NYT article on NPs - Doctoring, Without the Doctor

[blueridge]

There is a comment section following the article, and PAs already mentioned numerous times in comments.  Feeling particularly bold?  Work it!

 

http://www.nytimes.com/2015/05/26/health/rural-nebraska-offers-stark-view-of-nursing-autonomy-debate.html?ref=health

[delco714]

So much to comment on, don't know where to start. Not all nurses with master's degrees are NPs. There's a start. I perhaps will say in most cases, a holier than thou NP is probably better than no provider at all. There are truly places in this country where people have to travel ridiculous amounts for care. Hell if I'd be stuck out there practicing, kudos to those that want to, even though this article was drivel

[BruceBanner]

NPs never cease to amaze me with their Dunning-Krueger mentality. I think this guy has it mostly right:

 

I have been a family doc for 26 years. A few comments:
 

1. Nurse practitioners and physician assistants can do most of what I do. Physicians are over-trained for ear infections and stable diabetes. I could teach anyone at this blog to freeze warts.

2. NPs and PAs are more likely to have trouble with difficult cases, so immediate outpatient consultation (a doc on the premises, working with several NPs/PAs) makes clinical sense. It is unlikely to happen much. Corporations generally want doctors to have a full schedule in addition to helping out the other folks. This makes for a lousy job for the doctor. 

3. It depends on the field. NPs/PAs should not be orthopedic surgeons or radiologists. 

4. Docs are fighting a losing battle in some of the easier fields, like psychiatry or prim. care. Psychiatrists do not put stents into coronary arteries in the middle of the night. 

5. Over time, more and more docs will gravitate to the harder, more lucrative specialties and "going to see the doctor" will become less common. Some patients will resist but more will be ok with it. Heck, the NPs in our clinic are called doctor now. 

6. If an NP is willing to go to isolated area, most docs won't be worried about that. 

7. None of this will save any money. The income of family docs is a couple percent of total health care spending. 

8. NPs/PAs will drive out docs. Why should a med student spend 7 years in primary care training to be considered the equal of a nurse?

 

[db_pavnp]

Is there some forum out there populated by NPs ragging on PAs that I am unaware of?

[blueridge]

Essentially, I see such higher traffic comment sections as green pasture on which to piggyback on the NP press in a way that shines a bit of light on the PA profession.  Often, commenters lump NPs and PAs together in their assessments and perceptions.  However, many see it as an either / or issue - physicians or NPs - with no mention of PAs, which also makes mention of PAs all the more important.  Voices of PAs can enlighten the general public as well as healthcare policy makers who read these articles and comments.  It also provides a voice for those PAs who may wish to share their vision for the future of PAs - clinical doctorates or independence (or not…), etc. for those who desire such.  It is about presence, which can lead to articles on PAs too.  

[PACdan]

^^^Promote, promote, promote!

 

Our training, skills, and abilities are known within the medical community, but we don't have the "brand recognition" that NPs have.

[Acebecker]

I think one of the things that we need to get away from as PAs is offering the blanket statement that we are "just as good as our physician counterparts." 

 

In all of the comments that I read yesterday (and I read several hundred of them) the biggest and most repeated objection is the one along the lines of "How is a NP/PA's schooling equivalent to that of an MD/DO?  It's 2 years (part time on the part of the NP, I know) on top of an undergraduate degree whereas I (the doc) had to go to 4 years of med school and do a residency so there's no possible way the PA or NP can be equivalent to me." 

 

We all know of PAs and NPs who are equivalent diagnosticians (superior in some cases), equivalent in treatment planning, equivalent for skilled interventions/procedures, etc. to physician counterparts.  Heck, I think I'm pretty good at what I do and I think I'm just as good as the other doc who works at our urgent care with metrics to back up that claim. 

 

But we (both NPs and PAs) need to stop saying that we as a profession are equal to doctors.  Our new grads are not and were not made to be equivalent to MDs or DOs.  After 4-5 years in practice, yes, we likely are as good as many physicians out there.  We should have practice rights commensurate with that experience and skill, yes.  But out of the gate? No. 

 

I suggest that in our conversations with physician counterparts and physician leaders, we as a profession need to start making that distinction much more clear.  The general public and our colleagues need to know that we recognize the difference between a new grad and an experienced PA. 

 

We should also stop offering anecdotal evidence (like I just did) that defends our proposition that PAs are as good as MDs.  It can't be a claim about how "I picked up a diagnosis that this MD/DO missed," or "I know a PA who is treated like an ER attending."  We need data about inexperienced and experienced PAs which shows our learning curve, shows our knowledge base and our ability to equal the care provided by our colleagues. 

 

Any thoughts on this?

[EMEDPA]

Is there some forum out there populated by NPs ragging on PAs that I am unaware of?

allnurses.com

[EMEDPA]

I think one of the things that we need to get away from as PAs is offering the blanket statement that we are "just as good as our physician counterparts." 

 

In all of the comments that I read yesterday (and I read several hundred of them) the biggest and most repeated objection is the one along the lines of "How is a NP/PA's schooling equivalent to that of an MD/DO?  It's 2 years (part time on the part of the NP, I know) on top of an undergraduate degree whereas I (the doc) had to go to 4 years of med school and do a residency so there's no possible way the PA or NP can be equivalent to me." 

 

We all know of PAs and NPs who are equivalent diagnosticians (superior in some cases), equivalent in treatment planning, equivalent for skilled interventions/procedures, etc. to physician counterparts.  Heck, I think I'm pretty good at what I do and I think I'm just as good as the other doc who works at our urgent care with metrics to back up that claim. 

 

But we (both NPs and PAs) need to stop saying that we as a profession are equal to doctors.  Our new grads are not and were not made to be equivalent to MDs or DOs.  After 4-5 years in practice, yes, we likely are as good as many physicians out there.  We should have practice rights commensurate with that experience and skill, yes.  But out of the gate? No. 

 

I suggest that in our conversations with physician counterparts and physician leaders, we as a profession need to start making that distinction much more clear.  The general public and our colleagues need to know that we recognize the difference between a new grad and an experienced PA. 

 

We should also stop offering anecdotal evidence (like I just did) that defends our proposition that PAs are as good as MDs.  It can't be a claim about how "I picked up a diagnosis that this MD/DO missed," or "I know a PA who is treated like an ER attending."  We need data about inexperienced and experienced PAs which shows our learning curve, shows our knowledge base and our ability to equal the care provided by our colleagues. 

 

Any thoughts on this?

agree. places need to stop lumping all PAs together regardless of background or years of experience. someone with a "traditional" hce background and several years experience is degrees of magnitude ahead of a new grad who was a cna for 200 hours yet many health care organization treat them the same.

[db_pavnp]

allnurses.com

 

Yeah?  Where?

[acozadd]

emedpa- And as you always fail to mention, there are PAs without a traditional nursing, medic, RT background that are magnitudes ahead of those that do have such a background upon graduation. :)

[EMEDPA]

emedpa- And as you always fail to mention, there are PAs without a traditional nursing, medic, RT background that are magnitudes ahead of those that do have such a background upon graduation. :)

exception, not the rule.

[EMEDPA]

Yeah?  Where?

do a little digging. not hard to find.

[acozadd]

It completely depends on the field of prior medical experience, and the field that you ultimately practice. If we all worked in primary care or ED, then your statement might apply. but PAs work in nearly all specialties. I think your opinion is slightly tainted as you went from medic to ED PA, but we've gone round with this before so it's not worth getting into again :)

[Acebecker]

It completely depends on the field of prior medical experience, and the field that you ultimately practice. If we all worked in primary care or ED, then your statement might apply. but PAs work in nearly all specialties. I think your opinion is slightly tainted as you went from medic to ED PA, but we've gone round with this before so it's not worth getting into again :)

 

I think this is more person dependent than past-medical-experience dependent.  Some people have the drive to learn their stuff and they have a brain that can take book smarts and put it into practice effectively even though they did not have a lot of HCE.  Others that I have seen have a lot of street smarts and excellent HCE but have no drive/desire and so end up as mediocre as the rest of us.  The idea candidate will have a combination of the two.

[tunafish]

i still want to learn from someone how prior career of CNA, EMT or even RN can prepare you to be a better PA-C...apart from obvious "yes, I can deal with sick and sad individuals and I want to help them". None of above mentioned jobs have a slightest component of clinical thinking and reasoning, which is the main differentiating criterion between medical specialties. If you have Dx written on a patient's chart that any monkey can open "uptodate" and start treatment (apart from technicality of the surgery and procedures) but to get that Dx and get it correctly - this is what medical education is all about.

[tunafish]

In all of the comments that I read yesterday (and I read several hundred of them) the biggest and most repeated objection is the one along the lines of "How is a NP/PA's schooling equivalent to that of an MD/DO?  It's 2 years (part time on the part of the NP, I know) on top of an undergraduate degree whereas I (the doc) had to go to 4 years of med school and do a residency so there's no possible way the PA or NP can be equivalent to me." 

 

We all know of PAs and NPs who are equivalent diagnosticians (superior in some cases), equivalent in treatment planning, equivalent for skilled interventions/procedures, etc. to physician counterparts.  Heck, I think I'm pretty good at what I do and I think I'm just as good as the other doc who works at our urgent care with metrics to back up that claim. 

 

But we (both NPs and PAs) need to stop saying that we as a profession are equal to doctors.  Our new grads are not and were not made to be equivalent to MDs or DOs.  After 4-5 years in practice, yes, we likely are as good as many physicians out there.  We should have practice rights commensurate with that experience and skill, yes.  But out of the gate? No. 

 

 

 

I can only speak from my experience and this is what I see. Our program is within school of medicine and we interact with medical students on a regular basis. When we compare 2 years to 4 years - we are comparing apples to oranges. PAs have classes 8-5, MDs - 8-12 every day. Yes, they study in the afternoon, but so do we at night. They have way more "life balancing" activities planned that we couldn't dream of attending. They get 6-8 weeks off MS-2 for step I prep. They have most of MS-4 dedicated to elective activity with a huge chunk of time for residency interview travel. They have 3 year FM fast track ;-)

We had several classes with them during our didactic year. Anatomy, for example. We were together from 8-12 and then they went on with their lives and we had to be in class till 5. Yet we took same practical and same exam. And yet, our class average was higher than theirs. Now we are taking same rotation for family med as MS-3. We take the same shelf exam as they are. Our "honors" set at 10% higher than theirs (93% vs. 83%) and our fail is also 10% higher. So how is my education any different when I am new grad PA and they are PGY-1? Well, when they are done with residency, I will be 3 years on the job and there lots of things would depend on me. I could continue to learn or just go with the flow, but the education that we are getting in our program is definitely on par with medical school at our university. I can say more, we have a great respect of our med students and I think it is deserved.

I think MD way more superior to PA in other venues that docs can take: scientific and medical research, education, public speaking, consulting... there is simply no emphasis on those in PA school. But in medicine... we never had any lecturer say "you do not need to know it".

Again, I am not for the argument "We are equal with MDs (because we are not)" but I also do not want to have a stigma that I had some sort of half-ass medical learning experience that makes my care "midlevel" at best.

[EMEDPA]

i still want to learn from someone how prior career of CNA, EMT or even RN can prepare you to be a better PA-C...apart from obvious "yes, I can deal with sick and sad individuals and I want to help them". None of above mentioned jobs have a slightest component of clinical thinking and reasoning, which is the main differentiating criterion between medical specialties. If you have Dx written on a patient's chart that any monkey can open "uptodate" and start treatment (apart from technicality of the surgery and procedures) but to get that Dx and get it correctly - this is what medical education is all about.

a lot of medicine is pattern recognition. if you have seen the pattern 500 times it is obvious. if you have never seen it, "simple stuff" to a former medic or RN is not even considered by someone without that frame of reference.

Being a medic (my prior hce) requires a lot of what PAs do: take a hx, see a pt who has not had a prior evaluation for a given problem, do a physical, come up with a probable dx and initiate tx, all in the matter of a few minues on pts who may be in emergent need of medical treatment.

things like cna or medical assistant, while helpful, are not on the same level as medic, resp. therapist, or RN when it comes to prior responsibility and independent decision making, things important to every pa. not everyone can tell you their prior hx and meds. working up undifferentiated pts from scratch comes easy to folks with prior significant experience because they have already been doing it for years.

[acozadd]

EMEDPA- Your patient is a 27 year old male with an acute onset of hand/wrist pain with subjective instability following trauma.

 

The respiratory therapist has stabilized the airway, and the medic found a tree branch to splint it for comfort... now what?

[db_pavnp]

I can only speak from my experience and this is what I see.

 

I don't know what to think when PA students take the same coursework as med students.

 

Please bear with me on this, but why would you take the same anatomy class when you will never perform surgery or work as a radiologist?  What is also weird is that I know PA/NPs work in infectious disease, but I have never seen anyone suggest that they took micro with the med students (who sometimes take micro with the lab students).

 

Do you think PANCE has the expectation that you essentially get med school level anatomy?

[EMEDPA]

I don't know what to think when PA students take the same coursework as med students.

 

Please bear with me on this, but why would you take the same anatomy class when you will never perform surgery or work as a radiologist?  What is also weird is that I know PA/NPs work in infectious disease, but I have never seen anyone suggest that they took micro with the med students (who sometimes take micro with the lab students).

 

Do you think PANCE has the expectation that you essentially get med school level anatomy?

different programs have pa students doing some courses with med students. I could see anatomy being the same, but not a class like physiology.

[CAAdmission]

But we (both NPs and PAs) need to stop saying that we as a profession are equal to doctors.  Our new grads are not and were not made to be equivalent to MDs or DOs.  After 4-5 years in practice, yes, we likely are as good as many physicians out there.  We should have practice rights commensurate with that experience and skill, yes.  But out of the gate? No. 

 

Depends upon your definition of "out of the gate."

 

If you mean at graduation from school, I have found most PA students are certainly better clinicians than most medical students. PA school is a lot of applied, practical knowledge. Med school is a lot of fancy talk about things like embryologic development that don't apply to the bulk of clinical situations. If you give a med student a slide they can tell you where a cell came from but they don't know how to stop bleeding. Most med students are also incredibly lethargic on rotations not applicable to the specialty they intend to go into. 

 

If you are comparing graduation from PA school to completion of a residency, that is not apples to apples. 

 

If you want to compare the ability of a PA who graduates and works 3 years in family practice to a physician who just completed their 3 year residency, they should be pretty close.

 

"Out of the gate" I would never compare PAs to NPs. If you hire a PA you know exactly what their training was. NP coursework is an unstandardized patchwork of nursing philosophy, leadership and other idiocy designed not to serve patients but to take over the healthcare system. NPs can certainly catch up with experience but their curriculum is junk.

[acozadd]

db_pavnp-- in response to your quote (for some reason I am not able to use the quote function lately)...

 

My program also took a significant portion of our coursework with the med students, particularly second year students (pharm, surgical skills, renal, pulm, etc.). Our general science lectures were generally by the same professors that taught the med students, with the same powerpoints. That includes anatomy, etc. Like the poster above, we had 4 hours of extra lecture per day compared to the med students, and our expectations for "passing" was an 80% vs. their 70%.

 

Since anatomy, physiology, and pathophysiology are an integral part of medicine, it only makes sense that our standards should be no less.

[db_pavnp]

By that argument, how do you get a pass out of taking anything "integral" to medicine?  Why avoid microbiology, embryology, biochemistry, and immunology other than you just don't need it at that level for PANCE?

[acozadd]

All of those topics were covered in PA school as dedicated courses. I cannot compare the level/depth they were taught at compared to the med students, because we took these during the summer while the MS1s were on summer break, but as I mentioned before, we had the same professors and often same powerpoints. There was probably consideration as to what information was vital/clinically relevant, and the information that was trivial but necessary for STEP 1, but that's an assumption.

 

FWIW, in ortho none of those topics are clinically relevant ;)