Difference in NP & PA roles in the ED

zmansc, ASN, RN · May 8, 2014

I think what your asking would be more facility dependent (as to what NP/PA providers do). Warning: I've only worked in small, rural, community hospitals, so your mileage may vary dramatically in urban hospitals, especially lvl 1 & 2, and teaching hospitals.

Here, there is no difference in role between an NP or PA. Even though NPs have full independence, at my facility they still have all their charts signed by the MD/DO on duty just like the PAs do (It's not required by law for either). Our providers are MD/DO 24x7, and one additional provider (NP/PA) 12x7.

At one point there was a direction that the NP/PA would pick up the lvl 4&5 and some lvl 3s, and the MD/DO would take all lvl 1,2, and the rest of the lvl 3s. That lasted about 2 hrs, until two lvl 1 came through the door at the same time, the MD yelled at the PA and said "that one's yours"! lol The vast majority of lvl 1s are taken by the MD/DO. more than 1/2 of the lvl 2s are also taken by the MD/DO, but I doubt too many shifts go by where the NP/PA doesn't take a lvl 2. The rest are dived up mostly on a first come first serve basis by the providers.

The only major traumas we get are when they are too unstable to fly, because we will fly anything from the scene that needs a lvl 1 trauma center, so nobody gets the really hairy traumas, not that anyone at our facility complains about not getting something that we know we are unlikely to be able to handle. In the rare case a major trauma shows up, we generally have everyone attack it and sort out the details later.

All our providers suture on a regular basis, I'm not sure what IV lines any provider would do, usually the RNs take care of this, if we need an IO or EJ we typically get that from a paramedic if they are around somewhere. I honestly don't know if either can intubate, if they have the skill, they could get signed off and do it. During day shift anesthesia usually comes down and does it, at night it's usually the MD/DO. Not sure I've seen a need for a NP/PA to intubate, but that would be a facility sign off issue, not a scope of practice issue as RNs can intubate if their facility allows it in our state.

So in summary, neither is more hands on than the other in the facilities I've been in, but I can't confirm that isn't the case in other facilities. Of course the NPs are always cooler and more fun that PAs! Why? Because your on an NP board of course!

CraigB-RN, MSN, RN · May 8, 2014

The scope of practice for both is roughly the same. When you take into account individual state differences they are the same. The difference is more facility based and the level of the ED. Both can intubate, suture, do central lines, chest tubes, etc. They may be limited by the facility.

This is where I tend to get into trouble. I usually recommend to people, if your young and can swing it, (going to school full time for 2 years) i say go to PA school. If you've got a family, have to work, then do the NP route. But you do have to temper that with what level of provider is predom in the area you want to work.

It has nothing to do with one being better than the other. PA's are generalist and if you decide you want to change specialty, you can do it and learn on the job. NP's may (and i emphasise may) require you to go back to school for post graduate.

Either one is going to depend on how much work you put into it.

Altra, BSN, RN · May 9, 2014

Both nurses (RNs) and PA-Cs are educated as generalists. If you go the nurse route, NP graduate education is somewhat specialized (acute care vs. psych/mental health vs. women's health).

Both of these professions are masters prepared. Many PA programs require health care experience for application, and many NP programs require experience working as an RN.

In a hospital setting, chest tubes are inserted by physicians. Intubation is performed by physicians, and on occasion by respiratory therapists. A peripheral IV can be inserted by anyone who has been trained to do so. Uncomplicated suturing is often done by NPs/PAs in the ER.

Now for the part you may not like hearing ...

In an ER setting, NPs and/or PAs are used as "midlevel providers" or "physician extenders". These terms are important, because they accurately reflect the role of NPs/PAs. They care for lower acuity patients and are generally not, as you've described it, "on the front lines of action ... treating major traumas".

Have you considered medical school?

danielletardio · May 9, 2014

Both nurses (RNs) and PA-Cs are educated as generalists. If you go the nurse route, NP graduate education is somewhat specialized (acute care vs. psych/mental health vs. women's health).
Both of these professions are masters prepared. Many PA programs require health care experience for application, and many NP programs require experience working as an RN.
In a hospital setting, chest tubes are inserted by physicians. Intubation is performed by physicians, and on occasion by respiratory therapists. A peripheral IV can be inserted by anyone who has been trained to do so. Uncomplicated suturing is often done by NPs/PAs in the ER.
Now for the part you may not like hearing ...
In an ER setting, NPs and/or PAs are used as "midlevel providers" or "physician extenders". These terms are important, because they accurately reflect the role of NPs/PAs. They care for lower acuity patients and are generally not, as you've described it, "on the front lines of action ... treating major traumas".
Have you considered medical school?

ive looked into it but as much as I love emergency medicine I wouldn't want to put my life on hold for 10 years to become a physician

Guest 360983 · May 10, 2014

In the two hospitals I've worked at, the NPs and PAs are used the same. At the trauma center, the midlevels weren't allowed out of urgent care. At the community hospital, they see non dying patients first to order the labs and meds. They also do some procedures (I&D, suturing) when the docs are busy but usually the docs like to do procedures so they can bill for them.

If you want to be on the front line of trauma, become either a paramedic or an ER physician. I would be surprised to see midlevels at any hospital handle traumas because the level 1 trauma centers tend to be teaching facilities and the residents need to learn how to handle trauma. I know Acute Care NPs can do central lines and intubate but that's because (in my area anyways) they are trained to cover the ICU at night when there is no physician. All ER NPs I've met have been family practice NPs, who definitely are not trained for those procedures.

turnforthenurse, MSN, NP · May 24, 2014

It depends on the provider where I work. We have a PA who will only stay in their level 4/level 5 corner and will RARELY see level 3s. We have other NPs and PAs who will see the same patients that the physicians will see (level 3s and level 2s) but of course receive physician input.

traumadreams · Jul 15, 2014

It depends on the facility... Really it does! I work at a level 1 trauma center and our pit boss in trauma is a PA. All our providers (mid level, physician, resident) are assigned in teams and they rotate throughout the different areas (trauma, general, medical resuscitation, psych, urgent care, triage). The team will usually consist of 1 attending, 1 resident, 1 midlevel (NP or PA) and stragglers (whatever medical student, pa student, first year resident is doing their rotation). I have seen everyone in every area... We only have one acute care NP and she has intubated, PA's intubate, residents intubate.... Heck.... Intubations all around! Except for the FNP's... but they're not trained to do that. Hope this helps!

Guests · Jul 15, 2014

ive looked into it but as much as I love emergency medicine I wouldn't want to put my life on hold for 10 years to become a physician

Since you're only 17, I'll offer you some perspective...

It's not 'putting your life on hold for 10 years.'

The initial 4 (or so) years are undergraduate education... you can major in whatever tickles your fancy just so long as you complete the med-school prereqs. If you're a hard science major, the prereqs may be fully covered in your field of study. If you're a liberal arts type then you're probably looking at another 2 semesters worth of classes if you choose your electives appropriately.

Med school, like any other graduate school is, in a fashion, putting your life on hold... though I see med students who get married, have kids, etc.

Residents are busy but, I don't see any of them putting their lives on hold. Again, I see marriages, kids, houses... all the normal stuff that young adults do. And they have regular retreats and activities that look like a lot of fun.

It looks like a long haul from the front end... and it is... but it's not torturous and it doesn't mean the end of 'having a life'... and beginning one's professional career at the age of 26 (the age of the youngest graduates from our residency) and earning a solid 6 figure income with quite a bit of geographical flexibility is pretty cool.

Before you give up on the notion of being a physician, get to know some young docs and see what they say. I know a lot of them and only a couple express any reservation about their decision. The vast majority are very pleased with their choice.

zmansc, ASN, RN · Jul 15, 2014

I think song in my heart makes a very good point. I'm old, and crusty and I choose to become an NP for many reasons, but if I was young, I would probably not have chosen this route.

Let's consider the two education paths a bit more directly:

Undergrad:

Physician: 4 yr undergrad, any major with several science pre-reqs.

NP: 4 yr undergrad, BSN.

Grad School

Physician: 3 yr med school.

NP: 2 or 3 yr school depending on MSN vs. DNP program

Some NP programs can be taken over longer periods of time as "part-time" programs.

First few years of practice:

Physician: 3-5 years of practice for a relatively low salary while becoming an "expert" in a particular area.

NP: Often taking a fairly low salary to get a first job, likely no formal training, but OJT training is a must to become proficient in area.

Rest of career:

Physician: Many years of very lucrative work in chosen field. Very hard to switch to another specialty

NP: Much easier to switch specialties, but typically do not make the same $$ and have to fight for every inch of autonomy.

Which is going to have the better job satisfaction? That is very dependent on the individual. Who is going to be better compensated (typically) over their career? The physician. Who is more likely to work the level 1 in the ED? Definitely the physician.

I'm not suggesting you go one route over the other, because I think there are a lot of other factors for you to consider. However, the idea that NPs education is far less of a commitment is more of a myth to me than a reality.

PG2018 · Jul 17, 2014

Know also that PAs, although "generalist" in nature, are trained in all of the core disciplines of medicine. This includes the sciences that physicians study in medical school as well as clerkships in the major specialties; pediatrics, internal medicine, family practice, general surgery, emergency medicine, and psychiatry with added electives. It seems that a lot of PAs do clerkships in ortho, sports med, and cards as well.

I think their curriculum is infinitely better which I state as I am finishing up a NP program (psychiatry). I think the "specialized" nature of NP-dom is too specialized in a way in that we are overlooking the primary care-oriented nature for which NPs were first created. We generally share all of the same core classes, and let me go on the record now that a master's in nursing (NP) is going to be filled with "other stuff" that will add to your education. However, that other stuff will have nothing whatsoever to do with patient care. My master's is a 44 hour program, and 13 hours of that were in research methodology, research utilization, nursing theory (gag), practice management, and community health promotion. All of the NP tracts at my state university require those. They all then take courses called advanced physiology and pathophysiology, advanced pharmacology, advanced health assessment and diagnostic reasoning, and advanced health assessment and diagnostic reasoning practicum with live patients and anatomical models (live people you practice the nasty stuff on).

The family practice tract then requires a course in quantitative epidemiology while everyone else starts their specialty rotations. The psych folks take the most classes in their focus, follwed by peds, then adult, then women's health although the program was recently disbanded, and then family practice which takes one course each in peds, adult/geri health, and reproductive/women's health.

As I sit here at my desk not wanting to do any of 12 other things I really should be doing, I'm going to to summarize the same state university's PA curriculum.

Gross anatomy/cadaver lab, physiology, pharmacology, clinical assessment, diagnostic reasoning, medical genetics, behavioral medicine, pharmacotherapy, pathology, emergency medicine, intro to evidence based medicine, professional issues and ethics, professional communication, and surgical medicine followed by clerkships of 5 40 hour work weeks each in family practice, internal medicine OP, internal medicine IP, peds, women's health, surgery, geriatrics, orthopedics, psychiatry, emergency medicine, two electives (10 weeks total), and a capstone project.

If given the option I'd take the PA curriculum which requires mandatory prereq classes in A&P, micro, a year of general chem, one semester of organic chem, general psychology, abnormal psychology, statistics, genetics, and a year of general (cellular) biology. It appeals to my biologically-oriented nature.

If you choose to become a NP, you'll have to become a RN which is a psychosocial discipline that despite what the schools may tell you is, as a profession, not scientifically-oriented.

With every ounce of life experience I have, and I did something else entirely different before becoming a RN (now working on my NP), I suggest you get a bachelor's degree in some field that will satisfy the prerequisites of PA school. In doing so, you'll also complete many of the courses you would also need as prereqs for med, dental, vet, pharm, optometry, and chiropractic school. In my mind, that gives you some options. Get some healthcare experience along the way because at one time all PA programs seemed to require hours ad nauseum of it, yet that seems to be somewhat diminishing. A lot of PAs have been paramedics, military medics, nurses, and respiratory therapists. Get your master's, get your PA-C, and get to work.

Some caveats, within ten years I would speculate all states will have 100% independent nurse practitioner practice. The writing is on the wall. I doubt you will see that for PAs who are governed by their state board of medicine. Physicians aren't going to let their assistants loose to compete. Instead, revenue is actually enhanced by having them around. The physicians, some more than others, oppose NP due to perceived safety and competency issues as well as competition with NPs being generally governed by their state's board of nursing. It seems like I read about some state that differed, but I could be wrong. I'm not personally looking for practice independence as I am looking for an interesting job. Presently, in my state, NPs can independently diagnose, do office procedures (cut, sew, etc), and order tests without physician oversight with the docs holding the reigns at preventing independent prescriptive authority. Also, NPs here are limited to Schedule III-V meds as they are in most states, and PAs here are limited to those as well. Neither do NPs nor PAs need a doctor around to work. They can practice with autonomy, see their client load, do whatever they can do, and send them on their way. My state requires collaborative practice for NPs which ends up meaning having a doctor you can call if you need help, having a doctor do chart reviews (10% seems to be the norm), and providing some scope from which the NP will prescribe, i.e. with this disease or "group" of diseases use this list of meds with multiple options given but the script would be limited to those options.

I still think the PAs have it better because the medical board wants them around otherwise the board could readily do away with it. They share very similar educational paths, talk the same walk, and generally walk the same walk. PAs seem to have more exposure to variety coming out the gates while NPs do require a lot of OTJ. For example, although NPs can order all the xrays we want here none of the NP schools do a very good job (if any) at teaching this school or facilitating the learning of this skill.

Now, what are the advantages of NP programs. They are generally much more student/user-friendly. You can work, even full-time, and do it. There are even 100% online NP programs although I'm not sure if that's really a good thing albeit something that's here to stay. One can become a RN fairly readily. If you choose to do so, you can work your way through nursing school, get licensed as a RN, pick up your BSN along the way or do it later in a ADN-BSN program, enter your master's program, and graduate without ever missing a day of work or dollar of income - if you organize it right and stick to the "plan." You can go home and be with your family, earn a living, and do your homework. It isn't always easy, and in fact most of the time it's not. However, most of the PA students use the old mantra "it's like drinking from a firehose" meaning that the school is doable but there is more coming at you than you can really swallow.

Also, you'll find that PAs don't do a lot of psych stuff other than primary care psych visits, and you can't go on to do anesthesia (that I'm aware of) as a PA. Conversely, you'll find a lot of NPs don't do surgery stuff like actual cutting, etc. The PAs and NPs mostly get stuck doing ward rounds, but the PAs do a lot more interventional OR time than NPs as a whole. A CV surg or ortho surg PA does quite a bit to help out.

I hope that adds some food for thought. I'm not trying to sell PA. Nursing, although I admonish the profession body of which at times, has been good to me, and my NP program is informative and enjoyable. I would not "do over" anything, but if I were going back in time I'd actually become a physician. If I were going to make a career change again umpteen years post-college, however, I'd go PA. Also, with NPs the body is becoming increasingly more niche-focused making it unlikely that you'll see any acutely trained NPs in a clinic and any primary care trained NPs in a hospital. PAs are never really tied down.

You know, now that I think of it, forget healthcare and become an engineer, LOL!