[hotomalis]

Originally Posted by ANPFNPGNP

I practice in Texas and it is not true that NP's can practice independently in rural areas. We are fighting for full independence at this time (it's currently before the legislature) and we're hoping to "settle" for independence in rural areas.

Good luck with that. Seriously, I hope y'all get the independence you deserve. I do have to tell you that I went to a very small town south Dallas (about 1 hr away) and there was no MD, no where to be seen. The statement from the MD I got was during my intership. I don't know if he was kidding or whatever but he did make that statement. I have been praying for NP's, all NP's to get independent practice.
Y'all are strong, proud and extremely full of knowledge. You deserve it. We have "collaborative" practice (so far) in CT and also going in front of legislation this coming fall.
It will happen, is just a matter of time.

[JDCitizen]

Originally Posted by hotomalis

Good luck with that. Seriously, I hope y'all get the independence you deserve. I do have to tell you that I went to a very small town south Dallas (about 1 hr away) and there was no MD, no where to be seen. The statement from the MD I got was during my intership. I don't know if he was kidding or whatever but he did make that statement. I have been praying for NP's, all NP's to get independent practice.
Y'all are strong, proud and extremely full of knowledge. You deserve it. We have "collaborative" practice (so far) in CT and also going in front of legislation this coming fall.
It will happen, is just a matter of time.

When one speaks about independent practice is that:
1) No MD oversight whatsoever?
2) Total prescriptive authority?
3) Ability to order/request testing, procedures, consults?

Just curious........

[hotomalis]

I guess it depends on what state you are in. For example, in Maine you have to be under supervision for two years and then you have independence. In Rhode Island you have independent practice (no MD on site) but you can't write prescriptions, In other states you may not be able to diagnose and yet in others you may not order diagnostic tests. So it basically depends on where you are.
Also the word "collaborative" practice has different meanings in different states. In CT (where I'm from), you have no need for the MD to be on the premises, you can diagnose, you can prescribe but you have to have a contract with very specific instructions of what you can and can not do. That includes what medications you may give, etc.
Check your state statutes and the Pearson Report for which someone put a web link on a prior post. Check it out, is very informative.

http://www.webnp.net/ajnp.html

This may help.

[MarylouNP]

I just came across this article on a different thread and think it will clear things up some...

http://www.nytimes.com/2008/08/10/jo...em&oref=slogin

[ivanh3]

Originally Posted by core0

That being said, the vast majority of "holistic" medicine is simply ineffective. While most is not harmful, some is or may delay patients seeking better treatment options.
David Carpenter, PA-C

I think it is irresponsible to say that. All too often, holistic medicine is somehow thought to be synonymous with complimentary and alternative medicine (CAM), and I can understand where that comes from, but truly holistic just means treating the disease or problem in the context of the patient. It is not just using some CAM and ignoring evidence based medicine/practice. There is plenty of evidence that the holistic (mind/body/spirit) approach is effective. This approach is not just limited to the provider but should come from the team that is treating the patient. That is why hospitals employ patient educators and chaplains to help with patient care. When we as healthcare professionals do not consider the patient in their context then we contribute to setting the patient and us up for incomplete treatment and increased likelihood of a repeat event. Don't get me wrong. We can be as huggy shmoopy as want and still not be effective, but the holistic approach is sound. This is most definitely not limited to eastern medicine. I have worked in busy systems, and I have seen many physicians, NPs, and PAs, beat down and tired, take a look at/consider/treat the whole person and walk away the better for it in terms of patient AND staff satisfaction and respect. Now how is that ineffective? It does not do any good for the patients blood sugar if the patient has low self esteem which leads to actions that cause self care deficits to include not taking the medicine to fix the blood sugar issue.

I have my doubts about some CAM. For example, I just can't bring myself to embrace homeopathy (despite what my Boulder Colorado wife has to say. I love ya baby...). For others it has been different, and remember this: almost by definition almost every current "accepted" practice started out as a CAM. Once studied and examined these practices became standard, but that made them no less effective when they were still CAM. I do agree that the use of CAM needs to be monitored closely and I think they can be very dangerous. But to clarify "Holistic" and CAM are not synonymous. Related perhaps, but not the same.

As far as NP/PA/independent practice. I am working for my NP. It just works out better for me this way since I am already a nurse. If I was not already a nurse I would have probably gone the PA route. I work with both PAs and NPs, and I see no difference at the bedside in terms of patient/staff satisfaction or patient outcomes. None. I have heard NPs grumble about PAs having associates degree and no medical backgrounds. That is just silly. Many of them do have bachelors or masters, and some type of medical background. Many PA programs require it. What about a med surg nurse that only works with low acuity patients (still an important job) and has only been working for a year or maybe less. Does that count enough to be experience? Heck, CRNAs not only have to have a certain amount of experience, but they are required to have a certain kind of experience (usually ICU). PAs go though a lot of didactic and clinical training, and might I remind people that there are still NPs out there who do not have masters degrees, just post BSN certificates. PAs are vastly moving towards masters degree, have to take many hard science classes and deserve respect for completing their very hard programs. My wife's cousin just completed hers, and we are very proud of her.

As for this independence business, I have worked at two teaching hospitals, and I have seen the intense training that physicians receive, and what they have to go through and you know what? I want to be able collaborate with one when I need to. I think the states that require a certain number of years experience before independent practice are on the right track, and it is no reflection on me or my profession if I am required to have some form of collaborative practice in place even if its not on site. I have also been a paramedic for 15 years, and when I work in that capacity I work under the license of a doctor, and that is just OK with me. As a paramedic I get to do a lot of independent high speed/low drag type stuff like traumas, GSWs, and yes, cor zeros, but when I need a doc, all I gotta do is shout. I in no way shape or form think that two years of training (PA or NP) particularly without any kind of residency is enough for me to go out and hang a shingle. It is not fair to the public and its not fair to me.

[l_elisha]

Originally Posted by ivanh3

I think it is irresponsible to say that. All too often, holistic medicine is somehow thought to be synonymous with complimentary and alternative medicine (CAM), and I can understand where that comes from, but truly holistic just means treating the disease or problem in the context of the patient. It is not just using some CAM and ignoring evidence based medicine/practice. There is plenty of evidence that the holistic (mind/body/spirit) approach is effective. This approach is not just limited to the provider but should come from the team that is treating the patient. That is why hospitals employ patient educators and chaplains to help with patient care. When we as healthcare professionals do not consider the patient in their context then we contribute to setting the patient and us up for incomplete treatment and increased likelihood of a repeat event. Don't get me wrong. We can be as huggy shmoopy as want and still not be effective, but the holistic approach is sound. This is most definitely not limited to eastern medicine. I have worked in busy systems, and I have seen many physicians, NPs, and PAs, beat down and tired, take a look at/consider/treat the whole person and walk away the better for it in terms of patient AND staff satisfaction and respect. Now how is that ineffective? It does not do any good for the patients blood sugar if the patient has low self esteem which leads to actions that cause self care deficits to include not taking the medicine to fix the blood sugar issue.

I have my doubts about some CAM. For example, I just can't bring myself to embrace homeopathy (despite what my Boulder Colorado wife has to say. I love ya baby...). For others it has been different, and remember this: almost by definition almost every current "accepted" practice started out as a CAM. Once studied and examined these practices became standard, but that made them no less effective when they were still CAM. I do agree that the use of CAM needs to be monitored closely and I think they can be very dangerous. But to clarify "Holistic" and CAM are not synonymous. Related perhaps, but not the same.

As far as NP/PA/independent practice. I am working for my NP. It just works out better for me this way since I am already a nurse. If I was not already a nurse I would have probably gone the PA route. I work with both PAs and NPs, and I see no difference at the bedside in terms of patient/staff satisfaction or patient outcomes. None. I have heard NPs grumble about PAs having associates degree and no medical backgrounds. That is just silly. Many of them do have bachelors or masters, and some type of medical background. Many PA programs require it. What about a med surg nurse that only works with low acuity patients (still an important job) and has only been working for a year or maybe less. Does that count enough to be experience? Heck, CRNAs not only have to have a certain amount of experience, but they are required to have a certain kind of experience (usually ICU). PAs go though a lot of didactic and clinical training, and might I remind people that there are still NPs out there who do not have masters degrees, just post BSN certificates. PAs are vastly moving towards masters degree, have to take many hard science classes and deserve respect for completing their very hard programs. My wife's cousin just completed hers and I am very proud of her.

As for this independence business, I have worked at two teaching hospitals, and I have seen the intense training that physicians receive, and what they have to go through and you know what? I want to be able collaborate with one when I need to. I think the states that require a certain number of years experience before independent practice are on the right track, and it is no reflection on me or my profession if I am required to have some form of collaborative practice in place even if its not on site. I have also been a paramedic for 15 years, and when I work in that capacity I work under the license of a doctor, and that is just OK with me. As a paramedic I get to do a lot of independent high speed/low drag type stuff like traumas, GSWs, and yes, cor zeros, but when I need a doc, all I gotta do is shout. I in no way shape or form think that two years of training (PA or NP) particularly without any kind of residency is enough for me to go out and hang a shingle. It is not fair to the public and its not fair to me.

Thank you for this post, I hope it's not a stupid question- but what in the world is a cor zero? I've been a medic for 7 years and have never heard that term.

[core0]

Originally Posted by l_elisha

Thank you for this post, I hope it's not a stupid question- but what in the world is a cor zero? I've been a medic for 7 years and have never heard that term.

a Core0 in Denver (and only Denver as far as I can tell) is the same as a code blue at most other hospitals. Here in Georgia its seems to be a Dr. 99 (which in Denver was a restraint patient which continues to confuse me). Denver also has its other unique overhead pages. A fire alarm is a Mr Gallagher so named after a long time Denver fire Marshall who used to inspect the Denver hospitals.

David Carpenter, PA-C

[ivanh3]

Originally Posted by core0

a Core0 in Denver (and only Denver as far as I can tell) is the same as a code blue at most other hospitals. Here in Georgia its seems to be a Dr. 99 (which in Denver was a restraint patient which continues to confuse me). Denver also has its other unique overhead pages. A fire alarm is a Mr Gallagher so named after a long time Denver fire Marshall who used to inspect the Denver hospitals.

David Carpenter, PA-C

David, I see we have covered some common geography. I was a DG medic, worked at Aurora Medical center, and then I moved to Atlanta and became a Grady medic and then worked in the MICU and ER also at Grady. My favorite Denver overhead was the Paul Bunyan which as I recall was used when security was used for a fight or to help restrain a psych patient.

[core0]

Originally Posted by ivanh3

I think it is irresponsible to say that. All too often, holistic medicine is somehow thought to be synonymous with complimentary and alternative medicine (CAM), and I can understand where that comes from, but truly holistic just means treating the disease or problem in the context of the patient. It is not just using some CAM and ignoring evidence based medicine/practice. There is plenty of evidence that the holistic (mind/body/spirit) approach is effective. This approach is not just limited to the provider but should come from the team that is treating the patient. That is why hospitals employ patient educators and chaplains to help with patient care. When we as healthcare professionals do not consider the patient in their context then we contribute to setting the patient and us up for incomplete treatment and increased likelihood of a repeat event. Don't get me wrong. We can be as huggy shmoopy as want and still not be effective, but the holistic approach is sound. This is most definitely not limited to eastern medicine. I have worked in busy systems, and I have seen many physicians, NPs, and PAs, beat down and tired, take a look at/consider/treat the whole person and walk away the better for it in terms of patient AND staff satisfaction and respect. Now how is that ineffective? It does not do any good for the patients blood sugar if the patient has low self esteem which leads to actions that cause self care deficits to include not taking the medicine to fix the blood sugar issue.

I have my doubts about some CAM. For example, I just can't bring myself to embrace homeopathy (despite what my Boulder Colorado wife has to say. I love ya baby...). For others it has been different, and remember this: almost by definition almost every current "accepted" practice started out as a CAM. Once studied and examined these practices became standard, but that made them no less effective when they were still CAM. I do agree that the use of CAM needs to be monitored closely and I think they can be very dangerous. But to clarify "Holistic" and CAM are not synonymous. Related perhaps, but not the same.

As far as NP/PA/independent practice. I am working for my NP. It just works out better for me this way since I am already a nurse. If I was not already a nurse I would have probably gone the PA route. I work with both PAs and NPs, and I see no difference at the bedside in terms of patient/staff satisfaction or patient outcomes. None. I have heard NPs grumble about PAs having associates degree and no medical backgrounds. That is just silly. Many of them do have bachelors or masters, and some type of medical background. Many PA programs require it. What about a med surg nurse that only works with low acuity patients (still an important job) and has only been working for a year or maybe less. Does that count enough to be experience? Heck, CRNAs not only have to have a certain amount of experience, but they are required to have a certain kind of experience (usually ICU). PAs go though a lot of didactic and clinical training, and might I remind people that there are still NPs out there who do not have masters degrees, just post BSN certificates. PAs are vastly moving towards masters degree, have to take many hard science classes and deserve respect for completing their very hard programs. My wife's cousin just completed hers and I am very proud of her.

As for this independence business, I have worked at two teaching hospitals, and I have seen the intense training that physicians receive, and what they have to go through and you know what? I want to be able collaborate with one when I need to. I think the states that require a certain number of years experience before independent practice are on the right track, and it is no reflection on me or my profession if I am required to have some form of collaborative practice in place even if its not on site. I have also been a paramedic for 15 years, and when I work in that capacity I work under the license of a doctor, and that is just OK with me. As a paramedic I get to do a lot of independent high speed/low drag type stuff like traumas, GSWs, and yes, cor zeros, but when I need a doc, all I gotta do is shout. I in no way shape or form think that two years of training (PA or NP) particularly without any kind of residency is enough for me to go out and hang a shingle. It is not fair to the public and its not fair to me.

.
The reason that I put "holistic" in quotes I am used to seeing holistic use thus: "The term can imply a pretechnological lifestyle which uses alternative healing practices vs. contemporary established western practices."

I tend to practice in a fairly holistic manner by the true definition. I tend to see most people use holistic to be synonymous with CAM or whatever new age patchouli wearing pyramid sitting methodology they use (spent my own time in Boulder). My disgust with CAM is not with the patients. Instead its with the "practitioners" who claim their "holistic" methods work magic. I am aware that most medications originally would be considered CAM, but along with the development of modern medicine we have fairly strong scientific evidence of efficacy of most medications and we have removed those that are dangerous like mercury. If you look at three of the more popular CAM "medications" Saint Johns Wort, Saw Palmetto and Milk Thistle, all have been tested against placebo for efficacy. The data on Saint John's Wort is all over the place. Despite being the number one selling medication for depression in Germany most studies show it similar to placebo. There is good evidence that Saw Palmetto is somewhat efficacious in very mild BPH. There is also evidence that Milk Thistle is not harmful in liver disease even if it does not do much. So even among those "herbal supplements" that have been tested they do not preform much better than placebo. The rest have shown to be harmful in some cases and pretty much a complete waste of money in others. Despite this consumers in the US spend more than $4 billion. Interestingly ethically and legally I could not prescribe a placebo for my patient but I could recommend an herbal supplement. Thats the most telling point of there power in the market.

In my usual attempt to make this somewhat relevant to the topic at hand and to avoid angering the all powerful Siri I have noticed that most of the nurse practitioner programs in CAM have gone by the wayside (the UCSF program in particular). At least the ivory tower types are waking up to the dangers of tying their horse to that particular wagon (my provocative statement for the day).

David Carpenter, PA-C

[core0]

Originally Posted by ivanh3

David, I see we have covered some common geography. I was a DG medic, worked at Aurora Medical center, and then I moved to Atlanta and became a Grady medic and where I worked in the MICU and ER at also at Grady. My favorite Denver overhead was the Paul Bunyan which as I recall was used when security was used for a fight or to help restrain a psych patient.

Man that brings back memories. I worked at SAC and most of the Health One system (Mostly Pres, Swedish and Rose). I did more than my fair share of Paul Bunyans.

David Carpenter, PA-C