NPs are killing us

[Marinejiujitsu]

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.

Physicians are losing out to the PA/NP because we are cheaper labor. PAs are losing out to NP because they are growing with independent practice. That's what this threads about. Being a better clinician is just a pissing contest.

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[Marinejiujitsu]

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

It doesn't compare but when you work in the ER. I feel the charting is better out of the great as well as the differentials/treatment plan if they have been a scribe 30 hrs a week for 3-5 yrs. How can anything but a corpsman or foreign medical doctor be better than that. I wasn't a scribe btw. paramedics would excel in codes but what percentage of the job is that. Nurses maybe able to see big sick if they were icu/ER but if they were nursing home it's more like they were a medical assistant from what I see. RT better with lung exams but 90% of the job is forming differentials and charting.

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[jwells78]

On 2/7/2018 at 8:30 PM, Joelseff said:

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

Just wanted to comment on this little point.  

The beauty of experience as a scribe, assuming it is an acute care environment, is that you see the mechanics of formulating the DDX, you see all the imaging alongside the Doc, and if you pay attention and ask questions,  they'll teach you like a resident.

 

No, there is no hands-on component, and that is big---  but having several years experience in the mechanics of medicine is a HUGE asset on the road to any career as a provider.  Better experience than a lot I've seen, anyway.

[fishbum]

46 minutes ago, Marinejiujitsu said:

 paramedics would excel in codes but what percentage of the job is that. 
 

Codes aren't a big percentage of what paramedics do either...they have to be good at a little bit of everything (including charting that's done on every pt). Not hating on scribes by any stretch, but I wouldn't trade my past experience for anything. 

[Marinejiujitsu]

Codes aren't a big percentage of what paramedics do either...they have to be good at a little bit of everything (including charting that's done on every pt). Not hating on scribes by any stretch, but I wouldn't trade my past experience for anything. 

Not knocking paramedics either. Not a scribe either. Seems like most PAs are scribes but from what I see a lot in the ER is that the physicians invest in teaching the scribes a lot and sometimes the EMT/Paramedics are seen as delivery drivers.

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[Marinejiujitsu]

Gosh, my grammar sucks. Lol. To be more clear. It seems as physicians will invest in teaching a good scribe.

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[HmTwoPA]

5 hours ago, Marinejiujitsu said:

It doesn't compare but when you work in the ER. I feel the charting is better out of the great as well as the differentials/treatment plan if they have been a scribe 30 hrs a week for 3-5 yrs. How can anything but a corpsman or foreign medical doctor be better than that. I wasn't a scribe btw. paramedics would excel in codes but what percentage of the job is that. Nurses maybe able to see big sick if they were icu/ER but if they were nursing home it's more like they were a medical assistant from what I see. RT better with lung exams but 90% of the job is forming differentials and charting.

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I think you might be misinformed on what nurses do. RNs in a nursing home run it. They have CNAs and LVNs that run around and do everything while they are more admin. I know RNs that work in SNFs that have 32 patients under them, because they do mostly admin... maybe positions like this are why they get into leadership more often. RNs not only work in ICU/ER that see sick patients. You have Med surg, oncology, OR, Tele, Neuro floors. They constantly are catching providers mistakes, especially residents. The provider sees the patients once a day if that. The rest of the monitoring and decision making is up to the RN. I cant tell you the number of stories my wife has told me about catching orders ,inappropriate discharges and other things that residents are putting in the computer when they have never seen the patient that day. Outpatient clinic RNs often do a lot of phone triage. Being a nurse requires critical thinking and they put their ass on the line each time they make decisions. The misinformation of nurses on this forum is kind of surprising. Its almost like when I hear people not in medicine talk about how bad a doctor or PA is for making a decision that makes sense medically.  

[EMEDPA]

I have seen very little teaching of scribes during my time working in EDs that have them. they don't order things without being told to do so and NEVER touch a pt. from the perspective of someone who has had medics and scribes as students (with all else being equal) I would prefer a medic hands down as a pa student.

[Marinejiujitsu]

I think you might be misinformed on what nurses do. RNs in a nursing home run it. They have CNAs and LVNs that run around and do everything while they are more admin. I know RNs that work in SNFs that have 32 patients under them, because they do mostly admin... maybe positions like this are why they get into leadership more often. RNs not only work in ICU/ER that see sick patients. You have Med surg, oncology, OR, Tele, Neuro floors. They constantly are catching providers mistakes, especially residents. The provider sees the patients once a day if that. The rest of the monitoring and decision making is up to the RN. I cant tell you the number of stories my wife has told me about catching orders ,inappropriate discharges and other things that residents are putting in the computer when they have never seen the patient that day. Outpatient clinic RNs often do a lot of phone triage. Being a nurse requires critical thinking and they put their ass on the line each time they make decisions. The misinformation of nurses on this forum is kind of surprising. Its almost like when I hear people not in medicine talk about how bad a doctor or PA is for making a decision that makes sense medically.  

I'm not discounting others, I've seen non medical people that are pretty savy. Overall, as said in a previous post, its about the individual. We have pretty crappy RNs in SNFs over here. I bet 10% of PA students are scribes now, just sticking up for them.

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[Joelseff]

...and if you pay attention and ask questions,  they'll teach you like a resident...

This can be said for other pre-pa jobs as well

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[Kaepora]

1 hour ago, Joelseff said:

 

 

This can be said for other pre-pa jobs as well

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RNs and RTs are present for teaching rounds, every day, for each of their patients.  So that argument is a wash.

[Joelseff]

RNs and RTs are present for teaching rounds, every day, for each of their patients.  So that argument is a wash.

I think we are making the same point about scribes.

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[jwells78]

26 minutes ago, ACNPstudent said:

RNs and RTs are present for teaching rounds, every day, for each of their patients.  So that argument is a wash.

Look, I'm not arguing that experience as a scribe is "better" than exp. as an RN or RT.  I started at the bottom and worked my way up, so I understand the roles.

 

But dont try to tell me "being present for rounds in the morning" is the same as being attached at the hip to a physician everyday in the ED, because it's not.  Not even close.  

 

 

[TheFatMan]

On 2/7/2018 at 10:51 PM, lkth487 said:

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.

I would bet that they would be less likely to be feeling TOTALLY overwhelmed and burned out after 1-2 years.  New grads with 5+ years of healthcare experience probably already know what it is really like to be crapped on by docs, nurses, and most importantly patients. When this happens to them as a provider, it will not be shocking or demoralizing to them, like it potentially could be to a new grad who has no idea what those things feel like.

[lemurcatta]

I am an applicant with >10k hours. ultimately I accepted an offer at a shorter program (24mo) with a higher average prior HCE in its admitted students. I feel I don’t need lots of extra time and also want to get started in my career as quick as I can. But also, I feel like a diverse PA profession is probably a good thing, as long as the programs taking those fresh from college are longer. 

To that NP student who chimed in earlier- another thing I forgot to mention is that the average PA program is 27 months long (with no breaks), with literally thousands of hours of clinicals, across many different specialties. We have longer and more diverse didactic and clinical training than NPs. So yes, some of us don’t come in with years of floor RN experience (tho many do),but we leave our programs with more hours of clinical training in the actual practice of medicine. 

Edit: another thought. Also don’t think we should quell our criticism of NP training in service of some notion of health care kumbaya where nothing can be better than anything else and everyone has their role, or to prevent hurt feelings. We live in an era where people now think they can present “alternative” facts and believe their own truths. But that’s BS. Facts are facts, and the truth is that while a lot of NPs are rockstars, by and large the education programs for their profession lack appropriate rigor for their role. A lot of the good ones find a way to compensate and do great. But they all deserve better. Also just to be clear, I have no personal bias against nurses or nursing- my mom is an RN and so is my PCP, and I also see an NP at my cardiologist office (I had tetralogy and surgery, and I trust these NPs to take care of me). Again, there are rockstars out there. 

[HmTwoPA]

This forum is turning into another SDN. People talking bad about other professions and patting themselves on the back with out anyone checking them, and most times before they even start PA school. Saying scribe experience is just as good if not better than RN experience. Scribes have no accountability. They write the stuff down that the doctors says and the doctor reviews it and approves it. If they fuck up someone either catches it or they have an error in the patient chart. RN, RT, Paramedic, Corpsman if you mess up there are real consequences. Thus puts the emphasis on really learning and knowing what you're doing. In rotations if a preceptor just has you shadowing them your not getting the full experience because you're never held accountable to your knowledge. If your going and seeing patients and then reporting back to your preceptor and they pimp you on what you asked and didnt ask and what you were looking for, the learning is much more significant due to the responsibility. 

2 hours ago, lemurcatta said:

Also don’t think we should quell our criticism of NP training in service of some notion of health care kumbaya where nothing can be better than anything else and everyone has their role, or to prevent hurt feelings. We live in an era where people now think they can present “alternative” facts and believe their own truths. But that’s BS. Facts are facts, and the truth is that while a lot of NPs are rockstars, by and large the education programs for their profession lack appropriate rigor for their role. A lot of the good ones find a way to compensate and do great. But they all deserve better. Also just to be clear, I have no personal bias against nurses or nursing- my mom is an RN and so is my PCP, and I also see an NP at my cardiologist office (I had tetralogy and surgery, and I trust these NPs to take care of me). Again, there are rockstars out there. 

Speaking of "alternative facts" here you are presenting an opinion as if its true. Do you know for certain that every PA program has more clinical hours than every NP program. You've never gone to PA or NP school. You've never been a PA or NP, so how can you judge what the correct "rigor" is. You also cant speak on the "rigor" of a school because you havent attended a "large" amount of their programs. The true BS is you making stuff up off of what you've heard other people say or off of very very limited anecdotal experience. Not to mention that less clinical time is even necessary due to two reasons 1. NPs have specific titles and field of practice such as FNP or ACNP. 2. They have real experience before coming into PA school. Taking Pharmacology in their program isnt the first time they've heard the names of these meds.

[lemurcatta]

You’re right. I haven’t been a PA. But  I have looked at the classes and credit-hours of many PA and NP programs, and you can do the same (I can also provide the relevant links if you want to DM me). So no, nothing I say is based on anecdotes or second hand information; I’m basing this entirely on what how each program represents their own curriculum.

It is just a fact that the vast majority of NP programs have 3 units of pathophysiology, and 3 unit pharm class. Many of these are taught online using self-directed learning models. That is usually the extent of in-program basic science education. I have seen online programs with a single term of patient assessment taught online with only two weekends on campus to practice history taking and physical exam (check out USC’s NP program for a prototype). These are facts. Here is where my opinion comes in: that is inadequate. Feel free to disagree with me. But please do substantively and try to avoid ad hominem attack’s to rebut my points. Just an FYI, I base my opinions on the importance of basic science education on the years of teaching lower and upper division life sciences at the university level, along with clinical experience.

 

Side note: majority of Np programs I’ve looked at have between 600-800 hours of self-reported clinical rotation time. PA programs I applied to have 2,000+. Again, I can provide relevant evidence through program curriculum links as requested. You can make your own judgments here.

[HmTwoPA]

My program requried 3 units of patho. The first program I saw after typing in Nurse practioner programs on google is OHSU and they have 6 units of pharm in their program which is the same as mine. Again these are not "facts", I just disproved that "fact" by looking at the very first program that popped up. 

I guess if my experience as a Corpsman with 1/5, 3D LAR, and the wing has taught me anything its that if a school enrolls students in their program with no HCE or HCE that never required them to put a stethoscope in their fucking ears. They might want to teach a few more weeks of Physical exam skills than NP school lol. 

 

Why would a FNP need 2000 hours of clinical experience? What are they going to do with a rotation in ER, Gen surg, and 3 electives? They are getting an FNP, Family Nurse Practitioner. 

[Kaepora]

7 hours ago, Joelseff said:

I think we are making the same point about scribes.

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We are.  Haha.  I'm just here to back you up.

[Kaepora]

First of all, the ICUs in my health system have RN led rounds.  So no, the RNs are not just present for rounds.  They get pimped just like the students present.  Some RNs hate it but the ones that plan on going back to CRNA/NP school engage.

And I'll agree that some NP programs suck.  Without a doubt.  But to put some things in perspective, I had a year of undergraduate pharmacology and pathophysiology.  So by the time I got to my NP program and had another 2 semesters of each of those classes, I have more time in those subjects than a PA.  NP school is a continuation of BSN education.  It's meant to build on our previous education.  I also had a year of physical exam in undergrad.  Hands on labs THEN practicing it in clinical THEN working as an RN in the ICU for years.  I've got physical exam covered.  So another semester in NP school is just to correlate with expanded diagnosis.  It's not that we're being introduced to it for the first time.

I think a lot of PAs look down their noses at RNs and have no idea what RNs actually do.  I am in clinical rotations with PA students right now.  I have worked with PAs in the hospital.  I know what the training is like and the clinician that is produced.  PAs seem to think they are light years ahead of NPs.  Ultimately, IMO, the differences in training between NPs and PAs amount to a wash.  Physicians certainly don't care which they hire.  Yes some have preferences but, overall, NPs and PAs are being hired in fairly even amounts (although there are more NPs than PAs in practice).

These arguments are so ridiculous.  Go to school, get a job, take care of patients, work nicely with others, and keep your head down.

 

[ProSpectre]

1 hour ago, HmTwoPA said:

Why would a FNP need 2000 hours of clinical experience? What are they going to do with a rotation in ER, Gen surg, and 3 electives? They are getting an FNP, Family Nurse Practitioner. 

 

Actually, FNPs, pediatric NPs and adult NPs are often hired to work in EM or other specialties (this may vary by state due to different nursing board rules). So in those cases, not having rotations outside of a primary care environment could definitely be a disadvantage; prior work in those setting as an RN would surely help, but not all NP programs require prior RN clinical experience. 

I think all that lemurcatta is saying is that the PA model of education is more standardized; the clinical hour requirements for PA programs are set at a minimum of 2000 hours by ARC-PA, while NP programs may only require 500-1000 (https://www.nursinglicensure.org/articles/nurse-practitioner-programs.html). This isn't to say PA's are better than NPs, but our educational model is a strength of our profession, and all PAs should be proud of this and should be willing to advocate for the advancement of our profession because of it. 

http://aaenp-natl.org/images/AAENP_ENPeducation_regulation_paper.pdf

https://www.ncbi.nlm.nih.gov/pubmed/21605324

https://www.medscape.com/viewarticle/832164 

 

[Kaepora]

1 hour ago, HmTwoPA said:

Why would a FNP need 2000 hours of clinical experience? What are they going to do with a rotation in ER, Gen surg, and 3 electives? They are getting an FNP, Family Nurse Practitioner. 

And this is my argument.  I am rotating with PA students right now.  They rotate through peds (3 weeks), primary care a few times, OB (3 weeks), IM, ER, etc.  So these students are really trained mostly for primary care.  Not even peds or OB with only 3 weeks of exposure.

I am in an ACNP program.  My rotations are 12 weeks each and are all inpatient medicine - ICU, hospitalist, surgery, etc.  No pediatrics and no women's health (except for very common or very morbid diagnosis) and no primary care.  I'll never work in those environments.  All my hours are in hospital based medicine.

But PNPs get all their hours in pediatrics.  WHNP/CNM get all their hours in women's health.  PMHNP get all their hours in psych.  FNPs only train in outpatient family medicine.

Again, it's a different training model.

[Kaepora]

5 minutes ago, ProSpectre said:

Actually, FNPs, pediatric NPs and adult NPs are often hired to work in EM or other specialties (this may vary by state due to different nursing board rules). So in those cases, not having rotations outside of a primary care environment could definitely be a disadvantage; prior work in those setting as an RN would surely help, but not all NP programs require prior RN clinical experience. 

I think all that lemurcatta is saying is that the PA model of education is more standardized; the clinical hour requirements for PA programs are set at a minimum of 2000 hours by ARC-PA, while NP programs may only require 500-1000 (https://www.nursinglicensure.org/articles/nurse-practitioner-programs.html). This isn't to say PA's are better than NPs, but our educational model is a strength of our profession, and all PAs should be proud of this and should be willing to advocate for the advancement of our profession because of it. 

http://aaenp-natl.org/images/AAENP_ENPeducation_regulation_paper.pdf

https://www.ncbi.nlm.nih.gov/pubmed/21605324

https://www.medscape.com/viewarticle/832164 

 

That's a good argument.  And one that NPs are currently debating within their own ranks.  The NP licensing agencies are attempting to standardize NP practice areas and population foci so that NPs can not practice in areas they were not trained to practice in.  An FNP being hired to work in the ICU is obviously a huge malpractice liability for the hospital and the NP themselves.  But one could argue that PA programs do not expose PAs to ICU medicine as a standard, or other subspecialty practice.  It's a grey area for sure, but one that NPs are attempting to address.

[camoman1234]

3 hours ago, HmTwoPA said:

My program requried 3 units of patho. The first program I saw after typing in Nurse practioner programs on google is OHSU and they have 6 units of pharm in their program which is the same as mine. Again these are not "facts", I just disproved that "fact" by looking at the very first program that popped up. 

I guess if my experience as a Corpsman with 1/5, 3D LAR, and the wing has taught me anything its that if a school enrolls students in their program with no HCE or HCE that never required them to put a stethoscope in their fucking ears. They might want to teach a few more weeks of Physical exam skills than NP school lol. 

 

Why would a FNP need 2000 hours of clinical experience? What are they going to do with a rotation in ER, Gen surg, and 3 electives? They are getting an FNP, Family Nurse Practitioner. 

Why to family MD/DO do rotations in ED, Gen surg., Rheum, Ortho, Endo, Plastics, Neuro, ENT, etc. Cause it makes on well round as well PA/FNPs/MD/DO are in primary care so they should be aware of most cases or at least seen one or heard of one. Your argument is very flawed about FNPs, my wife is an FNP and she is in primary care so why should she not have different rotations (which she did not have ER or gen. surg) and it shows with her DDx. When I was on my  ED rotation I rotated with a first year Rheumatology resident. So why was he in the ED for 4 weeks?  

[Kaepora]

7 minutes ago, camoman1234 said:

Why to family MD/DO do rotations in ED, Gen surg., Rheum, Ortho, Endo, Plastics, Neuro, ENT, etc. Cause it makes on well round as well PA/FNPs/MD/DO are in primary care so they should be aware of most cases or at least seen one or heard of one. Your argument is very flawed about FNPs, my wife is an FNP and she is in primary care so why should she not have different rotations (which she did not have ER or gen. surg) and it shows with her DDx. When I was on my  ED rotation I rotated with a first year Rheumatology resident. So why was he in the ED for 4 weeks?  

Physicians have the luxury of time.  NPs and PAs have 1 year to gain clinical experience.  5-6 weeks rotating through a random specialty is not extremely worthwhile.  I am in a rotation with PA students at the moment.  They have 6 weeks in this specialty.  I have 4-5x as long.  They are almost done and we have only just scratched the surface.  NP programs choose to concentrate time in what they perceive to be high yield areas for the specialty they have chosen.  PAs choose to spread their time in multiple areas as they view that to be a more high yield strategy.  One of my very best friends is a PA.  She practices in pediatrics.  She got 3 weeks of training in peds in her program.  She almost gave up on her goal of practicing in peds because she felt so very unprepared to practice in that specialty as she spent much of her time in school rotating through areas that had little cross over to pediatrics.  Had she attended a PNP program she would have had 8x that amount of clinical time in pediatrics.  She is great now, but she struggled for a long time playing catch up.

It's great the rheumatology resident had the ability to rotate through the ED.  But s/he has years to gain that knowledge. We (APPs) do not have that opportunity.