One method many practices use to try to balance patient demands and physician availability is to hire advanced practitioners — NPs and PAs. However, the role each of these providers play within the practice or clinic can be challenging to navigate. In some areas, NPs and PAs function fairly independently. In others, they are required to work very closely with the physician to manage or assist with patient care. Unfortunately, the exact role they play is not always well-defined at the beginning of the professional relationship.
Within my primary-care group, we are trying to navigate the optimal way to use NPs and PAs as part of the care team. This is made more difficult by the fact that the advanced practitioners do not universally agree upon the role they wish to have. Some NPs and PAs jump in with both feet, anxious to manage a patient panel and sometimes even provide nursing home, hospital, and call coverage. Other NPs and PAs find it preferable to manage primarily acute care and less complex patients.
In addition to the confusion that physicians and advanced practitioners have is the viewpoint of the patients. Many patients adore the NPs and PAs from whom they regularly seek care. Others feel that the care provided by advanced practitioners is somehow second best to seeing a physician. This can make the cooperation between physicians and advanced practitioners strained. Without a clear understanding of an advanced practitioner's role, it is difficult for physicians to counsel their patients on the function of each member of the team.
I have a few thoughts about this topic. The first is my own experience as a patient. I have my own family physician who works with a PA who happens to be an excellent clinician. While I like my family physician very much, I am completely happy to see the PA whenever she is available. In fact, a few years ago, when I realized my day off and the day off of my family physician coincided, I asked to be transferred to the PA's panel. I was told that in their practice, advanced practitioners do not carry their own panel of patients but that I could certainly request to see the PA whenever I wanted. I was disappointed.
In my practice, the advanced practitioners are great clinicians who have a wealth of experience. Each manages her own smaller panel of patients and plays a big role in managing acute care needs of the practice's patients. I have no concerns with one of the advanced practitioners seeing one of my complex patients as I trust their medical judgment. However, we don't coordinate or collaborate on care as well as we should; they function more like a physician colleague than a team member. As such, I suspect we lose some of the potential power in their role. Patients would likely feel more confident about seeing them instead of me if they knew that we worked closely together.
I don't know the right answer — what is the best role for an advanced practitioner? I suspect it has a lot to do with all three members of the care team — the physician, the NP or PA, and the patient, and their respective strengths, weaknesses, beliefs, biases, and experience.