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...

I chart as I see patients as well, but that doesn't leave much time for answering messages, going through transferred records, dealing with labs, dx results, writing and reading referral letters, refilling meds, FMLA and disability paperwork. So, admin time would be great, especially since the MDs in my practice get it.

I'd love to get admin time, but I don't. I'm expected to see patients for 40 hrs/week. This aggravates me since the docs in our practice get 4 hours/week and I usually see more patients than they do. Our medical director is working on getting the NPs admin time, but for now there isn't any.

For the record, I have my MSN from an online program from a brick and mortar school and I've been actively recruited by the military and yes they do use FNPs, CRNAs, Psych NPs and I believe CNMs as well. Family Nurse Practitioner (66P) | GoArmy.com Nurse Corps | GoArmy.com

I'm in Ohio and as long as my collaborating agreement states that I can prescribe medications for off label uses, then I can. I do it all the time. I'll use gabapentin for pain syndromes (already mentioned) and restless leg syndrome and beta blockers for migraine and anxiety, also I've had good results with sertraline for men with premature ejaculation issues. All of these are off label uses, but are very common. If there is proof it works I see no reason not to prescribe it.

I don't have much to add, but will say that out of my 15 years of nursing experience prior to becoming an FNP, the last 14 years were in OB. I won't say that med surg/ICU/ER experience wouldn't have been beneficial, because in many ways I think it would have been, but I did well in school and passed my boards without any problem. If you love OB, go for it and if you eventually want to be an FNP, go for that too. Good luck

I don't work in pain management, but due to lack of this specialty in my very rural area see way more of these patients than I would like. Most of the time a referral to pain management gets a patient 1-3 months of appts at the specialist and then they are referred back to me because they are stabilized on a pain regimen. This usually includes some type of schedule 2-3 med. Obviously, Georgia is much like Ohio where I practice as I cannot write for schedule 2 meds. So, what I do is see the patient, evaluate how they are doing and then go to my collaborating doc and discuss with him/her what I think. Since we have a good working relationship, they will refill the schedule 2, or rarely if needed increase the dose/frequency for the patient. In my note I simply state something like: Consulted with Dr. Collaborator and he agrees that refill of percocet 5/325 as the patient is stable on this medication. My collaborating doc then prints/signs the script and I send the patient on their way. I suppose in states with restrictions like mine and your APNs in Pain managment do much the same. They assess and plan and then consult with their collaborating doc who then prescribes. I also use this for other meds I cannot prescribe in Ohio, such as ADHD meds and some antidepressants.

I worked OB in a rural hospital with the same staffing you mention for 15 years. We did drills. It was part of our yearly re-orientation/safety training. It's like any other mock code and we used the hospital's old full body dummy as our patient. Someone is the moderator who explains what is going on and then you role play the rest. We did have an emergency kit for hemorrhage. It had IM methergine, Hemabate and cytotec, plus pitocin in it along with syringes and 2 liters of IV fluid, IV start kits and other assorted items. It was kept in a locked box that could be grabbed if you needed it.

They need your FINAL transcript. You said you sent one August 1, but finished August 12, they need a transcript from after you graduated.

Wow! I'd LOVE to only be expected to see 70-80 patients/week. I see between 20 and 25 patients a day, with an occasional slow day of 15-18. At my current rate of seeing patients I might make the first hurdle to bonus (there are 2, the first of which is the # of patients/half), but I haven't been there a full bonus cycle to see if I will. I do know that the other NP in the office sees a few more than I do and she does bonus.

I want to point out a couple of things. First, you sound like you will have to be working and going to school at the same time. You may not be at work for 60 hours, but you will be working for AT LEAST 60 hours/week during this time with class, work and homework. Then when clinicals start you'll be at your job 40 hours and then at clinicals somewhere in the 15-20 hr/week range PLUS homework and class. Second, you want to work "Dr's office hours". I work as an FNP in a rural FNP practice. I work M-F and my first patient is scheduled for 8:15, which means I am at work no later than 8:00, my last patient is scheduled for 4:45. Most days I'm at least 30 min behind. So I see that patient at 5:15, if it's an easy, acute thing (it's supposed to be, but isn't always) I'm done with that patient by 5:30. Then there are phone messages that I need to address and critical lab results that need to be dealt with and any documentation that I didn't have a chance to finish. I usually leave the office at 6:30. My days are 10.5 hours long. I often work through lunch, or eat between patients. The other providers in the office (2 MDs and 1 other NP) do the same, so this isn't just me. That comes up to about 50 hrs a week. My point is, if you want a 9-5 job, working in an office probably isn't going to be what you think it is. Also, there I days I wish I could go back to 3 twelve hr shifts. I wish I could give report to the oncoming shift and not worry, but it doesn't work that way. I go home and worry about patients, worry that I missed something or ordered the wrong tests. I don't do this obsessively, but it does occupy my mind sometimes. My kids are teens, but if they were young I wouldn't see much of them. I still leave around the time they do for school and when I come home it's still dinner, homework for them and bed (usually for me before them). Also, sometimes I have charting or messages I need to finish from home. I make myself leave at 6:30 so I can see my family at home. I'm not saying don't do it, but I am saying you might not be realizing how much time you're going to have to invest to graduate with your NP, while working or how much time "office hours" actually take. I love my job, but there is a lot to be said for only working 3 days a week and having 4 days to yourself.