I read sometime ago on a different site a ...

debate concerning if it was better to become a Physician's Assistant, or Advanced Practice Nurse. Those who advocated the PA path referenced the fact that many MD's preferred working with PA's who were trained in the "medical school" model of patient accessment rather than the "nursing school" model. What are the salient points of departure between these "models" of patient accessment? Furthermore, what are the supposed advantages and liabilities of each approach?I have been unable to find hardly any relevant information expanding upon this topic.

Sincere Thanks,

[loisane]

Roland,

Is it important to you what MDs prefer? I don't mean to be flip, but think about what you are really asking.

So what if MDs think theirs is the best way. Do YOU think its the best way?

This could lead to a huge philisophical debate. I know the prevailing view has been that "health care" means "medical care". But I think there is a difference. The most excellent of "health care" is interdisciplinary.

I am an advanced practice nurse, and I believe in the inherent value of nursing care. APNs are not "physician extenders". PAs are physician extenders.

APNs function autonomously on their own license. They are responsible for their own action, and accept the attached liability. PAs function only under the direction of a physician. The physician accets the responsibility and liability.

You can't really say which is best. We need both in the overall health care system. Which is best for you personally as a career choice depends upon which suits your own goals.

Of course there are other issues to consider besides personal philosophy. For instance, financial concerns. You could compare salaries in your area. CRNAs can do their own billing, form their own groups, etc. Which makes the earning potential large. But the other side of the coin is you are taking a greater risk and responsibility than if you work for someone else.

You raise many good debatable issues with your question. Maybe more than you intended Good luck with making an informed decision.

loisane CRNA

[meandragonbrett]

Loisane,

How do you pronounce your name?j\w

Brett

[Roland]

existed substansive differences in "patient accessment" training between doctors and nurses. Until I read that persons post I was unaware that such differences even existed on something so basic as patient accessment (sorry I cannot even remember the board on which I read the discussion it was about a year ago). After reading that such differences in training DO exist, I was left to ponder WHY, and perhaps even more importantly what are those differences. To me patient accessment like all elements of medical care should to the extent possible be based upon "the best" methods as established by objective research. Since I am only a first year BSN student my knowledge in this area is scarce. I was hoping that someone more knowledable than myself could delinate what these differences might be. Furthermore, I had contemplated the possibility of supplementing my formal nursing education on "patient accessment" with self study along the lines of the "MD model" (whatever that might be!).

I couldn't at this point begin to debate which approach is better (or if indeed there exists an actual substasive difference). Thanks for the input!

[loisane]

Ah, yes---------research. A good word. How about another good word?----------theory.

I know-------groan. But it applies here. One of the reasons theory is important is to justify that what nurses do is "nursing" and not just "helping the doctor".

I believe the comment you noted, that started this thread, was really a veiled critisism that APNs are doing "doctor's work" or that they "want to be doctors". The person was implying that only physicians can do a real patient assesment. That patient assesment by a nurse is not as good, because it is grounded in nursing theory, not medical theory.

There is really another, even deeper level to this debate (Are you still with me?). What the person was actually complaining about is that APNs are not under the MDs control, like a PA is. And the biggest issue of all is money. APNs can bill independently (CRNAs can, and the others are making progress). Meaning they are in direct financial competition with MDs. PAs pose no such threat because their practice is dependent on the MD.

Now you might begin to see why your investigation into two types of assesment did not yield any results. It really is a bigger debate than patient assesment skills.

You are just beginning your entry into nursing. Much of this may be of little interest to you now. But tuck it away in the back of your brain. These are issues of great importance, that will affect you later.

But for now, know that all those theory and research classes are important, no matter how abstract they seem to you now. Learn all you can about NURSING. If you want to learn about medicine, make sure you are really doing what you want to do. (And remember that "medicine" is not all there is to "health care") If you learn all you can about patient assesment from all the books, instructors, experienced RNs, ICU nurses, APNs, etc then you will learn to perform excellent NURSING assesments.

Thank you for allowing me to use your quesstion to get up on one of my favorite soapboxes. I know I turned what you thought was a simple question into a philosophy exercise. But if even a few nurses in cyber-land stayed with me enough to at least give this some thought, I think it can help our profession.

loisane

[Roland]

it is grounded upon this thesis. All "medical service providers" whether they be doctors, nurses, radiographers or labratory technicians exist primarily to serve their customer which is ultimately the patient. Therefore, ALL practices should be determined based upon how that can best be accomplished. In some circumstances objective research as to the best approach is difficult. However, with regard to patient accessment and certain other issues (I remember for instance reading a debate several years ago concerning the relative efficacy between several cardiac "clot buster" medications, I think they were streptokinase and TPA. Research eventually indicated that both were equally effective however the streptokinase was much cheaper) the scientific method should be more than capable of elucidating the "statistically best" approach with regard to patient outcomes.

Indeed, part of my curiosity with regard to this issue emanated from my desire to learn IF the poster was in fact expressing a sincere concern (that is to say if he/she was REALLY interested in differential patient accessment approaches practiced by AP nurses and PA) or instead used this criticism to veil their other actual concerns (such as the ones you mentioned).

To the extent that nurses differ from other health professionals (such as PA's) in the administration of health services we should be able to defend those practices with research that validates our approach. Nursing theory if fine so long as like any theory it continues to be supported by research and experimentation. Furthermore, one must exercise care that long held theories or practices do not degenerate into unquestioned dogmas.

[alansmith52]

Research, while absolutly required is not often viewed in the same light by all professions. Even if there were some objective peice of quatitative research there would be to many factors.

The independant variable would be easy ie. the doctor or nurses physical assesment. but, the dependant varible would be disgusting. you would have age, medical history, diagnosis, culture, relgion, sex, on and on and on. the research couldn't even be done in one project.

Say hypotheticaly there was peice of research like this (wich would cost millions and millions). and say that it yeilded an outcome that said doctors or nurses did the better assessment. The next one hundred years would be spent debating wheather the research was even valid. One group would obviously say it was good reseach while the other would fight it with all their power.

Would it change patient care? likely not. only one thing changes patient care and thats money. when it comes right down to it. The people really making decisions don't care about pateint outcomes. their priorties come in this oder 1 make money, 2 don't get sued, 3 look noble to the public.

there is group who makes decisons that does care about patient out comes and like it or not thats JCHO (Joint commision) and they have done a rescent study that shows the nursing shortage is causing bad outcomes. that is good for nursing.

[lgcv]

O.K. I am going to open myself up to a massive flame here.

My entire nursing career I have thought of nursing theory as ridiculous.

We make up new names for old problems. We say we are treating a "different" aspect of the patients disease. We say that by doing so we are providing an infinately different, yet neccesary mode of therapy. We provide treatments which are clearly medical in nature yet call them by different names, while trying to lay claim to them as nursing interventions.

Originally nursing diagnosis and interventions were developed as a means to promote third party payment for nursing services. I don't think there is a third party payer out there that provides reimbursement for "fluid volume excess" and resultant interventions, or any other nursing diagnosis.

Most of the theory is psychosocial in nature and has limited value in the treatment of patients.

My belief has always been that by doing this we do a disservice to the profession of nursing. When we call CHF anything other than what it is we look ridiculous. When we talk about the theory of providing nursing care, from this psychosocial standpoint what are we acheiving? In my opinion we are conveying that we do not have the ability to deal with the intricacies of the disease processes and treatments, so we cover the superficial aspects of it. This is not true of most nurses, we can, and do regularly deal with medical problems from a medical standpoint and do so successfully.

Off my soap box here, let the flames begin!!

[Roland]

the scope of my original question. My "gut" tells me that much of the nursing theory trend "may" have been forced by doctors who basically legislated themselves a monopoly (in passing laws forbiding the practice of medicine without a license). However, I think in actual practice much of nursing can be defined as the implementation of medical care where as doctors provide the theoretical basis for the care which is to be implemented. Of course this is a gross generalization, and like all such generalizations falls short of defining the physician/ nurse/ patient relationship accurately. In any case this issue if far beyond the scope of my current knowledge base, thus my rantings are largely conjecture.

However, my original question involved this relatively simple, and straightforward question. ASSUMING someone is beng totally sincere and makes the following statement: Physicians prefer working with PA's trained in the medical school model of patient accessment instead of AP nurses trained in the nursing school model. What are they in fact saying IF again they are being sincere. What are these differences?

Thanks for all the great input!

[kmchugh]

1. Physicians are generally not "being sincere." The fact is (as already mentioned) that a licensed PA still cannot practice unless under the direct supervision of a physician. Nurses, on the other hand, can hold a nursing license, and can practice nursing, without "benefit" of a physician. Hence, PA's are under the thumb of physicians, and cannot generally disagree with physicians. Nurses, on the other hand, practice independently of physicians, and their jobs (usually) do not depend on the good will of the physician. This simple fact has been a burr under the blanket of the AMA for years. Simply stated, most physicians want everyone in the health care community to be "under" them. Many long for the return of the day when nurses stood up when physicians entered the room. So, the question is flawed. The statement "Physicians prefer working with PA's trained in the medical school model of patient accessment instead of AP nurses trained in the nursing school model." may be better restated "Physicians prefer working with PA's whose licenses depend on physicians, and are therefore subservient to physicians, over nurses, who have independent licenses, and are therefore not under the physician's thumb."

2. Igvc and I are in agreement where nursing theory is concerned. Most nursing theory is merely an academically reworded statement of the obvious. The one glaring exception is Roger's theory of unitary human beings. This "theory" was obviously conceived while stoned on hash, and fleshed out in full at the height of an LSD trip. At best, it is more a metaphysical treatise rather than a scientific theory. That's the problem with many "nurse scientists." They cannot tell the difference between religious belief and solid scientific theory.

Feel free to flame.

Kevin McHugh, CRNA

[lgcv]

To to the basic question of patient assessment.

You do a head to toe physical assessment if your a MD, PA, or a nurse.

What is elucidated in that assessment has more to do with experience and attention, than with the type of degree the person performing the assessment has.

The forces behind the statements you read were very clearly explained by Kevin, so I will delve no further.

[AL bug]

I am probably going to be banished from the nursing world, but here goes. I have since day one of my nursing career thought of nursing theory as irrelevant. I may be just too lazy to exericise my brain enough to think how the theorists think. Kevin, I agree about Roger's theory...I have always called it the "space cadet theory". I can't believe the woman actually got paid real money to come up with that crap nor that we force people to learn it in nursing school. Why? It does not behoove a nursing student to learn theories such as that. I also agree with the statement that most nursing theories are rewording of the obvious, like..."the nurse should take on the role of the patient helper while the patient is not able to care for himself". Well duh. Those kind of thoeries are probably why I think they are irrelevant. I can spend my time better by learning to do something real, like keep someone alive while they undergo surgery. Ok that's my $0.02

I cannot begin to tell you how many changes I would make to a nursing program if given the chance. It is rediculous that we have to actually teach "nurses" how to be nurses when they get out of school. 4-5 years while getting a baccalaureate degree is plenty of time to get the basics of nursing. I have precepted several senior nursing students and new grad nurses who don't know how to do a head to toe assesment. And it could be argued that maybe they were learning how to interact with families and do the holistic blah blah blah, but we all know that real nurses better get their stuff together quickly and learn how to take care of the patient. couldn't help myself...another $0.02