Nurse Practitioner or Physician's Assistant?

core0 · Feb 21, 2010

Sorry, I refuse to believe that any PA's are making a quarter of a million dollar salary, unless they are working as partners in some mega-million dollar plastic surgery clinic or something.
PA training is NOT the equivalent of MD training minus the residency. MD's have an entire year of Anatomy - first year is basically spent dissecting a cadaver. PA's, like NP's are taught the cliff's notes version of a medical education, enough to make them able to handle a range of mainstream cases within a specialty.
David Carpenter pointed out a salary survey that showed that the difference between PA and NP salaries was about $5,000 on the whole. The 95th percentile in both was very high, the median in both was $70k-$90k. There's just not that much difference.

The mean cardiovascular surgery salary in 2008 was $110k. The standard deviation was $28k. If this was normally distributed the 95th percentile would be $166k. Between the 97th and 98th percentile would be $200k. So are there PAs making more than $200k? Yes but they are the minority. I would guess around 100 if you include some of the other specialties (plastics and surg onc). In actuality New York salaries are in the bottom half for states (although its probably Bimodal NYC vs upstate). The PAs that I know that are making that kind of money are in California and Nevada.

To reply to Guest2 one thing the PA profession has determined is that they are not going to move to the practice doctorate. This is official AAPA policy and supported by PAEA. There are a number of reasons for this but the principle one is that the profession remains competency based. 10% of the programs are still certificate or associates programs. There are currently two PA specific doctorate programs. Wake Forest has a PA/PhD program and Baylor runs a DPAS postgraduate program for the Army.

David Carpenter, PA-C

bajasauce07 · Feb 21, 2010

He's right, It's not equivalent to MD training, it is the same model though, but I think you guys are a little confused. PA's do dissect a human cadaver.

bajasauce07 · Feb 21, 2010

oh, and as far as salary, mean salary across the nation 2 years ago was $89,950. There are actually some PA's that make 250K but you could probably number those on your 2 hands. I've also heard of some PA's taking jobs for 65K

bajasauce07 · Feb 21, 2010

EQUUZ, as far as this comment:

"Your suggestion that NP's need to know every arcane disorder in family medicine is ludicrous. Would you trust an oncologist to deliver a baby, or an OB-GYN to treat lymphoma? How about a dermatologist running a code? Sure, they learned it in med school, but that doesn't mean they would or should try to treat something they haven't practiced since. "

You are right, it's impossible to memorize every arcane disorder, neither can one learn all of them. But you need to be able to recognize a good bit of them, of course OB/GYN docs don't remember pulmonary arcane disorders, I'm in internal medicine, so the strangest thing I know about in OB is a molar pregnancy (which as we all know can metastasize to the lung), but does the OB know a lot of arcane disorders in their field? The dermatologist could darn well recognize a sezary syndrome, or the derm manifestations of Crest, of course. I would be hard pressed to find any midlevel who even knows these disorders exist

My point is not that NP's cannot practice medicine. Only that it is ludicrous for them to imagine that they can practice without a physician. Yes there are NP's that might be better than MD's but that is not the norm. there's a reason they have 12 years of medical training as opposed to a midlevels 4. PA's are moving toward a doctorate as well, with half of the profession resisting that change. It's silly, if you want a doctorate in this field, be a doctor. Midlevel degrees ought to stop at the masters level.

nurseman78, BSN, RN, NP · Feb 21, 2010

I would be hard pressed to find any midlevel who even knows these disorders exist
My point is not that NP's cannot practice medicine. Only that it is ludicrous for them to imagine that they can practice without a physician.

Well, they do, haha. I wonder how many actually do, though. I suppose if you've been practicing for 10-15 years, why not? You probably know the ropes by that time.

There's a reason they have 12 years of medical training as opposed to a midlevels 4.

Right. Physician's obviously have more medical training than a midlevel. They are the authorities.

It's silly, if you want a doctorate in this field, be a doctor. Midlevel degrees ought to stop at the masters level.

I agree completely. If you want to be the authority on medicine, be a doctor. Don't be a mid-level and spend all your time trying to make yourself look like a physician. If you want the title, do the time and the work. If you are a mid-level, accept your limitations and move on.

And honestly, what's with the doctorate level degree? Maybe a three year master's. But honestly, if I have to spend 4 years of my life in grad school to be a mid-level, why don't I just go to med school?

bajasauce07 · Feb 21, 2010

exactly, one thing I want to point out, though just to drive my overall philosophy:

"Well, they do, haha. I wonder how many actually do, though. I suppose if you've been practicing for 10-15 years, why not? You probably know the ropes by that time. "

I am a midlevel with 2.5 years in the workforce, I know what these things are I LOVE studying about them, I've made quite a few diagnosis that my attendings/supervisings didn't even think of, but that in no way qualifies me to be a doctor. The main problem I have with any midlevels wanting to take the role of an MD is that just because you can do the easy stuff, that does not make you an independent provider. And if you have no idea what the disorders I mention are, you have no business being independent in this field. Everyone argues "oh, we wouldn't be "independent" when we don't know what to do we would refer, just like the docs!" well why not let a highschool student with a textbook open a clinic and refer to an NP when they were confused? it's the same rational? He works in "collaboration" with those better trained than him.

The fact is that, even though his patients may LOVE him, and he would be quite adept at titrating BP meds and Diabetes meds, There are a few patients that would have something weird. He wouldn't know, he would draw on his limited knowledge banks and treat them as a common disorder (as most rare disorders start that way). The patient would happily accept his treatment, after all, he's done such a good job with his z-packs and lisinopril! Diagnosis would be delayed, since most rare disorders are invariably fatal, the patient and the family would accept nothing else could have been done when the patient finally died. However, if the disorder had been diagnosed a year prior, perhaps therapy could have granted him 5 more years with his family. Who's to say though? the highschooler would not understand what they did and feel no guilt because, when the symptoms became severe enough he did the appropriate thing and referred, right? It's the same rational that all midlevels pushing for independence have and it is irresponsible to the patient and to your profession. They are all too willing to throw patients under the bus of ambition.

They also argue that with enough experience they'll be ready, well guess what: even with 10-15 years experience, an MD with 10-15 years experience will be that much better, just because an NP can compare themselves to a new grad and have a few more concepts under their belt doesn't qualify you to play doctor!

I'm not arguing against you SAMWESTONPOTTER, just helping clarify things for anyone else reading this who doesn't get it yet.

EquuszARNP · Feb 21, 2010

My point is not that NP's cannot practice medicine. Only that it is ludicrous for them to imagine that they can practice without a physician.

Ludicrous? I beg to differ. Many NP's practice medicine "without a physician". And in many states, like mine, the law is very clear that the NP is independent and is held accountable independently.

The fact is that, even though his patients may LOVE him, and he would be quite adept at titrating BP meds and Diabetes meds, There are a few patients that would have something weird. He wouldn't know, he would draw on his limited knowledge banks and treat them as a common disorder (as most rare disorders start that way). The patient would happily accept his treatment, after all, he's done such a good job with his z-packs and lisinopril! Diagnosis would be delayed, since most rare disorders are invariably fatal, the patient and the family would accept nothing else could have been done when the patient finally died.

You mean like happens with so many primary care physicians as well? I think you're being fairly insulting to the mid-level practitioner (NP or PA) by saying that their knowledge is so "limited" that are only good for titrating meds. PCP's misdiagnose rare disorders as common disorders all the time. In the ideal situation, the PCP refers the patient with a rare disorder to a specialist so it's caught and correctly diagnosed. The NP or PA should do the same. Part of being a good diagnostician is recognizing when there is a parameter or finding that differs from the diagnostic group of a common illness. The NP (or PA) doesn't have to know that this particular strange finding means this particular arcane disorder, what he or she has to know is that this particular strange finding is outside the usual findings of the common illness he or she would otherwise be diagnosing. Then the patient gets referred to the specialist physician. Yes, a responsible NP or PA would probably make that referral earlier than a primary care physician, but it's the same goal in the end. And the NP is independent until that point is reached. At least, that's what makes sense to me.

They are all too willing to throw patients under the bus of ambition.

As are some primary care physicians who insist on keeping the unusually-presenting patient instead of referring them to a specialist. Simple pushing for independent practice does not mean the patient's quality of care gets sacrificed. In the end, it comes down to the humility and cooperative spirit of the individual provider, whether NP, PA or physician.

--Equusz

caffeineRx · Feb 21, 2010

well, i graduated with an associate's degree, and passed my nclex in january. i've been working in an ltc since feburary. i have an opportunity to return to school, and i've already been accepted to a local college to complete a bachelor's in nursing. this is the quandry i am in. i'm realizing that nurses are not respected or well treated, and i don't like it. i don't know how long i'll be able to put up with it. i have been headed toward nurse practitioner. is physician's assistant a better goal? what are the differences? is the same amount of schooling from associate degree rn?

first off, good for you for realizing what you want in life. i am also realizing that this profession is abusive. it's sad because i really want to help people. however, make sure you move around, first, before coming to a solid decision. perhaps it is your facility alone, maybe you are not in the specialty you flourish at the most. :)

both professions generally require a masters now. there are, however, pa programs that are bachelors programs. however, most places would like a masters degree.

pas are paid more and they can jump around to different specialties. i believe, though, that they must always practice under an md.

nps generally make a little less, but they seem to have a bit more autonomy. i have also heard that nps can make significantly more should they open up their own practice.

have you been accepted to a pa program yet? :clown:

wannabecnl · Feb 21, 2010

Very, very true, Equus. Not every physician is a good diagnostician. We had a primary care physician whom we eventually left because he failed to diagnose three conditions, none of which were particularly complicated (in every case, we went in with a clear idea of what we thought the problem was, and in every case, we turned out to be right). First he misidentified a rash I had on my leg, and I wasted 2 weeks exacerbating it with the wrong meds because he refused to believe that I could be right about what it was (stupid me for believing him and not just changing therapies!). Then he refused to send my husband for an ultrasound when he started having ab pain, preferring to blame my husband's weight and then deciding he had a lactose intolerance (despite NO history of this). After a year and a half of fruitless visits to this doc, it got really bad one night, we went to the ER, had the u/s, and LOOKY LOOKY, hubby had horrible gallstones! But the final straw was when I called with a terrible sore throat for 3 days and was told to stay home because it was obviously viral and they wouldn't treat it anyway. 3 days later, when it hadn't resolved and I couldn't even drink a sip of water without feeling like I was swallowing gravel, I begged my way in, listened to him tell me it couldn't possibly be strep, and then switched to another doc when the rapid strep came back positive.

I'm not saying that NPs are expert diagnosticians, but frankly, neither are PAs, and neither are some physicians. This was not an incompetent fool of a doctor; he was a primary care physician with plenty of experience who just didn't acknowledge problems outside his comfort zone (not to mention listening to his patients). Every tier of medical care requires people to be competent at their level of responsibility and refer to someone else when it gets beyond their scope of practice or expertise, from LNAs to surgeons. I've watched this debate rage for weeks now, wanting to weigh in with examples of what I'm learning in my pharmacology class (nursing masters program), good and bad experiences with NPs and PAs (some of both for both), etc., but this was just too much. Sure, a nurse practitioner right out of school hasn't had to perform the level of diagnosis that he or she will master after a few years. But neither has a PA. And BTW, what do you call a guy who graduates last in his medical school class? Doctor.

nurseman78, BSN, RN, NP · Feb 21, 2010

There are obviously a lot of egos in health care, which is unfortunate. From how I see it, you have an opportunity to give excellent care in whatever profession you go into, be it PA, NP or MD/DO. You also have the opportunity to be an egotistical jerk and not listen to anyone but yourself, putting yourself before the patient.

Again, I reiterate, "the health care provider you want to be is the one who knows what they don't know." In the end, it's not about how great and knowledgeable you are, but about taking care of people.

laurentrilli · Feb 24, 2010

my 2 cents worth: I just had a NP do my annual physical and she was great! I'm not easily impressed; I'm in med school, the oldest in my class. if I ever go into primary care, I hope that I'm as good as the NP that did my physical. is she a doctor? mo, but she has a doc to back her up. and let me tell you this: most MD's are less than enthusiastic about treating "routine", boring issues like HTN, obesity (I'm overweight) etc.....I work with a PA (surgical) and NP's (last rotation). I'm happy that a NP is basically in charge of my health...........

bajasauce07 · Mar 30, 2010

Medicine has EVERYTHING to do with how knowledgeable you are and NOTHING to do with how nice you are. It's just good to be nice as well. As far as the comment above about NP vs PA? You can come out of training as either an NP, PA, or MD and be a moron. It's all up to the individual. I have not touted PA's as masters of diagnosis, I do think the training is different and I prefer the methods of the PA way, but my argument has been, and will likely always be, that midlevels should not practice independently.

Of course, as someone pointed out, NP's do practice "independently," depending on how you define that. But it's irresponsible. We all have a place in healthcare, but if you want to be the boss, be the MD. You don't learn construction and then try to practice as an engineer.