Hello, I am coming here to see if I can pick some information off of you all. I will state that I appreciate ahead of time the responses I will hopefully receive and hope to put them to good practice.
I am an ER physician in the southeast-ish area of the US, and usually do much travelling around. I work for various staffing agencies, usually just taking the most needed bids and such. I tend to work with many different nurse practitioners and physician assistants in the various locations, mostly in the bigger ERs. The smaller ones usually it is just me since the volume is low.
The reason I come here is because I am looking or some info on the education of nurse practitioners. Sine I occasionally lecture on ER topics at one of the local PA schools in front of medical students and Pas I have been able to get a thorough glimpse at the PA ED model, which really is not too much different than a condensed version of ours it seems. I did go to a med school here in the US which also has a PA program close by so I understand this aspect.
I have noticed at many of the facilities I work at, a higher than average (in comparison to PA and other docs) the nurse practitioners often (not a total majority) seem to be oblivious to many aspects of ER level care. Some are unable to understand the interpretation of a basic set of lab panels, X-rays, and some are unable to suture well, if at all. There are a few that are Excellent at what we do (the term we used because we are a team and I dislike the dichotomy many use separating physician practice from other types of providers since it just stems unneeded conflict and perpetuates social gaps).
I have not noticed such a large gap in practice from the physician assistants that I work with though. Nearly all of them are able to suture, interpret labs, splint, suture, read most X-rays (abdominal X-rays can be very difficult to read at times, often we physicians consult rads on these). (I am also referring to flat plate x rays not CT/MRI and the such when providing the term Xray).
The gap is narrowed it seems between the PA/NP when it comes to diagnosing illness in the fast track though, I do notice it seems the PA do edge out slightly on better diagnosis (but my time is limited in the fast track, I am only there when they have a question about something, if something gets miss-triaged, or if family requests to see me, etc etc.)
But the whole point of me coming here is to ask if they teach nurse practitioners during their educational adventure how to read X-ray, suture, splint, read basic lab panels, intubate, and what not. I have looked through curriculums but course names often do not tell accurate stories in any aspect of education.
I would feel rather rude asking my coworkers these questions, since they may take it as demeaning and I like to maintain great relationships with the other providers. So again, here I am looking for a bit of info on what type of education they provide nurse practitioners in school (we use mostly FNPs in er) to see what you all thought of the situation.
Hope I am not stepping on toes with this,,,, just looking to gather some information in an objective manner.
This physician who is the original poster of this thread works in the ER. Of course in the ER, one must be able to read and interpret xrays (simple) and suture. Those are standard procedures.
However, when you compare an ER MD to a family practice (FP) MD or Internal Med (IM) MD, the expectations are different. 10-20 years out of school, one would not expect the same familiarity with suturing and xray interpretation for these MDs as those of an ER MD. The same would hold true for an NP.
I did not have suturing rotations in school. However, like many of my colleagues here, I purposefully sought out opportunities to learn/practice these skills. Now 10 years out of school, I do not use them on a daily basis so doubt I should inflict my woefully (now inadequate) skills on any unsuspecting patient.
As to my education (and I need to mention I'm a CNS in a state where CNS=NP as to scope of practice) I completed two programs for a total of 1200+ hours of clinical. However, I do not consider myself on par with my MD counterparts. In my very large practice though, the respect runs both ways - I have no physician on-site with me. I make my own clinical decisions, run my own codes in rural clinics and am fully responsible for my own conduct.
However, that said, experience is an excellent teacher too. Although education provides a basis for knowledge, it is honed thru years of experience and as clamchow has stated, one has to be mindful of those providers that believe their basic education provides them with ALL the knowledge they will ever need. Those are the dangerous providers.
IMHO - your education is the basis not the end-all of your professional career.
My anecdote was defined as a reminder about past events, it is often proposed to support or demonstrate some point and make readers and listeners laugh. While any professional person jokes regarding other professions( NP/PA/students/fellows/others) that they are less trained/ has loose skills and other "bushtit", NP/CNS are doing clinical research in ]National Institutes of Health (NIH) as Principle Investigators.( just "google" how many nurses are there...wow)
The fact is: physicians lost "control" for prescribing authority." It is not once upon a time" issue. All this only because of too many law suites, management policy changes and high cost to train MD and then to pay for MD/DO treatment.
NPs /CNS are chipper and much better in quality of care, preventative care specially for chronic patients in outpatient settings.
What can we do if patients like us, trust us and prefer to be treated by NP's/ PA's?
Jealousy, that NP's are so successful will not help to patient care.
I had not thought specifically about using anecdotes in my writing. I will from now on. They would work well in both fiction and nonfiction.
Other ANECDOTE : Psychotherapy treatment therapists.
In the past only PHD trained psychologist could treated with psychotherapy.
The training is long, complicated, no enough clinical sites for training, no many supervisors and the treatment IS so expensive.
Clinical Social workers , Marriage therapist and even counselors with CSAC training do therapies now. They are trained to do "psychotherapy" CBT , DBT, play therapy and other. The only advantage that left in PHD trained psychologist is testing. Unfortunately "test" is not covered by commercial insurances and almost not done in outpatient settings. I see that PHD psychology training will disappear one day as "dinosaurs".
My point is MD/DO is not NP/CNS , but the quality of treatment is the fact and the demand.
PhD psychologist is not Clinical Social Worker , but all the same:but the quality of treatment is the fact and the demand.
In economics, the demand curve is depicting the relationship between the price of a certain commodity and the amount of it that consumers are willing and able to purchase at that given price.
We just need to work all together to improve the quality of care and provide continues care for chronic patients. And this topic for other discussion.
I am quite unsure of the context on a few of the responses, mostly by yhthr. The context of his/her posts seems rather difficult to follow and am I not sure of the point he/she is trying to provide. I do not really get involved much in the NP/PA/MD/DO etc debate. I do not feel we will lose any or much ground if that is what many of my counterparts are worried about. But back on topic, it does seem that many of the nurse practitioner programs do not offer a few of the rudimentary skills that psychguy describes. This probably does vary greatly, but it does answer my question. At least now I will know what to expect and will be wary on many new graduate nurse practitioners and attempt to give them the guidance they may need when they are pulling shifts in the ER. As others agree with, the problem of overconfidence does spam all professions, and I think I stated that earlier on to show my impartiality toward the topic. As previously stated there are great providers out there of all sort, but when it comes down to pulling teeth, it is very difficult to be prepared for any provider role in 700 hours or so. I also do agree that much nursing experience prior to does help. Often times the ER nurses at the facilities already have everything done before one of us provider type enter the room. And many of them are almost always correct on what to do and many could probably run the ER if needed.
I know most people also know that there are many doctors that are rather not excellent†in a way to put it and often not motivated. This is very true, but the major difference is to be able to make it through medical school and residency without sinking into a subpar depressive state, is one must enjoy what he/she is doing. By forcing us through the tens of thousands of hours of residency, they are able to pound the needed information so thoroughly into our brains that even the least motivated physician will have the needed background to perform decently. The lack of motivation would provider a larger detriment toward the pa or np who has not been forced through this ringer quite as long and where each hour must be cherished to maximize knowledge gained.
The self-motivated will always come out on top, and again, the self motivated nurse practitioners are excellent, and can do almost all of what we can do within a year or two of practice and mentoring. But it is somewhat concerning that one can come out prescribing thousands of different medications without the solid knowledge of what most of these chemicals do to the body.
All in all, with the experience you all have described it seems once a motivated nurse practitioner gains footing there is nothing to worry about, if they are motivated. The general consensus seems to be that (again) education is very school specific, some are good, some are not so good (the online schooling part is rather terrifying). I am simply attempting to sum up what I have read so please excuse me if my response does not flow perfectly, but by putting it in my own words it allows me to understand it better and also portray my train of thought to you all, since we are all hopefully on the same team, at least theoretically.
From a pa friend the PA education is superior to that of a np- pa actually use textbooks from med school and are taught to diagnose--- NP don't have that extensive training needed because the schools ( majority) still force to much theory for nursing instead of adequate tools needed like xray review-- plus some np are better than others based on their experience so one may be able to take the lack of training provided by the schools and still be successful while others can't...
From a pa friend the PA education is superior to that of a np- pa actually use textbooks from med school and are taught to diagnose--- NP don't have that extensive training needed because the schools ( majority) still force to much theory for nursing instead of adequate tools needed like xray review-- plus some np are better than others based on their experience so one may be able to take the lack of training provided by the schools and still be successful while others can't...
PA education is superior to that of a np?
What does it mean "superior"?
What exactly NP program? We have Midwife, anesthesiology, geriatric, psychiatric, FNP, pediatric and Acute care /pain management/other programs.
Every program is different and use different textbooks.
What school is "forcing" nursing theory?
NP'S have 2 major scopes of practice:
1.Nursing: patient/family education, symptoms management ,preventative care and other.
2. medical: supposed to be the same as PA's in FNP . This medical approach is deeper in specialty.
PA's programs now " are working out" on new specialty programs, NP/CNS programs are example for them. PA's programs tiring to be with Master programs, again NP/CNS are example for them.
Hello, I am coming here to see if I can pick some information off of you all. I will state that I appreciate ahead of time the responses I will hopefully receive and hope to put them to good practice.
I am an ER physician in the southeast-ish area of the US, and usually do much travelling around. I work for various staffing agencies, usually just taking the most needed bids and such. I tend to work with many different nurse practitioners and physician assistants in the various locations, mostly in the bigger ERs. The smaller ones usually it is just me since the volume is low.
The reason I come here is because I am looking or some info on the education of nurse practitioners. Sine I occasionally lecture on ER topics at one of the local PA schools in front of medical students and Pas I have been able to get a thorough glimpse at the PA ED model, which really is not too much different than a condensed version of ours it seems. I did go to a med school here in the US which also has a PA program close by so I understand this aspect.
I have noticed at many of the facilities I work at, a higher than average (in comparison to PA and other docs) the nurse practitioners often (not a total majority) seem to be oblivious to many aspects of ER level care. Some are unable to understand the interpretation of a basic set of lab panels, X-rays, and some are unable to suture well, if at all. There are a few that are Excellent at what we do (the term we used because we are a team and I dislike the dichotomy many use separating physician practice from other types of providers since it just stems unneeded conflict and perpetuates social gaps).
I have not noticed such a large gap in practice from the physician assistants that I work with though. Nearly all of them are able to suture, interpret labs, splint, suture, read most X-rays (abdominal X-rays can be very difficult to read at times, often we physicians consult rads on these). (I am also referring to flat plate x rays not CT/MRI and the such when providing the term Xray).
The gap is narrowed it seems between the PA/NP when it comes to diagnosing illness in the fast track though, I do notice it seems the PA do edge out slightly on better diagnosis (but my time is limited in the fast track, I am only there when they have a question about something, if something gets miss-triaged, or if family requests to see me, etc etc.)
But the whole point of me coming here is to ask if they teach nurse practitioners during their educational adventure how to read X-ray, suture, splint, read basic lab panels, intubate, and what not. I have looked through curriculums but course names often do not tell accurate stories in any aspect of education.
I would feel rather rude asking my coworkers these questions, since they may take it as demeaning and I like to maintain great relationships with the other providers. So again, here I am looking for a bit of info on what type of education they provide nurse practitioners in school (we use mostly FNPs in er) to see what you all thought of the situation.
Hope I am not stepping on toes with this,,,, just looking to gather some information in an objective manner.
Best wishes
Let me ask you this... Do all MDs come out of medical school knowing everything or do they specialize? Yes, they specialize and learn their specialty. You won't see a dermatologist delivering a baby or interpreting a TEE... Same goes with NPs. Curriculum is intended for the advanced RN to safely diagnose, treat, educate and counsel at the PCP level. Those that want to specialize in ER, ICU etc then have more training to excel in those specific jobs. Also, for every bad FNP there will be a bad MD. Don't assume all are incapable because of several experiences. Perhaps you should do a research study and get statistical inferences versus assuming NP schools don't train nurses up to your standards.
Let me ask you this... Do all MDs come out of medical school knowing everything or do they specialize? Yes, they specialize and learn their specialty. You won't see a dermatologist delivering a baby or interpreting a TEE... Same goes with NPs. Curriculum is intended for the advanced RN to safely diagnose, treat, educate and counsel at the PCP level. Those that want to specialize in ER, ICU etc then have more training to excel in those specific jobs. Also, for every bad FNP there will be a bad MD. Don't assume all are incapable because of several experiences. Perhaps you should do a research study and get statistical inferences versus assuming NP schools don't train nurses up to your standards.
I do apologize it my post came off as sounding as I believe that nurse practitioners are incapable. I think I stated in my posts that I did not believe that to be the case. My purpose was to state an observation (which a single observation, or even a few from one person has significant sampling bias so take what I say as a grain of salt), but much of what I restated in my third post was an integration of what many of the other posters have stated.
I feel as I may have tread on your toes, which I am not sure how, but I do apologize if that was inferred from previous posts.
We do specialize, and we do not come out of medical school knowing everything. An example would be a farmer who has tended his field to all crops, is able to grow all crops in his field, but his field is not able to be excellent or practical at growing a specific crop, and thus is not economical for baseline use. Freshly minted docs prior to residency are as that, just minted fields ready to become accustomed to growing one crop to the best of his or her ability. The crop would be the product of a finished resident (the resident's work), the early field as of a newly graduated MD/DO, and the finished field as a resident who has completed residency. The farmer could be considered a conglomerate of those who have trained the doc/resident/etc.
The argument that nurse practitioners must specialize in Er does not quite answer the question since most NPs are placed in the fast track which has very little difference from a family practice clinic and even less of a difference from an urgent care clinic. I do remember performing lab evaluations, sutures, and the like during primary care rotations in both school and residency.
Again though, I am not here to bash nurse practitioners, as I did state before they are a very important part of the team and do not doubt their intellectual capability. I feel as you may be looking for reasons to be offended though, which is unfortunate.
Specializes in ACNP-BC, Adult Critical Care, Cardiology.
I would try my best to not be biased here but what this thread sheds light on is one of the fundamental differences between a PA and an NP from a hiring physician's standpoint. NP's will come from a diverse clinical background not only in terms of educational preparation but in their pre-NP medical knowledge as nurses.
Prelicensure nursing programs (or RN programs) barely go into detail about medical therapeutics. Nursing has had this long held stand that in order to distance itself from medicine as a separate profession, concepts taught in nursing school must be the least identical to medical verbiage, hence the focus on theories of nursing and "caring". Perhaps also a shortcoming of clinical instruction in nursing programs, students are taught to assess patients and report "worrisome" findings to a physician and this is where things can sometimes stop.
Even the act of giving medications to a patient becomes a task of checking vital signs first and asking a physician if it's OK to give that medication without going into detail about the complexity of the patient's clinical picture and the indications for the medication. Unfortunately, this is not going to change due to scope of practice issues and regulatory/legal constraints of being a nurse.
Nurse Practitioner programs hopefully will undo that "nursing mentality" and mold the NP student to think more as a healthcare provider...one who is capable of assessing a patient, using clinical data from labs and diagnostics to tie the assessment with differential diagnoses, and use concepts in medical therapeutics to come up with a treatment plan. This is easier done in PA programs where all students go through a condensed version of medical school. NP programs in contrast, have long been developed into "specialty focused" tracks that do not always align with the realities of the medical fields.
The OP's medical specialty is a perfect example of the disconnect between how training in medicine is done vs how NP programs are set-up. Emergency Medicine broadly treats patients of all ages in the entire spectrum of primary care, urgent care, and emergency/trauma. There is no single NP track that could adequately prepare us in that field from the get go. FNP tracks can limit the students clinical exposure to settings where x-rays are probably not even uploaded and read because of the strict primary care focus mandated by the curriculum.
Acute Care NP programs separate the age groups between adults and peds, and because of the focus on Acute and Critical Care, exposure to urgent care procedures such as those in orthopedics (splints and casts) and OB (pelvic exams) can be missed from the training. We do have combined FNP/ACNP programs now in a few schools that hope to bridge that training gap in the field of Emergency Medicine.
I have been an NP since 2004 and I think we NP's as a collective group have successfully made a difference as providers alongside physicians in various medical specialties. I think what would work best for someone interested in hiring NP's to join their team is to evaluate each candidate on their individual merits due to the variables in backgrounds and training. For instance, in my field of Adult Critical Care, we find that ex-ICU nurses transition to the role much easier than someone who didn't have that background. We also find that those who graduated from Acute Care NP programs and had ICU rotations in school require less training in figuring out what tests to order and looking at chest x-rays and other imaging films.
The take home message for me is that when dealing with a brand new NP, it's best to start with an inventory of what the NP already knows and have some experience on and strengthen that knowledge while remediating on those not touched on or exposed to during NP training. It would require being upfront on the new NP's part of his/her deficiencies and a commitment on the physician part who is willing to provide the training. That would make for a competent and safe NP and a satisfying relationship with physicians who work with them.
I'm going to throw in another tidbit about nursing. Nursing, as a body, wants to align itself with psychosocial disciplines rather than biological fields such as medicine. Much of the theory base for nursing is a sort of convoluted psychology-sociology-philosophy hybrid. Why this is, I do not know. I didn't know this was the case when I entered the field or I would've probably selected the PA route since I came to nursing after another career. The push in graduate nursing is to write papers in perfect APA (American Psychological Association) formatting. Egg on my face. It's hard to sell onself as a colleague of sorts to physicians, and even PAs, when our background is largely fluff.
Nursing, as body, has done a great disservice to working nurses by focusing on inapplicable theory rather than practical knowlege. Nursing wants to professionalize itself from physician handmaidens to that of scholarly, scientifically trained clinicians. Unfortunately, most programs have failed to adopt any essential science.
While my wife is napping, and I have nothing else to do I'm going to list my nursing program curriculum to give you an idea of what I took as a RN and then Psychiatry NP. I hold another BS degree (actually general science: biology) with some graduate training as well as prereqs to a MBA program I enrolled in some years ago without finding the impetus to finish the MBA. My first career was law enforcement. I later went back, and below is what nursing required.
Undergraduate Prerequisits (not counting typical bachelor's degree courses such as history, lit, etc.)
Human Anatomy/Physiology I and II with labs. 4 semester hours each
Statistics (either from psychology dept. or school of business) 3 sem. hours
Nursing:
Foundations 5 hours - how to interact with pts, wipe butts, change beds, take vitals, and address "core" health issues such as defecating, urinating, eating, and drinking
Health Assessment 3 hours - was actually a NP level course but for undergrads, included all the bells and whistles but not provided adequate practice hours
Gerontology 3 hours - learn about the psychosocial and physical elements of aging
Pharmacology 3 hours - half the course wasted learning calculations, the other have very rudimentary mechanisms of actions, common drugs, etc.
Pathophysiology 3 hours - interesting for the layman but still of insufficient depth
Mental Health Nursing 3 hours - essentially how to talk and walk with the mentally ill, very little psychopathology taught
Research Methodology 3 hrs. - basic research class akin to any BS degree research class
'Acute Care" 9 hours - cardiovascular, respiratory, gastrointestinal, renal, endocrine perhaps some other systems, focus on health teaching, prevention
Issues and Ethics in Nursing 3 hours - cakewalk class of no substance
Community Health 5 hrs - really have no idea what this was about but it wasn't epidemological, rotated in the health dept., STD clinic, VA, home health,
Women's and Children's Health 7 hrs - combined OB/Gyn, Peds course. Very little peds. OB far too indepth for the four weeks given. my greatest overall weakness in healthcare knowledge
"Complex Care" 7 hrs - ortho, neuro, review of acute care, and emergency/critical care-lite
Synthesis 1 hr - review for nursing board exam/ opportunity for military recruiters to hound us for the rest of the semester
Leadership & Management 4 hrs - very very base course in healthcare admin and some really theoretical leadership concepts
Master's/ NP
Research Methodology 3 hrs - exactly the same course and book as in undergrad
"Advanced Pharmacology" 3 hrs - one of the most practical courses I've ever taken although not in comparison to med school texts
"Advanced Physiology and Pathophysiology" 3 hrs - had high hopes for this one but was utterly disappointed, largely read the book and take online quizzes with a comp. final.
Intro. to Practice Management 1 hr - name says it
"Advanced Resarch Utilization" 3 hrs - more research centered around performing research and drafting policy/practice changes and implementing them in a practice environment (base)
Nursing Theory 3 hrs - gut wrenching, paper driven course somewhat traumatic to my education
"Advanced Community Concepts" 2 hrs - no idea what this was about really, but I had to draft a health promotion plan for heart disease in some BFE town I've never been to
Advanced Practice Mgmt 1 hr. - name says it
"Advanced Health Assessment" 3 hrs - basically learning assessment techniques, fairly in depth and comprehensive likely physician equivalent with anatomical models, however, after this semester little opportunity to go on practicing or utilizing new found skills; I do chase my wife, kid, and dog around with the otoscope and opthalmoscope from time to time
something like Intro to Advanced Practice Mental Health 3 hrs- largely devoted to psychotherapeutic communication, cultural diversity, human development, miscellaneous psychiatry-related theories
Psychopharmacology 3 hrs - one of the more useful courses I've taken, name says it. the epitomy of my present practice.
Mental Health Advanced Practice I or a similar title 3 hours - introductory psychotherapy, psychopathology, evaluation, and diagnosis
Some kind of title for a practicum course, I forget the credits - essentially psych evals, individual and group therapy (I detest group therapy)
Mental Health Advanced Practice II hours become vague here - continued psychopathology and diagnosis
Practicum hours divided between peds and adult/geriatric
Mental Health Advanced Practice III again credits are vague at this point - intrusion of family therapy into the education, more psychotherapy and counseling-oriented techniques and theories
Practicum hours devoted to running our own patient load, i.e. here's your patients, now treat them. (eval, referral, therapy, meds, CT/MRI, labs, sleep study)
I realize it's very psych oriented, but it gives you an idea of how fundamental NP training is. Unlike psychiatrists, I received no rotations in neuro or medicine. I'm grateful my training was with the VA system with staff who were kind enough to expose me to consult-liason psych, inpatient psych, outpatient, psych, addictions, and whatever else I wanted to learn about. My RN experience was in the ED and urgent care which gives me a perspective and insight many psych-dedicated RNs and NPs are oblivious to. I'm grateful for the primary care exposure and education I received in those settings usually from PAs although I wish I had more of it on a higher level, if you will. What you may not know is that NPs are not merely "specialized" generalists, i.e. we're very compartmentalized by specialty and related tradecraft. NP school does not include the broad coverage of MSIII and MSIV, and nursing school (RN) training in related environments is largely devoted to fetching water and wiping butts as well as the nursing academic coveted "care plans." If you want to be a psych NP, you get psych training only. If you want to be a neonatal NP, you only get neonates. Women's health spend all their training looking up the tunnel. Peds folks never seen an adult, etc. Peculiarly adult NPs are now spending all of their training focusing on geriatrics sans exposure to something like a 30 year old guy with lumbosacral sprain.
traumaRUs, MSN, APRN
87 Articles; 21,287 Posts
This physician who is the original poster of this thread works in the ER. Of course in the ER, one must be able to read and interpret xrays (simple) and suture. Those are standard procedures.
However, when you compare an ER MD to a family practice (FP) MD or Internal Med (IM) MD, the expectations are different. 10-20 years out of school, one would not expect the same familiarity with suturing and xray interpretation for these MDs as those of an ER MD. The same would hold true for an NP.
I did not have suturing rotations in school. However, like many of my colleagues here, I purposefully sought out opportunities to learn/practice these skills. Now 10 years out of school, I do not use them on a daily basis so doubt I should inflict my woefully (now inadequate) skills on any unsuspecting patient.
As to my education (and I need to mention I'm a CNS in a state where CNS=NP as to scope of practice) I completed two programs for a total of 1200+ hours of clinical. However, I do not consider myself on par with my MD counterparts. In my very large practice though, the respect runs both ways - I have no physician on-site with me. I make my own clinical decisions, run my own codes in rural clinics and am fully responsible for my own conduct.
However, that said, experience is an excellent teacher too. Although education provides a basis for knowledge, it is honed thru years of experience and as clamchow has stated, one has to be mindful of those providers that believe their basic education provides them with ALL the knowledge they will ever need. Those are the dangerous providers.
IMHO - your education is the basis not the end-all of your professional career.