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Still not clear about NPs vs. IM

Discussion in 'Internal Medicine and IM Subspecialties' started by coolness, Apr 26, 2004.

  1. coolness

    coolness Senior Member
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    I have been searching and reading posts in regards to this issue, and I still haven't seen a clear definitive answer on why NPs are not a threat to IMs. I've noticed that NPs can prescribe medicine and also do most tasks that IMs do. If this is the case, wouldn't hospitals hire NPs due to their lower salaries. Exactly what can IMs do that NPs can't. This girl I know where I volunteer is going for her NP and she claims that NP's knowledge is on par with MDs and DOs.
     
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  3. cbc

    cbc Senior Member
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    Yeah. If you browse the Physician Assistant forum, PAs there will also say they know just as much as docs plus they do the same stuff, plus they care and spend more time with the patients. Then, they will go ahead and say NPs are inferior to them. From posts like those, I only see that those in various health professions will always say they know as much or more than any body else.

    The details of your questions, I do not know. NPs have existed for a few decades now, but they have been unsuccessful at phasing primary docs out. NPs are probably efficient at dealing with common illnesses (common colds, diabetes, sprains), but IM is a highly cerebral specialty that requires a widespread and detailed knowledge about various diseases. The differential of some complicated or multiple diagnosis could mean the difference between life and death (unstable angina versus lung cancer versus esophageal varices).

    There are the Johnny Cochrans who are rich, and there are the homeless lawyers. The richer will always demand the better lawyers, or their insurers to give them the higher trained health care provider. Many will have severe and/or multiple medical problems who want docs who not only can make proper diagnosis, referrals, but also can understand and follow-up the directions given from specialists. If your mother is suffering from a severe acute pain, or begins coughing up/defecating blood, or notices a lump on her breast, are you going to tell her to immediately see an NP or doc?

    Another note, regarding joint pains, you have NPs, nurses, PAs, chiropractors, DOs, physcial therapists, physiatrists, PM&Rs, and sport medicine docs. All these people claim they can do an excellent and sufficient job at joint problems, and they probably can, but they have failed to replace orthopedic surgeons who remain to be the highest paid specialty in medicine.
     
  4. Andrew_Doan

    Andrew_Doan Doc, Author, Entrepreneur
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    I think physicians need to wake up and be more aware of other fields with strong political lobbies and agendas. NPs want to replace the family care physician. Ophthalmology is facing this very threat with optometry, and we must stand strong together as physicians. Give money to the AMA and your PAC! ;)

    http://forums.studentdoctor.net/showthread.php?t=118416
     
  5. MacGyver

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    NPs will take over FP before IM.

    IM is the next target on the list though.
     
  6. Goofy

    Goofy Senior Member
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    This is the most insightful advice I have seen on these boards in a long time. I don't particularly care for some of the things the ama does, but we need them as a lobby, and if you don't support your lobby, don't complain.
     
  7. rad_one

    rad_one Member
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    Hospitals won't replace IM docs w/ NP's/PA's because they're not DOCTORS. It is a total BS statement that their knowledge base is equivalent to an MD/DO. They are not qualified to manage complex patients and, IMO, shouldn't be prescribing drugs. No one in my family will have their health issues managed by some glorified nurse. I'm not saying these folks lack the intelligence to be doctors, they are lacking the training. If you want the same prvileges as a physician, then ante up and go to med school and endure the rigorous training and time committment that doctors do. I echo the sentiments of Dr. Doan.
     
  8. Andrew_Doan

    Andrew_Doan Doc, Author, Entrepreneur
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  9. Leukocyte

    Leukocyte Senior Member
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    I say MDs should run public ads to inform the public about what is going on. Let the patients vote. It's their health anyway.

    CRNA or Anesthesiologist

    NP or FP/IM

    Optometrist or Ophthalmologist

    PA or General Surgeon

    It would be interesting to see how the patients will react. :smuggrin:
     
  10. Andrew_Doan

    Andrew_Doan Doc, Author, Entrepreneur
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    I agree. I think most people, once educated about the difference, will prefer physicians (MDs).

    Look at this new campaign in regards to optometry doing laser surgery at the VA:

    http://forums.studentdoctor.net/attachment.php?attachmentid=2227

    Most VET groups are supporting ophthalmologists.
     
  11. kinetic

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    Man, oh, man; that's the worst idea EVER. I know I'm going to get a lot of flack for this, but most patients - regardless of EDUCATIONAL background - are idiots. These are the same people who want to get a test because their Aunt Mathilda was recently diagnosed with some random illness. These are the same people shelling out money for full-body CTs on a elective well-check basis. These are the same people who yell about how much prescription medications cost while studies show that they are more willing to pay for homeopatic medications. These are the same people who would listen to Katie Couric before they listened to a physician. And, best of all, these are the same people who are almost randomly suing physicians without an understanding of what "standard of care" means.

    The people who should decide this issue are the people who are informed (i.e., physicians), not laypeople. Laypeople are the ones who think optometrists ARE physicians (one of my relatives even called an optometrist "doctor" once and I almost choked [with laughter] - of course, the guy just grinned and didn't say a word to correct her [skeeve]). And they are the ones who (no offense to nurses) often attribute their medical care to nurses because "I see her more often than you doctors".

    Forget that.
     
  12. Andrew_Doan

    Andrew_Doan Doc, Author, Entrepreneur
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    These are great points. However, it requires political clout to pass laws. We need public opinion on our side. Politicians care most about the votes. Thus, it's important to talk to local groups and educate them. Ultimately, it will be the people who decide, but it will be the physicians who are responsible for the education of the public.

    Physicians need to start talking to the public, give money to their PAC and the AMA, and start being proactive about their future!
     
  13. Kalel

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    It's a shame that the AMA no longer has the sway over the medical profession and general public it once held. My understanding is that many of the older physicians don't want any part of it because of many of their past stances which they have since amended, and I know that many of the newer physicians won't join because the membership fees are ridiculous (something like 500/yr for a practicing physician). I know that lobbying organizations need money, but you can't expect that many people to join an organization that costs that much just for membership fees. I heard that a recent proposal to do away with membership fees was shot down by the leadership (who probably draw salaries from these fees).
     
  14. Andrew_Doan

    Andrew_Doan Doc, Author, Entrepreneur
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  15. Square Pants

    Square Pants HyperMegaGlobalCompu .net
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    The threats are not just from domestic M.D./D.O. wannabe's.
    Outsourcing of Rads reads will become more of a problem (IMHO)
    And as slide digitization becomes more routine, you can bet path will be heading in that direction too (again, IMHO)

    It's all about the $$$.

    And patients are idiots, I completely agree.
     
  16. Pilot

    Pilot Senior Member
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    Perhaps you have forgotten there are many DO orthopedic surgeons.
     
  17. cbc

    cbc Senior Member
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    sorry, but what is IMO or IMHO?
     
  18. mig26x

    mig26x Senior Member
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    very scary whats happening with optometrist vs optha specialist. Here in Puerto Rico ( a USA territory) politicians are discussing a project to let optometrist prescribed medicine to there patients and they are winning the battle. The propaganda the optometrist are using to persuade politicians to vote in favor of this project is that NOT all doctors are sufficiently educated and trained to prescribe antibiotics or medicine to treat eye illnesses but they ( optometrist) are, when i read that i almost fainted!!! Now i read on this thread that optometrist are trying to do eye surgery?? whats going on? Optometrist school or education in no way resembles med school, how can optha specialist let this happen? But you know whats the biggest problem? We as future physicians are divided, we are letting the opthalmology association fight alone this battle, instead of all physicians associations uniting and figthing a common cause, that one day is gonna affect all physicians. We have to unite to defend what we fought so hard for, you cannot substitute for 4 years of med school, 3 years of residency and 2-3 years of fellowship training.
     
  19. Andrew_Doan

    Andrew_Doan Doc, Author, Entrepreneur
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    Thank you for voicing your support! :thumbup:

    We do have to stand together as a group. As a whole, physicians can be a very strong political group. ;)
     
  20. DrMom

    DrMom Official Mom of SDN
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    IMO=in my opinion
    IMHO=in my humble opinion
     
  21. Svetlana117

    Svetlana117 Junior Member
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    Here is a quote to muse about..

    "Knowing a little medicine is VERY dangerous..."
     
  22. cbc

    cbc Senior Member
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    IMAO (in my arrogant opinion), docs already have their hands full fighting for their own specialities rights. chiropractors, physical therapists, DOs are already trying to get a piece of orthopedics and sports medicine. PAs and NPs are all threatening the primary care sector. techs are trying to take over jobs of anesthesiologists. and lawyers are trying to have their salary made from suing all docs.
     
  23. Pilot

    Pilot Senior Member
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    Blah, blah, blah. Please spare us the DO "infractions" into the practice of medicine. In case you hadn't hear, DO's are fully licensed physicians in all 50 states. Just IMAPAPO (in my arrogant physician and pharmacist opinion.)

    Pilot, D.O., D.Ph.
     
  24. coolness

    coolness Senior Member
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    I think I wasn't clear about my questions. NPs have the power to prescribe medicine. So are they free to prescribe all medications that an IM would? What specific conditions can IMs diagnose that NPs can't. I know that NPs can treat simpler conditions such as colds and flus. But what about heart disease and high blood pressure? If NPs can prescribe all medications as IMs can and they can also diagnose all diseases as IMs can, common sense would say that NPs would replace IMs (I hope not) based on economics. But if this was the case, there would already have been a movement towards this. Honestly, if I had a serious condition, or even a simple condition like ear ache, I still prefer to see a physician (MD/DO) based on their extensive and rigorous education and training.
     
  25. HeavyD

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    Back to a point re: educating patients. Look, when the drug companies can air 30 sec. commercials during every evening news broadcast the general population, ie the 'idiot' patients come swarming with questions/demands for the newly advertised drug. Throw in a little 'bling' for these same consumers in comercials displaying a little political-ad type bashing of these folks with glorified bachelor degrees (ie Optomitrists, NP's, etc) level of education, time in post-grad training (or lack there of-) and some crippled kids or a chest-clutching grandpa (something very political ad-ish) and any issue will quickly become obsolete. As our esteemed college Dr. Doan has mentioned, we as current and future physicians, must be pro-active with PAC's (despite my utter loathing of lawyers- who make up PAC's by and large). Until more physicians become politically active or at least more savvy so as to do away with the mud-sucking leaching lawyers who make up PAC's, having lobbying power is a necessary evil.
     
  26. Neuron

    Neuron Aequanimitas.
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    Oh. My. God. :wow:
     
  27. cbc

    cbc Senior Member
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    Yeah but did all DOs do a 6 year orthopedic surgery residency?

     
  28. dbiddy808

    dbiddy808 Senior Member
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    As a soon-to-be third-year internal medicine resident, I think I have a bit of knowledge about this topic.

    I think that comparing a seasoned NP or PA to a good intern may be comparable, but there is no comparison to a board certified internist or even a medicine resient. There is SO much to know in medicine and it is always changing. To be an effective internist requires a great deal of knowledge. As a resident, we spend 2-4 hours a day discussing minute details of patient care in the various lectures and attending rounds. It is not easy managing complex patients (such as most of our patients who are noncompliant, overweight, diabetic, hypertensive smokers with coronary artery disease, COPD and renal insufficiency).

    And as far as nurse anesthetists, don't even get me started...........
     
  29. Andrew_Doan

    Andrew_Doan Doc, Author, Entrepreneur
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    You and I know this. The public doesn't. The politicians don't care. They care about the votes. I can't emphasize enough the necessity to support your PAC and the AMA. As a whole, the nursing PAC is very strong! ;)
     
  30. jean25

    jean25 New Member

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    You certainly have some very ignorant ideas about DOs. As a soon to be DO who will go into IM you are more than welcome to keep my piece of the orthopedic and sports medicine pts because despite what you may think, not all of us have an interest in those areas. And those who do usually do their 5yr ortho residency or do a sports med fellowship just like you MDs.

    PS. DOs are docs also.
     
  31. Hotsauce21

    Hotsauce21 Huh?
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    exactly. watch out rads.. your films may be read by people in india in 10 yrs for half the pay!
    by the way, what is the abbrev. imho?
     
  32. juddson

    juddson 3K Member
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    You know, I am one of the last people who would want to agree with Kinetic, but the fact is that he is right on this point. Perhaps the notion that the public is too stupid to choose docs is a bit aggresive, but my own informal survey of even "educated" adults (ie., college educated) suggests that they have no objection to mid-level practitioners practicing medicine on them. In two instances (both were pregnant and due in the following two months), neither person objected to the use of a CRNA during the C-section. AND, the opinions of the people I surveyed did not change even when confronted with the reality (dubious, perhaps) that the costs for medical care would NOT decrease with greater access to mid-level practitioners.

    I think MUCH of this comes down to the perception among even the educated public that doctors are over-compensated and generally held in poor regard. There is no sense in looking to the average joe for "sympathy" when it comes to physician salaries OR scope of practice.

    Judd
     
  33. juddson

    juddson 3K Member
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    I would very much like you to "start" on this. Too rarely do we have residents and doctors give opinions on these forums about the relative expertise of the mid-levels vis-a-bis the docs (we have some, but not enough).

    I must say that 6 months ago I was almost of the opinion that perhaps much of doc training was useless if, in fact, PA's and NP's could do it all on virtually no training. But as I learn more and more about what the training for a doc consists of, I am more of the opinion that mid-levels ARE illsuited, and that perhaps docs will not be replaced.

    Here's one example - I was at the optometrists the other day with my wife. This was a stand-alone office with an optometrist, a "nurse" (or something) and a receptionist. It had a VERY visceral "doctor's office" feel to it. But having witnesses the rest of the office, the visit by my wife and the "scope" of the OD, I have to say that he was (1) ill-equipped and (2) ill-motivated to make the leap from glasses fitter to "surgeon".

    For one, his office did not have the "treatment rooms" or the equipment to make any "meaningful" inroads into what MDO's do. Moreover, no matter how lucrative the sorts of surgical procedures OD's may be able to do, there is NO WAY that these procedures could be carried out in any "meaningful way" (ie., in such quantities as to threaten MDO's) if the OD was to continue his function as the examiner and fitter of corrective lenses. I did NOT get the impression that one could sell eye-glasses AND do the occassional LASIK as part of one practice.

    Perhaps I am wrong about this, but it is my impression that a "meaningful" encroachment of OD's into MDO's scope of practice would require a significant ceding of the "bread and butter" of what an OD generally does. Perhaps this IS the intention of some OD's. But somehow I doubt it.

    Judd
     
  34. nathansackett@e

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    as someone who is studying to me an NP, i have to speak up. NP's should not be compared to MD's. There is this whole BS comparison between PA's, NP's and MD's.
    I have great respect for MD's. I am not a junior MD's who works with patients that are too easy for MD's (sprains, colds etc). NP's are trained in totally different aspects of healthcare. We look at social-political-environmental issues. We have a good understanding of the physical as well, that is why we can often write prescriptions. But as an NP, we are part of a team. Most of the NP's I know have no illusions of replacing an MD, nor do most want too. FOr those who are trying to replace the MD, they are in for a long battle. I chose to be an NP becuase I like the patient centered model. but this model also NEEDS THE DISEASE CENTERED FOCUS that MD's use. I think both are great, and both need the other. MD's clearly know more about pathology, pharm, etc. nurses may have something to offer regarding quality of life, treatment options, success rates, social issues, and symptom management. I strive to work with MD's and share input to come up with a plan. I DO NOT WANT TO REPLACE ANYONE!!!
    Why can't we all get over this issue of being threatened and trying to prove our role? Whether you are an MD/PHD or a lab tech, everyone should be after one thing- to work together and provide care. THis whole turf war thing is so tiring. :)
     
  35. cbc

    cbc Senior Member
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    Whatever. Not "all of" chiropractors and sports meds have interests in those particular areas either. And chiropractors are docs too, so what's your point?

     
  36. PA_to_MD

    PA_to_MD Junior Member
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    I have news for you CBC, orthopods want to operate. Chiropractors, physical therapists, non-ortho DO's are not trying to do that. Nonoperative orthopaedics can be done by anybody. I can't think of any orthopods dying to get there hands on nonoperative back pain patients. :laugh:
     
  37. cbc

    cbc Senior Member
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    Orthopods would want to diagnose and treat non-operatively if these other health profs didnt drive up the competition and down the price. They'd be doing the same things ENTs do (diagnosis, non-op and op treatment), plus manipulative procedures.
     
  38. sdude

    sdude Member
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    Are you saying that that if it wern't for those nasty FP/Sports med docs providing affordable (and evidently satisfactory) non-operative orthopedic care, orthopods MIGHT consider non-operative treatment?

    I know a few orthopedic surgeons and admire them greatly, but face it; they're surgeons. I'm an athlete, and if I have some sort of soft tissue problem I'd feel much more confortable seeing a FP/SM doctor I know is interested in athletes and trained in non-operative treatment. If I did need surgery, I'd rather hear it first from a doctor who WASN'T a surgeon.
     
  39. cbc

    cbc Senior Member
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    Once I had a broken pinky, and I saw an FP, who referred me to an orthopedic surgeon and xray. I had to copay the FP for the referral, and received non-surgical care by the orthopod. I never said anything was nasty, but competition with orthopods does exist.


     
  40. sdude

    sdude Member
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    If I had anything broken, I *would* go to an orthopod first. They are definitely the experts in that area, and I wouldn't want to take any risks of it healing incorrectly (that pinky is pretty darn important if you play the guitar :)). (Not to say that an FP couldn't be a bone-setting ace, but they definitely all aren't).

    I guess I'm just puzzled by the idea that orthopods really WANT the mundane soft tissue stuff. I think it's cool--definitely. Every internist I've seen seemed very bored by my minor health issues, and would basically shoo me away if I had a funny looking mole or sore knee. I assumed that orthopedic surgeons would be similar, and would prefer to focus on patients with nasty bone injuries and surgical issues.

    Probably orthopods just need to do some more PR. It's counterintuitive for most people to see a surgeon unless they have a serious issue, and I really think most people don't know that orthopods have any training or interest in ordinary lower back pain, sore shoulders, etc.
     
  41. PA_to_MD

    PA_to_MD Junior Member
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    That's a great study...n=1, you should publish that. :laugh:
     
  42. bennyhanna

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    Though I am not a doctor, and therefore regardelss of my education am uneducated as a previous post suggests, I would like to comment if my slang English is understandable.

    Medicine is delegated by the physician. Though regulated by federal, state, county, local laws and the practice at which he/she works, everyone who is not a physician ultimately pratices under the physician.

    An RNP, RN-A, and PA-C cannot practice without a physician's signature. Furthermore, a physician can expand or limit the scope of practice (within limits) of these providers, and therefore, would be able to limit them so as not to be a 'threat' to buisness.

    So why are they being hired? If we the public are a brood of invalids because we don't have the initials MD after our names, why then do our insurances pay for them, and why do doctors use them? Profit and manpower. The billing is the same, however physician and RNP/PA salaries are not. The bottom line increases. Additional healthcare providers means the less critical patients can get treated faster by these sub-ordinates. More patients means more billing, which means more money.

    Lastly, if a physician is 'scared' or inconfident about the RNP/PA because they share the public's lack of education, then he/she should further educate the clinician to a level that he/she sees fit to reflect him/her and his or her practice.

    ~BB
     
  43. nathansackett@e

    [email protected] Junior Member
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    bennyhanna,
    NP/s do not need MDs signatures to practice in most states. in CA, they are independant. that said, they are hired becuase they look at the patient with a difference lens. they should refer to MD's when needed, when they feel it is out of thier scope. all clinicians know that point (or should). NPs bring a more social perspective, they look at the environment, the family. they bring important input and are trained in totally different theories.
    learn more about nursing before you thrash it.
    nathan (NP to be)
     
  44. bennyhanna

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    I am sorry that you interpreted my post to be thrashing NPs. I apologize if that is how you took it, but it was not the intention.

    Based on your post I did further research and found that indeed they do not require physician signatures or supervision, but instead are limited in practice by the board of nursing, the state in which they reside, and their employer.

    Which brings up a question for RNPs... the role between RNP and MD is becomming increasingly blurred. Are doctors (family medicine) at risk of becoming replaced by RNPs? Will this force doctors to specialize who normally whouldn't have because of this competition?
     
  45. DOsDad

    DOsDad Junior Member
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    Having a daughter-in-law who is an OD degree, meaning, Doctorate of Optometry, she has every right to be called Doctor in her professional setting. You seem remarkably uninformed about both Optometrists and DO's
     
  46. emedpa

    emedpa GlobalDoc
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    bennyhanna-another clarification. pa's practice under indirect supervision which means an md/do need not be present at the same time. pa's write prescriptions under their own names with their own dea #s. they are not cosigned. in my state the supervisory requirement is 10% chart review within 1 month. in north carolina the requirement is that a pa and their supervising doc meet every 6 months to discuss their practice without any specific chart review at all. as a pa you can basically work as independently or interdependently as you choose, based on where you live, your experience, and the type of field you enter.
     
  47. bennyhanna

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    That saved my next question... in another forum about RNPs it was discussed that in some states, they too, can practice with minimal supervision... I was wondering if this was the same for PA-Cs.

    You are an Emergency Department PAC. What is your scope of practice in this setting? Can you prescribe all meds the ED doc would? What are some of the invasive and more advanced procedures you can do?

    BB
     
  48. emedpa

    emedpa GlobalDoc
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  49. bennyhanna

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    great site, thanks!
     
  50. Dr. Whatever

    Dr. Whatever Junior Member
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    I used to go to an NP for primary care until I realized that I brought my dog to somebody with more education and training than I brought myself to. I wonder if Vets are worried about vet assistants taking over their jobs... or if vet assistants are worried about the vet receptionists taking over their jobs. The whole thing just doesn?t make any sense to me. You want to be a doctor, go to undergrad/medical school/residency/fellowship. The rich politicians who endorse giving greater practice rights to non-doctors will never be seen by them. They will go to the best and the brightest docs, leaving the less fortunate to be treated by non-doctors. The truth is, the public does not know the difference. Put a white coat and a stethoscope on somebody and you assume they are a doc. I totally agree with previous posts... send money to the AMA or your PAC. MD/DO's are currently in a defensive posture but need to go on the offense. Protecting your career will also bring protection for the public with QUALITY OF CARE.
     
  51. cbc

    cbc Senior Member
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    Optometrists are considered docs.

    I'd rather be seen by an NP than PA in primary care or emergency any given day.
     

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