title will come across to the layman as referring to a "colleague of a physician who is himself/herself a physician". Maybe that's the goal... To enhance themselves..... By way of obfuscating their title a bit. But to hear it from name changer PAs and PA students, they just want a title that reflects the autonomous nature of the role they find themselves in. I do agree that changing their name would be important in helping them separate themselves from physicians, but I just feel like having "physician" in the title doesn't help because its a word that the doctors are right to own (it's theirs). If PAs really want to cut the cord, they should retool their name as far as they can. If you are going to keep "physician" in your name (implying equivalence) then docs are going to naturally want a descriptor in there reflecting non equivalence as well, hence "assistant". Otherwise the title "physician associate" denotes equivalence (physician), as well as equivalence (associate)....for folks that doctors know aren't trained as well as them.

I bet if they swapped "physician" in their title, PAs would see less resistance to measures towards independence. I think that although bom's like exercising control over PAs, being adequately identified as different from physicians might be enough for many haters among docs. Many just don't want party crashers around. If the crashers are open about the fact that they are indeed not one of the crowd, it becomes less of a big deal for the folks there by birthright. Then it's just a matter of being labeled just another non physician out there not matching up in their eyes, just like NPs are. You'll get the family practice physicians groups doing press conferences dissing on you like they do on NP's. that wii serve as a reward for living free, I guesse.

 

[pamac]

It is hard to find the stats. Finally found it.

http://nurse-practitioners-and-phys...wnloads/2010/010410/NP010110_SalarySurvey.pdf

Third page, under the section in which they talk about practice owners. So that >96% number comes from the fact that ~3% of NP's run their own independent practice.

NPs running practice independently really is more of a novelty than anything else. I've seen tons of stats just like this. It's roughly the same between PAs and NPs, and usually around 3%, just like that source said. Just because a state is independent for NPs doesn't mean it's easy to deal with billing, reimbursement, hospital red tape regarding privileges, and collaboration agreements. Reality can be harsh even if you are good to go from a legal standpoint. The fun begins when you want to get paid for all those services you render independently.

 

[AnnoyedByFreud]

Interesting to get the citation regarding ind. practice. Thanks! I still think that NPs are in a better positioned than PAs in some respects (and vice versa), but it really depends on your career goals in the end.

Also, someone earlier mentioned people wanting to practice independently as new graduates and I want to clarify that is not my interest at all (and not the interest of any of my classmates). That would be terrifying. I am interested in my own practice later on in my career.

I also don't believe that MD and NP training are equivalent. Not sure who posted about that, but it seems obvious to me that they are not equivalent levels of training.

 

[dudestheman90]

h

 

[JoBreeze]

Thanks for the lack of respect. Hope you don't try to learn anything from us "car mechanic" types during your educational training and career. And actually a lot of my friends did do engineering and undergrad and decided to pursue medicine after.

Hmm and about the prestige thing. I don't know, maybe it is because it is the physicians who are calling all the shots and making the big decisions in patient care.

For example, an ER doc or neurologist making the decision on giving tPA to an acute stroke. To an interventional cardiologist deciding to take a patient to cath. Or a surgery to take a person to the OR or not for there belly pain. Or the radiologist calling the brain MRI as no ischemic findings and allowing the treating doc to treat a bells palsy over an acute CVA. Do you know what it is like to take full responsibility and liability for every medical imaging scan you read? Do you know how much time it takes to develop these skills? This takes the skills and expertise of a board certified physician. And to get to that point takes a lot of hard work and sacrifice.

No short cuts.

Please don't let me know when the day comes that a PA or nurse is reading my patients' images or path slides.

 

[dudestheman90]

[

 

[JoBreeze]

lol it's already happening. Every state is different, but 26 states allow for no physician involvement (18) or a collaboration to prescribe meds only (8).

NP'S and CNS's are considered independently licensed practice providers under my states law and their is a difference between a collaboration and direct-supervision (PA's). NP's and CNS's are responsible for their own actions and the blame does not fall on the physician. This is different from a PA, who's physician is ultimately responsible for the PA. This is according to my states laws.

Oh yeah? Can I get a whipple at the minute clinic too?

 

[NYCGuy86]

lol it's already happening. Every state is different, but 26 states allow for no physician involvement (18) or a collaboration to prescribe meds only (8).

NP'S and CNS's are considered independently licensed practice providers under my states law and their is a difference between a collaboration and direct-supervision (PA's). NP's and CNS's are responsible for their own actions and the blame does not fall on the physician. This is different from a PA, who's physician is ultimately responsible for the PA. This is according to my states laws.

What do you mean by "direct supervision"?

Also, are you saying that PAs are not responsible for their own actions (and that the physician does not hold any responsibility in states that require NPs to have a collaborating/supervising (I'm looking at some documents for California, and they use the word "supervising" for NPs) physician?

 

[dudestheman90]

l

 

[NYCGuy86]

The PA profession is relatively new and not well-known. The nursing profession is very powerful and has a strong lobbying group in D.C. That's why our profession has grown so much over the last years, converting to a clinical doctoral degree, independent practice with more states to follow suit, ect...A PA student goes into school knowing he's going to be a physician "Assistant" and that he/she has to practice under a MD/DO license. I personally feel that shouldn't change, that supervision needs to remain, that's why its called PA school. An NP is different since he/she operates under a different model of care and practice under our own license.

PAs have their own license as well.

You do realize that PAs and NPs are interchangeable in the vast majority of cases, right (many jobs ask for either a PA or NP, and there are a few fellowships/post-grad programs that take both PAs and NPs)? You do realize that in hospitals, PAs and NPs will have some form of physician oversight (whether or not this is in an "independent practice" state), right?

You seem focused on the word "assistant", which doesn't tell how PAs generally function, as autonomous clinicians. Physician supervision for a PA is not hand holding.

Perhaps you should read more about the PA profession.