MD, DO, NP, DC, OD -- Who deserves the title PCP? - page 5

our professional scope of practice asserts that our role is to assess, diagnose, and treat in health and illness - head to toe, physical and behavioral. from assessing, diagnosing, treating -... Read More

  1. by   CraigB-RN
    I've never seen an NP write a nursing DX on a chart. I'm sure my HIM people wouldn't allow that either. Again it sounds like semantics to me. Using nursing DX doesnt' put the NP any farther ahead of things than my staff nurses.

    How is this patient going to be treated differently?
  2. by   Traveler
    All right, I'll jump in here. I am an RN with ten years of expereince. My goal is to earn my MSN and FNP but it is slow going. I have been in home health for years and have been around many MD's, PAs and nurse practitioners. Here is my take. The nursing model of care promotes a more holistic model. There may not be much of a difference with the way the pt with CP is treated. However, where ongoing primary care is concerned- this is where I think the difference is seen. Because the nursing model of care promotes holistic thinking the np is going to be more likely to ask a broad range of questions related to the entire patient and not just the presenting problem. Will be more likely to counsel as far as nutrition, etc. If a patient with a wound on their foot comes into the office, I would think that the np would be more likely to look and teach about nutritional status as well as basic wound care. The np would be more likely to assess things like: what type of shoes is the patient wearing that may be counterproductive to the wound. This is why np's are such a good fit with primary care.
  3. by   CraigB-RN
    UNfortunatly this may be what the "nurse union" is pushing, but In my experience. 25 years, I'ts been the individual provider and not the type of license the provider that makes a difference. Then after I watched my wife studying to be a PA and compate it with my ACNP and now the FNP, I'm sorry I don't see any difference at all. The NP's that I"m working with now couldn't be distiguashed from an MD, PA or DO without the name tag. One of the PA's actually spends more time with the patients expalining things and treating the patient as a whole, than all the NP's put together.
  4. by   TMnurse
    This orginal post is well said with some nice thought. I liked the call for more professional recognition. I am currently enrolled in an NP program. I must say that the first instinct it compare ourselves (APNs) with other professional health providers. However, I have finished some courses on health care systems in the US and the bottomline is--your wasting your time/energy bothering with trying to compare APNs with other health care providers. THE BOTTOMLINE is that right now... now... we have huge gaps of care where we need health care providers (all types). The boomers-immigration-- natural population increases coupled with the fact that there are already shortages of all allied health providers--means there is plenty to keep all of us busy. If chiropractors think they are "healers", let them. Take a look at our legislation and the Bills that congress is working on. If one thing has been forseen by our government is that we are apporaching a crisis (several actually)... for instance-if you agree to work in a rural setting for a year--the feds WILL pay 100% of your schooling to become an APN. Why? Medicine is no longer pumping out enough primary care providers and/or nobody wants to become one-does not pay in comparision to specializing. I can only speak for what I have been learning mostly studying bills slated to be ratified and/or moving through Congress but WITHOUT A DOUBT (in the eyes of Congress) APNs are a well recognized - needed/professional/valuable heath care providers. Sure we still have a ways to go with salary and making sure we get paid for what we do.... and that I think should be our focus. Again, I think that's where our energy should be.... let the others worry about themselves (PA/chiro/homeo). The arguement pops up every few months and goes on and on without any resolve. Why? There really is no answer. Both PA and NP are needed today.. and will be in the years to come. Both need to make sure that they are lobbying to make sure the keep their scope of practice. What we should all be worried about are things like malpractice insurance & socialize care. Best of luck to all.
    Last edit by TMnurse on Mar 5, '05
  5. by   patnshan
    Quote from CraigB-RN
    UNfortunatly this may be what the "nurse union" is pushing, but In my experience. 25 years, I'ts been the individual provider and not the type of license the provider that makes a difference. Then after I watched my wife studying to be a PA and compate it with my ACNP and now the FNP, I'm sorry I don't see any difference at all. The NP's that I"m working with now couldn't be distiguashed from an MD, PA or DO without the name tag. One of the PA's actually spends more time with the patients expalining things and treating the patient as a whole, than all the NP's put together.

    I agree with all of this above. If NP's are practicing medicine under the supervision/collaboration of a physician, then why are there two professions, PA's and NP's. NP's are trained in nursing and come out to practice medicine. How does that work? It is the skilled nursing politicians who benefit from saying nursing is distinct from medicine.

    My arguement is not with NP's, because most who understand the above, do just fine. The arguement is with the NP movement and this independence garbage, given that there is obviously less education provided in the NP program than PA, despite PA's not trying to be independent. We just don't get how this could even be considered after 40 or so graduate credits in nursing theory and "soft" medicine (they call them nursing) courses.

    As far as that "less education" statement I made above, I challenge those who disagree with to go to any university's online course catalog and compare an FNP or ANP cirriculum with the PA cirriculum at the same university. It is glaringly "softer" in most cases. The example I used because it is local to me is Marquette University.
    They are 42 credits over two years without summers for NP, and 130 hours with summers full-time for PA. The clinical year for NP programs is not even full-time (ie: less than 40 hours per week). How can you compare that? How can you be ready for independence after just that? I am sure there are more rigorous NP programs, I just
    have not seen them. I will stand corrected if someone can show me an NP program that is that rigorous.

    Thanks,
    Pat
  6. by   SKM-NURSIEPOOH
    Quote from patnshan
    "....as far as that "less education" statement i made above, i challenge those who disagree with to go to any university's online course catalog and compare an fnp or anp cirriculum with the pa cirriculum at the same university. it is glaringly "softer" in most cases. the example i used because it is local to me is marquette university. they are 42 credits over two years without summers for np, and 130 hours with summers full-time for pa. the clinical year for np programs is not even full-time (ie: less than 40 hours per week). how can you compare that? how can you be ready for independence after just that? i am sure there are more rigorous np programs, i just
    have not seen them. i will stand corrected if someone can show me an np program that is that rigorous."
    perhaps the typical np credits required are less due to np candidates having had prior nursing educational credits, experience, &/or both...yet the pa program don't require such credits prior to entering ?

    for example: one typically has to complete at least 60 credits (30 being nsg courses...the other 30 being preqs) for asn/aas level; & 60 more credits (approx 50 being nsg courses...the remainder being research, statistics, computer, or other elective). then of course...you have those diploma educated nsg that return to school for their rn-bsn/msn track as well as second bachelors' degree folks who go through an accelerated pathway. now i can see the diploma nsg being able to clep-out of certain bsn nsg courses from having extensive experience brought forth in their profolios...but i do find it hard to go along with those bsn/msn prior bs degree candidate who go through the accelerated track without having any prior nsg experience. i'm more uncomfortable with said candidates being *safe* or *competent* clinically...but studies haven't proven them to be any more or less unsafe or incompetent than those who've gone the long route. now the typical or traditional np pathway requires approx 42 additional nsg credit hours....totaling anywhere from 92 to 122 nsg credit hours over the course of asn to bsn to msn track (122) ; or straight bsn to msn track (92).

    now take the pa candidate...they may or may not have a bs at the beginning...depending on the school/university...but they don't have any prior medical/clinical experience that's required of them. now that's not to say none haven't had any prior medical, nsg, or clinical experience...but i don't believe any of those credits &/or experience would count towards their program's criteria. so it would make perfect sense for so many credit hours to go towards the didactic, some to go towards electives, & the bulk of the remaining to go towards the clinical aspect. if the pa program requires a total of approx 130 hours total...that's only roughly eight credit hours difference...which could very well be spent on professional development, research, computer elective type courses.

    so for me...there really isn't that much of a disparity in terms of the amount of credit hours that are required for either np or pa programs...the disparaty...i suppose...would come from how those courses are taught & understood!

    you say the np model courses are *soft medical* courses...i fail to understand your meaning except to say that the np courses are *watered down* :uhoh21:. am i correct in my understanding of your reference? i sincerely hope that i'm wrong in my assessment of your statement. both np & pa programs are fast paced & extremely difficult. i wouldn't dismiss either of them as being *soft* or *easy* & to suggest that is grossly insulting as well as invalid :angryfire ! my main concern is that the candidates in both programs understand what it is that's being taught & for them to competently apply what they've learned to their practice.

    cheers!
    moe
  7. by   patnshan
    Quote from skm-nursiepooh
    perhaps the typical np credits required are less due to np candidates having had prior nursing educational credits, experience, &/or both...yet the pa program don't require such credits prior to entering ?

    for example: one typically has to complete at least 60 credits (30 being nsg courses...the other 30 being preqs) for asn/aas level; & 60 more credits (approx 50 being nsg courses...the remainder being research, statistics, computer, or other elective). then of course...you have those diploma educated nsg that return to school for their rn-bsn/msn track as well as second bachelors' degree folks who go through an accelerated pathway. now i can see the diploma nsg being able to clep-out of certain bsn nsg courses from having extensive experience brought forth in their profolios...but i do find it hard to go along with those bsn/msn prior bs degree candidate who go through the accelerated track without having any prior nsg experience. i'm more uncomfortable with said candidates being *safe* or *competent* clinically...but studies haven't proven them to be any more or less unsafe or incompetent than those who've gone the long route. now the typical or traditional np pathway requires approx 42 additional nsg credit hours....totaling anywhere from 92 to 122 nsg credit hours over the course of asn to bsn to msn track (122) ; or straight bsn to msn track (92).

    now take the pa candidate...they may or may not have a bs at the beginning...depending on the school/university...but they don't have any prior medical/clinical experience that's required of them. now that's not to say none haven't had any prior medical, nsg, or clinical experience...but i don't believe any of those credits &/or experience would count towards their program's criteria. so it would make perfect sense for so many credit hours to go towards the didactic, some to go towards electives, & the bulk of the remaining to go towards the clinical aspect. if the pa program requires a total of approx 130 hours total...that's only roughly eight credit hours difference...which could very well be spent on professional development, research, computer elective type courses.

    so for me...there really isn't that much of a disparity in terms of the amount of credit hours that are required for either np or pa programs...the disparaty...i suppose...would come from how those courses are taught & understood!

    you say the np model courses are *soft medical* courses...i fail to understand your meaning except to say that the np courses are *watered down* :uhoh21:. am i correct in my understanding of your reference? i sincerely hope that i'm wrong in my assessment of your statement. both np & pa programs are fast paced & extremely difficult. i wouldn't dismiss either of them as being *soft* or *easy* & to suggest that is grossly insulting as well as invalid :angryfire ! my main concern is that the candidates in both programs understand what it is that's being taught & for them to competently apply what they've learned to their practice.

    cheers!
    moe
    that prior nursing experience arguement is a common, but generally invalid arguement. being an rn does not teach you to independently diagnose and treat medical problems. you still need the training in how to do that, as well as the science behind what you are doing, so you can understand the reasons for it.
    i feel that np training in general lacks some of the specifics needed to understand the scientific, evidence based, reason of when and why to do what you are doing. too much nursing theory, not enough medicine and medically-related science.

    examples of missing science education are gross anatomy with disection, neuroanatomy, neurophysiology. each program will vary, but to get the info into only 42 hours of part-time study, you have to leave something out.

    the credits you cite for nursing training in undergrad are just that, undergrad. most pa's have bachelor's degrees and significant experience prior to pa school. for example: i was an emt, er tech, phlebotomist, and registered nurse prior to pa school. i went to school with other nurses, pharm d's, med tech's, resp therapists, etc. all of these involve significant patient care experience. but, none are a substitute for learning and "practicing" medicine (pun intended) in you clinical year.

    for the record, i am totally against the movement of accepting pa students who have no prior experience. i am equally against np programs doing the transitional thing, allowing people to go straight through without experience. most pa's and np's i know agree with me.

    watered down is a good word, but yours, not mine. i prefer soft. what i mean by soft is that they scratch the surface and are often not taught by experts in their field. a soft course in my mind would be a pharmacology course taught by a nurse, a pulmonology course taught by a non-pulmonary md, pa, or do. a basic science course not taught by a phd in that field. i think this explains my drift.

    i agree that pa programs and np programs are difficult, in their own right. but in saying that, there is no way that anyone in their right mind would try to tackle the rigors of a full-time pa program while working full-time. from what i understand and know from people doing it, that this is quite doable to work as a full-time rn and full-time np school.

    i think i am a bit more qualified to criticize the np educational standards, having been an rn and having graduated from a university that offers msn and phd nursing programs. i decided to go to pa school halfway through nursing school. i studied both programs as well as their ideals. i could not, and still cannot understand why one could feel that this level of education could prepare you to practice independently. most np's i know believe this as well, but that is not what is taught in academia.
    i could have continued to work as an rn nearly full-time, taken out less loans, and been less in debt if i would have chose np school. instead, i quit my job, took out mass loans, and went to pa school. i made the right choice for me. i felt that practicing medicine is a serious business and one should immerse themselves in it while training. i didn't think part-time study and part-time clinicals would cut it. now i know it doesn't.

    i work with many great np's. they know that they are practicing medicine. they know that the patient and themselves are best served having a doctor to confer with. they know that collaboration is the same exact thing as supervision. they know that they are not doctors and do not pretend to be one. they do not strive for independence, as they know that there education did not prepare them for that.

    i hope you understand my point and did not mean to insult anyone.

    pat, rn, pa-c, mpas
  8. by   happthearts
    There is only one school of Chriopratic that allows the 2 years that is back East Sherman Penn. I think .Only excepted in some states most must be grand-father in Or The Doc's have to go back school. Most states requires a BA. Chriopratic colleges ask for the BA. Before entering school Now .

    My husband Has been out of school for over 14 years practicing in Utah and Calif. My husband went to school for 9 years Not including the Pre -requists My husband schooling was not that unlike a MD's same amount of hours. Less on using Pharmaclogy and alot More on using Phyical medicine etc
    My husband Owns a medical clinic here in SLC and has an NP who works for his clinic.Which he refers to and vice versa .

    Regarging scope of Pratice
    1 Cannot prescribe - not even an aspirin That is only in some states. In some states they even do minor surgery and deliver babies.
    2.Chiropractic is a total-body health-care system, and not a method of pain management.
    Regarding Pain management Not true! Pain is not emphasis . That is why people go to see Chrioprators because there pain is not being managed allopathic Medicine,
    3.Procedures? - Scant more than "moist heat";
    Not correct .They can exam diagnose, laser, ,malpualtion any anything a PT can Pretty much do and most Physical medicine things.

    This is why DC.have the title of doctor.Its not an Honorary title But an earned one in each and every state.
    Just to let you know most of the students in My husbands class were MD , NP.,nurses,and PT's before they started Chriopratic school. Most all had other medical education.

    You might wish to check out Chiroweb.com
  9. by   zenman
    Quote from patnshan
    I agree with all of this above. If NP's are practicing medicine under the supervision/collaboration of a physician, then why are there two professions, PA's and NP's. NP's are trained in nursing and come out to practice medicine. How does that work?
    Because there is a difference. PAs can only practice medicine; NPs benefit from their background in nursing. Hopefully, they will be able to integrate it into their practice.

    My arguement is not with NP's, because most who understand the above, do just fine. The arguement is with the NP movement and this independence garbage, given that there is obviously less education provided in the NP program than PA, despite PA's not trying to be independent. We just don't get how this could even be considered after 40 or so graduate credits in nursing theory and "soft" medicine (they call them nursing) courses.
    Why so much crying over independence? I think most NP's know when to call for help, same as PA's.

    As far as that "less education" statement I made above, I challenge those who disagree with to go to any university's online course catalog and compare an FNP or ANP cirriculum with the PA cirriculum at the same university. It is glaringly "softer" in most cases. The example I used because it is local to me is Marquette University.
    They are 42 credits over two years without summers for NP, and 130 hours with summers full-time for PA. The clinical year for NP programs is not even full-time (ie: less than 40 hours per week). How can you compare that? How can you be ready for independence after just that? I am sure there are more rigorous NP programs, I just have not seen them. I will stand corrected if someone can show me an NP program that is that rigorous.
    You're trying to make a point of a "rigorous" program. That's nothing to be proud of from an educational standpoint. I'd rather go part-time and have time to let that knowledge soak in and to practice than to rush around barely keeping my head above water...which is not conducive to learning and retention.

    I compared Duke University PA and NP programs. The PA program is 11 months pre-clinical and 13 months clinical practice. The thing I prefer about the NP is that you can focus on an area; I'm considering Adult NP or Psych NP. In either of those, I would not want to have to do clinical in peds, ob-gyn, general surgery, etc. so the the total hours in PA clinical vs the 600-700 hrs in NP clinical mean little to me. If I wanted I could just continue taking the clinical courses till I had several years of clinical.

    Some people bark about nursing experience not being relevant. That's bull. I've been around 30 years and know my drugs and diseases, labs, etc.. Even though an NP would be ordering procedures, tests, etc. rather than actually doing them, the years of doing them comes in handy and can benefit both the patients and nursing staff in the way in which they are ordered.

    Even though I already have my masters in nursing, the post-masters programs I'm looking at would still take me 2 years to complete.
  10. by   Traveler
    <<Some people bark about nursing experience not being relevant. That's bull. I've been around 30 years and know my drugs and diseases, labs, etc.. Even though an NP would be ordering procedures, tests, etc. rather than actually doing them, the years of doing them comes in handy and can benefit both the patients and nursing staff in the way in which they are ordered>>

    I agree with zenman, the nursing experience is very relevant. I work as an RN in home health. In this area especially, we very often "recommend" tests, treatments, etc. to be performed. We are also often the eyes and ears for the MD's about a patient's condition and are pretty good at assessment and picking up on changes. This goes hand in hand with what the role of the NP is and only helps to make a better NP.
  11. by   patnshan
    What I meant, but not what I said, was that nursing experience is no more relevant than say ER tech, paramedic, respiratory therapist, etc. in the preparation of an individual for midlevel providership (is that a word?).
    I would argue that my ER tech experience was more helpful in my personal preparation than was the nursing. The reason for that is that as a tech, my job was to assist the docs in procedures, apply casts and splints, do EKG's, do CPR, etc. The nurses were too bust doing other nursing activities to allow them to learn by "osmosis" from the docs. I am sure some nursing jobs allow you to do more of this. My point is that nursing is not medicine.

    What I do stand-by, exactly as I said it earlier, is that nursing experience is NOT a substitute for learning how to be a midlevel medical provider. That is the beef I have. The training is too "thin" to adequately do this. NP's must "catch up" more than other disciplines because of this.

    Bottom line for me, if you pit a new grad PA and a new grad NP, both with identical RN experience, you will see the PA shine in most practice settings. I have seen this numerous times, and even hear it from NP's and people who hire both types of practitioners.

    Pat


    Pat
  12. by   patnshan
    And for Zenman's comment about PA's only being able to practice medicine. For your info, ALL of nursing is in the scope of practice of a physician. PA's can do ANYTHING that their supervising physician does. That includes start IV's, give injections, change dressings, teach patients, perform counseling, etc.
    So, don't flatter yourself with that, "Can only practice medicine" stuff. There is not much that this scope of practice does not cover.

    Pat
  13. by   dorisemoore1
    Hey pat
    I agree with you the NP is a "softer" course compared to a PA course. I volunteer at a hosp in minneapolis and I brought this topic to them doing lunch. And the NP's agree about what you said. Both is great professions but one is just in-depth though medince than another. Nothing wrong with that in my book. I guess if people want more than they need to go to med school....just my thought on this topic

    wish every luck
    from the twin cities

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