Holy poo! Hate for midlevels.

[Moniker]

It is not like inpatient care is the holy grail of medicine and that only the highest qualified are worthy of making the life and death decisions required there every day. No reason why NPs and PAs with adequate experience can't manage inpatients. Given some of the poor care I have seen from insecure FPs and internists, a hospitalist PA or NP service would sometimes be a blessing.

I worked on a service where we had an NP that took care of most of the inpatient care. The patients however wheren't admitted under his name and he worked under the general supervision of the various attendings. The day to day decisions where up to him, not because he pulled out some ANA position statement to assert his independence, but because he had gained their trust over the years of teamwork.

PS. my wife and newborn baby are in the hospital right now. Many thanks to the RNs who take care of them as well as the CNM who skillfully assisted the OB during the c-section.

the fact that somehow incompetent doctors slip through the cracks and are practicing medicine does not mean we should offer the same rights to other providers with questionable competency. as has been stated, the fact remains: if you want to change the status of care (by giving autonomous medical practice rights to individuals with lesser training), the burden should be on you to prove it's JUST AS GOOD. no, you don't get the benefit of the doubt.

of course PA's and NP's are valuable in the right setting. it's not realistic to keep blurring the lines of that setting unless we're all comfortable with choosing cost-effective over better trained.

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[Farmer Jane]

I'll be honest. I would not be comfortable with a NP independently caring for inpatients, for several reasons. First, there's not yet enough consistency in NP education. Second, I do not think it is anywhere near equal the education and training of a board-certified physician.

An example: The job I took in August requires me to be telemetry certified, and I had very little prior experience with telemetry (my prior experience was med/surg, orthopedics, oncology, and obstetrics), so in September I took a telemetry course. In my class was a recently graduated, already passed her boards NP. Her prior experience as a nurse had centered around would and ostomy care. She had NO experience with telemetry or EKGs. At all. She failed the class (I passed with a grade of 99/100, and I'm still undergrad).

I don't know about you folks, but I would not be comfortable if my primary care provider didn't know a thing about EKGs. A couple of years ago I kept feeling my heart racing (this has since disappeared, who knows why, come to think of it, it was probably all the freaking caffeine I was chugging at the time) so I mentioned it to my physician at my annual appointment. She did an EKG to rule out WPW. Would someone with no knowledge of EKGs even know enough about WPW to know to rule it out? I'll stick with going to my internal medicine physican and gynecologist, thankyouverymuch.

Now, can an NP be very knowledgeable about cardiac rhythms? Of course! But obviously there is no requirement that they are. I can't imagine a family practice or internal med physician completing residency and not even be able to pass a telemetry course.

 

[OnPump]

For OnPump to blithely state that there's no reason to assume NPs are any less able or prepared to manage inpatients ignores pretty basic differences in training and education. If he/she wishes to supplant the current standard of care in inpatient medicine, it's going to take a little more than "professionals don't make assumptions" to convince anyone. Thankfully.

Let's not get away from the issue I was addressing. Senor Taurus was commenting that "people needlessly became injured or died because of their inferior care"....this is clearly inflammatory rhetoric that needs to be stopped in its place. By stating that NPs (who currently do NOT manage inpatients indepedently but do manage many outpatients), if put in this role, will lead to bad outcomes is unfounded. Err....what's the term the kids use????? oh yeah, $#!+ talking. Yeah, $#!+ talking, that's it. That's what I have a problem with.

Denying the claim that NP care will lead to unnecessary M&M is not attempting to supplant the current standard of inpatient care.....it's about preventing a notion about subpar NP care from perpetuating when there's no basis for it.

You do learn about evidence based medicine, no?? It helps to carry it into professional discourse as well.

And Tired, I already realize that you folks can't be "convinced" .

 

[Moniker]

Let's not get away from the issue I was addressing. Senor Taurus was commenting that "people needlessly became injured or died because of their inferior care"....this is clearly inflammatory rhetoric that needs to be stopped in its place. By stating that NPs (who currently do NOT manage inpatients indepedently but do manage many outpatients), if put in this role, will lead to bad outcomes is unfounded. Err....what's the term the kids use????? oh yeah, $#!+ talking. Yeah, $#!+ talking, that's it. That's what I have a problem with.

Denying the claim that NP care will lead to unnecessary M&M is not attempting to supplant the current standard of inpatient care.....it's about preventing a notion about subpar NP care from perpetuating when there's no basis for it.

You do learn about evidence based medicine, no?? It helps to carry it into professional discourse as well.

And Tired, I already realize that you folks can't be "convinced" .

He never said it was a fact that there would be more suffering and death, he said in his opinion there would be. Realistically, he's probably right. It's probably most accurate to say he's overstating the consequences and you're understating them. I feel like you're still not getting the point however: Taurus said NP provided care that was previously MD provided care is more likely to have negative consequences. You say that he can't prove NP's are less competent, and therefore shouldn't suggest negative consequences based on their care. Apparently the only way to "convince" you, my friend, is to have hard data of outcomes of both, the lives of the "negative consequences", if we see them, being the convincing argument you seek. He says he's all for that, because apparently the burden of proof is falling on the patients living or dying to prove who the best provider is. I wonder if you understand that how unethical that is, and why therefore physicians have an imperative to resist opening the doors.

And for what it's worth, midlevels (and even their representative organizations/societies) are notorious for their agendas and rhetoric, I think it's a little hypocritical to fault one MD/MD student for painting an opinionated picture of the opposite perspective. For example with "Nurse Anesthetist week" that apparently recently occurred (ridiculous, by the way), there were posters up with shocking rhetoric, basically under the guise of "educating the public about our role & skills".

I don't want to read things like, "When anesthesia is administered by a nurse anesthetist, it is recognized as the practice of nursing; when administered by an anesthesiologist, it is recognized as the practice of medicine. Regardless of whether their educational background is in nursing or medicine, all anesthesia professionals give anesthesia the same way."
(from the AANA website)

I mean they're flat out saying: we're doing the exact same thing as doctors...and we can get away with doing it with less training because we call it "nursing practice". If people really valued lesser trained providers more than doctors, I would probably concede that the physician has become obsolete. But the fact is that people are allowing lesser trained providers to take over physician roles for a PURELY FINANCIAL reason. It's cheaper. They're cheaper to train, they're cheaper to hire, and they bill cheaper. Anyone comfortable with that? Make damn sure you know what you're getting before you burn your bridges and push out the anesthesiologists. Or FPs. Or internists. Or ER docs. Or whoever else they have their sights on....

 

[deleted6669]

. I've had a lot of PA students on teams I've been at in various hospitals. I have yet to see an NP student making inpatient rounds.
.

for what it's worth a majority of pa clinical education tends to be hospital based. I only had 1 rotation(family medicine) that was community based.

 

[OnPump]

Assuming that NPs will be able to provide equivalent care, despite any available evidence to support that claim, is precisely the opposite of good evidence-based practice.

There's a difference between assuming that NPs can provide equivalent care (which I don't know if they can) and assuming that the definitely cannot (I don't know that either)....or even worse stating that "patient will suffer" (if you are as reasonable as you seem than can you really go along with such comments?????).....this is derrogatory to NPs simply because the few MS/MDs I read here feel that their territorry is being encroached on.

I don't presume that NPs would be guaranteed to be inferior.

No one knew if PAs or NPs would be sufficient as outpatient providers carrying their own panels. But they are now. Do you think there were professions of "doom & gloom" before that happened?

No one knows if NPs could be sufficient as inpatient providers (which for the aforementioned billing reasons won't happen). The issue (to me) is avoiding the leap in logic that NPs would be inferior by nature of their training and experience, because claims could me made about the difference in MD and PA/NP for the outpatient setting and that model works.

 

[silas2642]

There's a difference between assuming that NPs can provide equivalent care (which I don't know if they can) and assuming that the definitely cannot (I don't know that either)....or even worse stating that "patient will suffer" (if you are as reasonable as you seem than can you really go along with such comments?????).....this is derrogatory to NPs simply because the few MS/MDs I read here feel that their territorry is being encroached on.

I don't presume that NPs would be guaranteed to be inferior.

No one knew if PAs or NPs would be sufficient as outpatient providers carrying their own panels. But they are now. Do you think there were professions of "doom & gloom" before that happened?

No one knows if NPs could be sufficient as inpatient providers (which for the aforementioned billing reasons won't happen). The issue (to me) is avoiding the leap in logic that NPs would be inferior by nature of their training and experience, because claims could me made about the difference in MD and PA/NP for the outpatient setting and that model works.

You're right, no one knows with 100% certainty that NP's would be incapable to provide care that meets the quality of that provided by a fully trained attending physician to inpatient physicians. I suppose it is plausible that if Nurse Practitioners, with only two years of post-bac education that doesn't even compare to the rigor of med school or residency could suddenly step on the wards and the Ghost of William Osler would suddenly appear in fairy form and suddenly-- lo! Behold! A fully competent and autonomous clinician would be born complete with all the knowledge and skills of an MD. It could definitely happen. But evidence and a "leap of logic" dictates that it probably won't. Therefore, for the sake and safety of our patients, physicians like to keep an eye on nurses.

Does the outpatient model for NP's and PA's work? I think so when they work under the supervision of a physician and when that physician has the say on how much autonomy the PA or NP has in patient care.

 

[foreverLaur]

IMO, a PA/NP learns via experience and working with a physician and a doctor learns via residency/med school.

The PA that has worked with my orthopaedic surgeon (shoulder specialist) for 20 years can probably perform a rotator cuff repair just as well as the doctor can. However, the PA does not have the broad based medical knowledge that the doctor does. If other problems arise during surgery, the doctor will need to at least be close by.

PAs and NPs are very good at doing what they are trained to do. The problem with being completely autonomous is that it is impossible for them to have the broad medical knowledge that doctors possess to solve other issues that come up that the PA/NP may not have been trained in or have that much knowledge in.

Anyways - just my thoughts from what I have seen and those I have spoken with. I'm also all for the PA field as I am pursuing it : )

 

[fab4fan]

Ow, that really hurt. No, there is no doom and gloom here. I just wish that things were the way they used to be-- when doctors used to be doctors and when nurses actually used to be nurses and liked their role without trying to want to expand it into something that it was never intended to be.

Well, maybe you can find Michael J Fox, Christopher Lloyd and do a remake of those "Back to the Future" movies, only make it your fantasy medical version, where doctors are gods and nurses are servile, simpering handmaidens. Deny it all you want, that's what you really wish things were like.

How do you even know how things used to be? You're a med student! What wealth of experience are you drawing from? (Reading The House of God doesn't count.)

 

[zenman]

I'm sure most of us have heard about stupid nursing diagnosis such as "energy field disturbance" and honestly I find it embarassing that my profession has allowed this to make its way into our list of official diagnosis.

Just because you have a lack of knowledge in how to use that diagnosis doesn't make it stupid...only the user. But it probably shouldn't be used in nursing since most nurses are not trained in higher level interventions.

 

[Farmer Jane]

Just because you have a lack of knowledge in how to use that diagnosis doesn't make it stupid...only the user. But it probably shouldn't be used in nursing since most nurses are not trained in higher level interventions.

That is exactly the kind of crap that makes us look so freaking unprofessional--right up there with wearing teddy bear scrubs.

 

[Miss Mab]

Wait..where'd I go? Dammit...the computer stole my coherence........#%$%*&

From what little I know of NP education, the majority of it is focused on outpatient assessment and treatment. If I am off-base here, someone let me know. I've had a lot of PA students on teams I've been at in various hospitals. I have yet to see an NP student making inpatient rounds.


.

I'm really NOT the resident nurse defender here--forget who claims that one and lord knows I have enough issues with my current profession myself---but I will happily share a little bit about NP education and perhaps clear up any misconception that seems to be out there.


As there isn't just one standard 'NP'---you need to remember that there are specialized advanced practice roles. They are all wrapped around a bunch of distinguishing letters, which can be annoying, but they represent very different NP roles and educational models.

A FNP(family NP) is probably what you are referring to when you say most are trained on an outpatient or community based level. Well and true.

However, you also have psychiatric NP's, Acute Care NP's, Emergency NP's and so on. EACH of these have different educational programs and clinical components. I can guarantee you that Acute Care NP's spend the great majority of their time doing inpatient work(sometimes they hook-up with an outside Card. practice, etc) but their entire clinical training is focused in the acute care realm--not outpatient. BTW, I'm pretty sure an ACNP knows how to read an EKG and when/why to order one.

Obviously someone undertaking an ENP program will not be at the community health clinic but instead in the ER like everyone else. There are obviously more specialties but the point is NP education is clinically focused on a specific certification area from the get go.

What I'm saying in an incredibly exhausted kind of way(loooong day) is that, sadly, even those within the healthcare arena don't realize that one 'NP' is not interchangeable with just any other. They "specialize" immediately when they choose the focus of their entire master's education and many find it both difficult and sometimes impossible(based on differing scopes of practice between NP roles) to move to other arenas without having to go back and complete another full post MS program. You don't get to be a Pediatric NP and then one day decide you want to now be a general acute care hospitalist. (That's usually an ACNP or Adult NP or sometimes even FNP but I digress).This isn't the PA model with identical curriculum of 'jack of all trades--master of none."

There are pros and cons to each educational model but that might explain why some seem to know that PA's do the majority of their rotations in house and a 'NP' (if you have no idea what 'kind' of NP they are and whether or not they are pursuing a degree program whose focus is on inpatient care---(though actually, I think most are) may or may not be clinically present in the hospital setting.

Then again, maybe it's just been your rotations......

So, to sum up:

A PA is a PA is a PA--because they share the exact same clinical and didactic training which I believe is a proud tenet of their background. Except there are different "levels" of PA? Some are associate degree, some are bachelor's PA's and then many are also MS PA's. I also think they can go on to specialize but I'm sure some one will come in to explain how that all works.

AND a 'NP' is not interchangeable with any other advanced practice 'NP'---unless of course they hold the same certification--because each different role has it's own didactic and clinical components specific to its clinical focus yet they do have in common that all of their training and education has been at at least at the post bachelor's (MSN) level (as it is a requirement). Don't even get me started on the DNP.......freaking ANA!

Yes, we do have too many intitals........

I have no interest/desire/gag reflex to discuss clinical hour reqs. or previous experience issues or any of that. I was speaking to ONE very important aspect to advanced practice nursing education that often gets glossed over, sometimes even by our fellow mid-levels who I know have the ability to differentiate a few letters, and to me another aspect that quite significantly differs from the PA training approach.

 

[fab4fan]

I'm really NOT the resident nurse defender here--forget who claims that one and lord knows I have enough issues with my current profession myself---but I will happily share a little bit about NP education and perhaps clear up any misconception that seems to be out there.

I have no interest/desire/gag reflex to discuss clinical hour reqs. or previous experience issues or any of that. I was speaking to ONE very important aspect to advanced practice nursing education that often gets glossed over, sometimes even by our fellow mid-levels who I know have the ability to differentiate a few letters, and to me another aspect that quite significantly differs from the PA training approach.

That was my former moniker. Then I changed it to something similar to your "Generally Disenchanted" title.

 

[Miss Mab]

Ahhhhh.. my evil plot to take over is coming to fruition......


Come to the dark side...........

 

[core0]

Wait..where'd I go? Dammit...the computer stole my coherence........#%$%*&



I'm really NOT the resident nurse defender here--forget who claims that one and lord knows I have enough issues with my current profession myself---but I will happily share a little bit about NP education and perhaps clear up any misconception that seems to be out there.


As there isn't just one standard 'NP'---you need to remember that there are specialized advanced practice roles. They are all wrapped around a bunch of distinguishing letters, which can be annoying, but they represent very different NP roles and educational models.

A FNP(family NP) is probably what you are referring to when you say most are trained on an outpatient or community based level. Well and true.

However, you also have psychiatric NP's, Acute Care NP's, Emergency NP's and so on. EACH of these have different educational programs and clinical components. I can guarantee you that Acute Care NP's spend the great majority of their time doing inpatient work(sometimes they hook-up with an outside Card. practice, etc) but their entire clinical training is focused in the acute care realm--not outpatient. BTW, I'm pretty sure an ACNP knows how to read an EKG and when/why to order one.

The problem is that nobody enforces the scope. Pretty much every state has as part of its scope that an NP should only practice in areas that they are trained in. However, most NPs in practice are FNPs. Given the newness of the ACNP degree, most NPs working in the hospital are actually FNP (some ANP). They were not trained in the role but there they are working there. Kind of the unspoken secret of the NP world.

Or take the ENP. There is no ENP certification. Despite that there are 10-15 ENP programs that are all different. Some of them give a FNP cert but do extra training in EM. Some of them go off the ACNP certification which is the group that claims the ER. Unfortunately since they cannot see peds it makes them unemployable in any ER that does not have a designated peds ER. So many of the NPs that want to work in EM get a FNP despite the fact that it is a primary care outpatient certification.

Obviously someone undertaking an ENP program will not be at the community health clinic but instead in the ER like everyone else. There are obviously more specialties but the point is NP education is clinically focused on a specific certification area from the get go.

What I'm saying in an incredibly exhausted kind of way(loooong day) is that, sadly, even those within the healthcare arena don't realize that one 'NP' is not interchangeable with just any other. They "specialize" immediately when they choose the focus of their entire master's education and many find it both difficult and sometimes impossible(based on differing scopes of practice between NP roles) to move to other arenas without having to go back and complete another full post MS program. You don't get to be a Pediatric NP and then one day decide you want to now be a general acute care hospitalist. (That's usually an ACNP or Adult NP or sometimes even FNP but I digress).This isn't the PA model with identical curriculum of 'jack of all trades--master of none."

See above. Nursing claims that NPs should work in their scope but in most states there is no enforcement of this concept. So you have a "master" of a different trade working in the hospitalist trade. Kind of like hiring a plumber to do your electrical.

There are pros and cons to each educational model but that might explain why some seem to know that PA's do the majority of their rotations in house and a 'NP' (if you have no idea what 'kind' of NP they are and whether or not they are pursuing a degree program whose focus is on inpatient care---(though actually, I think most are) may or may not be clinically present in the hospital setting.

Then again, maybe it's just been your rotations......

So, to sum up:

A PA is a PA is a PA--because they share the exact same clinical and didactic training which I believe is a proud tenet of their background. Except there are different "levels" of PA? Some are associate degree, some are bachelor's PA's and then many are also MS PA's. I also think they can go on to specialize but I'm sure some one will come in to explain how that all works.

We train to clinical competence. The degree does not matter as all PA schools train to the same standard. Some programs may have a different emphasis (peds, surgery, primary care) but all PAs get roughly the same education and clinical experiences. The scope of a PA is defined by the physician they work for. If we specialize it is because we work in collaboration with a physician that specializes and works with us to develop the skillset to deliver medicine most efficiently. The competence based training is similar to what physicians go through and the training was adapted from shortened physician programs developed during WWII.

AND a 'NP' is not interchangeable with any other advanced practice 'NP'---unless of course they hold the same certification--because each different role has it's own didactic and clinical components specific to its clinical focus yet they do have in common that all of their training and education has been at at least at the post bachelor's (MSN) level (as it is a requirement). Don't even get me started on the DNP.......freaking ANA!

Yes, we do have too many intitals........

I have no interest/desire/gag reflex to discuss clinical hour reqs. or previous experience issues or any of that. I was speaking to ONE very important aspect to advanced practice nursing education that often gets glossed over, sometimes even by our fellow mid-levels who I know have the ability to differentiate a few letters, and to me another aspect that quite significantly differs from the PA training approach.

To me the difference in the training approach is that their is a unified standard (that and no nursing theory). While you state that each specialty has its own requirements, in reality there are multiple certifications for many specialties with no set curriculum and two different accrediting agencies for NP programs. The confusion that this engenders far outways any consistency that a "degree" might bring.

David Carpenter, PA-C

 

[f_w]

Yes, we do have too many intitals........

I allways thought that the initials indicated some sort of hierarchy. If there is a disagreement between two nurses, the one with more initials wins

 

[telenurse]

Just because you have a lack of knowledge in how to use that diagnosis doesn't make it stupid...only the user. But it probably shouldn't be used in nursing since most nurses are not trained in higher level interventions.

Energy field disturbance as a diagnosis was only created for alternative practices such as Therapeutic Touch, which IMO is a bunch of crock and has yet to be proven to be more than a placebo effect. Many nurses dispute this inclusion as an official NANDA diagnosis.

I prefer,
Pain, Acute or Chronic
Impaired Gas Exchange
Ineffective Airway Clearance
Ineffective Breathing Pattern
Risk for Infection
Decreased Cardiac Output
Altered Tissue Perfusion
Impaired Skin Integrity
Altered Nutrition
Fluid volume excess,
Risk for injury, 2nd to anticoagulation therapy


Nursing interventions, by nature usually are low tech. The absolute best nursing with a compliant pt will have decreased post op atelectasis and pnuemonia, no skin breakdown, decreased to no wound infection, no postop ileus or constipation, be up walking sooner, healing faster, and be well educated on post op care and meds. And with EXCELLENT nursing care and a REALLY motivated pt, we can do this with little to NO prn meds except for pain meds. The pt will be ready to be discharged with all home health needs and supplies ready to go. Unfortunately, rarely are nurses staffed at ratios where they can spend the time with each pt it takes to provide that type of care.

 

[Miss Mab]

no sleep make mabby tired....

 

[Miss Mab]

Golly,

And here I hoped to respond to someone seemingly open to receiving clarification of what is a commonly held misconception regarding 'NP' education:

Originally Posted by Tired

From what little I know of NP education, the majority of it is focused on outpatient assessment and treatment. If I am off-base here, someone let me know. I've had a lot of PA students on teams I've been at in various hospitals. I have yet to see an NP student making inpatient rounds.

And so I adressed that issue----that of the erroneous belief that the majority of advanced practice nursing education is outpatient based. That singular area, amongst the myriad endlessly enjoyable debate worthy issues encompassed by the whole of nursing/PA education. (for some, anyway). To try to explain why that perception was more than likely false.

And, oh yeah, I even remembered to add a caveat that I wasn't entering, entertaining or inviting discussion about the assumed or actual flaws of NP education or of their role as competent mid-level providers.

For the short term memory crowd, Tired specifically asked a question about NP EDUCATION being predominantly focused on outpatient assessment and treatment. It's clear that some of our healthcare team are under the mistaken impression that 'NP' education is a sort of one size fits all. That any advanced practice nurse has followed the exact same educational plan, the majority of which included outpatient assessment and treatment as the focus. Hopefully a greater understanding of the widely varied NP tracks has been touched on.


Props for once again injecting your endlessly rote party line for no reason germane to the topic at hand, except perhaps to deflect attention of increasing awareness of growing deficits and divisiveness in your own house. Bonus points for doing so when specifically asked to refrain from doing so as it wasn't in any way the area being addressed.

A question was asked and answered. Your treatise of what sometimes can happen AFTER school has no bearing on either the question asked or the answer I provided. But you wouldn't want to let a chance to insert something negative about the advanced nursing practice get away from ya. Guess what? Weren't talking about the weird laws/loopholes/etc. that can come about after licensure. We were talking about the graduate school part. Do you even read what you are responding to or is it more like a Pavlovian thing----see NP--must piss on.......Enough already.

Get it through yer head, please! I know there's nothing you enjoy more than to wax eloquent, as a PA, on all things nursing while knowing full well that most nurses(RN, APN or otherwise) are excrutiatingly aware of the problems in own ivory tower. It is what it is. I also know the majority of us didn't get a vote in how that all came about. Those problems don't preclude an, I don't know, ability to dialogue without assuming and interjecting an adversarial tone at any perceived opportunity, whether it be appropriate or relevant to the situation or not.

So AGAIN, incessently inserting PA "talking points" into each interaction that even remotely involves your NP colleagues no matter how off topic, is, and I'm certainly hesitant to ascribe motive, but perhaps undertaken as a form of self-empowerment or maybe even a misguided attempt at ingratiating yourself to your MD supervisors or PA colleagues. Io an equal number of others, howver, and most certainly I speak for myself, it just seems a desperate attempt to reconcile what is a desired professional fantasy into what, in fact, is our mutual healthcare reality.

I dunno, seems demoralizing on a repetative basis and yet any possible opening and there ya are! More power to you but to me it seems dangerously close to the textbook definition of insanity. Just repeating the same falsehoods over and over again doesn't make it so. Ask George W.....

My stance was made public long ago. The nursing model is flawed. Wow---newsflash. Yet, professional opportunities for APN's abound in my neck of the woods. And luckily I'm a pretty smart cookie. Should I decide to continue on with this trip down the rabbit hole, I'm fairly certain I can perform my future role competently and capably while, strangely enough, retaining the ability to do so sans what's gotta be a time consuming second career dedicated to nitpicking a complementary and collaborative field in a grossly transparent attempt to justify and elevate my own.

What time's the show tomorrow? I think by now i know all your lines by heart. The easy part is the scenes and the acts continue to change but that chorus, man, that same chorus is a panacea for everything.

 

[zenman]

I allways thought that the initials indicated some sort of hierarchy. If there is a disagreement between two nurses, the one with more initials wins

What counts? Professional degrees and/or diplomate status only or all those silly certifications, ACLS, PALS, etc..,

 

[Miss Mab]

I allways thought that the initials indicated some sort of hierarchy. If there is a disagreement between two nurses, the one with more initials wins

Nah, the only initials that matter on the floor are the ones that start with B#I#T#C###


Hmmmmm.....will it fit on the badge???

Miss Mab, RN, BSN, BI....
Stay tuned....

 

[silas2642]

Well, maybe you can find Michael J Fox, Christopher Lloyd and do a remake of those "Back to the Future" movies, only make it your fantasy medical version, where doctors are gods and nurses are servile, simpering handmaidens. Deny it all you want, that's what you really wish things were like.

How do you even know how things used to be? You're a med student! What wealth of experience are you drawing from? (Reading The House of God doesn't count.)

You're right-- I wasn't there "back in the day." Wasn't there during World War II or Vietnam, or during the fall of the Berlin Wall (although I saw it on tv), but I can kind of get an idea of what it was like by talking about it with others who did experience it. It kind of sounded nice, not having nursing administrators with only four years of a community college education telling attending physicians what they could and could not do along with HMO's re: patient healthcare, it was probably less frustrating when a physician could write an order without wondering if the nurses would follow it or not.

I don't want nurses to be handmaidens, I want nurses to be nurses and not doctors.

 

[fab4fan]

I allways thought that the initials indicated some sort of hierarchy. If there is a disagreement between two nurses, the one with more initials wins

Not necessarily. Often the amount of initials behind a nurse's name is inversely proportional to how much common sense that nurse has.

OK, now I'm really getting too cynical even for myself.

 

[core0]

Golly,
snip
For the short term memory crowd, Tired specifically asked a question about NP EDUCATION being predominantly focused on outpatient assessment and treatment. It's clear that some of our healthcare team are under the mistaken impression that 'NP' education is a sort of one size fits all. That any advanced practice nurse has followed the exact same educational plan, the majority of which included outpatient assessment and treatment as the focus. Hopefully a greater understanding of the widely varied NP tracks has been touched on.

Thank you for providing that information. What I attempted to clarify is that for physicians (ie the primary employers for NPPs) they have to understand not only the educational background of the NP but also the scope of the NP in regards to their setting. I would also agree that the the reason that Tired has not seen NP students is their relative paucity of ACNP programs relative to other NP programs.

A question was asked and answered. Your treatise of what sometimes can happen AFTER school has no bearing on either the question asked or the answer I provided. But you wouldn't want to let a chance to insert something negative about the advanced nursing practice get away from ya. Guess what? Weren't talking about the weird laws/loopholes/etc. that can come about after licensure. We were talking about the graduate school part. Do you even read what you are responding to or is it more like a Pavlovian thing----see NP--must piss on.......Enough already.

Hmm seems to me you have the same issue:

A PA is a PA is a PA--because they share the exact same clinical and didactic training which I believe is a proud tenet of their background. Except there are different "levels" of PA? Some are associate degree, some are bachelor's PA's and then many are also MS PA's. I also think they can go on to specialize but I'm sure some one will come in to explain how that all works.

Same old tired argument. NPs have a masters PAs don't. Straight from the Ivory tower.

My stance was made public long ago. The nursing model is flawed. Wow---newsflash. Yet, professional opportunities for APN's abound in my neck of the woods. And luckily I'm a pretty smart cookie. Should I decide to continue on with this trip down the rabbit hole, I'm fairly certain I can perform my future role competently and capably while, strangely enough, retaining the ability to do so sans what's gotta be a time consuming second career dedicated to nitpicking a complementary and collaborative field in a grossly transparent attempt to justify and elevate my own.

What time's the show tomorrow? I think by now i know all your lines by heart. The easy part is the scenes and the acts continue to change but that chorus, man, that same chorus is a panacea for everything.

Same time same station. Apparently you know me very well. I think that I have stated my opinion. That NPs do a great job on a daily basis but the educational and certification model is greatly flawed to the detriment of the NP students.

David Carpenter, PA-C

 

[Farmer Jane]

You're right-- I wasn't there "back in the day." Wasn't there during World War II or Vietnam, or during the fall of the Berlin Wall (although I saw it on tv), but I can kind of get an idea of what it was like by talking about it with others who did experience it. It kind of sounded nice, not having nursing administrators with only four years of a community college education telling attending physicians what they could and could not do along with HMO's re: patient healthcare, it was probably less frustrating when a physician could write an order without wondering if the nurses would follow it or not.

I don't want nurses to be handmaidens, I want nurses to be nurses and not doctors.

1) Everywhere I have worked, nurse administrators have a master's degree.

2) Nurses hate HMOs just as much as anyone else.

3) Nurses not carrying out orders for no reason is cause to speak with the nursing supervisor. Nurses using judgment about orders, clarifying when necessary, and following the chain of command on the rare case that an order is unsafe, is good for everyone: nurses, doctors, and patients. It is an absolutely critical part of our role, just like having pharmacy review med orders.

If you don't want nurses to be handmaidens, then what exactly do you mean by you want "nurses to be nurses and not doctors." As has been said numerous times in this thread, the vast majority of nurses have no interest in competing with physicians.

ETA: The reality of "the old days" is far different from the myth. Part of the reality of not being held accountable to administration is that physicians were allowed to practice "cowboy medicine." There were plenty of excellent doctors back then, but there were also far too many rogue docs on a power trip, and their behavior was left unchecked. Look into the history of lobotomies, twilight birth, and tell me it was so much better than.

 

[primadonna22274]

IYO, ForeverLaur, as someone who hasn't done either....
IMO, you're partly right. There are a lot of limitations to on-the-job training. Depends on a myriad of factors: how bright is your mentor; how willing to teach; how much time do you have to communicate and learn together; how much you move around from practice to practice.
My first year in practice was a very steep learning curve. Typical for a newbie PA. We were in a multispecialty group practice, about 15 other FPs, also IM, surgery, Ob/gyn in the same group (42 docs total, 3 PAs, 3-4 NPs). My doc requested and was granted an hour a week worked into both of our schedules for mentoring. We typically met at a coffee shop 1-2 hr before clinic on Wednesday morning and over several months went through an entire curriculum of important FP topics (particularly drug choice: antibiotics, antihypertensives, treatment of asthma, advanced EKG reading, etc). It was incredibly valuable. She also mentored me plenty in clinic--typical outpatient surgical procedures etc. By the end of that first year I was functioning pretty well with a high level of autonomy in the outpatient setting. There were some power struggles, sure, when I wanted to fly and she wouldn't let me just yet; but I look back on that time with a lot of gratitude.
I'm sure a lot of PAs/NPs don't get that kind of mentoring. If you do a residency, sure you do; but without one, it's a crapshoot. (Are there "residencies" for NPs? not sure).
Now, here's a dirty little secret for you: I attended a community-based PA program (not a hospital-based). So more than half of my rotations were primarily outpatient. Subsequently, I was shortchanged on inpatient rotations and therefore never felt very comfortable with inpatient care. Six years into practice I changed gears and went to work in EM and again, steep learning curve. You'd be surprised how little my outpatient experience as a FP PA helped me. Since then my PA program has built into their curriculum a standard inpatient rotation for each student (good move) and I think they try to balance the experiences better. So while there is continuity from PA program to PA program (we have to cover all the same core rotations, FP, peds, OB/Gyn, surgery, EM, IM, psych, electives....) the setting might be very different.

IMO, a PA/NP learns via experience and working with a physician and a doctor learns via residency/med school.
)

 

[Taurus]

As I asked before, how much inpatient experience do you have, senor onpump? Have your experiences been mostly outpatient and you're basing your opinion of inpatient off of that? Anyone who has spent some time on the wards know that this is not the place to be making mistakes or not knowing your stuff. These are sick, unstable patients. There may not be a margin of error for these patients. You miss something and the patient is dead.

Nothing less than NP is 100% as good as MD will do in the inpatient setting. 80% just as good is not enough. Did you see those Washington Post article about how Congress started an investigation because 2 people died when there were no physicians available in those emergency rooms? Neither the American public nor Congress will tolerate deaths that would have been preventable if better trained professionals, ie, physicians, were in charge. The key word is preventable. You would never go to the emergency room or hospital if you thought that the main person who is taking care of you is still learning his medicine.

 

[deleted6669]

"You would never go to the emergency room or hospital if you thought that the main person who is taking care of you is still learning his medicine."

so avoid all depts with em residencies?
I don't think so....

 

[f_w]

so avoid all depts with em residencies?
I don't think so....

Actually, avoid ALL hospitals. Wherever you go, you will run into people on various slopes of the learning curve. Contrary to popular belief, the greatest learning experience is not residency but rather the first 2 years out as attending.

 

[f_w]

Did you see those Washington Post article about how Congress started an investigation because 2 people died when there were no physicians available in those emergency rooms?

What are two people in a medical system that if we believe the IOM report kills 98,000 patients every year through medical errors.

Neither the American public nor Congress will tolerate deaths that would have been preventable if better trained professionals, ie, physicians, were in charge.

Right, that for example is why we have a nationwide system of ALS level ambulances staffed with paramedics. This system reaches every nook and cranny of the country because it is so generously funded through health department grants.

 

[foreverLaur]

What is OnPump? I guess perfusionist by the name, but that was just a guess.

 

[deleted6669]

What is OnPump? I guess perfusionist by the name, but that was just a guess.

nope, residency trained ct surgical/hospitalist pa....

 

[Miss Mab]

From what little I know of NP education, the majority of it is focused on outpatient assessment and treatment. If I am off-base here, someone let me know.

Note to self:

When senior officer makes statement that seemingly indicates openness to correction of a knowledge deficiency regarding differing practitioner education:

Do not read this as a request for clarifying information.
Do not waste valuable time.
Do not attempt to provide said corrective information.

Express gratitude and continue on as the original assumption is undoubtedly correct.

Thank you, Sir.

LT. MM
whose notes of self correction continues to grow exponentially each day....

 

[zenman]

NP care = inferior to that of MDs

Not always. I'm not an NP but I have lot's of experience. The FP I work with asked me the other day to let her examine all potential broken bones because during her residency she only saw ortho patients in the clinic...after they had already been casted and/or had surgery. Based on my experience only, I can tell almost 100% when a bone is broken...prior to x-ray.

I won't even go into how I can feel the energetic difference because I don't want nurses chewing my pants, lol!

Good luck, I'm done with this thread

What, tired?

 

[Taurus]

"You would never go to the emergency room or hospital if you thought that the main person who is taking care of you is still learning his medicine."

so avoid all depts with em residencies?
I don't think so....

Main person who is taking care of you = attending

 

[Taurus]

What are two people in a medical system that if we believe the IOM report kills 98,000 patients every year through medical errors.

If you can identify causal relationships or areas of deficiency, then it can be addressed through laws and regulations. Needles today have those retractable sheaths to reduce people sticking themselves. People call out timeouts in the OR to reduce the chance of operating on the wrong person or doing the wrong operation. Random errors on the other hand are hard to correct and are not easily fixed with laws and regulations.

If we allow NP's to be attendings and the patient dies under their care, you can do a post-mortem and look for areas of deficiency in the care. Did the NP follow the standard of care that a board-certified physician would have? If not, then there are areas of deficiency. If you see that on average NP's have worse outcomes which I would expect, then you have your data. At these large tertiary hospitals, staff physicians have to discuss deaths during weekly morbidity and mortality conferences where everyone from the chair on down get to grill your decision-making. Everyone has to be held accountable, including physicians.

 

[silas2642]

"You would never go to the emergency room or hospital if you thought that the main person who is taking care of you is still learning his medicine."

so avoid all depts with em residencies?
I don't think so....

Of course the attending physician is still learning his/her medicine-- we're always learning, and that's part of being a good physician. It certainly is reasonable to conclude that going to a hospital that has residency training program is fine because those residents are operating under the supervision of an attending physician. But the point is that the fund of knowledge and the skill set of a fully trained physician vs. an NP is far greater and it would be detrimental to the health of the patients to let NP's care exclusively for patients, particularly those who are critically ill.

 

[f_w]

Ceterum censeo Carthaginem esse delendam

 

[foreverLaur]

Main person who is taking care of you = attending

When I shadowed in the ER, the attendings didn't do crap besides lounge around. The residents did all the work. They would see all the patients, including traumas. The would order all the tests, do all the discharge papers, or admit. They would have to present the patient to the attending who would occasionally go and visit the patient, but not always. I never saw an attending disagree with a resident on his/her chosen methods to deal with the patient. The attending would just sit there and say "yep sounds good."

 

[Farmer Jane]

That's good. The goal of teaching is to no longer be needed.

 

[foreverLaur]

That's good. The goal of teaching is to no longer be needed.

Maybe they were third year residents?
Trying to look on the bright side...

 

[Taurus]

Neither the public nor legislatures will tolerate deaths or serious injuries that could have been prevented if a physician was involved. This is the line in the sand that midlevels would be wise to not cross. Legislative rights that were granted can easily be revoked.

While we still don't know the full story behind this case, the response nevertheless is telling.

The state Health Department said it is investigating the deaths of three patients at Mercy Medical Center after a surgeon accused a physician assistant of improperly performing invasive procedures.

http://www.newsday.com/news/local/ny-limerc0212,0,1561166.story

http://abclocal.go.com/wabc/story?section=news/local&id=5950501​

 

[foreverLaur]

That is a bit different than a resident seeing the patients and then presenting to the attending. The attending is still a few seconds away if needed.

 

[fab4fan]

You mean like at 2am, when I see ER consults and wake up the attending at home? Or when I get floor calls while the attending is scrubbed in to a 5hr case?

No please, tell me more about what it's like.

I can hardly wait for the response. Maybe I should make some popcorn; this could be more entertaining than the episode of "Project Runway" I'm currently watching.

 

[JRJ26]

You mean like at 2am, when I see ER consults and wake up the attending at home? Or when I get floor calls while the attending is scrubbed in to a 5hr case?

No please, tell me more about what it's like.

well she shadowed in an ER and obviously has a friend that's a surgical resident, so she knows what it's like.

 

[fab4fan]

well she shadowed in an ER and obviously has a friend that's a surgical resident, so she knows what it's like.

Please tell me you're being sarcastic.

 

[JRJ26]

Please tell me you're being sarcastic.

HAHAHA I definitely am. I won't lie, I sometimes come to SDN just to see her latest posts, career interests, and circle of friends. makes procrastination funnier.

 

[Farmer Jane]

At least it's more entertaining than my "Nursing Leadership & Management" class I'm trudging through at the moment.

 

[foreverLaur]

You mean like at 2am, when I see ER consults and wake up the attending at home? Or when I get floor calls while the attending is scrubbed in to a 5hr case?

No please, tell me more about what it's like.

All I am saying is that when I shadowed in the ER at one particular hospital (both night and day shifts), the residents saw ALL the patients and then presented to the attendings who rarely left their chair. If something went wrong (which it did not while I was there) the attending could be in any room of the ER in under 15 seconds. An attending was always right around the nurses station in the ER. Not in a call room. Not at home. Not in the OR. There, but not seeing patients.. just hanging out. 24/7.

This doesn't mean that every hospital does it the same way or that the way this particular hospital does it is right or wrong. This is just how it happened to be done during the month of May in 2007 at this one particular hospital.

 

[lawguil]

All I am saying is that when I shadowed in the ER at one particular hospital (both night and day shifts), the residents saw ALL the patients and then presented to the attendings who rarely left their chair. If something went wrong (which it did not while I was there) the attending could be in any room of the ER in under 15 seconds. An attending was always right around the nurses station in the ER. Not in a call room. Not at home. Not in the OR. There, but not seeing patients.. just hanging out. 24/7.

This doesn't mean that every hospital does it the same way or that the way this particular hospital does it is right or wrong. This is just how it happened to be done during the month of May in 2007 at this one particular hospital.

Holly smuckers foreverLaur,

Join date: Feb. 2007
1095 posts to date
how did you ever find the time to shadow in May of 2007

Happy 1 year with SND