Doing doctors' work

Line between physician assistants and nurse practitioners may be blurring


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You see them everywhere, these two breeds of health care professionals called nurse practitioners and physician assistants. They're in medical clinics, doctor's offices, and hospitals -- even in operating rooms -- and often they're performing duties you might be more accustomed to seeing handled by your doctor, such as conducting physical examinations, diagnosing illness, and prescribing drugs.

Are there differences between them?

Some, but not as many as there used to be.

"There's a lot of overlap ... but they're not identical," said Jacqueline Dunbar-Jacob, dean of the School of Nursing at the University of Pittsburgh.

"The differences are more and more indistinguishable," said Luis Ramos, director of the physician assistant master's degree program at Chatham University.

"When it comes to what we do on a day-to-day basis, we are essentially interchangeable," agreed Jessica Lazar, a physician assistant in Allegheny General Hospital's McGinnis Cardiovascular Institute. "A nurse practitioner reading that the two fields are interchangeable may say that's not true or vice versa, but as someone who has helped hire them, I think there are minute differences. In the functional world of patient care I think there are a lot of similarities."

Primary differences are in education and in their relationships working with -- or for -- doctors.

"In training, that's a big difference," Mr. Ramos said. "Nurse practitioners are first and foremost nurses and their training is based on the nursing model, not on the medical model. The PA training is based on the medical model." In fact, he said, PAs and medical students take many of the same courses.

Nevertheless, in Pennsylvania, nurse practitioners also do many tasks handled by doctors.

"[Nurse practitioners] can diagnose and treat illness; they can do medical histories and a physical examination," said Ms. Dunbar-Jacob. "They can order diagnostic tests; prescribe medication and certain other treatments. They can provide prenatal care; they can provide well-child care. They can educate patients who we see in the primary care arena.

"And we see an increasing number of nurse practitioners being hired into hospital settings where they may provide care within an ICU [intensive care unit] and other settings. They work in hospitals, community clinics and health centers, in nursing homes and physician offices. They may work as school nurses. Almost any kind of health care setting, you'll find nurse practitioners."

Though they enjoy much independence, nurse practitioners in Pennsylvania must have some physician supervision, not necessarily on-site. For example, at the nurse practitioner-manned MinuteClinics in CVS drug stores, there is a physician on call to answer questions or suggest treatments. Those doctors also review the nurse practitioners' charts and provide feedback.

Physician assistants, on the other hand, work directly for and at the discretion of a doctor. The two sign a "delegation agreement," which outlines what work the PA can do, Mr. Ramos said.

"[The PA] could potentially do [everything a physician does], but usually you are delegated a set of medical privileges that are basic to start with. If you work with the physician long enough, if he becomes comfortable with your work, he may add additional duties."

Those duties might include prescribing narcotics and serving as first assistant in a surgery.

Schooling


To become a nurse practitioner, one must first have a bachelor's degree in nursing and then go on to get a master's degree in a subspecialty such as neonatal care, pediatrics, mental health, adult care, family care and acute care, Ms. Dunbar-Jacob said. And soon, she added, they may need to complete doctoral programs to be licensed as nurse practitioners. "It's not mandatory at this point, but things are moving in that direction," she said.

Physician assistants have no such background requirements, Mr. Ramos said. Some go into PA programs from training and experience in other medical positions such as emergency medical technicians, paramedics and licensed practical nurses, while others might have bachelor's degrees in science or even the arts.

Similarly, PAs don't necessarily end up with a college bachelor's or master's degree, though he said all the PA programs in Pennsylvania are master's track. They also can come out of certificate programs, Mr. Ramos said, in which they get the same medical training as they would have in a college curriculum.

Regardless the certificate or degree, a PA can't practice until he or she is certified by passing a national board exam. "Every six years they have to take another exam and recertify," Mr. Ramos said.

Nurse practitioners also need to be nationally certified in their specialties and state-licensed. They too must undergo periodic recertification and accumulate continuing education credits.

"The nurse practitioner practice is governed by state boards of nursing and the regulations vary from state to state," Ms. Dunbar-Jacob said.

But once they're on the job, the differences blur.

Consider, for example, the days put in by Jacqueline McDaniel, a nurse practitioner who mans the MinuteClinic in the Centre Avenue CVS in Shadyside, and Jason Homer, a physician assistant in Allegheny General's neurosurgery department.

One morning in early February, Ms. McDaniel arrived at work to find a man waiting for her to open up. He told her he needed antibiotics for a throat "burning like fire, like in hell." But the "rapid strep [throat] test" she gave him was negative, meaning antibiotics would serve no purpose. Instead Ms. McDaniel got him some immediate pain relief with over-the-counter gargle and lozenges and also explained why prescription drugs wouldn't work on his throat.

And so it went the rest of a busy day for Ms. McDaniel, 46, of Weirton, W.Va., who went back to school to become a nurse practitioner after 12 years as a nurse.

Patients she treated included a teenager with sinusitis, for whom Ms. McDaniel did write a prescription for antibiotics, and a couple of clients who got flu shots. There also were a few patients she couldn't treat. One person, for example, needed a tuberculosis test read, something MinuteClinics don't provide. And Ms. McDaniel also sent to the closest hospital emergency room a young mother whose child had a big bump after hitting her head.

For Ms. McDaniel, who's been a nurse practitioner for five months, it was a thoroughly satisfying day.

"I gave good quality care and did exceptional patient teaching," she said.

"I like the fact that we are able to treat and diagnose and assess patients," she said of her new career. "We have a wealth of support with our collaborating physicians and our MinuteClinic nurse practitioners, and I like that because we can provide safe, wholesome care and at the same time, explain conditions and treatments to patients that will enable them to take care of themselves."

As a nurse, she said, she could neither diagnose nor treat.

Mr. Homer, 28, of Richland, works the neurosurgery unit at AGH with three other physician assistants.

"We get here around 6 a.m., take [case] histories and give physicals," he said. "We make sure labs [test results] are OK, go over pre-op [pre-operation] orders and answer questions as we're getting them ready for surgery that day. There may be seven patients, and everyone takes a patient.

"We do rounds to see the patients, anyone who's already had surgery or consult on trauma [cases]. We'll write notes, start on discharge planning, and do basic medical care of the patients. We pull drains, do lumbar punctures [spinal taps] and halo placements."

Like Ms. McDaniel, Mr. Homer enjoys his job and answered quickly when asked what he liked specifically: "Interacting with all the doctors, the patients -- you do get some autonomy dealing with patients -- learning something new every day, the science."


Pohla Smith can be reached at psmith@post-gazette.com or 412-263-1228.


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