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Why is that NP's can be independent or PA's are limited in this role?

scoopdaboop

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    Can someone explain. PA's clearly have a more competitive path to school, and their schooling is harder. Why would someone working as a nurse all of a sudden when being a NP be independent when their schooling is pathetic.
     
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    Apollo1

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      Can someone explain. PA's clearly have a more competitive path to school, and their schooling is harder. Why would someone working as a nurse all of a sudden when being a NP be independent when their schooling is pathetic.

      Don't know if this is an attempt to troll, but I'll bite.

      NP practice freedoms are a legislative issue; they don't operate under the Board of Medicine, so they can set their own rules regarding "independent" practice. In addition, they can exert more legislative influence b/c there will always be a greater need for nurses (manpower-wise) in the current health system setup. Legislators can be swayed by emotional arguments, which the nursing lobby often makes.

      IMO, the push for greater independence by NPs partly comes across as an emotional reaction to how their profession is viewed. The nursing profession is still seen as blue-collar (regardless of whatever educational requirements they seem to endlessly tack on), and perhaps they want to be perceived as something more. However, the way they're going about it seems to reinforce the perception.
       
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      scoopdaboop

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        It’s a lobbying decision, neither should be independent

        Yeah, I find it hilarious that almost every NP/PA that makes the decision to go to med school admits the lack of knowledge they had as NP/PA and that the profession shouldn't be allowed to practice independently. But that's neither here nor there, I don't want to make this thread another flame post like happens often.

        I allow this thread to be closed.
         
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        pamac

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          I agree with much of the above. I’ll add in some aspects that I think were key to establishing the lack of independence PAs have compared to NPs.

          Back in the day that both the PA and NP professions were conceived, NPs decided to forge their own path. This was an active decision on their part. PAs were hitched to physicians, as one would expect they would have to be because they had no kind of toehold career of their own to operate from. NPs presented themselves as “more of a nurse”, and PAs were left with being “less of a doctor”. And it probably seemed wise to be hitched to physicians that way, as a winning proposition. The problem is that they had nowhere to go from there that wasn’t approved of by the folks who created and nurtured them. This persists today. Any independence that they ever will obtain is created by an act of succession that must accompany the purists they want to accomplish. That’s an entirely different concept than what NPs need to do, which is simply for them to expand on something that they don’t have in hand. An analogy is that to build a beach house, PAs first have to demolish the house that is already on the land. That’s a different prospect than simply building on bare land. The effort is exponentially more difficult, particularly when the owner of the house doesn’t want to sell. It’s not much more complicated than that. Physicians not only aren’t going to help them, but they literally also aren’t going to allow PAs to branch off and add to the pool of providers that aren’t physicians. They don’t really seem to want more physicians out there either, But given the choice, would probably rather have 3 physicians instead of 10 nonphysician providers of any flavor, particularly nonphsyician providers that they don’t control like many NPs. And I don’t blame them for this.

          I don’t see PAs really ever being free from that dilemma, because they would have to be released from bondage by a group that for whatever reason has no incentive or inclination to do that. Even to spite NPs, it doesn’t make sense for them to add even more providers to the landscape when they see themselves as the keystone for the healthcare system. They are right about that for the most part.
           

          DrNotaDr

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            PA's are getting doctorates too, and are displaying their education proudly in their signatures in patient charts:


            PA's want independence too:


            While most NP's come with years of experience as a RN: " Prior RN experience ranged from zero to 38 years with a mean of 13.75 years." (J Nurse Pract, 2016) Exploring the Factors that Influence Nurse Practitioner Role Transition other studies have confirmed the same. As noted, years of experience doesn't seem to help the role transition, but there is a significant safety component in that an experienced inpatient RN usually can pick up patient deteoriation quicker than a PA.

            The thought that PA's don't want to achieve what the NP's have is untrue, they are just slower about it, preferring to let the docs hate the NP's while they themselves work towards the same goal.
             
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            pamac

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              PAs may want it, but they are terrible at obtaining independence though. NPs are fully independent (or at least have a pathway toward being fully independent) in over half of states. PAs have nothing like full independence in even one state. All the low hanging fruit has been snatched by NPs, and the states that offer independence the moment NPs graduate have been established. Now, NPs have made the switch to pushing for whatever they can get, and even at that it’s a pretty good deal. So in places like Virginia and now California, there is a framework for becoming independent after NPs work under supervision for a few years. It’s not perfect, but it still is more independence that anything any PA can achieve. I predicted that California would be the turning point, and we can see that now the biggest state in the US now allows NPs to become independent providers, albeit after a 3 year supervision period. And now we have it. And it doesn’t end there. All the states with those kinds of arrangements will have the nursing lobby revisit these arrangements at the first available convenience, and they will push to have the break in period shortened or ended so they can be just like the multitude of states that do just fine without those. My state is independent, and has been for decades, and things are just fine. But if NPs agree to the incremental approach to independence in states like California (like the just have) then it gets them that much closer to revision at a later date.

              Independence is mostly worthwhile to me as it pertains to the employment relationship between NPs and physicians. The overwhelming majority of NPs won’t be out there owning their own practice. But if one is an independent provider, one has a more streamlined employment conditions. I don't have to jump through the hoop of establishing and cultivating a dependent interaction with another provider. I’m hired by a boss just like any other employer, and I don’t have to worry about being a vassal of the physician so that I can do my job. no doc is responsible for any mistakes I might make, and I’m not at the mercy of having my ability to prescribe and work be dictated by another provider. Other than that, my work and my ability to consult with a physician when I want to is unimpressed. I probably function very similar to any dependent provider you would find in a state that requires being tied to a physician, which is to say we operate with a fair amount of daylight between us in both regards.
               

              chocomorsel

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                Bruh Pamac, why are your posts always 2 + massive paragraphs long.
                It's called
                Propaganda - information, especially of a biased or misleading nature, used to promote or publicize a particular political cause or point of view.
                You are welcome.
                 
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                Socrates25

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                  The reason NPs are more independent is because 30 years ago they were successful in convincing state legislatures that scripting meds and doing surgery is actually the pracitce of "nursing" and not "medicine" therefore they can't be regulated by state medical boards.

                  Right now the state nursing boards could unilaterally declare that brain surgery is the practice of "nursing" and there's not a damn thing the medical board could do to stop them.

                  Would hospitals grant the NPs brain surgery operating privileges? Probably not, but it would still be "legal" for them to do brain surgery if they decide to declare it within their scope of practice.

                  PAs have now caught onto this and many of them want their own PA board that's separate from the medical board. That way they can go to state legislautres and say that scripting meds is actually the practice of "physician assisting" and not "medicine" therefore they shouldnt be controlled by medical boards.
                   
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                  jl lin

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                    The reason NPs are more independent is because 30 years ago they were successful in convincing state legislatures that scripting meds and doing surgery is actually the pracitce of "nursing" and not "medicine" therefore they can't be regulated by state medical boards.

                    Right now the state nursing boards could unilaterally declare that brain surgery is the practice of "nursing" and there's not a damn thing the medical board could do to stop them.

                    Would hospitals grant the NPs brain surgery operating privileges? Probably not, but it would still be "legal" for them to do brain surgery if they decide to declare it within their scope of practice.

                    PAs have now caught onto this and many of them want their own PA board that's separate from the medical board. That way they can go to state legislautres and say that scripting meds is actually the practice of "physician assisting" and not "medicine" therefore they shouldnt be controlled by medical boards.

                    I honestly do not know one, not one NP, whom desires or is hot to do major surgery on patients. Those of us who have practiced for a long time in serious places with seriously sick patients, surgical and otherwise, know (witnessed) a good amount of the incredible work it takes to go through well-controlled, arduous residencies and fellowships, and how precious that hands-on experience in such highly specialized area is absolutely vital. Anyway, most NPs I know want the nicer day hours. If they wanted to go to medical school, they would endeavor to do so and play their cards to do so. Remember that a lot of NPs are looking to balance their lives with families. No worries for physicians. Surgery is just fine and needs no protection in this regard. More PAs do surgery than any of the minor procedures some NPs do. Smart, experienced nurses know it's not worth the risk w/o getting the proper training/experience from a residency/fellowship. Also, most NPs I know have zero issues with working under the supervision or guidance of an excellent, experienced physician. It's about the lifestyle for 99.9% of NPs.
                     
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                    pamac

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                      I honestly do not know one, not one NP, whom desires or is hot to do major surgery on patients. Those of us who have practiced for a long time in serious places with seriously sick patients, surgical and otherwise, know (witnessed) a good amount of the incredible work it takes to go through well-controlled, arduous residencies and fellowships, and how precious that hands-on experience in such highly specialized area is absolutely vital. Anyway, most NPs I know want the nicer day hours. If they wanted to go to medical school, they would endeavor to do so and play their cards to do so. Remember that a lot of NPs are looking to balance their lives with families. No worries for physicians. Surgery is just fine and needs no protection in this regard. More PAs do surgery than any of the minor procedures some NPs do. Smart, experienced nurses know it's not worth the risk w/o getting the proper training/experience from a residency/fellowship. Also, most NPs I know have zero issues with working under the supervision or guidance of an excellent, experienced physician. It's about the lifestyle for 99.9% of NPs.

                      Practicing independently provides the most value for me for things like employment mobility, negotiations, onboarding, etc. The doctors I work with appreciate that none of them are liable for my actions. I do some work on the side in an arrangement that is much less complicated because I don’t have to have any kind of agreement with a physician. But overall, it’s the lifestyle aspect that speaks to me. The money is very good, and the hassles are few. The psyche NPs that I know that are on their own tend to do quite well, but also have the hassles of running a business. I really haven’t seen enough NPs that are making physician style money to make it worth it to me to try to run my own operation.

                      You’ll usually find NPs working in such a way that they are employees.
                       

                      Heist

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                        PA's are getting doctorates too, and are displaying their education proudly in their signatures in patient charts:


                        PA's want independence too:


                        While most NP's come with years of experience as a RN: " Prior RN experience ranged from zero to 38 years with a mean of 13.75 years." (J Nurse Pract, 2016) Exploring the Factors that Influence Nurse Practitioner Role Transition other studies have confirmed the same. As noted, years of experience doesn't seem to help the role transition, but there is a significant safety component in that an experienced inpatient RN usually can pick up patient deteoriation quicker than a PA.

                        The thought that PA's don't want to achieve what the NP's have is untrue, they are just slower about it, preferring to let the docs hate the NP's while they themselves work towards the same goal.
                        With the flood of nps from diploma mill schools that cost a lot, that average will go way down
                         

                        Emedpa

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                          PAs in North Dakota with 4000 hrs of practice may now be independent providers and open their own clinics. PAs can now also independently bill medicare.
                           
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                          pamac

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                            PAs in North Dakota with 4000 hrs of practice may now be independent providers and open their own clinics.
                            Just in time for everyone in the medical world to be getting out of being a mom and pop shop.

                            No, that’s actually pretty cool, particularly for the area they are in that is underserved, and was left without a single provider when those two got fired for rocking the boat where they were at before.

                            Problem is that they still had to go to the state board of medicine and petition to be able to open up a shop on their own. NPs do not. Here’s a map of independent practice states for NPs, and it doesn’t include states like Virginia, Illinois, California, and Florida that have added independent practice for NPs after certain conditions of tenure:


                            You’ll notice that even in those states that have independence after conditions of tenure, the AANP doesn’t stop with that, or consider that satisfactory. They come back the next year to work until full independent practice is obtained. My point with this is to communicate to folks that they should know what they are getting into when they pursue a career as a PA vs an NP. There are forums out there where there are a bunch of disgruntled PAs (both students and very seasoned PAs) that act shocked, and lash out at NPs regularly for their station in life as independent providers, while PAs lack that. It’s to the point now that PAs want to change the official name of their profession to mimick NPs by calling themselves “Medical Care Practitioners”, in hopes that they can just shorten it to “MPs” and sound like “NPs”. So if you are on the fence, and want to practice independently, one should know what the landscape is like at this moment before you invest tens to hundreds of thousands of dollars to pursue PA education. Unless you want to practice in South Dakota, have over 4000 hours of tenure, and request permission from the physicians on the South Dakota Board of Medicine to open your own clinic in a place where there are no other medical providers, you’ll be practicing under the supervision of a physician. NPs there can practice on their own the moment they graduate and get their papers filed with the Board of Nursing. If that doesn’t harsh your buzz for being a PA, and you can handle that, go for it. If you have dreams of being working for yourself, you’ll need to look elsewhere. Those two PAs in that article are probably going to be lucky to just break even in less than 3 years. Any PA looking to open a derm practice in downtown Fargo, Bismarck, or Grand Forks will be promptly denied by the Board of Medicine. Right now, those two PAs are practicing where literally nobody else is practicing, even NPs. They want to run psyche services to keep the lights on, but an enterprising PMHNP will establish telepsyche there and get that off the table.

                            I’m not saying that what they are doing is anything other than noble, but it’s not repeatable for the thousands of new PAs who will hit practice each year. Know what you are waking into as a Pre PA, and you’ll be satisfied with your career choice. Don’t operate simply off of what you wish to walk into.

                            The best thing I’ve done in my professional life was choose to become an NP vs PA, and I did it based on knowing the terrain. That’s not to say that PA isn’t a great career, or that you can’t have an awesome experience as a PA, but you have to know what advantages and disadvantages either advanced practice provider role carries with it. In some places, NPs are screwed, and they practice at the same level of independence as PAs do, and it wouldn’t matter much what you were (PA or NP). But the PA forums are filled with folks that are shocked that the profession that they are in is the same profession that they signed up for, and it doesn’t make them happy because they felt like it would be something else altogether.
                             
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                            Splenda88

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                              Don't get for the life of me how these people can practice medicine independently. Maybe I am dumb and the people who attend PA/NP are geniuses. Then again, I was not impressed with the 2 PA students I had on my team ~2 months ago. The 3rd year med student on the team was better than them in both basic science and medical management. I just don't get it.
                               

                              pamac

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                                Don't get for the life of me how these people can practice medicine independently. Maybe I am dumb and the people who attend PA/NP are geniuses. Then again, I was not impressed with the 2 PA students I had on my team ~2 months ago. The 3rd year med student on the team was better than them in both basic science and medical management. I just don't get it.
                                Yeah, you keep coming onto the PA/NP forums and talking nonstop about that. Non... Stop....

                                Non stop.
                                 
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                                Emedpa

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                                  Yeah, you keep coming onto the PA/NP forums and talking nonstop about that. Non... Stop....

                                  Non stop.
                                  Yup, why is it that we don't hear about the PA/NP student rockstars who made all the MS3s look like they hadn't done their homework on rounds? More common than you think. Prior experience as an RN, Medic, Resp therapist, etc for years before attending PA/NP programs confers a significant advantage over the typical 25 yr old bio major who has never had a job and lists their housing as with mom and dad. Life and prior medical experience matters.
                                   
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                                  Emedpa

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                                    Don't get for the life of me how these people can practice medicine independently. Maybe I am dumb and the people who attend PA/NP are geniuses. Then again, I was not impressed with the 2 PA students I had on my team ~2 months ago. The 3rd year med student on the team was better than them in both basic science and medical management. I just don't get it.
                                    N=1. I have seen PA students put MS3s to shame more often that not. and yes, my N=1. equally worthless.
                                     

                                    pamac

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                                      If you want to become a doctor, be a MD or a DO.. Nurses are valuable but they are supposed to have that role, and their role is not to have a role of MD or a DO..

                                      It’s not up to you what nurses roles are. NPs have their scope. The problem folks with your mindset face is that in about 28 states, NPs function independently just fine. I’ve said this before, but most of the states with the poorest health outcomes are states that don’t allow NPs to have independent practice. There isn’t a huge tragedy taking place in states with independent practice compared to those that don’t have it. Independence is mostly a factor of administration vs clinical flexibility.... ie, less red tape, more job mobility. One could come to my independent practice state and not notice much difference at all to the bottom line or practice. In the dependent states, docs aren’t heavily supervising NPs anyway, they just have administrative power over them.
                                       
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                                      Splenda88

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                                        N=1. I have seen PA students put MS3s to shame more often that not. and yes, my N=1. equally worthless.
                                        Maybe these 2 PA students HCE was not great. I should have asked them if the 500-1000 hrs they did to fulfill admission requirements were shadowing hours, or volunteering, or if they were just scribe or CNA.
                                         
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                                        Emedpa

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                                          Maybe these 2 PA students HCE was not great. I should have asked them if the 500-1000 hrs they did to fulfill admission requirements were shadowing hours, or volunteering, or if they were just scribe or CNA.
                                          Most of us did more than that. The national avg is > 2500 hrs of experience. I was an ER tech for 5 years and a paramedic for 5 years with a solid science degree from the University of CA when I applied. I was pretty typical of my class.
                                          "Most students have a bachelor’s degree and about three years of health care experience before entering a program."
                                          source: Become a PA: Getting Your Prerequisites and Certification - AAPA
                                          Yes, some programs have gone away from significant HCE prior to application, but most still value it and many programs(obviously from this stat) weigh it heavily in admissions decisions. I am on two admissions committees and I will round file any applicant without good HCE, regardless of GPA or LORs from anyone. In my book scribe is worthless. A scribe is a mobile transcriptionist without any responsibility aside from avoiding typos.
                                           
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                                          Splenda88

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                                            Most of us did more than that. The national avg is > 2500 hrs of experience. I was an ER tech for 5 years and a paramedic for 5 years with a solid science degree from the University of CA when I applied. I was pretty typical of my class.
                                            "Most students have a bachelor’s degree and about three years of health care experience before entering a program."
                                            source: Become a PA: Getting Your Prerequisites and Certification - AAPA
                                            Yes, some programs have gone away from significant HCE prior to application, but most still value it and many programs(obviously from this stat) weigh it heavily in admissions decisions. I am on two admissions committees and I will round file any applicant without good HCE, regardless of GPA or LORs from anyone. In my book scribe is worthless. A scribe is a mobile transcriptionist without any responsibility aside from avoiding typos.
                                            I see...

                                            I jus look at HCE for PA of the School of Medicine that my residency is affiliated with, and I can see why these PA students were struggling.

                                            The program requires applicants to complete at least 500 hours of direct patient care experiences (e.g., patient care attendant or nurse’s aide, clinic assistant, Peace Corps volunteer or other cross-cultural health care experience, technologist, therapist, clinical research assistant, etc.)

                                            I can see why they had a hard time on an inpatient medicine floor at a big trauma center in an inner city... I also think 8 wks is not enough for IM since IM is the foundation of medicine. Hopefully, they can catch up once they start working.
                                             
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                                            Emedpa

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                                              I see...

                                              I jus look at HCE for PA of the School of Medicine that my residency is affiliated with, and I can see why these PA students were struggling.

                                              The program requires applicants to complete at least 500 hours of direct patient care experiences (e.g., patient care attendant or nurse’s aide, clinic assistant, Peace Corps volunteer or other cross-cultural health care experience, technologist, therapist, clinical research assistant, etc.)

                                              I can see why they had a hard time on an inpatient medicine floor at a big trauma center in an inner city... I also think 8 wks is not enough for IM since IM is the foundation of medicine. Hopefully, they can catch up once they start working.
                                              This is more typical of programs I work with:

                                              Clinical experience prerequisite overview:​

                                              • In addition to the academic requirements, all applicants must meet the minimum 2,000-hour paid, direct, hands-on clinical patient care prerequisites.
                                              • Competitive candidates have more than the minimum 2,000 hours – averaging a total of 6.5 years – of paid experience, usually in primary care or emergency medicine.
                                              • When considering a position in health care, remember that the clinical experience must be in the direct delivery of patient care.
                                               
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                                              manwelio

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                                                I agree with much of the above. I’ll add in some aspects that I think were key to establishing the lack of independence PAs have compared to NPs.

                                                Back in the day that both the PA and NP professions were conceived, NPs decided to forge their own path. This was an active decision on their part. PAs were hitched to physicians, as one would expect they would have to be because they had no kind of toehold career of their own to operate from. NPs presented themselves as “more of a nurse”, and PAs were left with being “less of a doctor”. And it probably seemed wise to be hitched to physicians that way, as a winning proposition. The problem is that they had nowhere to go from there that wasn’t approved of by the folks who created and nurtured them. This persists today. Any independence that they ever will obtain is created by an act of succession that must accompany the purists they want to accomplish. That’s an entirely different concept than what NPs need to do, which is simply for them to expand on something that they don’t have in hand. An analogy is that to build a beach house, PAs first have to demolish the house that is already on the land. That’s a different prospect than simply building on bare land. The effort is exponentially more difficult, particularly when the owner of the house doesn’t want to sell. It’s not much more complicated than that. Physicians not only aren’t going to help them, but they literally also aren’t going to allow PAs to branch off and add to the pool of providers that aren’t physicians. They don’t really seem to want more physicians out there either, But given the choice, would probably rather have 3 physicians instead of 10 nonphysician providers of any flavor, particularly nonphsyician providers that they don’t control like many NPs. And I don’t blame them for this.

                                                I don’t see PAs really ever being free from that dilemma, because they would have to be released from bondage by a group that for whatever reason has no incentive or inclination to do that. Even to spite NPs, it doesn’t make sense for them to add even more providers to the landscape when they see themselves as the keystone for the healthcare system. They are right about that for the most part.
                                                My understanding is that PA school is largely a procedure-based training program whereas nurse practitioner programs are more and more commonly focusing on a medical model for the whole lifespan.

                                                NPs are being developed to take the place of primary care physicians because there aren't enough primary care specialists nor enough primary care residencies when you consider the surplus of people INTERESTED in that kind of work. First they need to get beyond the extremely exclusive medical school entrance process which is closely attached to residency space. So NPs are largely functioning as "less educated" physicians because hospitals and cities and states NEED them to be.

                                                PAs, however, never shifted their training or purpose. They were developed as a more advanced paramedic and like someone else said a lesser physician. The fact that PA school is still so closely tied to "previous medical experience" is also in itself limiting.

                                                I follow a Facebook group focused on PAs and PA school and you'd be amazed by how many people are scrambling to pass unheard-of community college courses and hurrying to acquire phlebotomy certificates and the barest of minimums of shadowing and medical experience so they can quickly apply to unheard-of PA schools in various regions.

                                                "I work at the Lens Crafters, how long do I have to work here before my hours are sufficient to apply?" Literally the tone of their comments.
                                                 
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                                                manwelio

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                                                  Can someone explain. PA's clearly have a more competitive path to school, and their schooling is harder. Why would someone working as a nurse all of a sudden when being a NP be independent when their schooling is pathetic.
                                                  I think the assumption here is PA school is better than NP schools, but there are plenty of people graduating from name-I-never-heard-of PA schools after dipping a toe in nursing home volunteering. Then there are people who spend 2.5 years at UPenn for advanced practice nursing. Is Unknown PA School really better than UPenn?

                                                  There is a selection of name schools with NP programs that are moving toward a primary care medical model more than a nursing model rooted in holistic "comfort" and patient-centered "feelings" and lifestyle.

                                                  I'm throwing quotes in here because they're my interpretations of how this plays out.

                                                  Personally I'd rather pursue a name NP program that focuses on a medical model designed to position NPs to replace MD PCPs. While I fully admit an NP with 2-3 years of training thrust into a medical office or hospital environment is experientially at a disadvantage, that's akin to a first-year intern MD. You get better with time and experience.

                                                  The only difference is NPs don't have special categories and titles and placement tests and lotteries and eventually parties for when they complete their first three years of work.
                                                   
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