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The Inbox: Are NPs and PAs Usurping Practice Authority?


In our recurring blog "Inbox" we share comments from physicians and practice administrators telling us what keeps them awake at night.

Editor's note: We work hard to write about issues that will help physicians run their practices in a manner that is both prosperous and efficient, while still delivering quality patient care. And we are delighted when our readers let us know what they are thinking. This month we are excerpting an article written by managing editor Gabriel Perna in response to the heated debate over the limits of scope of practice for nurse practitioners and physician assistants. The article has been edited for space and is followed by comments made by readers at PhysiciansPractice.com.

The Uncertain Role of NPs and PAs in Today's Practice

According to HHS' Health Resources and Services Administration (HRSA), there will be a shortage of 20,400 primary-care physicians in the U.S. by 2020, thanks to the aging population and more people insured through the Affordable Care Act. Another estimate, from the American Association of Medical Colleges, projects a shortage of up to 90,000 doctors by 2025 for the same reasons that HRSA stated.

HRSA says PAs and nurse practitioners (NPs) integrated into a Patient-Centered Medical Home-type delivery system can ease this shortage. Perhaps not coincidentally, PAs and NPs are becoming more commonplace in practices across the country.

… That PAs and NPs are a more integral part of healthcare than ever before is not a fact up for debate. No one disputes it. Whether or not advanced practitioners can address the primary-care physician shortage is, however, not a unanimous sentiment.

Parveen says: I think if the PAs and ARNPs want to have all the privileges and freedom to practice [like] physicians, all they have to do is go to the medical school. Really it's not that hard. If you need a lawyer's help would you ever consider a paralegal instead? If no is the answer, why would you consider paramedical healthcare providers as your primary physician. If you want a physician you go to a physician not to the paramedical or mid-level workers. Go to medical school of you want to be a doctor, simple as that.

Gerry Keenan MMS, PA-C, Associate Professor, A.T. Still University writes: It is the rare legal office that does not use the services of their paralegals. PAs work as a team, in a somewhat, but not exact, similar fashion to lawyers and paralegals. PAs do want to provide quality care for their patients and every study in the last 50 years of their profession shows that they do. Your answer is trite and flawed. The research shows that the care of patients by a PA or NP in primary care is comparable and in some cases better than the physician, so why sir do you put the profession down? I have been a PA for 35 years in primary and emergency medicine, across the country. I have been a preceptor and taught medical students, PA students, NP students, and MD/DO residents. Your comments shows a narrow view and a "silo" approach that is dated and dangerous, and a limited experience. …
Debra Castner, NP, says: … I find it insulting to all practitioners (RNs, PAs, social workers, physical therapists, etc.) to insinuate that only a doctor has a "calling." I would save that term for the religious and pious who give up everything to pursue the service of others and who truly give up social life and financial reward. I would be careful in your use of terms. All of us who work with patients sacrifice in some way whether it be long hours, stress, or missing time with family. We do it for the rewards of helping patients come to terms with their illness or wellness. This "calling" that's described pertains to all of us. We have all seen devoted and un-devoted health providers and that includes doctors. Let's stay focused on how can we most effectively and caringly provide services our patients want and deserve. …

Shannon Whitten NP-C, APRB-BC, AACP, AACC says: I disagree in that it's not a job for me. How audacious. In rural Georgia my practice is a calling and often consumes every part of my life. I have a vested interest in overall patient care and safety. I see more patients than my delegating DO and I manage CHF and acute problems/disease processes. Due to living in a rural area my patients stop me on the street, grocery shopping, and at church. I never stop practicing or caring for them. I attend marriages and funerals. They are more than my patients. They are my life. This should be a team approach. After 17 years of practice I've done more hours than a medical internship or residency, so after years of practice I can function as a PCP utilizing specialists for surgery or MIs. This plain and simple is not about safety. Studies have shown in primary care NPS practice is equal or better than physician care. So never say my life's work, my tears, my hours of taking call, and being there is just a job.

Deborah writes: I agree with the difference in training hours. I think NP programs are turning out inexperienced NPs. I think they need to require a minimum of five years of experience working as an RN in a hospital or similar type setting before being accepted into an NP program. If they don't have this experience they need to be required to have more hands-on clinical hours.

NYS NP says: I find it offensive that Dr. Mary Christ makes the blanket statement that nurse practitioners think of our professions as "jobs" and not a "calling." Being a nurse practitioner for me is a calling. I find many, not all, physicians I work with who treat their professions as "jobs" high tailing it out of the office at the close of the clinic day while many dedicated NP's stay after hours or come in on the weekends to make calls to patients following up. I have many patients who come to me after seeing the doctor to "make double check" what the doctor told them.

In addition I do agree on some level regarding the difference in training, however as an NP I have never felt I know more than the doctors. …Stephen comments: … A primary focus and a goal of the ACA was to remove the patient from the ER as their PCP. PAs may be a cost effective frontline provider that while paid at a lesser level than MDs/DOs, they seem to be willing to serve in areas that the physicians seem to avoid for a whole variety of real and other reasons. There are always cases that require a higher level of care and training - but a good percentage could be addressed by a PA and other advanced practitioners and the real complex ones treated by physicians as needed. I am not convinced yet that an advanced practitioner needs to be an employee of a physician practice versus out on their own if they so choose with backup. Medicine may have been a calling from the days of "Charitable Immunity," but today I do not see as much "calling" as there used to be.

Do you believe that independently practicing NPs and/or PAs are the answer to the impending physician shortage? Tell us what you think; join the conversation at bit.ly/debate-np-pa.

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