What is the physicians role in health care versus NP and PA

dangit

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Hello,

I am trying to find sources and read up on the differences between the physicians' role in health care versus the role of NP and PA. Can anyone point me to a source or could anyone shed some light? I've been reading various books and searching on the net, but I can't really distinguish their roles and responsibilities... thanks in advance!
 

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I think the point of inventing both the PA and NP profession was to create a faster track to providing high level care to patients. This had the potential to save money through lower salaries and fill vital positions quickly (they don't take as much time as DO/MD degrees).

Of course, some PAs/NPs can make as much or a little more than some DOs/MDs. However, there is still a gap in the median salaries.

Hopefully others can lend some insight on the scopes of practice. I know they vary tremendously between states/cities/hospitals/departments.
 

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Forgot to mention the fact that the differences between the primary care doc and the PA/NP have become increasingly blurred. This is a hot-button issue for some, but the fact remains that things have changed and seem to be continuing to do so.
 
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Forgot to mention the fact that the differences between the primary care doc and the PA/NP have become increasingly blurred. This is a hot-button issue for some, but the fact remains that things have changed and seem to be continuing to do so.

increasingly blurred, yes, but that's not bad for the health care field or so some think.

Check out this paper for some interesting NP/primary care type issues:

http://futurehealth.ucsf.edu/pdf_files/NP%20Scopes%20discussion%20Fall%202007%20121807.pdf

Here's how JAMA sees primary care roles:

http://jama.ama-assn.org/cgi/content/full/300/10/1262
 
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Altruist

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I have a few co-workers who have gone back to school for NP and PA, so I can give some idea of this.

Graduates of the nurse practitioner programs around here are FNP's, or family nurse practitioners, when they graduate. The national push is to make these doctorate programs, so that they might call themselves "Dr. so-and-so," despite not being a physician. They can work independently without a supervising physician, so they could have their own family practice office if they wanted. Some states do require a physician "consultant" that an FNP could presumably talk to if they were really stumped. As far as I know, FNP is a 2 year program, some are 3 years. There may be more general nurse practitioner programs I'm not aware of.

Two of my friends are in school to become physician's assistants. They can do a lot of the same work, but are required to work under a physician's license. The training is generally 2 years long and awards a masters degree. (The local program is 8 months of classes and 16 months of clinicals.) They are usually called PA-C's (Physicians Assistant - Certified). PA's receive general training but can "specialize" by working for certain physicians. For example, if you work for a cardiologist, you might supervise cardiac stress tests, or you might do the history and physical on a patient before the cardiologist does the angiogram. Or, you might assist with the procedure. It depends on what the physician wants you to do.

PA's and NP's are usually referred to as mid-levels, i.e. somewhere between physicians and nurses. Rural hospitals in my area often hire a PA or FNP to cover the emergency room (and often the rest of the hospital) on weekends when the family practice physicians aren't around or they don't want to be on call. That means a PA or FNP might have to intubate and stabilize an unstable patient if necessary.

In my experience, a good FNP or PA is just as good as a physician at general medicine. A doc I work with says that they aren't trained to look for unusual presentations, and that's why you still need a physician around, but take that with a grain of salt, it's just one opinion.

The New York Times had a great article about midlevels a couple months ago: http://www.nytimes.com/2008/08/10/jobs/10starts.html?scp=6&sq=physicians assistant&st=cse (free registration required)
 

dangit

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with no clear distinctions, doesn't it make sense that more ppl should be leaning towards becoming nurse practitioners? for me, the only thing that really distinguishes NP vs. physicians is that NP do not have autonomy in all states...yet. in most states, they need to colloborate with physicians and even when it comes to prescribing medication, it's not allowed in all states. so basically, even though NP sounds pretty good, if you're the type to want autonomy and not want to report to anyone, then being the physician is the way to go. what about you? do you guys agree?
 

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I shadowed a PA and he said he loved his job. He got to be in on all the surgeries and do pre-op and post-op appointments on his own. He got to do almost as much as the surgeon, but he said if he had to do it again, he would become a physician. He said no matter how much you know or how good you are at your job, you still are under the supervision of a physician, and he didn't like not having the autonomy. I would think it would be much the same for NPs in states where they need to practice under a physician.

Here's a plus side for being a PA: I have a good friend who is pre-PA and according to her, specialty changes are very easy if you are a PA. If you're a family practice physician, you need to go back to residency in order to become a surgeon. A family practice PA that wants to get into cardiology just needs to find a job opening. Assuming this a correct assessment, it sounds like a pretty good deal if you think you might become dissatisfied with your choice in specialty after a few years.
 

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Here's a plus side for being a PA: I have a good friend who is pre-PA and according to her, specialty changes are very easy if you are a PA. If you're a family practice physician, you need to go back to residency in order to become a surgeon. A family practice PA that wants to get into cardiology just needs to find a job opening. Assuming this a correct assessment, it sounds like a pretty good deal if you think you might become dissatisfied with your choice in specialty after a few years.

You forgot the best part: no malpractice insurance
 

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Doctors still make more in spite of malpractice insurance. So keeping with the theme, sandwich artists have no malpractice insurance either.

yes, true... you're comparison of sandwich artists to PA's is a little unnecessary.. i was more getting at the idea that doctors have to deal with lawsuits and this insurance coverage to a much greater degree which make life that much more complicated. A general surgeon I shadowed just got sued and he was telling me how much of a headache it was. It is also lame to see a significant percentage of your income drain away towards malpractice..For specialties that get sued at a higher rate this can be up to 100,000/yr if im not mistaken (depending on the state)!!! This closes the income gap a ton.
 

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You can blur the lines and make the professions seem similar, or you can step back and see that they're totally different.

A physician has a license to practice medicine. Physicians are ultimately responsible for diagnosing and developing a treatment plan for the patient.

Nurses/PA are responsible for ensuring that the patient's treatment plan is carried out and for providing the practical needs of the patient.

Two very different jobs, both of which are essential in health-care.

Like I said, you can blur the lines and say that some NPs can practice independently; you can say that PA's can have almost the same responsibilities as a FP physician, etc. But ultimately they don't.

Going into PA or NP school with the attitude that after 2 years you will be able to fill the same role in health-care as a family practice physician is DANGEROUS and irresponsible. I'm just saying this because we have a PA/NP program at my med school and I hear students argue about this all the time..... NOT true. Go to PA school because you want to take care of patients and ensure that the treatment plan decided on by the physician is being carried out in the best interests of the patient, not because you want to be a doctor without going through medical school.
 

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yes, true... you're comparison of sandwich artists to PA's is a little unnecessary.. i was more getting at the idea that doctors have to deal with lawsuits and this insurance coverage to a much greater degree which make life that much more complicated. A general surgeon I shadowed just got sued and he was telling me how much of a headache it was. It is also lame to see a significant percentage of your income drain away towards malpractice..For specialties that get sued at a higher rate this can be up to 100,000/yr if im not mistaken (depending on the state)!!! This closes the income gap a ton.

mo money mo problems
 
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Level of autonomy varies greatly between states for PA/NP. They can have their own private practices as long as they contract a physician to sign off on their paper work for a fee. They usually are not allowed to prescribe as many drugs as physicians but can prescribe a good spectrum of common drugs. I just shadowed a PA in Internal Medicine and based on her daily duties and clinical judgement I would never have known she was a PA and not a physician had I not been told.

They're good career choices in that they pay well, only require 2 yrs of graduate training, and allow you to practice medicine without having the liability of a doctor. Some NP/PA see the lack of complete autonomy as restrictive but others welcome it because protects them from the liability physicians face (ie malpractice and lawsuits). If an NP/PA makes a bad decision the supervising physcian is the one that gets in trouble.
 

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Nurses/PA are responsible for ensuring that the patient's treatment plan is carried out and for providing the practical needs of the patient.

PA's shouldn't be lumped into the same category as nurses (non-NP's, that is). Your argument holds true for nurses, i.e., carry out patient management plan, but not for PA's, who tend to provide care essentially at the level of a resident physician (meaning they do create patient management plans and order tests and interventions, but are generally overseen and cosigned by an attending physician). They can first-assist in surgeries, as well. In general, PA's have a large degree of autonomy and the distinction between them and physicians have most certainly blurred in this day and age. I think this is a result of how they are being used today, due to shortage of physicians. Perhaps at the beginning they were used more to provide high level assistance to physicians (thus the name, "PA"), but that was then and this is now. In many states, there is a significant degree of overlap in practice and scope, but ultimately physicians are the ones who are responsible for the overall management and care of the patients. The "buck stops" with physicians. However, PA's can and do function quite well on the wards, in clinics, and offices, as stand-ins for physicians as long as appropriate supervision is in place, particularly for those 10-20% or so of cases that require a greater depth of medical understanding and supervision.

Two very different jobs, both of which are essential in health-care.

I agree that both are essential, but I disagree that they are completely different jobs. If you acknowledge reality, then you'll see that there is a significant degree of overlap developing.

Like I said, you can blur the lines and say that some NPs can practice independently; you can say that PA's can have almost the same responsibilities as a FP physician, etc. But ultimately they don't.

Well, the lines ARE blurred and PA's absolutely do, in practice, have similar responsibilities and scope, but, yes, physicians are ultimately responsible for the care and management of patients. That's sort of why I think that PA's function at the level of resident physicians. I do think that, ideally, PA's should function at the level of augmenting a practice.

Going into PA or NP school with the attitude that after 2 years you will be able to fill the same role in health-care as a family practice physician is DANGEROUS and irresponsible. I'm just saying this because we have a PA/NP program at my med school and I hear students argue about this all the time..... NOT true.

Agree. Don't go to PA school and expect to be a physician. It isn't a back door.

Go to PA school because you want to take care of patients and ensure that the treatment plan decided on by the physician is being carried out in the best interests of the patient, not because you want to be a doctor without going through medical school.

I disagree that PA's simply carry out treatment plans, but otherwise, yes, you shouldn't got to PA school expecting be a physician. Just makes sense.
 

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with no clear distinctions, doesn't it make sense that more ppl should be leaning towards becoming nurse practitioners? for me, the only thing that really distinguishes NP vs. physicians is that NP do not have autonomy in all states...yet. in most states, they need to colloborate with physicians and even when it comes to prescribing medication, it's not allowed in all states. so basically, even though NP sounds pretty good, if you're the type to want autonomy and not want to report to anyone, then being the physician is the way to go. what about you? do you guys agree?

Well, I think you are overstating the similarities, just as coldweatherblue overstated the differences. The distinctions are not that unclear as to make them the same. You will see functional overlap, but in my understanding, PA's and NP's are there to augment a practice, not to be the primaries on staff. We are starting to see more use of PA's and NP's as primaries due to shortage of physicians, but this is not necessarily for the better. Yes, it's good that there is some level of care present and it's probably true that PA's and NP's can handle a good many cases on their own, but you can't really substitute 4 years of medical school plus residency training for the depth of care necessary to oversee and comprehensively manage a full range of patients, particularly with the more medically complex or obscure conditions, where it might be necessary to use that depth of knowledge to tease out what needs to happen. Furthermore, it takes a good range of knowledge and experience to cast a wide net and sometimes to think of the worst case differential for a given presentation, as the primary care physician is often called upon to do. The role of the primary care physician cannot be understated and patient's deserve the best and most knowledgeable care available to them. It is wrong to assume that NP's or PA's can be primary care physicians, but they can play an excellent role in augmenting a practice. Anyway, that's my assessment.
 

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yes, true... you're comparison of sandwich artists to PA's is a little unnecessary.. i was more getting at the idea that doctors have to deal with lawsuits and this insurance coverage to a much greater degree which make life that much more complicated. A general surgeon I shadowed just got sued and he was telling me how much of a headache it was. It is also lame to see a significant percentage of your income drain away towards malpractice..For specialties that get sued at a higher rate this can be up to 100,000/yr if im not mistaken (depending on the state)!!! This closes the income gap a ton.
Find a group or hospital that covers your malpractice insurance and that has its own legal team.
 

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To a lot of people, even those in the healthcare field, it's hard to tell the difference between the role of an NP/PA and an attending physician. The distinction is even more blurred in outpatient settings.

Spicedmanna is right in that for inpatient care, the role of PA/NP is similar to those of a resident physician. They may initially see the patient, write orders, do procedures, and even implement plans, but the final say is with the attending physicians. SB25's experience shadowing a PA in the surgical field is the perfect example - he basically described the job function of a junior surgical resident.

For outpatient, the line is more blurred. In most situations, there is no difference. But what about atypical presentations? What about zebras? Sure - doctors will miss them too. But there is a famous quote often used in medicine - "the eyes does not see what the brain does not know". The attending physician's experience and training may raise a red flag on something, or increase suspicion for something. But if you never heard of a disease, how do you know to be on the look-out for it? Patients do not come in with "doc, I think I have an atypical presentation of something." It's the clinical acumen from medical school, residency, or beyond - that will cause the clinician (whether doc or PA/NP) to go "something isn't right".

Another thing - when you get or see a NP/PA - you have no idea what their training/experience is. You don't know if that PA is a former medic in the military with 20 years of experience, or an NP who worked as an ICU nurse for 20 years before going to NP school to become an critical care NP - OR if the PA is someone who have shadowing experience with docs before going to PA school and is a fresh hire after 1 year of rotation OR if the NP is a direct hire from a program that takes people with no nursing experience and simultaneously give them their BSN/MSN and NP training.

At least with attendings, you know they went through medical school, passed their licensing boards (whether USMLE or COMLEX), did their residency training, maybe fellowship, and passed their specialty board certification exam.
 

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This is just to clarify about malpractice and mid level providers.
In our wonderful litigious society, which many of you will be soon face, everyone is liable with “bad outcomes”. On a side note, these “bad outcomes” are not always mistakes or poor care. A lot of times they are the natural progression of disease that couldn't be helped. Many people in our country can't always see that side. As a result, they go sue happy to justify their suffering or those of their loved ones. Being a NP or PA means you can get sued as well. The physician's role as their supervisor doesn't provide a force field against lawsuits. Everyone who is taking care of the patient is ultimately responsible for the outcome of their care. Mid level providers need to have their own malpractice insurance. I don't know anyone practicing that isn't covered.
 

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.... I don't know anyone practicing that isn't covered.

Plenty of physicians in Florida aren't covered. I don't know any OB at all who is because it can be over 100 grand a year. Florida law allows you to post a letter of credit or other assets in the amount of $250,000.00 and you can get hospital priveledges-- $100,000.00 if you don't admit patients.
 

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I don't know anyone practicing that isn't covered.

wow...Im really not sure about PA's here..I was under the impression that they don't have malpractice ins. to nearly the level that physicians do.

Edit: I found this link, it seems to be a PA census of sorts...nearly all the way down the page it says 'professional liability insurance,' of which >95% are covered by their employer. This answers a few questions!
 
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primadonna22274

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You're right to point out that PA malpractice insurance is far less expensive than physicians' malpractice; but it's getting more expensive every year.

I was SHOCKED (SHOCKED) that my EM group paid $5k/year for my malpractice...to work part-time. They got a little break on the premium because I work per diem now. Our ED director told me the PA malpractice is roughly half of the docs' there.

I'm really not sure how much my FP group pays for me to be covered on our plan. I do think it's much less expensive but probably at least a couple thou. Part of the cost of doing business.

I have NEVER paid my own malpractice insurance and the only way I would is if I were compensated far more than I am (e.g. independent contractor). As I said, it's just part of the cost of doing business, and it's one of the perks of being an underling. Dependent provider and all that.

FWIW, PAs are still sued far less frequently than physicians. I'm not sure of the suit rates for NPs. Those in the know state that the dependent PA-supervising physician relationship does cut down on risk, but I suppose that depends a lot on what you call supervision. Where I am now I generally have to beg a doc to see my patient if I need help. (Not an ideal situation either.)

8 years in practice and never been sued...knock on wood. :xf: People say it's inevitable, but there are things you can do to cut down on the likelihood of being sued--simply communicating with patients goes a very long way.




wow...Im really not sure about PA's here..I was under the impression that they don't have malpractice ins. to nearly the level that physicians do.

Edit: I found this link, it seems to be a PA census of sorts...nearly all the way down the page it says 'professional liability insurance,' of which >95% are covered by their employer. This answers a few questions!
 
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lapelirroja

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Nurses/PA are responsible for ensuring that the patient's treatment plan is carried out and for providing the practical needs of the patient.

Go to PA school because you want to take care of patients and ensure that the treatment plan decided on by the physician is being carried out in the best interests of the patient, not because you want to be a doctor without going through medical school.

Wow. Clearly my profession needs more advertising because this is ridiculous. Please go to www.aapa.org or even Wikipedia for God's sakes and look up what a PA is and what they do before posting again.
 

primadonna22274

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Gawd, I can't believe I missed this. Thanks to lapelirroja for pointing it out.

Um, coldweatherblue, whoever you are, the ONLY time the physician decides on the treatment plan I embark on is when I ask him/her for his/her opinion. This is called "consultation". It happens about once or twice a day. On an average urgent care day I see 30-40 patients, so yeah, 28-39 of those treatment plans have been devised by, um, me, the PA.

Might wanna check your facts.

Go to PA school because you want to take care of patients and ensure that the treatment plan decided on by the physician is being carried out in the best interests of the patient, not because you want to be a doctor without going through medical school.
 

coldweatherblue

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lol, many thanks to spicedmanna for the info. My views are representative of the roles I have seen PA's play, particularly in specialized private practice settings (dermatology, anesthesiology). However I recognize the limitations of my experience and welcome hearing the views of others. I am very much pro-PA's as they help out a lot and are licensed under medical boards.

to the ladies above... thank you for reminding me of the valley-girls I dated in high-school and their ridiculous but endearing way of starting drama. I have a few questions about Physician's Assistants: Do they have medical licenses? Can PA's legally practice medicine without MD supervision? THANKS and PEACE.
 

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If I recall this similar debate raged on a while back when CRNA's became the rage and the medical community fretted about the demand for anesthesiologists withering and dying.

While I appreciate the concerns people have about being "replaced", especially those of you pining for the quixotic career of the country doc. I have yet to see anything that really convinces me that well-trained primary care docs won't be high in demand.

And as far as I can tell, NPs and PAs make the lives of doctors easier not harder.
 

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Coldweatherblue: in answer to your questions, 1) PAs are licensed (I believe in almost all states now, if not all, check aapa.org; the old process used to be "registration"); licensure for the most part happens through the state medical board; individual states vary a bit. I, for example, am licensed in South Carolina and in Oregon (inactive since I moved). 2) In no situation may a PA practice totally independently; a PA must always have physician MD/DO supervision, but that supervision can mean wildly different things depending on where you are and what you're doing. "Remote supervision" is especially useful to the very-rural PAs who practice where nobody else wants to. This can be supervision via telecommunication, once/month MD/DO visits (or less), etc. Generally the folks who choose this are PAs with many, many years of experience and roots in the community.
Also, we are Physician Assistants (drop the 's). The 's indicates possession and is very annoying to us.
;)
 

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Most premeds, like myself, are relatively uninformed of PAs and NPs. What information many of us have received has been biased by a premed advisor or medical professionals we've spoken to.

Thanks for the firsthand info being provided, here. Whatever clarity we can gain now will help ensure that we all know the best ways to utilize the many distinct, vital professionals that make up our healthcare system, when we become a part of it. :thumbup:
 

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Well said, Chocolate Bear. It is for that reason that threads like this are vital to SDN. The more each of the varying health professions can learn about each other before they collide in the healthcare arena, the better.
 

dangit

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yes thank you to the PA and PA-students who posted on this forum. I learned a lot and definitely cleared up the distinction and confusion from second hand information.
 

primadonna22274

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You're very welcome. Happy to help.

Keep in mind that you will work alongside plenty of PAs & NPs throughout your training and, most likely, in your career as physicians. We can be a valuable resource and can make your lives much easier, if you let us. We can also make your lives harder if you deserve it. :laugh:

L.
 

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You're very welcome. Happy to help.

Keep in mind that you will work alongside plenty of PAs & NPs throughout your training and, most likely, in your career as physicians. We can be a valuable resource and can make your lives much easier, if you let us. We can also make your lives harder if you deserve it. :laugh:

L.

Anyone else find it irritating when midlevels threaten to "make your life harder"? :rolleyes: Is that really necessary?
 
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