PA-C, DO

I certainly hope you do not believe that any NP has more medical training than a physician. Shall we compare here? 1) All physicians have a bachelor's degree first, and at least 75% of them have these degrees in hard sciences. Most RN's take the basic A&P, chem, micro etc...and then get their BSN. As much as you don't want to hear this, those hard science courses in undergrad are way more relevant to the practice of "medicine" than are those nursing courses taught in the BSN degree. 2) Medical students go through 4 more long hard years of school, while NP students usually work and go to school at the same time. I don't know any medical students that had time to work. The average NP program has 500 hours of minimum clinical hours, while medical school has a minimum of 6000 hours in years 3 and 4 of medical school. 3) Physicians go through a minimum of 3 more years of residency. Np's do not. I think you will see that there is no way to compare the two. Please don't say things like this as it only fuels the fire in an already touchy debate. I do want to say though that I am proud to know some of you RN's and NP's who feel this push to DNP is just not necessary. As one of you humbly and rightly stated, a DNP will still just be a nurse. I can tell you that this issue is being discussed very cautiously among physician organizations, and presently there are dozens of states with this issue on their legislative agenda. NP's stand to alienate themselves from the physicians who currently employ them, which will not help you gain future collaborative physician agreements I can promise you. When do you think enough will be enough?

Nothing that a good exam under Versed can't uncover

We agree Tenesma

Fergus, you are out in left field. You do not learn pathophys as a resident. You learn it in medical school. You may get some clinical concepts related to path reinforced in residency, but pathophysiology is a basic science of medicine. As a resident, one has already proven that they have mastered the basic sciences by passing the USMLE steps one and two. No NP would be teaching a resident pathophys in residency. They might be teaching some via their vast clinical experience, but lets not try and make it sound like midlevels are routinely teaching residents on service. Don't take this wrong Fergus, but as an RN, you really wouldn't be sure if you were listening to a path lesson or not. You are describing an abnormal phenomenon when midlevels teach residents, and that is not to say it is wrong, because there are many midlevels who are good enough at what they do to teach like this. But this usually means they are not well rounded in the other areas of medicine that the resident has already had to master. That is what makes physicians unique. They have to be responsible for everything. Remember, you can teach a janitor to do a pap smear and have them teach residents to do them as well. But this is not teaching anything other than personal experience and technique, and this is where midlevels excel.

See Randy, we have more in common than you thought. I was a corpsman with Marine infantry for 4 years and spent the entire GW campaign on the ground in a damn hole! can I say that here?? :) I have actually been in the OR with Dr.Cooley when I was in PA school when he was really big at St. Lukes. I have also worked with Red Duke, and I know you know who he is. But I have to disagree with you on one point Randy. NP's cannot do manipulation and certainly cannot bill for it. MD's believe it or not, can do manip and bill for it but most are smart enough to take a course on it first to learn how. After all, DO's take about 3000 hours of OMM in medical school. Crazy enough though, you nurses are starting to grow on me. I do understand much of your animosity toward physicians in general, but there are plenty of us out there who are not condescending and do know who really runs the hospital. :)

Hi Terminator, FP all the way my friend. There are tons of FP residencies that are considered "high speed" in terms of getting you the numbers of procedures necessary to get credentialled to do them in rural areas. It is very common to practice OB and do these minor surgeries as an FP, but it means you are very busy!! We have a general surgeon but he is basically in retirement now, and he comes in to help with complicated procedures or when we get in over our heads. Even a simple herniorrhaphy can go bad and it is not anyone's fault but the anatomy. Take a look at some of these residencies on the AAFP website under "residents" and choose the residencies by state. Some of the best are the programs in Anchorage, Ak, Ventura, Ca, and John Peter Smith in FW, Tx. So do you see what I mean Terminator? No one will ever replace the small town physician, because it would require multiple specialists.

Hey Randall, I appreciate your assumptions about my age and background, but unless you are elderly I doubt you have much up on me. I was putting in chest tubes in combat while you were wiping noses in your white student uniform. Hide behind your shield of knowledge of "normal medicine" but be ready to refer out the patients you simply cannot deal with while perusing your cookbook algorithms of how medicine should be. I have news for you; there are very few patient encounters that follow the book, and you have to be able to think outside the "normal box" to really help your sick patients. And don't assume that the body of physicians in this country do not want to work in rural areas. People like myself (NHSC scholar) have dreamed of going to rural areas to practice small town medicine, and be the one who does it all. You won't find any NP's going to small town America to deliver cradle-to-grave medicine because their scope will never allow it. Can you perform C-sections or do routine OB and deliveries as an FNP? Can you do in office vasectomies, minor OR lap choles, appies, hernias, and even hysto's? Can you do any manip at all? You guys just aren't diverse enough to be able to take over the world of medicine some of us practice in the sticks, no matter how much you want to dream about it. My partner has an NP, and I have a PA. We both agree that the NP is excellent at routine minor care, and even the NP agrees on such. Our PA actually shares call, first assists in the OR, and is quite knowledgable about zebra pathology. The NP sees most of the kids and does literally all the WWE's for my partner. I value the NP and PA alike, but they know their place. Why can't the entire profession be like that? You don't ever see renegade PA factions trying to become independent of physicians, and why? Because they know that even though their schooling is the closest professional equivilant to physician training, that they are still nowhere near capable of being independent.

So nurses fill gaps huh? Don't give me that crap, because if it became popular overnight for docs to want to go to rural areas, NP's would find some reason to feel that they are more qualified to be there. You say you want to fill niche markets where physicians won't go, but your rhetoric is more about convincing physicians and the world that you are just as qualified. And why do you feel the need to lump all physicians into this mold of being inconsiderate, socially inept, uncaring, incapable...???? For your information, MD and DO schools alike have changed for the better over the past decade. The "patient centered" process is the model followed by most medical schools to train physicians how to deal with people, and evaluations are constantly done to be sure young physicians are capable of using all the qualities you seem to think we don't have. But whoever it was that said the list I provider earlier is a list of rare diagnoses, I thank you for proving my point. None of those things listed were more in depth than basic pathophysiology, and many were not even diagnoses. Some were just common terms used to describe features of disease. For instance p53 is a tumor suppressor gene that goes awry in many and most cancers. Her2/neu are tumor markers that give a poorer prognosis in breast Ca. In fact, each of these things listed are hit heavily on even step one of the USMLE. So any of you ready to take the USMLE? It is arrogant of you to think that because you are better socially with patients that you don't need to know the basics of path. You guys are dangerous, and you are slowly alienating yourself from the medical world. Don't forget that physicians own and operate medicine, and you can do nothing without their support. Good luck to those of you who understand your limitations and embrace the team approach.

I have no doubt that NP's satisfy patients, often to a level better than physicians. I have no doubt that NP's spend more time with their patients and make them feel more special. I did all those same things as a PA, and when I left to go to medical school I left behind a huge practice of patients that felt abandoned and without their "doc". But I was personable and caring because I knew I had to be in order to compete with doctors who knew a lot more than I. But just because a patient feels satsified does not mean they received the best care. Lets face it, 90% of patients that come to the FP's office could probably leave after a consultation with the LVN and do just fine. But the other 10% need a bit more that PA's and NP's cannot provide. The biggest problem though is that you have to be trained to know what you "don't know" in order to know you don't know it!!! Its easy as an NP to say that you will refer out things when you need to, but how do you know you need to? And don't kid me Terminator, you didn't know half the things on that list, because some of them are just molecular medicine that is not taught even in medical school. So one of you knew and taught about SIADH. Whoopteee....!!!! That was by far the most recognizable term on the list. And what do DO's and MD's alike have in common? They each put in 4 years with the EXACT basic sciences, yet DO's receive an additional 2 years of manipulation that they can either choose or not choose to embrace. I personally find about 50% of manip rather useless, while the other 50% is useful. DO's also have the same number of required years in residencies, and are licensed to practice autonomous medicine and surgery and worthy of the title physician in all states. We also take the USMLE, the same licensing exam that would in my mind put this whole argument to rest were NP's actually allowed to take it. Personally, I would be more than happy to vote to allow you guys and PA's to take all 3 steps of the USMLE. I say this because even being a PA prior to medical school, if I had tried to take one of these exams, I would never have passed. I simply did not know "what I didn't know" until I made it to the higher level and started paying some real dues. And Roland, how hard was it for you to come up with a study in the British Journal of Medicine about osteopaths?? Were you even aware that osteopathic physicians in Britain are not equivilant to US DO's? They are not medical doctors in England, and are the equivilant of a chiropractor. I think the good NP's out there are going to be really dissappointed when you renegade NP's make your whole profession lose its scope of practice. Your profession could easily find itself without a legal right to practice unsupervised if you try to force the issue of equality, but my guess is that the AMA and AOA will eventually allow you to make your own bed and lay in it. That is, I think they will allow you to take the physician licensing exams that you would have about a 5% pass rate on or less. Then it really won't be an issue. And yes, I may actually hire an NP sometime, but I will allow them no more and no less autonomy than my PA. Why is it that PA's far surpass NP's in starting and average salaries anyway? My guess is that physicians still tend to be the sole hirers of NP's, and they know the true value of each profession.

I think physicians just cannot possibly understand how an NP can even feel comfortable practicing solo medicine. I mean come on, even right out of residency a physician is very green, and often needs to seek the advice of other physicians. How can an NP practice without knowing some of the more detailed pathophysiology taugth in medical schools? I am at least willing to admit that NP's probably get decent pharm and clin med courses compared to medical school, but without the detailed histo, path, embryo, immuno, how can one really feel confident that they know enough to practice alone? I just can't see why NP's feel the need to try and be autonomous when they are more useful working with physicians. The best NP's I have ever worked with were ones that were plenty smart enough to know that to be independent was simply dangerous. I mean if you are an NP, and the following terms are foreign to you, then my guess is you don't have the in depth knowledge necessary to practice as an independent practitioner. Rapidly progressive glomerulonephritis (RPGN) Focal Segmental Glomerulosclerosis (FSGS) Carcinoid Syndrome PTHRP secreting tumors of the lung MEN I II and III SIADH Goodpastures Wegener's Waldenstrom's macroglobulinemia GP41 Her2/Neu P53 Prader Willi Pregnenelone pathway Finasteride These are just off the top of my head, and are things that are common in my everyday vocabulary now, but were probably not known well to me as a PA-C when I was practicing. And the list could go on forever. PA school is way more rigorous than NP school and we all know that, but PA school is not even close to as detailed as medical school. Why can't NP's just agree that they provide excellent care when working with physicians? I would not have a problem hiring an NP in family medicine, OB, peds, but in IM, I would choose a PA, as well as in nephro, cardio, pulmo, gastro, any surgical field, and in EM I think the two are equal. But I worry about putting an NP in a rural setting alone because they have no supervisory requirements. At least a PA has to have the doc come by and sign charts, and collaborate from time to time. Well I hope I have not pissed off any of you NP's who really know your place in medicine, but I think the ones who are pushing for solo practice rights will never see eye to eye with me.

The reason that physicians are hostile toward NP's is that NP's attempt to seek more autonomy when their training does not prepare them to be solo providers. The pathophysiologic knowledge necessary to be a medical provider is simply well above that taught in any NP program. At least in PA school they teach the basics of the medical model, and they humbly agree that they need supervision to provide the best care. NP's will slowly alienate all state medical boards to the point that the they will push them to urge legislators to repeal the current nursing practice acts. NP's should simply learn that they serve an important role, but one that should be supervised. NP's will only cut off their own tails if they continue to seek autonomy.