To Current NPs and Students - Diagnostic Ability?

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    Hey everyone,

    I'm a pre-nursing student (hope to be accepted in a few weeks to a BSN program!) and my goal is to become a NP or CRNA, though I'm equally split right now. I have a question about the diagnostic ability of an NP that I was hoping some current NPs or NP students could help me answer:

    So one of the draws of the healthcare field for me is the challenge of figuring out what is wrong with people. I wanted to be a doctor for a long time, but after shadowing one I realized they spend 95% of their time doing insurance and about 3 minutes per patient. In addition, the hundreds of thousands of dollars in loans is a little daunting, so I decided I wanted to either be a PA or NP. I figured we'd do essentially the same thing as a doctor. I finally settled on NP because I don't want to have a doctor supervision requirement.

    I realized today, however, that NPs are trained in the nursing model. Nursing is primarily set up as a reactionist field, more of a "this is happening so give this" approach instead of the medical model's "let's find out WHY this is happening." My question is, does this continue past the RN degree and into NP? How much education do NPs receive in diagnosis of illness? Do they learn a wide range of illnesses like doctors do - everything from cancer to skin diseases, etc, or do they just learn a brief overview of the most common problems. I'm really curious because I will be upset if after NP school I find myself unable to diagnose anything more challenging than the very common ailments, having to call a doctor in.

    I really just want to make sure NP school has a lot of time dedicated to advanced diagnostic abilities and covers a lot of material covered in medical school. Can anyone help me out?
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  4. 10 Comments so far...

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    I would actually offer an alternative viewpoint on the nursing model. I'm not a student yet, but am hoping to do a direct entry FNP program soon so this is based on my shadowing and research.

    I've found and heard that generally the medical model is much more reactionary as they deal with patients symptomatically (I'm talking primarily of primary care/chronic - it may be different in hospital settings/acute). They treat what is happening. the DO and nursing model seem to be more geared towards not just alleviating symptoms but actually finding the ROOT (which, in chronic stuff, can often be diet and lifestyle).
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    Quote from thenewguy8
    I would actually offer an alternative viewpoint on the nursing model. I'm not a student yet, but am hoping to do a direct entry FNP program soon so this is based on my shadowing and research.

    I've found and heard that generally the medical model is much more reactionary as they deal with patients symptomatically (I'm talking primarily of primary care/chronic - it may be different in hospital settings/acute). They treat what is happening. the DO and nursing model seem to be more geared towards not just alleviating symptoms but actually finding the ROOT (which, in chronic stuff, can often be diet and lifestyle).
    Ok, good to know. I have this thread going on in another room and had to simplify my question for better answers. So to all current NPs:

    How often does the average NP feel "stumped" when presented with a case, and have to refer to an MD (in the same field as the NP) who ultimately makes the diagnosis?
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    I'm a relatively new NP, but usually if I'm stumped, so is my collaborating doc. I mean I do ask their opinion on occasion, sort of run my thinking past them, for maybe stubborn blood sugar or BP, or maybe if some infection didn't clear up with first round of ABX, but that's probably because I'm still new.

    Most of what I see are the same things: high cholesterol, high BP, diabetes, bronchitis, colds, coughs, strep throat, chicken pox...things that the doc sees too. Sure, once in a while a rash looks odd or the symptoms aren't as cut and dry as the text book, but I usually have a good idea what it is and at least have it narrowed down to 2, maybe 3 differentials. This is the same thing my collaborating docs do. If I'm stumped, they usually are too and then after discussing I refer to a specialist just like they do.

    Keep in mind, NP work, or MD work for that matter, is not like an episode of House. Most people have "normal" things wrong with them. The saying is: If you hear hoofs; think horses, but keep in mind zebras exist. So, rule out the life threatening and work them up for the usual things, if they need a specialist refer to specialist.
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    Thanks for your response. So what you're saying is, generally, it seems NPs have about the same diagnostic ability has an MD. If the NP is stumped, the doctor is too, so their levels of education in diagnosing ailments is roughly similar?
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    I think it depends too much on the individuals. I really think diagnostic ability is a talent that is developed, but some people are more talented than others. The best diagnostician I ever knew was a DO that also unfortunately had a drug problem and went to jail for trying to kill his wife. The man just had an insight and some outstanding assessment skills and never seemed to over order unnecessary diagnostics. He just knew. I could go to Harvard med school and never be that good, and he could have gone to pudunk U and he'd still have been that good. My NP program taught me enough to be a safe and effective entry level provider. I don't think I can say how good a diagnostician I am for another year or two.
    gauge14iv likes this.
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    I'm in an adult NP program right now (just 4 months from DONE!) and it is NOTHING like the RN portion of my education, even though I did them at the same place. When you're working as an RN you already have the diagnosis on the chart...the treating physician/PA/NP has determined that and decided what medical treatments need to be administered. The nurse then follows through with that plan, monitors it for the prescriber, and informs the MD/PA/NP of the patient's progress. He or she should also have input into what changes should be made to the treatment plan, especially if their experience is greater than the doc.

    The nurse also writes or contributes to the nursing care plan, which is used alongside the medical care plan to enhance the health or recovery of the patient. These may include pharmacologic measures, but also includes nonpharm such as activity, fluid intake, help with personal care needs, etc. The nurse is also the person who has eyes on that patient and he or she must be able to recognize signs that the patient is not doing well so appropriate care can be sought.

    NP education (so far) has been about advanced assessment techniques, pathophysiology, pharmacology, and that particulars of caring for different populations (geriatrics, adolescents, etc.). We're also learning about how research is conducted so we can read the literature and determine when a study is valid and what new knowledge we want to bring to our patients in practice (new drugs, new treatments, what type of antibiotics are effective against infections we're seeing in our population, etc.) so we can follow sound principles of evidence based practice.

    It's an entirely different world, but still with the focus on the WHOLE person rather than on just symptoms and drugs.
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    Honestly what I'm saying is that in family practice there is a whole lot of normal and not so much stumping. The doctor has WAY more training and WAY more education in diagnosing. NPs for the most part are trained to care for the normal, to treat routine health problems and to recognize when things aren't normal. There are specialists for reasons. I was really trying to point out that the NP role is geared more toward prevention and treating routine health problems.

    I'm not saying I won't get stumped and the reason I'm not getting stumped is most likely because I'm seeing the most "normal" patients we have since I'm new. It takes experience to be good as an NP and a doc. Doctors get soooo much more training than NPs...internship, residency and tons more schooling.

    Like linearthinker stated, my program taught me how to be an effective entry level provider, but it will take experience for me to be a great NP.
    aet111, Guinea, and mammac5 like this.
  12. 1
    As a PMHNP, I'll offer another perspective. Very little of our diagnosing is done by looking at labs, x-rays, etc., but by direct observation of the patient and by talking with them. Then, I have to consider if they are being truthful, is their family being truthful, are my gut feelings correct? Then I must pick a therapeutic modality, of which all seem to work about the same. However, what is most effective is the relationship between me and the client and of course that differs with each client. Diagnosis continues as it can only be garnered from the client's responses to treatment. Basically, it's a continually learning experience and the clients are the teachers.
    NPinWCH likes this.
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    I have a family member that is a CRNA, and the closest thing to that is an Anesthesiologist obviously. She does all thing things that Anesthesiologists can do; even awake craniotomies, spines, and complex free-flap procedures - all with a liberal amount of autonomy (because she's good and the MDs trust her).

    She says that aside from being able to choose if she takes call the best thing about her job is that if she has any catastrophic issues that she feels she can't tackle she has a MD to consult - which often isn't the case when you're the Anesthesiologist in the room.

    One thing to remember too is that the educational process by which physicians are generated is steadily falling behind demand. So, NPs and PAs are stepping up and filling that void for a number of reasons, but the good news for people interested in the field is that their scope of practice is ever expanding. I know the PACU I use to work in as a Nurse's Aid (a busy NYC academic hospital) was more-or-less run by a PA and NP. They'd round on patients, write orders, interpret labs, and direct treatment to stabilize patients post-op.

    As someone else said the ceiling that you'll hit will be self-imposed. If you're good at what you do, the MDs you work with will give you more responsibility and trust your judgment. If you're not good at what you do, well then you'll be sidelined and won't be used to the fullest extent your degree allows.


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