Don't Hate Me, All....

Trauma Columnist · Aug 5, 2009

No bashing here - we welcome lively debate.

elkpark · Aug 5, 2009

This all seems like a phoney selling point that is SO subjective that there is no way to argue it, putting NPs in a position which is easy to defend and impossible to refute.
Thoughts?

Well, my first thought is that the proof is in the pudding, as the saying goes -- if that argument is a "phoney selling point," then it probably won't get NPs v. far.

Sheri FNP-C · Aug 5, 2009

I don't know if it is the previous nursing experience or my relative lack of NP experience, but I do think there is a difference. There are good MDs, PAs, and NPs just like there are bad MDs, PAs, and NPs. However, there is something I see in myself and many (not all) of my NP friends. We may all prescribe the same medication for OM, but rather than hand the script to the family on there way out the door we discuss cost, antibiotic overuse and how that relates to the need to finish all the abx, side effects, when they should note improvement, etc. All of this before the patient asks! There is a place in healthcare for NP, PA, and MD providers and I would not say one is better than the other. When I worked as a nurse, during a code I couldn't care less how empathetic you are and how good at anticipatory guidance you are...I wanted a competent provider there regardless of credentials!

I do think NPs, most likely by incorporating the nursing model, do treat the person/family not just the disease. There is so much more to a simple OM when the miserable child who hasn't slept in 2 nights is cared for by a single mother, working 1+ jobs, has other kids to care for, little if any support, etc. I, and I think most NPs, see that other side in our patients. By empathizing with this mother and offerring reassurance that the child will recover sooner rather than later and the wonders of Tylenol/Motrin so her life and sleep cycle can return to normal we are caring for the patient/family in addition to the disease. Not something I even think about, it just happens. As I said, I have no proof, but I tend to believe this is due to our previous nursing experience. This is not something I saw very often with MDs or PAs. Not to say never, just not often as opposed to NPs where I see it pretty consistently.

No hate here...I will be interested to read others responses.

TakeBack · Aug 5, 2009

Well, my first thought is that the proof is in the pudding, as the saying goes -- if that argument is a "phoney selling point," then it probably won't get NPs v. far.

I'm not so sure. If PAs can provide equivalent care to MDs/DOs- which there is evidence to support that I've seen for diabetic populations- then how do we prove that their efficacy (how "far" they get) is due to simply matching docs in the practice of standard western medicine vs this nebulous character of treating patients holistically?

JDCitizen · Aug 5, 2009

Oh fun, fun.... I get to rant

First: Is this just another political, turf protecting kind of thread???

The subjective/objective interpretation of holistic treatment will vary from provider to provider and patient to patient...The perception of holistic treatment will vary from provider to provider and patient to patient...

The very way this thread was introduced will influence the responses...

The title of the person introducing this topic will influence the responses...

The titles of the people responding will influence the responses...

The place where this thread was introduced will influence the responses..

Background, motivation (political, religious, career loyalty, etc.), training, experience(s), and/or the direction the wind is blowing in Bermuda could/can effect the perception one gives or one sees of treatment standards delivered.

Lets put holistic into context: Doctor/NP/PA, male or Female age.. etc...

Does a man do a better prostate check than a woman? Does a woman do a lady partsl exam better than a man?

Which one does a better prostate check a doctor or NP or PA ...

Which one does a better lady partsl exam a doctor or NP or PA ...

Now ask the patient in the end who was more holistic? Do you think the size of the providers fingers might have anything to do with the patients response? Did the provider forget the KY?

This is soooo old but just comes in different flavors:

MD vs DO

MD vs PharmD

Surgeon vs non surgeon

RN vs NP vs PA vs MD vs DO vs…..

RN (diploma, ASN, BSN) vs each other

Male provider vs Female provider

Old vs young

Experience vs no experience

etc..

etc...

etc....

In the end it does not matter what we say here or in the PA forum or any forum... We can argue, we can rant and rave... Someone is eventually offer us all some cheese and crackers to go along with all the "whine."

Now for the break down:

Nursing perspective: Heck yes there is such a thing that is usually why the patient asks the nurse for an explanation after the doctor leaves. That’s why the patient often looks at the nurse when the doctor is in the room...

Treat the patient, not the disease.. and what’s wrong here??? We are all probably guilty of not doing this.

Look at the patient as a whole... and what’s wrong here??? We are all probably guilty of not doing this.

Offer prevention as well as treatment.... and what’s wrong here??? We are all probably guilty of not doing this.

If you don't have a nursing degree the discussion about a nursing perspective is well in your terms; subjective. Its actually very subjective when discussed inside the nursing profession itself.. The nursing perspective varies from nurse to nurse. The nursing perspective is complex and the seed was first planted for the most part when we all were in our first nursing programs... Experiences of all types during and after school will have had influence on that perspective. In the end we as nurses were taught by nurses who were themselves taught by nurses.

Treat the patient not the disease, look at the patient as a whole, offer prevention as well as treatment.... Do we all do it all the time? Does any field of practice do this more than the other? Is this taught in any one program than the other?

In 25 years of practice: There is always someone better. I am not always right. Sometimes no matter how hard I tried or how good I thought I was: The patient got mad, the family got mad, one of my fellow staff members got mad and/or the doctor got mad. Regardless of anyone’s actions or inactions patients lived and patients died... In end it usually all boils down to if the patient is not happy no one is happy.. If the patient is getting better for the most part that is all the patient cares about all the fluff and stuff is just extra..

My disclaimer: I bring a very varied medical training background to the table. I have multiple years of experience. I have been on the receiving end on life sustaining medical care. I have seen the best and maybe not the worst (but probably close) that the medical conglomeration has to offer.. I have very good friends that cover most every field of medicine from research to teaching to hands on... We have been talking about "who cares more" and "who gives better care" for years. When we are dead and forgotten the discussions will still be going on...

Oh my do I dare admit it: My training came from paramedics, doctors, nurses (of all flavors), PA’s the patients and their families.

Last thoughts:

Do you want to know what a specialist is? A specialist is a patient (and probably their family member) who has a disease. That one disease and the multiple exposures to the internet, the library, and multiple healthcare providers..

Now when any of us make when we make rounds and examine a patient and think we have the whole picture.. Just go ask the tech what he/she noted/found out during the bed bath that morning.

In the end it is a team approach or not... We all have to decide.

TakeBack · Aug 5, 2009

I don't know if it is the previous nursing experience or my relative lack of NP experience, but I do think there is a difference. There are good MDs, PAs, and NPs just like there are bad MDs, PAs, and NPs. However, there is something I see in myself and many (not all) of my NP friends. We may all prescribe the same medication for OM, but rather than hand the script to the family on there way out the door we discuss cost, antibiotic overuse and how that relates to the need to finish all the abx, side effects, when they should note improvement, etc. All of this before the patient asks! There is a place in healthcare for NP, PA, and MD providers and I would not say one is better than the other. When I worked as a nurse, during a code I couldn't care less how empathetic you are and how good at anticipatory guidance you are...I wanted a competent provider there regardless of credentials!
I do think NPs, most likely by incorporating the nursing model, do treat the person/family not just the disease. There is so much more to a simple OM when the miserable child who hasn't slept in 2 nights is cared for by a single mother, working 1+ jobs, has other kids to care for, little if any support, etc. I, and I think most NPs, see that other side in our patients. By empathizing with this mother and offerring reassurance that the child will recover sooner rather than later and the wonders of Tylenol/Motrin so her life and sleep cycle can return to normal we are caring for the patient/family in addition to the disease. Not something I even think about, it just happens. As I said, I have no proof, but I tend to believe this is due to our previous nursing experience. This is not something I saw very often with MDs or PAs. Not to say never, just not often as opposed to NPs where I see it pretty consistently.
No hate here...I will be interested to read others responses.

I think this is where the bias- against providers trained in the medical model- comes into place. Your first paragraph reads to me that PAs/MDs ARE simply handing the script from the doorway and out the door without answering questions. Good medicine involves knowing your therapies and how they interact with the patient- including if the pt will be compliant, how it will work into the social situation.

Why is it that medical model trained providers are presumed out of hand to lack the ability to include this in their practice? Why is it presumed that they "hand the script to the family on there (sp) way out the door"? This is a prejudice against physicians, and perhaps PAs, that we don't take the necessary time to discuss important issues like "cost, antibiotic overuse and how that relates to the need to finish all the abx, side effects, when they should note improvement, etc"....this is BASIC medicine, not something exclusive to nursing. I know that there are in-and-out the door docs, but to brandish us all with that label, and set NPs aside as a standard of excellence in that respect, is highly stereotypical......

TakeBack · Aug 5, 2009

Oh fun, fun.... I get to rant
First: Is this just another political, turf protecting kind of thread???
No. As a CTS PA, I have little to no turf to protect from NPs.
In the end it does not matter what we say here or in the PA forum or any forum... We can argue, we can rant and rave... Someone is eventually offer us all some cheese and crackers to go along with all the "whine."
Now for the break down:
Nursing perspective: Heck yes there is such a thing that is usually why the patient asks the nurse for an explanation after the doctor leaves. That's why the patient often looks at the nurse when the doctor is in the room...
In my 12 yrs I have not seen this to be the case. And that includes a lot of rounds. Not to say it hasn't happened with you, but your experience is not the norm.
Treat the patient, not the disease.. and what's wrong here??? We are all probably guilty of not doing this.
Look at the patient as a whole... and what's wrong here??? We are all probably guilty of not doing this.
Offer prevention as well as treatment.... and what's wrong here??? We are all probably guilty of not doing this.
Agree. We all engage in this, so there is no objective superiority to it regarding NPs.
If you don't have a nursing degree the discussion about a nursing perspective is well in your terms; subjective.
Admittedly so.
Its actually very subjective when discussed inside the nursing profession itself..
Good to hear!
The nursing perspective varies from nurse to nurse. The nursing perspective is complex and the seed was first planted for the most part when we all were in our first nursing programs... Experiences of all types during and after school will have had influence on that perspective. In the end we as nurses were taught by nurses who were themselves taught by nurses.
Treat the patient not the disease, look at the patient as a whole, offer prevention as well as treatment.... Do we all do it all the time? Does any field of practice do this more than the other? Is this taught in any one program than the other?
That's my contention.
In 25 years of practice: There is always someone better. I am not always right. Sometimes no matter how hard I tried or how good I thought I was: The patient got mad, the family got mad, one of my fellow staff members got mad and/or the doctor got mad. Regardless of anyone's actions or inactions patients lived and patients died... In end it usually all boils down to if the patient is not happy no one is happy.. If the patient is getting better for the most part that is all the patient cares about all the fluff and stuff is just extra..
My disclaimer: I bring a very varied medical training background to the table. I have multiple years of experience. I have been on the receiving end on life sustaining medical care. I have seen the best and maybe not the worst (but probably close) that the medical conglomeration has to offer.. I have very good friends that cover most every field of medicine from research to teaching to hands on... We have been talking about "who cares more" and "who gives better care" for years. When we are dead and forgotten the discussions will still be going on...
Oh my do I dare admit it: My training came from paramedics, doctors, nurses (of all flavors), PA's the patients and their families.
Last thoughts:
Do you want to know what a specialist is? A specialist is a patient (and probably their family member) who has a disease. That one disease and the multiple exposures to the internet, the library, and multiple healthcare providers..
Well, a nice take on the verbiage but inaccurate nonetheless. Using the term specialist is clearly situation dependent. I trust the patient more than the provider to rate their cancer pain, but I trust the surgeon more than the patient (or their family) to perform a cholecstectomy.
Now when any of us make when we make rounds and examine a patient and think we have the whole picture.. Just go ask the tech what he/she noted/found out during the bed bath that morning.
In the end it is a team approach or not... We all have to decide.

And I certainly don't see any PAs (and likely a good group of MDs/DOs) arguing against the team apporach. Physicians still must consult amongst each other. PAs/NPs do as well, whether referring to collaborative/supervising physicians or requesting spec consults.

Team medicine seems to be a somewhat separate issue from the distinction that NPs, by nature of a nursing background, offer a "brand" of the practice of medicine (nursing if you insist) which results in superior 1) patient outcomes when compared to docs/PAs in controlled comparison or 2) patient satisfaction......

Sheri FNP-C · Aug 6, 2009

You seem to have missed the part about good providers and bad providers. Handing a patient a script is they walk out the door is bad, regardless of your credentials. I will reiterate that in my limited experience (about 10 years as an RN, including 3 years in hospital management, and only a couple months as an NP) my perception has been that most NPs provide family-centered holistic care versus a much smaller proportion of MDs/PAs that do the same. I agree with you, considering extranous factors when treating a patient is very important, though I don't think all providers feel that way. There is a huge family practice group in my area where the MDs/PAs/NPs all see 40+ patients in an 8 hour day. There is no way I will ever believe that any provider there offers individualized care-they couldn't begin to in the amount of time they spend with each patient. For my patients that I see every 15 mintues for non-preventative (including sick visits and even quick ear rechecks), 30 minute preventative, and 45 minute psych/adhd/developmental concerns, etc. I can and do. That was important enough for me to turn down some other positions that didn't seem like they would allow me the time to provide the level of care I want to provide.

The perception is my community is that if you want a caring, competent provider-hire an NP, if you are willing to sacrafice a little bed side manner to get a more intensively trained individual-hire a PA. Trust me, I would like NPs and PAs to be considered equals here as I am not a fan of belonging to the group with inferior training. Just as I am sure you wouldn't want to be classified as one with less bedside manner due to your credentials. I actually had an MD and practice manager that I interviewed with tell me that they were glad I was an NP rather than a PA b/c they wanted someone that was nice even though it would take me longer to "get in the swing of things." Wow...that was an inappropriate statement on so many levels! I wonder if midwives and OB docs have this same issue...one being considered more caring, one more competent.

Anyway, you are right, I am biased. I am a mom so I think moms are better than dads. I am in my 30s so I think it is so much better to be 30-something than a 20 year old "kid." I am tall so I think being able to weigh more than someone six inches shorter than me and still having the same BMI is great. I am an NP, so I think NPs are the best! You feel the same about PAs, it is great that we both have pride in our professions!

TakeBack · Aug 6, 2009

You seem to have missed the part about good providers and bad providers. Handing a patient a script is they walk out the door is bad, regardless of your credentials. I will reiterate that in my limited experience (about 10 years as an RN, including 3 years in hospital management, and only a couple months as an NP) my perception has been that most NPs provide family-centered holistic care versus a much smaller proportion of MDs/PAs that do the same.

I agree that good and bad providers pervade medicine, but repsectfully decline the notion that patient-oriented care is specific or even significantly more common in NPs. I wonder if there are pt satisfaction surveys in the literature that support this, or if there an even a way to measure it. Not a "call-out", I would love to see that literature if it exists. If it truly is impossible to measure in a good objective way, then the discussion begins and ends with "well, we think we do a better job b/c of nursing background/etc"....

I agree with you, considering extranous factors when treating a patient is very important, though I don't think all providers feel that way.

How? In PA/MD training, the H&P is drilled in from day one. The importance of the social situation and the patient's nonmedical circumstance impact diagnosis and treatment just as much as the CT results or the blood cultures. Again, I know that all PAs/MDs/NPs don't practice these skills with excellence. I also don't see (yet!) how NPs can claim with such authority...to the extent that it is a major marketing point to patients.....as a way to contrast themselves with physicians and PAs.......that they, well, "care more". And that's what it boils down to.

The perception is my community is that if you want a caring, competent provider-hire an NP, if you are willing to sacrafice a little bed side manner to get a more intensively trained individual-hire a PA.

This is what really gets me. It's all right there. Patient preception- NPs care, PAs don't.

I would not want to associate with the premise that you promote your own profession by painting another in a bad light. That PAs and physicians lack bedside manner....is this really what it has come down to?

Trust me, I would like NPs and PAs to be considered equals here as I am not a fan of belonging to the group with inferior training. Just as I am sure you wouldn't want to be classified as one with less bedside manner due to your credentials. I actually had an MD and practice manager that I interviewed with tell me that they were glad I was an NP rather than a PA b/c they wanted someone that was nice even though it would take me longer to "get in the swing of things." Wow...that was an inappropriate statement on so many levels! I wonder if midwives and OB docs have this same issue...one being considered more caring, one more competent.

And this is a common thread I see on the PA forum. NPs have fewer clinical hrs of training and are claiming superiority as providers. Well, the NPs argument is that their previous nursing experience adds into/"subsidizes" those clinical hrs. The counter is of course, PAs have 2000 - 10000+ hrs previous health care experience before PA school (although unfortunately more and more PA programs are accepting PA students with minimal previous HCE..a bad trend that many of us PAs disagree with....

Anyway, you are right, I am biased. I am a mom so I think moms are better than dads. I am in my 30s so I think it is so much better to be 30-something than a 20 year old "kid." I am tall so I think being able to weigh more than someone six inches shorter than me and still having the same BMI is great. I am an NP, so I think NPs are the best! You feel the same about PAs, it is great that we both have pride in our professions!

The reason I posted this thread is that I don't think that PAs are the "best". There's good and bad in all groups. The NPs I work with are great and they are an asset to their (and my) practice. All these groups have their role, just as there are MDs and DOs that have separate pathways, and have had their differences but function identically in many settings.

I have yet to see evidence that NPs are superior for the above mentioned reasons. Why not be satisified in providing equal care as MDs and PAs without drawing distractions that create unecessary animosity, and are clearly not true in many situations.

JDCitizen · Aug 6, 2009

sorry but i wanted to keep this together and the site wouldn't let me

jdcitizen [/url]