How is the NP role different from MD

[abcdefg]

Hi,

I started my FNP program this year, part time and have not yet begun clinicals. But I'm already getting worried- it seems like NP's diagnose, treat and chart just like MD's do. They say NP's see mainly 'routine' illnesses but I'm quickly realizing it's not always that straightforward. The medical knowledge base is so vast, I'm not sure how we can be expected to function the way MD's do with only a fraction of the training. Can some practicing NP's out there tell me in what ways there job is like/unlike a full flegded MD?

[core0]

And doctors will continue to earn double what NPs and PAs make. Even with an extra 100k in debt, 160k/yr vs 80k/yr is a no-brainer, the doc comes out way ahead in the end.

Not necessarily. It depends on what the specialty is and when they enter the workforce. Take an RN that has done all the pre-reqs for med school. Say they are making the $60k per year (salary.com). Now lets project that same person going to medical school and NP school. Let assume that they can work enough to support themselves in school and school costs $60k (to lay out a number). Assume they make $40k while going to school. So the cost of the education is $60k and they make $80k while in school for a net of $20k for those two years.

Now take the same RN as a medical student. Most medical students do not work or work very little. So there is no income and the expense of school plus living expenses. The average student debt is $130k according to the AMA and it is not unlikely to see graduates of some schools with more than $200k of debt. Lets use no income and $130k. So the net after four years is -$130k so the RN is already $150k in the hole here.

Now the RN is out of school and lets say they take a job as an NP at the average salary according to Advance which is $81k. At the end of medical school the MD is -$130k while the NP is +$182k (school + 2 years work). For a difference of $312k. Now the MD goes to residency. Lets say they get $40k per year in residency. After a three year FP residency the MD is +$120k, while the NP has worked three more years and has made another $243k. The difference is now $435k.

Now the FP starts work. The average FP salary in the US is around $150k depending on where you look. So the difference is around $70k per year. It will now take the FP 6.2 years to catch up. So from time zero the Physician will catch up with the FNP 13 years after starting medical school.

This assume a number of things. That the FNP does not get any raises in the time that the MD is medical school or residency. That the MD makes at least average salary. If you look at a scenario where the NP is making toward the top of the salary range (around $100k) and the FP is making toward the bottom ($110k) then it takes the FP 43 years to catch up. Worst case scenario they may never catch up especially if they enter medical school when older.

Never underestimate opportunity cost.

David Carpenter, PA-C

[westcoastgirl]

what an excellent breakdown David!

I think it is up to each mid level provider to seek out an environment where they are comfortable with their role, and balance that with their future career growth needs. I always have MD backup, that was one thing I was firm on when seeking a job as a recent graduate. A seasoned NP may prefer a NP-only practice instead.

In my personal experience the PAs have been very good at teaching me how to draw a line in the sand, they seem stronger negotiators and will not hesitate to say this pt is not appropriate for them to see. It's pretty scary to be sure, balance clear boundries with your own professional needs.

I have seen job postings for FNP to do mostly gyn and non-OB women's health, basically they needed a female NP to do those annuals in otherwise all male MD practice. Now that role can be a lot less daunting, but over time would you be satisfied with that role? Could you really grow in that job past 5 yrs?

[amzyRN]

Where I am in CA, in SF to be particular where UCSF is located, there are many opportunities for NPs and PAs in a wide variety of settings, including acute care, and surgery for PAs. I'm not sure that NPs are in surgery yet. I don't think so though. So if a PA or NP is in SF, there are more than just OB type jobs. So it must depend on what state you work in. I'm a little surprised to hear that things feel daunting given the level of training that NPs and PAs get (especially PAs lengthly clinical rotations) plus the medical experience that the RN or who ever may have had before, which does help. I really think that the mid level practitioner in general is very well trained and I emphatically and enthusiastically endorse that road to providing health care. For me, who does have pre-med course and could have gone the MD route, it seems like the best option time wise and money wise. If I prefer the medical model then I can go the PA route. And if I were in the ER, I wouldn't be asking to see credentials, I'd have to trust that I was in good hands and I'd know that experience goes a long way including for NPs and PAs that probably already have medical experience. I think that some people believe that because MDs have to do so much training and so much education that that is required to do certain duties and that is false. Years ago, physicians did a lot of things that nurses do now. Imagine if things stayed the same and MDs were still hanging IV bags, how would that work? Now NPa and PAs interpret tests and diagnose certain illnesses and help in complex cases with the help of physicians, because physicians will always have a role to guide care. With enough guidance NPs and PAs through experience can gain what the some of the skill that these same physicians have without going through med school. Why is that wrong? Why must there be a rigid line between MDs and everyone else? I think a lot of it comes down to confidence in ones intelligence and training. I have a very strong science background, like other people here, and want to go to a very good school for graduate training in either NP or PA or both and if I have that I don't think I'll have reason to doubt my abilities. I think if the training is good and the basic material is there, there shouldn't be a problem.

[n_g]

Why must there be a rigid line? Because people's lives and well-being are at stake. Why must airline pilots require so much training? Because people's lives are at stake.

[jjjoy, LPN]

jzzy88 - (on an aside here) I've seen you regularly argue that NP training is definitely sufficient for safe, effective practice. However, I understand that you're not yet a nursing student. How closely have you reviewed the curriculum of nursing programs? Have you ever audited any nursing classes?

I went into nursing school assuming that it would prepare me to be able to at least minimally function in an acute care setting. But the difference between school and reality was way bigger than I'd ever imagined. I was also disappointed that it didn't seem very scientifically rigorous. Yes, new developments in nursing care & theory are based on research studies, but the physiology & pathophys covered from a nursing perspective felt rather superficial to me, compared to other science courses I'd taken.

Perhaps more importantly, though, many nursing programs these days just don't have that much clinical experience that mirrors anywhere close to even the minimal responsibilities of a full-time floor nurse. Look at the first year nursing boards and notice how sorely unprepared many new graduates feel; how many change jobs and feel totally incompetent despite doing well as student nurses.

I'm sure there are great NP programs out there. And hopefully, most of them are doing a better job preparing students for the transition to full responsibility than many RN programs are these days (again, not all programs, some really are great.)

Yes, graduates will eventually learn what they need to know on-the-job. The question is how much training should they have prior to being allowed on-the-job. I think this is one of the major concerns in regard to NP education.

I definitely think it's possible for mid-level provides and advanced practice nurses to function perfectly well. I've no issue there. But I am concerned that some nursing programs as they currently stand might not be as robust as they could be, especially those programs training nurses who don't already have expertise in their area of study.

I challenge you to move beyond the theoretical possibility that NP programs can sufficiently prepare their students and get more specific information on the actual curriculums that are being used out there as well as how well prepared graduates feel during their first year out & how successful graduates are in their first forays in the real world as practitioners.

[NeuroNP]

I went into nursing school assuming that it would prepare me to be able to at least minimally function in an acute care setting. But the difference between school and reality was way bigger than I'd ever imagined. I was also disappointed that it didn't seem very scientifically rigorous. Yes, new developments in nursing care & theory are based on research studies, but the physiology & pathophys covered from a nursing perspective felt rather superficial to me, compared to other science courses I'd taken.

Yeah, I've found that too be true as well. I have a previous degree and my minor was Biology. I was really surprised at the lack of depth of science in nursing school. I supose that you could make the argument that nursing school teaches you what you need to know as a nurse and as a floor nurse you don't need the in depth study. I don't think that's true, I personally feel that the fact that I've had upper-level physiology has helped me out even in clinicals as I've got a better understanding of what's going on with my patient. I can see how everything works together and predict what will happen in a situation rather than just knowing an algorithim.

Bryan

[platon20]

If you look at a scenario where the NP is making toward the top of the salary range (around $100k) and the FP is making toward the bottom ($110k) then it takes the FP 43 years to catch up. Worst case scenario they may never catch up especially if they enter medical school when older.

You're comparing the top 5% of NP salaries vs the bottom 5% of doc salaries (which is most likely to be MDs working part time anyways)

NP salaries are tied to MDs in the same specialty/region. Can you cite a salary survey in the same specialty/region in which MDs only make 10k above NPs? I seriously doubt you can.

You have to use AVERAGES to compare the two, not cherry picking comparisons of top % of NPs vs bottom % of MDs.

[CraigB-RN, MSN, RN]

You're comparing the top 5% of NP salaries vs the bottom 5% of doc salaries (which is most likely to be MDs working part time anyways)

NP salaries are tied to MDs in the same specialty/region. Can you cite a salary survey in the same specialty/region in which MDs only make 10k above NPs? I seriously doubt you can.

You have to use AVERAGES to compare the two, not cherry picking comparisons of top % of NPs vs bottom % of MDs.

I think it's a valid way to make a point. In making hypotheticals you usually take an "extream" view. This is the same when discusing patient scenarios. Again David was pointing out a way to look at things and things to take into account when making those long term career desicions. When I was making my descisions on what to do, I used both best and worst case scenarios. I had ot add the fact that as an RN that started in the late 70's, I might actually make more as a staff nurse than as an ACNP.

But like all postings here, they need to be kept in perspective.

[dilleweed]

Why must there be a rigid line? Because people's lives and well-being are at stake. Why must airline pilots require so much training? Because people's lives are at stake.

I would rather look at the individual (if I"m in a position to take my time!) and how skilled they are. An M.D. after your name does not guarantee superior expertise or intelligence. Ever heard of the saying C=MD? Would you honestly rather be treated by someone who squeaked by in med school with straight C's than a NP with all A's in a doctoral program?

My personal plan to become the best NP I can be is to take charge of my own education. If I don't feel that I"m learning enough on a certain subject, I've got the internet/libraries/experienced practitioners to research. Even now, as an aide in a children's hospital, I do my own research on illnesses I see in the unit because I'm interested. My education is my own responsibility, not that of the program I go through.

[SteveNNP, MSN, NP]

Why must there be a rigid line? Because people's lives and well-being are at stake. Why must airline pilots require so much training? Because people's lives are at stake.

Sounds like a doctor or play doctor or doctor wannabe is trolling our boards......

While it is true that midlevel providers do not get the same number of clinical hours or the depth of education, it does not mean that they cannot be intelligent, effective. evidence-based primary caregivers. As long as there is a system in place that allows for physician backup, why argue that the only safe care is provided by physicians?

[DaisyRN, ACNP]

there are plenty md vs. np vs. pa threads/sites out there. i feel like we should focus back on the original topic at hand... how nps' roles are like/unlike mds'... and how abcdefg's concerns are valid.

abcdefg: being a new acnp, i want to assure you that i can completely relate to your concerns. i am still nervous in my position that i have had since december, but i have an excellent supervising md and i know that should i ever have a question, i can call her or another partner. you can't be afraid to ask for help. i'm struggling internally regarding what i want to know vs. what i already know. i want to know it all right now... but its a continual process that i have to accept. i am learning something every day and know that by the end of the year, i will have a much better handle on things. it just takes time that you have to allow yourself. (*note to self: take your own words to heart).

[PackMule]

I take great comfort in that I can always defer to the physicians I work with when something arises that I am not comfortable with. For example, saying things like, "Yes, I can see that you want to do this, take this med, or have this assessment, but the physicians I work don't agree with that treatment approach and I think you should do this, that and the other first, then you can come back and discuss it with one of my docs". I never feel like I have to be the last word in things if I don't want to. If you want to call that good cop, bad cop, then thats the way we can work things at my job should that become necessary.

Otherwise, in general, we all see and manage pretty much the same kinds of pts-none are really reserved more for the physicians in my practice. Of course there is one of me and 4 of them where I work.