The great English scientist Isaac Newton is credited with saying: “We build too many walls and not enough bridges.” This site began as a bridge of sorts. But there’s a new bridge everyone is talking about: a physician assistant to nurse practitioner bridge.
A PA to NP bridge?
Say, what? A PA to NP bridge? The very thought is incomprehensible to some.
“Why would you even want to do that?” responded one PA when the question was raised on social media. I can imagine the respondent, with one eyebrow raised, lips pursed, genuinely confused. Perhaps even wondering if the original poster was a burned out, disillusioned PA asking for help or an internet troll looking for a few laughs.
Others commenting on the post were quick to point out where nurse practitioners trail physician assistants in clinical training. “You’re just about as likely to find a PA to airline pilot bridge” quips another.
Are PAs and NPs the same?
Are the two professions even that different? As Virginia Hass explains, “The two professions enjoy significant areas of overlap, yet are still distinct in their education, initial certification, maintenance of certification, and licensure.” Ms. Hass ought to know–she’s both a PA and an NP.
Yes, NPs and PAs are different. Dr. Hass (also a Doctor of Nursing Practice), goes on to explain how the average PA program averages 27 months and includes almost 2,000 clinical hours while NPs train for 15-24 months, accruing just over 700 hours of clinical instruction.
Nursing Model vs Medical Model
Then there’s the old nursing model vs medical model, thing. Whats the difference?
According to one article, nurses “implement a nursing care plan based on the nursing process, using both nursing theory and best practices derived from nursing research.” Huh?
Some might try to explain the difference by saying that the nursing model considers the whole person while the medical model focuses only on the disease. Nonsense. No good clinician would take a patient’s condition out of the context of their lives–where they live and work, what they eat, what hobbies they may have, etc. It’s all pertinent information.
According to another article, ‘It is argued that nursing cannot be a distinct profession unless it has its own knowledge base, organized into a model for practice, against which nursing activities and interventions can be evaluated.” Ok, so it’s just a way to say that nurse practitioners do things differently–that makes sense.
“Brain of a doctor, heart of a nurse.”
What is that difference then between the way nurse practitioners and PAs and physicians practice? One physician explained it like this: NPs are trained in pattern recognition while the medical model teaches physicians and PAs to understand why certain patterns emerge in the first place.
Understanding this fundamental difference, it makes little sense for a physician assistant to want to practice on a more superficial level. That’s not to say pattern recognition has no place in the practice of medicine, however.
This brings up another salient issue: Do nurse practitioners practice medicine or advanced nursing? Honestly, it’s another silly argument that really depends on how your state defines the terms. The answer also depends on who you’re talking to. Defending their day-to-day practice, NPs might borrow more from medicine but when it comes to regulation, it’s all nursing governed by nursing boards.
Physician Assistant Bridge to Anywhere
So why would a physician assistant want to bridge to become a nurse practitioner then? It really comes down to 3 little words: Full. Practice. Authority.
Full practice authority can also be a tough term to pin down. Critics see it as a claim of independence and “scope creep” while proponents argue that it’s more about responsibility. In their response to the AMA’s “tone-deaf” initiative to promote physician-led care, the AAPA notes that “This is not only contrary to what evidence shows is best for patients but is also out of touch with how medicine is practiced today.”
How is medicine practiced today?
This gets to the heart of the physician assistant to nurse practitioner bridge argument. The American Association of Nurse Practitioners indicates that NPs have “full practice” in 25 states and US territories. Full practice is defined as laws allowing “all NPs to evaluate patients; diagnose, order and interpret diagnostic tests; and initiate and manage treatments, including prescribing medications and controlled substances, under the exclusive licensure authority of the state board of nursing.”
State laws in the rest of the country limit NPs to certain tasks or require them to work with a collaborating physician. Up until very recently, a similar map illustrating PA practice laws would have been a lot less interesting. And even today, no state has true full practice authority in the way nurse practitioners have been able to achieve it. [Update: Since this article was first published, significant advancements have been made in several states.]
Stopping Scope Creep
Physicians often criticize NPs and PAs for wanting off the leash (remember the cringe-worthy scope creep thing?). Nurse practitioners tend to argue that they don’t need physicians. PAs, on the other hand, have tried to maintain a team-based approach.
But one thing is clear–you can have team-based care without outdated administrative policies. This is what PAs really want and what NPs have overshot. Too many physicians, unfortunately, refuse PA’s attempts to reduce unnecessary burdens thanks to the festering wounds associated with the battle for NP independence.
Optimal Team Practice vs FPA
While physician assistants are now considered fully responsible for the care they provide (i.e. independent) within the Indian Health System, real progress still lacks in state legislatures.
North Dakota was one of the first US states to remove the requirement that PAs have a written agreement with a physician. There’s a major catch, however. In order to operate in the streamlined environment, they must practice at licensed facilities (e.g., hospitals and nursing homes), facilities or clinics with a credentialing and privileging process, or physician-owned facilities or practices. North Dakota PAs can own their own practice with the approval of the North Dakota Board of Medicine but PAs with less than 4,000 hours of experience must still have a collaborating physician. That’s not a bad compromise actually.
Maine recently passed a similar law that requires PAs with less than 4,000 hours of professional experience to practice in a collaborative agreement with a physician while those with more than 4,000 hours may practice without a written agreement. A physician must simply be available for consultation. If the PA is the principal provider in a practice that does not include a physician a practice agreement would still be required.
A Bridge in My Backyard
Some PAs, feeling their employment prospects contracting, are unhappy with anything short of full independence. I recently heard a representative of my state’s medical society say that if PAs wanted full independence, they could probably get it in a legislature very sensitive to anything that’s anti-competitive in nature.
What route did we choose to follow? The only one we could–appeasement. We didn’t have the money or the manpower to go up against the physician groups, and they were quite clear that a move for independence (as they defined it) would be an act of war.
What do NPs do when confronted with organized medicine? They forge ahead. Look at what happened in Florida, for example. The push for independence in Florida began with both PAs and NPs but when physician groups objected, PAs were dropped, and the NP machine rolled on. NPs outnumber PAs 2 to 1. That matters. Add 4 million registered nurses and not even physicians stand a chance.
O Captain, My Captain!
The discussion of a physician assistant to nurse practitioner bridge and full practice authority versus independence brings up another important question: who should lead the healthcare team? To some, the answer may be obvious–physicians. But not all patients have, or want, the chance to be seen by a physician.
PAs are vital to rural health care in America. These patients receive quality care from PA-led teams and the outcomes are often indistinguishable from physician-led care. Patients don’t care about credentials as much as they care about competency and compassion. All patients deserve good outcomes from capable providers and there’s no single degree that can offer that without fail but I don’t blame PAs for wanting to do so without all the baggage.