Just a note on the NP vs PA debate... - page 6

I did not want to fuel this debate. In fact, I hadn't realized there was this much NP-PA hostility until I found this board. Honestly, I think it a trivial debate in the grand scheme of things....... Read More

  1. by   sdgreen
    Quote from jackal
    pa's are assistants, they always have been, and always will be...they assist doctors with all the scut work

    my my, such arrogence and anger towards the pa's! maybe if they are just for "scut work" and are merely "assistants", then can you tell me why they receive much more education and training? namely, on average the pa will complete nearly 2200 hours of clinical vs. the np's barely sufficient 300-700 hours? why do pa's do 5-12 weeks of rotations vs. np's only completing a pathetic 40 hours?

    as far as "anyone" getting a pa, more and more programs demand a master's degree in order to practice, something not seen in the np training. oh! and the majority of pa schools of medicine require 500 hours of direct helath care experience before admission where the nursing schools do not require any direct care experience.

    maybe you should actually learn a little bit about what you're railing against. it's obvious you're uniformed but it's admirable that you are so proud of your little profession. it's always been my experience that it is those who yell the most who are the least competent.
    it is unfortunate that you would suggest such unfounded diatribe as this. clearly, you have been misinformed about the np programs, or have just regurgitated unfounded hearsay and claims by a passionate group of quibblers trying to protect their staked claim to the land of medical extenders.

    first of all, do yourself the fairness of reading more comparative analysis of nps and pas, rather than ones that seek to show differences. try those studies done by mundinger or safriet, instead of trying to demonstrate a profound insight and knowledge base that you certainly are not credited with.

    just to state some facts for you...

    1. all nps are trained in programs that provide a master's degree title once completed.
    2. nps are always nurses first - this means they come from a background of medical/nursing experience they will often bring to the program.
    3. pas are not required to have any medical background, although many do.
    4. the pa program is very difficult to get into - such as is the np program.
    5. pas do have more hours of clinical contact in their programs. this is largely due in part to the fact that most pa students do not hail from a medically based background. therefore, it makes good sense to increase their clinical experience. right?
    6. pas do not "average" 2200 hours of clinical (i have no idea where you came up with that one). their averages on a national level is more around 1200-1600 depending on the school and program.
    7. pas and nps do the same thing when it comes to clinical care of patients. the outcomes are comparable, and in many cases, better than physicians. be proud!!

    i've been a nurse for almost nine years now. i consider my nursing experience very clinically based, and i've worked in a variety of areas in patient care. so, if you add it up, i brought more than 16,000 hours of clinical experience into the np program when i started - a firm foundation to say the least.

    please don't assume that experience is just what you get from the program. pas will require more, and that's just the way it is. if the outcome for the patient is equivocal, then what the hell is the problem with that? i don't feel the need to wave a flag or brag alliance to my credentials, but perhaps you do. i think there are others who have been unfair in their remarks, and i'm sorry about that. but, alas, it is a two-way street. for some reason there will probably always be someone out there destined to prove a difference, rather than be constructive towards the similarities.

    be proud to be a pa or np. just don't boast how "better" one is over the other.

    best,

    sean g. msn aprn fnp-bc
    Last edit by sdgreen on May 24, '05
  2. by   patnshan
    Quote from sdgreen
    6. PAs do not "average" 2200 hours of clinical (I have no idea where you came up with that one). Their averages on a national level is more around 1200-1600 depending on the school and program.

    Sean G. MSN APRN FNP-BC
    Sean,

    I agree with a lot of what you said but just have to clarify one of the things, just to be correct. Most (if not all, but I cannot confirm the all part) PA programs involve one year of full time clinicals. That is 12 month, usually about 50 weeks. These rotations are almost always 40 plus hours per week (my ER and surgery, 2 months each, were many more than that ). So, adding that all up is where people get the 2000+ hours thing. It is correct, likely more like 2500 hours.

    I am not quite sure where you got the 12-1600 thing?

    Bottom line, we have different training but compete for the same jobs. There most certainly are enough jobs for all of us. If you are unsure about that, check out the US BLS website and look at their projections.

    People choose NP or PA for a variety of reasons, some good, some not. Regardless, our goal should be to make both professions better at serving the patient.

    Also, all PA programs will be Masters degree granting shortly.

    Check out American College of Clinicians and Clinican Forum for ways we are trying to become united.

    Best Wishes,

    Pat, RN, PA-C, MPAS
  3. by   sdgreen
    Quote from patnshan
    I am not quite sure where you got the 12-1600 thing?
    Actually, that was from 3-4 different PA websites that I found (listed in their curriculum) and from a couple of PAs that I've worked with. This, once again, may not be everywhere. Such as there are probably NP programs that require a greater number of clinical hours than others. Thanks for the heads up though!

    ~Sean
  4. by   Traveler
    I went to a Diploma school for my RN and graduated ten years ago. The clinical component was over 1,000 hours. I don't know how many clinical hours are required for initial BSN or ADN. But, most NP programs don't admit until you have been a practicing RN for at least several years. Add this to the inital clinical component required for the RN plus the clinicals for the NP and this adds up to quite a few hours of clinical practice.
  5. by   patnshan
    Quote from Traveler
    I went to a Diploma school for my RN and graduated ten years ago. The clinical component was over 1,000 hours. I don't know how many clinical hours are required for initial BSN or ADN. But, most NP programs don't admit until you have been a practicing RN for at least several years. Add this to the inital clinical component required for the RN plus the clinicals for the NP and this adds up to quite a few hours of clinical practice.
    The clinical rotations during the NP and PA program is what really count. You are not a practitioner as an RN. I agree, RN or LPN experience should help you get into a PA or NP program and prepares you well, but does not substitute for training to be a clinician. I was well served by my training as an RN, but it did not make me need the clinical rotations less.

    Pat, RN, PA-C, MPAS
  6. by   mystcnurse
    Quote from alnamvet
    pa's are not licensed, but certified, therefore they (pa's) only demonstrate having successfully completed a pa program, and pass a certfying exam. np's are licensed...big difference when it comes to admitting privileges, prescripted authority, independence, and degree of autonomy.
    not anymore. in sc, pas are now allowed to practice without a physician on site, they can write and sign their own orders (not even sure if the md ever has to sign them, as i've been seeing un-cosigned orders from pas in the facility where i work, and they can now as of a few weeks ago, write for the same drug classes as nps. mds in sc are using pas more and more. i applied for a job, that listed for an "np or a pa". the next week the job was relisted as looking only for a "pa". can't fight the good ol boy system here, at least i haven't seen anyone do it successfully.
  7. by   mystcnurse
    Quote from cgfnp
    you're right, even though you don't really know you are. it has nothing to do with what time the class starts or whether you take all of them in two years or four years. it does, however, have to do with the medical model vs the nursing model training. msn program sucks something awful. i have to write papers about what sister calista roy thinks about hand washing, yet i don't know how to read an ekg. but, i realize this so i'll be teaching myself the important stuff that i know i don't have a clue about because of the msn bullsh*t. i'm still glad i did it this way because many of the docs in my state are going with nps because we can practice without them in the building, whereas pas cannot. other than that, i'd go pa any day over the pure crap i have to learn at the present.

    the scary thing is, most of my classmates and probably many of the current practicing nps don't have a clue that the training is so terrible, so they think they know what they need and go out and make fools out of the profession. i hear that a lot from docs i work with now. but, the good thing is they can recognize the 1-2 out of 10 nps that are really good.

    as much as i hate to admit it, i actually had an excellent education in my fnp program, that is, despite some of the power hungry abusive instructors that i had, there were some good ones as well. the overall program did include sooooo much, but honestly, i think your education is what you make it. when there was something that i came across that i did not understand, i made it a point to learn it. i learned to read an ekg on a telemetry unit, as an rn, and to this day there are many primary care physicians who cannot read an ekg, or even a telemetry strip that i run into on almost a daily basis. word of the day = cardiac consult. my np education provided, in addition to two years of on site clinicals in many different areas, nursing theory (which included approach to patients of all types), research, basic business, nursing law and politics, etc, etc. my experience as a registered nurse was paramount to becoming an effective np.

    the biggest difference, to me, between an np and a pa (or even an md, for that matter) is supposed to be approach. holistic, nursing practice vs. the medical model. the medical model should be incorporated into an np's practice, but it is not the model which they are educated to use. for example, i saw a pa the other day, because i am very, very sick. i am sick because i worked too many night shifts in a row and i have a lot of stress in my life, currently. i haven't been working out or doing some of the things that i normally do in order to keep myself healthy. the pa gave me the z-pack that i asked for, because i knew that what i had was bacterial, i knew who i got it from, etc, etc. he gave me a big old guiafenisen horse pill and told me to come back in 10 days for a recheck (yeah, right). i had to ask him for a prescription for diflucan, just in case, since i haven't taken an antibiotic in years, and i know that i will probably get a yeast infection. he refrained from eye contact as much as possible and i spent about 3.5 minutes in the exam room after a two hour wait.

    now, as an np, i would ask the patient about stress in her life, i would clue into the yeast infection thing with the antibiotic. if my patient were a nurse i would give a little pep talk about taking time for herself, getting enough sleep, etc. i would focus on prevention - and, btw, when i went into the office i had been awake for nearly 30 hours, coughing, after having worked a 13 hour shift.... and i was very distressed, emotionally because of my sleep deprivation. i was frustrated and tearful because i had to call out of work that night, and my unit was extremely short staffed. the pa couldn't handle that and did not address it... he acted like i was sitting there calmly, which i was - for the most part, except the tears. as a nurse i would have addressed it... i would have said, "you seem very frustrated..." or something.... not to open a can of worms that kept me from my other patients, but, oh yeah, i was the last patient of the day....

    i recently had an older patient who had some "skin breakdown" on her sacral area. the pa who saw her in the hospital asked the wcn to dress it, and labeled it as a sacral decub, stage i. of course, as a nurse, and having actually looked at the area, i noticed right away that it really looked like an hsv infection. the pa said, "no way", probably because of the patient's age. well, i got the md on the phone later, and we swabbed it, and it was hsv. can you imagine putting a duoderm over hsv???? all i'm saying is that nurses know their patients inside and out. we spend time with the family, we look closely at their skin, we truly see the gait, we truly see the emotional difficulties that cause stress in a patient's life, and even their difficulties in accessing healthcare.

    a pa once saw one of my patients and her baby son, who had strep. she was uninsured. i suggested that he give her samples for her other two children who had the same symptoms and were also uninsured. (which he did not know about, but i determined in the history i took before he came into the room). of course, that wasn't going to happen. she had to come in. she wasn't about to bring the other kids in (who were established patients), because she couldn't afford to and it was terribly inconvenient. she ended up, instead, bringing the other two kids into the emergency room about a week later, by taxi, with fevers of 103, which they had had for days, and positive strep tests... how much did this cost our health care system - since she is a single mom and recieves no child support, but makes just a little too much to qualify for aid, it won't ever be paid by her.

    i'm not saying anything against pas, but they are trained in the medical model. nurses are holistic, preventative and can deal with things - heavier things... because as nurses, we do. we are educated to incorporate all of the many aspects of a person into the plan of care. now... the question becomes, what is more cost effective.... short term, it may be the pas.

    all i know is that in my state, pas are winning out. our laws have changed to eliminate the benefits of having an np vs. a pa. many of the nps who are practicing, have become doctor juniors. the most serious part of this is the way that they treat rns.

    i was working a very busy clinic once, as an rn, while i was in np school.... and this np comes in, it is myself, an lpn and a cna and we have like 15 rooms of patients with three types of clinics for about 6 mds.... she comes to pull me out of a room to take vital signs on her patient.

    it was that day that i promised myself i would always be a nurse, no matter what my credentials became.... and part of being a nurse, to me, is caring for those around you... being observant, efficient, and respectful.

    fortunately, i do love patient care. i doubt i will remain in the hospital for long, however, because there is an underlying disrespect for nurses that i honestly can't deal with. i worry about my nursing liscense when i can't get an md to answer my call. i'm sorry for my patients when i go. but i have an entrepreneurial spirit, and until and unless my profession and my place of employment supports me in my quest to provide the best care possible while maintaining my own health, i'll eventually have to leave. i'm sure i will always be successful in life.

    i also hope that there will always be a place for nps in this world, who truly practice using the nursing model. family nurse practitioner... maybe i was being idealistic, but i really wanted to provide care to families... to help them to be physically and emotionally healthy, and to assist and guide them through all of the different phases of life and growth. to practice preventative, holistic health care, not just episodic and chronic disease management. again, i have nothing against pas... i hate to have to compete, i'm not even sure it is worth it anyway.... but being nurses simply gives nps a different perspective....

    i will say, however, that if i had known that nps would have no advantage over pas in the job market, i probably would not have spent the time and money becoming one. pas have always had the advantage of being under medicine, which is why the mds like them. nps had the autonomy, which made less controlling mds like them. now, they can have both in a pa. it will be interesting to see what happens in future to the role of the np.

    finally, i hope i didn't say anything to offend anyone... i realize that i probably made some generalizations... and there are exceptions to every rule. and honestly no offense to pas - i have met many who practice very good medicine.


  8. by   Noreaster
    Quote from patnshan
    Sean,

    I agree with a lot of what you said but just have to clarify one of the things, just to be correct. Most (if not all, but I cannot confirm the all part) PA programs involve one year of full time clinicals. That is 12 month, usually about 50 weeks. These rotations are almost always 40 plus hours per week (my ER and surgery, 2 months each, were many more than that ). So, adding that all up is where people get the 2000+ hours thing. It is correct, likely more like 2500 hours.

    I am not quite sure where you got the 12-1600 thing?

    Bottom line, we have different training but compete for the same jobs. There most certainly are enough jobs for all of us. If you are unsure about that, check out the US BLS website and look at their projections.

    People choose NP or PA for a variety of reasons, some good, some not. Regardless, our goal should be to make both professions better at serving the patient.

    Also, all PA programs will be Masters degree granting shortly.

    Check out American College of Clinicians and Clinican Forum for ways we are trying to become united.

    Best Wishes,

    Pat, RN, PA-C, MPAS
    In my Master's PA program, I had 12 full months of rotations with like 1 week off (and a holiday or 2) for 40-50 hours per week. The numbers that were origionally quoted weren't too far off, really. The clinical rotations were typically 5 days a week; some took some call with their preceptors, only adding to those hours.
  9. by   alkaleidi
    Ok, I hate to bring a somewhat dead topic out of the grave, but I have a question, and would like any answers that are as unbiased as possible.

    I was speaking to a PA student who is an RN today, and asked why choose PA instead of NP. He said that he chose PA because of the specialty. He said that (at least in IL) the bulk of NP jobs are in dr's offices, making rounds, etc. More "boring" jobs for lack of a better word to describe it. Not saying being an NP is boring, but the tasks they are typically assigned to are more consistent, repetitive, and in the same areas.

    One example he used was surgery. He said (and I agree that I personally have never seen it) that rarely would a surgeon hire an NP; they frequently use PAs. The reason behind that being the difference in billing. Nurses are considered ancillary staff and the surgeon isn't able to bill more by using an NP to assist. But PAs are considered as a different role (I don't remember what he called it), therefore the surgeon is able to tack on something like 17% as a billing fee for the PA.

    My questions are (1) how often do you see NPs assisting in a surgical setting and (2) is the billing statement accurate?
  10. by   core0
    Quote from alkaleidi
    ok, i hate to bring a somewhat dead topic out of the grave, but i have a question, and would like any answers that are as unbiased as possible.

    i was speaking to a pa student who is an rn today, and asked why choose pa instead of np. he said that he chose pa because of the specialty. he said that (at least in il) the bulk of np jobs are in dr's offices, making rounds, etc. more "boring" jobs for lack of a better word to describe it. not saying being an np is boring, but the tasks they are typically assigned to are more consistent, repetitive, and in the same areas.

    the bulk of pa jobs are in the boring category. as a surgical pa a lot of what we do and a lot of the value that we bring to the practice is the boring stuff. making rounds is just as important (and requires more medical decision making than assisting). there are a few pas that only assist and move between different surgeons, but the majority of pas that work in surgery see patients in the office, round and assist.

    one example he used was surgery. he said (and i agree that i personally have never seen it) that rarely would a surgeon hire an np; they frequently use pas. the reason behind that being the difference in billing. nurses are considered ancillary staff and the surgeon isn't able to bill more by using an np to assist. but pas are considered as a different role (i don't remember what he called it), therefore the surgeon is able to tack on something like 17% as a billing fee for the pa.

    rns are considered ancillary staff and you cannot bill for them. nps are considered non-physician providers (as are pas) and you can bill for them. both nps and pas can collect 14.5% of the surgeons fee (85% of 18% if you care) for first assist or second assist where allowed (not all surgery allows an assist). for a liver transplant for example that works out to about $1000. the big money is in cardiac where the vein harvest is considered a separate surgery and the pa gets 85% of the physicians fee.

    note that these billing rules only apply for medicare. most insurance generally follows them but may allow other providers such as rnfas or sas to bill. the payment for other providers is hopefully above medicare.

    my questions are (1) how often do you see nps assisting in a surgical setting and (2) is the billing statement accurate?
    (1) in four years working in the or i saw two nps that first assisted. one in pediatric urology and the other in general surgery. on the other hand i probably worked with more than 100 pas. in my current job the department of surgery has 100 or so pas and no nps as far as i can tell.
    (2) the billing statement is not accurate. the reason that you don't see nps in the or is twofold. one is that surgeons are used to pas. pas have been assisting in surgery since the start of the profession. one of the first pa programs (uab) was a surgical pa program.
    the other is that while some rnfas consider themselves apns by all the other defiintions they are not. either because of the rnfa or for other reasons there has not been a np program that covers surgery. the uab program recently started but i do not believe has graduated a student yet.

    the credentialing requirements for surgery require you to demonstrate that you are no what you are doing before you enter the operating room. in the old days surgeons would train scrubs (or other providers such as nps or rns) on the job to assist. this is no longer allowed. this is one of the reason that all pa students are required to have a surgery rotation with operative experience.

    the problem with a program such as the uab program is that it is trying to fit a nursing domain onto a medical profession. besides the fact that it is longer and more expensive than the pa program with less clinical and didactic time it also suffers from the inherent problem of basing it on the acnp. many practices work across age groups. for example i see pediatric and adult liver transplant patients. if you work for an ortho group then you may be expected to take er call and set an arm or a five year old. all outside the scope of practice of an acnp.

    david carpenter, pa-c

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