Nurse Practitioner or Physician's Assistant?

[arelle68]

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 a bachelor's in Nursing. This is the quandry I am in. I'm realizing that nurses are not respected or well treated, and I don't like it. I don't know how long I'll be able to put up with it. I have been headed toward Nurse Practitioner. Is physician's assistant a better goal? What are the differences? Is the same amount of schooling from associate degree RN?

[eddoc]

I can only use my limited experience to reply. My content area was afforded ~ 45 hours in the PA program and 8 in the FNP program. The FNP program approached the "medical" issues from a bio/psycho/social perspective. They clearly had a great deal of experience on which to draw, but did not seem to have the underlying science. The PA students generally speaking had less experience but a much better grasp of the underlying pathophysiology. So the bottom line seemed to be IMHO, that the NP students had a framework that allowed them to apply what was taught but with a less thorough understanding of the "why." The PA students understood the "why" and the "how" but lacked perspective on prevalence and application.

[tothct]

A Physician Assistant completes around 3000 hours for didactic and clinical education (1000+2000). A Nurse Practitioner completes about 1000 hours total or a little over (500+700). Also, a PA is trained in the medical model (just like physicians) and as such are general practitioners. NPs are trained in the nursing model (biopsychosocial) and they must specialize, which greatly limits their job opportunities. I have found that PAs are paid more in general. As for a PA and NP practicing in the same specialty, their duties are relatively similar.

I do want to comment specifically on how NPs claim they can practice independantly of a physician. This is misleading. It doesn't broaden their scope of practice whatsoever. Sure they can open their own clinic but they are still limited in what they can do. Collaboration vs supervision is a myth. Both PAs and NPs are under physicians.

[EquuszARNP]

tothct:

You're wrong. Do your research.

NP's are not "under" physicians in many states. In my state, they practice independently and can/should refer to a specialist directly if there is a patient outside their capabilities. A FNP in Oregon does not have to refer to a family practice MD that they are "under". They can refer directly to a specialist, same as the MD would.

Everyone here is now talking in circles. You can keep saying that NP's have less training and that makes them less safe. Then you can look at the percentage of patients who sue their NP's vs. those who sue their docs. And you can look at what the state legislatures authorize NPs to do. Just because an NP has to specialize doesn't mean they're less capable. They simply choose a field and focus on their clinical hours on that field, whereas a PA is diluting their clinical hours with many different areas of medicine. That's why they have more hours. You may think that makes the PA better, but I don't, especially not within a specialty. There has to be a reason that PAs have to have a supervising physician in every state, whereas in many states NPs do not. What do you think that reason is? Why would a nursing model practitioner with less hours have more autonomy? Do you think it's a big conspiracy or the power of the nursing boards? I doubt it. States look to their bottom line and that bottom line is nurse practitioners, in their view, can handle full autonomy with less liability than PAs can. They must have some basis for that decision, as its becoming more and more the norm.

[tothct]

That's funny, because when I graduated from The University of Pittsburgh with a BSN and from Yale as an Adult Care Nurse Practitioner, I thought I had the schooling and job specifications down pretty straight...

Trust me. The fact that we are licensed by the nursing boards and not the medical boards really means nothing. Yes they can't legislate anything in regards to our capabilities, but it in no way means we are on equal footing with a doctor. Working apart from them doesn't open new worlds of possibilities and make us better than PAs. And looking back on it I wish I could have had a more general education instead of specializing. I think it broadens your scope of practice and better allows you to extend the services of physicians... hey! Isn't that what a mid-level practitioner was created for?

[EquuszARNP]

Would you like me to send you the FNP scopes for Oregon and Washington? Perhaps they're less restrictive than where you practice.

No one on this thread has said that an NP is on an equal footing with an MD. That would be ludicrous. What is being said is that an NP is on an equal footing with (and somewhat more autonomous than) a PA, and the debate is whether an NP is less safe or less capable because he/she has less clinical hours than a PA. Is that what you, as a nurse practitioner, also believe?

Everyone agrees that if something is out of your scope or knowledge base then you should refer to higher level of care. This is common sense. It's just that in the PA's case, everything he/she does is somehow reviewed by a higher level of care, whereas in the NP's, in many states it's left to his/her discretion. The NP scope in Oregon simply says, when considering whether or not something is in your scope, you consider whether it falls within your specialty and is something the NP would reasonably do. That leaves a lot up to the NP's own decision-making instead of regulation, and so far I have not heard of many cases where it's being abused enough to become a problem. I haven't seen a lot of NPs with "god complexes" is what I mean. When they need to refer, they refer, and yes, that's what being a mid-level is all about.

[core0]

Would you like me to send you the FNP scopes for Oregon and Washington? Perhaps they're less restrictive than where you practice.

No one on this thread has said that an NP is on an equal footing with an MD. That would be ludicrous. What is being said is that an NP is on an equal footing with (and somewhat more autonomous than) a PA, and the debate is whether an NP is less safe or less capable because he/she has less clinical hours than a PA. Is that what you, as a nurse practitioner, also believe?

Everyone agrees that if something is out of your scope or knowledge base then you should refer to higher level of care. This is common sense. It's just that in the PA's case, everything he/she does is somehow reviewed by a higher level of care, whereas in the NP's, in many states it's left to his/her discretion. The NP scope in Oregon simply says, when considering whether or not something is in your scope, you consider whether it falls within your specialty and is something the NP would reasonably do. That leaves a lot up to the NP's own decision-making instead of regulation, and so far I have not heard of many cases where it's being abused enough to become a problem. I haven't seen a lot of NPs with "god complexes" is what I mean. When they need to refer, they refer, and yes, that's what being a mid-level is all about.

As far as PA review, the requirement for review is entirely state dependent. To use Oregon for example. There is no requirement for any review of a PAs actions. Instead the requirement for supervision is determined by the PA and physician in accordance with a board approved practice description. The autonomy is earned.

What is codified is that the requirements for general supervision must be met. This means that at any time a physician must be available (either in person, telephonically, by radio or TV (yes thats what the statute says)). What this codifies who and how a PA must contact the physician when something exceeds their scope or experience. For NPs (in Oregon) there is no requirement for supervision or collaboration. The difference is that in the event that something exceeds the scope or experience of the NP or PA in the PAs case there is a clearly defined chain of communication and responsibility for the patient.

Medicare on the other hand requires collaboration. For states with no requirement the practice can maintain the agreement. There is also no requirement that the physician agree. So for example the agreement could say in the case of a problem exceeding scope of practice the patient will be referred to Dr. X. On the other hand Dr. X could legally refuse the consult which would mean that for practical purposes there is no collaboration agreement. Its one of the items that Medicare chooses not to deal with.

For PAs the other place that supervision comes into play is in scope. In general a PA cannot do anything that the supervising physician is not trained to do. So the supervising physician will define the scope of practice for the PA. NPs on the other hand are defined by a combination of training, certification and experience (in conjunction with the BONs interpretation of this). In theory even in a state with a collaboration agreement an NP could do something that the collaborating physician is not trained to do. Whether they would be willing to accept the liability is another thing.

Autonomy is earned. 98% of PAs and NPs will work for a medical practice. The physicians of the medical practice will incur liability either in a corporate manner or through medical directorship for both providers. Therefore any autonomy will be based on demonstrated competence (or benign neglect in the case of the lazy). For the vast majority of PAs and NPs there is no difference in the job. The differences usually revolve around the administrativa (which can be different from state to state between NPs and PAs) and the scope of practice which state to state can be less or more restrictive for NPs).

David Carpenter, PA-C

[EquuszARNP]

Thanks, David. I think you've got it nailed down quite accurately there.

[nurseman78, BSN, RN, NP]

Wow, you guys are all still going at this. Don't you have better things to do? Sheesh. Bottom line is, you all are trained well, you all have jobs, and neither PA's nor NP's are particularly "better" than the other.

Now can we talk about something that actually matters?

[ok2bme]

Medicine has EVERYTHING to do with how knowledgeable you are and NOTHING to do with how nice you are. It's just good to be nice as well. As far as the comment above about NP vs PA? You can come out of training as either an NP, PA, or MD and be a moron. It's all up to the individual. I have not touted PA's as masters of diagnosis, I do think the training is different and I prefer the methods of the PA way, but my argument has been, and will likely always be, that midlevels should not practice independently.

Of course, as someone pointed out, NP's do practice "independently," depending on how you define that. But it's irresponsible. We all have a place in healthcare, but if you want to be the boss, be the MD. You don't learn construction and then try to practice as an engineer.

I complete disagree with your first sentence. Yes of course it is essential that physicians are knowledgeable and competent, but it also crucial that they build rapport with patients, listen, validate, and overall demonstrate kindness and respect to patients and colleagues. A physician's bedside manner, in my experience, has a huge impact on patient satisfaction, compliance, and perception of their condition and treatment. Your assertion is a very old school view that is fortunately fading.

[nurseman78, BSN, RN, NP]

During my experience as a nursing student, I've heard many an account from patients who have self-diagnosed a condition, but had a physician ignore their diagnosis due to the physician's arrogance. Only later did the physician find out that the patient's instincts were correct... and it was too late to treat the condition.

[bajasauce07]

Well, Golden Girl. I agree with everything you said, You'll have to read the previous posts and take in context my above sentence. It often asserted that patient "happiness" is a measure of practitioner quality. They aren't related. At all. They should be, but many patients love their doctor in spite of incorrect care/ diagnosis, etc. That's all. And many patients think their specialist who saved their lives is a stupid jerk and switch. You won't keep patients without bedside manner, and you will miss out on important history if they aren't comfortable with you. but again. Quality is more dependent on knowledge than rapport.

[ughhmehh]

I have a Biology degree and have applied to nursing school so that I can become a NP in the future. Then I realized that the amount of schoolong for a NP seems to be alot more than a PA. If you look up certified PA programs in California, half of them are associates, bachelor's, or certificate programs. To finish my NP certification, I will have to do 2 more years of nursing, plus 3 years for the NP, not including all of the extra classes I had to take to get into the nursing program. Which is weird considering I had 3 years of chemistry, etc. but was told I needed to take human physiology, that my upper division mammalian physiology didn't count.

With the lower pay and higher education requirements, why does anyone become a nurse practitioner if they both have similar roles?