Pysicians run the show everywhere in terms of the providers. They bring in the money and have the top level expertise. No PA or NP is going to supplant that. However, how that hierarchy manifests itself is changing wit time. I've seen a doctor fired because of complaints by nurses regarding that physician's performance in their eyes (which I frankly disagreed with and am sad about). I've seen an abusive physician forced to change their approach to staff due to the liability they laid at the doorstep of the hospital by how they treated people. So to avoid a lawsuit that would cost the hospital a lot of money, the physician was told to take a hike or shape up. I've seen a couple physicians get nurses fired, and frankly, one of those cases was bunk, and would have been litigated to the benefit of the nurse if that nurse had really wanted to stick around and fight it. The other case was a nurse that everyone was glad to see leave, and wished it had happened sooner.... and it took having a physician complain to make that happen. I've also seen several NPs try to interfere with RNs who they thought they knew better than, and those situations all panned out differently. I've never had an issue with a PA, and frankly find them to be the most agreeable of the folks I run into, although I really can't complain much about 99% of the physicians, and pretty much love them all. I'm not impressed with a couple of the NPs, but most of that has to do with the being idiots rather than a reflection on the field itself, because I have the suspicion that these folks would suck regardless of what professional path they took. So my point is that even though some kind of heirarchy exists, you can decide for yourself what you think that heirarchy will get for a provider in today's work environment. Reality is closer to what was said about admin having the most say overall.
Ultimately, if your day consists of you having to expend energy navigating through a heirarchy to get work done, you are doing healthcare wrong. If you are a nurse that throws a suggestion out to a provider just to have it thrown back at you in leu of another approach, or if you are a PA that has an attending physician stop you from going ahead with a care plan for a patient, you really aren't functioning the way you are supposed to be. A decent nurse or PA/NP will go about most of their shift and not need to fight a battle with someone "above them" on the totem pole. If I'm not in the ER, I can go entire shifts as a nurse without having any direct contact with a provider, and I would assume PAs would have a similar situation. An employee is more valuable the more independent and trusted they are. If you have to be supervised constantly, your days are probably numbered.
