NPs and PAs Fight For Your Rights Now!!

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Oh - one last question? Why aren't you pursuing this topic in the podiatry forum?

It was discussed there already.

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I can't speak for other professions, but I would greatly disagree with the impetus for the DNP. It is not a political move, but more a logistical one. We need more doctorates in order to increase nursing school enrollment. Most of the students in my class are faculty members of a school of nursing. Yes, there are some that work strictly as NP's, and one or two that just want the title "doctor." However, there will always be some in every profession that want to be something they are not. However, that was not the reason for starting the program. Contrary to popular belief, most nurses do not want to be physicians, and don't want people to think they are physicians. there are only a few.

no offense intended here but aren't they pushing the dnp as a clinical doctorate with the idea of producing more clinicians as opposed to more faculty or researchers? all the dnp websites talk about the role of the dnp in clinical medicine.
there have been phd rn programs for years for faculty development.
 
no offense intended here but aren't they pushing the dnp as a clinical doctorate with the idea of producing more clinicians as opposed to more faculty or researchers? all the dnp websites talk about the role of the dnp in clinical medicine.
there have been phd rn programs for years for faculty development.

Most of the ones in my class are faculty. The reason is actually two-fold: to make beter clinicians at the bedside and disseminate current research into better practice methods; and to increase the number of doctorally-prepared faculty. The problem with the PhD is that many of us have absolutely no desire to do research; aside from the fact that I am too old to do 2 years of course work followed by 2-3 years of research. If I had to do that much research I think I would have to hurt myself. I like to read research and discuss it; I HATE doing research. Right now there is lots of nursing research but no one who is willing to put it all together and disseminate it to bedside nurses.
 
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no offense intended here but aren't they pushing the dnp as a clinical doctorate with the idea of producing more clinicians as opposed to more faculty or researchers? all the dnp websites talk about the role of the dnp in clinical medicine.
there have been phd rn programs for years for faculty development.

From what I have seen your correct. The intent for DNP education is clinical not faculty.
 
Primary care, nothing!! We intend to RULE THE WORLD!!! (Insert evil laugh here) :smuggrin:

I'm all for DNPs moving into the primary care market. MDs/DOs will likely become specialists or administrators in this scenario, which most will accept because they are "on top." The public's healthcare needs will be better met and egos on both sides will be satisfied. Win win.
 
I'm all for DNPs moving into the primary care market. MDs/DOs will likely become specialists or administrators in this scenario, which most will accept because they are "on top." The public's healthcare needs will be better met and egos on both sides will be satisfied. Win win.
You're confusing DNP's with NP's - Doctorate of Nursing Practice (which supposedly would include all major "advanced nurse practice" specialties including anesthesia, CNM, etc.) and simply Nurse Practitioner.
 
You're confusing DNP's with NP's - Doctorate of Nursing Practice (which supposedly would include all major "advanced nurse practice" specialties including anesthesia, CNM, etc.) and simply Nurse Practitioner.

The main focus is on the NP, the others are part of the discussion. Most of the NP programs have signed on to the DNP as the educational standard for 2015. From what I hear the CRNA is having the most difficulty with the DNP.
 
But really.... I don't worry about the whole "D"NP thang too much. That's because most doctors I know hate the "D" in NP and feel threatened by it. Their lobby is powerful enough. Conversley, the "A" in PA is much less threatening (To MDs) and therefore infinitely more marketable :D
 
From what I hear the CRNA is having the most difficulty with the DNP.


That would be an understatement. Truth is, the majority of clinical CRNAs do not want the DNP for the most part. The AANA already put out a position statement to this effect, I can try to dig it up if you would like. The DNP changes our scope of practice, clinical ability, and pay EXACTLY ZERO. It would seem as if we are riding (actually getting dragged kicking and screaming) on the coats of the hopes of the NPs here. The whole "dr" issue puts a bad taste in my mouth actually.
 
Being ignorant on this DNP topic, I'm confused. What advantage does that bring over a NP or PA???
 
You need to actually READ the bill.

The problem is that some non-physicians, especially those with doctorate degrees, seem to think that it is acceptable to be referred to as DR. in a healthcare setting, and in fact DO mislead patients into thinking they are a physician when they are not. This happens NOW, and includes doctorate-prepared CRNA's, PT's, PharmD's and others. When patients hear the word "doctor", they assume physician. They don't assume therapist, nurse, pharmacist, etc.

Although the wording of the bill might not be perfect, the intent of the bill is perfectly legitimate and reasonable.

I think you should start worrying about how to find better treatments for patients, rather than wasting your time worrying about who deserves to be called "Dr." so and so...Do you really really care about patients because the non-medical doctor will "mislead patients into thinking they are a physician when they are not." or just because you feel insecure for the fact that you are not competent at what you're doing, plus you want a little bit extra power in the healthcare setting? Give me a break...

Personally, I don't give a crap if patient calls me, "Dr" or "Hey, dude". What's the point? What do you get out of it?

As of the bill, I totally agree with it due to the facts that MD have more rights and privileges than any NP or PA. Can someone give me a recap of how many years to become an MD? Forget about the foreign medical part, just tell me about a typical MD. 4 yrs of undergrad + 4 yrs of + 3 yrs residency, right ? How about NP? 4 yrs of BSN + 2-3 more years = 6-7 yrs. Of course 12>6 (2x actually). So please, give the MD the right respect and privileges.
 
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But really.... I don't worry about the whole "D"NP thang too much. That's because most doctors I know hate the "D" in NP and feel threatened by it. Their lobby is powerful enough. Conversley, the "A" in PA is much less threatening (To MDs) and therefore infinitely more marketable :D

Most MDs I know don't care (or know) too much about nursing or nurse practitioners. What they do care about is the ability to care for patients. Do you really think MDs are "threatened" by the "D" ? What difference will the "D" make for MDs? Why would you equate being an assistant with being more marketable? Is less threatening equal to dominance by another profession, one who uses the word supervison for comfort? The word that threatens the AMA leaders is independence.
 
What you pretend not to know will hurt you. "D" is synonymous with Independence. Just as "less threatening" is synonymous with more marketable, Arrogance (Insinuating MDs are less clinically competant, or 'equal' to mid-levels...."What difference will the "D" make for MDs?"... ) is a marketplace liablity.
 
What you pretend not to know will hurt you. "D" is synonymous with Independence. Just as "less threatening" is synonymous with more marketable, Arrogance (Insinuating MDs are less clinically competant, or 'equal' to mid-levels...."What difference will the "D" make for MDs?"... ) is a marketplace liablity.

I am not sure what you are basing your marketable thoughts on? I am also confused as to where you developed the idea that MDs are less clincally competent or equal to midlevels?
 
Your words, not mine....slick. I do not think MDs are less competant or equal. The rest is self explanitory. i.e.- Less threatening = more marketable. Arrogance (Overuse of "D" title by those other than MDs, or insinuating Mid-Levels are equivalent somehow to MDs) is Less marketable. Some people are just too thick to get it, I suppose.



I'm off to the poolside for the weekend. Y'all have fun fingerpainting!
 
Your words, not mine....slick. I do not think MDs are less competant or equal. The rest is self explanitory. i.e.- Less threatening = more marketable. Arrogance (Overuse of "D" title by those other than MDs, or insinuating Mid-Levels are equivalent somehow to MDs) is Less marketable. Some people are just too thick to get it, I suppose.QUOTE]

I must be slow, please explain how being less threatening = more marketable? While your on your "explanitory" platform provide ONE reference that documents midlevel’s overuse of the "D". In addition, please tell me how using "slick" and "too thick" helps make your point? Don't you think using the "spell check" function would be a better use of your time?
 
Don't you get dizzy from chasing your tail?:laugh:
 
I was a pa major and im applying to pa schools for next yr. It depends on the state where your liscenced. In new york, pa's can prescribe meds. But I think that california doesnt allow that. Its different state by state. Surgical pa's can assist in surgery. Consults, tube insertions. In reality, the pa does most if not just about all the work that a doctor/resident would normally do.
 
So PAs in NY can prescribe all kinds of meds? And diagnose?


PA's in california have very autonymous practice, they can scrip all meds (including sched II) ...... If you want to find out about what a PA can and can't do in various states, go to AAPA.org and hunt around. PA's practice medicine in all states, they write RX in all but 1? state?? and most states give schedule authority as well. The variations from state to state often have more to do with how fast a supervising physician must co-sign a chart, and what volume need to be reviewed.
 
So PAs in NY can prescribe all kinds of meds? And diagnose?

PA's can diagnose in any state where they practice. PA's work under delegated practice. Depending on the state you can essentially do what the MD allows you to do. Most states do not allow a PA to do things that their supervising physician cannot do.
PA's can prescribe in 49 states and the District of Columbia (Indiana FTL). What the PA can prescribe is dictated by the state and can lead to some very strage situations (in Pennsylvania PA's can prescribe if they work for MD's but not if they work for DO's).

For NY
NEW YORK
Qualifications: Graduation from approved PA program and NCCPA examination.
Application: By PA for state registration.
Scope of practice: Medical acts and duties delegated by the supervising physician, within the physician's scope of practice and appropriate to the PA's education, training, and experience.
Prescribing/dispensing: PA may prescribe Schedules III-V and non-controlled medications. PA prescribers of controlled drugs must register with the DEA.
Supervision: Physician not required to be physically present at time and place where PA performs services.
Participation in regulation: At least two PAs appointed to medical examining board.
New York State Board for Medicine, Office of the Professions, State Education Bldg., 2nd Floor, Albany, NY 12234; (518) 474-3817.

David Carpenter, PA-C
 
People call you doctor!

That is it??? There are no other advantages in privileges?

If you wanted to be called doctor you can get a PhD in basket weaving. That is not an advantage in my mind.
 
That is it??? There are no other advantages in privileges?

If you wanted to be called doctor you can get a PhD in basket weaving. That is not an advantage in my mind.

DNP is equal to PhD, but instead of research, you do a "practice" project. For example, I am evaluating a new computerized medication administration system; a friend is starting a screening program for postpartum mood disorders; another friend is evluating a pilot for 5-tiered triage. Instead of being concerned with new knowledge, we are taking the research and implementing or evaluating new programs based on the current literature.

As far as advantages, what are the advantages of a PhD, other than learning new things and expanding one's horizons. It's the same for the DNP. Both programs have people who just want to be called "doctor", but I personally don't think it's worth all the work just for the title.
 
DNP is equal to PhD, but instead of research, you do a "practice" project.

You may just be the only one in the country who thinks a DNP is even remotely equivalent to a PhD. That's TOTAL BS.

Actually, I take that back - let's put it another way - outside of nursing, NO ONE in the country thinks a DNP is remotely equivalent to a PhD.

You're taking programs already in existence at a master's degree level - adding a few months (if any) to the program, and calling it a DNP.
 
You may just be the only one in the country who thinks a DNP is even remotely equivalent to a PhD. That's TOTAL BS.

Actually, I take that back - let's put it another way - outside of nursing, NO ONE in the country thinks a DNP is remotely equivalent to a PhD.

You're taking programs already in existence at a master's degree level - adding a few months (if any) to the program, and calling it a DNP.

You are always such an jerk. Are you a DNP??? You are an AA, and are like the new kid on the block. You inferiority complex is amazing.

DNP thanks for the answer. I figured the DNP was similar to a PhD. It offers more teaching/research opportunities, but I wanted clarity that there were no other privileges involved. Don't let this CRNA wanna be ruffle your feathers.
 
You are always such an jerk. Are you a DNP??? You are an AA, and are like the new kid on the block. You inferiority complex is amazing.

DNP thanks for the answer. I figured the DNP was similar to a PhD. It offers more teaching/research opportunities, but I wanted clarity that there were no other privileges involved. Don't let this CRNA wanna be ruffle your feathers.
A DNP and PhD are not remotely equivalent. You need to understand the issue (which you freely admit you are "ignorant" about) before you accuse anyone of being a jerk. And the flippant comments from Baylee that "people call you doctor" is exactly the problem.

BTW - I'm hardly a new kid - I've been in practice more than 25 years as an AA.

This is all pretty funny coming from a student.:laugh:
 
A DNP and PhD are not remotely equivalent. You need to understand the issue (which you freely admit you are "ignorant" about) before you accuse anyone of being a jerk. And the flippant comments from Baylee that "people call you doctor" is exactly the problem.

BTW - I'm hardly a new kid - I've been in practice more than 25 years as an AA.

This is all pretty funny coming from a student.:laugh:

JWK is closer to being right on this one. The DNP is not equal to the PhD, the DNP is a clinical doctorate. Considered the same as the Pharm D and other "D" for physical therapy, speech, Occupational......
The proposed curriculm for the DNP is 3 years in length (including summers), or 4 years without summers. A bit more than a "couple of months" beyond a masters.
 
JWK is closer to being right on this one. The DNP is not equal to the PhD, the DNP is a clinical doctorate.



:thumbup: As usual, JWK is the voice of reason on these boards. And he's right about the DNP - PhD issue also.
 
You may just be the only one in the country who thinks a DNP is even remotely equivalent to a PhD. That's TOTAL BS.

Actually, I take that back - let's put it another way - outside of nursing, NO ONE in the country thinks a DNP is remotely equivalent to a PhD.

You're taking programs already in existence at a master's degree level - adding a few months (if any) to the program, and calling it a DNP.

I'm curious to know how many DNP programs you have investigated. I have been told by every PhD that is teaching this program, that the degrees are equal. Also, having already gotten a masters in nursing, there is not one single thing that we are talking about now, that was in my masters program. This is definitely above and beyond the work I did in my masters program.
 
JWK is closer to being right on this one. The DNP is not equal to the PhD, the DNP is a clinical doctorate. Considered the same as the Pharm D and other "D" for physical therapy, speech, Occupational......
The proposed curriculm for the DNP is 3 years in length (including summers), or 4 years without summers. A bit more than a "couple of months" beyond a masters.

I don't mean that we do the same things in the DNP that are done in the PhD. I just mean that degrees are equlivalent in the amount of work done. The PhD is a research degree-the student focuses on research. The DNP is a clinical/practice degree-we focus on clinical/practice issues.

As for calling myself "doctor" I don't really care if anyone ever calls me that. It is not important to me.
 
PhD lengths and work are variable - it can take 7+ years fulltime or 2-4 years fulltime, so it's hard to compare the workload of a PhD program to a DNP program.

But the one absolute thing is that the PhD is the HIGHEST academic degree ... all other degrees are professional degrees (MD, DO, DDS, JD, DPM). It is standardized such that if you have a PhD, you have gone through a standard process that is recognized by all universities, and is held as the gold standard in academia (ironically, by PhD holders). And in the height of academic snobbery, only PhD graduates are allow to wear the school's customize academic garb but not other doctorates (MD, DNP) (see pictures for examples)

The emphasis on research (and the recognized degree and ability to be tenured faculty) is why people get a PhD in psychology instead of a PsyD, a PhD in public health instead of a Dr.PH, a PhD in education instead of a Ed.D. (in some rare cases, the earned Sc.D is the equivalent of a PhD, ie MIT, Harvard)

Here is a position paper by Afaf I. Meleis, PhD FAAN and
Kathleen Dracup, DNSc, FAAN in regards to the DNP/PhD issue and why they think the DNP will bring nurses down a notch in academia.
http://www.nursingworld.org/ojin/topic28/tpc28_2.htm

HarvardRobe.jpg
Harvard

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Yale

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Johns Hopkins
 
I don't mean that we do the same things in the DNP that are done in the PhD. I just mean that degrees are equlivalent in the amount of work done. The PhD is a research degree-the student focuses on research. The DNP is a clinical/practice degree-we focus on clinical/practice issues.

As for calling myself "doctor" I don't really care if anyone ever calls me that. It is not important to me.

Please review the information at NONPF regarding the DNP and potential role. There is no suggestion in the document that the DNP is equal to the PhD or DNSc. I agree with your description of focus. The amount of work done? There is a reason for the high percentage of ABD in the pursuit of a PhD education.
 
You will care about being called Dr whether you think you will or even want to. It is simply behavioral psych; People will call you Dr, then they trust you more than nurse so and so. It greases wheels everywhere; if I call the lab, pharmacy, hospital etc and say this is Dr....... as opposed to Joe from the clinic I get a response. Do not fool yourselves with this. If you get the DNP you can and will be called Dr, and it is your job to explain you are not a physician; I do this every day as a medical psychologist. I say I am Dr..... a psychologist here at ......, and nobody thinks I am a physician. That argument is ridiculous.
 
You will care about being called Dr whether you think you will or even want to. It is simply behavioral psych; People will call you Dr, then they trust you more than nurse so and so. It greases wheels everywhere; if I call the lab, pharmacy, hospital etc and say this is Dr....... as opposed to Joe from the clinic I get a response. Do not fool yourselves with this. If you get the DNP you can and will be called Dr, and it is your job to explain you are not a physician; I do this every day as a medical psychologist. I say I am Dr..... a psychologist here at ......, and nobody thinks I am a physician. That argument is ridiculous.

Thus, you are opposed to HR 5688?
 
No I am not opposed to it. PhDs have had the title doctor forever, but this does not equal pretending you are a physician. The language of the bill is vague as can be, and it will not pass without some very clear revisions.
 
Sorry, but I agree with the bill. If you want to prescribe and perform complex procedures, go to med school.


Megboo, just curious, did you think that PAs did not already prescribe for years in 49 states and DC. You seem to think this will prevent it. You seemed surprised that PAs could prescribe in New York. I see you've worked as a SLP, so I'm surprised you had no idea about the PA profession
 
pa's can eval and tx pts in all 50 states and all u.s. territories in addition to a growing # of foreign countries. they can serve as primary care providers. they can serve as military flight surgeons.they can serve as the medical officer at u.s. embassies abroad. the in house medical officer for the president and vice president at the white house is a military pa.when they travel the pa goes with them. when cheney shot his hunting buddy a while ago it was cheney's pa who saved the guy's life before medics arrived. when clinton had open heart surgery a few yrs ago the 1st assist was a pa. in 49 states they can write prescriptions with unrestricted/physician level rx rights in a majority of states with dea sch 2-5 credentials in their own names. all pa's take pharmacology in school. at many places they take it with med students. at other places the med school faculty teach the pa's separately.
this bill is not about pa practice. it is about folks who are not md/do/dds calling themselves "dr" which is unethical and confuses patients. it is aimed at the growing # of doctorate level np programs. it does nothing to restrict the clinical practice of any group, just how clinicians identify themselves to patients.
 
Actually, with a mother who is an FP and employs a few PAs, I do know a thing or 2 about PAs.

I don't mind prescriptions for birth control pills or similar drugs done by PAs, but they should not be prescribing serious medications. Now, just what are serious medications? Well, that would take a lot of sitting down with a Desk Reference and Drug journal to sort through, and since I haven't been to med school and spent +/- 4 years in a residency, I don't know much about medication and side effects and just what kind of training is necessary to be dealing out certain prescriptions.

As for being an SLP - I don't deal with PAs in a professional sense. All the insurance companies and state agencies I contract with require PHYSICIAN approval, not PA approval. I know several PAs, but not through my work.

When making a comment about "having no idea" about a profession - best to send me a PM first to check it out rather than making a silly comment like that.

That's like me saying you have no idea about the SLP profession based on your response to my post. I have no idea if you do or not.


My question was did you think that we did not? You said we should NOT so I was curious if you knew we already did?
I was surprised because you ARE in healthcare. I work with many SLPs, especially the dysphagia service (for all of our CVA patients)

And please stop dragging PAs into the whole DNP thing and posing as a "real" doctor. PAs have nothing to do with the fact that Pharmacists and now Nurses want to be called Doctors.
 
We are not in disagreement here about who should call themselves dr.
I don't think any pa(with or without a phd) should introduce themselves as dr smith.ditto np. ditto p.t.
carmona was the former surgeon general. as far as I know he is not in the white house 24/7 like the pa's who actually are the first line, in house medical officers there. the pa's are military and not public health service so they do report adminitratively to a physician offsite somewhere but it isn't/wasn't carmona.I beleive the current head pa at the white house is an airforce major.
biology grad students may take pharm but they don't take clinical medicine courses and do a full yr of rotations in family medicine, internal medicine, pediatrics, surgery, emergency medicine, obgyn, psych, etc like pa's do. this is the difference and the reason pa's can and do diagnose and treat patients. pa's require administrative oversight/supervision from a physician by law, this does not mean that the physician has to see the pa's pts or even be present while pts are being seen. it means they review a portion of charts every month for qa reasons. in my state I have to submit 10% of my charts as chosen by me every month. some states do not require chart review at all, just an ongoing review of care. in north carolina for example a pa may own their own clinic and supervision = a 30 min discussion with a physican every 6 months to go over issues at the practice.
on a side note- if medschool doesn't work out for whatever reason as an slp you meet the direct pt care experience requirement for some pa schools. we had a slp in my class who did very well and now works on a heme/onc service at a well known boston hospital.below is a link to a story about the pa who just retired from service after working in the white house and elsewhere with the vice president.
http://www.aapa.org/members/news/2006/27_01_011506.pdf
 
Yes I knew this, but I can still have an opinion.



I have years of experience in nursing homes, hospitals, rehab centers, and home health working with dsyphagia related to CVA, TBI, CP, Cx, etc., etc., and while some of the patients had PAs seeing them in lieu of a physician on rounds, per reimbursment issues, we had to get physician approval for assessment/treatment. I work in EI now and they are incredibly strict about that. Not my rules, but I like getting paid. In fact, the state audited 100+ charts of mine last year and one criterion for service compliance was to have a copy of the script written by a physician.



The title of this thread includes both NPs and PAs.... maybe you want to address this to the OP. Also, I have never claimed to be a doctor - you have even been commenting on my SLP work! Could you point out where I've indicated that I'm a "real" doctor?

OMG you are wayyy too sensitive, the "real doctor" comment was not about YOU. Its about DNPs and DPT and all other "not real" doctors. Geesh, lighten up.
 
That's all fine and dandy, but I think that those who call themselves Dr. in the clinical realm should go to med school.

However there IS a difference between an MD/DO and PA/NP, and sometimes it seems like NPs/PAs try to overstep the boundaries sometimes.
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Agree that non-MD/DO folks shouldn't represent themselves as a DR., but how does it seem to you that NP/PA overstep their boundaries...sometimes...?
You can make a stronger argument about NP's, but PA's do practice within the scope in which they are trained.... They are educated as medical practitioners. Clearly, a biology student who takes a pharmacology course wouldn't be qualified to prescribe. However, a person trained to perform a physical examination, order and interpret studies, diagnose, and treat accordingly or refer to the appropriate specialist is qualified to prescribe after taking the appropriate coursework in pharmacology. Not only are they qualified, but they have been given this privilege as a result. They are not given this privilege because it is unsafe, because they continue to screw up or because the outcomes are questionable. Aside from the physician, the PA is arguably the most respected healthcare practitioner and IS the next best thing to a physician!
 
Agree that non-MD/DO folks shouldn't represent themselves as a DR., but how does it seem to you that NP/PA overstep their boundaries...sometimes...?
You can make a stronger argument about NP's, but PA's do practice within the scope in which they are trained.... They are educated as medical practitioners. Aside from the physician, the PA is arguably the most respected healthcare practitioner and IS the next best thing to a physician!
I always thought PAs worked under their supervising physician's scope of practice. They do surveys every year on who is the most respected, it isn't the PA or NP. Probably because the general public isn't aware of the roles. The RN is usually on top of the list.
 
I always thought PAs worked under their supervising physician's scope of practice. They do surveys every year on who is the most respected, it isn't the PA or NP. Probably because the general public isn't aware of the roles. The RN is usually on top of the list.


I agree....It's difficult to hold the general publics opinion in high regard. Surely, the PA is the extention of the physician that "supervises", probably making them the next most autonomous as far as clinical decision making and the complexity of the cases and care they provide.
 
I don't disagree with you there. It just makes me uncomfortable that PAs in most states can prescribe all meds after only a year of internship.

If a PA is following their scope then I can't complain about that. I can have issues with the scope, though.

I see your point, but think that if you have issues with the scope, you should have substance to support what clearly is more opinion. I'm not a PA, but other PA's on this forum can tell you and you can confirm it by visiting a few of the schools websites, PA's do as much as 2000+ clinical rotation hours. Largely, the difference b/t a PA and an MD/DO is residency training (which is significant). However, a seasoned PA can bring something to a physician practice that another physician could never bring. PA's have a great deal of latitute and can work essentially any specialty without additional certification or training. Imagine a PA who worked IM, then ER, then Derm, then ortho, each for a few years.... then took a position in family medicine....imagine the experience and specialty knowledge this PA could bring to a practice.. A family practitioner couldn't begin to compete with a PA within the content area of Derm, ortho, potentially EM.....That family physician probably hasn't seen these specialties since med school.....just a thought! L.
 
Are PA/NPs able to work with DPMs?
NOPE....a pa must be supervised by an md/do only.
certainly a dpm could oversee the work of a pa if they worked together in a setting that also used md/do folks but they could not sign off on their charts and be the legal supervisor of record.
 
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