NPs are killing us

[EMEDPA]

13 hours ago, lkth487 said:

That is very interesting!  Was he bound by the rules and regulations that governed residents?  He had to complete all four years including the intern medicine year?  That sounds like a long time to spend if you're not going to be BE at the end.

He was already working for the PM&R dept as a pa at basically a resident's salary, so it was budget neutral. don't know specific details of what he did and did not do, but I would guess he probably did the pgy-2 to 4 component and not the intern year. could be wrong. it was a while ago.

[lkth487]

That's cool!  (if you want to work resident salary)

[HmTwoPA]

I've been watching this thread for a while. I was not going to say anything, but I guess I'll chime in. I've met some terrible PA's and some terrible NP's, and even more so terrible MDs. I am a 2nd year PA student with LVN experience and Corpsman experience. In my school, which I applied to because of the "high" Clinical experience requirements, most of the students (30-40%) are previous scribes. My wife on the other hand is an RN and she still is able to compete with me when we have medical "discussions". PAs might have been hot shit back in the day, but now they are just pumping out scribes with high GPAs. At the same time my buddies from the Navy with multiple pumps attached to Marines cant get into PA school, because they have a gpa of 3.4. 

[ilygurlie]

11 minutes ago, HmTwoPA said:

I've been watching this thread for a while. I was not going to say anything, but I guess I'll chime in. I've met some terrible PA's and some terrible NP's, and even more so terrible MDs. I am a 2nd year PA student with LVN experience and Corpsman experience. In my school, which I applied to because of the "high" Clinical experience requirements, most of the students (30-40%) are previous scribes. My wife on the other hand is an RN and she still is able to compete with me when we have medical "discussions". PAs might have been hot shit back in the day, but now they are just pumping out scribes with high GPAs. At the same time my buddies from the Navy with multiple pumps attached to Marines cant get into PA school, because they have a gpa of 3.4. 

100% agree with this. It seems like nowadays everyone gets into PA straight from undergrad if they have a 3.6 or higher with some scribe experience - no better than the NPs who enter a direct BSN to MSN program (but at least they have to go through clinicals in the BSN program). I just think that PAs generally have much more thorough, scientific training with no "fluff" courses. Acceptance rates are also much lower than NP programs but the quality of accepted students of both NP and PA programs may be just the same. 

[HmTwoPA]

They also have less of an applicant pool, so that may skew the numbers on acceptance rates. I have met amazing NPs that are extremely knowledgeable. I dont know about fluff courses in NP school because I have never been to one. I do know some of my classmates were "super nervous" about talking to patients, because they didn't know how to talk to them. We had a two day course on how to talk to patients. If healthcare experience was a real requirement, we wouldn't have to do this. 

[camoman1234]

17 minutes ago, HmTwoPA said:

They also have less of an applicant pool, so that may skew the numbers on acceptance rates. I have met amazing NPs that are extremely knowledgeable. I dont know about fluff courses in NP school because I have never been to one. I do know some of my classmates were "super nervous" about talking to patients, because they didn't know how to talk to them. We had a two day course on how to talk to patients. If healthcare experience was a real requirement, we wouldn't have to do this. 

Well you still would have to do the "two day course on how to talk to patients" even with HCE. I am not sure what you mean by "learn how to talk", but I take that is how to ask open ended questions and how to direct your questions toward the most likely diagnosis. Now I maybe wrong on how I interpret your dictum, but if you had a few days on how to just talk to people then we do have a problem. Please let me know what you mean by that 2 day class.  

[HmTwoPA]

1 minute ago, camoman1234 said:

Well you still would have to do the "two day course on how to talk to patients" even with HCE. I am not sure what you mean by "learn how to talk", but I take that is how to ask open ended questions and how to direct your questions toward the most likely diagnosis. Now I maybe wrong on how I interpret your dictum, but if you had a few days on how to just talk to people then we do have a problem. Please let me know what you mean by that 2 day class.  

No I wish it was about open ended questions. It was about how to be comforting and talk in a demeanor that was appropriate for the "scenarios" that they gave us. Things that I feel would be common sense to most people, but I was wrong.

[south]

17 hours ago, Marinejiujitsu said:

Is it just me or does anyone else think scribe work is some of the best experience you can get including 30 yr RN experience. (And that's not hating)

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I tend to agree.  When I happened upon a scribe, it took me about 30 seconds to realize that this is what I needed.  I would have paid for this experience, and it worked.  It was made very clear to me that I was a shoo-in for PA school based on my scribe experience. In fact, I hardly said anything at all in my interview as they went on and on about it.  

However, I will (and have been) the first to add that it doesn't stand alone.  You also need quality, touch-the-patient HCE (I was an EMT but struggled to get a decent amount of hours).  

But as an adjunctive experience, it's a one-two punch that cannot be beat. 

Others may disagree, but as we all know, those who disagree with me are wrong.

[Joelseff]

I see them stronger out of school charting and formulating a good differential in ER medicine. At least a good one I would imagine. I wasn't a scribe btw. Lol.

 

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I figure they would perform better at documentation but forming a ddx requires having some experience and training in diagnostics and pathophysiology. I don't know if they would be better than other students. Disclosure: all my PA students were clinicians (RT, EMT-P, RN etc) I have not had a scribe student but have scribes in the office and I doubt they can formulate a good viable ddx at their point in their career... The other jobs I mentioned will probably (im willing to bet) do better at ddx because they've seen it before or cared for someone with it before. But that's what PA school is for. Those scribe PA students (again I'm willing to bet) will have a better grasp at pathophysiology, pharmacology, A&P than the NP students I've seen.

 

I have a current NP student now who is really good but she was a MD in Asia and complains about the lack of depth and fluff work she has at her program (one of the top programs out here in California).

 

I enjoy teaching her because I don't have to cover much of the basics with her beyond a brief review/reminder and we actually have very good discussions on topics that are beyond basic. I actually let her see my more complex pts. She's an awesome provider.

 

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[Joelseff]

I've been watching this thread for a while. I was not going to say anything, but I guess I'll chime in. I've met some terrible PA's and some terrible NP's, and even more so terrible MDs. I am a 2nd year PA student with LVN experience and Corpsman experience. In my school, which I applied to because of the "high" Clinical experience requirements, most of the students (30-40%) are previous scribes. My wife on the other hand is an RN and she still is able to compete with me when we have medical "discussions". PAs might have been hot shit back in the day, but now they are just pumping out scribes with high GPAs. At the same time my buddies from the Navy with multiple pumps attached to Marines cant get into PA school, because they have a gpa of 3.4. 

It is sad. The tide turned a bit. If you have been around these forums long and read my posts, I have always been a proponent of high HCE high GPA applicants. But like I mentioned, my PA students have all been good and were previous clinicians. I only precept for PA schools with good HCE requirements. Now even my Alma mater caved in to the low to no HCE gospel and this is probably my last year as a preceptor for them. I already decided after my current NP student graduates, I'm done with NP students as well.

 

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[lkth487]

Just to just play the devil's advocate here, is prior HCE really that important? Meaning, if you come in as a student six months ahead of another student, does it really matter five years down the road?  I interviewed people for med school, and I didn't really care how much healthcare experience they had (I wasn't in the final decision committee so who knows how much my evaluations mattered in the end) - I cared more about their reasoning abilities and critical thinking skills as demonstrated by past endeavors and by talking to them.  I feel like you can teach someone the medicine, but it's much harder to teach the other stuff.

[lkth487]

Just to expand on it a little bit:  if you count med school, residency and fellowship, ill have ten years of training before I'm fully independent.   And from what attendings tell me, the first two years as an attending are also incredibly steep in terms of a learning curve.  I think that's true for anyone. So in some sense you're always getting more "HCE" for the rest of your career.  Does having six months more of it prior to school really matter?  If I had someone who knew how to start IVs and take vitals and knew what a low vs high MCV on a CBC meant - well that's fantastic - but I can teach those skills and knowledge.  I'd rather have a PA student/med student who can look at that new study published in a journal and tear apart the methodology and critically think through the implications.  Because latter is a skill that (in my opinion) is harder to teach than the former. 

Obvously, it's not an either/or thing, and the ideal candidate maybe should have both.  But if we are making that choice - the guy who has the clinical experience may be the better student during the clinicals, but in the grand scheme of things, looking over a 30-40 year career in medicine, it's the critical thinking, analysis, logic (e.g. that skills you learn while solving physics or math problems) that is going to be much more useful to you.  

Ill give you an example, I had a PA student rotate with us a few months ago on my service (inpatient peds, large peds university hospital) and we were talking about a post op liver transplant baby.  She  went to the primary literature (e.g. the footnotes on the recommendations) and brought it to our attention that even though the official recommendations said so, the way the study was designed meant that we couldn't really use that on our patient.  It changed our management and I'll be the first to admit that even though I've been treating post op liver kids for my entire residency, I hadnt looked that deeply into the literature. 

Now this student is/was no good at anything clinical - she couldn't even take a BP properly.  I'm sure she didn't have a lot of experience prior to PA school.  But based on my interactions, she will for sure pick up the clinical skills and knowledge, and I think she'll run circles around me ten years from now (I tried to convince her to go into my field :p).  

I gave her a glowing recommendation because she was smart in the way that matters and will really help her and her patients long term.  That's the kind of student I would pick any day over someone who had 10 years of healthcare experience. 

[Marinejiujitsu]

I don't know how many nurses, some even retired asking for antibiotics for their URI/Bronchitis. Sorry to break it to you with your 30 yrs experience but zithromax is an antibiotic meaning it does not do crap for your bronchitis. Lol.


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[HmTwoPA]

7 hours ago, Marinejiujitsu said:

I don't know how many nurses, some even retired asking for antibiotics for their URI/Bronchitis. Sorry to break it to you with your 30 yrs experience but zithromax is an antibiotic meaning it does not do crap for your bronchitis. Lol.


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I've noticed this in older patients that state they are "nurses", but I always wonder if they were really nurses. Ive heard people call themselves nurses when they are MAs or CNAs. I once had a patient tell me she used to be a Physician Assistant because she assisted the Physician when he was setting up for procedures in the 70s. 

[camoman1234]

10 hours ago, lkth487 said:

Just to expand on it a little bit:  if you count med school, residency and fellowship, ill have ten years of training before I'm fully independent.   And from what attendings tell me, the first two years as an attending are also incredibly steep in terms of a learning curve.  I think that's true for anyone. So in some sense you're always getting more "HCE" for the rest of your career.  Does having six months more of it prior to school really matter?  If I had someone who knew how to start IVs and take vitals and knew what a low vs high MCV on a CBC meant - well that's fantastic - but I can teach those skills and knowledge.  I'd rather have a PA student/med student who can look at that new study published in a journal and tear apart the methodology and critically think through the implications.  Because latter is a skill that (in my opinion) is harder to teach than the former. 

Obvously, it's not an either/or thing, and the ideal candidate maybe should have both.  But if we are making that choice - the guy who has the clinical experience may be the better student during the clinicals, but in the grand scheme of things, looking over a 30-40 year career in medicine, it's the critical thinking, analysis, logic (e.g. that skills you learn while solving physics or math problems) that is going to be much more useful to you.  

Ill give you an example, I had a PA student rotate with us a few months ago on my service (inpatient peds, large peds university hospital) and we were talking about a post op liver transplant baby.  She  went to the primary literature (e.g. the footnotes on the recommendations) and brought it to our attention that even though the official recommendations said so, the way the study was designed meant that we couldn't really use that on our patient.  It changed our management and I'll be the first to admit that even though I've been treating post op liver kids for my entire residency, I hadnt looked that deeply into the literature. 

Now this student is/was no good at anything clinical - she couldn't even take a BP properly.  I'm sure she didn't have a lot of experience prior to PA school.  But based on my interactions, she will for sure pick up the clinical skills and knowledge, and I think she'll run circles around me ten years from now (I tried to convince her to go into my field :p).  

I gave her a glowing recommendation because she was smart in the way that it matters and will really help her and her patients long term.  That's the kind of student I would pick any day over someone who had 10 years of healthcare experience. 

But how about myself or others that had > 5 years of HCE in EMT-P, RRT, RN? We do not have to be trained to assess a patient if they are "sick or not", which as you know comes with time. That is something you cannot really teach, just comes with experience. The BP measurement is not a big deal as you can train almost anyone in 1 hour how to take a BP. Same as an IV and other procedural skills. I agree about the literature interpretation is important, but you get a lot of that in your courses of EBM (we had 1 year of EBM) and it was not that easy. I have a friend that is in his 1st year of ER residency, he was a former RRT x 6 years. I bet he has to refresh on a few things, but the over concept and skills he had will just come natural such as intubation (when, how, etc), non-invasive ventilation, unconventional ventilation, assessment of ABGs/VBGs (and how to draw and perform Allen's test, etc), capnography, etc. I would think someone with good/strong HCE would run circles around all the newer PAs coming out and plus PA school is 100 weeks on average where medical school is around 150 weeks plus residency so you guys have a lot more time to fine tune your skills so having a previous background in healthcare is very important to me. 

[lkth487]

I understand where you are coming from - and as you say, PA school is 100 weeks and residency is where you pick up the bulk of your clinical skills.  Most PAs don't do a residency so that training happens on the job, which is fine. But that's where you'll pick up your clinical skills as it pertains to that specialty.    Is the goal to be a completely independent practitioner day one out of school in any specialty in medicine from neonatology to neurosurgery? I don't think that's a reasonable goal in a 100 weeks. Hell, it's not a reasonable goal if you had a 1000 weeks. I think most people realize (just as they do with new interns), that there is going to be a training period.  Yes, it's great if you come out of school knowing ventilator management, and you'll be ahead of the guy who didn't have that stuff for what? 6 months until it equalizes?   A year? In the grand scheme of a career, it's not that long.  Hell, I didn't know ANY vent stuff coming out of med school.  It was fine.  MAC was a computer and a Miller was my wife's maiden name.  But a great PA taught me when I rotated through the ICU.  You learn.  What is more important are people who know how to think and how to learn and how to critically analyze information.

I've taken a lot of EBM courses in med school and we have a regular journal club in residency....but I got to tell you, maybe yours was better, but mine was pretty much absolutely nonsense.  It was just memorizing a bunch of formulas to calculae PPV and sensitivity and some analysis of papers, but very superficial and not really in the same critical way that you need to have to really make a difference.  I think those skills take a long time to learn - and you have to keep doing it and be critiqued on it.   

[HmTwoPA]

3 minutes ago, lkth487 said:

PA school is 100 weeks and residency is where you pick up the bulk of your clinical skills, which is something most PAs don't have.

Umm... I think this may be the wrong forum to post this on. 

[lkth487]

I meant a lack of a residency, not a lack of clinical skills...haha. Edited my post to make that clearer.

PAs who get a job in a specialty usually get trained and pick up the clinical skills on the job rather than a formal residency.  Though I know there's more and more residencies out there now for PAs. 

[LT_Oneal_PAC]

26 minutes ago, lkth487 said:

I understand where you are coming from - and as you say, PA school is 100 weeks and residency is where you pick up the bulk of your clinical skills, which is something most PAs don't have.  But is the goal to be a completely independent practitioner day one out of school in any specialty in medicine?  I don't think that's a reasonable goal in a 100 weeks. I think most people realize (just as they do with new interns), that there is going to be a training period.  Yes, it's great if you come out of school knowing ventilator management, and you'll be ahead of the guy who didn't have that stuff for what? 6 months until it equalizes?   A year? In the grand scheme of a career, it's not that long.  Hell, I didn't know ANY vent stuff coming out of med school.  It was fine.  MAC was a computer and a Miller was my wife's maiden name.  But a great PA taught me when I rotated through the ICU.  You learn.  

I've taken a lot of EBM courses in med school and we have a regular journal club in residency....but I got to tell you, maybe yours was better, but mine was pretty much absolutely nonsense.  It was just memorizing a bunch of formulas to calculae PPV and sensitivity and some analysis of papers, but very superficial and not really in the same critical way that you need to have to really make a difference.  I think those skills take a long time to learn - and you have to keep doing it and be critiqued on it.   

Agreed. I had a buddy in PA school without a day of clinical experience vs my 5 years in critical care RN. He is a better clinician than me, way better. I handle more stuff because he is more content with doing less, I’m doing a residency, and I taught him the physics of the heart, but he is like a living textbook and has the common sense to apply it better than anyone. 

One’s personal characteristics trumps all else.

[lkth487]

Good critical care nurses are the best.  There is this one nurse in the PICU who's been doing this for 40 years, and when I was an intern, I was there at night sitting next to her and something happened and all of a sudden she BOLTED to a patients room across the unit. I was like that's odd, and was going to finish my note but when I looked over, my senior had a look on his face...and I knew he just shit his pants as he was scrambling to get up and run after her.  

 

I didn't realize until later that for an excellent experienced nurse like that to actually RUN, some REAL shit had to be going down.  Not your run of the mill code. 

[Marinejiujitsu]

I meant a lack of a residency, not a lack of clinical skills...haha. Edited my post to make that clearer.
PAs who get a job in a specialty usually get trained and pick up the clinical skills on the job rather than a formal residency.  Though I know there's more and more residencies out there now for PAs. 

Yeah, I don't think anyone is ready for independent practice without a residency or with at least 3-5 yrs of work experience in a teaching hospital. I've seen where brand PAs and NPs are put into independent roles in the ER. Scary.

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[sas5814]

Well it is deep into this thread but this morning I got an email from senior management stating they have been discussing my thoughts on these leadership positions and would like to continue the discussion with me involved. I don't know what will come of it but my early indicators are the people they picked haven't a clue what they are doing or how they are supposed to do it. "My" APP leader's first email was a "please send me your resume so I can get to know you" and the second was "you aren't doing chart reviews so send me a copy of them every month so I know they are being done."

For crying out loud....all the organization has done is add another unneeded level of administration to an already bulky machine.

[Anachronist]

As a PA-S matriculating this year with prior experience in EMS and an immediate family consisting of nurses, MDs, and PhDs, I find this thread a bit disheartening.

There are good MDs and bad MDs, and good and bad everything else including PhDs, PAs, NPs, nurses, and of course admins. Yes nurses have a powerful lobby, and have been at it a lot longer than PAs, some of the very first generation still practicing. Picking fights within respectable professions is a bad strategy. The focus should be on improving patient care and the tools students are given. If you want to compete with NPs then best them as clinicians (we might both benefit from such a friendly competition), the education fight will go nowhere, especially when it comes to HCE, after all, you can go to med school with zero, making any bickering about it irrelevant. 

Neither "philosophy" or "model" if you will, PA or NP, is without merit. Both methods have pros and cons and subsequently both professions have characteristics that are beneficial. And picking a fight with nursing whose NPs outnumber PAs (marginally) and whose RNs outnumber PAs (by about 30:1), is a fool's errand. 

I'm not saying don't lobby and don't push for a name change to Associate, but don't do it in the vein of "because we're better than NPs." That doesn't help anyone (not to mention isn't true; different yes, but "better" cannot be objectively quantified), and just makes an enemy of our fellow health care providers and a much more powerful lobby/union. And if you can't handle that reality, then go to med school and leave it all behind. If you're in any health care profession for money, accolades, or so you can become an administrator, I'm sorry to inform you, you chose poorly.

[Lexapro]

Comparing scribe experience to RN (or other clinician) experience is just ridiculous.

[sas5814]

Anachronist don't be disheartened. This kind of conversation goes on all the time and has for a long long time. It isn't limited to here. I have heard vitriol and derision the likes of which boggle the mind. I have been known to do it myself in the past. It is a manifestation of frustration and those kinds of conversations are becoming fewer as the years go by. It also isn't limited to us. The things I have heard said by physicians or NPs when they didn't know I was a PA would curl your hair.

My original post was about the NPs being wayyyyyy ahead of us in promoting themselves and their profession. Any "us vs them" is pointless. It's more...let's learn from them.

Being a youngster in the profession I promise you are going to be witness to some of the most seismic changes this profession has ever seen and they have already started. PAs seeking OTP...starting to work with NP groups instead of against them....physicians getting more comfortable with the idea there are more people in healthcare than physicians. These things all started years ago and have gained traction slowly. The folks who want to stay mired in the past will eventually fade away or be marginalized. It is all part of a complex evolution and you will get to see it and, if you choose, be a force in it.