NPs are killing us

[Joelseff]

I know that my continuing to say this will not change any minds on this board, but, I'll keep at it. PAs need more of this in school.  Nurses are assumed to have a certain level of knowledge and understanding upon entering a NP program.  Again, I had a year of pharm and pathophys in undergrad.  I already know the major classes of medications.  I know the common medications prescribed for disease states and the pathophysiology of the disease states.  The dosages, their MOA and the most common side effects.  I've studied them and then administered them as a nurse both in clinical and working in the unit.   The educational pathways are different for a reason.  You can't compare apples to oranges. 

 

 

I think that's great and I agree with you but for some reason I suppose, the students I have encountered at the 3 NP programs I precept for could not tell me basic MOA beyond "it helps thus and such disease by causing this effect" not about significant blockade or agony mechanisms which can lead to AEs and DDi etc. Or certain disease pathways and why a class of drug would affect these diseases via these pathways. That's what I look for from my students the questions go atcleadt at least 1-2 layers deeper than the question when I pimp them. The PA students were mostly able to describe some if not most of these things. I still think RN based (undergrad) level sciences cannot equal to provider level education sciences and unfortunately it comes out in the product. My MD FNP student has also corroborated thus to me but That's all I'll say on it.  I hope all NPs were taught like you. My experience (anecdote monster rears it's ugly head [emoji33]) has not been that. I won't post anymore anecdotal data as it's a fool's errand. I think NPs think they are adequately educated and maybe that is good enough for you all and your patients and colleagues. I don't think I see it fully but will contend if I meet one that would change my mind or impress upon me differently then I can rethink my position.  

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 Edit sorry had to edit so many damn typos. What I get for answering ewhile having a vertigo episode. ?

 

 

 

 

 

[Kaepora]

I'm going to assume you're precepting FNP students. I'll absolutely admit there's a problem with FNP education as there is rarely ever a *requirement* for prior experience as a nurse beyond clinicals in undergrad and their hour requirements are quite low. I am an ACNP and our standards and requirements are different (this is true for all specialty NPs). 

 

Anecdote alert: I am rotating with PA students right now and I can tell a big difference between their and my knowledge base. Now my educational background is different than most nurses, I'll admit, as I'm a second degree student with a hard science background. However, many of the topics we are puimped on in clinical should be roll off the tongue for these students and it's just not. The physician and PA precepting us have commented on it.  Heck, the one student even said she felt at a disadvantage compared to me. And I do attribute a lot of it to my BSN, nursing background and NP program. 

 

There is a lot of variation in all professions. You're experience is with poorly trained students and that's unfortunate but I can tell you the ACNP students in my experience are far better than the FNPs (any specialty trained NP is better than an FNP, IMO). 

[Joelseff]

I'm going to assume you're precepting FNP students. I'll absolutely admit there's a problem with FNP education as there is rarely ever a *requirement* for prior experience as a nurse beyond clinicals in undergrad and their hour requirements are quite low. I am an ACNP and our standards and requirements are different (this is true for all specialty NPs). 
 
Anecdote alert: I am rotating with PA students right now and I can tell a big difference between their and my knowledge base. Now my educational background is different than most nurses, I'll admit, as I'm a second degree student with a hard science background. However, many of the topics we are puimped on in clinical should be roll off the tongue for these students and it's just not. The physician and PA precepting us have commented on it.  Heck, the one student even said she felt at a disadvantage compared to me. And I do attribute a lot of it to my BSN, nursing background and NP program. 
 
There is a lot of variation in all professions. You're experience is with poorly trained students and that's unfortunate but I can tell you the ACNP students in my experience are far better than the FNPs (any specialty trained NP is better than an FNP, IMO). 

Yes I train FNP students and I would argue I likely would not do well as an acute care PA though I did some time in inpt. PA's are generalists... So are FNPs that is why I compare them. So then as GENERALISTS would you say that a PA education covers more than FNP education? That was what I was alluding to earlier. We as a PAs are taught a pretty well rounded breadth of sciences, clinical skills etc. It was adopted from the fast track MD education from WW2. I think this is one of our merits despite our pre-pa backgrounds the education itself is strong enough to get a PA grad to the next level (Which I refer to as their informal residency) If they take the right jobs. Some new grad PAs take the highest paying jobs out of school to help recoup from the huge debt they incurred or other reasons and I think that is detrimental to the further education of that PA. I think strong prior HCE (FMG, IDC/Corpsman, medic RN, RT, etc) helps offset some of that but nothing like getting down an dirty as an actual provider with all its consequences and trials to make one a good provider.

The FNP track from my experience (again anecdote lol) is lacking in some aspects and with some states granting these providers independent practice out the block gives me pause to simply accept they are ready and equal or superior to providers with 3-5 years in but don't have independence due to political lobbying (but that's another post [emoji6])

If a PA wanted to work acute care/cc/icu or other non general specialties they can do OJT (which may be fading away) or do a residency.

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[Kaepora]

19 minutes ago, Joelseff said:

Yes I train FNP students and I would argue I likely would not do well as an acute care PA though I did some time in inpt. PA's are generalists... So are FNPs that is why I compare them. So then as GENERALISTS would you say that a PA education covers more than FNP education? That was what I was alluding to earlier. We as a PAs are taught a pretty well rounded breadth of sciences, clinical skills etc. It was adopted from the fast track MD education from WW2. I think this is one of our merits despite our pre-pa backgrounds the education itself is strong enough to get a PA grad to the next level (Which I refer to as their informal residency) If they take the right jobs. Some new grad PAs take the highest paying jobs out of school to help recoup from the huge debt they incurred or other reasons and I think that is detrimental to the further education of that PA. I think strong prior HCE (FMG, IDC/Corpsman, medic RN, RT, etc) helps offset some of that but nothing like getting down an dirty as an actual provider with all its consequences and trials to make one a good provider.

The FNP track from my experience (again anecdote lol) is lacking in some aspects and with some states granting these providers independent practice out the block gives me pause to simply accept they are ready and equal or superior to providers with 3-5 years in but don't have independence due to political lobbying (but that's another post )

If a PA wanted to work acute care/cc/icu or other non general specialties they can do OJT (which may be fading away) or do a residency.

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I'll probably agree with you there. In all honesty, if I wanted to practice primary care I would have looked more closely at PA.

[LT_Oneal_PAC]

 I will disagree with the premise that they are more prepared for inpatient work than a PA, unless that ACNP went to work in the same environment they worked in as a RN. Though the same could be said of any PA who had experience with ICU prior to school would be better than medsurg RN on a critical care rotation.

[Kaepora]

21 minutes ago, LT_Oneal_PAC said:

 I will disagree with the premise that they are more prepared for inpatient work than a PA, unless that ACNP went to work in the same environment they worked in as a RN. Though the same could be said of any PA who had experience with ICU prior to school would be better than medsurg RN on a critical care rotation.

Well I'll disagree with you disagreeing. PAs receive very little training in inpatient medicine (focusing much more on outpatient) compared to ACNPs (who focus almost entirely on it). 

I know there's no convincing the PAs on this forum but  theres also no convicning me otherwise. Haha. 

[GatorRRT]

Nearly 1/3 (>500 hrs) of my program rotations were inpatient, careful with the generalizations.  Average TOTAL ACNP clinical hours are what 500hrs? ?

[Kaepora]

26 minutes ago, GatorRRT said:

Nearly 1/3 (>500 hrs) of my program rotations were inpatient, careful with the generalizations.  Average TOTAL ACNP clinical hours are what 500hrs? ?

Everyone on this thread is generalizing. When the sample size is so large you have to generalize to some degree. 

 

And the hours listed on the website for NP programs are super misleading. For example, this semester I need 160 hours on this rotation. BUT the only time that counts for me is from case start to case end - cut to close.  I round on inpatients and see them in clinic, and while I report that time, it doesn't count towards the minimum required hours. Moral of the story is my total hours are quite a bit more than the minimum required when all is said and done. The PA students on the other hand count every patient and every second spent on site. Even if they are just shadowing and didn't touch or talk to the patient they are logging them into Typhon.

[EMEDPA]

1 hour ago, ACNPstudent said:

Well I'll disagree with you disagreeing. PAs receive very little training in inpatient medicine (focusing much more on outpatient) compared to ACNPs (who focus almost entirely on it). 

I know there's no convincing the PAs on this forum but  theres also no convicning me otherwise. Haha. 

really depends on the program. all of my rotations were inpt except for fp:

trauma surg 1 day off in 5 weeks. lived in residents quarters. alternating 24 and 12 hr shifts

internal med/icu/nephrology

peds ER

psych (inpt)

ER (trauma ctr)

obgyn (inpt)

ER elective(community 12 weeks)

FP (12 weeks)

around 3000 hrs total in 54 weeks of clinicals. 27 weeks specifically dedicated to em/peds em/trauma surgery

not knocking ACNP programs as I know they are MUCH more intense than fnp, which are almost entirely outpt rotations.

[Joelseff]

Well I'll disagree with you disagreeing. PAs receive very little training in inpatient medicine (focusing much more on outpatient) compared to ACNPs (who focus almost entirely on it).  I know there's no convincing the PAs on this forum but  theres also no convicning me otherwise. Haha. 

 

Actually, although the bulk of our 2000+ hours of clinical year were spent in outpatient settings (I think I did over 6-7 mos of pediatrics and IM/FP rotations split between MWF IM/FP and TTh Peds) I did a considerable amount of inpatient training which were very long hours (10-14 hr days at times) though maybe less than an ACNP program but my inpt rotations (inpatient GI and hepatology transplant service and Pediatric trauma - lots of pediatric inpt post OP and GI inpt management at my school's specialty children's hospital also did geriatric inpt rotations at San Francisco's Jewish home which is a large unit geriatric and psych facility) which really helped me in my outpt practice afterwards. Had an opportunity to be a PA Hospitalist but wanted outpt lifestyle so I decided to go into outpt IM and FP. But I would not say I was trained specifically as an inpatient provider which goes back to my statement about shaping those "informal residencies" once you get out or actually now we have residency programs for inpatient care IIRC.  

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[EMEDPA]

22 minutes ago, Joelseff said:

Actually, although the bulk of our 2000+ hours of clinical year were spent in outpatient settings (I think I did over 6-7 mos of pediatrics and IM/FP rotations split between MWF IM/FP and TTh Peds) I did a considerable amount of inpatient training which were very long hours (10-14 hr days at times) though maybe less than an ACNP program but my inpt rotations (inpatient GI and hepatology transplant service and Pediatric trauma - lots of pediatric inpt post OP and GI inpt management at my school's specialty children's hospital also did geriatric inpt rotations at San Francisco's Jewish home which is a large unit geriatric and psych facility) which really helped me in my outpt practice afterwards. Had an opportunity to be a PA Hospitalist but wanted outpt lifestyle so I decided to go into outpt IM and FP. But I would not say I was trained specifically as an inpatient provider which goes back to my statement about shaping those "informal residencies" once you get out or actually now we have residency programs for inpatient care IIRC.  

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if one is lucky they can arrange their rotations around a particular focus like my program allowed. I did peds em for peds, trauma surg for surg, etc.

Those wanting peds did peds surg, extra peds electives, etc

[Kaepora]

7 hours ago, EMEDPA said:

really depends on the program. all of my rotations were inpt except for fp:

trauma surg 1 day off in 5 weeks. lived in residents quarters. alternating 24 and 12 hr shifts

internal med/icu/nephrology

peds ER

psych (inpt)

ER (trauma ctr)

obgyn (inpt)

ER elective(community 12 weeks)

FP (12 weeks)

around 3000 hrs total in 54 weeks of clinicals. 27 weeks specifically dedicated to em/peds em/trauma surgery

not knocking ACNP programs as I know they are MUCH more intense than fnp, which are almost entirely outpt rotations.

Your first sentence makes my point though. The 2 PA programs closest to me state it's their mission to produce primary care providers. So with PA programs, if your goal is to work inpatient, you probably need to do your research to see if you can arrange your clinicals that way. My other point is that ACNP programs train in critical care medicine as well, where PA programs (at least the programs near me) don't instruct their students in that at all. No vent management, pressors or other CCM modalities. And certainly no clinical time in the units.

Specialty APRN programs like ACNP, PNP, CNM, CRNA, PMHNP, etc, train the students fairly deeply in that specialty - believe it or not. FNP is a different story... And I'm not trying to say NPs are better than PAs in any way. I'm only trying to make the point that a lot if the ideas people on this forum have about APRN education isn't accurate.

[camoman1234]

3 hours ago, ACNPstudent said:

Your first sentence makes my point though. The 2 PA programs closest to me state it's their mission to produce primary care providers. So with PA programs, if your goal is to work inpatient, you probably need to do your research to see if you can arrange your clinicals that way. My other point is that ACNP programs train in critical care medicine as well, where PA programs (at least the programs near me) don't instruct their students in that at all. No vent management, pressors or other CCM modalities. And certainly no clinical time in the units.

Specialty APRN programs like ACNP, PNP, CNM, CRNA, PMHNP, etc, train the students fairly deeply in that specialty - believe it or not. FNP is a different story... And I'm not trying to say NPs are better than PAs in any way. I'm only trying to make the point that a lot if the ideas people on this forum have about APRN education isn't accurate.

I agree. I went to a program that was family medicine oriented and I did 45 weeks of outpatient family medicine rotations. I did do 4 weeks of general surgery, 2 weeks urgent care, 4 weeks of hospital rotations, 5 weeks burn/plastic surgery, and 1 week ophthalmology. I also had to rotate at night in nursing homes/assisted living centers. My psych. was in the FM location as it was a very rural clinic with a lot of psych. Also, my preceptor was double board certified in FM/OB so I did all my OB (inpatient and outpatient) with him as well. I never step foot in an ICU (except burn ICU) and my hospital rotations were good, but only worth so much as 4 weeks is not a lot. 

[WeBuyAndSellJunk]

This is simply not comparing the same thing. Training to be an ICU NP is more like a residency for a PA. PAs are generalist and the better comparison is obviously the FNP. I have no doubt that spending all your time on intensivist topics makes you better at them. I have no doubt that being a former ICU nurse helps tremendously too. But you cannot have your cake and eat it too. You cannot say that PAs are under prepared as a whole relative to you just as it wouldn’t be fair to grill you on run of the mill outpatient topics and call you ill-suited to the job. You are learning different things. 

[lkth487]

Are we really talking about pathology?  Jeez.  It's giving me PTSD.  Our path was mixed in with the subjects - we had a pathology book that was 2000 pages and over 5000 pictures and we'd have to (non multiple choice) identify the disease state based on a picture.  Good times. No idea how I got through that. I much preferred the lab where you actually looked through the microscope. 

Did going through all that make me a better physician? I hope not because I'm actively trying to erase that out of my memory.  :p

[Joelseff]

Are we really talking about pathology?  Jeez.  It's giving me PTSD.  Our path was mixed in with the subjects - we had a pathology book that was 2000 pages and over 5000 pictures and we'd have to (non multiple choice) identify the disease state based on a picture.  Good times. No idea how I got through that. I much preferred the lab where you actually looked through the microscope. 
Did going through all that make me a better physician? I hope not because I'm actively trying to erase that out of my memory.  [emoji14]

Not pathology sorry pathophysiology my phone abbreviated it patho.

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[lkth487]

The most important class for me, personally, in med school was actually anatomy - actually physically dissecting a a complete body, head to toe, including the separate course where we did the brain, was an experience that was so fundamental in terms of putting stuff together in terms of how the body works that I think it should be required for everybody.  The best 3 months of med school. And I'm not in a surgical specialty, and yet it was still super important. 

I think physiology/ pathophysiology and pharmacology is interesting but honestly you forget a lot of it.  I think you need to know the fundamental physiology of all the systems down cold - like everyone should be able to draw a nephron and know where all the diuretics act and why, or draw the complete cardiac cycle from memory, or understand action potentials and movements of ions across membranes, but very few people can talk about in detail about all the disease states and the complex pathophysiology involved, unless it's in your particular area of specialty.   Like I had to learn it at the time but right now if you gave me a spinal cord level and asked me to draw all the various tracks and predict what injury at each point would do, I'm not sure I'd do much better than chance. 

[EMEDPA]

10 hours ago, ACNPstudent said:

Your first sentence makes my point though. The 2 PA programs closest to me state it's their mission to produce primary care providers. So with PA programs, if your goal is to work inpatient, you probably need to do your research to see if you can arrange your clinicals that way. My other point is that ACNP programs train in critical care medicine as well, where PA programs (at least the programs near me) don't instruct their students in that at all. No vent management, pressors or other CCM modalities. And certainly no clinical time in the units.

Specialty APRN programs like ACNP, PNP, CNM, CRNA, PMHNP, etc, train the students fairly deeply in that specialty - believe it or not. FNP is a different story... And I'm not trying to say NPs are better than PAs in any way. I'm only trying to make the point that a lot if the ideas people on this forum have about APRN education isn't accurate.

I have a lot of respect for specialty nps. most really know their stuff. I think a lot of the bad rep nps get comes from the (let's be honest) weak online fnp programs out there that require 500 hrs of outpt rotations and allow folks to arrange their own rotations 2-4 week in length with mostly observational exposure with their friends. these fnp[s then apply to (and get) specialty slots that they are not prepared for in fields like surgery, ER, critical care, etc. That is the problem and our major beef. I have no problem with acnps, crnas, pnps, nnp, etc

most pa programs will allow someone with a specific interest to tailor their rotations around their field of interest. If you just go with the flow in pa school you will probably only end up with inpt rotations in im, em, and surg.

[Kaepora]

17 minutes ago, EMEDPA said:

I have a lot of respect for specialty nps. most really know their stuff. I think a lot of the bad rep nps get comes from the (let's be honest) weak online fnp programs out there that require 500 hrs of outpt rotations and allow folks to arrange their own rotations 2-4 week in length with mostly observational exposure with their friends. these fnp[s then apply to (and get) specialty slots that they are not prepared for in fields like surgery, ER, critical care, etc. That is the problem and our major beef. I have no problem with acnps, crnas, pnps, nnp, etc

most pa programs will allow someone with a specific interest to tailor their rotations around their field of interest. If you just go with the flow in pa school you will probably only end up with inpt rotations in im, em, and surg.

There are good FNP programs and then there are absolutely horrible FNP programs.  I don't understand how some are allowed to continue to operate.  

Regardless of whether an FNP attended a good or bad program, they were still only trained for primary care and that's, IMO, all they should be doing.  There's a huge debate within the NP community right now concerning education pathways, population foci/specialty tracks and where each type of NP should and should not be allowed to work.  I absolutely do not think any FNP should be hired in any inpatient role, or in a straight pediatric specialty, or psych, or straight women's health either.  

As more and more states are giving independent practice to FNPs, more and more scrutiny is being given to their education and practice.  Which I think is a good thing as it's kind of forcing FNPs to re-evaluate.  At some point a critical mass will be reached for FNPs and something will have to change.

 

[Kaepora]

4 minutes ago, mcclane said:

Does your opinion change if said FNP could confidently and definitively pass the exam required for those specialties?

No.  My opinion of boards for PAs and NPs is that it's a minimum barrier to entry.  I think too many poorly prepared providers pass as it is, and I would favor a process more similar to MDs.  And, not that it makes any difference in my opinion, are we talking about a new grad FNP attempting initial certification in a specialty, or an FNP that has been practicing outside of their scope for multiple years challenging the exam?

You could look at it this way - if an NP took the PANCE and passed, would you be ok with them being a PA?  Or if a PA took the AANP cert and passed, would they be a NP?  OR, heaven forbid, if a PA or NP passed the steps are they now a physician?

I think there's a reason that certification exams are coupled with specific educational pathways.

[ventana]

ACNP - 

many ICU's are now staffed exclusively with PA's intead of residents, with proven better outcomes.

Since we are all in the same boat I would propose that it is very unwise and exceptionally poorly thought out to come to a PA specific board and bash PA's.  

I am going to close this thread as it seems to be degrading into simple name calling and has no added value.  I would ask in the future you consider who your audience is prior to posting.

[Kaepora]

Really?

[Kaepora]

8 minutes ago, ventana said:

ACNP - 

many ICU's are now staffed exclusively with PA's, with proven better outcomes then residents.

Since we are all in the same boat I would propose that it is very unwise and exceptionally poorly thought out to come to a PA specific board and bash PA's.  

I am going to close this thread as it seems to be degrading into simple name calling and has no added value.  I would ask in the future you consider who your audience is prior to posting.

I guess I didn't realize I was "bashing" and "name calling".

And the literature absolutely supports ICUs staffed with APPs.  But, here's a snippet from the local APP ICU residency.  There is a general idea out there in the ether (not just made up by me to bash PAs) that PAs need extra training in CCM.

In 2011, the UPMC Department of Critical Care Medicine began hiring APPs to supplement the existing house staff throughout the ICUs on the Oakland campus.  CRNPs with a background in critical care medicine or critical care nursing were the first hired to staff the ICUs.  As a mechanism initially to train PAs without prior dedicated critical care experience, Dr. Scott Gunn and Mitch Kampmeyer, PA-C developed the residency program based on the Department’s MCCTP, the first physician fellowship in critical care medicine nationwide founded in 1963.  In 2012, the residency began as a PA postgraduate program and became the first postgraduate training program of any specialty for APPs in the UPMC system or western Pennsylvania.  By the second year of the residency a second position was created and the first CRNP was accepted.

Again, do I think FNPs should be accepted to this - no, but I don't get to control such things.

[lkth487]

2 hours ago, ventana said:

ACNP - 

many ICU's are now staffed exclusively with PA's intead of residents, with proven better outcomes.

Since we are all in the same boat I would propose that it is very unwise and exceptionally poorly thought out to come to a PA specific board and bash PA's.  

I am going to close this thread as it seems to be degrading into simple name calling and has no added value.  I would ask in the future you consider who your audience is prior to posting.

To defend residents a little bit (:)) - that's not necessarily a fair comparison if you look at PAs who may have a decade of experience with a resident who graduated school last week, and how much better were the outcomes even accounting for that?  Did the studies look at PAs with 1-3 years right out of PA school (the length of the time you are a resident)?  We have to change rotations monthly, so obviously we are not going to be functioning at an expert level in every area we rotate though - that's the point of a residency.   There are also studies showing slightly better outcomes for resident teams in a hospitalist settings, but in the end, most of it is probably statistical noise and I'd definitely expect PA teams to be smoother because it just comes with experience.  You know the unit inside and out instead of rotating through it once a year for a month.

I don't think it has to be residents vs fellows vs attendings vs PAs.  There's plenty of patients to go around and we all have skills that we can learn from each other.

[LT_Oneal_PAC]

On 2/11/2018 at 9:56 PM, ACNPstudent said:

Well I'll disagree with you disagreeing. PAs receive very little training in inpatient medicine (focusing much more on outpatient) compared to ACNPs (who focus almost entirely on it). 

I know there's no convincing the PAs on this forum but  theres also no convicning me otherwise. Haha. 

It varies by school. I’ve had both ACNP training (at a major university based level one trauma center) and PA training. My PA training far better prepared me. But that was just my schools and admittedly I was in ACNP training in 2008-9. 

Im not invalidating your anecdote.  Dry well may be better trained for inpatient than those PA students, but your implying a universal truth based on anecdote. I’m simply refuting your assumption that all ACNPs are better prepared for inpatient. Neither of us case say which way the majority goes, though I suspect based on my higher experience with both it’s much more equal than you suspect and that it has little (not nothing) to do with prior experience and more to do with the training as a clinician the person receives at their respective school.

ETA: sorry, you do not seem as one sided as I previously thought based on your responses. Just finished reading the rest of the thread.