Should physicians let NP/PA take over primary care and anesthesia?

[FNP_Blix]

I just want data that proves they're as safe as physicians. The easiest way would be a long term study against physicians. Either they will be able to do the job or they won't, that's what I want to see to prove safety of fresh NPs.

No NPs right out of school I know practices independently - especially in a setting like Kaiser. No employer will allow for an NP to practice independently right out of school. Trust me, you wont be able to get that type of pool that you are asking for (i.e., new grad NPs practicing independently right out of school). The studies that show equivalency in practice are head-to-head studies with experienced NPs and physicians in primary care and urgent care type settings.

Let me ask you, in a study like this would you be able to control for the one-million confounding variables that are going to crop up over a ten year study like this? A study like this I would imagine have lots of holes in it. And the funding? Do you think you would get IRB approval? How about consent from the NPs, physicians, and patient's participating in the study? Will you have a large enough sample size? Can you guarantee continuity of care?

Last point - lets just say that you do make this study happen, are you suggesting that we pull all the NPs that are currently practicing with autonomy until the results of this said study are posted? If you do think that, and in theory it did happen, how do you think that would impact access to medical services and wait times, and work load of physicians, etc.? A lot of things to consider here.

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[Mad Jack]

No NPs right out of school I know practices independently - especially in a setting like Kaiser. No employer will allow for an NP to practice independently right out of school. Trust me, you wont be able to get that type of pool that you are asking for (i.e., new grad NPs practicing independently right out of school). The studies that show equivalency in practice are head-to-head studies with experienced NPs and physicians in primary care and urgent care type settings.

Let me ask you, in a study like this would you be able to control for the one-million confounding variables that are going to crop up over a ten year study like this? A study like this I would imagine have lots of holes in it. And the funding? Do you think you would get IRB approval? How about consent from the NPs, physicians, and patient's participating in the study? Will you have a large enough sample size? Can you guarantee continuity of care?

Last point - lets just say that you do make this study happen, are you suggesting that we pull all the NPs that are currently practicing with autonomy until the results of this said study are posted? If you do think that, and in theory it did happen, how do you think that would impact access to medical services and wait times, and work load of physicians, etc.? A lot of things to consider here.

But if you have reached the end of your training, and your training is adequate, you should be able to do your job, no? Or are you admitting your training is inadequate?

And you wouldn't need to fund it- Kaiser collect a bajillion data points on every provider. They'd merely have to wait and then compile the results at the end. As to confounding, over a patient population that is literally 400,000 individuals in size, there is unlikely to be much of it so long as the physicians and nurses are working in the same area, but that is why one does the study and looks for anomalies in the results. All they have to do is hire people, that's it. Don't even need to have the stipulation about physician backup- I'm confident enough to say that NPs will fail recognizing that they need backup often enough to make a statistical difference over a long enough period of time. Because it is practice as usual, yes an IRB would approve it. And I view NPs as like a drug the FDA pushed out too fast- it's considered safe until we get long-term data that shows it was actually a horrific mistake, at which point we pull it from the market. Once harm can be demonstrated, then we can start dialing things back.

 

[Mad Jack]

And I don't believe NPs should be stopped from practicing, I believe they should not be practicing independently. They are not qualified to do so unless they can prove otherwise, which they haven't. The studies to date have panels that are so small that they basically could cover a single NP's practice. To generalize the study to all NPs, you'd need somewhere around the mid 500s in number, and analyze their entire practices for a period of at least 10 years. Current studies suffer from serious length time bias, as it is the harm is likely to be insignificant over the short term and not show up until long-term damage is done or small mistakes start to pop up more frequently. I want to quantify the failure rate of NPs as compared to physicians over a long period of time. If it is nonexistent, then feel free to practice independently to your hearts' content.

 

[FNP_Blix]

But if you have reached the end of your training, and your training is adequate, you should be able to do your job, no? Or are you admitting your training is inadequate?

And you wouldn't need to fund it- Kaiser collect a bajillion data points on every provider. They'd merely have to wait and then compile the results at the end. As to confounding, over a patient population that is literally 400,000 individuals in size, there is unlikely to be much of it so long as the physicians and nurses are working in the same area, but that is why one does the study and looks for anomalies in the results. All they have to do is hire people, that's it. Don't even need to have the stipulation about physician backup- I'm confident enough to say that NPs will fail recognizing that they need backup often enough to make a statistical difference over a long enough period of time. Because it is practice as usual, yes an IRB would approve it. And I view NPs as like a drug the FDA pushed out too fast- it's considered safe until we get long-term data that shows it was actually a horrific mistake, at which point we pull it from the market. Once harm can be demonstrated, then we can start dialing things back.

NP training is good training, but because we lack residency, no employers would ever hire NPs to practice independently right out school. I talked about this before so I feel like we're sort of going in circles on this point. Doesn't mean that the training is inadequate. Means that the pathway to independence is different. Regarding you study idea and how data will be collected, the VA already does this. So far the data shows they are safe. They compile data and measure competency and safety of their NP providers. I believe they've been doing this since 1990. Actually the VA is increasing scope even further for NPs. Probably in response to when they had some 25 sentinel events mainly d/t delays in treatments they moved forward with this.

 

[anbuitachi]

I think NP can cover areas in shortage independently, but they should do further training similar to a residency. They can cover basic things like HTN and diabetes management etc. It's better than nothing in rural areas. CRNAs are more questionable. Managing HTN and diabetes and common primary care problems is less dangerous than managing patients intra op. One wrong move and the patient can die. However, CRNAs do do training before graduating, and can mostly handle basic ambulatory healthy cases. However the issue i have w CRNAs is that there is a HUGE variation in quality of graduated CRNAs. Some are great and some are worse than a first year anesthesia resident 6 month in. CRNA school is simply not regulated enough. Primary care is not a field where seconds count, so even if you dont know you can look it up on various reputable sites. That's often not the case in anesthesiology

 

[Mad Jack]

NP training is good training, but because we lack residency, no employers would ever hire NPs to practice independently right out school. I talked about this before so I feel like we're sort of going in circles on this point. Doesn't mean that the training is inadequate. Means that the pathway to independence is different. Regarding you study idea and how data will be collected, the VA already does this. So far the data shows they are safe. They compile data and measure competency and safety of their NP providers. I believe they've been doing this since 1990. Actually the VA is increasing scope even further for NPs. Probably in response to when they had some 25 sentinel events mainly d/t delays in treatments they moved forward with this.

Yeah, because the VA has such a focus on actually providing quality care They have never published a study of their data on nurse practitioners, and have never made any statements about said data. The VA is also not the optimum environment for such a study, as it has a very specific patient population (veterans) and would not be generalizable. I'd still love for them to make the data available for analysis though. Oh wait... Nevermind. Their NPs didn't get independent practice until last year so it wouldn't be valid since they were under physician supervision and auditing per VA policy.

As to "a different path to independence," uh, you are fully licensed to practice independently right out of school. That IS your path to independence, and there's more than one NP in my area that's opened up a clinic directly after graduating from the local Direct Entry Nurse Practitioner program, so don't even feed me that line of crap.

 

[FNP_Blix]

Yeah, because the VA has such a focus on actually providing quality care They have never published a study of their data on nurse practitioners, and have never made any statements about said data. The VA is also not the optimum environment for such a study, as it has a very specific patient population (veterans) and would not be generalizable. I'd still love for them to make the data available for analysis though. Oh wait... Nevermind. Their NPs didn't get independent practice until last year so it wouldn't be valid since they were under physician supervision and auditing per VA policy.

As to "a different path to independence," uh, you are fully licensed to practice independently right out of school. That IS your path to independence, and there's more than one NP in my area that's opened up a clinic directly after graduating from the local Direct Entry Nurse Practitioner program, so don't even feed me that line of crap.

Well then lets see how they do. To me thats very bold to go into solo practice right out of school. I personally wouldn't do it and the vast majority of NPs wouldn't. Wonder how they're doing nevertheless.

And im sure that data is available somewhere, I will look for it when my plane lands. But even for solo NP or physician, you still ask questions, inquirie with colleagues, and make referrals. So dont know what you want here. Auditing still would take place for solo practitioner of their performance to ensure no harm. No one is ever truly practicing independently.

 

[IlDestriero]

FYI, using the VA as an example of good care equivalence is laughable. A witch doctor could provide equivalent care to many VA "providers".


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Il Destriero

 

[MBVT]

As a patient I am OK with a PA or NP when I know what the problem is and it is relatively simple or if they are acting on what a physician has directed be done. For example I had surgery on a finger earlier this year and then subsequently a PA took the stitches out. Another time I was concerned I might have lyme disease and it was a PA that looked at my arm and ordered a lyme disease test. NP's administered all of my bladder cancer treatments that my urologic oncologist ordered. Another time an NP lanced, drained, and froze a ganglion cyst based on her own assessment of what I had.

Conversely in response to sporadic light headedness I saw my primary care physician and my cardiologist because I didn't know what the issue was and I wanted their level of education and expertise trying to figure out what was wrong. Same with chest pains and a lingering cough. Only physicians when what's wrong is not clear and is potentially serious.

What I have not resolved for myself is whether I would go to a PA or NP for a routine annual physical. I haven't done it yet and wonder if they might miss something that a physician would have caught.

 

[FNP_Blix]

As a patient I am OK with a PA or NP when I know what the problem is and it is relatively simple or if they are acting on what a physician has directed be done. For example I had surgery on a finger earlier this year and then subsequently a PA took the stitches out. Another time I was concerned I might have lyme disease and it was a PA that looked at my arm and ordered a lyme disease test. NP's administered all of my bladder cancer treatments that my urologic oncologist ordered. Another time an NP lanced, drained, and froze a ganglion cyst based on her own assessment of what I had.

Conversely in response to sporadic light headedness I saw my primary care physician and my cardiologist because I didn't know what the issue was and I wanted their level of education and expertise trying to figure out what was wrong. Same with chest pains and a lingering cough. Only physicians when what's wrong is not clear and is potentially serious.

What I have not resolved for myself is whether I would go to a PA or NP for a routine annual physical. I haven't done it yet and wonder if they might miss something that a physician would have caught.

All bantor aside, for a routine physical either is fine. Both PAs and NPs are great providers for the things you described in your experience as well.

 

[FNP_Blix]

FYI, using the VA as an example of good care equivalence is laughable. A witch doctor could provide equivalent care to many VA "providers".


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Il Destriero

Thats really too bad they have such a bad reputation. Anyway, they've had their fair share of issues and its not reflective of NPs or their nursing staff as you just made it sound. Its access to medical care thats a major issue with them causing delays in treatment. But we're not debating VA stuff right now so...

 

[tymont12]

As a patient I am OK with a PA or NP when I know what the problem is and it is relatively simple or if they are acting on what a physician has directed be done. For example I had surgery on a finger earlier this year and then subsequently a PA took the stitches out. Another time I was concerned I might have lyme disease and it was a PA that looked at my arm and ordered a lyme disease test. NP's administered all of my bladder cancer treatments that my urologic oncologist ordered. Another time an NP lanced, drained, and froze a ganglion cyst based on her own assessment of what I had.

Conversely in response to sporadic light headedness I saw my primary care physician and my cardiologist because I didn't know what the issue was and I wanted their level of education and expertise trying to figure out what was wrong. Same with chest pains and a lingering cough. Only physicians when what's wrong is not clear and is potentially serious.

What I have not resolved for myself is whether I would go to a PA or NP for a routine annual physical. I haven't done it yet and wonder if they might miss something that a physician would have caught.

The problem though, is that you are approaching your own health from a position of understanding what is potentially going on. The average patient may not care or know what the hell is going on, or who to go to for that matter.

 

[IlDestriero]

Have you been to a VA? There are a lot more problems than just access and treatment delays. They wish it was just access.
(Though there are some high quality VAs that are at least partially staffed by university faculty.)


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Il Destriero

 

[FNP_Blix]

Have you been to a VA? There's a lot more problem than access and treatment delays. They wish it was just access.
(Though there are some high quality VAs that are at least partially staffed by university faculty.)


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Il Destriero

No cant say that I have. Thats too bad :-/

 

[Mad Jack]

All bantor aside, for a routine physical either is fine. Both PAs and NPs are great providers for the things you described in your experience as well.

A good physical can be the difference between finding something early or late.
Knowing the difference between this:

This:

This:

This:

and this

can save a patient's life. I'm not telling you which will kill your patient, but it's most of them in one way or another. That's just the eye, and a small sample. Don't trust a physical exam to a hack unless you actually don't care about your health.

 

[FNP_Blix]

Don't trust a physical exam to a hack unless you actually don't care about your health.

Calling NPs hacks wasn't very nice Mad Jack :-( You hurt my feelings. 1st image looks like aniridia, 2nd looks like PAM, 3rd looks like melanoma, 4th one looks normal to me but would need retroillumination to see iris transillumination defects and 5th one, not sure what I'm looking at..Contrary to what you think, I know that if you spot a primary acquired melanosis it can potentially lead to a malignant melanoma which both require referral to ophthalmologist.

At the end of the day, you know that anytime the patient complains of severe and sudden vision loss or sudden severe non-traumatic eye pain or if physical exam reveals things like irregular pupil, hazy cornea, suspected herpes zoster ophthalmicus, corneal ulceration, limbal flush, muscle paresis, elevation of fundus on funduscopic exam, patient is seeing flashy lights (the list goes on) then those complaints or findings on exam should all lead to referral.

I (nor should any primary care provider) should not even be messing with the eye unless for management of basically just conjunctivitis, keratitis sicca, hordeolum, blepharitis, and if you have the means to administer parenteral antibiotics, periorbital cellulitis. Can't think of a whole lot of anything else I would be managing in the office..

 

[Mad Jack]

Calling NPs hacks wasn't very nice Mad Jack :-( You hurt my feelings. 1st image looks like aniridia, 2nd looks like PAM, 3rd looks like melanoma, 4th one looks normal to me but would need retroillumination to see iris transillumination defects and 5th one, not sure what I'm looking at..Contrary to what you think, I know that if you spot a primary acquired melanosis it can potentially lead to a malignant melanoma which both require referral to ophthalmologist.

At the end of the day, you know that anytime the patient complains of severe and sudden vision loss or sudden severe non-traumatic eye pain or if physical exam reveals things like irregular pupil, hazy cornea, suspected herpes zoster ophthalmicus, corneal ulceration, limbal flush, muscle paresis, elevation of fundus on funduscopic exam, patient is seeing flashy lights (the list goes on) then those complaints or findings on exam should all lead to referral.

I (nor should any primary care provider) should not even be messing with the eye unless for management of basically just conjunctivitis, keratitis sicca, hordeolum, blepharitis, and if you have the means to administer parenteral antibiotics, periorbital cellulitis. Can't think of a whole lot of anything else I would be managing in the office..

Incredibly wrong on all but one count. You saved our melanoma patient, but our poor third patient develops dystonia and ataxia, and begins to hallucinate. Your first patient wonders how they can have aniridia if they've had perfect eye exams their whole life and never sees you again. Your fourth patient also has this on exam

While your fifth says her father has some eye issues and wonders if she should see a specialist or if she is fine. Wut do?

A physical exam is about taking a thorough inventory of a patient. This is all basic board material for physicians, I want to see how well you do by providing you with textbook cases that are of the sort that most medical students can answer them easily. You're failed 2/3 attempts so far, let's see how you do with more information.

 

[Mad Jack]

Calling NPs hacks wasn't very nice Mad Jack :-( You hurt my feelings. 1st image looks like aniridia, 2nd looks like PAM, 3rd looks like melanoma, 4th one looks normal to me but would need retroillumination to see iris transillumination defects and 5th one, not sure what I'm looking at..Contrary to what you think, I know that if you spot a primary acquired melanosis it can potentially lead to a malignant melanoma which both require referral to ophthalmologist.

At the end of the day, you know that anytime the patient complains of severe and sudden vision loss or sudden severe non-traumatic eye pain or if physical exam reveals things like irregular pupil, hazy cornea, suspected herpes zoster ophthalmicus, corneal ulceration, limbal flush, muscle paresis, elevation of fundus on funduscopic exam, patient is seeing flashy lights (the list goes on) then those complaints or findings on exam should all lead to referral.

I (nor should any primary care provider) should not even be messing with the eye unless for management of basically just conjunctivitis, keratitis sicca, hordeolum, blepharitis, and if you have the means to administer parenteral antibiotics, periorbital cellulitis. Can't think of a whole lot of anything else I would be managing in the office..

The thing you're missing is that only one of these is an eye problem. One of them is a fatal or disabling condition that can easily be fixed and is often first noticed in the eye by primary care physicians, and is a patient that will never develop eye-related complaints. Once symptoms appear, they are irreversible. It isn't the job of a doctor to just notice things your patient is pointing out to you.

And I never called NPs hacks. I said doubt trust your physical exam to a hack. That includes basically anyone that won't or can't do a proper physical exam.

 

[FNP_Blix]

Incredibly wrong on all but one count. You saved our melanoma patient, but our poor third patient develops dystonia and ataxia, and begins to hallucinate. Your first patient wonders how they can have aniridia if they've had perfect eye exams their whole life and never sees you again. Your fourth patient also has this on exam

While your fifth says her father has some eye issues and wonders if she should see a specialist or if she is fine. Wut do?

A physical exam is about taking a thorough inventory of a patient. This is all basic board material for physicians, I want to see how well you do by providing you with textbook cases that are of the sort that most medical students can answer them easily. You're failed 2/3 attempts so far, let's see how you do with more information.

Okay the 3rd image is the melanoma patient. You mean the 2nd image? (if that one is not melanosis) this patient may be taking chlorpromazine which probably explains the dystonia and ataxia, and would be one explanation for the brown spot on her sclera, but I'd find out doing a thorough history to see what meds she taking, or if she's consumed any metals..The 4th one with the cafe au lait - are there a lot of these spots and is the patient experiencing any vision loss? May be NF. But still, I hold that that eye looks normal and would need retroillumination to deterimine iris transillumination defects if she is having symptoms..The 5th one, while I don't know what I'm looking at here (eye appears normal), I'd def. have her follow ophthalmologist, again if she is experiencing any changes in visual acuity, has diplopia, photophobia, etc. and especially given her family history. Is the 1st one glaucoma? Are his/her pupils reactive to light? How's that patient's vision? Any pain? Vomiting, headaches? Halos and lights? ...Not really sure what I'd call that in the 1st image, but I would def. do a thorough history and physical here and refer this patient to ophthalmologist.

Again in general, any acute changes in vision, pain in the eye, irregular borders, or outside of the common conditions differential list that can be treated in the office, I'm referring them out always.

 

[Mad Jack]

Okay the 3rd patient may be taking chlorpromazine which probably explains the dystonia and ataxia, and would be one explanation for the brown spot on her sclera, but I'd find out doing a thorough history to see what meds she taking, or if she has a special appetite for metals lol..The 4th one with the cafe au lait - are there a lot of these spots and is the patient experiencing any vision loss? May be NF. The 5th one, while I have no idea what I'm supposed to be looking at here, I'd def. have her follow ophthalmologist, again if she is experiencing any changes in visual acuity, has diplopia, photophobia, etc. and especially given her family history. Is the 1st one glaucoma? How's that patient's vision? Any pain? Vomiting, headaches? Halos and lights? ...Not really sure but I would def. do a thorough history to rule that out. Again any changes in vision, pain in the eye, irregular borders, or outside of the common conditions differential list that can be treated in the office, I'm referring them out always.

NF, congrats, you're two for four, but you've failed the fifth patient and the health care system by referring her to a specialist and not asking about her father's eye condition (he's colorblind)- this is why many of the specialists I know refuse to take consults from NPs. As to our other patient, they are 22, were otherwise healthy prior to the onset of new symptoms, take no medications and are otherwise asymptomatic.

 

[Mad Jack]

Oh, and patient one is completely asymptomatic, healthy, 22, and female

 

[FNP_Blix]

NF, congrats, you're two for four, but you've failed the fifth patient and the health care system by referring her to a specialist and not asking about her father's eye condition (he's colorblind)- this is why many of the specialists I know refuse to take consults from NPs. As to our other patient, they are 22, were otherwise healthy prior to the onset of new symptoms, take no medications and are otherwise asymptomatic.

Okay well it could be benign (nevus), could be excessive exposure to sun, the patient may be pregnant which could darken the sclera, or underlying hemorrhage. Those are my best guesses. And I would have asked about what her father's history is - that is part of basic history taking. Don't think that a referral to ophthalmologist would be "failing the patient" or the healthcare system. If anything, it shows that I'm a safe provider, know my limits, and frankly it would be negligent to not refer a patient for something I'm not sure what it is. And funny, most physicians I know would and should take consults from NPs if they care at all about the population and their patients. Would you as a psychiatrist not refer a patient where melanosis or malignant melanoma should be ruled out? How can you say for sure that that brown spot is not melanosis without further testing from a specialist who is an expert in eyes? It's best practice to refer patient's for all the reasons I stated above.

 

[Mad Jack]

Okay well it could be benign (nevus), could be excessive exposure to sun, the patient may be pregnant which could darken the sclera, or underlying hemorrhage. Those are my best guesses. And I would have asked about what her father's history is - that is part of basic history taking. Don't think that a referral to ophthalmologist would be "failing the patient" or the healthcare system. If anything, it shows that I'm a safe provider, know my limits, and frankly it would be negligent to not refer a patient for something I'm not sure what it is. And funny, most physicians I know would and should take consults from NPs if they care at all about the population and their patients. Would you as a psychiatrist not refer a patient where melanosis or malignant melanoma should be ruled out? How can you say for sure that that brown spot is not melanosis without further testing from a specialist who is an expert in eyes? It's best practice to refer patient's for all the reasons I stated above.

Appropriate referrals are fine. Inappropriate referrals waste valuable time and resources. Not being able to make a basic diagnosis leads to wasted time and money for everyone involved.

 

[MBVT]

The problem though, is that you are approaching your own health from a position of understanding what is potentially going on. The average patient may not care or know what the hell is going on, or who to go to for that matter.

Yes I do go about it from a position of understanding having had my share of medical issues and from having observed family members navigate the medical system. Don't get me wrong, I do not try to self-diagnose but rather recognize what is doctor stuff vs what is OK for a PA or NP to do.

On the matter of physicals, my current primary care physician is in practice for himself and does not have any staff other than a receptionist/billing clerk that he shares with another medical provider, so the matter of a PA or NP doing a physical is not in the cards at this time. I still lean towards a physician for physicals because I don't know what he might see that would concern him. It was a primary care physician doing a routine physical who discovered what turned out to be a rare high grade and aggressive bladder cancer before it got too far. I did not have any of the risk factors, and was well younger than most patients. In a family where many have died of cancer I am literally the only cancer survivor. Maybe a PA or NP would have discovered it too. That's not anything I can know but the experience made me somewhat conservative in my approach.

I apply this same approach to whether I seek care at the small regional hospital (I live in a rural area) that is only 10 miles from here vs driving two hours to a large teaching hospital. They each serve a purpose and those purposes are different.

 

[FNP_Blix]

Oh, and patient one is completely asymptomatic, healthy, 22, and female

For patient one, what the heck is that Mad Jack??? lol I'm going to be totally honest, I've tried looking this one up, and I even asked a few of the physicians I work with and none of us can say for sure what that is...Is it a contact lense, Pterygium? I already said aniridia but you said that's not what it is.

 

[Mad Jack]

For patient one, what the heck is that Mad Jack??? lol I'm going to be totally honest, I've tried looking this one up, and I even asked a few of the physicians I work with and none of us can say for sure what that is...Is it a contact lense, Pterygium? I already said aniridia but you said that's not what it is. So what is it?

It's a normal eye.

 

[FNP_Blix]

It's a normal eye.

lol okay! We're talking about this image right?

 

[Mad Jack]

lol okay! We're talking about this image right?

Yep, totally normal eye. Number two is Wilson's disease.

 

[FNP_Blix]

Yep, totally normal eye. Number two is Wilson's disease.

Darn, I missed the kayser ring. Showed that to one of my docs here too just a couple of minutes ago and we both thought melanosis cause of the brown discoloration on the sclera.

 

[FNP_Blix]

A good physical can be the difference between finding something early or late.
Knowing the difference between this:

This:

This:

This:

and this

can save a patient's life. I'm not telling you which will kill your patient, but it's most of them in one way or another. That's just the eye, and a small sample. Don't trust a physical exam to a hack unless you actually don't care about your health.

Can you tell me what you think these are smarty pants? Just curious to see if I can stump you on some abnormal dermatologic findings. If you're any good, these should be fairly easy...be careful now because 2 of these can kill your patient.

1.

2.

3.

4.

 

[Noisewater-TDX]

As a RN who is going the medical school route, I have mixed feelings about NPs taking the lead in the PCP area. PAs and CRNAs i believe have far superior IN CLASS and CLINICAL exposure and training than most NP programs.

When I was looking into the CRNA, PA, and NP routes I found that large majority of NP programs have classes online and lean heavily on the RN's prior experience. This could be 1-2 years of Med Surg nursing (not ideal) or a 10-15 year ER/Trauma/ICU veteran who could out preform a senior resident.

I don't like this wide variation in pre-NP experience. I hope in the near future the bar is raised and made uniform across the board. This would raise my confidence in NP skills.

Now, note, I see a Endo NP and a PCP PA. I haven't seen a MD or DO in YEARS. But I vet my providers and trust them with my life.

 

[FNP_Blix]

As a RN who is going the medical school route, I have mixed feelings about NPs taking the lead in the PCP area. PAs and CRNAs i believe have far superior IN CLASS and CLINICAL exposure and training than most NP programs.

When I was looking into the CRNA, PA, and NP routes I found that large majority of NP programs have classes online and lean heavily on the RN's prior experience. This could be 1-2 years of Med Surg nursing (not ideal) or a 10-15 year ER/Trauma/ICU veteran who could out preform a senior resident.

I don't like this wide variation in pre-NP experience. I hope in the near future the bar is raised and made uniform across the board. This would raise my confidence in NP skills.

Now, note, I see a Endo NP and a PCP PA. I haven't seen a MD or DO in YEARS. But I vet my providers and trust them with my life.

There is actually a wider range of variability (in regards to experience in the medical field) in pre-PA school students vs. NP students. The average NP has 10-11 years of RN experience (though this is beginning to change I think). However, it's hard for me to disagree with you in respect to raising standards and having more uniformity amongst ARNP school entry standards.

 

[Noisewater-TDX]

There is actually a wider range of variability (in regards to experience in the medical field) in pre-PA school students vs. NP students. The average NP has 10-11 years of RN experience (though this is beginning to change I think). However, it's hard for me to disagree with you in respect to raising standards and having more uniformity amongst ARNP school entry standards.

Yeah, i have no doubt pre-PAs are much less experienced than Pre-NPs. There are those few Paramedics and Combat Medics who go PA who could blow me away (diagnostically).

 

[FNP_Blix]

Yeah, i have no doubt pre-PAs are much less experienced than Pre-NPs. There are those few Paramedics and Combat Medics who go PA who could blow me away (diagnostically).

Ummm sure, if you let them I guess... You put in the time, study, inquire, etc., you can become just as good as a physician. Forget about comparing to a PA.

 

[Noisewater-TDX]

Ummm sure, if you let them I guess... You put in the time, study, inquire, etc., you can become just as good as a physician. Forget about comparing to a PA.

No no, i wasn't saying it in a negative light. Just that there are a few people who go into PA school with a solid clinical background, less than NP student though. In general.

I'm a OMS 1 right now, so in 3.5 years, I hope to be a pretty good diagnostician.

 

[FNP_Blix]

No no, i wasn't saying it in a negative light. Just that there are a few people who go into PA school with a solid clinical background, less than NP student though. In general.

I'm a OMS 1 right now, so in 3.5 years, I hope to be a pretty good diagnostician.

I understand you now. Good luck to you man. We need more physicians for sure and ultimately, you guys will be the heavy hitters in medicine.

 

[mxg67]

I have had my share of unfavorable experiences with midlevels professionally, and have heard many stories from colleagues, but after seeing NP care from a patient's perspective (a family member) at a prominent nationally recognized hospital, I don't think NP's should practice independently. Certainly they can serve as an extension to the MD, doing low-risk or routine tasks, helping out with the routine chronic conditions, spending time educating patients, etc. However, doing their own workup, diagnosing and treating, forget it, even for "simple" things. My family member presented with simple symptoms but a less simple history, which would concern most MD's, but the NP just looked at the symptoms, did a weak H&P (the med student on the consulting team did a better job), and jumped to the most basic diagnosis (which was way off). This falls in line with how other NP's I've worked with tend to practice, they seem to rely more on pattern-recognition and algorithms, and sometimes they just don't know what they don't know. I can certainly see this type of thinking causing big problems.

 

[IlDestriero]

More algorithms less thinking.
Except sometimes it's a zebra.
Or at least a donkey, or Lupus.


--
Il Destriero

 

[FNP_Blix]

I have had my share of unfavorable experiences with midlevels professionally, and have heard many stories from colleagues, but after seeing NP care from a patient's perspective (a family member) at a prominent nationally recognized hospital, I don't think NP's should practice independently. Certainly they can serve as an extension to the MD, doing low-risk or routine tasks, helping out with the routine chronic conditions, spending time educating patients, etc. However, doing their own workup, diagnosing and treating, forget it, even for "simple" things. My family member presented with simple symptoms but a less simple history, which would concern most MD's, but the NP just looked at the symptoms, did a weak H&P (the med student on the consulting team did a better job), and jumped to the most basic diagnosis (which was way off). This falls in line with how other NP's I've worked with tend to practice, they seem to rely more on pattern-recognition and algorithms, and sometimes they just don't know what they don't know. I can certainly see this type of thinking causing big problems.

Sorry to present the reality to you, but you see this with physicians too (and probably a lot more of the time b/c of time constraints placed on physicians). Can't tell you how many times I've seen physicians just run in and out of the hospital wards or dictate notes without even seeing the patient while documenting that they spent 45 minutes with their patient... NPs in the states where they practice independently and collaboratively have proven (since the 70s I should add) to be safe providers. They tend to be more cautious and much less negligent as you described.

 

[FNP_Blix]

More algorithms less thinking.
Except sometimes it's a zebra.
Or at least a donkey, or Lupus.


--
Il Destriero

Hows this for less thinking? My diagnosis is that YOU are a donkey.

 

[MBVT]

Let me interject a bit of reality to the debate.

I recently came to the conclusion that I needed a new primary care physician. This was after more than a year with a couple symptoms going undiagnosed and nothing more than a couple referrals which didn't get me any closer to addressing the problem. It came as a shock to me but I could not find a single internist MD that is taking new patients within 1.5 hours of where I live. Most practices had more NP's, APRN's and PA's than MD's. Most of the NP/APRN/PA's weren't taking new patients either. I only found several that were. What I ended up deciding was that I would take anyone I could find that was taking new patients at a large teaching hospital 1.5 hours from here. My urology and gastroenterology care was already there and I figured if I could get into there as a primary care patient and also move my cardiology from the local hospital to there I would be 100% within that system and maybe get better coordination than I have had.

They had a PA taking new patients and so I signed on with him. Let me repeat. There was not a single internist MD within 1.5 hours of here taking on new patients. I checked every single one of them. Available NP's or PA's were few and far between. I figure I have nothing to lose switching to the PA because my doctor wasn't helping much for more than a year now.

If NP's and PA's outnumber internist MD's in this region and it is hard to find an NP or PA that is taking on new patients, we have already reached the point where NP's and PA's have taken over primary care. If the NP's and PA's weren't here, most of us would be going without primary care. Good, bad, or indifferent, it is the reality. What you are debating has already come to pass in rural areas at least.

 

[Noisewater-TDX]

Let me interject a bit of reality to the debate.

I recently came to the conclusion that I needed a new primary care physician. This was after more than a year with a couple symptoms going undiagnosed and nothing more than a couple referrals which didn't get me any closer to addressing the problem. It came as a shock to me but I could not find a single internist MD that is taking new patients within 1.5 hours of where I live. Most practices had more NP's, APRN's and PA's than MD's. Most of the NP/APRN/PA's weren't taking new patients either. I only found several that were. What I ended up deciding was that I would take anyone I could find that was taking new patients at a large teaching hospital 1.5 hours from here. My urology and gastroenterology care was already there and I figured if I could get into there as a primary care patient and also move my cardiology from the local hospital to there I would be 100% within that system and maybe get better coordination than I have had.

They had a PA taking new patients and so I signed on with him. Let me repeat. There was not a single internist MD within 1.5 hours of here taking on new patients. I checked every single one of them. Available NP's or PA's were few and far between. I figure I have nothing to lose switching to the PA because my doctor wasn't helping much for more than a year now.

If NP's and PA's outnumber internist MD's in this region and it is hard to find an NP or PA that is taking on new patients, we have already reached the point where NP's and PA's have taken over primary care. If the NP's and PA's weren't here, most of us would be going without primary care. Good, bad, or indifferent, it is the reality. What you are debating has already come to pass in rural areas at least.

True. I did a travel gig in a little town in MT, loved it. But Mid levels are the only thing keeping that towns healthcare afloat. There were 3 IM docs (2 were like 70 years old), 1-2 FM docs, 1 Pathologist, 1 gen surg, Rads was tele from Billings, and 1 Rad Onc guy. All this for ~3,000 residents and ~3-5,000 transient oil field workers. Crazy.

 

[MBVT]

NickMT-RN, I live in rural Vermont and while we might be considered the boonies by most urbanites, it is not like we are isolated like some remote places out West. I looked in a 1.5+ hour circle from where I live at at 45, 99, 133, and 400 bed hospitals & surrounding communities. Not a single Internist MD is taking patients in this wide circle and most NP's and PA's are fully booked too. Not only is there a shortage of primary care physicians, it seems primary care NP's and PA's who outnumber the MD's are barely adequate to meet the demand for primary care. That they all have as many patients as they can handle means there is a good living to be earned, yet there is a shortage.