The future of the profession - concerns of a recently accepted student

[NAP1986]

Dear Friends,

 

I have had the great honor of being accepted to both Emory's dual Master of Public Health and PA Program, and Vanderbilt's Accerated ("pre-specialty entry") Acute Care Nurse Practitioner program. I thought I had decided to become a PA, but I have some lingering doubts that have re-emerged after being accepted to the NP program. I truly believe PA education is a superior model of training compared to an accelerated NP program. I honestly would feel scared to practice medicine with the curriculum of this NP program (and most NP programs I compared). In fact, I have recently spoken with several recent grads from the accelerated NP program, and both spent 1-3 years working as a floor nurse in an ICU before they felt comfortable practicing as a NP because they felt they were not prepared in time-management, clinical decision making, and proper usage of equipment and interpretation of diagnostic tests.

 

However, it seems there are many more pathways for career advancement and leadership for NPs (even though they provide identical clinical services), such as chief nursing officer, dean of a school of nursing, and in my area NPs sit on and have more representation in committees and panels making hospital policy decisions and doing research on patient outcomes. I don't feel like PAs have a career path. I applied to the dual public health / physician assistant program track as a way to potentially hedge my bets and give myself more career options in healthcare administration, policy, and epidemiology research if I felt too limited as a PA.

 

Also, as legislators see NPs as the "apex of nursing" and PAs as "lesser physicians", it seems as though NPs will only have greater autonomy and leadership potential in the future, simply by virtue of the way the profession is conceptualized.

 

In Tennessee, where I currently live, PAs and NPs have identical physician supervision requirements, and the other state I am interested in living in, North Carolina, also has identical rules for PAs and NPs, though North Carolina is less restrictive than Tennessee overall. So, currently there would not be a difference as a clinician for me, but I am concerned by the career path and potential changes in the future.

 

Also, how do you see the name change movement progressing? I am frustrated with explaining that PAs are not simply "technicians", and that there is a difference between a medical assistant and a physician assistant, and I am not even in school yet!

 

So, please help me. I LOVE PA training and believe it is a superior education model, but I fear for my future mobility and legislative changes in favor of NPs in the future due to their large lobbying efforts and the differences in conceptualization of the professions.

 

Thank you for your time and thoughts!

[Guest Paula]

#1. Will you be stuck in the acute care nurse practitioner role if your training is limited to that specialty? Do you already have an RN degree?

#2. Combination PA/MPH can only be a good thing. You can decide to be an assertive and proactive PA to elevate the PA profession. You can decide to ask to be on hospital committees and prove PAs are valuable members of health care. You can decide to use or develop your leadership abilities.

#3. If you truly believe PA education is superior compared to the NP program you were accepted at, then why go the lesser route?

#4. You could eventually obtain a Phd or DHsc or other doctorate and use the degree to assist the healthcare industry in their conceptualization of the PA profession.

#5. Get involved in PA legislation and join PAFT and be an active member.

#6. Or, just go to medical school for full autonomy and practice, although you will not be able to transfer from one specialty to another as easily as you can with PA profession.

[ATCLATEMTB]

I work with some GREAT NP's, and in a more NP centric state. However, I do not feel their training NOR clinical rotation time and exposure can compare to that of a PA program. Especially one of high ranking, such as Emory's. (not sure on Emory's NP ranking)

 

I work in a sub-specialty surgical field, we often have the hospitalist team cover our patients. This team is made up of MDs, NPs and PAs. I find myself doing more general hospital care on patients who have been covered by our NPs on the team. Now, this is a small sample and experience of one....however I am prepared to do that care. My SP will often boast that he does not need a hospitalist team, he has an amazing hospitalist / critical care / surgical PA on his team already. As a product of broad clinical experience and training a PA receives I am able to handle and understand the care in every patient from straight forward CV patient to the hormonal alterations in the post-pregnancy cardiomyopathy patient.

 

Just because you are a PA does not mean you can not take on leadership roles, it might mean you have to work harder at it, or prove your salt a bit more.....but nothing prevents you from doing that.

 

Also, while no provider knows everything, and there is not all knowing expert clinician.....would you feel comfortable taking care of a patient having gone the fastest possible route with focused scope or a little longer with broader scope (and mobility in speciality) and (I think) a greater understanding of pathophysiology and the amazing interconnected "system" our bodies are. With an appreciation for womb to death development?

 

(As another aside....and again experience of one) I interviewed for a moonlighting gig at a more rural ER....they are looking only for PA's. They have NP's on staff who can not care for pediatric patients as they did not have license or education to care for kids. In addition, my sister a PA in Ortho was evaluating a patient in the clinic, mother was a Critical Care NP at work and was on the cell phone of husband. The mother had limited to no exposure of ortho in school and had limited understanding of the injury. Critical Care NP had a wildly inappropriate workup and treatment plan in mind and was very verbal in trying to get her plan completed. However, had she had broader training as PA she might have been more reasonable and appropriate in her care of her family and ability to be an advocate.

 

OK....enough of PRO-PA chatter.....

 

As a Proud Emory PA alumni, just go to PA school and make us all proud.

[jmj11]

NAP1986, I just wanted to comment, for a pre-whatever, you have a very good grasp of the issues. It is a hard decision based on the exact things you just said. I'm working though these same issues with my daughter right now who is trying to decide to follow her father's footsteps or become a NP. I love the PA profession and we are well trained and do good work, but politically it has been impotent. I hope that will change but I'm not sure.

[Joelseff]

I understand the many reasons (mostly personal) that you have to lean towards NP training but ask yourself, which path would benefit your PATIENTS most?

 

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[discogenic]

But isn't it generally agreed that after a certain number of years in practice, NPs usually become more or less equally clinically competent compared to PAs?

[EMEDPA]

But isn't it generally agreed that after a certain number of years in practice, NPs usually become more or less equally clinically competent compared to PAs?

no. pa's will always have a generalist background to fall back on but an acute care np would never get training in outpt issues, etc

I work with some np's who are great IN THEIR FIELD but out of their depth once they try to leave that narrow field. a psych np working in the er isn't going to be up to speed on airway management for example.

[lovinglifefully]

I don't know of any PA that comes straight out of school that feels super comfortable in practice either... at least for a couple of years....no matter what "experience" they had prior (unless they were already treating and diagnosing)... exceptions to this of course, but few and far between.

[LT_Oneal_PAC]

Do PA, then you have the training. If unhappy with prospects, get in a cheap online program, like USA, and you can get over 3 years part time and its pretty cheap. You can also get it in two year full time and its pretty doable, especially if you've already done all the classes once before in PA. Clinicals will be a breeze since you could just do them where you work. Trust me I've been there and left because of fear of practicing with what (little) they were teaching me. Vandy might be different though.

[NAP1986]

The curricula are not even half the same. They don't even look related. Year one of the NP curriculum for the pre-specialty entry (students with a bachelor's degree in a field other than nursing) is composed of classes to become a Registered Nurse. Year two is the year where you study for your specialty. It's 3 semesters (year one) to become an RN and 3 semesters to get the MSN (year two).

 

Vanderbilt Pre-Specialty Entry, Adult-Gerontology Acute Care Nurse Practitioner Curriculum:

Year One:http://www.nursing.vanderbilt.edu/msn/prespec_plan_ft.html

Year Two: http://www.nursing.vanderbilt.edu/msn/acnp_plan.html

 

Emory Physician Assistant Program Curriculum:

http://www.emorypa.org/MMSc_PA.htm

 

I look the NP curriculum and think, "where's the beef?" It makes me scared. Many NPs I've talked to say they've learned most of what they need to learn "on the job", but I find it hard to believe you can ever really compensate for the differences.

 

So, I feel torn between getting the education I want (and that I feel is science-based and will prepare me to practice!), and having a career with potential for advancement and leadership. I do not need to be the doctor. I really don't. I just want the same advancement options as a NP, and to know that PAs will have the same functional autonomy as NPs. And no one can answer for that. If I get the PA training and then get the MSN, that ends up not making any sense financially or time-wise.

 

Thank you all for your perspective!

[EMEDPA]

you could do the uc davis program (after getting a bsn) and get both pa AND np certs.

not a bad option.

[lovinglifefully]

I've heard the same from both PAs and NPs. I've also known those that feel comfortable upon graduation, with proper SP mentoring. There are advantages to either route (yes, I said it).

How much pre- experience do you have? What type of experience?

Curriculums differ across the spectrum for many PA schools as well as NP schools.

I have a friend that went through Vandy's program and he is a very successful and competent NP.

 

If you are frightened by the prospects, have your considered medical school?

[eddoc]

I ran a peds service that had both NPs and PAs and asked the department chair what differences he saw in their preparation and overall practice. It was his position that the PAs were much more likely to hit the ground running relative to pediatric NPs but that after six years (!) they were essentially the same. I also taught both NPs and PAs at a school that had both programs - the NP students would "sneak" into my courses whenever they could because (their words, not mine) their "training was so weak." At this point, NPs do have some political advantage but given the current health care climate, we are on the cusp of seeing considerable change in the climate.

[PACProvider]

Dear Friends,

 

However, it seems there are many more pathways for career advancement and leadership for NPs (even though they provide identical clinical services)

 

I don't feel like PAs have a career path.

 

it seems as though NPs will only have greater autonomy and leadership potential in the future, simply by virtue of the way the profession is conceptualized.

 

I am frustrated with explaining ... that there is a difference between a medical assistant and a physician assistant, and I am not even in school yet!

 

 

The OP raises interesting questions and shares valid concerns. I would appreciate hearing more ideas relative to his remarks that I quoted. Most of the excellent discussion thus far is about the differences between PA and NP training and competency. He is asking an important question. How is the PA profession perceived by hospital management, legislators and the public as compared to NPs? He suggests that NPs are doing better work in influencing and messaging to those three audiences (hospital management, legislators and public). It would be nice if some of the members and leadership of the PAs for Tomorrow would add something to this discussion and perhaps even differentiate their vision from that of the AAPA.

[EHOLDENPA-C]

PAFT is looking to advance the following:

do away with terms like midlevel provider, assistant, and supervision in favor of terms like advanced practice clinician, associate, and collaboration.

we believe pas can lead medical homes while still working with physician colleagues. we would like to see a system in which pas can work with a number of physicians and if one dies or moves away the pa can continue to practice. this is not currently the case if your "supervising physician" stops practice for any reason. we would like to see research conducted and disseminated widely showing pas deliver quality care. we would like to see a major PR campaign so that every american knows exactly what a pa is and we are never confused with medical assistants again. we aggressively repute poor portrayals of pas in the media. we are working with the institute of medicine to hopefully produce a study (similar to one they just did for nps) showing that we do excellent work and current legislation restricts us from performing to the top of our training potential.

for more on paft and our goals see here:

http://pasfortomorrow.us/goals.html

if you agree, please join us. our numbers and influence are growing every day with every new member.

[EMEDPA]

How is the PA profession perceived by hospital management, legislators and the public as compared to NPs? He suggests that NPs are doing better work in influencing and messaging to those three audiences (hospital management, legislators and public)..

several issues here.

many hospital administrators are nurses. in order to improve the lot of pa's in hospital practice pas will need to get graduate management degrees and land some of these positions traditionally held by nurses. legislators frequently ignore us because they consider us part of the PHYSICIAN and pa team, much like medical assistants. pas need to continue working with legislators to increase our visibility as a unique profession on our own. most people do not know what a pa is. an aapa study several years ago showed this. only the aapa was surprised. working pas already know this. the heart of the issue is that there are many more nurses and np's than pas. their lobby is huge. they have corporate support from giants like johnson and johnson who offer np but not pa scholarships and fund entire programs. this means as pas we just have to work harder and support organizations like paft(of which I am a member) which seek to advance our cause.

[EMPAhopeful]

The curricula are not even half the same. They don't even look related. Year one of the NP curriculum for the pre-specialty entry (students with a bachelor's degree in a field other than nursing) is composed of classes to become a Registered Nurse. Year two is the year where you study for your specialty. It's 3 semesters (year one) to become an RN and 3 semesters to get the MSN (year two).

 

Vanderbilt Pre-Specialty Entry, Adult-Gerontology Acute Care Nurse Practitioner Curriculum:

Year One:http://www.nursing.vanderbilt.edu/msn/prespec_plan_ft.html

Year Two: http://www.nursing.vanderbilt.edu/msn/acnp_plan.html

 

Emory Physician Assistant Program Curriculum:

http://www.emorypa.org/MMSc_PA.htm

 

I look the NP curriculum and think, "where's the beef?" It makes me scared. Many NPs I've talked to say they've learned most of what they need to learn "on the job", but I find it hard to believe you can ever really compensate for the differences.

 

So, I feel torn between getting the education I want (and that I feel is science-based and will prepare me to practice!), and having a career with potential for advancement and leadership. I do not need to be the doctor. I really don't. I just want the same advancement options as a NP, and to know that PAs will have the same functional autonomy as NPs. And no one can answer for that. If I get the PA training and then get the MSN, that ends up not making any sense financially or time-wise.

 

Thank you all for your perspective!

 

Perhaps you should also ask this on a nursing/NP forum to get "the other side" as well.

 

Yeah Emory definitely does look "beefier". As a PA, like a physician, you'll have a generalist education, with clinical rotations in various areas of medicine. With the Vanderbilt program, you'll certainly have experience in various areas of medicine, but this will be beside RN experience, which isn't the same as a provider role experience. So, you won't have the pediatrics, psychiatry, etc NP role experience, if you're interested in that (though I assume not, since you chose ACNP).

 

Looking at Vanderbilt's curriculum, it looks like some of the "beef" is hidden under the course titles (I've heard this mentioned before by NP students on other forums, that it doesn't "look" like it is intense since they have multiple subjects covered under one course name. For example, " Pathophysiology and Collaborative Management in Acute Care I for the Adult-Gerontology ACNP" (whoa, that's a long course name!) covers "pathophysiology, assessment, diagnosis, and collaborative management of adults and older adults with selected episodic/chronic health problems in acute/critical care, including pulmonary and cardiovascular disorders", which II covers "oncology and renal and fluid and electrolyte disorders." while III covers "hematologic, hepatic, endocrine, and gastrointestinal disorders as well as psychosocial needs." Other courses cover history and physical exam, performing and interpreting diagnostic studies, etc. Also, if you're interested in critical care, Vanderbilt has an ACNP-Intensivist track that seems interesting. Here are a few links on that:

 

http://www.nursing.vanderbilt.edu/msn/acnp_intensivist.html

http://www.vanderbilt.edu/vanderbiltnurse/2012/04/on-a-patients-worst-day/

http://www.vanderbilt.edu/vanderbiltnurse/2012/04/acnp-fellowship-the-next-step/ (though I don't really see that they've combined the "fellowship" with the DNP, at least not yet).

 

It seems like you can tailor the regular ACNP program to your clinical interests. They have subspecialties in "cardiology, cardiac surgery, intensivist, diabetes and endocrine disorders, emergency care, nephrology, pulmonology, oncology, orthopedics, sports medicine and trauma". Also they say that ACNPs practice in

• Specialty Clinics (e.g., cardiology, transplantation, oncology, nephrology, neurology, HIV, sports medicine-orthopedics)
  
• Emergency Departments
  
• Trauma Centers
  
• Hospital Inpatient Units (e.g., cardiology, oncology, nephrology, neurology, surgical, medical)
  
• Intensive Care Units (e.g., medical, surgical, coronary, trauma)
  
• Rehabilitation Units
  

 

So I think that if you're set on "acute care", the ACNP does provide a wide variety of areas of medicine (I mean "advanced practice nursing") that you could work in, though if you end up wanting to do family medicine later on, you'd have to go back to school and do a post-masters (post doctorate?) certificate program. I say all of this as someone recently accepted to PA school as well, but am considering doing the nursing route for the same reasons that you brought up (I actually started a thread on leadership opportunities for PAs recently, but no one responded). I LOVE the educational model of PA school, gives me the all the sciences I enjoy, a well -rounded clinical education with elective opportunities, plus PAs are utilized far more than NPs intraoperatively, so I could potentially have the full perioperative clinical role, etc. But, I like that nursing has more opportunities for leadership, representation on various committees, could do things like transplant coordinator, research NP, etc, and of course the differences (state dependent of course) in collaboration vs supervision.

 

This could also just be the brainwashing of working with nurses for the last 5-6 years. Some of the nurses I've worked with are now CRNAs (one of them actually left her ACNP program, did ICU nursing for 2 years, then ended up at Penn Nurse Anesthesia), FNPs, and a couple ACNPs (including Surgical Critical Care NP, Neurosurgery NP, and Cardiothoracic Surgery NP).

 

Good luck with your decision!

[Arkansas Ranger]

If you want to know more and do more medically then be a PA. If you want to sit in meeting rooms and do admin stuff do NP.

[Friction]

If you want to know more and do more medically then be a PA. If you want to sit in meeting rooms and do admin stuff do NP.

 

Ha, I almost posted this exact same thing in the other thread after I read your response.

[WanderlustPA]

Judging by your post, I'd say you should go the PA route. It sounds like that is what you believe in, and you should always fight for YOUR beliefs. Stay true to yourself. As for the political issues, I wouldn't spend too much time worrying about them, but if you want to see positive change, as Gandhi said, "Be the change you want to see in the world." It is not an impossible mountain to climb.

[Acebecker]

Any venture into a new profession is a gamble, no question about that. The gamble with becoming a PA is whether or not you'll have the autonomy and reputation you desire. Several people have commented that indeed it appears that the PA profession is continuing to make inroads with respect to these areas. This is what I have seen over my short career so far - PAs are very well thought of and embraced once we prove ourselves. Some have laid rocky groundwork for me, but working hard to provide good care wins the autonomy and reputation battle. The gamble with going to the NP program is that you might not get the training you want to practice medicine well and you'll then have to struggle to get the OJT that you need to be safe, efficient, and provide good care. Their reputation is well established and supported by a HUGE nursing lobby. What's funny is that the more I work with young NPs and NP students, the worse their reputation is in my mind. I value my colleagues in my office, but when I hear about other places or have new students come in, I cringe at what they lack.

 

In summary: the gamble of going to a PA program is worth it... the gamble of going the NP route is not.

 

Andrew

[discogenic]

Any venture into a new profession is a gamble, no question about that. The gamble with becoming a PA is whether or not you'll have the autonomy and reputation you desire...

 

Andrew

 

...and having enough income to pay back what will be LARGE student loans. :=Z:

[cinntsp]

...and having enough income to pay back what will be LARGE student loans. :=Z:

 

Paying back PA loans on a PA salary shouldn't be a struggle.

[Hemegroup]

Paying back PA loans on a PA salary shouldn't be a struggle.

 

That depends. I went to school for 9 years total, I owe over 200K. Payments will be over 2K a month, once they come out of forbearance. If I were to still be outside of either a NHSC or higher paying position, I had better get my debt taken care of before it happens otherwise things could be very tight.

[primadonna22274]

$200k for a PA is nearly impossible...yikes. I will be just a little over that after DO and PA school and I'm sweating the repayments....