Differences (Educative/Clinical) between NP & PA

[jstuben]

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?

Thank you very much!

[mango-lo-maniac]

I do not know of any states that allow NP's or PA's to do lumbar punctures, but they can perform intra-articular and trigger point injections. PA's can work in surgery, but a NP must complete a "first assist" course (9 hours online, 6 full days of training and then assist with 15 surgeries). I do not know of any NP programs that include the "first assist" courses in their programs, but all PA programs do. As far as lumbar injections, you would have to become a nurse anesthetist to perform those and it would depend on your state's laws as to whether you could actually practice independently and bill for those services.

Actually, learning to do lumbar punctures is standard in most PA programs. I don't know for certain, but I imagine that NPs who work in emergency med do LPs as well.

Also, depending on the setting, PAs (maybe NPs, too??) can do lumbar injections. "BlocDoc" at the PA forum is an RN/PA who works in pain management. I think he's a member here too, but less active. Anyways, he's a really approachable guy and could elaborate much more than I ever could on the topic.

Physicians DO have ownership of PA's. PA's will NEVER be able to practice independently because the State Medical Boards will never allow it!

I certainly don't foresee independent PA practice, but I wouldn't say that PAs are "owned" by physicians. Like "collaboration", "supervision" has many different interpretations. Indiana is to PAs what Georgia is to NPs. We can't prescribe there, and while a doc doesn't have to be physically present during PA practice the physician must review every chart within 24 hours. But North Carolina is PA-progressive, somewhat analogous to New Mexico and NP practice. NC PAs prescribe schedule II-V (30-day limit for Sch II), and supervision is a meeting once every 6 months. PAs can also own their practice in NC.

summary of PA practice regulations

[Osiris55]

I certainly don't foresee independent PA practice, but I wouldn't say that PAs are "owned" by physicians. Like "collaboration", "supervision" has many different interpretations. Indiana is to PAs what Georgia is to NPs. We can't prescribe there, and while a doc doesn't have to be physically present during PA practice the physician must review every chart within 24 hours. But North Carolina is PA-progressive, somewhat analogous to New Mexico and NP practice. NC PAs prescribe schedule II-V (30-day limit for Sch II), and supervision is a meeting once every 6 months. PAs can also own their practice in NC.

summary of PA practice regulations

Personally, looking at it from a pt. perspective I'd be a little worried about seeing an NP that doesn't have ANY physician oversight at all. I've looked very hard at NP programs and such and have been very drawn to them, but I can't see how a mid-level would be able to practice without a physician going over a sampling of charts every x months. I don't understand why that is a bad thing.

One of the reasons I was turned off by PA programs was that I had always thought they had a greater degree of oversight then NPs. It just seemed silly to me to train someone to do all this stuff that allows you to be a physician extender but requires you to go running to the physician every 10 minutes. It is interesting to learn that there are states with less oversight. In fact I just checked with that link and I see my own state, NH, has what seems to be almost the exact same regulations as NC.

Now I'm really thinking about which one would be better for what I want to eventually do. Not that I'm anywhere near the point of entering either type of program, but what before was a one sided decision (If I wanted any independence I'd need to be an NP) has been given a new, and very intresting, dynamic.

[brownrice]

Mango-Lo-Maniac:

Can you please share the address of the PA forum website?

Thanks.

[mango-lo-maniac]

The main PA forum is www.physicianassociate.net. The sister site, for PAs and NPs to discuss issues of mutual concern, is www.clinicanforum.com.

[Danielle4]

osiris55

I am glad to hear that you have decided to consider PA school which will give you another option. I think it is really smart to consider several options.

I agree with you 100% when also when you say about being worried about seeing an NP with no supervision. I agree ANY mid-level trying to practice medicine without it is bad news. I don't think a NP/PA should have to carry all that legal strain on them in the long run the doc is the only one that went to med school and they get more paid for it- let them do it. I think NP and PA's are completely capable of handing medical cases and all, but they should have a doctor to consult when needed for sure. It does not hurt to have someone check your charts- the medical field should have tons of checks and balences just like our government. I think it makes the healthcare TEAM better.

My doctor employs 3 PAs who all work independantly (all work when she is not in the office) but they all have pagers, etc and can always contact the doctor. I have complete confidence in all my healthcare providers in that respect and I trust them. I also trust them in that if they don't know what to do they will ask the doctor and as a patient I feel I trust them with my life and I feel that a midlevel practitioner owes it to their pts to feel like they can go to a doc if need be.

mango-lo-maniac thank you for enlightening us with your knowledge. I was really interested to read your posts.

I agree DocBloc is a really nice guy who is very approachable! He is very knowledgable about his field. He even has his doctorate and has done a fellowship that only usually doctors do because he is such a brilliant PA-C. I have not talked to him much but from what I know about him he is genuinely very nice. you should definitely ask him questions if you are interested in pain management.

[Josh L.Ac.]

Thanks for your repply,Cyndee,MSN,NP!

I've considered PA route also after leaving the med school. With all my pre-med prereqs, and NO BSN, PA could be a faster route, but I gather not neccessarily a better one.I've been an RN for 15 yrs now. "Crossing over" to another profession, rather than advancing one I'm in now, and basically starting from scratch..... . And all for the first assist thing.I'm a lot more interested in PM&R, cronic pain and fatique, fibromyalgia type of patients, rather than slicing someone open. I'm quite happy with what I do with acupuncture, but I haven't been able to truely blend it with my RN. So I thought may be NP would give me that edge of the decision making.

Thanks again

I finished my acupuncture master's degree a year and a half ago, and I felt like to practice I really needed to know more conventional medicine, so I am going to an accelerated BSN then NP school.

I know it is off-topic, but I am curious how long you have been doing acupuncture and what problems you had attempting to integrate it with your RN. Thanks.

[Papadoc]

I finished my acupuncture master's degree a year and a half ago, and I felt like to practice I really needed to know more conventional medicine, so I am going to an accelerated BSN then NP school.

I know it is off-topic, but I am curious how long you have been doing acupuncture and what problems you had attempting to integrate it with your RN. Thanks.

Hi Josh,L.Ac!

I've been practicing OM since 2001. At first I wasn't trying to blend two professions. Then more and more patients started to ask me something like..."you rae such a bright guy, why don't you go all the way to be a doc?"etc.I was already an RN for a while, and finally it got me. I've applied to 3 major off-shore schools (in the Caribbean), got accepted to all 3:rotfl: (much to my surprise).Another thing that triggered this shift was interacting with too many doctors who were certified in Acupuncture with 200 hours or less:eek: of some home-video training. I've gotten many patients from these who went to these doctors, "tried" acupuncture and "it didn't work":angryfire for them:chuckle .What was more troubling for the business aspect is that many insurance companies would reimburse "certified" acupuncturists (MD/DO), but they wouldn't consider a licensed acupuncturist (L.Ac) with more then 4000 hrs training (core, electives, herbology,outside externships with Master-Practitioners).So you get the picture. The only gratifying experience was that if patients did come to me and tried real acupuncture (and different styles I'm trained in) they usually did "180" on "it doesn't work":D I guess I decided to become a part of the system rather than trying to fight it, and off I went to the med school.But that's a whole different story. In retrospect, IMHO if you want to do Acupuncture ond OM only you really don't need to have more of the Western medicine training, provided that you had basic bioscience credits, requiered for licensure by your State.I already had my RN for 10 yrs by the time I've got my M.S. in A&OM.But I don't want to tell you the wrong thing...like "don't do NP training." If that's what you want to do, then by all means go right ahead.But just like in my case becoming an MD, so I could incorporate acupuncture better than my compitition does...simply silly. The truth is there is only so much time, and as you become busy, and a better practitioner, you simply won't be able to concetrate on so many things in your practice. I can see it now. Doing it for a sake of "blending" something that doesn't really mix would be a mistake, IMHO.

Have a good one:)

Happy New Year!

[brownrice]

Hey Josh:

For a sample of what an integrative practice can do, search for kahala natural health center on the web. This is a Naturopathic Doctor who also has an acupunture license, which was not earned in 200 hours, but the real way! Her practice in Hawaii is very successful, but....

In my opinion, being an NP would be an even better mix. You are then bridging Eastern and Western philosophy...how powerful! And, you carry more credibility with the folks involved in the existing standard, Western Medicine.

I would encourage it.

[Papadoc]

Hey Josh:

For a sample of what an integrative practice can do, search for kahala natural health center on the web. This is a Naturopathic Doctor who also has an acupunture license, which was not earned in 200 hours, but the real way! Her practice in Hawaii is very successful, but....

In my opinion, being an NP would be an even better mix. You are then bridging Eastern and Western philosophy...how powerful! And, you carry more credibility with the folks involved in the existing standard, Western Medicine.

I would encourage it.

Hey Brownrice!

I'm glad you've mentioned the great State of Hawaii, because it's the only State in the nation that doesn't let other professions to sneak in the licensed profession of Acupuncture through the back door. So good for the N.D who had to sweat just like everybody else to earn their degree. I wish that most States would adopt such a hard line. It really serves and protects the public.

I for one couldn't just take 200 hours home-video instruction in medicine or surgery (no tests, no licensing exam) and just practice it.The problem is that many ppl who are involved in the law-making take the reductionistic approach to the whole Orintal Medicine complex, treatin it like a "modality" to "complement" the existing Western medical model.That view, by and large, is being pedaled by AMA and such. It's very frustrating for us in the profession, how everybody is trying to rip it to shreads, by some turf war, to make a few quick bucks:angryfire.And the OM movement itself is deeply devided in this country, and does not have a unified voice.

As for Josh getting into the Western medical model by all means do NP,although, if you ask me...If I haven't been an RN already, I'll just go straight for PA. Please don't flame me.I'm an RN myself, but to get your NP will take you 4-5 yrs (gotto have RN first), PA is 2-3yrs, and very much "get to the point" thing.

Anyway, it's your call.

Goodluck

[Josh L.Ac.]

Thanks for the replies. In my home state of Kansas (where I am moving back to in June for school), MDs/DOs can get licensed by the state to do acupuncture with no training, while the state doesn't license real acupuncturists. Oh, and DCs can practice with 100 hours of training. After I graduated from Bastyr university, I did an internship in China, where I had the pleasure of witnessing a group of medical acupuncturists completing their 200 clinical hours. Now the Chinese seem to be all about pain when it comes to getting acupuncture, but these poor folks were the first people that the MDs had ever needled. The MDs didn't even practice on each other during their intensive 100 hour courses! After word got around the hospital, we had to get our translators to tell the patients that we were supposed to treat that we were not MDs and actual acupuncturists. But hey, I guess the MDs are sold the whole medical acupuncture idea so why would they question it? [/off topic]

Anyway, I am going the NP route for several reasons...and it should only take 3 1/2 years (1 year accelerated BSN, 2 1/2 years NP program). I looked into several PA programs, and while they looked a little higher speed in terms of didactic and clinical requirements, the NP degree should give me more autonomy to practice how I think I should practice. But I could always be wrong.

[ICRN2008, BSN, RN]

Hey Brownrice!

but to get your NP will take you 4-5 yrs (gotto have RN first), PA is 2-3yrs, and very much "get to the point" thing.

Goodluck

This was my major consideration in going back to school to be an NP instead of a PA. Many PA programs require that you quit your job to complete the program, and this was not an option for my husband and I because of our mortgage, etc. Going the NP route is taking longer (1 year prerequisites, 16 months BSN, 1 year of nursing, and then 2 years of grad school for NP). However, I am able to work and pay my bills in the meantime. I was only 24 years old when I started, so time wasn't a major consideration for me.

I never took into consideration whether being an NP was better than a PA or vice versa, because everyone I've talked to has told me that either route would get me to my goal. I believe that both NPs and PAs are excellent clinicians (I have experience with both), and it is in our best interest to work together to promote our mutual interests.

[imisscoco]

I will graduate in June with my Master's in Nursing, and this summer will sit for both the Adult Primary Care Boards and Geriatrics, and hopefully I will pass both and be dual certified as an NP. I have been an RN for 30 years this summer. There are 45 students in my class. All have at least BSNs and none have been RNs for less than 5 years, most longer. PAs and NPs alike practice the medical model. It's just the way it is. And both are supervised by physicians. People come into each profession through different doors. Don't kid yourself. There are GEP programs (graduate entry pathways) for NPs now, where in 3 years you can become an RN, then NP. I thought this was a terrible idea, until I met some of the students in the GEP program at my university. Some GEP students have maturity and life experiences that make them better practitioners than nurses in the traditional programs who have been practicing for years. And some don't. It all depends on the individual, and the program. My program wants us to think that NPs practice in a nursing model. My preceptors have been very upfront with us and have told us the truth, which I am finding in my clinicals this year, and we are indeed practicing in a medical model. There are good NPs and PAs and bad ones. Practice with integrity, whatever you do, whichever path you choose, but come together as health care professionals, value what we have in common, and stop nitpicking the differences. I am sick to death of this argument.