Nurse Practitioner or Physician's Assistant? - page 6

by arelle68

147,966 Visits | 111 Comments

Well, I graduated with an associate's degree, and passed my NCLEX in January. I've been working in an LTC since Feburary. I have an opportunity to return to school, and I've already been accepted to a local college to complete... Read More


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    David:

    As PA curriculum is set by ARC-PA, NP curriculum is set by the CCNE. PA's have to take the PANCE to get their state license, NP's have to take a certification exam from one of the credentialing agencies. I'm not seeing a huge difference here, except I guess there are states where NP's still practice under their RN license gained by the NCLEX only, but I think that's almost completely gone now. An article I recently read said, "Eventually, the four certifying organizations and the NCSBN agreed to a third-party review of the examinations in late 1996. As of now [1999], all four organizations have had their exams validated as psychometrically sound and sufficient for regulatory purposes." So they're considered valid for licensure, and most states require them before an RN can enter advanced practice.

    Additionally, there certainly IS an Emergency NP specialty certification. Vanderbilt's program is the one that immediately springs to mind, but I know there are others. The Acute Care specialty would also cover Emergency. I just saw an ad on SimplyHired asking for an "Emergency Nurse Practitioner to join our group of 2 PAs and 3 NPs..." for a hospital south of Portland. So they're definitely out there. Vanderbilt has a dual FNP/ENP specialty track that I'm especially interested in.

    PA's do have broader scope like an earlier poster said, with regards to "if their doc says they can do it, they can do it." NP's are restricted by their specialty, so a pediatric NP couldn't prescribe for adults, etc. I think FNP gives the broadest scope for NP's.

    Bajasauce: I agree that NP programs are less intensive than PA programs, to a greater or lesser extent. However the question needs to be asked: do NP programs need to have that much content, or do PA programs need to cut it back somewhat?

    In the end, it's up to the individual to "know what you know, but more importantly, know what you don't know." Before I ever entered private practice I would certainly work with a physician for several years.

    And that's what makes this kind of moot in the end right? Whatever model you're trained in, the physician is the next higher level. There's no super-nurse to whom an NP refers a patient that is beyond their scope. Both PA's and NP's send difficult patients up the chain to a physician. So in my opinion, when you've reached mid-level practitioner, you're practicing medicine, not nursing.

    (This is just my opinion being a long-time medic, a new graduate nurse, and working around a lot of both PAs and NPs. I freely admit I could find out I'm just talking out my hole when I actually get into NP practice.)

    --Equusz
    Last edit by EquuszRN on Feb 19, '10
  2. 0
    Quote from Equusz
    David:

    As PA curriculum is set by ARC-PA, NP curriculum is set by the CCNE. PA's have to take the PANCE to get their state license, NP's have to take a certification exam from one of the credentialing agencies. I'm not seeing a huge difference here, except I guess there are states where NP's still practice under their RN license gained by the NCLEX only, but I think that's almost completely gone now. An article I recently read said, "Eventually, the four certifying organizations and the NCSBN agreed to a third-party review of the examinations in late 1996. As of now [1999], all four organizations have had their exams validated as psychometrically sound and sufficient for regulatory purposes." So they're considered valid for licensure, and most states require them before an RN can enter advanced practice.

    Additionally, there certainly IS an Emergency NP specialty certification. Vanderbilt's program is the one that immediately springs to mind, but I know there are others. The Acute Care specialty would also cover Emergency. I just saw an ad on SimplyHired asking for an "Emergency Nurse Practitioner to join our group of 2 PAs and 3 NPs..." for a hospital south of Portland. So they're definitely out there. Vanderbilt has a dual FNP/ENP specialty track that I'm especially interested in.

    PA's do have broader scope like an earlier poster said, with regards to "if their doc says they can do it, they can do it." NP's are restricted by their specialty, so a pediatric NP couldn't prescribe for adults, etc. I think FNP gives the broadest scope for NP's.

    Bajasauce: I agree that NP programs are less intensive than PA programs, to a greater or lesser extent. However the question needs to be asked: do NP programs need to have that much content, or do PA programs need to cut it back somewhat?

    In the end, it's up to the individual to "know what you know, but more importantly, know what you don't know." Before I ever entered private practice I would certainly work with a physician for several years.

    And that's what makes this kind of moot in the end right? Whatever model you're trained in, the physician is the next higher level. There's no super-nurse to whom an NP refers a patient that is beyond their scope. Both PA's and NP's send difficult patients up the chain to a physician. So in my opinion, when you've reached mid-level practitioner, you're practicing medicine, not nursing.

    (This is just my opinion being a long-time medic, a new graduate nurse, and working around a lot of both PAs and NPs. I freely admit I could find out I'm just talking out my hole when I actually get into NP practice.)

    --Equusz
    The CCNE accredits nursing schools as does the NLNAC. However, neither accredit NP programs. There is no central body that sets out the blueprint for what NPs need to know or ensures that students get the necessary exposure to practice. Compare this to the the COA for CRNA. The COA ensures that programs meet the requirements for CRNAs to graduate. They ensure that programs have sufficient resources and that programs ensure that the students meet the requirements. A similar body exist for the CNMs the ACME. These parallel the ACGME for allopathic physicians and the ARC-PA. Pretty much every medical profession has a separate accrediting body except for the NPs.

    As far as ENP certification, please show me a certification body that certifies ENP (or for that matter a state that accepts ENP certification). Yes there are ENP programs but the underlying certification is either ACNP or FNP. There has been talk of a separate ENP certification for some time but that would necessarily limit the NP to the ER. The AACN feels that the proper certification for an NP to see all age ranges of patients is the ACNP/PNP-AC. Other opinions vary of course.

    As for whether the PA programs are too long or the NP programs too short, the PA profession has decided that the minimum needed to train a competent new grad PA is described by the blueprint. The other caveat is that the training occurs regardless of previous health care or life experience. In theory Dr's Silver and Ford designed the NP programs to take advantage of pediatric nurses that had years of experience in their field. The original design made the PNP an expert in the field of advanced pediatric nursing just as the original design of the PA was to train corpsman to work in all areas of medicine. As the composition of the student changes (less experience) both PA and NP programs changed. The PA programs added didactic and codified clinical hours. The NP programs lessened theirs in the name of access. Who was right, hard to say.

    David Carpenter, PA-C
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    "Bajasauce: I agree that NP programs are less intensive than PA programs, to a greater or lesser extent. However the question needs to be asked: do NP programs need to have that much content, or do PA programs need to cut it back somewhat?"

    This comment astounds me. I agree with a lot of what you said, but I have a huge problem with this mentality. Do you have any idea the responsibility we have to our patients? What it means when you put on your white coat? Yes, you are as good as you want to be, practitioners are individual, but I see this alarming trend in NP discussions. "We want to be DNP's and practice independently, but even though our training is not as intense as PA training or nearly at all that of MD training, it's ok, because we are capable practitioners, or cold and diarrhea patients all do just as well as the docs." You say that you would work with a physician for "several years" before opening your own practice. Are you during these years studying all the physiology and disorders no one bothered to teach you in school? I doubt it, but If so, why not include it in the original curriculum since the end goal of many NP's is precisely that?

    It's astounding that anyone could think that we need to dumb down curriculum to make it more accessible. If you are not bothered constantly by what you may not know, MD, PA, or NP, you have no business in this profession. Your patients trust you to be the best they can be, not only when they have diarrhea, but also when they have a T. Whippelli infection. or positive anti-SCL70 antibodies, or positive anti-mitochondrial antibodies. all these things masquerade as common, everyday disorders, but if you can't identify them you've just done a great disservice to your patient.
    David the endocrine PA says:

    "As the composition of the student changes (less experience) both PA and NP programs changed. The PA programs added didactic and codified clinical hours. The NP programs lessened theirs in the name of access. Who was right, hard to say. "

    I'm assuming this was tongue in cheek. If anyone ever believes that we can "water down" medical curriculum beyond that of the PA degree it indicates they have their priorities out of line. I'm not sure that PA school is rigorous enough (although anyone who has spent the 40 hrs/wk in the classroom and the additional 40hrs/wk studying outside of class may disagree). Our first responsibility is to the patient, not to ease of degree and easily attained titles.

    I pray that you simply misspoke when you typed that sentence EQUUSZ, with your background I"m sure you understand our responsibilities to the patient even if you aren't sure what that means as a practitioner on the other side of the chart yet.
    kalevra likes this.
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    Wow, a lot of stupid, schoolyard worthy chest-beating going on here.

    Aren't a lot of these comments based on bias, conjecture and speculation? Have the pro-PA folks on here actually attended a Nurse Practitioner class? Has anyone actually witnessed any shortcomings when comparing a PA and NP with comparable experience levels? If Nurse Practitioners were actually as bad as some of these PA-fanboys and fangirls want to make them seem, wouldn't there be obvious statistical information saying how bad the care was and huge efforts to stop them? I'll break down the fallacies here.

    1. Docs don't respect PA's more than NP's. I know that my dad, a family practitioner, works with NP's and he says they do a great job. He suggested that I become an NP as opposed to PA because of the greater autonomy. This is coming from a physician. I'm not saying that PAs are any less than NPs, I'm just saying that most doctors with half a brain will value a mid-level practitioner based on their competency rather than the intitials behind their name.

    2. PA's work more in surgery / get paid more than NPs. Not true. Look at the University of Utah Healthcare's website and you'll find a number of ACNP's working in surgery, cardiology, and so forth. As to their pay, who knows? I'm sure there are NP's that make quite a bit, too.

    As far as intensity, a lot of the NP / CRNA programs are moving to a Doctorate of Nursing Practice program, which usually is completed in three years. Here is the curriculum for the University of Utah's DNP Acute Care Nurse Practitioner program. Looks pretty intense to me.

    Either way, good luck to all of you, be you PA, NP, CRNA, CNM, or any other acronym you choose to pursue.
    kalevra, Conqueror+, Househead4life, and 1 other like this.
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    I agree 100% with both of those bullet points, especially that last sentence of #1.
  6. 0
    No, BAJASAUCE, I didn't misspeak. Sure, PA schools cram all this information into a two year program. Does that make them better? This point has been debated in many other places. The fact is that care given by a PA and care given by an NP have been determined to be equivalent in the eyes of patients and the medical community at large. If treatment by NP's was not of the same quality as treatment by PA's, or if it was deficient or dangerous in some way, then as Sam said above there would already be a movement to get rid of NP's or curtail their autonomy. Yet every other day it seems I'm reading about another state expanding the scope and/or autonomy of NP's to address the shortage of primary care MD's and the healthcare budget crisis in their state. Are they doing that for PA's? Maybe, but I'm certainly not reading about it as much. PA's still need a supervising physician in every state.

    Your suggestion that NP's need to know every arcane disorder in family medicine is ludicrous. Would you trust an oncologist to deliver a baby, or an OB-GYN to treat lymphoma? How about a dermatologist running a code? Sure, they learned it in med school, but that doesn't mean they would or should try to treat something they haven't practiced since. We have specialties because no one can remember everything. So are PA's better equipped because they get more info thrown at them? Somehow I doubt it, and the evidence in practice doesn't bear that out. The important thing is to know what you don't know and escalate the patient to the appropriate physician specialty.

    Having said that, I believe the ANA is constantly striving for more credibility, confidence in the profession, quality control, and thus more autonomy for NP's. Hence the move to the DNP, which I plan to complete as well. But I can do it in stages, which I couldn't do in a PA program.

    --Equusz
  7. 1
    Probably the best piece of wisdom posted on here was,
    The important thing is to know what you don't know and escalate the patient to the appropriate physician specialty.
    One of my favorite nursing instructors tells me that time and time again. The best nurse (or you could say health care provider in general) is the one who knows what they don't know and puts the patient before their ego. The dangerous health care provider is the one who doesn't want to look like they don't know, so guesses, and potentially does harm.
    kalevra likes this.
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    Okay but if you check out AAPA or NYSSPA, PA programs are going to move toward a doctorate degree as well; which, in my opinion is retarded for both professions. If your going to do a masters and\or doctorate you might as well have gone to medical school and received your D.O. or M.D. And statistically speaking--throughout the country, PAs are paid more. This is a national statistic however, so it might be different per state and that might change in the next couple of years. Regardless, in general NPs have more autonomy and PAs are gradually getting more autonomy which is stupid because that does not adhere to the defintion of the Physician Assistant's role. PAs have great ties and support from the AMA; so, what's going to happen if they can practice independently like NPs? This is going to cut a lot of strings with their supervising physicians. And NPs are still NURSES that are trained under the nursing model and have independence according to where they work--again not the medical model. A hospital may MANDATE the NP to have a collaborative physician. On the other hand, as we all very well know--they may open up their own practice--it depends. Being that I live in New York, I know PAs that are making 200-250 K (my dad sold a car to them a couple of months ago). I know PAs that are making a little less than that however, have dual roles because they
    are academic coordinators at PA programs as well.
    So yes, PAs and NPs in reality pretty much do the same thing, however, PAs training is equivalent to the MD minus an internship and residency because again it is defined by the AMA's medical model. Remember, PAs came about in 1967 when there were a shortage of DOCTORS in world war II. So they took 3rd year medical students and fast-tracked them to be these spring-chicken physicians due to the shortage of health care professionals trained under this medical model. This turned out to be a great success and as a result Dr. Stead established the PA profession--hence, a profession that was started by a physician who saw the benefit of this 'fast-tracking' doctor. In addition, HMOs saw that PAs were providing 79% of care DONE by primary care physicians at half the cost---another reason why the profession has been on the rise. The training of a PA is equivalent to a primary care doctor and because of the obsession of specializing and sub-specializing (because it's more money)--PAs have ultimately filled that gap and they have also filled the gap of reduced MD hours (the law nobody follows that residents can only work 80 hours a week).
    But listen in the end--to each his own, we all have to work together and one of my best friends is an NP and we duke it out like this all the time. lol this is funny to me b\c you guys know this debate is never going to end. And since PA degrees are headed towards a doctorate--it should probably just be one profession and call it the "physician practicioner" instead of PA or NP alone. Maybe that would resolve all the bickering.

    take care- back to my soap note and crying that I have no social life until 2012.
  9. 0
    Sorry, I refuse to believe that any PA's are making a quarter of a million dollar salary, unless they are working as partners in some mega-million dollar plastic surgery clinic or something.

    PA training is NOT the equivalent of MD training minus the residency. MD's have an entire year of Anatomy - first year is basically spent dissecting a cadaver. PA's, like NP's are taught the cliff's notes version of a medical education, enough to make them able to handle a range of mainstream cases within a specialty.

    David Carpenter pointed out a salary survey that showed that the difference between PA and NP salaries was about $5,000 on the whole. The 95th percentile in both was very high, the median in both was $70k-$90k. There's just not that much difference.
  10. 0
    PAs training is equivalent to the MD minus an internship and residency because again it is defined by the AMA's medical model.
    Yeah, I'm tending to believe Equusz on this one.


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