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Understanding Scope of Practice

Understanding Scope of Practice

To Philip Bain, an internal-medicine doctor with Dean Health System in Madison, Wis., the midlevel providers who administer care at his clinic aren’t just treating patients. They’re helping to solve one of the biggest challenges in healthcare today.

“When I started practicing in 1988, physician assistants and nurse practitioners were not commonly used, but over the course of time I’ve become a big advocate for them,” he says. “I don’t see more general internal-medicine doctors entering primary care anytime soon so using midlevels is one way to deal with the physician shortage. It’s an answer to a vexing problem.”

Indeed, the cadre of more than 200,000 midlevel providers that work in healthcare today provide a valuable service to the industry, enabling practices to expand their service offerings, improve patient satisfaction, and get their doctors back to the business of medicine. “Midlevels allow us to have more time to see the sicker, more complicated patients, because they can see the single-problem, more straightforward cases,” says Bain.

The other benefit of midlevel providers, of course, is that they provide cost-effective care, because they’re trained to perform most of a physician’s scope of practice at a fraction of the cost. Nationally, physician assistants and nurse practitioners both earn about $90,000 a year compared with family-medicine doctors, for example, who earn more than twice that amount. From a recruiting perspective then, the case for hiring a midlevel provider at many growing practices seems clear.

Yet, while NPs and PAs bring many of the same skills to the table, they are not one and the same. Before you solicit resumes, you’ll need to educate yourself on the differences in their educational backgrounds and areas of expertise. You should also develop a plan to integrate your new hire into the fold, which includes adequate training and supervision.

Breanna Elliott, director of recruiting for Merritt Hawkins & Associates, a healthcare staffing firm in Dallas, says that many of her clients who are looking for a midlevel to function independently opt for a nurse practitioner, since they are licensed to work autonomously. Those focused on a teamwork approach, however, more often request a PA, which requires varying degrees of physician supervision depending on state laws. “Some of the practices I work with are open to either, they just want the most qualified candidate,” says Elliott. “Others want someone to come in and be totally autonomous, so they ask for a nurse practitioner.”

Scope of practice

To ensure your practice hires the right midlevel for the job, it helps to compare their scope of practice. The American Academy of Nurse Practitioners says NPs are independent practitioners certified to diagnose and treat acute and chronic conditions such as diabetes, high blood pressure, infections, and injuries. They can prescribe medication in all 50 states, update charts, manage patients’ overall care, and provide patient counseling — all without physician supervision. More than 70 percent of NPs work in primary care, because “we really like the ability to work with patients over time and educate them,” says Mary Jo Goolsby, director of research and education for the AANP in Austin, Texas. “It’s something we are taught and bring with us from our nursing background. We do a lot of disease prevention counseling.”

Nurse practitioners have completed formal education beyond that of a registered nurse through nursing schools, including advanced coursework in pathophysiology, pharmacology, and clinical diagnosis. In addition to clinical care, nurse practitioners focus on health promotion, helping patients make healthy lifestyle choices.

NPs typically specialize in family practice, acute care, family health, oncology, pediatric health, psychiatric or mental health, and women’s health. Sub-specialties may include allergy and immunology, cardiovascular, endocrinology, neurology, and orthopedics. Most have master’s degrees and many have doctorates, bringing with them an average of 10 years nursing experience, says Goolsby.

Physician assistants, meanwhile, are trained to coordinate patient care, from delivering care and providing patient education to dealing with the patient’s family. “These are things traditionally that physicians had time to do and that’s where PAs can really step in to help,” says Jennifer Hohman, assistant director of professional affairs for the American Academy of Physician Assistants, noting PAs are capable of performing up to 80 percent of the physician’s scope of practice. “It’s a great blend and it tends to make the patients a lot happier.”

PAs require some degree of supervision from a physician in all 50 states. Some states require a designated physician to review all of the PA’s charts, while others require only 10 percent chart review. Yet, the term “supervision” should not turn practices off, says Hohman. By law, she notes, the PA and supervising physician must be in constant dialogue with each other about their patients, but that doesn’t mean being physically together. The whole idea of the PA, she adds, is to act as an extender of physician care — a flexible part of the team whose role can be customized by the physician.

Indeed, state law grants physicians the authority to determine how best to integrate PAs into their team and how much to delegate. The AAPA provides an overview of state laws and regulations on its Web site. Depending on state laws, for example, PAs may be authorized to obtain histories, perform physical exams, order and perform diagnostic and therapeutic procedures, formulate a working diagnosis, develop and implement a treatment plan, assist at surgery, counsel patients, and make referrals. They are also authorized to prescribe medicine in all 50 states.

Another important distinction, says Hohman, is that PAs are trained in the medical model using the same facilities, same teachers, and sometimes even the same classes as the physicians — which helps to cultivate a homogeneous approach to patient care. Their educational program emphasizes treatment and diagnosis, taking 26.5 months to complete. The first year is comprised of essential classroom courses including microbiology, anatomy, medical ethics, pathology, and physiology. PAs then perform a year of clinical rotations in private practice and institutional settings.

A slim majority (26 percent) of PAs practice in family and general medicine, while 25 percent work in surgery and surgical subspecialties. Another 16 percent work in internal medicine, while 11 percent are in emergency medicine. PAs are also found in pediatrics, occupational medicine, obstetrics and gynecology, and dermatology.

Integrating the midlevel

Once you’ve decided which type of midlevel to hire, you’ll have to determine how best to incorporate them into your staff. PAs, of course, will require a supervising physician, who must be educated on his or her responsibilities under state law. Whether you opt for a PA or NP, the doctor must also decide how much of their scope of practice to delegate, which may change over time.


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