Physician, NP, PA...so what is that 20%

[Lshapley]

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So many times I have heard people talk about how NPs and PAs can do 70-80% of what a physician can do. Can someone who is much wiser than I and who has more experience than my sad, little pre-med self please explain to me what that magic 20% consists of?

As it seems to me know, they seem to be set to always practice on the same level as a resident (i.e., always under the "supervision" of an attending). Can someone please enlighten me?

 

[Yourmother]

So many times I have heard people talk about how NPs and PAs can do 70-80% of what a physician can do. Can someone who is much wiser than I and who has more experience than my sad, little pre-med self please explain to me what that magic 20% consists of?

As it seems to me know, they seem to be set to always practice on the same level as a resident (i.e., always under the "supervision" of an attending). Can someone please enlighten me?

You might want to post this in the Allo or Osteo forums or Resident's forums, there is also a Clinician's Forum for the NP/PA/etc

Your going to get limited treatment here.

Sincerely, Mofo

 

[Lshapley]

You might want to post this in the Allo or Osteo forums or Resident's forums, there is also a Clinician's Forum for the NP/PA/etc

Your going to get limited treatment here.

Sincerely, Mofo

Well, if the mod wants to move me, that's cool. I just thought I would post here because there are some healthcare career changers, residents and med students around these parts. Also, a lot of us who are pre-med certainly must be, or have, considered the option of being a mid-level.

 

[2008orbust]

It varies A LOT state to state. Some states give mid-levels a ton of autonomy and some do not. I realize that is not a lot of help, sorry. I am an NP in Michigan, so I can elaborate on my state if it would be helpful.

 

[Lshapley]

It varies A LOT state to state. Some states give mid-levels a ton of autonomy and some do not. I realize that is not a lot of help, sorry. I am an NP in Michigan, so I can elaborate on my state if it would be helpful.

I'm in PA and not applying to any MI schools, but I'd still love to hear what you have to say!

 

[Isoprop]

They all do the same thing which is paperwork!😳

 

[deleted6669]

the common wisdom is that a new pa grad can do 80% of what an fp md does and 90% of what a peds md does in an outpt setting. md's have a greater understanding of basic science principles delving deeper into physiology, biochem, etc so have a better understanding at least initially of pts outside the realm of common primary care issues.
a new md will have much more experience in hospital based medicine......that being said there are senior hospitalist pa's who teach critical care, emergency medicine, etc to md students and residents after doing it for years themselves. medicine requires ongoing learning and that learning is open to anyone who puts in the time and effort. an experienced pa can practice at the level of a senior resident in many specialties outside of surgery.

 

[ForbiddenComma]

An "NP" is a nurse who wants to be the doctor and wear the white coat without having to do any of that icky "med school" or "residency" stuff

 

[146233]

the common wisdom is that a new pa grad can do 80% of what an fp md does and 90% of what a peds md does in an outpt setting.

This is an excellent point. I'm rather tired of hearing, "PA's can do 80% of what a doctor can do." If that were true in all specialties, then medical school + residency would be two years. The fact remains that the PA scope of practice varies by state and individual autonomy is also affected by your practice environment (i.e., varies by physician).

 

[Law2Doc]

So many times I have heard people talk about how NPs and PAs can do 70-80% of what a physician can do. Can someone who is much wiser than I and who has more experience than my sad, little pre-med self please explain to me what that magic 20% consists of?

As it seems to me know, they seem to be set to always practice on the same level as a resident (i.e., always under the "supervision" of an attending). Can someone please enlighten me?

First, that "70-80%" is made up and probably represents someone just talking off the cuff -- don't put much stock into these numbers, they are wrong. Perhaps if you qualified it to 70% of what a generalist in primary care might do, you would be more on target. There are very few (perhaps no) NPs and PAs who work outside of the primary care arena, so all of those medical specialties (ortho, optho, rads, rad onc, derm, psych, all the IM subspecialties, neuro, etc etc.) represent things non-physicians won't be doing equivalently. There are very few NPs and PAs involved in surgery, so that too represents a huge world of things they aren't comparably involved in. So we are really talking about positions in very generalist primary care. Within that field there is certain limitation of autonomy -- very few will work without some physician supervision at some level. So the real answer is that if you want to work alongside a physician in a generalist primary care practice with some supervision, these ancillary health professional jobs probably suffice.
Folks who actually are PAs feel free to correct me -- I'm just calling it as I have seen it.

 

[remo]

The one NP I know works for a group of trauma/general surgeons. He basically rounds for them, see patients in the clinic for follow ups, and also assists on many surgeries (and gets paid as an assistant surgeon). This probably isn't the norm and he has been well trained by these guys. He is basically doing most of the grunt work for these guys. Good deal for them.

 

[Law2Doc]

The one NP I know works for a group of trauma/general surgeons. He basically rounds for them, see patients in the clinic for follow ups, and also assists on many surgeries (and gets paid as an assistant surgeon). This probably isn't the norm and he has been well trained by these guys. He is basically doing most of the grunt work for these guys. Good deal for them.

So basically the equivalent of a med student, not a physician then.

 

[deleted6669]

First, that "70-80%" is made up and probably represents someone just talking off the cuff -- don't put much stock into these numbers, they are wrong. Perhaps if you qualified it to 70% of what a generalist in primary care might do, you would be more on target. There are very few (perhaps no) NPs and PAs who work outside of the primary care arena, so all of those medical specialties (ortho, optho, rads, rad onc, derm, psych, all the IM subspecialties, neuro, etc etc.) represent things non-physicians won't be doing equivalently. There are very few NPs and PAs involved in surgery, so that too represents a huge world of things they aren't comparably involved in. So we are really talking about positions in very generalist primary care. Within that field there is certain limitation of autonomy -- very few will work without some physician supervision at some level. So the real answer is that if you want to work alongside a physician in a generalist primary care practice with some supervision, these ancillary health professional jobs probably suffice.
Folks who actually are PAs feel free to correct me -- I'm just calling it as I have seen it.

actually at this point more pa's work in specialties than primary care. below is a list of pa's avg salary by specialty, not to show $$ but just to give an idea of fields that pa's work in. LOTS of pa's at this point work in surgery as opposed to your contention. in fact there are a # of surgical residency programs for pa's now. see www.appap.org
anyway, the specialty list as promised:
Specialty MTI
Cardiovascular/Cardiothoracic surgery $104,681
Dermatology $100,735
Neurosurgery $93,979
Emergency medicine $92,896
Surgical subspecialties $91,364
Orthopedics $90,093
Critical care medicine
$89,113
Plastic surgery $88,900
Pediatric cardiology $88,086
Interventional radiology $87,603
Anesthesiology $86,801
Trauma surgery $86,752
Geriatrics $86,712
Pain management $85,014
Occupational medicine $84,801
National mean $84,396
Urology $84,204
General surgery $83,296
Diagnostic radiology $82,837
Surgical oncology $82,571
Medical cardiology $82,374
Addiction medicine $82,034
Otorhinolaryngology $81,233
Hospital medicine $80,563
Psychiatry $79,104
Medical oncology $78,972
Family medicine $78,893
Radiation oncology $78,514

Pediatric gastroenterology $78,504
Allergy $78,241
Pediatric neurology $77,664
Pediatrics $77,452
Pediatric oncology $77,047
Medical gastroenterology $76,858
Medical rheumatology $76,366
Medical neurology $76,361
Medical nephrology $76,295
Medical endocrinology $75,157
Obstetrics/Gynecology $74,658
Public health $73,180

 

[Law2Doc]

actually at this point more pa's work in specialties than primary care. below is a list of pa's avg salary by specialty, not to show $$ but just to give an idea of fields that pa's work in. LOTS of pa's at this point work in surgery as opposed to your contention. in fact there are a # of surgical residency programs for pa's now. see www.appap.org
anyway, the specialty list as promised:

Interesting to know, but I'd be curious as to the scope of practice in surgery or those specialties. Hard to imagine they are doing the surgeries (assisting isn't the equivalent to a physician because med students and sometimes even scrub nurses sometimes get to do that), or what they are doing in, say, diagnostic radiology -- because it's unlikely they get final read on any films. All I know is that I've certainly seen such ancillary professionals in the more primary care and ED settings, but not in the surgical or non-primary care competitive specialty settings, and I've seen quite a few settings at this point, so in my mind that makes them a rarity in those areas. And being in those areas doesn't mean their scope is as close to equivalent as it might be in, say, FP. Not arguing with you, just curious.

 

[Lshapley]

Love the discussion here, this is really helping to clarify my thinking on this topic.

One question that comes to mind for me, after reading all of this, is what is the prevalence of NPs and PAs at teaching hospitals? Do the majority (not the exceptions...) find themselves working in private practice and non-teaching hospitals? I have seen many NPs working in the ED that I did research in, but I don't know about the other departments (it is a teaching hospital). Are there any numbers on this???

 

[SoCuteMD]

At the hospital at which I'm doing my surgery rotation, all but 2 of the PAs do what interns do. They respond to pages about patient issues, deal with the ones they can and call the attendings for what they can't. They do a lot of the consult gruntwork, so the attending just comes and sees the patient briefly. They take care of progress notes and discharge summaries. Actually, now that I'm writing this, I'm realizing they do a lot of what I do as a third year medical student.

2 of the PAs function as intraoperative assistants. These PAs have had more training and work with surgeons (gastric bypass and plastics) who do a very limited variety of cases. The gastric bypass PA does a lot of the gruntwork in the OR - camera-driving, suture-cutting, etc. The plastics PA is a little more independent and works on one side of the breast reconstruction (that is most of what this plastic surgeon does) while the surgeon does all of one side, and still a significant part of the other side.

 

[montessori2md]

Agree w/ above post about needing to do your research elsewhere, beginning w/ looking at PA assoc. websites, google, wiki, and searching these forums, there have been some really long threads on the "what's the difference".

I don't think teaching/non-teaching hospital is necessarily a factor for prevalence of "mid-levels" (eg, np, pa). I do think geography is big factor, and also whether the teaching hosptal grants pa degrees -obviously, if you're training them, they'll be around. That said, some non-teaching hospitals who have trouble recruiting physicians, or can't afford them, or just prefer mid-levels for whatever reason, choose to place PAs or MDs in roles w/ a lot of responsibility for the pts.

Mid level practitioners can be a huge cash cows for specialists like derm, b/c they exponentially increase their pt turnover, w/o paying another derm's salary.

Thought really long and hard about going PA myself -the possibility of changing specialties was especially seductive, as was the lower debt, but there is too much of me that wants the "firehose" input of med school curriculum, and to know that I will eventually be the person in charge (well, except for the administrators and insurance companies and the other mds in my practice, etc etc). I may be kicking myself a year from now, we'll see.

 

[deleted6669]

MOST radiology pa's at this point work on interventional services and do ct guided biopsies, u/s guided line placement/thoracentesis, etc
I know of some pa's who do prelim reads on plain films and u/s but there are not a lot of pa's doing diagnostic rads in general at this point.

 

[MacGyver]

actually at this point more pa's work in specialties than primary care.

Which is why the AAPA's propaganda about PAs "alleviating primary care shortage" is nothing more than bull****.

 

[core0]

First, that "70-80%" is made up and probably represents someone just talking off the cuff -- don't put much stock into these numbers, they are wrong. Perhaps if you qualified it to 70% of what a generalist in primary care might do, you would be more on target.
The number came from a study in the 1970's by the NIH. They broke down the work of a family practice physician and looked at what percentage of this was covered by PA training. The number they came up with was 80%. This was re looked at in the 80's if I remember correctly by the department of labor and found to be about the same.

There are very few (perhaps no) NPs and PAs who work outside of the primary care arena, so all of those medical specialties (ortho, optho, rads, rad onc, derm, psych, all the IM subspecialties, neuro, etc etc.) represent things non-physicians won't be doing equivalently.
Currently 34% of PAs work in specialty medicine practice. Pretty much and\y specialty that you would care to name.

There are very few NPs and PAs involved in surgery, so that too represents a huge world of things they aren't comparably involved in.

35% of PAs work in surgery. Ortho is huge and represents 10% of all PAs. Next are CV with 3.5% and General with 2.5%.

So we are really talking about positions in very generalist primary care. Within that field there is certain limitation of autonomy -- very few will work without some physician supervision at some level. So the real answer is that if you want to work alongside a physician in a generalist primary care practice with some supervision, these ancillary health professional jobs probably suffice.
Folks who actually are PAs feel free to correct me -- I'm just calling it as I have seen it.

Corrected. PAs are trained in general medicine with a broad exposure to other areas including internal medicine and surgery. PAs work in pretty much every area of medicine. The amount of work they handle and what depends on the PA, the physician and the type of work.

David Carpenter, PA-C

 

[princekc]

Interesting to know, but I'd be curious as to the scope of practice in surgery or those specialties. Hard to imagine they are doing the surgeries (assisting isn't the equivalent to a physician because med students and sometimes even scrub nurses sometimes get to do that), or what they are doing in, say, diagnostic radiology -- because it's unlikely they get final read on any films. All I know is that I've certainly seen such ancillary professionals in the more primary care and ED settings, but not in the surgical or non-primary care competitive specialty settings, and I've seen quite a few settings at this point, so in my mind that makes them a rarity in those areas. And being in those areas doesn't mean their scope is as close to equivalent as it might be in, say, FP. Not arguing with you, just curious.

I suggest to look up a job description for a surgical PA or PAs in any other specialties. During one of my surgical rotation, I witnessed a CT surgical PA did a saphenous vein harvesting (aka EVH) without the surgeon presence prior to an open heart surgery. He plays a vital role during the entire procedure which is superior to what a medical student or a scrub nurse can do as you put it. PA scope of practice is solely base individual state law. Most surgical PA have completed a 1yr PG1 training where they are trained and shared responsibility as their MD counterpart.

 

[core0]

So many times I have heard people talk about how NPs and PAs can do 70-80% of what a physician can do. Can someone who is much wiser than I and who has more experience than my sad, little pre-med self please explain to me what that magic 20% consists of?

As it seems to me know, they seem to be set to always practice on the same level as a resident (i.e., always under the "supervision" of an attending). Can someone please enlighten me?

I'll go back and answer the OP since no one else seems to have directly answered the question. As I explained above the 80% refers to Family practice. More specifically it refers to physician work type. If you take all the patients that walk in the door, a PA should generally be able to handle 80% of the problems right out of school. This depends on the experience of the PA and the type of patient seen by the practice. There are Kaiser studies that show that an experience PA can handle 90+% of family practice patients. Compare this to a Family Practice Physician who is expected to handle 100% of what walks in the door.

Things that might be deferred to a physician would be something like refractory hypertension or uncontrolled diabetes. That being said there are PAs that are capable of handling these conditions. Generally things that are better handled by a physician are conditions that benefit from physician experience and potentially better understanding of pathophysiology.

In many ways PAs do function in a manner similar to residents. Unlike residents who will have unrestricted licenses when they finish, the PA evolution is more gradual and is based on trust between a physician and the PA. There are PAs with significant experience that have defacto independence in rural clinics. There are new PAs that present each case to the attending. Like many things in life most are in between.

David Carpenter, PA-C

 

[core0]

Interesting to know, but I'd be curious as to the scope of practice in surgery or those specialties. Hard to imagine they are doing the surgeries (assisting isn't the equivalent to a physician because med students and sometimes even scrub nurses sometimes get to do that), or what they are doing in, say, diagnostic radiology -- because it's unlikely they get final read on any films. All I know is that I've certainly seen such ancillary professionals in the more primary care and ED settings, but not in the surgical or non-primary care competitive specialty settings, and I've seen quite a few settings at this point, so in my mind that makes them a rarity in those areas. And being in those areas doesn't mean their scope is as close to equivalent as it might be in, say, FP. Not arguing with you, just curious.

The scope of practice in surgery settings is more limiting. As you pointed out there is no magic in assisting. The big issue is that unlike the other individuals that you mentioned is that PAs can bill. The model in surgery and specialty care is completely different.

In surgery there are two areas that provide PA income. PAs primarily make their salary in assist fees. They generally do inpatient management which frees up the physician to do procedures where no assist fees are authorized and do more consults which generates more procedures. This is know as downstream revenue. Also PAs can see follow ups which allows the physician to see more new patients. There are a few other areas such as ortho where the PA may do the initial evaluation and order tests if necessary. They may also supervise any attempts at rehab and can do injections and other procedures. These can be quite lucrative.

Specialty care is different. In non-procedure oriented care they generally function in a manner similar to primary care, treating new and continuing patients. In many practices the management of chronic patients is shifted to PAs which allows the physician to see more new consults.

In procedure oriented specialties there are two models. One is to have PAs do multiple repetitive procedures. The classic example of this is Derm. The Dermatologist sees the patient and does the initial consult. If there is a superficial lesion that need to be excised they have the PA do these. PAs can also do non-lucrative derm such as acne clinics. The revenue that PAs pull in here is huge. This is one of the reasons that Derm PAs are so well compensated.

The other model is for PAs in procedure oriented specialties to see patients in consult to free up the physician to do more procedures. I will use GI as an example. In this case the PA sees the patient in consult and refers for appropriate procedures as well as seeing follow up for patients with chronic diseases such as IBD or Hep C. This allows the physician to do more procedures which reduces waiting time and increases physician income.

As far as university hospital setting, the resident work hour restrictions should be known as the PA employment act. It generally takes two PAs to replace one resident. In the University I work at pretty much every service has 1-2 NPs or PAs. Much of what we do is what you might refer to as scut. However, it still needs to be done.

David Carpenter, PA-C

 

[SoCuteMD]

Most surgical PA have completed a 1yr PG1 training where they are trained and shared responsibility as their MD counterpart.

While they may say it's "shared responsibility," this is not the truth. It is the MD whose license the PA is practicing under, and thus the MD's responsibility.

 

[njbmd]

The greatest difference is in the "decision-making" capability. By virtue of my training - medical school, residency, fellowship- I decide how every patient is treated and by which means. I decided the course of the entire physician-patient encounter. If a patient is flown into my hospital with a leaking abdominal aortic aneurysm, I decide how the repair will be done suture by suture as the case unfolds. A PA/NP may open the abdomen, put in the lines, prep the patient, cut sutures, etc but I decide what the PA/NP does on the case. I decide every aspect of the case from beginning to end by virtue of my experience.

My medical school education and performance therein, enabled me to complete a residency (not open to a PA/NP) and my residency education/experience and performance therein enabled me to complete a fellowship in vascular surgery (not open to a PA/NP). The reality of the situation is that as a PA/NP, you will not be the final common denominator on many patient care decisions. Dictating discharge summaries, performing H & Ps, holding a scalpel/suture or even writing a prescription is not the same as what I do on a daily basis though I have done some of these things as a medical student, resident or fellow. My experience and education enable me to do more and decide more and I am well-compensated for my decision-making.

The PA/NP who works with me is assigned duties within the scope of their experience and decided pretty much by me as it is my practice. This relationship comes out of my deciding what the PA/NP will do in my practice and the state laws that govern the role of the PA/NP. If you understand the role of the PA/NP and are happy practicing within that role, then definitely being a PA/NP is going to be a great vocation for you. If you are looking to do more, then you won't like your role as an PA/NP. As a PA/NP, you will never be a "substitute" for me as a physician but an extension of me as a physician. If that works for you, then you will find your role as a PA/NP pretty satisfying. We all work on the same team but make no mistake, we all have different roles by virtue of our education and experience.

 

[deleted6669]

"The reality of the situation is that as a PA/NP, you will not be the final common denominator on many patient care decisions. Dictating discharge summaries, performing H & Ps, holding a scalpel/suture or even writing a prescription is not the same as what I do on a daily basis though I have done some of these things as a medical student, resident or fellow. My experience and education enable me to do more and decide more and I am well-compensated for my decision-making. "

while this is certainly true in the surgical arena it is much less so in primary care or emergency medicine. many pa's who work in family medicine or emergency medicine only have retrospective review of their care, often only on certain cases and often weeks to months after that care has occured. in these cases while the physician may have done things differently they are not the final decision maker on pt care decisions. they can comment after the fact but at that point their impact is basically academic along the lines of "next time why don't you think about xyz or I prefer x over y".
in my setting 10% of my charts as chosen by me are reviewed within 1 month. some states require no chart review just "discussions regarding the practice" every few months. I certainly seek consults as appropriate and submit those cases for review which were more challenging(admits, codes, complex procedures, etc) but as a solo provider in a small e.d. I have a high level of independent decision making and am very well compensated for this, better in fact than many primary care physicians.

 

[princekc]

While they may say it's "shared responsibility," this is not the truth. It is the MD whose license the PA is practicing under, and thus the MD's responsibility.

-an MD PG1 and a PA PG1 are trained together and shared calls. They are trained equally as their MD counterpart hence the term "Shared responsibility".

 

[deleted6669]

-an MD PG1 and a PA PG1 are trained together and shared calls. They are trained equally as their MD counterpart hence the term "Shared responsibility".

this is true really only on residency services that have both pa and md residencies. there are a number of 1 yr pa residencies where the pa does a pgy-1 md yr. the difference is that the md then does 2+ more yrs to polish their skills while the pa is done with residency after a yr working on the fundamentals. a pgy-2 surgical resident for example knows a lot more surgery than a new grad from a pgy-1 surgical pa program.

EXAMPLE:
PA Surgical Residency
Montefiore Medical Center
The University Hospital for the Albert Einstein College of Medicine
111 East 210 Street
Bronx, New York 10467
Phone: (718) 920-6223
Fax: (718) 547-2929


--------------------------------------------------------------------------------
Length of Program 14 months
Class Size 10
Starting Date: August
Ending Date: October 31

PROGRAM DESCRIPTION AND HISTORY:
In 1971 Montefiore became the first hospital to utilize PA's as house officers on an inpatient surgery service. PA's quickly became an integral part not only of the surgical team, but also of the medical center at large, significantly predating the current wide utilization of PA's in the hospital setting. The current residency program grew out of the early use of PA's in surgery and was the first and therefore, the oldest postgraduate training program for PA's in surgery. 267 PA's have completed the residency program.

CURRICULUM:
Didactic: During the two-month didactic phase, the PA attends lectures and conferences covering surgical and medical topics designed to deepen knowledge and prepare him/her for the clinical rotations. Included are ACLS training, surgical skills, radiology, orientation to the operating room and surgical instruments and techniques and preparation for clinical rotations.

Clinical: The clinical portions consists of eleven four-week rotations and one month of vacation. The PA receives four to five months of general surgery, one month each of emergency room at a level I trauma center, cardiothoracic surgery, peripheral vascular surgery, and three months at surgical specialties. On rotation, the PA works side-by-side with physician house staff and assumes full PGY-1 level responsibility, which includes assignment to the operating room. Education on the clinical rotations comes from bedside clinical teaching by house staff and attendings as well as formal conferences. The call schedule is every third night.