Monday, January 5, 2009

American College of Clinicians...NP and PA

So I got my renewal reminder for the ACC in the mail today. The ACC for those of you not familiar, was created a few years back by a group of NP's and PA's (Bob Blumm among them, whom I know from the Academy) in order to foster a more collaborative atmosphere and to encourage a partnership between the two groups. I think their aims are admirable, so I usually send in my check.

It reminds me however, how often I am asked to explain the differences between the two, both at policy meetings, and by patients and even MD's (who should know this)

I will start by saying that I hold no personal grudge against NP's, hell, I supervise two of them in our group.

There are however, some substantial differences between the two.

Educational Degree:

PA's Master's level for the most part, there are still some baccalaureate programs remaining, and I believe one or two certificate programs.

NP's Master's mandated now, however, the NP leadership has now mandated that the Doctor of Nursing Practice degree (DNP) be the entry level degree for the profession.

Educational Structure:

PA's Based on the medical model. All schools must meet stringent criteria, and be accredited by the APAP. There is ALWAYS one full didactic year, followed by one full clinical year. We are told that we get the "meat" of medical school, essentially the 2nd and 3rd years. As I have not been to medical school, I cannot qualify this statement.

NP's All over the place, there is no nationally based criteria for NP school structure, and many have a mix of didactic and clinical hours, but do not seem to follow any pattern, hence there are sometimes serious questions regarding their educational model.

Board Examinations/CME:

PA's Licensed by the state medical board, we have to fulfill the same requirements as the MD's....50 hours of CME every year, and we have to take our boards over again EVERY six years. Most MD specialties require boards to be taken every x number of years, most are every ten.

NP's Licensed by the board of nursing, they have to fulfill the minimum CEU requirements for their state. They take a state based NP board exam only once. They do not ever have to take their boards again, and as their board exam is state based, there is wide variability on the testing that actually takes place.

Practice:

PA's Generally, although not always, much better at procedural medicine, and much better at acute care (ICU's, ER's, Surgical specialties).

NP's Generally, although not always, much better at preventative medicine, and patient counseling, as well as geriatric nursing home care.

Bottom line is, there are differences between us, it is important to recognize these, but also to work together.

I do have a problem with the NP pursuit of the DNP degree as their entry level degree, as they are creating a potential legal minefield for themselves. I have 3 friends who are PA's that have PhD degrees as well, and not a SINGLE one of them will identify themselves as "Doctor" to patients. They don't even have the PhD listed on their clinical nametags, as it is simply NOT worth the potential confusion. I know that I am finishing my Doctoral degree now, and I will follow their example. I can see everything being fine for the NP's until something goes wrong. Which it will, when you practice medicine, as an NP, PA, MD, DO, CRNA, CNM, etc.etc., if you practice long enough, you will have complications and/or bad outcomes. It's just a statiscal reality, and I can see a defense attorney having a FIELD day with the DNP degree. "So, (snidely) DR, was the patient aware that you do not in fact, have an MD?....before you answer that, WHERE did you go to medical school? Where did you complete your residency....DR?, I mean you are ABSOLUTELY SURE that the patient was aware that you are not, in fact, an MD? How could they be so sure, I mean after all, you call yourself a DR, you are treating the patient, are you not?"

And that would likely end badly. So, to any NP that reads this, it is not a slam, merely a concern. I would like to see us both flourish........

(PS.......you should have to re-board too.....dammit)

25 comments:

Anonymous said...

Well, I wish I only had to take boards again every 6 years. However, as an NP credentialed by the American Academy of Nurse Practitioners, we are required to recertify every 4 YEARS, NOT 6 YEARS. We can either test again or submit proof of CMEs in our field and proof of clinical experience over the past 4years. It is not an easy process, trust me. And, though we can keep our NP licenses without being credentialed, we must be credentialed to bill Medi-care and most other insurances so there is no point really not to be credentialed. Further, we do have to have a masters degree, whereas there are still some PA programs out there that do not even give out a Bachelors degree. As for the American College of Clinicians - the ACC - yes, all NPs and PAs need to join and unite our professions - it is the only way we are going to have a voice.

physasst said...

We have to submit our CME every two years in addition to having to take boards every six, but the NP's that work in our group have said that they merely have to submit their CME/CEU's. If I am incorrect about NP's having to re-board then I apologize. We have to re-certify with the NCCPA every two years, and then every six we HAVE to take the PANRE. I think I discussed that their were still baccalaureate PA programs, and even a couple of certificate programs still in existence. I agree about the ACC.

Johnny Hudson said...

I don’t believe your comment on NP education being "all over the place" is not accurate. It’s true, we don't have one curriculum model as I understand PA programs do. Our programs are specialty programs n various areas, such as Family Practice, Acute Care, women's health, etc. We are then certified in our specialty area. The concept is that when you enter NP school, you already have some basics in your RN program. That basic training, if you will, is built upon based on the specialty that NP's choose. If you don't have the basics, it’s included in the program. Most NPs go to school for three years to complete their program, though some finish faster.
As for educational requirements, there are specific requirements for minimum didactic and clinical hours for each specialty. A NP can’t sit for boards unless their program meets these minimum requirements.
There are two big differences between the two professions that I see. One is the training: The PA model is more focused on he “medical Model” and in most states must be supervised by a physician in some capacity. NP’s do have a “nursing model” slant to their training, although I believe that he training has shifted over the years to be closer to the traditional “Medical Model”. The Second difference that I see is that NP’s are trained and intended to practice more independently. Most states require some level of physician collaboration I their practice, though some states require no level of collaboration or supervision, and they practice independently.
What I have found, over my years of being a NP in both practice and education, is despite these differences, most of NPs and PAs (often referred to a Advanced Practice Clinicians, or APCs, collectively) evolve in nearly equivalent providers, and often work in concert with each other. There are outstanding clinicians in both groups and both fulfill what I see as a tremendous need in healthcare, ad they fulfill his need extremely well.
I, too, am a member of the ACC. I believe that the mission of its founders is certainly a honorable one, and one I support. I encourage all APCs to join and support this organization. Further, be sure to check out www.clinician1.com, a website devoted to the needs of APCs. Any APC can join for free.

Robert Blumm said...

Nice Blog. Where have you been? Good comments and although some need to be flushed out a bit more, most of this dialogue focuses on the fact that we can and do work together and that there should be some type of educational standard after our first certification. I think that if the PA world were to vote, the would go the same way that the NPs have and make sure that this was a real educational seminar, in their specialty are and they would give some type of feedback.
I have worked with both species of clinician and have trained both. I have also learned quite a bit from knowing both NPs and PAs. My endocrinologist is an NP. She is better than four real live MD's that saw me and never asked me to take off my socks to do an exam of the foot on a first diabetic checkup. I equate this with going to the OB/GYN and keeping one's panties on.
There is now a great blur between all medical professionals because some have become disillusioned and lost the vision that first led them into medicine. Some, for this reason, have left medical practice in search of their other interests. It's up to us to keep our fingers on the pulse of the professions and to encourage and affirm one another as the healthcare of America is at stake and we will be the likely gatekeepers in the next 3-5 years.
Bob Blumm

physasst said...

Well, this whole post started after a rebuttal of this post....

http://scalpelorsword.blogspot.com/2008/12/why-pas-and-nps-dont-help.html

Are you going to San Diego Bob?

Anonymous said...

A PhD is NOT a clinical Doctorate. So a PA with PhD in Persian History would not qualify to use title Doctor in the health care setting. Only professionals who are independant practitioners and trained at the Practice Doctorate level are qualified to use that title. Secondly, I am strongly opposed of The ARNPs affiliating with the ACC. It does not represent the Professional Nurse practitioner but lends legitimacy to PA. The two are NOT equal in education,training and history. The ARNP has its own Professional organization that correctly represents them. Further, APC might be appropriate for a PA but NOT a Nurse Practitioner.

Anonymous said...

Your story on PAs is misleding and inaccurate. PA education is entry level. Your suggestion that you get the "meat" of medical school is way over stated. Your "post graduate" training in a specialty is introductory. The world does not rest on your shoulders, as you would have all of us believe.

Anonymous said...

Your condensending and disparaging remarks concerning ARNP's education, training, and license and board requirements shows your total lack of knowledge and ignorance of that profession. PA are and will continue to be a supervised, health care worker regardless of your over bloated claims to the contrary. As one other commentor in this blog stated, health care is composed of Medicine, Nursing and Denistry i.e., MD, RN, DDS. These are the professions that have historical legitamacy behind them. PA are new and were developed as "extenders" to help the Doctor. You do NOT practice medicine but follow standardized procedural instructions on patient care. Reason, you have an entry level health care education.

Anonymous said...

I have had several Associates ask me to view this site. I would have to say that the information offered as facts concerning Advance Pracice Registered-Nurses Practitioners has been poorly researched or distorted. The Nursing Profession has been the crutch which medicine has built itself on. Many, many health care innovations in patient care has come directly from Nursing research. The acceptance criteria of RN, BSN applicants into ARNP programs is extremely competitive and rigorous. Clinical and diadatic training is at an Advanced level NOT a basic health education. The Doctorate of Nursing Practice (DNP) is the next logical level for these independent, advance practitioners. Finally, I do not think that Professional ARNPs should "join" a non-nursing association that does not represent their goals and ideals.
Thank you,
D.G,ARNP,DNP

Anonymous said...

phyassst, I can not believe the "propaganda" that you are blogging as fact concerning Physicans and Nurse Practitioners. I guess if you say it long enough, sincere enough and often enough, you will convince someone and yourself that you're a "little doctor". Some health care providers see "physician" in your title and give you more credit than is do. Others know the real facts but still appreciate your "assistance".

physasst said...

Anon,

Please tell me where I was incorrect.

There is one singular body accrediting all NP schools?

As far as the garbage aboove about "entry level" education.

PA's are educated in the medical model.

BTW, PA's are no newer than NP's.

The first classes for BOTH professions started in 1965. We are of the same age.

But thanks for playing.

Anonymous said...

phyasst, you are incorrect. Nurse Midwifes were the first "Nurse Practitioners" to practices independently followed by Nurse Anesthetist. PA is a relatively new healthcare worker that followed on the introduction of primary care NP of the mid 1960's. Medex was the program that ex-military medics entered to become "Physician Extenders", as they were known back then. It wasn't until 1970's that the term PA was truly introduced and accepted.
Retired PA1965

physasst said...

I never commented on Nurse Midwives OR CRNA's, as both are older in one form or another than NP's or PA's. My point was, the first class of PA's was enrolled at Duke University in 1965. At the same time, the first NP's were enrolled in Colorado. ARNP's and PA's are of the same age. That fact is not in dispute.

"The first PA program was created at Duke University (Durham, NC) in 1965, at approximately the same time as the first pediatric NP program was being developed under the combined auspices of the Department of Pediatrics of the School of Medicine and the School of Nursing of the University of Colorado, Denver. During the 30 years since their inception, the education, training, and practice of NPs and PAs have changed substantially."

http://aappolicy.aappublications.org/cgi/content/full/pediatrics;103/5/1050

Anonymous said...

I never understand why this is even an argument. NPs are great practitioners in many respects and so are PAs. Physasst said nothing that isn't true, but several notions by the NPs here are. Let me enlighten everyone.

http://paprogram.mc.duke.edu/s_admiss_genInfo.asp

http://main.uab.edu/Shrp/Default.aspx?pid=32650

http://www.nursing.vanderbilt.edu/dnp/study_plan.html

http://www.uab.edu/images/sonimg/academic/msn/Acute_Continuing_Care_Adult_NP.pdf

I'm a current Acute Care NP student that has started clinicals and finished didatics, so I can speak with great authority on current NP education. We don't need to recertify, a NP can go through a direct entry program and have no experience, NP education has no more slanted to the medical model than kindergarten has shifted to college, NPs are no more trained to practice independently that a PA, and there is one (hopefully so there will be more) clinical doctorate for PAs through Baylor.
http://www.baylor.edu/graduate/index.php?id=51996

Also the average PA has 4 years medical experience, has more basic science pre-reqs (From UAB PA program)

The following prerequisites:

3-4 semester hours of biology I (lab preferred)

3-4 semester hours of biology II (lab preferred)
3-4 semester hours of microbiology (lab preferred)
3-4 semester hours of human anatomy
3-4 semester hours human physiology (UAB BY 116 or BY 409)
8-9 semester hours of general chemistry (labs preferred)
3-4 semester hours of statistics (upper level, population, and/or health-related with lab preferred)
9 semester hours of psychology (general, developmental, abnormal)

They have higher requirements. This is from the Duke PA program and is representative of most Master's level PA programs.

The ranges of academic and experiential qualifications for the middle 50 percent of accepted applicants for Fall 2008 were as follows:

* Overall GPA: 3.3 – 3.7
* Natural science GPA: 3.1 – 3.6
* Total natural science credits: 47 –74
* GRE General Test scores:
o Verbal: 460 – 598
o Quantitative: 600 – 708
o Analytical Writing: 4.0 – 5.0
* Months of full-time patient care experience: 12 –60

, more advanced science in the didatic year (See UAB PA link above), and does 2000-2600 clinical hours total in the same medical rotations as doctors.

And since NPs have thrown down the gauntlet, let me take you down a peg.(See UAB's ACNP program) The Master's NP is a 18 month long program (24-37 part time which is what many choose to do). It contains a handful of science courses, and don't give me the "I went to nursing school" crap because I have a BSN and it didn't have but handful of sciences. Definitely no biochemistry or gross anatomy.The GRE is waved for students above a 3.2 GPA. The icing on the cake is they do a MINIMUM OF 675 CLINICAL HOURS! Vanderbilt only has 500 and their DNP doesn't add any clinical hours. Just look at the curriculum from the link above for Vanderbilt. How can you even argue that you have received more education.

Even if you somehow did, PAs can go on to post-graduate residencies and will have ~5000 clinical hours in a year. There are quite a few
http://www.appap.org/index1.html

And just because there were Midwives that practiced out long, long ago, doesn't mean that they somehow magically bequeathed knowledge to all future nurse practitioners.

Neither NP or PA practices "cook book" medicine. PAs can be very independent by owing their own practices or being 6 hours away from their SP. Yes, NPs have the "collaborative" practice which many have taken to mean independent, but it's really semantics. Just because PAs have "supervised" doesn't mean the MD goes through every chart and watches every thoracentesis the PA does. Even if there was a possibility for independent practice with absolutely no MD oversight, PAs don't want it. They know that the terminal degree to practice independently should be the MD/DO education.

I would like for someone to prove me wrong, but since I have links to actual school admissions and curriculum I doubt that you can.

P.S. I'm quitting NP school (sucks because I'm 2/3 through) to become a PA. I've seen both and researched both and find PA to be a better new grad (as long as the have health care experience), have more versatility in their profession (can switch specialties), and more opportunities for growth (PA residencies).

physasst said...

Anon 4:33, that is the BEST post I have read in some time.

Thank you for your thoughtful response.

Anonymous said...

anon 4:33 why don't you just apply to medical school and rid yourself from the self doubt and worry of being a NP or PA? You have certainly sold me on your abilities and deep insight.

Anonymous said...

NP enter their program with many clinical hours from BSN program then years of work experience. I had biochemistry, pathophysiology among many other "hard core" sciences and high GRE scores before I got to NP program. Maybe you went to the wrong school or something but you are very atypical of any NP student I know. After reading all these "angry" repetitive comments in this blog it becomes tiring and unproductive to visit. I enjoy working with PAs but this Blog would make this NP feel somewhat hesitant to work with one.
Ann T.,FNP,ARNP,MSN

physasst said...

Ann,

No one is trying to be angry. I am merely trying to discuss our differences. Also, trying to discuss areas in which BOTH professions can improve. I am not singling out NP's solely. The PA profession needs to work on some issues as well.

As far as your "years of work experience" Good. That's a good thing. Unfortunately, there are combined RN/NP programs, where students never graduate and work as RN's prior to matriculation into the NP program. The clinical hours in a nursing program are of course, helpful. But they are nowhere close to a substitute for real world patient contact and experience.

Some of us, including myself, have been guilty of overreacting to the slightest criticism. You have my apologies for that.

NP's and PA's are BOTH outstanding clinicians, who while educated in slightly different models help patient care in this country immensely.

We just need to also step back, and look at what is working, and what is not.

Anonymous said...

I am not familiar with that entry pathway for NPs nor has any of my colleagues (NPs) ever heard of it. I would also like to correct your impression that BSN clinical hours are not "real world". They are,in fact,direct patient care hours in all clinical areas and that gives the RN valuable axperience over his/her four years in the BSN program. Those hours are substantial in total. I don't want to appear argumentative but there is a fair amount of "incorrect" information concerning NPs on this blog.
Thank you
Ann T

Anonymous said...

Presently, the DNP degree program follows AFTER the NP has completed his/her Masters degree and advanced clinical training. In 2015, it will be the ONLY entry for ARNPs.

Alison said...

The University of Wyoming has a RN to FNP program. I know because I have a friend who didn't have an hour of on-the-job, paid RN experience before starting her FNP program. Those programs do exist and more and more are starting up every year.
I really appreciated Anon 433's post. After reviewing the U of Wyoming program and comparing it to my upcoming PA program, I feel like the medical science courses are much more indepth and we get a wider range of coursework in various specialties. However, NPs certainly go more indepth when it comes to Family medicine, womens health, preventative health, etc. I just really appreciated Anon 433's point that PA school isn't a walk in the park either and getting into the programs are quite intense and full of very hard prerequisites. Another friend of mine will be in the FNP program next year after graduating with a 4.0 in her BSN but she's never taken any sort of chemistry class. She's only taken one course in microbiology. None in immunology or virology. I think this is a strength for the pre-PA students. Most PA students have a bachelors degree in a specialized science, like mine in Medical Microbiology, or in Zoology or Physiology. I think it is important to have a strong health science background before taking on the medical science courses in either the PA or NP programs.
Just my 2 cents. My mom is an NP and I'll be a PA in a few years. My mom has had a wonderful career and she is certainly the smartest person I know.

Alex said...

I came across your blog and was offended by your comparison of NP education to PA and various certification requirements. I also know that you are not projecting a Mayo Clinic image in your blog as you are comparing one profession being more superior or more intelligent to another and as a former Mayo Clinic employee I know that is not a philosophy they would want to project. Both professions carry a lot of weight and play an important role in health care and provision of care. I would like to remind you both schools were founded on different philosophies and will have a different structure to their standards. I have worked with PA and NP in settings including trauma ICU, ER, Surgical Floor and Urgent Care and was impressed with knowledge and expertise projected by both professions. I have also received care from NP’s and PA and have been very happy with care I was provided. It is important to recognize the fact that a starting NP student has more than 3 years (6000 hr’s) of RN experience and will be working part time as they are completing their NP school on top of all their clinical hours. That experience will include recovering patients after MI, Sepsis, DIC, Graft vs Hose disease, doing ACLS, BLS, recognizing arising complications, administering thousands of medications and not just learning the side effects from the medical dictionary but seeing them in person and dealing with them. Moreover calling MD/PA on a night shift when the patient is developing complication and recommending what may need to be done at that point. Most importantly family dynamics which play a huge role in patient care. That experience and intuition built over the years can’t be substituted by any knowledge from biochemistry or virology class. This is the main reason why NP school doesn’t require more hours in clinical. To also point out basic entry level education of NP student includes the following prerequisites:

4 semester hours of Anatomy I with lab

4 semester hours of Anatomy II with lab
4 semester hours of microbiology with lab
3-4 semester hours human Physiology
8 semester hours of Biochemistry with Lab
3 semester hours of statistics (upper level, population, and/or health-related)
8-12 semester hours of psychology (general, developmental, abnormal)
68 credits of nursing classes that once again cover physiology, pharmacology, anatomy, geriatric considerations, pediatrics considerations Obstetrics, psychology, mental health, community health, financial considerations/reimbursement.

* Overall GRE: Who cares I would trust Experience over how to calculate the probability of hitting pegs at the bowling ally.
To summarize please take the time to advance your profession, grow and build the leadership skills that would project not just the intelligent side of PA’s but also a level of professionalism and respect.

Andrew said...

Like the blog. I am in a mixed marriage. My husband is a PA and I am an APRN. My brother-in-law (BIL) is an MD (only because he failed to get into PA school and went to medical school as his "back up"). My husband and BIL compared their classes and the time spent in class. The difference? One economics of medicine class that the MD had to take. Granted, BIL also had to do a residency after graduating and my husband went straight into practice. However, as my husband has been in practice for nearly 10 years now...

APRN is very different. I chose to become an APRN over MD or PA. I am much more holistic in viewpoint and it seemed a better fit for my personality. While I would have to agree that APRN's do not get enough clinical experience in school, that experience is obtained quickly in practice. The knowledge is there. Most APRN's also enter their Master's or Doctoral degree with additional clinical experience as RN's. One could argue that this helps flesh out the programmatic requirements.

I think anyone who earns a doctoral degree deserves the title that has historically come with it. I think we just need a massive paradigm shift to calling a MD/DO a physician, rather than a doctor (pipe-dream). However, if an NP/PA does obtain a clinical doctorate, they should be allowed to use that title and should have equivalent rights in their area of specialty as anyone else with a clinical doctorate. We call psychologists (who cannot prescribe, etc), "doctor" and after a couple of visits the patients figure it out.

Lets be honest, these arguments are about territory, job security and money. The best MD/DO's I know have no problem with the development of another group of health care providers. The same goes for the best PA's and NP's. People should have a choice about what provider they see and as long as we all know our limitations, does it really matter? No provider of any degree is going to perform major surgery for which they are not trained. An internist is not going to amputate a leg, an orthopaedic PA...might be appropriate...

9yrsPA&yourProfessionalColleague said...

Wow! I am reading this blog for this first time & I am astonished at the lack of professionalism that most of the postings reflect. After working for the last 4 years in an area very strongly supported by both PAs & NPs & CNSs & APRNs & residents/MD/DOs, I thought the purpose of the formulation of the American College of Clinicians was to work together. Much of the back & forth here would make most of my work collegues sick to just read it.

We are all trained, certified, licensed, credentialed, & continuing our education in various forms i.e. Masters (medicine/nursing-related or not), Doctorate (clinical or not), residency, & oh yeah, patient care experience for all of us. When the "midlevel provider" has situations in which the role is threatened, where will our support for one another be? Realize that the combination of all "midlevel provider" positions together is still not stronger than the AMA.

Remember the purpose of the formulation of this blog & this organization. Bashing each other is not productive.

9yrsPA&yourProfessionalColleague

John said...

Some great comments here. The issue is that many degrees are not 'earned' like they used to be. I invite anyone to show me factual evidence that by a person getting a DNP degree from the University of Phoenix - online shows that this person 'earned' the title of doctor. Further, it is frightening that for-profit schools of this low caliber are awarding doctoral degrees (or master's degrees) in nursing. I have yet to see any for-profit schools offer PA degree programs.