NPinWCH

We are primary providers, but what are we the primary providers of is the question. If we say medicine, then we are going down a path that leads us to be controlled by the MD/DOs, the AMA and the boards of medicine. This is not where I want to go because as I talk to friends of mine who are PAs they are struggling for their autonomy, things that we as NPs already have. I have more autonomy in my state than they do. I agree with Abe and myelin, we have what we have because we ARE nurses,

I want to clarify some of my statements. The PAs I know want independent practice. They don't want to be called Assistants anymore, they want independence, freedom and the ability to practice like NPs. PAs haven't been able to get their independence because they are associated with the AMA. When the only power you have comes from physicians it's hard to break away. How can you stay licensed if your authority comes from the AMA and you want independence? The AMA isn't going to give that control up, they don't like NPs on their turf, which is why they created PAs in the first place. So, while the nursing board lobbied for NPs, the AMA isn't going to lobby for PAs and neither are physicians. Why would you? You don't want more competition... Second, I never said I was equal to an MD/DO, or had equal training to an MD/DO. I said in my family practice setting I do the same job as the MDs I work with. We all see the same patients, we all treat the same patients, refer and consult the same things. I by no means know everything and am the first to acknowledge my limitations. I run things by my colleagues if I have a question and never hesitate to do a quick consult in the hall. The docs do actually ask me or the other NP for advice at times. Sometimes, we NPs have the answer...after all we are the ones in the office the docs refer to the get their difficult patients BPs and Hgba1cs under control with diet, exercise and gasp, yes even medication adjustments. I know my limitations, if I am not sure of something I question, refer or consult. I know that MD/DO have more training, spend more time learning, med school, internship, residency...I get it and I respect you all for it. I am an FNP and I feel that the training I received prepared me well to care for the patient population I see. Could it be that an MD/DO is over-trained for primary care? Possibly. Could it be that the future of primary care may better be served by FNP/PA, with MD/DO as specialists? Could be. There is a VERY, VERY large shortage of MD/DO in primary care as it is...maybe this turf war is a moot point to begin with????

First, there should be a policy for documenting all phone calls and messages. We've all been taught, if it isn't documented, it isn't done and that includes any advice given by any person the receptionist/MA/LPN gives over the phone. So, if a pt calls in a note should be generated in that patient's chart with time, person who called and question/complaint. Then the message should be addressed to you or another provider to be answered. Once answered, that to should be documented in the chart and if a phone returned, med called in, advice to make appt or go to ER given that should also be noted. Second, there should be a policy on about who can give what advice. In my office, if the receptionist takes a call and it is a medical question it is routed to one of the clinical staff, who is a trained MA or LPN, they triage the call and take a message, advise appt or ER or they will ask one of the providers (NP/MDs) if they have a question about what to do. Our receptionists don't give advice, they may take a simple message like, "Ms. Smith would like her atenolol refilled and please send it Walgreens" but they forward questions such as the ones in your post to the appropriate triage person. Third, speak up if you have a problem with someone. If you aren't in charge, go to whoever is. I once heard someone give advice and I went to our office manager and spoke with her, she then spoke with the girl at the front desk, she was actually filling in from another office, she stopped after that and has not been back to help out since. Also, encourage any non clinical staff to ask questions if they have them and thank them when they do. I have had the receptionists come ask me a question that a patient has asked them at the desk at check out and have no problem letting them pass the info along and honestly, the girls "know" the answer, but they always check. "Sally, wants to be sure that if the baby gets a fever it's 1/2 a dropper of tylenol right?" -Yes- "I was pretty sure, but I wanted to check before I told her." I'm always sure to tell the girls, "Thanks for checking and taking good care of my patients." It is a team effort and I want them as invested as I am.

First, your assumptions are probably incorrect. If you are calling to see the NP for an acute issue, you'd be fine seeing the NP. I'm sure they could diagnose and treat you just fine. I see acute and chronic issues daily, from colds, pinkeye, bronchitis to pneumonia. I have had patients complain of gastro symptoms with dehydration and dx acute renal failure, seen pts post fall with dizziness and worked them up and dx anything from benign positional vertigo to concussion to TIA/stroke, and chest pain that has been anything from heartburn, rib fx to MI. I see chronic patients from childhood to 100 years old with anything from ADHD, constipation to chronic renal failure/COPD/CHF/HTN/DM. I manage all their meds and consults and lab tests. I do exactly what my MD colleagues do. I work the same job and I am held to the exact same standards they are. My point is, an NP has seen it in family practice and can dx it. I don't know what state you practice in, but in many states NPs actually have more independent practice than PAs. As an NP in Ohio I can have my own practice, sure I need to have an MD/DO collaborator, but I can hire him and he can be on my payroll. I work under my own license and I can write just about all rx that an MD can. The exceptions in my case at this point now would be certain cancer meds, inpatient IV meds, certain psych meds and certain hormones such as growth hormone. Some I cannot write, some need to be MD/DO initiated and some I only need to discuss/consult with my MD/DO either in person, email or over the phone before starting a patient on before writing the rx. PAs in many states have much more restrictions to their practice (they cannot practice independently), which they are rightfully working to change. They seem to have more freedom, but that is because they have for the most part remained good little soldiers and stay obedient to their MD masters. You have the option to see the MD or NP, you are correct, but you may be doing yourself a disservice by waiting to see the MD. Sure, the cost isn't any different, but you may find the level of service is much better...

As for where I am, it's rural Ohio, not too rural. I'm within 1 hour of Columbus and Cincinnati. The problem is there are still too few psych providers even in the city and when we do get one, they quickly get overwhelmed and leave. Also, IF they accept them, they quickly fill their quota of medicare/medicaid patients, which is the majority of the patients I have problems placing. The waiting lists are 6-8 months for an intake visit. Do you want to live here? Problably not.

I totally agree with the collaborating MD idea, but I also totally get where the OP is coming from. If I had a resource to send my psych patients to then I wouldn't have to treat them beyond my comfort zone, which I very often do. Sure, I can can throw some Prozac at depression, but like that FNP in zenman's comment, I too may miss that Bipolar. (Yes, I have some experience with it now, but it still can be missed if you don't have much history on the patient and only 15 min to make a dx). My most recent example: I have a pt with schizophrenia who currently has no psychiatrist because his retired and no one is accepting new medicaid patients within a 3 hour drive. So, now I'm suddenly responsible for trying to find him care. I was the one who found him care initially and that was only because I had him hospitalized (for the third time) due to suicidal ideation and delusions. He's on medications I've never heard of and I've had to try to figure out how to dose and if I'm even allowed to prescribe. As for my collaborating MD and my complicated cases, he's about as lost as I am. He shrugs and says, "Well, do your best. I trust you."

The only way is to complete the course work for all three and take 3 certifications. So, get a masters in one and pass the exam and then go back and finish up the other course requirements to get the post masters certificate in the others that let you sit for those exams. There are some dual masters programs out there is certain areas such as FNP and WHNP, but you still have to sit for each cert. exam separately.

I'm an FNP, with now 1 yr experience as such, but I had 15 yrs experience as an RN. Most of my RN experience was in L&D. I work in a busy family practice with 3 MDs and one other FNP. I see newborns all the way through 90 yr olds. I do preventative medicine and then I see some extremely complicated patients. Yes, many of them see specialists that co-manage, but let me point out that even then you still need to have a grasp of things. You have to remember, you are the PCP and often, WAY too often, the specialists are not communicating with each other. My practice is rural, many of my patients have no insurance or only have some kind of limited charity care, so I have many patients who can afford to see me, but have no way to afford a specialist, so I am it. I treat some very complicated things...it is me. I may manage to get them in with cardio x 1 for a recommendation, but then it's up to me. I do consult with my fellow MDs and the NP in my practice, who are great and help me tremendously. I also read, research and look things up constantly.

I'll touch on your second question by saying check with your state BON. Independent practice for ANY NP varies by state. The acute care vs. family/primary care debate continues to argued, so I don't know if there is a clear answer. I know in my state, Ohio, the BON has issued an opinion that acute care should focus on acutely ill inpatient, hospital based clients and primary care NPs (WHNP,FNP,ANP, PNP) are just that, providers of primary, outpatient care. This is based on guidelines from the National Organization of Nurse Practitioners Faculties: According to the competencies set forth by the National Organization of Nurse Practitioner Faculties (NONPF),2 the Scope and Standards of Practice for the ACNP (acute care nurse practitioner),3 and NAPNAP,4 acute care nurse practitioners are educationally prepared to provide advanced nursing care to patients with complex acute, critical and chronic health conditions, including the delivery of acute care services, such as those patients found in the critical care areas throughout the hospital. These programs of study do not contain adequate clinical and didactic content to support the ACNP for a broader role in outpatient primary care diagnosis, treatment, and follow-up. In contrast, adult, women, geriatric, family and some pediatric nurse practitioners educational focus is on primary care. For instance, the family nurse practitioner is a specialist in family nursing, in the context of community, with broad knowledge and experience with people of all ages.5 NPs prepared with a primary care focus primarily practice in ambulatory care settings, including family medical practices and women health centers. This environment of primary care is not congruent with the acute care secondary or tertiary care training focus. A lack of congruence between the practice environment and level of expertise results in a decreased level of safety for the patient and increased risk of liability for the CNP.6,7 The Consensus Model goes on to say: The certified nurse practitioner (CNP) is prepared with the acute care CNP competencies and/or the primary care CNP competencies. Scope of practice of the primary care or acute care CNP is not setting specific but is based on patient care needs. Programs may prepare individuals across both the primary care and acute care CNP competencies. If programs prepare graduates across both sets of roles, the graduate must be prepared with the consensus based competencies for both roles and must successfully obtain certification in both the acute and the primary care CNP roles. CNP certification in the acute care or primary care roles must match the educational preparation for CNPs in these roles. There are still some grey areas. Is ER considered to acute for an FNP? Derm may be okay for an FNP, but is cardio ACNP only? No one really knows. So, many hospitals are making their FNPs working inpatient go back and add ACNP and any ACNPs in primary care are being told they need to get their FNP/ANP within a certain time frame. The BON isn't saying fire anyone, but they are hinting that after the dreaded 2015 you may not have a legal leg to stand on in certain situations. All a lawyer has to do is point at the consensus model and say, "It says right here that your training as an acute care NP would not fully prepare you to care for patients in a primary care setting. You didn't certify as and FNP, yet you took care of Mr. Doe in Anytown Family Practice. How can that not be malpractice?...Thank you very much, Mr. Doe here is your $$$$$ check." APN Scope of Practice « Council for Ohio Health Care Advocacy

BlueDevil, how long did you practice as an NP with your MSN before getting your DNP and it what way do you feel the DNP made you a better provider? I also agree that one certifying body is needed and that the bar is low in some institutions, but no one seems to agree on how to improve that. The embarrassment is common in the profession, not just here on AN, but also in real life.

The ONLY reason there is no longer a differentiation between MD and DO is that the DO programs changed to mimic the MD programs. They just included their osteopathic theory and manipulation techniques. I didn't want to go to medical school. I wanted to continue my education and training to specialize in an area of advance practice. If I wanted to be an MD or DO, I would have gone to MEDICAL school and become one. I want to practice at the fullest scope of my practice, but not beyond it. I have been well trained to do what I do, which is provide good primary care to families, but I know my limits, use my collaborating docs as needed and refer when appropriate. I agree, the DNP is still an academic degree, no matter what we keep getting told and I have no desire to go beyond the masters I have to get it because it will in now way help me provide better care to my patients. I might agree that it could help me run a better business, bill better, research better, meet meaningful use better...whatever, but honestly so will a book or conference on those topics.

Well said and I couldn't agree more.

I only want to add that even if/when DNP becomes the standard, MSN prepared NPs won't have to worry about "salvaging" their careers as long as they keep their certification up to date. Believe it or not, but there are currently APNs with ONLY BSN degrees practicing. Why? Because, before the MSN became the standard you could do the job with only a bachelor degree. One of my good friends is a CRNA with ONLY a BSN after his name and he is one of the best anesthesia providers, MD or RN, I have ever worked with. So far, the DNP doesn't add to an APNs clinical skill; I haven't seen a large increase in clinical hours or classes. That may change, but so far it seems to be more focused on setting up business and understanding regulations, insurance and other such requirements. Not that that is bad, but it's not going to make a new NP a better clinician, though it may give them more tools to set up independent practice.

Like other posters mentioned, it does depend on your job market, but I'd add also on your own willingness to do certain work. I've seen plenty of retail quick care clinics that offer PT or even per diem jobs. I've also had plenty of offers for locum type short term 1-3 shifts/week family practice jobs. Those may not be ideal, but they are options.

I'm an FNP in family practice with another FNP and 2 MDs. I provide annual well visits for women on a regular basis and have found early, and not so early cervical cancers and breast cancers. Myself and one of the MDs both do colposcopy as well. This is well within our scope of practice and often the patients get diagnosed and treated much quicker since the waiting lists for the specialist OB/GYNs is quite long. It does not take a specialist to do a pap and breast exam and it does not mean you are getting poor or substandard care if you get this done by someone in primary care. Preventing cancer comes down to getting screened, period...