Should physicians let NP/PA take over primary care and anesthesia?

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Eh, I think the breaking point with healthcare will be 22% of GDP when people start clamoring for change. Probably end up with a NHS-style system and lower wages across the board. Hoping I can pay off my loans before that happens.

I think it's ridiculous that they (the federal government) don't do a better job funding medical education. And couldn't you do Locums and make lots of money or work in underserved area for a year or something?

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I think it's ridiculous that they (the federal government) don't do a better job funding medical education. And couldn't you do Locums and make lots of money or work in underserved area for a year or something?
I have 400k in loans. With taxes and living expenses, I'm looking at a bare minimum of three years to pay that down if I hit it hard right out of residency.
 
Hi Blix, in short yes I feel comfortable managing every one of those situations. I can go through them if you like, but I am not sure what that proves really (most of those are pretty easily googled). The pelvic exams I do these days are less of the chronic variety, and more the acute stuff (e.g. Did i lose my baby).

For your knowledge though, those are all situations that every third year medical student has been through (exception being tertiary syphilus, that must be from working in a prison :) ). Most of the questions you asked are covered in first or second year of medical school at a fair degree of depth.

Personally, I have found that nps and pas can be very useful in the right settings. My only real problem with nps is the variability of your education. I have met nps who were competent, and others who were significantly less so. The field needs standardization, and there needs to be more required clinical hours if people are going to go straight from college.

I agree
 
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Step I was arguably the hardest exam i ever took. If a provider cant demonstrate this knowledge how can they be equivalent to someone who did-unless the detail learned in the first 2 years of medical school are not necessary to practice medicine. A physician has a profound and integrated knowledge of physiology pharmacology pathology and medicine. Let me be clear it is not a matter of intelligence, it is a matter of the rigors of education- assuming this level of education is necessary to provide safe quality care.
 
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You won't like this analogy I'm sure, but hear me out.

I used to be a medical scribe for 4 years in a community ED. After 3 years, I truly thought that I "got it". I would know the workup for 90+% of the patients that came through the doors and I "knew" what the management would be for the vast majority of patients after watching the H&P. I even thought it was easy as it seemed mostly formulaic and I was literally standing next to the doc for the full shift listening to and observing everything that they would do. I would pick up on some of the teaching pearls that you mentioned in your earlier post and I really thought that I was something clever.

Fast forward 3 years into medical school and I'm semi-mortified at how cocky I was as an undergrad. Medicine really does take a highly structured learning pathway to learn and master and you cannot simply 'learn by doing'. Every one of your examples are singular points along a higher and more complex understanding of disease and medicine that can only be appreciated through exhaustive study and thousands of hours of application. Taking your point about syphilitic gummas for example: do you know the difference between gummas and condyloma lata? What abx do you use for penicillin-allergic patients? What's the difference between VDRL and FTA-ABS testing? How do you know when you've adequately treated neurosyphilis? When would you consider secondary syphilis in the ddx of a patient with non-specific viral syndrome and macular rash? Who should be screened for syphilis? What are common causes of false-positives when testing for syphilis? Would you recognize a syphilitic chancre and be able to differentiate it from other STD's or malignancy? This is all still basic material similar to what posted beforehand, but it's just highly unlikely that anyone would know ALL of this without a structured and rigorous education.

I don't say this to be a jerk, but the oft repeated adage "you don't know what you don't know" is so true. I'm well into my M4 year and kicking butt clinically and yet only starting to grasp how much I don't know. The worst part is that I know that if I were to have a frank conversation with my 3 year younger self I would find him to be a cocky little **** stain.

Hey, I can appreciate what you just wrote. In my education, we actually did cover the differences between primary, secondary, and tertiary syphilis. We went over the difference between a gummas and condyloma lata, and all the clinical manifestations that present with each one. Of note, the patient that we did penicillin challenge on was allegedly allergic to penicillin, thats why we did the challenge. He ended up getting the penicillin but doxy would be the preferred alt drug. The particular patient we treated also had HIV and HPV. He was high risk. Patients with mucous patches or open lesions are highly contagious. Having said that, I don't claim to remember all the content on this lecture, so I do need to review this, especially if I ever go back and work in corrections..
 
I have 400k in loans. With taxes and living expenses, I'm looking at a bare minimum of three years to pay that down if I hit it hard right out of residency.

You can do it. You'll probably be earning a strong salary to pay it off in that time frame.
 
I'm sure that if NP schools changed the curriculum, you would see NPs passing.
You mean if NP schools became Medical schools? then yes they would. And that article of NPs taking a step was step 3, by far the easiest and most "nurse friendly" yet they still did horribly (I believe far below 50% but someone can look it up). They shouldn't have to take steps because they are a not physicians, they're a vital part to healthcare but they are no where close to being the equivalent to physicians and anyone pretending equivalence, just as if a MA pretended to have the same training and knowledge as an RN, is posing harm to the patient,
None of these criticisms of NP training are directed at you personally, I'm sure you do a great job, it's a criticism of a system that allows for immensely unqualified young NPs to be churned out at an exponential rate, many of which you yourself said you would not hire.
 
You can do it. You'll probably be earning a strong salary to pay it off in that time frame.
Highly unlikely. To pay my loans down in my state and have enough money left over for basic cost of living for a family on a single income, I'd need to make 350k, which is well beyond the 90th percentile for psychiatry compensation in my area.
 
Highly unlikely. To pay my loans down in my state and have enough money left over for basic cost of living for a family on a single income, I'd need to make 350k, which is well beyond the 90th percentile for psychiatry compensation in my area.
Open couple of offices and staff them with PA...
 
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That's not actually correct.
If you're going to quote articles, learn what they said and what they did, not just what you think the abstract said.
You mean if NP schools became Medical schools? then yes they would. And that article of NPs taking a step was step 3, by far the easiest and most "nurse friendly" yet they still did horribly (I believe far below 50% but someone can look it up). They shouldn't have to take steps because they are a not physicians, they're a vital part to healthcare but they are no where close to being the equivalent to physicians and anyone pretending equivalence, just as if a MA pretended to have the same training and knowledge as an RN, is posing harm to the patient,
None of these criticisms of NP training are directed at you personally, I'm sure you do a great job, it's a criticism of a system that allows for immensely unqualified young NPs to be churned out at an exponential rate, many of which you yourself said you would not hire.

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Il Destriero

True. Just looked it up. It was similar content the USMLE 3 and was a contract between the NBME and CACC. It was a pilot in 2008, and hasn't really taken off as a standard.
You mean if NP schools became Medical schools? then yes they would. And that article of NPs taking a step was step 3, by far the easiest and most "nurse friendly" yet they still did horribly (I believe far below 50% but someone can look it up). They shouldn't have to take steps because they are a not physicians, they're a vital part to healthcare but they are no where close to being the equivalent to physicians and anyone pretending equivalence, just as if a MA pretended to have the same training and knowledge as an RN, is posing harm to the patient,
None of these criticisms of NP training are directed at you personally, I'm sure you do a great job, it's a criticism of a system that allows for immensely unqualified young NPs to be churned out at an exponential rate, many of which you yourself said you would not hire.

Careful now, I said I wouldnt hire an NP that has no RN experience. Now, I started young because I became an RN young. Now im 27 with over 5 years of RN experience and counting who is now a FNP. Regarding the STEP 3 exam, that test was made by the CACC (a DNP group) and NBME. It was designed to be like the USMLE 3. 45 DNP students took this test for the first time ever and 1/2 passed, 1/2 failed. Though not all that impressive, 1/2 did pass it. If more took this exam, I'm sure you'd see more pass rates as the content of this exam include the subject matter in our curriculum. If this actually became "a thing" Id go take it and probably pass if I prepare. But I think the bigger question is if nursing is its own profession, why take any medical licensing exam at all? We have our own credentialing process and I think they should make changes to the variability of education that we currently face (i.e., online nurse practitioner programs, and direct entry programs). To be fair though, there is a lot of variability in medical schools too. Some medical schools will take prereqs done online; students with weak backgrounds and GPAs; I believe Oceana has an online program where many medical students go if the cant cut it in the states; and one medical school I believe in one of the Carolinas allows direct entry (i.e., not all the basic sciences) for RNs to get in with good MCAT scores (RNs sometimes study for the MCAT without taking the courses and still do well, imagine that); and another school I heard in Texas has accelerated medical school (3 year program).
 
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It was a watered down version of step 3... Med students/residents don't study for that exam; the NP probably studied their ass off for it so they could prove to the medical community they can practice independently, and a half of them still did not pass it...
 
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To be fair, this has never been tried (i.e., taking large number of NPs and having them take USMLE exams). But I would venture to say that you are right... I'm sure that if NP schools changed the curriculum, you would see NPs passing. I know some article that I read not too long ago stated that some 19 DNPs tried it and about 1/2 passed. I don't know man...Nursing just has a different approach to medicine. We have good outcomes, and manage a fair amount illnesses. I don't want to sound cocky, but if you worked with me like so of my physician colleagues, I'd grow on you and you'd see that I'm pretty darn good at what I do ;-) The MDs and DOs I work with are happy to work with me and train me. The pediatrician I worked with, his wife who manages the office was so happy with me she wanted to hire me out of school. Don't know what to say man, there's good one's and bad one's in every profession.
Half tried taking a greatly watered down version of step 3 only (not the real thing) and half failed it. And thats the easiest of all 3 exams.
 
It was a watered down version of step 3... Med students/residents don't study for that exam; the NP probably studied their ass off for it so they could prove to the medical they can practice independently, and a half of them still did not pass it...

It was a watered down version of step 3... Med students/residents don't study for that exam; the NP probably studied their ass off for it so they could prove to the medical they can practice independently, and a half of them still did not pass it...

Yea I know the saying, "just a number 2 pencil for 3" right? Anyways, I don't know how much they studied actually. And you as a doctor know that you can't make any inferences for a group that took this exam for the 1st time and with a small sample size...What stick crawled up your a** this morning? I bet if we were told tomorrow, "hey, you need to pass the USMLE 3 boards to become an NP", I would welcome that and pass this exam. But again, nursing is its own profession and we already have a credentialing process. Things need to be improved with the variability in NP schools, that is something I can agree with you guys on.
 
Half tried taking a greatly watered down version of step 3 only (not the real thing) and half failed it. And thats the easiest of all 3 exams.

Not a good result, I know. But only 45 DNPs took this exam and this was the 1st time something like this was done. ARNPs, if they decide to make this a part of their credentialing process, would tailor their education to this exam and likely pass it. You're making a big deal out of basically a pilot study.
 
Physicians do not have to be in the premise for PAs to do their job. The state I live in allows monthly chart review...

Let me ask you a question W19. If you have PAs working under you, do you actually review their charts?
 
Mad Jack, you see!? I knew I liked you! lol.
Just being objective about it. Psych NPs have psychotherapy training and focus on psych meds, while PAs barely scratch the surface. In the ICU or OR, I prefer PAs due to their training and mire extensive anatomy and physiology knowledge. Outpatient, it's six if one, half dozen of the other, but I still prefer PAs.
 
Yeah, with all those patients and all that capital that I don't have...
You do that after being in practice for at least 2 years... Opening a psych practice does not cost that much I was told. I assume it's not difficult to build a patient base in psych..
 
You do that after being in practice for at least 2 years... Opening a psych practice does not cost that much I was told. I assume it's not difficult to build a patient base in psych..
It also boxes you into taking insurance, which substantially increases your overhead
 
Just being objective about it. Psych NPs have psychotherapy training and focus on psych meds, while PAs barely scratch the surface. In the ICU or OR, I prefer PAs due to their training and mire extensive anatomy and physiology knowledge. Outpatient, it's six if one, half dozen of the other, but I still prefer PAs.

Ah man you ruined my excitement :-/ I thought we were bonding Mad Jack. If all is equal, and you take a direct entry NP (i.e., no RN experience) vs. a PA right out of school, then yes, I would hire the PA, no question. But if you take an RN with years of acute care experience with good credentials, and now is an ARNP, I would hire him/her over the PA, no question. That nurse with the RN experience in the acute care setting will be able to exercise better judgement and recognize subtleties in a patient, like we do in the hospital. In OR, yes, I would go with PA everyday, any day unless you have some exceptional NP who is well trained in surgery.
And this is a debate for another forum, but I would argue that the traditional ARNP path is far more extensive in training and time spent with patients than any PA school. By the time RN finishes ARNP school he/she has received a ton of pharmacology and pathophysiology training too, and has strong understanding in the management of their population focus (in my case family so womens, peds, geriatrics and adult).
 
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Let me ask you a question W19. If you have PAs working under you, do you actually review their charts?
Probably for the 1st 3 months... By the way, I was a nurse for almost 8 years and I know many of my former classmates that are dumb as rock that are NP, so that's why I will NEVER trust any NP until they prove themselves...
 
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Ah man you ruined my excitement :-/ I thought we were bonding Mad Jack. If all is equal, and you take a direct entry NP (i.e., no RN experience) vs. a PA right out of school, then yes, I would hire the PA, no question. But if you take an RN with years of acute care experience with good credentials, and now is an ARNP, I would hire him/her over the PA, no question. That nurse with the RN experience in the acute care setting will be able to exercise better judgement and recognize subtleties in a patient, like we do in the hospital. In OR, yes, I would go with PA everyday, any day unless you have some exceptional NP who is well trained in surgery.
And this is a debate for another forum, but I would argue that the traditional ARNP path is far more extensive in training and time spent with patients than any PA school. By the time RN finishes ARNP school he/she has received a ton of pharmacology and pathophysiology training too, and has strong understanding in the management of their population focus (in my case family so womens, peds, geriatrics and adult).
I'd hire an experienced PA over an experienced NP though. A strong foundation makes for a stronger base for growth.
 
Probably for the 1st 3 months... By the way, I was a nurse for almost 8 years and I know many of my former classmates that are dumb as rock that are NP, so that's why I will NEVER trust any NP until they prove themselves...
Basically my issue as well, there is zero quality control.
 
To be fair though, there is a lot of variability in medical schools too. Some medical schools will take prereqs done online; students with weak backgrounds and GPAs; I believe Oceana has an online program where many medical students go if the cant cut it in the states; and one medical school I believe in one of the Carolinas allows direct entry (i.e., not all the basic sciences) for RNs to get in with good MCAT scores (RNs sometimes study for the MCAT without taking the courses and still do well, imagine that); and another school I heard in Texas has accelerated medical school (3 year program).
You are misinformed. No US accredited school has these online programs, there's probably not a single doctor in the country that went to that oceana school if that is even possible. I'm not sure about the Carolina and Texas programs but it doesn't matter, NP is still nowhere close to the standards of physicians. An NP would never pass step 1 from two months of study, I would bet the farm on that, I rarely talk in such absolutist terms but it is a one in a million chance. NP orgs are free to make up things that are "like step 3" and continue to try to maliciously confuse the public in hopes of offering substandard and cheaper care. If you want to say you're on equal training to a doctor you need to go to medical school and more importantly a physician residency, theres no getting around that no matter what the nurse leaders make up.
 
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You are misinformed. No US accredited school has these online programs, there's probably not a single doctor in the country that went to that oceana school if that is even possible. I'm not sure about the Carolina and Texas programs but it doesn't matter, NP is still nowhere close to the standards of physicians. An NP would never pass step 1 from two months of study, I would bet the farm on that, I rarely talk in such absolutist terms but it is a one in a million chance. NP orgs are free to make up things that are "like step 3" and continue to try to maliciously confuse the public in hopes of offering substandard and cheaper care. If you want to say you're on equal training to a doctor you need to go to medical school and more importantly a physician residency, theres no getting around that no matter what the nurse leaders make up.

No one is claiming equivalency in education or approach to medicine. We keep going in circles with this debate. I just don't have the time to keep explaining this to you. Look if you don't like NPs so much, then what have you done to change anything? Do you work with NPs?
 
Basically my issue as well, there is zero quality control.

I agree, they need to raise standards. But I don't know, I would go with experienced NP, who has gone traditional route, all of the time over a PA. But I'm a little bias. Many physicians I know that I actually see in person think like this as well.
 
Probably for the 1st 3 months... By the way, I was a nurse for almost 8 years and I know many of my former classmates that are dumb as rock that are NP, so that's why I will NEVER trust any NP until they prove themselves...

How would you define proving themselves? I think nurses prove themselves if they have strong RN background and then decide to go to a good ARNP school. You hire ones that you know have gone the traditional pathway (i.e., no direct entry or online programs) and have a strong background in floor nursing. No data gives any reason for your and Mad Jack to have such mistrust of NPs. It's really quite sad how much sh** you guys talk. Nothing shows that we produce bad outcomes..Things are actually going really well for the ARNP profession and its impact on access to medical services and healthcare industry. So what gives?
Anecdotal thought: I really hope that in your professional life you work with NPs and get to know their back stories and what motivated them to go this route. Work with them and train NPs. Doctors that are open, and like and train NPs work with them because they soak things up like sponges and are great to collaborate with. NPs tend to take constructive criticism very well and seek improvement day in and day out. These physicians that are open to NPs are mature about things and realize that it is the present reality that NPs exist and are here to stay. So rather than bitc*** and complaining, they train them and work with them. 9 times out of 10, the physician develops a good working relationship. I've met ARNPs that are partners in a physician practice.. Your pears are supporting NPs guys. Suggest you get on board and do what you can to work with your nursing colleagues.
 
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How would you define proving themselves? I think nurses prove themselves if they have strong RN background and then decide to go to a good ARNP school. You hire ones that you know have gone the traditional pathway (i.e., no direct entry or online programs) and have a strong background in floor nursing. No data gives any reason for your and Mad Jack to have such mistrust of NPs. It's really quite sad how much sh** you guys talk. Nothing shows that we produce bad outcomes..Things are actually going really well for the ARNP profession and its impact on access to medical services. Don't know why you guys hate NPs so much.
Basically, there is a nursing school in every corner of my state. Some of them do fraudulent stuff and I know about these things... Getting into NP school should be where the nursing organizations draw the line, and they have failed. They have no admission standards like PA schools...

I have a friend who applied to what is supposedly a good and established NP school, and that friend asked me to write her a LoR as I was starting med school in 2014, needless to say i was pretty busy... Do you know that the school email me 2x and tell me that they have been waiting for the LoR so they could give her spot.? That how desperate they were...

How would I define proving themselves? When they start working with me and show me they are capable... or a physician colleague tell me they are competent.
 
Basically, there is a nursing school in every corner of my state. Some of them do fraudulent stuff and I know about these things... Getting into NP school should be where the nursing organizations draw the line, and they have failed. They have no admission standards like PA schools...

I have a friend who applied to what is supposedly a good and established NP school, and that friend asked me to write her a LoR as was starting med school in 201, needless to say i was pretty busy... Do you know that the school email me 2x and tell me that they have been waiting for the LoR so they could give her spot.? That how desperate they were...

How would I define proving themselves? When they start working with me and show me they are capable... or a physician colleague tell me they are competent.

Fair enough. I agree they need to elevate standards. However, ARNP route is not easy either when the only undergraduate degree you can have is in nursing (unlike PA or Medical School for that matter). But hey, if you are willing to work with NPs and train them, and you're open to that, then that awesome. I think you'll be pleasantly surprised at how NPs work. Typically they are very eager to learn and will likely boost your bottom line too if you have a private practice.
 
Fair enough. I agree they need to elevate standards. However, ARNP route is not easy either when the only undergraduate degree you can have is in nursing (unlike PA or Medical School for that matter). But hey, if you are willing to work with NPs and train them, and you're open to that, then that awesome. I think you'll be pleasantly surprised at how NPs work. Typically they are very eager to learn and will likely boost your bottom line too if you have a private practice.
I have nothing against NP... I was (or I am) a nurse and some of my friends are NP. So naturally I should be more open to the idea of working alongside NP, but it's hard for me to close my eyes when the barrier to entry into NP is nonexistent.

The way I put it: If I hire a PA when I become a doc, I will assume he/she has a minimum competency until proven otherwise... For NP, I will assume that he/she is incompetent until he/she shows me s/he isn't...
 
I agree, they need to raise standards. But I don't know, I would go with experienced NP, who has gone traditional route, all of the time over a PA. But I'm a little bias. Many physicians I know that I actually see in person think like this as well.
Given the lack of QC, I'd prefer the PA. On average they've got 5,000 hours of experience in health care, which is stronger than many of the NPs I've worked with that just went straight through. And the quality of graduate education (3,000 clinical hours, on average, versus 750) and their clinical courses crush any undergraduate or graduate nursing courses- many of them take courses directly alongside medical students.
 
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Given the lack of QC, I'd prefer the PA. On average they've got 5,000 hours of experience in health care, which is stronger than many of the NPs I've worked with that just went straight through. And the quality of graduate education (3,000 clinical hours, on average, versus 750) and their clinical courses crush any undergraduate or graduate nursing courses- many of them take courses directly alongside medical students.

Mad Jack, PAs are trained as "generalists" so of course they do more clinical and course work. Most PAs that came from worlds like business or were teachers or whatever have ZERO experience in healthcare and if they do need it for admission, it can be in any area. With NPs, they have nursing experience which typically guarantees that that student had exposure and training in patient care, pharmacology and pathophysiology among other applied sciences related to patient care. NPs focus on a SINGLE population of foci. Again, that's why they do less class time and clinical time. If we got advanced training in all the areas that PAs and medical students did, we'd have more clinical hours and course work, by far compared to PAs. Like for example, if I got a post masters certificates as neonatal NP, acute care NP, and psych NP - in addition to what I've already obtained (FNP certification), then my education would dwarf a PAs education and dare I say, be analogous to that of a medical education. The training is just simply not the same because of that fact (i.e., population focused training that NPs obtain).
Regarding standards of entry, I agree there are "nurse mill" schools. I despise these programs. But for myself, and majority of NPs out there that go the traditional route, rest assure we come out with, as w19 said about the PAs, "minimal competency" where the rest is learned in practice with proper structure and physician/administrative support.
 
In response to the original post, the answer is of course no. I say this as an individual that has been working in a direct patient care for many years (prehospital, ED, ICU, uro, FP, and interventional pain management) and now a second year PA student. The role of the PA/NP should be to extend the services that the MD/DO provides, as is described in a contractual agreement determined at the site level. While I cannot speak for NPs, the role of the PA was never to replace that of the physician. While some physicians may allow the PA to essentially work "independently" this is at the discretion of the practice as well as the PAs ability. The VAST majority of PAs do not wish independent practice and this is not a part of our formal training. In terms of anesthesia, PAs/NPs do not have much of role, as this is overwhelmingly an area that is dominated by CRNAs. AAs (anesthesiologist assistants) do provide anesthesia services, but once again, are not pushing for independent practice and understand their role in the medical model.

I personally feel that if physicians are concerned of NP encroachment, then they need to stop training and hiring them. I understand that physicians are increasingly making fewer of the hiring decisions, however I think if more and more refused to work with NPs, in preference of PAs, then medical groups would listen. After all, most hospital administrators know nothing of the difference in our training, and frequently interview individuals that represent both professions for employment. Although PAs tend to make more than NPs, the difference is drastically marginal when you consider physician salaries. The AMA needs to know that PAs are on their side, and the few malcontents that push for independent practice are few and far between. The PA profession is ultimately governed by the AMA and our training exceeds that of NPs. We take an almost identical pre-med pathway as med students. Our formal education follows the medical model, with many of our classes being taught alongside medical students. Our board exams are patterned after the USMLE, and our review material for said exam is the same. We recertify just like physicians, and because of our generalist education we are able to move around specialties much more easily than an NP. Our profession would not exist without the MD/DO professions, and we in no way wish to usurp the role of the physician/surgeon. PAs come to you with a standardized training model (that the AMA helps dictate) and with an understanding that most days we will see the "easier" patients and you will see the "harder" patients. If you expect that we do see the "harder" patients as well, you better believe that we are going to be consulting you regularly, even after we have years of experience under our belts.
 
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Mad Jack, PAs are trained as "generalists" so of course they do more clinical and course work. Most PAs that came from worlds like business or were teachers or whatever have ZERO experience in healthcare and if they do need it for admission, it can be in any area. With NPs, they have nursing experience which typically guarantees that that student had exposure and training in patient care, pharmacology and pathophysiology among other applied sciences related to patient care. NPs focus on a SINGLE population of foci. Again, that's why they do less class time and clinical time. If we got advanced training in all the areas that PAs and medical students did, we'd have more clinical hours and course work, by far compared to PAs. Like for example, if I got a post masters certificates as neonatal NP, acute care NP, and psych NP - in addition to what I've already obtained (FNP certification), then my education would dwarf a PAs education and dare I say, be analogous to that of a medical education. The training is just simply not the same because of that fact (i.e., population focused training that NPs obtain).
Regarding standards of entry, I agree there are "nurse mill" schools. I despise these programs. But for myself, and majority of NPs out there that go the traditional route, rest assure we come out with, as w19 said about the PAs, "minimal competency" where the rest is learned in practice with proper structure and physician/administrative support.
Ah, but physician assistants generally do have prior HCE- most schools require it, and, as I noted prior, the average PA matriculant has 5,000 hours. Many of them were even, shockingly, nurses. But the smoke fact is, no amount of experience at the basic level prepares one to practice at the advanced level. It is a different capacity, a different way of thinking, a different skill set. We cover more in twelve weeks of medical school than is covered in the entirety of an undergraduate nursing education, and PA education is based on our model. NP education is largely fluff, courses in Nursing theory or on capstone projects that are basically BS. The actual clinical work NPs do leaves much to be desired- it is often outpatient in nature, part time or a mere 40 hours a week when full time. PAs rotate alongside medical students must of the time, working our hours in many cases and getting exposure to the same stuff we set in third year.
 
Basically, what I'm saying is intense education can turn a non-healthcare provider into a healthcare provider in 24 months, but no amount of lax education can ever create one.
 
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Mad Jack, PAs are trained as "generalists" so of course they do more clinical and course work. Most PAs that came from worlds like business or were teachers or whatever have ZERO experience in healthcare and if they do need it for admission, it can be in any area. With NPs, they have nursing experience which typically guarantees that that student had exposure and training in patient care, pharmacology and pathophysiology among other applied sciences related to patient care. NPs focus on a SINGLE population of foci. Again, that's why they do less class time and clinical time. If we got advanced training in all the areas that PAs and medical students did, we'd have more clinical hours and course work, by far compared to PAs. Like for example, if I got a post masters certificates as neonatal NP, acute care NP, and psych NP - in addition to what I've already obtained (FNP certification), then my education would dwarf a PAs education and dare I say, be analogous to that of a medical education. The training is just simply not the same because of that fact (i.e., population focused training that NPs obtain).
Regarding standards of entry, I agree there are "nurse mill" schools. I despise these programs. But for myself, and majority of NPs out there that go the traditional route, rest assure we come out with, as w19 said about the PAs, "minimal competency" where the rest is learned in practice with proper structure and physician/administrative support.

I would like to see referenced statistics on this. I know lots of PAs, and almost ALL of them had prior direct-patient care experience before beginning PA school. Some of them were even nurses, most of them noting the lack of educational standards for NP programs as the reason they pursued the PA pathway. If the PA student didn't have much in the way of prior clinical, then they were rock stars in undergrad, with strong science backgrounds, and most definitely near straight As in their prerequisite coursework, which includes organic chemistry, biochemistry, and usually several upper division biology classes. Besides, what is wrong with having a background in "business" or "education"? Even if the PA applicant was a professional pilot (yes, I know one) for over a decade, what makes you believe that this individual would not be able to practice medicine in a supervised capacity? I will agree that experienced RNs bring with them excellent clinical judgement and skill, but they are designed to follow orders and preexisting protocols. They are not trained in the medical decision making capacity to that of a physician. I know lots of nurses that come from non-nursing backgrounds. Does this make them less able to provide excellent bedside care. Absolutely not!
 
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I don't understand how NP can understand pathophysiology at the level needed to practice medicine without first having a good understanding of biology/physiology/biochem. For instance, my first pharm test in MS2 was basically biochem again... In order to understand gynecology, you have to have a good grasp of the endocrine system... How are NP able to understand this things at the level needed to practice medicine is beyond me? I can go on and give many examples of the interconnectedness of these things... But NP seem to think they can skip all these things and still be competent...
 
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I would like to see referenced statistics on this. I know lots of PAs, and almost ALL of them had prior direct-patient care experience before beginning PA school. Some of them were even nurses, most of them noting the lack of educational standards for NP programs as the reason they pursued the PA pathway. If the PA student didn't have much in the way of prior clinical, then they were rock stars in undergrad, with strong science backgrounds, and most definitely near straight As in their prerequisite coursework, which includes organic chemistry, biochemistry, and usually several upper division biology classes. Besides, what is wrong with having a background in "business" or "education"? Even if the PA applicant was a professional pilot (yes, I know one) for over a decade, what makes you believe that this individual would not be able to practice medicine in a supervised capacity? I will agree that experienced RNs bring with them excellent clinical judgement and skill, but they are designed to follow orders and preexisting protocols. They are not trained in the medical decision making capacity to that of a physician. I know lots of nurses that come from non-nursing backgrounds. Does this make them less able to provide excellent bedside care. Absolutely not!

Your right about some of your points except that we cant make clinical decisions or be independent. The same can be said about PAs since by nature they are assisting the physician. Wont knock your program or education but pa schools consider CNA experience as medical experience. RN is unique because the entire RN training from day 1 is involved around patient care. So while anybody can go into medicine and recieve intensive training in 2 years at pa school, NPs are trained for 5-7 years and work as RN in collaboration with physicians. Im sorry but i just dont see how this adds up. All our courses have built into it patho, pharm, micro, epidemiology, etc. etc. And until you guys can show how NP education is unsafe to the public or cite some study, then all you rhetoric is based of fear of the unknown. Fear of an approach that you aren't familiar with and therefore react in the only way you know how - with fear and disdane
 
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I don't understand how NP can understand pathophysiology at the level needed to practice medicine without first having a good understanding of biology/physiology/biochem. For instance, my first pharm test in MS2 was basically biochem again... In order to understand gynecology, you have to have a good grasp of the endocrine system... How are NP able to understand this things at the level needed to practice medicine is beyond me? I can go on and give many examples of the interconnectedness of these things... But NP seem to think they can skip all these things and still be competent...

You would understand better if you look closer at our curriculum. Like I told the PA in the post before from day one nurses are being taught pharmacology pathophysiology, epidemiology, clinical skills, and how to interact with patients; in addition nurses focus a lot on health promotion and disease prevention. In every course I have taken, we are constantly reviewing anatomy physiology, pathophysiology and tying that into the populations that we focus on for that semester. Like you guys always say, you don't know what you don't know, right? So look into what we are actually studying don't just look at the course names. If you look at the power points, the lectures, the books we study out of and see what we are doing, And the approach we have to medicine, you will see be able to corroborate what I'm talking about. I don't claim to know more than a doctor or the nurse practitioner training is more than physician training, but we at least come out with minimal competency that grows as we practice
 
Basically, what I'm saying is intense education can turn a non-healthcare provider into a healthcare provider in 24 months, but no amount of lax education can ever create one.

You're just wrong about that read my post to the PA and W 19. And FYI at my school, theory and research were two of some of the most difficult didactic courses. They were considered weed out courses for my program
 
You're just wrong about that read my post to the PA and W 19. And FYI at my school, theory and research were two of some of the most difficult didactic courses. They were considered weed out courses for my program
Just because they're difficult doesn't mean they're useful. As to my perception of your education, it largely comes from NPs turned PA or MD/DO. They know better than I do, or than you for that matter. I've never heard, from any NP-turned-PA/MD/DO, that their prior education was anything other than lackluster.
 
Just because they're difficult doesn't mean they're useful. As to my perception of your education, it largely comes from NPs turned PA or MD/DO. They know better than I do, or than you for that matter. I've never heard, from any NP-turned-PA/MD/DO, that their prior education was anything other than lackluster.

Really, that's quite a claim that our education isn't useful! Try telling that to the millions of people that rely on NPs and the thousands of physicians that utilize NPs in there practices. Try saying that to the policy makers, and the people that back NPs and have actually looked at what we do objectively. Do you have anything to back up that we "aren't useful"? You have ANY data that shows we are unsafe, or don't know what we are doing? All you have is stories and anecdotal pearls. I have plenty of stories about "useless" psychiatrist and doctors too. But do I paint the whole medical establishment with a mass generalization? No, I don't. Like for example, because of this conversation I've had with you, I can potentially say that all physicians are bitter a** holes. But I know better to not do that.
 
I don't understand how NP can understand pathophysiology at the level needed to practice medicine without first having a good understanding of biology/physiology/biochem. For instance, my first pharm test in MS2 was basically biochem again... In order to understand gynecology, you have to have a good grasp of the endocrine system... How are NP able to understand this things at the level needed to practice medicine is beyond me? I can go on and give many examples of the interconnectedness of these things... But NP seem to think they can skip all these things and still be competent...

But, you see, they have taken those classes. Ask any BSN student and they'll say, "We took organic chemistry, too!" It turns out to be a chemistry course for non-science majors where they learn vocabulary words and some basic structures, but hey, there was some organic chemistry involved so it counts. They take a watered down pathophysiology course in nursing school armed with an undergraduate level physiology course as foundation for "normal" and claim to have a similar background as a graduating medical student. The false equivalence has been around since I was in undergrad which was...sadly over 10 years ago now. None of this is new. The NP craze has just taken it to a higher level. You look at DNP curricula from even top rated schools and its filled with fluff about nursing theory and education, lobbying, and health policy. There is usually a credit hour or two to "advanced pathophysiology" and then community health/family health/global health/whatever. This gets topped off with 700 or so hours of clinical exposure of varying in quality, and now you get a false equivalency that someone with this level of education is as qualified to provide primary care as someone who has finished an IM or FP residency.

The outcomes studies for both NPs and CRNAs have been ripped apart for poor methodology and so on multiple times in multiple subforums here, so I won't belabor that point.

Dunning-Kruger effect (Dunning–Kruger effect - Wikipedia) has been exhibited perfectly in the whole advanced practice nursing area, hell, even med/surg nursing, for a long time. I saw it personally when my sister and friends were in nursing school (these doctors are idiots! Listen to this story where the doctor did something that I thought was wrong because I don't have the necessary background to understand the decision making process in this patient! We know more than they do AND we take care of the patient!), saw it in medical school, and continue to see it in residency.

Unless something changes with the healthcare system here they are not going anywhere, though. The need for primary care is present, and DNP programs shoot up faster than medical schools. The only group really interested in doing outcomes studies are the nursing organizations. Maybe if the AAFP had a fire lit under them they could pursue a study, but if you think about it this is a difficult study to pull off and would require long term follow up. Imaging and referral differences have been explored in a small amount of studies, which did show increased imaging use and referral patterns for advanced practice nurses, however it is again difficult to draw conclusions based on methodology and certain unknowns. The best thing we can do as physicians is try and educate and close the education gap somewhat for the sake of patients. I frequently get inappropriate referrals from NPs (and to a much lesser extent physicians), and I make it a point to call or email them to discuss the patient and decision making process. I do this in a non-judgmental manner and phrase it around "closing the loop" so they know what's going on with the patient. I do this in hopes that it will change their practice patterns, but also ensure they aren't afraid to refer a patient that actually does need evaluation.

I certainly don't hate nurses, don't get me wrong. A good floor or OR nurse makes my life much, much easier when I'm not constantly having to double check that a med was given on time, vitals or I/Os have been charted, etc. I don't hate NPs, either, as long as they understand the limitations of their training- in the same way an intern needs to understand their limitations as well. They can play a critical role as physician extender.

For us the situation stings. We spend 4 years in undergrad, 4 years slaving away in medical school, and then 3+ years in residency to have someone with a lot less training and experience say they do the job just as well. In a lot of clinical situations that may be true, but those usually aren't the ones that are life/limb/eyesight threatening.
 
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But, you see, they have taken those classes. Ask any BSN student and they'll say, "We took organic chemistry, too!" It turns out to be a chemistry course for non-science majors where they learn vocabulary words and some basic structures, but hey, there was some organic chemistry involved so it counts. They take a watered down pathophysiology course in nursing school armed with an undergraduate level physiology course as foundation for "normal" and claim to have a similar background as a graduating medical student. The false equivalence has been around since I was in undergrad which was...sadly over 10 years ago now. None of this is new. The NP craze has just taken it to a higher level. You look at DNP curricula from even top rated schools and its filled with fluff about nursing theory and education, lobbying, and health policy. There is usually a credit hour or two to "advanced pathophysiology" and then community health/family health/global health/whatever. This gets topped off with 700 or so hours of clinical exposure of varying in quality, and now you get a false equivalency that someone with this level of education is as qualified to provide primary care as someone who has finished an IM or FP residency.

The outcomes studies for both NPs and CRNAs have been ripped apart for poor methodology and so on multiple times in multiple subforums here, so I won't belabor that point.

Dunning-Kruger effect (Dunning–Kruger effect - Wikipedia) has been exhibited perfectly in the whole advanced practice nursing area, hell, even med/surg nursing, for a long time. I saw it personally when my sister and friends were in nursing school (these doctors are idiots! Listen to this story where the doctor did something that I thought was wrong because I don't have the necessary background to understand the decision making process in this patient! We know more than they do AND we take care of the patient!), saw it in medical school, and continue to see it in residency.

Unless something changes with the healthcare system here they are not going anywhere, though. The need for primary care is present, and DNP programs shoot up faster than medical schools. The only group really interested in doing outcomes studies are the nursing organizations. Maybe if the AAFP had a fire lit under them they could pursue a study, but if you think about it this is a difficult study to pull off and would require long term follow up. Imaging and referral differences have been explored in a small amount of studies, which did show increased imaging use and referral patterns for advanced practice nurses, however it is again difficult to draw conclusions based on methodology and certain unknowns. The best thing we can do as physicians is try and educate and close the education gap somewhat for the sake of patients. I frequently get inappropriate referrals from NPs (and to a much lesser extent physicians), and I make it a point to call or email them to discuss the patient and decision making process. I do this in a non-judgmental manner and phrase it around "closing the loop" so they know what's going on with the patient. I do this in hopes that it will change their practice patterns, but also ensure they aren't afraid to refer a patient that actually does need evaluation.

I certainly don't hate nurses, don't get me wrong. A good floor or OR nurse makes my life much, much easier when I'm not constantly having to double check that a med was given on time, vitals or I/Os have been charted, etc. I don't hate NPs, either, as long as they understand the limitations of their training- in the same way an intern needs to understand their limitations as well. They can play a critical role as physician extender.

For us the situation stings. We spend 4 years in undergrad, 4 years slaving away in medical school, and then 3+ years in residency to have someone with a lot less training and experience say they do the job just as well. In a lot of clinical situations that may be true, but those usually aren't the ones that are life/limb/eyesight threatening.

Population increase and lack of physicians is the driving force for NPs coming in and filling the void. Can you control that? Can you run a practice without nurses? Lets see how useful you are without a nurse by your side. Then publish a study and make the necessary changes, since you want it so bad.
And did I say that ARNPs know more than doctors or that doctors are stupid? No. You are missing the whole point. This whole debate is clearly fear based.
 
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