What do ER's hire more: PA-C, FNP or ACNP ?

TakeBack · Apr 15, 2011

I can tell you about WA state. I used to work as a telemetry RN in a hospital for 2 yrs & I often used to get floated to ER when overstaffed. We had both PA & NPs in ER. Basically, the collaborating MD/PA had same schedule as MD & MD had to sign off all PA orders w/i 24 hrs because they worked under MD license. If pt. was transferred to floors & PA orders were not signed off w/i 24 hrs, we used to call MDs & remind them to come and sign off. After 24 hrs all orders were automatically voided if it wasnt signed off by supervising MD. Whereas, orders from NPs were not voided because they worked as independent providers under their own license & no supervising MDs were needed. We had lots of hospitalist NPs (palliative/hospice in onco floors, GI, IM) & lots of PAs worked in trauma team. A lot of MDs were irritated by that 24 hr signing protocol and they preferred to work with NPs than PAs in ER. So, most of our PAs were slowly switching to trauma/surgery 1st assist team where as NPs worked as hospitalists. It really depends what you wanna do.
I am in a NP school now. NP school really builds on RN skills. For eg. if they are teaching CV system, they totally skip EKG analysis, chest tube care etc because they expect you have mastered that skill as RN. They skip a lot of things like diagnostics tests/ reasoning because there's certain expectation that as a RN you've mastered them as well. Even in health assessment, they skip lot of things (heart/lung sounds--you must have mastered them--diff type of murmurs--for eg, diff. between murmur sound like mitral regurgtitation vs. aortic stenosis, systolic vs diastolic murmurs etc) and jump directly to adv diagnosing. If I hadnt worked as a RN for 2 yrs in a tele floor doing own EKG strips q shift for last 2 yrs & listening to diff heart/lung sounds etc, I would have been so LOST in assessment class in NP school. They assume, you have mastered most of the skills/assessment. The only new assessment for me was pelvic exam in women. Honestly, I think PA school teaches from scratch which is better for people w/o experience. When I worked as a nurse, I learned a lot from fellow nurses, charge nurses, NPs, MDs etc. & I believe my experience of 2 yrs (more than 2000 hrs) & 800 NP clinical hours easily compensated for the 2000 hrs of PA. Without experience though, I would have definitely felt deficient. I would say go to PA school since you dont have that skill/education to build on.

Just to clarify a few things here:

PAs are licensed, they don't practice "under an MD license". They have their own license to practice medicine (at least that's what my WA state license says). We have supervisory relationships whose terms are state dependent (not unlike the majority of NP states).

Second, I'm surpirsed at your description of NP education. EKG analysis, diagnostic tests, murmurs, lung sounds- too trivial? Not all NP students are former tele nurses I'm sure. NP and PA programs have students entering with vast clinical backgrounds. The average PA student has 1-2 yrs experience; our local program at MEDEX UW has students with 4000-10000 hrs as the standard. And yet they are all taught these fundamentals. Pre-PA or Pre-NP experience is valuble but it doesn't supplant the clinical experience gained in a professional training program to practice medicine (or advanced nursing if that's what it continues to be called).

TakeBack, PA-C

SkiBumNP · Apr 15, 2011

I 2nd what TakeBack says.

I am a new graduate NP, I felt my program lacked much of the hard skills.

In fact, I decided to take PA classes in EKG, Radiology, Skills, and Emergency Medicine.

NP programs NEED to teach and re teach these "basics".

they are the foundation of good medicine, and must be perfected.

reeya · Apr 17, 2011

@ takeback:

Yes, of course PA has their own license but our hospital had this 24 hr rule that any assessment, interventions, labs/orders etc done by PA had to be signed off by their supervising/collaborating MD where as they did not for NP. I am not saying EKG classes, murmurs, lung sounds as too trivial but NP programs (at least mine) did not reteach these skills. They had expectation that you've mastered them as RN. Our class had RNs with tons of experience in various acute settings (most of them CCU). I was the least experienced in my incoming NP class. PA program assumes you need to know the skills from start but NP school assumes you have some skills to build on (at least my progrma). I know UW PA program is very good. I went to UW BSN program myself. I am saying that NP school is not for everyone at least if one does not have couple of yrs of experience as RN or otherwise I would have been lost.

linearthinker, DNP, RN · Apr 18, 2011

Interesting that the rates of NP independent practice remain so low.
A political battle, it seems, to overcome the legislation in the majority of states which still require collaboration.

I have ZERO interest in being a business owner. Sounds like a hella lot of hassle to me. So while I probably will not need/want/seek someone to look over my shoulder, I am quite happy to work my 30-40 hours, let someone else own the business, manage the Bullsheet and write me a check at 4pm on Friday!

TakeBack · Apr 20, 2011

@ takeback:
Yes, of course PA has their own license but our hospital had this 24 hr rule that any assessment, interventions, labs/orders etc done by PA had to be signed off by their supervising/collaborating MD where as they did not for NP. I am not saying EKG classes, murmurs, lung sounds as too trivial but NP programs (at least mine) did not reteach these skills. They had expectation that you've mastered them as RN. Our class had RNs with tons of experience in various acute settings (most of them CCU). I was the least experienced in my incoming NP class. PA program assumes you need to know the skills from start but NP school assumes you have some skills to build on (at least my progrma). I know UW PA program is very good. I went to UW BSN program myself. I am saying that NP school is not for everyone at least if one does not have couple of yrs of experience as RN or otherwise I would have been lost.

This speaks to a couple of things:

-The heterogeneity in NP curricula, particularly the clinical component. How can you transpose this model of education to a program that doesn't have an incoming class of all former CCU nurses?

-The disconnect between training an nurse and training an NP (a clinician). The concepts and connections when teaching physical diagnosis and lab/test interpretation are VASTLY different when teaching RNs (who will not be developing tx plans other than those w/in nursing scope) and NPs (who are diagnosing and treating). Whatever assessment skills you learned in nursing school are not the same as those taught (or should eb taught, in this case) at the NP/PA/MD/DO level.

-The direct entry NP programs can't even consider using this model if the MSN has no or minimal bedside experience.

Your example about PAs and NPs in the ED in WA just illustrates the regressive nature of PA practice in many states. To have different rules for what are essentially equivalent providers (in experienced, real world practice) demonstrates pure political gamesmanship.

TakeBack · Apr 20, 2011

I have ZERO interest in being a business owner. Sounds like a hella lot of hassle to me. So while I probably will not need/want/seek someone to look over my shoulder, I am quite happy to work my 30-40 hours, let someone else own the business, manage the Bullsheet and write me a check at 4pm on Friday!

Again, explains the reason why so few PAs or NPs go into clinic ownership.

Advanced Practice Columnist / Guide · Apr 21, 2011

It is totally state dependent, at this time. The NP organizations are pushing for big changes though. One of which is the scope of practice through the national certifying board instead of the states. All 50 states will have the same NP certifications and such.
Right now it is state dependent as well as hospital bylaw and credentialing dependent. In an independent state, the hospital would have to be totally stupid to not credential you as independent if state law allows. That is a huge decrease in liability. Being an employee has no bearing on independent practice.
Here in Alaska (same with Montana when I was there), I have full independent practice, to include admitting my own inpatients.

I always thought Medicare patients are required to have a physician on record as the admitting attending when they are hospitalized per CMS regulations.

nomadcrna, DNP, CRNA, NP · Apr 21, 2011

Note that that is ONLY for billing. I can provide services to anyone that I want. Getting paid for it may be an issue.

If I think a patient needs a specialist, I medivac them to anchorage. I do just as a physician does when he thinks the patients needs specialized care. Part of Alaska's requirements for licensure as a NP is having on file with the board of nursing, a plan to collaborate with other health care providers when needed.

So if I get some in with diverticulitis and I admit them. 24-48 hours later they are not getting better or symptoms worsen. I call a surgeon for a consult and medivac the pt.

Before, when I had surgeons in the same hospital, I would consult them and they would come see the patient. Exactly the same as physicians do.

Do I need to have a collaborative agreement to see Medicare patients and bill directly, even though I am in an Independent Practice State?

Practice > Practice FAQs

Q. Do I need to have a collaborative agreement to see Medicare patients and bill directly, even though I am in an Independent Practice State?

A. When the regulations were written to implement the 1997 Balanced Budget Act authorization of direct reimbursement of nurse practitioners by the Center for Medicare and Medicaid Services (CMS), a requirement for physician collaboration was inserted. The regulations require: written documentation of the nurse practitioner's scope of practice and the process used to refer patients to physicians if the patient's needs fall outside the nurse practitioner's scope of practice or require consultation from a physician. There is no requirement to provide a copy of the documentation of scope of practice and collaboration to CMS in order to be reimbursed. Regulations regarding coverage of nurse practitioner services and collaboration are found below. Section C, 3, ii describes what nurse practitioners in independent practice states should do. A recent informal survey of nurse practitioners working in independent practice revealed that following these processes, they are able to obtain Medicare reimbursement for their billed services.

c. Medicare Part B covers nurse practitioners' services in all settings in both rural and urban areas, only if the services would be covered if furnished by a physician and the nurse practitioner-

1. Is legally authorized to perform them in the State in which they are performed;

2. Is not performing services that are otherwise excluded from coverage because of one of the

statutory exclusions; and

3. Performs them while working in collaboration with a physician.

i. Collaboration is a process in which a nurse practitioner works with one or more physicians to

deliver health care services within the scope of the practitioner's expertise, with medical

direction and appropriate supervision as provided for in jointly developed guidelines or other

mechanisms as provided by the law of the State in which the services are performed.

ii. In the absence of State law governing collaboration, collaboration is a process in which a nurse

practitioner has a relationship with one or more physicians to deliver health care services. Such

collaboration is to be evidenced by nurse practitioners documenting the nurse practitioners'

scope of practice and indicating the relationships that they have with physicians to deal with

issues outside their scope of practice. Nurse practitioners must document this collaborative

process with physicians.

iii. The collaborating physician does not need to be present with the nurse practitioner when the

services are furnished or to make an independent evaluation of each patient who is seen by the

nurse practitioner.

CRF250Xpert · Apr 21, 2011

in hindsight i wish i went to a pa program for the stronger didactic classes and the more organized clinical placements. this is why i have pushed to make this fellowship happen, so i will be a stronger provider when i am done. i am not a fan of the "nursing" approach, and i work with all my patients from the medical model. i don't see a place for any other mindset when practicing medicine.

i think you have a y-linked chromosomal disorder. given all of the years and $$ i've invested into nursing, i too wish i'd have chosen something else - like md. your rationale is exactly why i discourage everyone from trying to "get more rn skills" before doing xyz. as a fnp, i don't need more rn skills; i need to be a master diagnostician, drug expert, and planner. i'm certainly not masterful or omniscient yet, but i spend my day trying to be the best provider i can be.

folks forget that as they consider going to np school - the end result is a 100% role change that has nothing to do with rn skills. when we need nursing interventions performed, we write an order, ask the nurse to make it happen, and go see the next pt.

reeya · Apr 22, 2011

This speaks to a couple of things:
-The heterogeneity in NP curricula, particularly the clinical component. How can you transpose this model of education to a program that doesn't have an incoming class of all former CCU nurses?
-The disconnect between training an nurse and training an NP (a clinician). The concepts and connections when teaching physical diagnosis and lab/test interpretation are VASTLY different when teaching RNs (who will not be developing tx plans other than those w/in nursing scope) and NPs (who are diagnosing and treating). Whatever assessment skills you learned in nursing school are not the same as those taught (or should eb taught, in this case) at the NP/PA/MD/DO level.
-The direct entry NP programs can't even consider using this model if the MSN has no or minimal bedside experience.
Your example about PAs and NPs in the ED in WA just illustrates the regressive nature of PA practice in many states. To have different rules for what are essentially equivalent providers (in experienced, real world practice) demonstrates pure political gamesmanship.

I agree with you on both. No two NP schools are similar, i.e., the curricula varies among academic programs especially clinical component. So, it is the individual student's responsibility to research/talk to departments/profs before accepting admissions to tailor their individual needs. Our school does not admit new grad nurses or nurses with non acute experience (like school nurse, rehab nurse, nursing home nurse). For those RNs with non acute experience are required to gain at least 1 yr of acute RN experience. I am the only one in my program with least experience (2 yrs tele) and most of them are MICU, SICU, ICU, ER nurses. Some are in dual FNP/ACNP program. Sometimes, I feel dumb in front of them. I can only imagine if I went straight from BSN to MSN in other programs that accepted new grad RNs. I also agree that PA and NP are equivalent providers. I think WA is one of those 19 states with complete NP autonomy. Now, DNPs will be pushing hard to gain complete autonomy in other states. May be its time for you guys to be politically active too.

RN1980 · Apr 22, 2011

in mississippi there are vastly more np's providing care in the er's than pa's. i think there is just one pa program in the whole state and it might have just started about 1 yr ago. though i have worked and continue to work with many pa's while i go active duty in the nat. guard, but those have went to school elsewhere.

CCRNDiva, BSN, RN · Apr 22, 2011

i think you have a y-linked chromosomal disorder. given all of the years and $$ i've invested into nursing, i too wish i'd have chosen something else - like md. your rationale is exactly why i discourage everyone from trying to "get more rn skills" before doing xyz. as a fnp, i don't need more rn skills; i need to be a master diagnostician, drug expert, and planner. i'm certainly not masterful or omniscient yet, but i spend my day trying to be the best provider i can be.
folks forget that as they consider going to np school - the end result is a 100% role change that has nothing to do with rn skills. when we need nursing interventions performed, we write an order, ask the nurse to make it happen, and go see the next pt.

all i can say is my 7 yrs as a rn in the icu have given me a strong foundation to build my future career as an acnp. i am very fortunate to work with great docs who trust our judgement, enjoy teaching and view us as team members. i have been exposed to many disease processes and have thus learned several treatment protocols. i may not write the order but i know how to treat an acute chf exacerbation and manage a septic patient. i serve as a rapid assessment team and code blue responder so i know how to treat arrythmias, hemoynamic instability and pes. i am required to provide thorough assessments that our docs often base their treatment plans on. they are very receptive to our suggestions and very appreciative of the care we provide in their absence.

my career as a critical care rn have served me well and will serve my future patients as well.