mango-lo-maniac

You know, very few posts in this long thread have addressed the OP’s question – what are the CLINICAL differences between PAs & NPs. Instead there has been a lot of rhetoric, much of it unfounded, about the educational and perceived professional differences. Unfounded information has come from both views. I hope I am not violating TOS by saying this, but as a PA I am embarrassed by the garbage in that old post by Kristen. I am a PA in emergency medicine. In my practice setting there are NO clinical differences between PAs and NPs. None – not even one single one. Granted, I do work in a state that is friendly to both professions. State law does not require my charts to be cosigned. The hospital requires chart cosignature for all midlevels with in 24 hours. The docs usually sit down with a pile and scribble on the bottom corner of each while chatting or doing something else. They are not looking at the actual chart. This is mean to be “midlevel supervision” but in actuality it is not. Supervision would be looking over our shoulder and guiding our actions during patient care. State law allows me to write my own scripts, sched II-V. They do not have to be cosigned. I am limited to a 14-day supply of sched II & III. In my setting this is not a limitation – if you are sick enough to leave the emergency department with a script for a schedule II, you need to follow up with your PCP or specialist, who should manage your ongoing need for medications. In other settings, it may be a limitation to not be able to write a month’s supply of schedule II. I know that NPs can write up to sched II as well, but have never asked if they have a limit like ours. For those who would say we are “only assistants” I invite you to spend a day with me in practice. You will see that while my badge says “assistant” I do not assist the docs with their patients. Instead, I see my own. I evaluate & treat, discharge & admit all without consulting a physician unless I feel it is needed. I see the same acuity of patients except for patients requiring immediate resuscitation. I hear/read nurses saying that the public does not understand the scope, intellect and abilities of nurses. I agree, but I submit to you the same for PAs. “Assistant” may have fit the job 35 years ago, but it does not any longer, except in the operating room. I have my own license. I have my own malpractice policy, paid for in full by my employer. I have my own DEA number. I have my own UPIN. This is not new. Other than my lack of a nursing license I am no different from an NP in this regard. I do not practice under anyone else’s license, policy, etc. I don’t understand why some people refuse to accept the truth, and persist in claiming that we cannot be licensed or insured on our own. Perhaps it is because we are nationally certified but state licensed? PAs in my state can (and do) own their own practice, but it is not common. I know PAs who own their own urgent care clinic, family medicine clinic, occupational medicine practice and psychiatric practice. NPs can own a practice here too, but I do not know of any off hand. In all 50 states a PA must have active national certification in order to be licensed. Some states allow PAs to let that certification lapse, my state being one of them. To maintain national certification, a PA must log 100 hours of CME every two years for six continuous years, and take a primary care exam at the end of that period. In order to maintain state certification, a PA must log 100 hours of CME every two years. The only difference is not taking the primary care exam. Is this a sign of weakness or inferiority of the PA? I don’t think so. I know PAs and FNPs in neurosurgery. Both educated in primary care but practicing in a surgical subspecialty – would you think less of the FNP if her primary care knowledge were not retested every six years, so long as she maintained her knowledge though CME? If not, then why look down on a PA who chooses not to retest in primary care? It is true that PA education is offered at several levels while NP education is almost entirely at the master’s level (there are a few stragglers in California). However, PA education is standardized nationally. Compare the applicant prerequisites and the curriculums at a certificate program and a master’s program. In almost every case you will see that the only true difference is they type of degree awarded at the end. The actual education is equal. Some may persist on looking down on the “lesser” degrees but I think that the quality of education is a more important issue. National curriculum standardization and accreditation ensures this quality. It is true that some PA programs enroll students with no previous experience. Ironically, this tends to be the master’s programs – those that superficially seem to be superior degrees. Many PAs do not support this change in admission policies. However, there is verifiable proof that the majority of PA students do have prior clinical experience. Both professions, for better or for worse, are allowing new students without strong patient care backgrounds. To point at the PA profession as being inferior for this trend is to ignore the fact that the same thing is happening in the NP profession. PA education is in the medical model, but I was not trained to focus on symptoms and throw medications at patients. I listen empathetically. I explain treatment options and side effects and encourage patients to have a role in deciding how their care will progress. I discuss complications and prognoses of diagnoses. During my training and also in my professional career, returning patients have asked for me by name, so I would say that they appreciate the care that I give. I am not a nurse and do not know how my training differs from the "holistic method" that nurses and NPs are trained in, but I do attempt to treat the whole person. I believe that most PA (and physician) training programs are going in this direction - rightfully so. Just as a disclaimer, I am not anti-NP by any means. I work with NPs, some whom I respect and some whom I don’t – respect is earned by showing me that you are a capable provider, and in the long run that is what I care about the most. My husband and I see a PA, but my OB care was from physicians, a PA and NPs. Our children see docs & PNPs. The sole purpose of this lengthy post is to address the OP’s question with my real-life experience and to dispel some untruths propagated about the PA profession. I encourage anyone who is trying to decide between PA and NP to research both and use verifiable, objective information to make your decision.

changed mind about post

General Forum InformationNurse Practitioners (NP) Number: 141,209 (51% of all APRNs) Education: Nurse Practitioners (NPs) include RNs prepared beyond initial nursing education in an NP program of at least 3 months. Approximately 65 percent of NPs have completed a master’s degree program and an additional 10 percent have a post-masters certificate as their NP preparation. What they do: Nurse Practitioners may practice independently, or they may work in hospitals, long-term care facilities, and for various health care agencies. Most NPs function primarily as clinicians. NPs may diagnose and treat a wide range of acute and chronic illnesses and injuries, interpret lab results, counsel patients, develop treatment plans, and they may prescribe medication.I think this is what the OP is referring to?

Psychologists with extra training can write scripts from a limited formulary in New Mexico & Louisiana. Don't know anything about chiros, PTs or pharmacists, though.

Trauma, PM to you

Please don't think I intend to start an NP vs PA thing. I have no problem with the NP profession nor the NPs I work with. We treat each other as colleagues and get along very well. I don't want to hijack the thread either, so I'll just post my source of information. PAs are dependent practitoners; no way around that. We are licensed in most states, though, which is what I intended to address. I'm no lawyer, so maybe I misinterpret the IL PA Practice Act, but this is where I got my information from.

You may want to recheck your sources. According to the IL Physician Assistant Practice Act, "Physician Assistant" means a person licensed by the Department and who practices in accordance with the provisions set forth in the Physician Assistant Practice Act of 1987." PAs practice under physician supervison but not under another person's license. You are much more credible if you are armed with the facts, not misinformation :)

My Welch-Allyn works just as well as the wall-mounted sets in the clinic. I'd check ebay for deals. You can usually find a student who was required to buy a set but rarely used it.

Really? As a PA, I thought NPs had the stronger lobby! :chuckle Nurse Ratched gave you the best link for getting the facts about the PA profession, www.aapa.org. It's a huge site that will take a long time to go through! Here's a link to "Where PAs are allowed to prescribe" from that site. You'll see that PAs write scripts in all states but two. Kinda... Here's a summary of California's "hinky";) supervision requirements: "Physician must be available in person or by electronic communication at all times PA is caring for patients. Written guidelines for supervision must include one or more of the following: same-day examination of patient by physician; countersignature of all medical records within 30 days; protocols for some or all tasks. Supervising physician must review, countersign, and date at least 10% of medical records within 30 days for patients treated by PA, for PAs working under protocols." Arizona's laws are more relaxed: "Physician need not be present on site; weekly meeting required. Board approval needed for PA utilization in separate location." (no chart signatures) And NC is probably the best for PAs: "Supervision continuous but physical presence of physician not required at all times. PA must meet with supervising physician monthly for first six months of employment and every six months thereafter to discuss clinical problems and quality improvement measures." (no chart signatures) But I'll bet my NP colleagues will agree, what your state will let you do is not always what your employer will let you do. And in reality, new grads in both professions will probably need more supervision than the laws require. IMHO, the least restrictive laws should only apply to the more experienced PAs and NPs. Here's a link to the AAPA's summaries of State Regulation of PA practice. PAs are certified nationally, but 41 states grant PAs licensure. We get our own DEA numbers (in most states) and our own PINs in all states, and are required to be separately insured. PAs do practice under MD supervision, but not on the MD license. And while the definition of supervision varies from state to state, it is a fact of the PA life... if you are uncomfortable with that, then you should not consider the PA profession.

i just read about it on another forum. here's what was posted: according to the 2002 article in the american journal of infection control by guinan et al, more than 164 million school days are missed annually in american public schools due to the spread of infectious diseases and approximately 3 million school days are lost as a result of acute conjunctivitis. a study by the carnegie foundation revealed that missed school days represent the main problem that 83% of teachers face in their school. approximately 2% of all primary care visits and 1% of all emergency room visits are related to conjunctivitis. adenovirus represents the most common form of a red eye worldwide and most frequently presents to the primary care physician. the fda has recently approved a new, rapid point of care diagnostic test for viral conjunctivitis called the rps adeno detector (rapid pathogen screening, inc.). the test completed a multi-center, blinded fda clinical trial to compare the efficacy of the rps adeno detector against cell culture for detecting adenoviral conjunctivitis. this study demonstrates the high degree of sensitivity and specificity of the rps adeno detector at correctly identifying patients with adenoviral conjunctivitis in 10 minutes. currently viral conjunctivitis is a clinical diagnosis and viral cultures and pcr are not routinely done. the rps adeno detector would make a laboratory confirmation of the diagnosis readily available. because the rps adeno detector test empowers a physician to accurately make a diagnosis and appropriately treat or not treat a patient, it ultimately allows a physician to practice better medicine. physicians often feel pressured by their patients to institute a treatment even if they think it is unnecessary. when patients visualize a positive test result themselves, physicians can achieve better patient acceptance for more supportive therapies. the rps adeno detector can effectively identify contagious viral conjunctivitis requiring more time away from work, school, or daycare. unlike bacterial conjunctivitis that becomes relatively noncontagious after 48 hours of appropriate antibiotic therapy, adenoviral conjunctivitis does not improve and continues to shed a significant virus load until the eye is no longer red and tearing. moreover, up to 30-50% of severe cases of adenoviral conjunctivitis can lead to significant long term morbidity including decreased visual acuity and photophobia from persistent subepithelial corneal infiltrates (superficial corneal opacities), chronic epiphora (tearing) from lacrimal drainage problems, and severe visual loss and pain from a cicatricial entropion associated with symblepharon (shortening and scarring of the conjunctiva) formation. thus, in some regions, nearly half of all patients with acute infectious conjunctivitis presenting to a primary care provider or emergency room physician may receive unnecessary antibiotic treatment. antibiotic resistance is also a problem in the eye. many studies have elicited high rates of antibiotic resistance for staphylococcal and streptococcal species with commonly prescribed topical antibiotics including rates respectively approaching 30-40% for erythromycin; 20% of aminoglycosides, and a five-year review study reported that s. aureus resistance to both ciprofloxacin and ofloxacin dramatically increased from 5 percent in 1993 to 35 percent in 1997. in a 2000 study of resistance to haemophilus influenzae and streptococcus pneumoniae that caused bacterial conjunctivitis, older medications, such as gentamicin, polymyxin b, neomycin and sulfamethoxazole, were found to be either intermediately or not at all active against these pathogens. furthermore, antibiotics such as aminoglycosides are toxic to the epithelia and tend to retard healing. for some topical antibiotics, adverse external ocular effects were estimated to be as high as 16%. up to 8-20% of eyes treated with aminoglycosides will develop a hypersensitivity reaction and become red regardless of the type of infection. a recent 2005 study out of ucsf suggests that topical antibiotics may also contribute to nasopharyngeal antibiotic resistance. the rps adeno detector provides health care professionals with a true point of care test for infectious conjunctivitis. the test requires only 10 minutes to obtain a result that can empower physicians to practice better medicine, foster patient acceptance, and identify contagious viral conjunctivitis and limit spread of disease while simultaneously reducing ocular antibiotic resistance. the management style utilizing empiric antibiotic treatment may not only increase the risk of antibiotic resistance, side effects, allergies, and corneal toxicity, but also may lead to increased cost to the individual and society as a whole. http://www.topix.net/forum/us/fda/t5ajlfrs256h3qr2p

The main PA forum is www.physicianassociate.net. The sister site, for PAs and NPs to discuss issues of mutual concern, is www.clinicanforum.com.

Actually, learning to do lumbar punctures is standard in most PA programs. I don't know for certain, but I imagine that NPs who work in emergency med do LPs as well. Also, depending on the setting, PAs (maybe NPs, too??) can do lumbar injections. "BlocDoc" at the PA forum is an RN/PA who works in pain management. I think he's a member here too, but less active. Anyways, he's a really approachable guy and could elaborate much more than I ever could on the topic. I certainly don't foresee independent PA practice, but I wouldn't say that PAs are "owned" by physicians. Like "collaboration", "supervision" has many different interpretations. Indiana is to PAs what Georgia is to NPs. We can't prescribe there, and while a doc doesn't have to be physically present during PA practice the physician must review every chart within 24 hours. But North Carolina is PA-progressive, somewhat analogous to New Mexico and NP practice. NC PAs prescribe schedule II-V (30-day limit for Sch II), and supervision is a meeting once every 6 months. PAs can also own their practice in NC. summary of PA practice regulations

depending on the setting, there isn't much difference in the roles of nps and pas. if you do a web search for jobs, you will find many that advertise "pa/np wanted," and there is no difference listed in the job or pay based on the educational background. my personal experience has been the same. i've seen pas & nps who work in specialty practices where a physician sees every pt behind them. i also know pas who own their practices, something that nps are able to do. i think your best bet will be to explore both professions, the educational processes, and the job settings you are interested in. then chose the path that speaks most to you. to get you started here are a few sources for objective data about pas: facts at a glance - check the job outlook by the us bureau of labor statistics pa education summary of state regulation of physician assistant practice

That has been my experience, too, at least in places where PAs & NPs work side-by-side. PS Go Paladins! I'm a Furman Girl, too!

Actually, this isn't true. According to the American Academy of PAs 2004 New Student Survey, only a third of newly-enrolled students had no prior direct pt care experience. More than half had over 3 years experience. It is the trend, though. The 2000 New Student Survey showed that only 15% didn't have prior experience. And for what it is worth, PAs with experience give prospective/new grad PAs who have no experience a hard time. You NPs who think that prospective NPs should work as nurses first play much nicer :)