Hello. I am considering NP and PA school. I have a few years of experience as an ED Tech in a Level 3 Trauma Center in California (busy, but not too intense). Our ED is staffed with PA's no NP's.
I have a few questions about clinical differences between NP's and PA's. I know that PA's seem to have a great ability to work in surgery specialties like ortho, neuro, peds, and cardio surgery. They do pre and post surgery exams, order interprets tests, and prescribe meds (at least in 47-49 states). Are there any NP's on this forum who do this? Are there any in California who can comment?
Second. I know that most PA schools have a much longer clinical component than do NP schools. I have been told it is because NP's already have so much clinical experience as nurses. But can you really compare the two? In our ED, the nurses are not making differential diagnoses, determining etiology of disease, etc. etc., they are monitoring the pt's overall state and response to the treatment ordered by the Physician (or sometimes PA). Therefore, does this experience compare to the rigorous training PA's get in diagnosing?
Part of my interest in medicine is the actual procedures themselves. I want to do chest tubes, central lines, suturing, first assistant surgery, etc. etc. Are there any NP's out there who are doing this?
Finally, I know some people (including some nurses) who deride the "nursing diagnosis" concept. Can anyone offer up a brief rationale for how nursing diagnoses are of value to an NP in clinical practice?
Where a state does not have a law or regulations that govern collaboration, it is to be evidenced for Medicare purposes by the nurse practitioner documenting the scope of his or her practice and the relationships that he or she has with physicians to handle issues that arise which are outside the scope of his or her practice.
David Carpenter, PA-C
So for states in which NP's can practice independent, the NP is operating under the provisions of that state law in the context of the absence of a required supervising physician relationship, as this is not required by law within those states. Therefore, NP's need only document this and provide a policy statement for referral when assessment-treatment falls outside of the NP's scope of practice, training and experience. Then could the NP get directly reimbursed?
So for states in which NP's can practice independent, the NP is operating under the provisions of that state law in the context of the absence of a required supervising physician relationship, as this is not required by law within those states. Therefore, NP's need only document this and provide a policy statement for referral when assessment-treatment falls outside of the NP's scope of practice, training and experience. Then could the NP get directly reimbursed?
Two issues. NPs in all states can be directly reimbursed. This is pretty much the only difference between PAs and NP under Medicare. PA reimbursement must either go to the supervising physician or the corporation. NP reimbursement can go to either the NP, the physician or the corporation.
As far as collaboration on the line above the quote defines collaboration:
"Medicare defines "collaboration" as being a process in which a nurse practitioner works with one or more physicians to deliver health care services, with medical direction and appropriate supervision as required by the law of the state in which the services are furnished."
I am not aware of any case law on this. By strict interpretation there should be some sort of agreement with a specific physician. While it could be verbal, it probably should be written. Having a policy statement that states the patient will be referred to the ER will not suffice. The danger in not having a written agreement is that in the event that there is a complaint, Medicare can do an audit and if they determine that the services were not covered and retroactively deny payment. I have heard of this anectdotally but have no direct knowledge that this has happened. Also remember that Medicare carriers actually implement this policy so they may have specific policy guidance.
My understanding is that most NPs operate in the same way as most PA owned clinics. You form a corporation owned 99% (or 100% in the case of NPs) that bills for the providers services. The corporation hires a physician as medical director with sufficient safeguards to show physician autonomy. This also usually squares things with insurance companies who still require billing under a physician (bill under the physician who then assigns billings to the corporation).
This is just a curiousity of mine since I will graduate from a 2nd degree RN program in a few weeks and will be starting a L&D orientation in January. I plan on going to midwifery school after working as a nurse for a few years.
While I was in college a friend in my chemistry lab told me about how she was planning on going to PA school after graduation. That was the first time I had heard about the PA profession so I did some investigation. I liked everything about being a PA except that I only found that PAs were working in outpatient ob-gyn settings. Through my research I then found out about nurse-midwifery and decided that would be better for me since I was very interested in ob-gyn and birth.
So my question is do PAs ever work in labor and delivery? Is there any state that allows them to attend deliveries with a physician or on their own? Or do most work in ob-gyn offices like Women's Health NPs?
This is just a curiousity of mine since I will graduate from a 2nd degree RN program in a few weeks and will be starting a L&D orientation in January. I plan on going to midwifery school after working as a nurse for a few years.
While I was in college a friend in my chemistry lab told me about how she was planning on going to PA school after graduation. That was the first time I had heard about the PA profession so I did some investigation. I liked everything about being a PA except that I only found that PAs were working in outpatient ob-gyn settings. Through my research I then found out about nurse-midwifery and decided that would be better for me since I was very interested in ob-gyn and birth.
So my question is do PAs ever work in labor and delivery? Is there any state that allows them to attend deliveries with a physician or on their own? Or do most work in ob-gyn offices like Women's Health NPs?
Thank you!
PAs do work in L&D. There is even a OB-GYN fellowship for PAs:
There are no restrictions of PAs practicing OB-GYN as far as I know (although the website lists four states that have limits). As far as attending deliveries, that will be a matter of hospital credentiallng but is generally allowed as long as there is physician back up. That being said you will probably have an easier time finding a job with a CNM if all you want to do is OB-GYN. As usual its very location dependent. On the other hand there a are a fair amount of PAs doing GYN related areas such as GYN-ONC, surgical oncology, Uro-gynecology, and radiation oncology that are probably not available as a CNM.
Specializes in ER and family advanced nursing practice.
The thing that the uniformed don't understand is that having a dependent profession does not make me a lesser provider. The dependent part does not refer to my medical practice.
Fortunately for me there are plenty of NPs like the previous poster that are happy to spout of their opinion about NP independence and run down PAs. We have a name for that in the office, the PA employment act.
David Carpenter, PA-C
David,
Well said. I have brought this up in previous posts, but I am thankful you have stated it again so well. The PAs and NPs that I work with are skillful and competent. They deliver excellent patient care. They make good livings doing something interesting that matters. Guess what they are not worrying about? The perception that they are weaker/lesser providers because they are not independent. It has been suggested that some MDs prefer to work with PAs. I don't know if that is true, but if it were maybe it is because they get to work with a highly trained individual who isn't claiming to own the patent on caring and compassion.
To all reading this, I am really not trying to offend, but I am really getting tired of EBP (Ego based practice).
Well said. I have brought this up in previous posts, but I am thankful you have stated it again so well. The PAs and NPs that I work with are skillful and competent. They deliver excellent patient care. They make good livings doing something interesting that matters. Guess what they are not worrying about? The perception that they are weaker/lesser providers because they are not independent. It has been suggested that some MDs prefer to work with PAs. I don't know if that is true, but if it were maybe it is because they get to work with a highly trained individual who isn't claiming to own the patent on caring and compassion.
To all reading this, I am really not trying to offend, but I am really getting tired of EBP (Ego based practice).
I think that most of the problems could be avoided if NPs were taught about how PAs are trained and our scope of practice. My experience is that the information given out in the local programs is "less than accurate". The NPs that I work with and the NP students that I have precepted on the other hand know that I am always willing to help out. I kind of regard it as when nursing students are taught that they are not allowed to take orders from PAs. At first I would try to educate them with limited success (after all who am I compared to the all knowing nursing instructors). Then I went to a passive agressive - see how not doing the order works out for you. Now I suggest that they discuss this with their clinical instructor. This seems to be more productive as it is usually results in a quick apology from the student accompanied by the nursing instructor behind them either rolling their eyes or steam coming out of their ears (depending on the instructor). So I educate but in a different way:smokin:.
The "independence" thing is more annoying than anything. Its taught as an article of faith that it means something. In reality any autonomy that a provider is a complex interaction between regulation, policy and demonstrated ability. Once you have been doing this a while most providers understand this. Some never get it.
I realize that I am VERY late in joining this forum discussion and perhaps my comments will have already been stated and addressed. That being said....
I have been licensed as an RN for 20 yrs, the past 10 of which have been as an FNP.
My circuitous journey included enrollment and attendance at one of the country's first BS PA programs, a change to pre-med, and eventually completion of a BSN program (after enrolling and dropping out of a different BSN program several years earlier). After practicing as an RN for 7 yrs and being extremely disillusioned and disappointed in the nursing profession, I examined graduate school options (specifically MD vs DO vs NP). Again, to my regret today, I chose what appeared to be "the easier, softer way"....an MS and certification as an NP. Hindsight being 20-20, I would have chosen MD or DO, if I knew then what I know and have experienced now.
This has been a journey of youth, with impulsive decisions and high idealism.
IMHO the following specific real-world practice differences exist:
MD/DO programs and residencies: the primary focus of learning and care delivery is in the acute care setting, though rotations include various subspecialties, very little time is actually spent within the realm of primary care. (As an aside: As a new NP graduate in 1999, I worked in a Family Practice where the full-time MD mentored 3rd year IM residents during their 3-day primary care experience. One day, the MD that was the then Chief Resident of the large urban medical center was there for his primary care experience and said the following to me after spending 45 minutes with his head in textbook while I saw 3 patients "If someone comes to me with an acute MI, drug overdose, or a gun shot wound, I know what to do for them, but I have no idea how to treat sinusitis or an ear infection".
I realize this example only represents an IM resident and personally think that an MD/DO in a Family Practice Residency program would receive considerably more primary care/ambulatory care experiences.
PA: most programs mirror MD/DO programs, only on shortened time scale. They have subspecialty rotations and what is probably more exposure and training within the primary care field during those experiences.
MSN NP program: These programs have clinical experiences based entirely within the area of concentration. For primary care specialties (FNP, ANP, PNP, GNP) the clinicals can occur in all settings where primary care is delivered to their respective pt populations.
Acute care NP: these programs, obviously, have clinical experiences that occur in the acute care setting NOT in the primary care arena.
Therefore, it has been my experience that a Master's prepared primary care NP is better educated and equipped to provide primary care. I believe that MD/DO would be MUCH more able and proficient, due to their training and education, to provide complex care of patients as a specialist/subspecialist, which would make better use of their credentials. A PA has the background education and training to be quite versatile in many arenas.
Now...my thoughts on DNP... It's about time. We are late to jump on this band wagon and I believe that this should have been the entry credential for NP's since the beginning. (Not that I will go back and get one, however, when this does nothing for me professionally or financially).
On a different note:
My experience has been that MD/DO are MUCH more accepting of NP's as primary care providers and peers than Nurses.
Nurses are the reason that I cannot STAND my profession.
I was actually going for P.A. but decided against it, and hope to become a NP. From what i've read/ heard and from NP's i have talked to at my local hospital, can practice without being under a doctor(unlike a p.a. who needs to always be under physician supervision) personally, i like the idea that i can open my own clinic, office, whatever and be an independent practitioner, can specialize (p.a can enter just about any specialty, but can't become a specialist (ex: a pediatric nurse practitioner (PNP) (the diffference shows in pay, too), and i would personally be very proud of myself to hold that masters or doctoral degree to my name (p.a can get a masters, but that's only really for a p.a. if they want to teach, doesn't affect their salary or anything involved with practicing as a p.a) And yes, P.A have more clinical hours than an NP, but then again, as an RN you get real life experience and i think that's something you can't a true feeling for until you're actually on the job. But then again, i think P.A. is the easier route because all you need to do is complete the pre-reqs for the program of your choice and apply. But to me, they both seem similar, only NP seems to have mroe perks :)
I was actually going for P.A. but decided against it, and hope to become a NP. From what i've read/ heard and from NP's i have talked to at my local hospital, can practice without being under a doctor(unlike a p.a. who needs to always be under physician supervision) personally, i like the idea that i can open my own clinic, office, whatever and be an independent practitioner, can specialize (p.a can enter just about any specialty, but can't become a specialist (ex: a pediatric nurse practitioner (PNP) (the diffference shows in pay, too), and i would personally be very proud of myself to hold that masters or doctoral degree to my name (p.a can get a masters, but that's only really for a p.a. if they want to teach, doesn't affect their salary or anything involved with practicing as a p.a) And yes, P.A have more clinical hours than an NP, but then again, as an RN you get real life experience and i think that's something you can't a true feeling for until you're actually on the job. But then again, i think P.A. is the easier route because all you need to do is complete the pre-reqs for the program of your choice and apply. But to me, they both seem similar, only NP seems to have mroe perks :)
And the PA profession thanks you for your informed decision making:rolleyes:.
Hey everyone! I'm new to this site and still am trying to get my bearings about how things work on here.. I do have a few questions though for anyone who would be willing to answer! :nuke:
First off, I originally started off as a marketing major at a 4 year college, but after the turn the economy took and two years into my major, I took a risk and decided to switch into a nursing. I'm currently in my first year of an RN program at my local community college. I've already started to look at RN-MSN programs and am very interested in the NP programs. However, my friend is in a PA program and it seems as if these roles are quite similar..is there anyone who could tell me the difference between NPs and PAs?? I know that there are some difference that vary by state guidelines, but what exactly are the differences?
Also, I love working with kids and have been considering either a FNP or NNP specialty. Are either of those areas stable as far as jobs go? What are the most reliable specialties for NPs? And is there an experience requirement (like the one for CRNA programs) before entering an NP program?
Thanks so much for any help/advice anyone may be able to give me! I appreciate it greatly!! :redpinkhe
sirI, MSN, APRN, NP
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