PA vs NP?

[sarahangel53225]

Hi everyone! I am currently a senior getting ready to apply for college and I don’t know if I should go the nursing route ( to eventually become an NP) or the PA route. I wanted to go pre-med for a while, but after reading into it a little more (in terms of time in school, debt, lifestyle etc) I don’t think it’s for me. I would like to work in pediatrics or neonatology for sure, and if possible, have some type of leadership position or teaching role in addition to being an NP or PA. I love the work of a NICU nurse and can definitely see myself doing that, but I also would love being a primary care provider in Pediatrics. I don’t know if this matters, but I also would like to have a big family someday and thus, would prefer somewhat of a regular work schedule so I can spend a lot of time at home. Which route would be the best given my preferences?

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[mountainPA]

Hi everyone! I am currently a senior getting ready to apply for college and I don’t know if I should go the nursing route ( to eventually become an NP) or the PA route. I wanted to go pre-med for a while, but after reading into it a little more (in terms of time in school, debt, lifestyle etc) I don’t think it’s for me. I would like to work in pediatrics or neonatology for sure, and if possible, have some type of leadership position or teaching role in addition to being an NP or PA. I love the work of a NICU nurse and can definitely see myself doing that, but I also would love being a primary care provider in Pediatrics. I don’t know if this matters, but I also would like to have a big family someday and thus, would prefer somewhat of a regular work schedule so I can spend a lot of time at home. Which route would be the best given my preferences?

Congrats are deciding to join the medical field! Lots of good questions here.

For reference I am a PA currnetly working urgent care and family practice, and with several years of experience working in-patient internal medicine. I also currently teach several college science classes.

For NPs to work in the NICU you will need to go through a specific "neonatal nurse practioner - NNP" program. To work with pediatric populations you will need to eitther go through a "pediatric nurse practioner" program or a "family nurse practioner" program. For PAs you simply need to be credentialed as a PA, and more than likely also have the associated credentials of PALS and NRP (advanced CPR classes for spcific populations), which may or may not be part of your PA school cirriculum (mine only included PALS). PA school medical rotations do no focus heavily on neonatal populations, so if it is NICU and nothing else, you will need to schedule you elective rotations in the NICU to gain vailuable experience and networking. I might suggest working in the NICU or PICU as a tech/CNA, or even and RN prior to PA school to ensure that your "feet are already wet." Should you go the PA route, you will focus heavily on pediatric populations in multiple settings, so you should be able to hit the ground running in an oupatient peds office. Lots of new grad PAs working in outpatient pediatricis in my neck of the woods.

Generally speaking I feel that NPs tend to have a greater presence in the NICU than PAs. This is likely due to fact that they were NICU RNs prior to becoming and NNP. The only PA that I have ever known who was employed in a NICU worked in pediatric cardiology prior to the NICU, and from my understanding she is highly valuable and sought after. She essentially leads the team and consults with her attending on highly specialized cases. Then again, I'm not really up on the hiring habits of NICU teams, so there could be lots more I just don't happen to know them.

Another thing to consider is the crendential itself. It is important to note that NPs specialized by population, which outside of being a family nurse practioner, or potentially an acute care nurse practitioner, may greatly limit you ability ot find jobs in the future and/or switch specialities. Our urgent care does have a pediatric NP, however, as you might assume, she is only able to see that population, which ultimately limits her utility and revenue stream. An NNP only has a venues in which he/she would be allowed to practice, which further limits future growth outside of that arena.

In general, I say that if you are interested in women's health, neonatology, and psych...do NP, but be aware of that the future might hold as far as career shifts. If you are interested in anything surgical, defintely do PA. Everything else, just depends on the type of model that you wish to be educated in (nursing vs medical). Hope this helps!

 

[sarahangel53225]

This helps a lot, thank you! I personally prefer the medical model and am not 100% set on the NICU, so I’m thinking PA might be the way to go. Would you say that you’re still able to have a lot of patient interaction and at least some autonomy as a PA? I would most likely work pediatric outpatient (I shadowed a doc in this area and LOVED it), but I don’t want to have someone “hovering” over me if that makes sense. Also, what is your schedule like as a PA? I’m glad to hear that you do teaching because I’m definitely considering doing that as well.

 

[DrNotaDr]

This helps a lot, thank you! I personally prefer the medical model and am not 100% set on the NICU, so I’m thinking PA might be the way to go. Would you say that you’re still able to have a lot of patient interaction and at least some autonomy as a PA? I would most likely work pediatric outpatient (I shadowed a doc in this area and LOVED it), but I don’t want to have someone “hovering” over me if that makes sense. Also, what is your schedule like as a PA? I’m glad to hear that you do teaching because I’m definitely considering doing that as well.

If you want more independence, for better or worse, you should go NP.

 

[mountainPA]

This helps a lot, thank you! I personally prefer the medical model and am not 100% set on the NICU, so I’m thinking PA might be the way to go. Would you say that you’re still able to have a lot of patient interaction and at least some autonomy as a PA? I would most likely work pediatric outpatient (I shadowed a doc in this area and LOVED it), but I don’t want to have someone “hovering” over me if that makes sense. Also, what is your schedule like as a PA? I’m glad to hear that you do teaching because I’m definitely considering doing that as well.

I'm glad that helps!

Ha! I'm about 100% certain that if a doc had to "hover over me " all day long, I would be fired. Why? Because I would not be performing the essential functions of my position. My job to essentially act as an extension of the physician to help broaden patient care. Any new PA should be able to obtain a thourough history, before a detailed exam per the circumstances, create an assessment to include a listing of the most probable diagnosis and why or why not some items are higher on that list, and then establish a treatment plan. This takes practice. The level of "supervision" is mostly a legal term and is decided at the practice level based on a whole criteria.

For example -
As a new grad practicing in in-patient internal medicine, I was placed in various teams (ED admissions, discharge, code blue, and daily/nightly rounding). At first I was required to present to an attending physician each patient that I saw. As they gained confidence in my abilities I wasn't required to do this anymore, however each attending still had their own way of doing things, and as such some issues were always run by the attending no matter their comfort level with you. This was mostly for complicated type I diabetics and any post-surgical complcations. The PAs were held to the same standard as the 1-2 year IM residents - which again implies that our every move should not be monitored.

When I transferred over to family practice, my supervising physician essentially felt comfortable with me from day one (given that I had the above experience) managing anything that I felt comfortable with. At first pediatricis wasn't in my comfort level since I hadn't seen kids for a couple of years, but within the first few months I gained confidence in seeing them and my doc felt comfortably letting me manage them without reviewing their cases with him. Again, autonomy is best granted when proven through competence.

Now that I am in urgent care primarily, my level of "supervision" comes mostly in the form of chart reviews. I work completely autonomously without a doc on site most days. The doc of course is just a phone call away and I have access to a wide array of tools to manage my patients should they turn south. I am expected to manage a team of an x-ray tech and MA/RN, while seeing 30-60 patients per shift. I perform all initial reads on x-rays, interpret lab results, perform a wide variety of procedures, and see all ages and complaints. For patients that I feel would benefit from a certain type of management, I make referrals to physician specialists and/or plan to see the patient in our family practice for continued management. For the vast majority of cases a physician on-site checking in on every patient would be a horrible use of his/her training, as well as my own.

As a point of reference, I have worked at locations in whcih there was heavy preference of PAs over NPs, however I have never worked at a location in which one had different levels of job expectations based on credentials alone.

 

[pamac]

I'm glad that helps!

Ha! I'm about 100% certain that if a doc had to "hover over me " all day long, I would be fired. Why? Because I would not be performing the essential functions of my position. My job to essentially act as an extension of the physician to help broaden patient care. Any new PA should be able to obtain a thourough history, before a detailed exam per the circumstances, create an assessment to include a listing of the most probable diagnosis and why or why not some items are higher on that list, and then establish a treatment plan. This takes practice. The level of "supervision" is mostly a legal term and is decided at the practice level based on a whole criteria.

For example -
As a new grad practicing in in-patient internal medicine, I was placed in various teams (ED admissions, discharge, code blue, and daily/nightly rounding). At first I was required to present to an attending physician each patient that I saw. As they gained confidence in my abilities I wasn't required to do this anymore, however each attending still had their own way of doing things, and as such some issues were always run by the attending no matter their comfort level with you. This was mostly for complicated type I diabetics and any post-surgical complcations. The PAs were held to the same standard as the 1-2 year IM residents - which again implies that our every move should not be monitored.

When I transferred over to family practice, my supervising physician essentially felt comfortable with me from day one (given that I had the above experience) managing anything that I felt comfortable with. At first pediatricis wasn't in my comfort level since I hadn't seen kids for a couple of years, but within the first few months I gained confidence in seeing them and my doc felt comfortably letting me manage them without reviewing their cases with him. Again, autonomy is best granted when proven through competence.

Now that I am in urgent care primarily, my level of "supervision" comes mostly in the form of chart reviews. I work completely autonomously without a doc on site most days. The doc of course is just a phone call away and I have access to a wide array of tools to manage my patients should they turn south. I am expected to manage a team of an x-ray tech and MA/RN, while seeing 30-60 patients per shift. I perform all initial reads on x-rays, interpret lab results, perform a wide variety of procedures, and see all ages and complaints. For patients that I feel would benefit from a certain type of management, I make referrals to physician specialists and/or plan to see the patient in our family practice for continued management. For the vast majority of cases a physician on-site checking in on every patient would be a horrible use of his/her training, as well as my own.

As a point of reference, I have worked at locations in whcih there was heavy preference of PAs over NPs, however I have never worked at a location in which one had different levels of job expectations based on credentials alone.

Most of the PAs I know operate with autonomy similar to that, albeit ENTIRELY at the discretion of the supervising physician. But yeah, the idea is that work gets done without the need for a physician to be involved the vast majority of the time.

The independence aspect NPs enjoy is the real deal of you want to run your own business, and not everyone (myself included) wants to do that. I have friends and former classmates making over $300,000 as NPs. I have another friend who runs a business doing urgent care house calls (don’t know how or even if they make money doing that). But having that independent license in my state makes that possible. I work an occasional side gig where I don’t need a physician supervisor to agree to allow me to work that job (and pay him or her to supervise), and it pays quite nicely. I think most PAs could fly solo like NPs without a problem, but their regulatory structure just doesn’t lend as well to that. However, you can be an NP with an independent license, andstill have your employer require you to be supervised. Additionally, your contract could include provisions requiring certain conditions, like no side gigs, etc. But one of the reasons my wages are high where I’m at working as a psyche NP is because they know I could leave and be working the next week somewhere else, or at the very least set up my own shop and be making money as a competitor. That crosses their mind along with other reasons that make me a profitable employee.

For most PAs and NPs out in the workforce, there isn’t a big difference between the work they do on a daily basis.

 

[deleted6669]

This helps a lot, thank you! I personally prefer the medical model and am not 100% set on the NICU, so I’m thinking PA might be the way to go. Would you say that you’re still able to have a lot of patient interaction and at least some autonomy as a PA? I would most likely work pediatric outpatient (I shadowed a doc in this area and LOVED it), but I don’t want to have someone “hovering” over me if that makes sense. Also, what is your schedule like as a PA? I’m glad to hear that you do teaching because I’m definitely considering doing that as well.

There are postgrad programs in both neonatology and peds for PAs if that is where your interest lies. Best of luck whatever you decide.

 

[xDNA]

Currently working in a Level 4 NICU as an RN.

On our unit (100+ beds) it is overseen by solely NNPs and Neo-Docs. I honestly believe OP unless you are NICU or bust, you should go the PA route. Especially since you expressed more interest in the Medical Model of teaching. It'll save you from a lot of mind-numbing "Nursing Theory" type courses. Prior to deciding to pursue medicine, I was considering NNP and my experiences here have shown me that I do not want to pursue that specialty. The NNPs do a ton of procedures, have decent amount of autonomy, generally the first person us nurses call for issues, and really seem to enjoy their job. The reasons I have decided not to pursue NNP though is because I'm not a fan of their lifestyle. Some of our NNPs are in their 40s pushing 50, if not already in their 50s and work overnight, weekends, and holidays. Additionally, like a poster mentioned above once you do NNP, you're pretty much stuck. Although our NNPs are technically contracted from a group practice they only work in the hospital.

Something else to think about is competitiveness of NP vs PA. From what I've seen, PA school is much more difficult to get into than NP school. Having to be an RN prior to starting NP school (in most cases), does give a nice addition to a CV, by having substantial and meaningful clinical experience.

If your goal is to do Pediatric Primary Care, that is 100% achievable from either route. Just do a little research, make a pro and cons list for NP and PA. I would use that as my method for deciding.

 

[PikminOC]

Currently working in a Level 4 NICU as an RN.

On our unit (100+ beds) it is overseen by solely NNPs and Neo-Docs. I honestly believe OP unless you are NICU or bust, you should go the PA route. Especially since you expressed more interest in the Medical Model of teaching. It'll save you from a lot of mind-numbing "Nursing Theory" type courses. Prior to deciding to pursue medicine, I was considering NNP and my experiences here have shown me that I do not want to pursue that specialty. The NNPs do a ton of procedures, have decent amount of autonomy, generally the first person us nurses call for issues, and really seem to enjoy their job. The reasons I have decided not to pursue NNP though is because I'm not a fan of their lifestyle. Some of our NNPs are in their 40s pushing 50, if not already in their 50s and work overnight, weekends, and holidays. Additionally, like a poster mentioned above once you do NNP, you're pretty much stuck. Although our NNPs are technically contracted from a group practice they only work in the hospital.

Something else to think about is competitiveness of NP vs PA. From what I've seen, PA school is much more difficult to get into than NP school. Having to be an RN prior to starting NP school (in most cases), does give a nice addition to a CV, by having substantial and meaningful clinical experience.

If your goal is to do Pediatric Primary Care, that is 100% achievable from either route. Just do a little research, make a pro and cons list for NP and PA. I would use that as my method for deciding.

Nowadays, some people do accelerated programs and go directly to np school without much rn experience

 

[DrNotaDr]

Nowadays, some people do accelerated programs and go directly to np school without much rn experience

This is a pretty standard attack line from the anti nurse lobby, the only problem is I’ve been in healthcare for 20 years and I’ve never met a single person who did that. Not. One. Person. In reality it’s financially necessary to RN your way through NP school. I’ve found the minimum is 3 years of RN experience for the new NP. The average age of an NP is 47 and the average NP has 10 years of experience in their roles. If hiring docs have a problem with new grad NP’s or the random unicorn that did skip being a bedside nurse the remedy is easy; don’t hire them. NP Fact Sheet

 

[PikminOC]

This is a pretty standard attack line from the anti nurse lobby, the only problem is I’ve been in healthcare for 20 years and I’ve never met a single person who did that. Not. One. Person. In reality it’s financially necessary to RN your way through NP school. I’ve found the minimum is 3 years of RN experience for the new NP. The average age of an NP is 47 and the average NP has 10 years of experience in their roles. If hiring docs have a problem with new grad NP’s or the random unicorn that did skip being a bedside nurse the remedy is easy; don’t hire them. NP Fact Sheet

There are rich people who don't need the finances you know.
Here's a young np
Sarah skea st charles illinois
So there the unicorn for you.
Out in private practice and who knows where her "collaboration" physician is located

 

[PikminOC]

One year of experience needed to get into np program

How to Become a Nurse Practitioner: 5 Steps - Marquette

Discover how to become a nurse practitioner and enter this exciting field with help from Marquette University’s direct entry MSN program.

mastersnursing.marquette.edu

 

[PikminOC]

This is what I've been seeing in the community. Pay alot of money, get fast tracked thru. This is the new crop of nps out there

 

[DrNotaDr]

This is what I've been seeing in the community. Pay alot of money, get fast tracked thru. This is the new crop of nps out there

It’s kind of hard to tell how much experience this psych NP has, her resume is lacking, but that doesn’t mean the answer is none. If low experience NP’s are a problem simply use the power of the physician lobby to refuse to hire them. Again, I’ve never met Sarah, if she does have zero nursing experience, which we can’t verify, so my comment still applies. Also, any comment that the average NP has 10 years in their role at an average age of 47?

 

[PikminOC]

Im talking about this new crop. Not the nps who did it correctly and are appropriately supervised. This watering down of the degree is what private practice docs are seeing. I don't hire or train any of them. They ask all the time tho as there aren't enough training sites for them. Skeas resume bus lacking because she didn't do much at all.


Op, go for np and get your dnp online in a few semesters so you can be called doctor!

 

[DrNotaDr]

Im talking about this new crop. Not the nps who did it correctly and are appropriately supervised. This watering down of the degree is what private practice docs are seeing. I don't hire or train any of them. They ask all the time tho as there aren't enough training sites for them. Skeas resume bus lacking because she didn't do much at all.


Op, go for np and get your dnp online in a few semesters so you can be called doctor!

Then don’t hire them and the market will correct itself! Blame the physicians who want to pay an new grad NP nurse salary (because no one will hire them) simply so they can bill a million dollar practice with the lowest labor costs that can be found. Physicians made this for profit monster, why don’t you try changing your own profession, as they are the cause of everything you seem to hate.

 

[psychnurse]

It probably depends on where you are. I live in an area with lots of research hospitals, so I've worked with quite a few PMHNPs who went through Direct-Entry programs with very little (or no) RN experience. The ones I've worked with were acutely aware of their limitations and they seek either post-grad training programs or have frequent supervisions from psychiatrists.

But Direct Entry grads aren't the ones saturating the market because few programs offer them. In my PMHNP cohort of 14, only 3 were direct entry (2 of whom went onto NP residency), and the rest of us all worked as RN while in school.

 

[DrNotaDr]

It probably depends on where you are. I live in an area with lots of research hospitals, so I've worked with quite a few PMHNPs who went through Direct-Entry programs with very little (or no) RN experience. The ones I've worked with were acutely aware of their limitations and they seek either post-grad training programs or have frequent supervisions from psychiatrists.

But Direct Entry grads aren't the ones saturating the market because few programs offer them. In my PMHNP cohort of 14, only 3 were direct entry (2 of whom went onto NP residency), and the rest of us all worked as RN while in school.

I’ve still never met one. I had a friend who could not pass the boards x 3 attempts because she spent her entire career as a surgical nurse and no general nursing knowledge. I don’t know how you can pass NP school without nursing experience but I’m sure it happens.

 

[PikminOC]

Just because you have never met one doesn't mean they don't exist.
And it weird the way you write np 10 years in have avg age of 47.
Why not just say avg age of new np is 37?

And the fact these programs are being offered at all like the marquette one I posted that's not psych nurse, make the np degree look watered down

 

[PikminOC]

It probably depends on where you are. I live in an area with lots of research hospitals, so I've worked with quite a few PMHNPs who went through Direct-Entry programs with very little (or no) RN experience. The ones I've worked with were acutely aware of their limitations and they seek either post-grad training programs or have frequent supervisions from psychiatrists.

But Direct Entry grads aren't the ones saturating the market because few programs offer them. In my PMHNP cohort of 14, only 3 were direct entry (2 of whom went onto NP residency), and the rest of us all worked as RN while in school.

Sarah's work history is "exciting and powerful" according to her website

Meet Sarah | Values Based Psych

www.valuesbasedpsychiatry.com

 

[mountainPA]

In my area there are a steady stream of new grad NPs that either obtained their RN and went straingth into a NP program immediately after graduation without any prior clinical experience, or direct-entry NPs that have no prior clinical work experience. In either case, the vast majority of their academics are on-line and some even just have one clinical preceptor, which many times is another NP. As an EMT-P prior to PA school, I used to hate getting calls from practices that hired these NPs as the level of eye-rolling from the recieving attending ED doc was downright embarrassing.

In my state these NPs are allowed to practice with no physician supervision from day one. I have trained two of such individuals in the past at a site in which I did some contractual work...clinically it is not a difficult job. I have found that overall they are ill-prepared to manage even basic conditions, have next to no procedural skills, and cannot create a meaningful DDx. Our group refuses to hire them, and the places they do find employment often pay them far below market value and are typically areas that cannot attract more appropriate candidates.

It is confusing what the political wing of the NP profession is trying to accomplish. The public is starting to take note and it isn't a positive. If we do not allow 1st year residents to practice indepenently, why are brand new NPs (even with a few years of bedside experience) allowed to do so?

 

[DrNotaDr]

In my area there are a steady stream of new grad NPs that either obtained their RN and went straingth into a NP program immediately after graduation without any prior clinical experience, or direct-entry NPs that have no prior clinical work experience. In either case, the vast majority of their academics are on-line and some even just have one clinical preceptor, which many times is another NP. As an EMT-P prior to PA school, I used to hate getting calls from practices that hired these NPs as the level of eye-rolling from the recieving attending ED doc was downright embarrassing.

In my state these NPs are allowed to practice with no physician supervision from day one. I have trained two of such individuals in the past at a site in which I did some contractual work...clinically it is not a difficult job. I have found that overall they are ill-prepared to manage even basic conditions, have next to no procedural skills, and cannot create a meaningful DDx. Our group refuses to hire them, and the places they do find employment often pay them far below market value and are typically areas that cannot attract more appropriate candidates.

It is confusing what the political wing of the NP profession is trying to accomplish. The public is starting to take note and it isn't a positive. If we do not allow 1st year residents to practice indepenently, why are brand new NPs (even with a few years of bedside experience) allowed to do so?

In 20 years in healthcare I’ve never seen a single drop of this “steady stream” of direct entry NP’s with no RN experience. Sounds a bit hyperbolic. If the physicians are so worried about patient safety why are these people getting hired? It’s because the docs want to make a million dollars a year running a midlevel mill. Greed. Physicians to blame as much as the nursing lobby.,

 

[chocomorsel]

It’s kind of hard to tell how much experience this psych NP has, her resume is lacking, but that doesn’t mean the answer is none. If low experience NP’s are a problem simply use the power of the physician lobby to refuse to hire them. Again, I’ve never met Sarah, if she does have zero nursing experience, which we can’t verify, so my comment still applies. Also, any comment that the average NP has 10 years in their role at an average age of 47?

Average. Meaning there are plenty below and plenty above the age of 47. I have met plenty of NPs in their 20's and 30's. Plenty.
BTW the average age of an anesthesiologist is 50 years of age. Well I graduated 8 years ago. All my anesthesiologist friends are 45 and younger. There are plenty of young anesthesiologist out there.
So your comment means nothing really.
How old were you when you got your NP?

 

[PikminOC]

Average. Meaning there are plenty below and plenty above the age of 47. I have met plenty of NPs in their 20's and 30's. Plenty.
BTW the average age of an anesthesiologist is 50 years of age. Well I graduated 8 years ago. All my anesthesiologist friends are 45 and younger. There are plenty of young anesthesiologist out there.
So your comment means nothing really.
How old were you when you got your NP?

And it weird the way she says np working 10 years in have avg age of 47.
Why not just say avg age of new np is 37 in your experience?

 

[DrNotaDr]

Average. Meaning there are plenty below and plenty above the age of 47. I have met plenty of NPs in their 20's and 30's. Plenty.
BTW the average age of an anesthesiologist is 50 years of age. Well I graduated 8 years ago. All my anesthesiologist friends are 45 and younger. There are plenty of young anesthesiologist out there.
So your comment means nothing really.
How old were you when you got your NP?

Indeed, that’s what the word “average” means. If you don’t like new hire inexperienced NP’s with no nursing experience, don’t hire them. The market will self correct, whether the nursing lobby likes it or not. I blame greedy physician running mid level mills/hospital administration as much as the nursing lobby for some of the problems in NP education.

 

[chocomorsel]

Indeed, that’s what the word “average” means. If you don’t like new hire inexperienced NP’s with no nursing experience, don’t hire them. The market will self correct, whether the nursing lobby likes it or not. I blame greedy physician running mid level mills as much as the nursing lobby for some of the problems in NP education.

So then what is your point exactly and why do you keep on harping about the “average” age if you know it doesn’t mean s hit?
then? So the docs should all just hire people 47 and above? And there are plenty of nurses who don’t go into nursing until their late thirties and forties and go right in to NP school.


My answer would be not to hire any of y’all. And not to train any of y’all.
But yeah, the problem comes from greedy docs who want to use y’all.

 

[DrNotaDr]

So then what is your point exactly and why do you keep on harping about the “average” age if you know it doesn’t mean s hit?
then? So the docs should all just hire people 47 and above? And there are plenty of nurses who don’t go into nursing until their late thirties and forties and go right in to NP school.


My answer would be not to hire any of y’all. And not to train any of y’all.
But yeah, the problem comes from greedy docs who want to use y’all.

There are physicians who don’t want to hire or train any NP’s whether they are supervised or not. Take a stand, see what happens, the administrators always win. The best you can hope for is to hire the right people, which is what I’ve been getting at all along. If you guys refuse to hire direct entry people at any level, direct entry goes away.

 

[mountainPA]

In 20 years in healthcare I’ve never seen a single drop of this “steady stream” of direct entry NP’s with no RN experience. Sounds a bit hyperbolic. If the physicians are so worried about patient safety why are these people getting hire? It’s because the docs want to make a million dollars a year running a midlevel mill. Greed. Physicians to blame as much as the nursing lobby.,

I'm not sure what is "hperbolic" about my personal, lived experienced. Take what you want from that experience. What would I obtain from making up an anecdote like that?

You have placed blame on several groups for poorly trained NPs; the nursing lobby and physicians. How about also some blame on these outrageously priced on-line only NP programs that have no standards for entry? How about the individuals that graduate from these programs and cause harm to patients due to their complete lack of underlying pathophysiology and pharmacology? You can call that hyperbolic all you want, but I have seen it occur more than just a few times, and otherwise give a bad name to NPs that don't take shortcuts and overcome their nursing theory courses through additional personal study.

 

[DrNotaDr]

I'm not sure what is "hperbolic" about my personal, lived experienced. Take what you want from that experience. What would I obtain from making up an anecdote like that?

You have placed blame on several groups for poorly trained NPs; the nursing lobby and physicians. How about also some blame on these outrageously priced on-line only NP programs that have no standards for entry? How about the individuals that graduate from these programs and cause harm to patients due to their complete lack of underlying pathophysiology and pharmacology? You can call that hyperbolic all you want, but I have seen it occur more than just a few times, and otherwise give a bad name to NPs that don't take shortcuts and overcome their nursing theory courses through additional personal study.

I consider the nursing lobby and for profit degree mills equally liable. I’ve also seen physicians and PA’s cause harm, no one blames their education they are just poor clinicians.

 

[pamac]

I'm not sure what is "hperbolic" about my personal, lived experienced. Take what you want from that experience. What would I obtain from making up an anecdote like that?

You have placed blame on several groups for poorly trained NPs; the nursing lobby and physicians. How about also some blame on these outrageously priced on-line only NP programs that have no standards for entry? How about the individuals that graduate from these programs and cause harm to patients due to their complete lack of underlying pathophysiology and pharmacology? You can call that hyperbolic all you want, but I have seen it occur more than just a few times, and otherwise give a bad name to NPs that don't take shortcuts and overcome their nursing theory courses through additional personal study.

I’ve seen physicians, PAs and NPs all mess up.... more than a few times. I’ve seen PAs as green as can be that never worked a day in healthcare before their first job. I can’t remember the last time I met a new grad PA that was more than a CNA before school. All of my friends that are in the NP pipeline and in practice spent years as RNs in the hospital environment. I’ve never actually met anyone that has done a direct entry NP program. Whenever we have these conversations, it always moves quickly to the “but you have direct entry, and that sucks.” From what I’ve heard from people who have met direct entry folks, I haven’t heard anything terrible. I’d personally be wary myself of a direct entry graduate, or just about any graduate without much prior RN experience. In my program, there were a couple folks in my cohort who didn’t have much experience, and one of them had no experience as an RN outside of working in an office for like 6 months. If that’s a problem, and she sucks, then the BON will probably be involved. But I’m the meantime, I’m practicing safely and doing quality work. I’m doing light years better than the PA two providers ago before I got there who only had surgery experience prior to PA school. Didn’t know how to deal with mental patients. Got rolled all the time. Couldn’t read them. Didn’t know the nuance of how to tell folks no. Does that mean there is a problem with the PA pipeline? Maybe. But it doesn’t negate the fact that most PAs are well suited to the work.

Of the three professions, NPs probably do have the highest number of poor performers, and the weakest of the three for admission standards. I’m a little freaked out sometimes when I jump on Facebook and see one of my former coworkers posting that they just got accepted to Walden or whatever. I reckon back to working with them and worrying along with everyone else in the floor that the night was going to be rough. For every one of those folks, there are many more that are just fine. I know NPs that are working bedside and can’t land jobs, and that was pre COVID.

 

[PikminOC]

When i worked at the hospital I refused working with midlevels. In private practice i dont work with them either. Im not putting my license on the line for anyone but myself.
Med school has rigorous standards.

 

[xDNA]

I did see some RNvlogger on Youtube, go into a FNP program after having less than 2 months bedside experience. I tried to find her on YT but for the life of me can't find her page.

From MY personal experience, a lot of nurses DO wait a few years prior to starting a NP program. I'm currently studying for MCAT to pursue M.D and alot of my RN friends know that. When I ask them about their future plans and if it involves going to a NP program a lot of them express just wanting to take a break from schooling, overwhelming majority are females in their mid 20s looking for serious relationships and/or wishing to start a family. Obviously throughout this time they're also gaining clinical experience. With that being said, I HAVE spoke with those who hope to complete an NP program with less than 1yr experience at bedside, but it has ALWAYS been for FNP programs. NNP programs are from my understanding, pretty similar to cRNA programs in the sense that admission to these APRN specialties are locked behind at least 2yrs experience in NICU and SICU(ideally) respectively.

 

[PikminOC]

I did see some RNvlogger on Youtube, go into a FNP program after having less than 2 months bedside experience. I tried to find her on YT but for the life of me can't find her page.

From MY personal experience, a lot of nurses DO wait a few years prior to starting a NP program. I'm currently studying for MCAT to pursue M.D and alot of my RN friends know that. When I ask them about their future plans and if it involves going to a NP program a lot of them express just wanting to take a break from schooling, overwhelming majority are females in their mid 20s looking for serious relationships and/or wishing to start a family. Obviously throughout this time they're also gaining clinical experience. With that being said, I HAVE spoke with those who hope to complete an NP program with less than 1yr experience at bedside, but it has ALWAYS been for FNP programs. NNP programs are from my understanding, pretty similar to cRNA programs in the sense that admission to these APRN specialties are locked behind at least 2yrs experience in NICU and SICU(ideally) respectively.

2 whole years! Wow

 

[xDNA]

2 whole years! Wow

LOL. I know right.

I'm dissatisfied with my level of education as a Nurse, hence my decision to pursue medicine. I do not regret being a RN though, it has afforded me the opportunity to continue to follow my career goals and gave me a lot of valuable experiences.

I agree with you guys though @TikiTorches, @chocomorsel, @mountainPA

Had a pretty trash experience with an Emergency Room NP at one of the hospitals in my area regarding care for my wife.

I live in the DC metro area, and some of the most popular colleges here offer online NP degrees. Nursing is an extremely popular major here in general, with most schools having significant wait lists. I wouldn't be surprised one bit if a substantial amount of these grads went straight into one of those online NP programs immediately after completing their RN.

 

[chocomorsel]

LOL. I know right.

I'm dissatisfied with my level of education as a Nurse, hence my decision to pursue medicine. I do not regret being a RN though, it has afforded me the opportunity to continue to follow my career goals and gave me a lot of valuable experiences.

I agree with you guys though @TikiTorches, @chocomorsel, @mountainPA

Had a pretty trash experience with an Emergency Room NP at one of the hospitals in my area regarding care for my wife.

I live in the DC metro area, and some of the most popular colleges here offer online NP degrees. Nursing is an extremely popular major here in general, with most schools having significant wait lists. I wouldn't be surprised one bit if a substantial amount of these grads went straight into one of those online NP programs immediately after completing their RN.

I was a nurse before medical school. Good luck. You can do it!!
The problem I have with NP/CRNA's is they look for education from Physicians and then want to claim that they are just as good or even better educated than we are in the case of the CRNAs.
Have you guys seen those CRNA educational graphs that compare physician versus CRNA versus AA education? They discount all our undegrad, all our first two years of medical school and then just give us 6 years of patient care experience. In fact some of them don't even count our intern year because it's "got nothing to do with anesthesia". But their undergraduate BSN/ADN programs count towards Anesthesia education. How?
I mean talk about false advertisement.
And how they block AAs who they consider inferior is beyond me. Obviously if you don't feel threatened by these inferiorly trained "providers" why are you blocking their efforts to work in every stage? Why not the market/patients decide if they are indeed inferior?

I am beginning to have animosity towards all CRNAs these days.

 

[DrNotaDr]

Are there any nurses we are missing that you guys want to trash? Any midwife bashing? Now is the time, SDN at its finest.

 

[mountainPA]

I’ve seen physicians, PAs and NPs all mess up.... more than a few times. I’ve seen PAs as green as can be that never worked a day in healthcare before their first job. I can’t remember the last time I met a new grad PA that was more than a CNA before school. All of my friends that are in the NP pipeline and in practice spent years as RNs in the hospital environment. I’ve never actually met anyone that has done a direct entry NP program. Whenever we have these conversations, it always moves quickly to the “but you have direct entry, and that sucks.” From what I’ve heard from people who have met direct entry folks, I haven’t heard anything terrible. I’d personally be wary myself of a direct entry graduate, or just about any graduate without much prior RN experience. In my program, there were a couple folks in my cohort who didn’t have much experience, and one of them had no experience as an RN outside of working in an office for like 6 months. If that’s a problem, and she sucks, then the BON will probably be involved. But I’m the meantime, I’m practicing safely and doing quality work. I’m doing light years better than the PA two providers ago before I got there who only had surgery experience prior to PA school. Didn’t know how to deal with mental patients. Got rolled all the time. Couldn’t read them. Didn’t know the nuance of how to tell folks no. Does that mean there is a problem with the PA pipeline? Maybe. But it doesn’t negate the fact that most PAs are well suited to the work.

Of the three professions, NPs probably do have the highest number of poor performers, and the weakest of the three for admission standards. I’m a little freaked out sometimes when I jump on Facebook and see one of my former coworkers posting that they just got accepted to Walden or whatever. I reckon back to working with them and worrying along with everyone else in the floor that the night was going to be rough. For every one of those folks, there are many more that are just fine. I know NPs that are working bedside and can’t land jobs, and that was pre COVID.

So if your opinion is that betwen MD/DO, PA, and NP, NPs "have the highest number of poor performers, and the weakest of the three for admission standards," doesn't it stand to reason that NPs should not be allowed to practice solo, especially those with limited RN experience? Again, if a physician takes years of supervised practice before practicing without supervision, how does it make sense that a nurse can obtain that by entirely bypassiing medical school and resiedency? What exactly is being taught in nursing schools that allows for such a comphrensive transition?

I don't doubt that there are poor PA clinicians out there, however, there is a check-and-balance system in place between the PA and the attending that helps to ensure patient protection. An independently practicing NP has no such system, and is heavily reliant on their RN experience (if available) to help for medical decision making. I don't argue against RN experience as great experience before NP/PA/MD school; however, the role of the RN and the role fo the "provider" are not the same.

 

[pamac]

So if your opinion is that betwen MD/DO, PA, and NP, NPs "have the highest number of poor performers, and the weakest of the three for admission standards," doesn't it stand to reason that NPs should not be allowed to practice solo, especially those with limited RN experience? Again, if a physician takes years of supervised practice before practicing without supervision, how does it make sense that a nurse can obtain that by entirely bypassiing medical school and resiedency? What exactly is being taught in nursing schools that allows for such a comphrensive transition?

I don't doubt that there are poor PA clinicians out there, however, there is a check-and-balance system in place between the PA and the attending that helps to ensure patient protection. An independently practicing NP has no such system, and is heavily reliant on their RN experience (if available) to help for medical decision making. I don't argue against RN experience as great experience before NP/PA/MD school; however, the role of the RN and the role fo the "provider" are not the same.

No, it wouldn’t stand to reason that NPs shouldn’t be able to practice independently. Even if they are the folks with the weakest admission standards of the three, they are in good company. It’s the same reason that not every pilot needs to be able to fly the space shuttle. Yes, the role of RN and NP are a lot different, but I’d argue that the realm of having a high level of responsibility is what sets RN HcE apart from folks without it. Pretty much the only folks that settle in close to them might be experienced professional paramedics.

I’ve been an advocate for PAs being independent as well, but I just don’t see how that happens because you guys are locked in by the system. The reason I’m comfortable with PAs being independent is because on a daily basis, how much supervision are you guys really clinging to? How much of that check and balance takes place day to day? It’s a formality, but one that keeps you guys in an awkward employment relationship. Whatever the case, the physicians have literally all the say over how you operate, and your only choice is to leave or stay. That’s weird to me given that PAs tend to be excellent providers on the whole.

NPs practice independently in about half of all states right now, with no evidence that outcomes are any worse in states that allow independence vs those that don’t. In fact, the states that don’t allow independence for NPs keep company with states with some of the worst healthcare outcomes out there, vs some of the healthiest states allowing independent practice for NPs. California just created a pathway for independence for NPs after a few years supervision, and in a few years I expect that the time requirement will be lifted just like all of California’s neighbors. The same thing is happening in Florida. Virginia and Illinois have a similar time requirement before NPs can work independently. So it’s happening, and it’s going to be just fine, just like things are in my state. Doctors won’t go away. They won’t have to “supervise” NPs and risk their licenses like kikiscorches insists he is not willing to do (which is funny because where I work, they would just tell him “fine, take a hike if you won’t supervise like we tell you to”). Maybe he’s valuable enough to tell admin to pound sand, but times are a bit different than they used to be before most physicians were employees.

In any event, I am friends with PAs, NPs, and physicians. The professional atmosphere is excellent. Right now, I too am a bit put off by the legions of RNs becoming NPs, but I also am realistic in my thinking that I’d rather put up with that and be independent than throw the baby out with the bath water. I do like the option I have to go out and own my own business, and not have to pay a physician for the formality of “supervising” me. I like that I don’t have to worry about a supervising physician’s license, in addition to my own. In my specialty, if I was a dependent PA, I’d make roughly $60k less than I do now, because my employers know I can leave and do my own thing and do well if they don’t keep me happy. And I am truly mobile. I could leave tomorrow and open up a cash pay practice and have patients within a week. And many or most PAs with psyche skills could do that too, if not for the formalities involved in their chosen career.

 

[deleted6669]

I’ve been an advocate for PAs being independent as well, but I just don’t see how that happens because you guys are locked in by the system. The reason I’m comfortable with PAs being independent is because on a daily basis, how much supervision are you guys really clinging to? How much of that check and balance takes place day to day? It’s a formality, but one that keeps you guys in an awkward employment relationship. Whatever the case, the physicians have literally all the say over how you operate, and your only choice is to leave or stay. That’s weird to me given that PAs tend to be excellent providers on the whole.

Really depends on setting. I currently have 4 clinical jobs. At 2 I am a solo provider and at the other 2 I am the second provider with a doc seeing every other patient. At the solo jobs, the docs don't have any input into my care(my state has no required chart review) and at the double coverage jobs the docs only know what is going on with a patient if I ask them a question, which is rare because I have been working in EM longer than most of them have been alive. I think independence for PAs will happen eventually. New legislation in multiple states removes physician liability for docs working with PAs unless they were directly involved in, or directed the care and does away with required chart review. See Michigan or North Dakota for good examples.

 

[pamac]

Really depends on setting. I currently have 4 clinical jobs. At 2 I am a solo provider and at the other 2 I am the second provider with a doc seeing every other patient. At the solo jobs, the docs don't have any input into my care(my state has no required chart review) and at the double coverage jobs the docs only know what is going on with a patient if I ask them a question, which is rare because I have been working in EM longer than most of them have been alive. I think independence for PAs will happen eventually. New legislation in multiple states removes physician liability for docs working with PAs unless they were directly involved in, or directed the care and does away with required chart review. See Michigan or North Dakota for good examples.

Can a PA go open their own practice in Michigan or North Dakota? Can you in your state?

It’s nice that they let you practice with autonomy. But that’s them letting you practice with autonomy. That changes according to their preference. Them not having to review your charts means nothing. If they want to review your charts, they can and will. If they tell you how things are going to be, you’ll do it. When they don’t tell you what to do, it’s their choice. Think about that quote from GI Jane....”if you were like everyone else, then I suspect you wouldn’t be making statements about not trying to make a statement.” Similarly, if you were really independent as a profession, you wouldn’t have to make statements about how close to being independent you are. Instead, you’d just be independent. At this point in the western United States, only California would make me wait a few years to be an independent provider, and as far as I know, after the time requirement, it’s all done. And I expect that to change further, because the nursing lobby there isn’t just going to settle for that. They will be back next year, and the year after, and the year after... chipping away at the requirement until things look like Washington, Oregon, Idaho, Montana, Wyoming, Arizona, Nevada, Alaska, Hawaii, New Mexico, and Colorado. And that’s just that neighborhood.

 

[deleted6669]

North Dakota rules for PAs as of 2019:

H.B. 1175 makes significant changes to PA practice including:

• Removing the requirement that PAs have a written agreement with a physician if they practice at licensed facilities (e.g., hospitals and nursing homes), facilities with a credentialing and privileging process (clinics), or physician-owned practices;
• Allowing PAs to own their own practice with approval of the North Dakota Board of Medicine;
  • PA practice owners with less than 4,000 hours of experience must have a collaborating physician;
• Defining PAs scope of practice as determined by their education and training;
• Removing references to physician responsibility for care provided by PAs; and
• Clarifying that PAs are responsible for the care they provide to patients.

NP independence is great in primary care, but a hospital, even in an independent state, can require NP chart review and dictate your practice. In my state(which is an independent NP state) some hospitals still say "all PA and NP notes will be cosigned by a physician within X amt of time", so in hospital practice PA=NP. Many places are going to this model and considering both PAs and NPs to be "adv practice providers" (APPs) and treating them identically. A few of the major EM staffing groups(Like Team Health) do this at all of their sites, regardless of state. I agree that for outpt primary care and psych NPs have a significant advantage.

 

[pamac]

Indeed, facilities make their own requirements for their employees. But what matters most is the moment a PA or NP steps out of that job, and what happens then, and that’s where NPs have the edge. North Dakota’s rules are the closes to what independent NPs have, and yet so far from them. You know who I have to get permission from to open my own practice in my state? My spouse. Not the nursing board. Not the medical board.

But again... if you were really independent in any meaningful way in your state, you wouldn’t be talking about how in some facilities, NPs and PAs function under the same employment conditions. I don’t care about that. In those circumstances they can compel certain concessions from physicians as well.... i.e. “you will co-sign charts of our nonphysician providers and therefore inject yourself into a given situation and take on responsibility to your board and to the law for its outcome”. That’s the nature of the employee/employer relationship. But I chose to be an NP over PA primarily because they have power over their own realm as a whole (at least in my state, and the other independent states). I could move to your state next week, and start making money... on my own, by myself. Oddly enough, I could actually make money in your state and not even leave my own. However, you couldn’t walk out your front door next week and do the same thing... in your own state. I don’t care if working at x regional medical center, I’d be under the same constraints as any PA. That doesn’t affect my life the same way at all. What affects my life is if my ability to practice my trade is in the hands of more people than just me.

 

[deleted6669]

Not trying to be argumentative here. Both are great careers, and depending on location or specialty I would (and have) recommended one over the other.
Psych: always NP
Surgery: always PA
Inpatient: either
primary care NP
NICU/PEDS/OB NP
EM: Generally PA, but some places prefer NP and others treat them the same. State and practice dependent

 

[pamac]

PA training is great. I rarely run into a PA that doesn’t have their act together. I run into NPs more frequently that don’t. There are some issues that the NP industry does need to address. I think the world wouldn’t end for anyone if PAs gained independence. To do that, they really need to see things as they are, though. I think their national organization is starting to come around to that. When I was looking at the career, it was not nearly as eager to face the reality of what they are up against.

 

[deleted6669]

Agree that the AAPA is coming around. Almost every state has modernization legislation in the works. I think in 10 years every state will look a lot like north dakota.

 

[pamac]

Agree that the AAPA is coming around. Almost every state has modernization legislation in the works. I think in 10 years every state will look a lot like north dakota.

That’s where I disagree.

North Dakota got that because they are one of the smallest and most rural states.

Physicians aren’t going to give their blessing. They let NPs out of the barn, they won’t make that mistake with PAs. North Dakota isn’t turf anyone was going to fight hard for.

NPs don’t pay much mind to PAs as part of their long range outlook. But if they start to, you have two heavy hitting lobbies against you. PAs rightly feel like they have logic on their side. The ammunition in the battle isn’t logic, it’s clout. California did what I said last year that they would do. Florida has also provided a toehold for them. Texas will hold out forever, but it won’t matter. California was the prize. In 2-4 years, there won’t be time restrictions on NPs in California, and that approach will be the next front for NPs.... to make more gains upon ground they already won.

My prediction.... in 10 years, PAs don’t have a presence in primary care, and thrive only in specialty roles like surgery, and as force multipliers in busy ER fastracks. Physicians will make a push for more residency seats to counter the NP movement (and because they simply have a good case for the need for more residency seats). NPs will continue to churn out numbers, and so will docs.

 

[deleted6669]

I agree that places like CA, NY, and FL will be hard sells. The rest of the country, however, seems to be embracing PA modernization. Something like 20 states have already passed new legislation this year with many others looking at bills for next year. Most are incremental changes: collaboration instead of supervision, docs specifically not responsible for PAs errors, increasing #s of PAs on medical boards, allowing PAs to write for any DME item without cosignature, doing away with # of PAs a single doc can collaborate with, disaster rules stating no supervision required in declared disasters, etc

PAs Celebrate a Year of Unprecedented Wins at the State Level

State legislative wins in 2019 set in motion a positive shift for the PA profession, from eliminating the requirement for PAs to have an agreement with a physician to practice, to shifting from a supervisory model to a collaborative one.

www.aapa.org

It is a work in progress. We are probably a decade behind NPs, maybe 2, but progress is being made. I receive job announcements for solo ED positions in multiple states on a regular basis from ME, VT, NH, TX, WA, AK, MT, ID, NE, SD, ND, GA, MI, WI, and IA. Also Upstate NY.
the rapid rise in specialty postgrad programs for PAs is a game changer as well, especially in EM and critical care.

 

[pamac]

I agree that places like CA, NY, and FL will be hard sells. The rest of the country, however, seems to be embracing PA modernization. Something like 20 states have already passed new legislation this year with many others looking at bills for next year. Most are incremental changes: collaboration instead of supervision, docs specifically not responsible for PAs errors, increasing #s of PAs on medical boards, allowing PAs to write for any DME item without cosignature, doing away with # of PAs a single doc can collaborate with, disaster rules stating no supervision required in declared disasters, etc

PAs Celebrate a Year of Unprecedented Wins at the State Level

State legislative wins in 2019 set in motion a positive shift for the PA profession, from eliminating the requirement for PAs to have an agreement with a physician to practice, to shifting from a supervisory model to a collaborative one.

www.aapa.org

It is a work in progress. We are probably a decade behind NPs, maybe 2, but progress is being made. I receive job announcements for solo ED positions in multiple states on a regular basis from ME, VT, NH, TX, WA, AK, MT, ID, NE, SD, ND, GA, MI, WI, and IA. Also Upstate NY.
the rapid rise in specialty postgrad programs for PAs is a game changer as well, especially in EM and critical care.

Gotta take it where you can get it, I guess. But a patchwork of differing regulation across the country seems like it would take everything farther away from where you want to be. Maybe that sounds like it’s moving the goalposts on my part by suggesting change and then saying any change could be problematic. However my thoughts on that are that there are just some foundational strictures that won’t be removed. In ten years, PAs may have advanced, but NPs will be 15-20 years ahead of you guys, and that doesn’t seem to bode well for the future unless you look at PAs in isolation. NPs go in with clear goals and a united front. They just barely started settling for less, but only as a way to set themselves up for more. That’s where you see these laws that allow independence after x-number of supervised hours. Those will go away with the next round of lobbying.

But no, I’m not hoping for PAs to remain in stasis, I just think they will because of headwinds that are too robust. The PA realm is too fractured, and the ones that are riled up to push for change also carry baggage of their own involving the chip on their shoulder towards NPs. To harp on NPs as inferior means taking focus off of what the PA world needs to do to get their act together to succeed. So I predict many more years in the wilderness, which in a fast changing world is like going without oxygen as time ticks by. Solo gigs in rural areas? Rural hospitals are dying. I’m not convinced that is a harbinger of success to have those places be the bastions for the profession.

 

[PikminOC]

Why do "independent" NP still have collaboration agreement with Physicians?

My rn patients are saying there's a shortage of RN as many young nurses are going to Np school. There will be a glut...

 

[Kidpolean]

Why do "independent" NP still have collaboration agreement with Physicians?

My rn patients are saying there's a shortage of RN as many young nurses are going to Np school. There will be a glut...

It depends on the facility. Even if the NP practices in a state that allows them to practice independently, the facility they work for can still require physician supervision.