So Glad I Found This Site (Literate NPs!!)

[futurepsych0]

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While earning my M.A. degree in Clinical Psychology, I had to complete over 600 hours of practicum/internship as a mandatory requirement for graduation. This initial exposure to real-life patient care was barely enough time to get my feet wet--to dabble in the clinical trenches, so to speak--and yet, it seems about equivalent to the total number of clinical hours required by most NP programs.

In the counseling field, however, there is one extremely important difference: After completing graduate school, a newbie M.A. still has lots more work and learning to experience before earning the qualification to treat patients independently. Specifically, in order to achieve professional licensure (i.e., LPC in most states) to practice psychotherapy as an autonomous clinician, an additional 3,600 hours of directly-supervised clinical experience is required. This usually amounts to working for two years in a high-stress and low-paying job, under the constant critical scrutiny of your licensed supervisor, who will hopefully still be around (and willing) to "sign off" that your 3,600 necessary hours have finally been completed. Oh, I almost forgot--you must also pass the national certification exam, which is another requirement for licensure--but this can be done at any point along the process.

So, ultimately, when all is said and done--and the official LPC credential is finally in your hand--you will have performed a bare minimum of 4,200 directly-supervised clinical hours (but in reality, it's always significantly more than 4,200 hours, because it takes at least several months for the state licensure board to approve your application--always after rejecting it several times because you forgot dot an "I" or cross a "T").

And after all that experience, sometimes you still feel like you have absolutely no idea what you are doing! Therefore, I really cannot fathom how so few clinical hours in NP programs could adequately prepare students for the complexities of their future advanced-practice role in our healthcare system, or why such a modest amount of practical experience would be sufficient to enable students for immediate entry into full professional status upon graduation.

But I also don't think that NP programs should necessarily start adding extra clinical hours to their required curricula. Instead, why not institute a structured period of post-MSN supervised clinical practice (perhaps similar to the LPC model) as a future prerequisite for NP licensure? I think an innovative new pathway for NP professional credentialing would help to standardize the training process and would really end up being beneficial for everyone.

That is exactly what New York's NP independence act is looking to do. If passed, an NP has to be supervised for 3 years and over 3 thousand hours, and only after that can they practice free of the mandatory collaboration that is currently in place. I personally want to do a formal residency when I reach that level of education, but I like that New York' version of an independent NP includes a mandatory on the job residency. I am not sure if other states also require this but I think this should be more common practice.

 

[RedCole]

While earning my M.A. degree in Clinical Psychology, I had to complete over 600 hours of practicum/internship as a mandatory requirement for graduation. This initial exposure to real-life patient care was barely enough time to get my feet wet--to dabble in the clinical trenches, so to speak--and yet, it seems about equivalent to the total number of clinical hours required by most NP programs.

In the counseling field, however, there is one extremely important difference: After completing graduate school, a newbie M.A. still has lots more work and learning to experience before earning the qualification to treat patients independently. Specifically, in order to achieve professional licensure (i.e., LPC in most states) to practice psychotherapy as an autonomous clinician, an additional 3,600 hours of directly-supervised clinical experience is required. This usually amounts to working for two years in a high-stress and low-paying job, under the constant critical scrutiny of your licensed supervisor, who will hopefully still be around (and willing) to "sign off" that your 3,600 necessary hours have finally been completed. Oh, I almost forgot--you must also pass the national certification exam, which is another requirement for licensure--but this can be done at any point along the process.

So, ultimately, when all is said and done--and the official LPC credential is finally in your hand--you will have performed a bare minimum of 4,200 directly-supervised clinical hours (but in reality, it's always significantly more than 4,200 hours, because it takes at least several months for the state licensure board to approve your application--always after rejecting it several times because you forgot dot an "I" or cross a "T").

And after all that experience, sometimes you still feel like you have absolutely no idea what you are doing! Therefore, I really cannot fathom how so few clinical hours in NP programs could adequately prepare students for the complexities of their future advanced-practice role in our healthcare system, or why such a modest amount of practical experience would be sufficient to enable students for immediate entry into full professional status upon graduation.

But I also don't think that NP programs should necessarily start adding extra clinical hours to their required curricula. Instead, why not institute a structured period of post-MSN supervised clinical practice (perhaps similar to the LPC model) as a future prerequisite for NP licensure? I think an innovative new pathway for NP professional credentialing would help to standardize the training process and would really end up being beneficial for everyone.

While I do agree with you that NPs need many more clinical hours, the LPC model is not the way to go. I know far too many counselors who have their Master's in Counseling but cannot get their LPC because no one will supervise them. I cannot imagine how many NPs would be in the same boat - stuck with a useless degree because they cannot acquire the supervised hours for licensure. If they made more hours part of school and schools set them up, I would be all for it. But leaving that burden to NPs would be a disaster. No physician would want to hire an unlicensed NP whose services they cannot use to bill insurance companies.

In addition, the hours for an LPC is state specific, and 3600 is the high end. Some states are much lower, and states such as Colorado don't require the LPC at all.

I believe the way to increase hours starts in school. Stop making clinical hours as little as 12-16 per week to focus on "working nurses." This is a career, not a side job, if they can't quit their job long enough to focus on graduate school then they shouldn't be going at all. This move alone could double clinical hours to around 1500-1600 average. Then make the DNP the equivalent of a specialty residency where a student chooses a specialty and does classwork and full time clinicals for one full year to achieve the DNP. For example a Cardiology DNP would be didactic courses in cardiologt while rotating through CTICU, CT surgery, cath lab, and outpatient cardiology. This would add another 2000 or so hours to a DNP prepared NP while also expansing specialty knowledge.

 

[pamac]

While I do agree with you that NPs need many more clinical hours, the LPC model is not the way to go. I know far too many counselors who have their Master's in Counseling but cannot get their LPC because no one will supervise them. I cannot imagine how many NPs would be in the same boat - stuck with a useless degree because they cannot acquire the supervised hours for licensure. If they made more hours part of school and schools set them up, I would be all for it. But leaving that burden to NPs would be a disaster. No physician would want to hire an unlicensed NP whose services they cannot use to bill insurance companies.

In addition, the hours for an LPC is state specific, and 3600 is the high end. Some states are much lower, and states such as Colorado don't require the LPC at all.

I believe the way to increase hours starts in school. Stop making clinical hours as little as 12-16 per week to focus on "working nurses." This is a career, not a side job, if they can't quit their job long enough to focus on graduate school then they shouldn't be going at all. This move alone could double clinical hours to around 1500-1600 average. Then make the DNP the equivalent of a specialty residency where a student chooses a specialty and does classwork and full time clinicals for one full year to achieve the DNP. For example a Cardiology DNP would be didactic courses in cardiologt while rotating through CTICU, CT surgery, cath lab, and outpatient cardiology. This would add another 2000 or so hours to a DNP prepared NP while also expansing specialty knowledge.

So here's what keeps throwing me off about reading everything you are saying. You insist that nurses taking the time off of work as RNs to train more as NPs should be the norm, and yet for YOU, you'll stick with NP because its cheaper for you than PA school. Is the hipocracy on your part not aparent? So you'll sit there and complain, complain, complain, but when it comes to putting your money where your mouth is, you want no part of training yourself up to the standard you insist is all important. YOU absolutely could opt out of NP, and go ahead and get trained as a PA. I think it was cost that you cited as being your reason for going ahead and being an NP, and then you'd try for a residency and read a bunch to catch up?

Go ahead and keep telling us what YOU think should be happening. I'm all ears.

 

[RedCole]

So here's what keeps throwing me off about reading everything you are saying. You insist that nurses taking the time off of work as RNs to train more as NPs should be the norm, and yet for YOU, you'll stick with NP because its cheaper for you than PA school. Is the hipocracy on your part not aparent? So you'll sit there and complain, complain, complain, but when it comes to putting your money where your mouth is, you want no part of training yourself up to the standard you insist is all important. YOU absolutely could opt out of NP, and go ahead and get trained as a PA. I think it was cost that you cited as being your reason for going ahead and being an NP, and then you'd try for a residency and read a bunch to catch up?

Go ahead and keep telling us what YOU think should be happening. I'm all ears.

I don't insist RNs should take time off - I just don't think NP programs should be made with less clinical hours and in class time to accommodate working RNs. The NP curriculum doesn't need to be watered down in that way. Increased clinical hours and in class, hands on time should be the goal, not vice versa.

There are many reasons I am pursuing NP school over PA or medical school. Cost is one of those facts, indeed, but not the only one. I see no hypocrisy in believing that my educational pursuit could benefit from a bit of "beefing up." I would be more than happy to do the extra time.

 

[pamac]

I don't insist RNs should take time off - I just don't think NP programs should be made with less clinical hours and in class time to accommodate working RNs. The NP curriculum doesn't need to be watered down in that way. Increased clinical hours and in class, hands on time should be the goal, not vice versa.

There are many reasons I am pursuing NP school over PA or medical school. Cost is one of those facts, indeed, but not the only one. I see no hypocrisy in believing that my educational pursuit could benefit from a bit of "beefing up." I would be more than happy to do the extra time.

So you didn't insist that RNs should take time off even though you said things like "this isn't a side job" and "If you can't quit your job long enough to focus on grad school you shouldn't be doing it"? But then you go on and insist that programs "shouldn't accomidate working RNs". In what way are you not insisting that RNs take time off? Read what YOU are saying within your own paragraphs that YOU are writing.

One again... If NP is not beefed up enough for your tastes.... Then go to another profession that is. An NP program containing the elements you crave would probably cost as much as the PA schools you bemoan. Your solution is out there for YOU.... It's called a PA program. You seem to really like their curriculum (as evidenced by you posting an example to compare with NP programs), so go and someplace that will give you that.

I wil be working while I go to NP school. I worked full time through nursing school and graduated near the top of my class. I consistently did better than most of the folks who couldn't even handle part time or PRN work.

 

[priorities2]

So you didn't insist that RNs should take time off even though you said things like "this isn't a side job" and "If you can't quit your job long enough to focus on grad school you shouldn't be doing it"? But then you go on and insist that programs "shouldn't accomidate working RNs". In what way are you not insisting that RNs take time off? Read what YOU are saying within your own paragraphs that YOU are writing.

One again... If NP is not beefed up enough for your tastes.... Then go to another profession that is. An NP program containing the elements you crave would probably cost as much as the PA schools you bemoan. Your solution is out there for YOU.... It's called a PA program. You seem to really like their curriculum (as evidenced by you posting an example to compare with NP programs), so go and someplace that will give you that.

I wil be working while I go to NP school. I worked full time through nursing school and graduated near the top of my class. I consistently did better than most of the folks who couldn't even handle part time or PRN work.

regardless of whether s/he's being hypocritical, PA school doesn't fill the exact same function as NP school - it doesn't reach the exact same end goal for everyone. Some people really want to focus on psych and can only get a substantial amount of psych courses or work as a therapist/prescriber as NP. Some people want independent practice, or peds and they don't want to work with adults. It's not like you can always say "if you're complaning about NP school, go to PA school"... they don't result in the same thing for everyone, just as you wouldn't tell someone interested in surgery to "just become an NP" if they are fed up with PA education.

 

[deleted6669]

regardless of whether s/he's being hypocritical, PA school doesn't fill the exact same function as NP school - it doesn't reach the exact same end goal for everyone. Some people really want to focus on psych and can only get a substantial amount of psych courses or work as a therapist/prescriber as NP. Some people want independent practice, or peds and they don't want to work with adults. It's not like you can always say "if you're complaning about NP school, go to PA school"... they don't result in the same thing for everyone, just as you wouldn't tell someone interested in surgery to "just become an NP" if they are fed up with PA education.

it is possible to do psych as an PA.
some might argue a generalist PA who then does 80 hrs/week for a yr in a PA postgrad residency equivalent to a pgy-1 md psych year is trained as well or better than a psych NP as they are also prepared for the general medicine issues their psych pts will have. granted there are only 2 psych pa residencies and each only takes 2/yr but it is an option, especially if one desires to work for the va or indian health service where these residencies are presented.

 

[pianoman511]

Then make the DNP the equivalent of a specialty residency where a student chooses a specialty and does classwork and full time clinicals for one full year to achieve the DNP. For example a Cardiology DNP would be didactic courses in cardiologt while rotating through CTICU, CT surgery, cath lab, and outpatient cardiology. This would add another 2000 or so hours to a DNP prepared NP while also expansing specialty knowledge.

Who would train these providers ? Physicians ? I just don't see that happening, especially if these "specialty" DNPs were marketed as just as good as the cardiologist that they're training under. Residencies are a long and arduous process to train physicians and at the same time a way to get cheap labor for 3-5 years. It's just not the same. At a minimum most residents work 60+ hours a week. I just don't see that happening for DNP students who already are utilizing online/distance education and part time clinicals to be able to work at the same time.

 

[AnnoyedByFreud]

Who would train these providers ? Physicians ? I just don't see that happening, especially if these "specialty" DNPs were marketed as just as good as the cardiologist that they're training under. Residencies are a long and arduous process to train physicians and at the same time a way to get cheap labor for 3-5 years. It's just not the same. At a minimum most residents work 60+ hours a week. I just don't see that happening for DNP students who already are utilizing online/distance education and part time clinicals to be able to work at the same time.

Isn't that literally what happened with CRNAs?

 

[zenman]

it is possible to do psych as an PA.
some might argue a generalist PA who then does 80 hrs/week for a yr in a PA postgrad residency equivalent to a pgy-1 md psych year is trained as well or better than a psych NP as they are also prepared for the general medicine issues their psych pts will have. granted there are only 2 psych pa residencies and each only takes 2/yr but it is an option, especially if one desires to work for the va or indian health service where these residencies are presented.

I don't have time to deal with the general medical issues my psych patients have. I just need to recognize them and know their meds and how both impact on psych issues. I picked up on a patient with Graves Disease Friday and sent him to primary care. I'm not the one that's going to be managing that condition. I see the primary care PA has now referred him to endocrinology.

 

[RedCole]

Who would train these providers ? Physicians ? I just don't see that happening, especially if these "specialty" DNPs were marketed as just as good as the cardiologist that they're training under. Residencies are a long and arduous process to train physicians and at the same time a way to get cheap labor for 3-5 years. It's just not the same. At a minimum most residents work 60+ hours a week. I just don't see that happening for DNP students who already are utilizing online/distance education and part time clinicals to be able to work at the same time.

And here is the epitome of hypocrisy coming from physicians. They complain and complain about patient safety and how NPs don't have the training, but if NPs suggest more training physicians freak out because they don't want to have to compete with them. Which is it exactly? If physicians really valued patient safety as highly as they say, they would embrace higher NP training. The reality is it has nothing to do with NP competence and everything to do with competition.

 

[RedCole]

As for paying for the residency it would be easy:

1. It is a DNP program with the residency simply acting as clinical hours. There would still be didactic hours and a degree would be conferred, so the student would pay tuition. This would cover some cost.

2. It would be open to licensed NPs only, which means the clinical sires could bill for their services. In exchange for training the NPs the clinical sites are getting free labor. No different than a medical resident.

 

[Denatured]

Isn't that literally what happened with CRNAs?

CRNAs were doing anesthesia before physicians. It would be perfectly possible for CRNAs to only train themselves and this actually occurs in some areas .

 

[pianoman511]

And here is the epitome of hypocrisy coming from physicians. They complain and complain about patient safety and how NPs don't have the training, but if NPs suggest more training physicians freak out because they don't want to have to compete with them. Which is it exactly? If physicians really valued patient safety as highly as they say, they would embrace higher NP training. The reality is it has nothing to do with NP competence and everything to do with competition.

Again, the question is who will train them ?

 

[acceptmeplease]

CRNAs were doing anesthesia before physicians. It would be perfectly possible for CRNAs to only train themselves and this actually occurs in some areas .

Surgery was pretty crude back then. Medical training was crude. Nursing training was nonexistent. So "nurses" performing "anesthesia" were probably volunteers holding a rag of chloroform or ether... They got that job because they were probably the only one besides the physician who would not vomit during surgery.

 

[badasshairday]

The reality is it has nothing to do with NP competence and everything to do with competition.

Would you like it if graduating med students were allowed to function as midlevels and compete and saturate the NP/PA job market? I mean I'm sure board certified physicians would take a medical grad without post grad training to do the role of a NP/PA. In fact they may prefer them over NP/PA's because they have more extensive/rigorous education.

And that is a hypothetical that may become a reality in the near future as medical graduates outnumber post grad training spots.

 

[acceptmeplease]

Would you like it if graduating med students were allowed to function as midlevels and compete and saturate the NP/PA job market? I mean I'm sure board certified physicians would take a medical grad without post grad training to do the role of a NP/PA. In fact they may prefer them over NP/PA's because they have more extensive/rigorous education.

And that is a hypothetical that may become a reality in the near future as medical graduates outnumber post grad training spots.

Perhaps a one year internship to become "general practitioners". This would certainly help the PCP shortage and solve part of the postgraduate problem.

 

[RedCole]

Would you like it if graduating med students were allowed to function as midlevels and compete and saturate the NP/PA job market? I mean I'm sure board certified physicians would take a medical grad without post grad training to do the role of a NP/PA. In fact they may prefer them over NP/PA's because they have more extensive/rigorous education.

And that is a hypothetical that may become a reality in the near future as medical graduates outnumber post grad training spots.

Experienced NPs could provide the training, as well as physicians and even PAs. Regardless of who provides it, are you admitting you fear greater competition and marketability of NPs if they had extra training despite the increase in patient safety? Are you admitting physicians use the patient safety argument as a smokescreen when the real fear is protecting their turf and high income?

 

[badasshairday]

Experienced NPs could provide the training, as well as physicians and even PAs. Regardless of who provides it, are you admitting you fear greater competition and marketability of NPs if they had extra training despite the increase in patient safety? Are you admitting physicians use the patient safety argument as a smokescreen when the real fear is protecting their turf and high income?

Nope. I am not admitting that. I'm just asking how you would feel. And no I would not "fear" NP's, no NP is going to take my job.

I'm a physician. The gold standard to patient care.

Thanks for the laugh. I fear NP's who don't know what they don't know.

And no the training should be given by those who know inpatient, outpatient, ER, and critical patient situations. Have outpatient IM midlevels treated CHF in the critical setting? No. But all internal medicine residents have, and you will be sure they will be able to recognize certain impending factors better than a provider with superficial training in that pathology. In fact, look up papers regarding CHF management in the ED and see the difficulty in choosing inpatients versus discharging home. It is a difficult task that requires deep training, knowledge, and a bit of art.

We need midlevels. But there needs to be appropriate jurisdiction. Yes it is a patient safety argument. As a radiology resident I can give you numerous examples and reasons why appropriate supervision/collaberation is needed in our patient population. Heck I can give you many reasons why all ED's need 24/7 plain film coverage, even though some ER doctors are pretty good at teasing out emergencies on film.

At the same time, I think certain aspects of some fields can be done safely by an appropriately experienced midlevel. I absolutely respect my midlevel provider collegues for the patient care they provide. I talk to them nearly everyday regarding patient care. And in general they do a great job... in collaberation with physicians at a high acuity tertiary medical center.

I can teach a high school student to give 20mg of lasix when someone has dyspnea and a history of heart failure, does that mean they are safe to practice without collaberation?

 

[badasshairday]

greater competition and marketability of NPs if they had extra training despite the increase in patient safety?

Who will provide this training? Honestly? If want to be a provider with well rounded and intense post graduate training, go to medical school.

If you want to finish quickly, gain knowledge, get paid well and experience to treat patients (at the sacrifice of deep medical training) go to NP/PA school. That is the whole point of the midlevel provider. Let's not make things more complicated then they need be.

 

[deleted6669]

Heck I can give you many reasons why all ED's need 24/7 plain film coverage, even though some ER doctors are pretty good at teasing out emergencies on film.

Are there still places that don't have telerads/nighthawk etc coverage available to read pacs images 24/7?
I work in some small places and all of them have available rads 24/7 for overreads, either the local group or an online rads after hrs service

 

[badasshairday]

Are there still places that don't have telerads/nighthawk etc coverage available to read pacs images 24/7?
I work in some small places and all of them have available rads 24/7 for overreads, either the local group or an online rads after hrs service

Everyone has telerads coverage if they do not have in house radiology overnight. But for some reason at one of the gigs my wife is at, the telerads only do advanced imaging (CT/MR) after 7pm. Plain films are prelim by the ED providers and read by the in house rads in the AM. An unneeded stress and liability for the ED guys. Plus some interesting patient callbacks at times. Luckily it is a low acuity small ER and the tertiary level one center is 20 minutes down the road.

 

[RedCole]

Nope. I am not admitting that. I'm just asking how you would feel. And no I would not "fear" NP's, no NP is going to take my job.

I'm a physician. The gold standard to patient care.

Thanks for the laugh. I fear NP's who don't know what they don't know.

And no the training should be given by those who know inpatient, outpatient, ER, and critical patient situations. Have outpatient IM midlevels treated CHF in the critical setting? No. But all internal medicine residents have, and you will be sure they will be able to recognize certain impending factors better than a provider with superficial training in that pathology. In fact, look up papers regarding CHF management in the ED and see the difficulty in choosing inpatients versus discharging home. It is a difficult task that requires deep training, knowledge, and a bit of art.

We need midlevels. But there needs to be appropriate jurisdiction. Yes it is a patient safety argument. As a radiology resident I can give you numerous examples and reasons why appropriate supervision/collaberation is needed in our patient population. Heck I can give you many reasons why all ED's need 24/7 plain film coverage, even though some ER doctors are pretty good at teasing out emergencies on film.

At the same time, I think certain aspects of some fields can be done safely by an appropriately experienced midlevel. I absolutely respect my midlevel provider collegues for the patient care they provide. I talk to them nearly everyday regarding patient care. And in general they do a great job... in collaberation with physicians at a high acuity tertiary medical center.

I can teach a high school student to give 20mg of lasix when someone has dyspnea and a history of heart failure, does that mean they are safe to practice without collaberation?

No one is downing your accomplishments. You're highly trained and educated - congratulations. As a radiologist, you have little to fear from NPs and PAs, but your primary care colleagues are not as lucky. Despite physicians being the "gold standard" there is growing competition in the field and yes, NPs are starting to take a small slice of the pie. Hence the scare tactics from physician groups against NP independence and the "patient safety" claims.

 

[badasshairday]

No one is downing your accomplishments. You're highly trained and educated - congratulations. As a radiologist, you have little to fear from NPs and PAs, but your primary care colleagues are not as lucky. Despite physicians being the "gold standard" there is growing competition in the field and yes, NPs are starting to take a small slice of the pie. Hence the scare tactics from physician groups against NP independence and the "patient safety" claims.

Like I said, midlevel providers can do certain things just as safely and effectively as physicians. Follow up surgical care for wound checks. Diabetes management. Blood pressure. Sure a lot of primary care things, they can do INDEPENDENTLY.

But outside of routine medical care, as a physician, I wonder about delayed diagnosis for more ominous things. If you have never seen or thought of a diagnosis you will never find it. I know some providers, mostly physicians who really know how to work up malignant hypertension. They think of between essential HTN, pheochromocytomas (and know what test to get), renal artery stenosis (they know what tests to get such as lasix renograms), hyperaldosteronism, and everything in between. You learn more of this exotic stuff in med school/residency. An internist will do this work up himself. Midlevels would delay and try other meds or refer to a nephrologist (driving up costs).

Now your run of the mill obese hypertensive. You can bet your money that an experienced NP can educate healthy choices, promote weight loss, and provide medical management as well as a PCP.

Even certain many of emergency care can be done well. Like emedpa and my wife. If there was an emergency and I was the only doc around, I would defer emergency medical management to them in a heartbeat! I know my wife provides great care to appropriately and not so appropriately triaged patients, independently, the doctors don't see her patients. But she always has their back up if she has questions or ___ hits the fan (as they say in the ED).

 

[deleted6669]

Everyone has telerads coverage if they do not have in house radiology overnight. But for some reason at one of the gigs my wife is at, the telerads only do advanced imaging (CT/MR) after 7pm. Plain films are prelim by the ED providers and read by the in house rads in the AM. An unneeded stress and liability for the ED guys. Plus some interesting patient callbacks at times. Luckily it is a low acuity small ER and the tertiary level one center is 20 minutes down the road.

We get automatic telrads reads on ct/mri/us but they will read plain films for us by special request, otherwise they wait for the regular day rads folks to come on for overreads.

 

[badasshairday]

We get automatic telrads reads on ct/mri/us but they will read plain films for us by special request, otherwise they wait for the regular day rads folks to come on for overreads.

I told her to bring it up at her group meeting. Yeah telerads does CT/MR/US. Maybe they do plain film by request. Nothing like having a good in house radiologist though.

 

[RedCole]

Like I said, midlevel providers can do certain things just as safely and effectively as physicians. Follow up surgical care for wound checks. Diabetes management. Blood pressure. Sure a lot of primary care things, they can do INDEPENDENTLY.

But outside of routine medical care, as a physician, I wonder about delayed diagnosis for more ominous things. If you have never seen or thought of a diagnosis you will never find it. I know some providers, mostly physicians who really know how to work up malignant hypertension. They think of between essential HTN, pheochromocytomas (and know what test to get), renal artery stenosis (they know what tests to get such as lasix renograms), hyperaldosteronism, and everything in between. You learn more of this exotic stuff in med school/residency. An internist will do this work up himself. Midlevels would delay and try other meds or refer to a nephrologist (driving up costs).

Now your run of the mill obese hypertensive. You can bet your money that an experienced NP can educate healthy choices, promote weight loss, and provide medical management as well as a PCP.

Even certain many of emergency care can be done well. Like emedpa and my wife. If there was an emergency and I was the only doc around, I would defer emergency medical management to them in a heartbeat! I know my wife provides great care to appropriately and not so appropriately triaged patients, independently, the doctors don't see her patients. But she always has their back up if she has questions or ___ hits the fan (as they say in the ED).

I understand what you're saying but I don't really see your point. NPs and PAs treat conditions within their scope at a lower cost. That is 99% of what comes in. If they are stumped, they refer. This is no different from the primary care physicians they are working alongside.

I don't advocate independence for freshly graduated NPs - the clinical hours aren't enough and they need years of practice with experienced providers to learn their specialty. But I also think its ridiculous to hold back an NP with 20 years of specialty experience who knows as much as any MD. The vast majority of knowledge an experienced provider has comes from working in the field, not medical school.

 

[JoBreeze]

But I also think its ridiculous to hold back an NP with 20 years of specialty experience who knows as much as any MD. The vast majority of knowledge an experienced provider has comes from working in the field, not medical school.

What do they learn in medical school anyway??

 

[RedCole]

What do they learn in medical school anyway??

A basic foundation that allows them to begin residency where they really learn. I have many physicians in my family, they all agree the learned 99% in residency and practicing and barely remember medical school.

 

[Makati2008]

I understand what you're saying but I don't really see your point. NPs and PAs treat conditions within their scope at a lower cost. That is 99% of what comes in. If they are stumped, they refer. This is no different from the primary care physicians they are working alongside.

I don't advocate independence for freshly graduated NPs - the clinical hours aren't enough and they need years of practice with experienced providers to learn their specialty. But I also think its ridiculous to hold back an NP with 20 years of specialty experience who knows as much as any MD. The vast majority of knowledge an experienced provider has comes from working in the field, not medical school.

There lies the major fallacy in your last statement. Just because the NP spent 20 years practicing in a specialty they won't know as much as a Physician(especially when they are not getting the most complex cases consistently) they will know a lot of medicine no doubt but residency is where you will learn the most.

 

[JoBreeze]

A basic foundation that allows them to begin residency where they really learn. I have many physicians in my family, they all agree the learned 99% in residency and practicing and barely remember medical school.

Correct. Emphasis on basic. With any less training one absolutely cannot become an adequate physician. Medical school is inadequate preparation for residency, which is inadequate preparation for practicing medicine. I have no sympathy for anyone wanting to practice medicine without making the sacrifices necessary to do so.

 

[RedCole]

Correct. Emphasis on basic. With any less training one absolutely cannot become an adequate physician. Medical school is inadequate preparation for residency, which is inadequate preparation for practicing medicine. I have no sympathy for anyone wanting to practice medicine without making the sacrifices necessary to do so.

I am quite sure no NP/PA is interested in your sympathy, so good for you.

I find it quite hilarious how many physicians and pre-physicians make a point to come to this section and disparage their colleagues. Is this how you people act when you can no longer hide behind your screen name? When an NP refers a patient to you do you respond by telling them they are not capable providers? I mean, honestly, grow up. NPs aren't hurting you. They aren't hurting patients. They don't make you any less of an MD. Let NPs do their job and you do yours - this is as ridiculous as the people on college confidential who fight over USnewks rankings. .

 

[Makati2008]

I am quite sure no NP/PA is interested in your sympathy, so good for you.

I find it quite hilarious how many physicians and pre-physicians make a point to come to this section and disparage their colleagues. Is this how you people act when you can no longer hide behind your screen name? When an NP refers a patient to you do you respond by telling them they are not capable providers? I mean, honestly, grow up. NPs aren't hurting you. They aren't hurting patients. They don't make you any less of an MD. Let NPs do their job and you do yours - this is as ridiculous as the people on college confidential who fight over USnewks rankings. .

That's the problem some are hurting patients. They don't have the gestalt a Physician has IMHO. It's the newer NPs that are direct entry/little experience that I worry about. An NP that worked as a RN for years then pursues medicine I have less qualms(the only major one is independence but if they had true residencies then that would be resolved as well)

And honestly, being on the other side there seems to be a faction of Physicians that dislike mid levels and vice versa and the stuff I have heard here is tame to what I have heard in the OR, ED, clinic, etc... This is more blatant since I'm closer to the Physician side now and I don't mention my dirty little secret.

 

[joeDO2]

I am quite sure no NP/PA is interested in your sympathy, so good for you.

I find it quite hilarious how many physicians and pre-physicians make a point to come to this section and disparage their colleagues. Is this how you people act when you can no longer hide behind your screen name? When an NP refers a patient to you do you respond by telling them they are not capable providers? I mean, honestly, grow up. NPs aren't hurting you. They aren't hurting patients. They don't make you any less of an MD. Let NPs do their job and you do yours - this is as ridiculous as the people on college confidential who fight over USnewks rankings. .

Can't speak for everyone but I think a lot of us students and residents just get angry when we constantly hear how medical school is useless and NPs are equivalent in knowledge and skill. I think as we suffer through these 8+ years of our lives and go further into debt every day we need to at least tell ourselves we are doing something useful 🙁. When that is challenged, it becomes depressing and some respond with anger.

 

[RedCole]

Can't speak for everyone but I think a lot of us students and residents just get angry when we constantly hear how medical school is useless and NPs are equivalent in knowledge and skill. I think as we suffer through these 8+ years of our lives and go further into debt every day we need to at least tell ourselves we are doing something useful 🙁. When that is challenged, it becomes depressing and some respond with anger.

I am understanding to that - and I would never claim that the money and time spent in medical school is useless. I think both extremes are wrong - physicians that say NPs are incapable of being providers are as bad as NPs who say physicians are useless. It's counterproductive and just comes across as a childish pissing contest.

Physicians are integral to healthcare. The training they receive and knowledge they have surpasses almost any other profession. They are the front lines, and anyone who says otherwise is sadly mistaken. The problem only comes when physicians don't respect the other people standing on that front line with them. NPs have a role to play in healthcare, and despite all of the bickering, I really believe nurse practitioners have a positive benefit on patient care as a whole. The vast majority are working alongside capable physicians, learning from them and allowing more patients to receive high quality medical care. It is hurtful and discouraging when nurse practitioners read the vitriol coming from these boards - that because they don't have MD or DO behind their name that their role is doing more harm than good. It simply isn't true, and I wish everyone would just dispel these feelings of competition, hatred, and arrogance and see the value that every member of the healthcare team brings to the table.

 

[acceptmeplease]

I think it boils down to the fact that there are good midlevels, and there are bad ones, but people mostly hear about the bad ones.

I had a 47 y/o stroke patient whose NP d/c his statins because "Cheerios and oatmeal are just as effective" and "more natural". 100% blockage of his LIC, and a 75% blockage of his RIC makes him an unnecessary time bomb at the hands of a midlevel. However, it was a midlevel in the ER who pushed an ER doc into admitting him because the pt was drunk and was initially passed over as just a drunk.

Like I said, there are good and bad. It's a lot easier to see the bad.

 

[RedCole]

I think it boils down to the fact that there are good midlevels, and there are bad ones, but people mostly hear about the bad ones.

I had a 47 y/o stroke patient whose NP d/c his statins because "Cheerios and oatmeal are just as effective" and "more natural". 100% blockage of his LIC, and a 75% blockage of his RIC makes him an unnecessary time bomb at the hands of a midlevel. However, it was a midlevel in the ER who pushed an ER doc into admitting him because the pt was drunk and was initially passed over as just a drunk.

Like I said, there are good and bad. It's a lot easier to see the bad.

And over on the NP-centric forums there are countless anecdotes from NPs about how they saved patients from physicians who missed many routine red flags during either physical exams or lab work.

Why does one have to characterize a whole profession by a few bad apples? If people did that with physicians, no one would go to one at all. For every 1 new grad NP who doesn't know what they are doing, there are 100 amazing NPs providing high quality, evidenced based care.

 

[Makati2008]

I am understanding to that - and I would never claim that the money and time spent in medical school is useless. I think both extremes are wrong - physicians that say NPs are incapable of being providers are as bad as NPs who say physicians are useless. It's counterproductive and just comes across as a childish pissing contest.

Physicians are integral to healthcare. The training they receive and knowledge they have surpasses almost any other profession. They are the front lines, and anyone who says otherwise is sadly mistaken. The problem only comes when physicians don't respect the other people standing on that front line with them. NPs have a role to play in healthcare, and despite all of the bickering, I really believe nurse practitioners have a positive benefit on patient care as a whole. The vast majority are working alongside capable physicians, learning from them and allowing more patients to receive high quality medical care. It is hurtful and discouraging when nurse practitioners read the vitriol coming from these boards - that because they don't have MD or DO behind their name that their role is doing more harm than good. It simply isn't true, and I wish everyone would just dispel these feelings of competition, hatred, and arrogance and see the value that every member of the healthcare team brings to the table.

Very good post BUT it's those posts like the previous one(about an NP with 20years of experience knowing as much or more than the doc in the same speciality) that leads many of us on the Physician side to think that all that writing is not genuine.

Working with NPs that say things such as I know more than a doc or they don't even write a thesis in medical school(which I would take a thesis over histo/embryo/gross any day of the week) does make us a little bitter. And those quotes came from a NP educator that I know.

 

[Makati2008]

And over on the NP-centric forums there are countless anecdotes from NPs about how they saved patients from physicians who missed many routine red flags during either physical exams or lab work.

Why does one have to characterize a whole profession by a few bad apples? If people did that with physicians, no one would go to one at all. For every 1 new grad NP who doesn't know what they are doing, there are 100 amazing NPs providing high quality, evidenced based care.

I will ask you one question about NP education. Why do they not have to recert. every decade or so like their Physician/PA counterparts?

 

[RedCole]

I will ask you one question about NP education. Why do they not have to recert. ever decade or so like their Physician/PA counterparts?

Makati, I don't know. I'm not an expert in NP education and I do feel it could use more beefing up. As I have said countless times though, you simply cannot discount on the job training. My comment about an NP with 20 yrs specialty experience was not to suggest that they know more than a physician in the same specialty, but that by then they've seen enough and if they've been proactive about researching and learning they should know nearly as much a specialty physician and by default more than those from other specialties.

 

[Makati2008]

Makati, I don't know. I'm not an expert in NP education and I do feel it could use more beefing up. As I have said countless times though, you simply cannot discount on the job training. My comment about an NP with 20 yrs specialty experience was not to suggest that they know more than a physician in the same specialty, but that by then they've seen enough and if they've been proactive about researching and learning they should know nearly as much a specialty physician and by default more than those from other specialties.

Thanks for clarifying your statement and I agree with you actually.

 

[acceptmeplease]

And over on the NP-centric forums there are countless anecdotes from NPs about how they saved patients from physicians who missed many routine red flags during either physical exams or lab work.

Why does one have to characterize a whole profession by a few bad apples? If people did that with physicians, no one would go to one at all. For every 1 new grad NP who doesn't know what they are doing, there are 100 amazing NPs providing high quality, evidenced based care.

Well, a few bad apples spoil the bunch. I'm not opposed to midlevels. I have a lot of respect for people who work hard and get graduate degrees and genuinely want a more integral role in the advocacy of their patients. If you see 5 physicians and 1 is extraordinarily "bad", he/she will be the physician that you remember the most. The same is true of nursing care, and of NPs/PAs.

 

[fab4fan]

I'm not worried about you, ie: someone who clearly has access to excellent teachers. But what about all the NP students at these half-baked online programs who don't have a good network of excellent clinicians to teach them? The ones you see on AN constantly begging people to precept and can't find anyone to teach them? What kind of NP are they going to turn out to be? How does the school know whether or not they actually learn anything?

I don't think that's necessarily true. I've been here for 10+ years. Sure, there are some people here who don't have a lot of respect for nurses, but there are some who do, and say so. A lot has to do with how you come across in your posts. I've seen people come to real understanding over differences.

 

[fab4fan]

I'm surprised you can't find a NP program with a skills lab. My program has one (for both RN and NP level), though I suppose it isn't advertised. Also, the content of NP classes can be hard to tell from course titles. If I were you, I would call the schools I am interested in and inquire further about the didactic and clinical coursework to get an idea. Or just go to PA school if you don't want a nursing education. I disagree that there is no substance to nursing, though I do think the variability in education is a problem. There are great NP programs and then there are terrible ones. Definitely do your homework before deciding on a program.

Also, regarding AN.com, do keep in mind that 50% of nurses have an associates degree as their highest level of education. I took an issues in nursing course last spring (which was surprisingly meaningful and beneficial, despite the "fluffy" title) and I find the changing demographics of nursing fascinating. I had no idea that so many nurses only had an associates level education. It puts some of the inanity and grammatical errors on that forum into perspective.

I went to a three year diploma program and have no trouble expressing myself. My mother had no schooling after graduating high school, yet she uses proper grammar. You don't have to be a college graduate to be well spoken and write coherently.

I do agree that some of the posts over there (AN) are cringe-worthy.

 

[zenman]

What do they learn in medical school anyway??

That the majority of what they learn is from research that is hardly worth the glossy paper it's written on, in other words, wrong. 😀

 

[RoadTo]

a few PA programs are going to some online content. can't say I'm a fan of that either.
as other posters above have said, the clinicals make the program. make sure yours are good whether you do PA or NP.

This guys just knows too much... I have not seen a single thread that he didn't comment on!! I might seem new from my post count but I been lurking around for a while now lmfao. Also you have a powerful ego bro.... I think you should be chillin as a PA . Sucks that you regret going that route, but ull probably end up in the bridge program : ) I look forward to seeing where the next few years will take us. Hahah sorry that my response is somewhat irrelevant to the initial post.

 

[RedCole]

This guys just knows too much... I have not seen a single thread that he didn't comment on!! I might seem new from my post count but I been lurking around for a while now lmfao. Also you have a powerful ego bro.... I think you should be chillin as a PA . Sucks that you regret going that route, but ull probably end up in the bridge program : ) I look forward to seeing where the next few years will take us. Hahah sorry that my response is somewhat irrelevant to the initial post.

..Ummm..interesting post.

 

[sarjasy]

Like I said, midlevel providers can do certain things just as safely and effectively as physicians...I know some providers, mostly physicians who really know how to work up malignant hypertension. They think of between essential HTN, pheochromocytomas (and know what test to get), renal artery stenosis (they know what tests to get such as lasix renograms), hyperaldosteronism, and everything in between. You learn more of this exotic stuff in med school/residency. An internist will do this work up himself. Midlevels would delay and try other meds or refer to a nephrologist (driving up costs).

Not to nitpick, because I largely agree with your post (I'm an NP student). However, most FP or IM docs will treat hypertension as essential first, and only look for secondary with failed drug trials or with initial compelling indications. And, correct me if I'm wrong, they'll still ultimately refer for suspected secondary HTN. Having said that, physicians, at least in most cases, will have a deeper differential, but I can't imagine many FP (or IM) doc's initiating treatments for secondary HTN including renal artery stenosis and certainly not a pheochromocytoma. If you are an FP resident, 10 years out there is a good chance you will have never seen a pheochromocytoma. So it's nice it's in the recesses in your brain from med school that can be used as a differential, but in the end, you'll likely refer any secondary case.

 

[Boatswain2PA]

That the majority of what they learn is from research that is hardly worth the glossy paper it's written on, in other words, wrong. 😀

Does the Zenmaster prefer vellum or papyrus for reading the ancient zen-medical treatises??

 

[zenman]

Does the Zenmaster prefer vellum or papyrus for reading the ancient zen-medical treatises??

I prefer dealing with adults.