Full plates for NAs and PAs

When it comes to on-the-job responsibilities, physician assistants' and nurse practitioners' plates are fuller than ever, thanks to time-crunched doctors and financially strapped medical facilities.

In some respects, pulling double-duty is a blessing for the professionals, particularly PAs, who have feared they could be heading for extinction. Just last year, Physician Assistant Journal printed a letter from a certified PA who worried that "those in the field will become obsolete within the next decade or two."

On the other hand, some PAs say the job security doesn't balance out the hectic schedule, which mirrors that of a physician minus the respect, prestige and paycheck. "I am glad that my growing responsibilities mean I should have more of a stable career, but I'm not sure it's fair that we are acquiring more of physicians' traditional workload," noted one Atlanta-based PA. "Physicians are under so many constraints that their duties have had to be reassessed and prioritized. In most cases, that means we are doing more, much more. Unfortunately, the physicians are still getting most of the recognition."

Not that physicians can be blamed for the shift. Nurse practitioners and physician assistants became popular roughly 30 years ago in response to a perceived shortage of physicians, especially in medically under-served communities that were often economically deprived. Today, managed healthcare constraints, weak reimbursement rates and decreased funding for graduate medical education have spurred the need for qualified, cost-effective substitutions.

Although PAs and NPs are picking up the pace with regard to patient care, the two professions rarely share the same workload. In fact, the two are trained under very distinctive curricula and skill sets, sources told Pharmaceutical Representative.

Nurse practitioners are predominantly masters-prepared nurses who have completed one to two years of post-bachelor's degree nursing education. Traditionally, NPs have been educated in a specific area, such as pediatrics, adult health, women's health or geriatrics; however, an increasing number of NP students are now choosing to study in family-based programs that emphasize comprehensive care for clients of all ages.

The NP curriculum involves course work in pharmacology, physiology, pathophysiology, epidemiology, health assessment, diagnosis, clinical decision-making and management. Nurse practitioners function under professional standards of practice developed by the American Nurses Association.

Physician assistants, on the other hand, practice medicine under the supervision of licensed physicians. As members of the healthcare team, they provide diagnostic, therapeutic and preventive healthcare services as delegated by a physician. They are also trained to take medical histories, examine patients, order and interpret laboratory tests and x-rays and make diagnoses.

"In the simplest of terms, NPs train under the nursing model and practice independently, while PAs fall under the medical umbrella and work under the supervision of a physician," explained Nancy Hughes, vice president of communication and information services, American Academy of Physician Assistants, Alexandria, VA.

"Some mistakenly compare the two professions, when in reality they are quite different," she said. "Although NPs require an expanded scope of nursing and handle a broad range of responsibilities, they aren't technically part of the medical team, whereas PAs are trained in medicine to practice like a physician. The typical PA student has a bachelor's degree and more than four years of healthcare experience prior to admission to the PA program."

Despite some obvious differences, PAs and NPs do share some similarities. Both predominantly work in hospitals, community health clinics or individual physician offices and place a strong emphasis on disease prevention and health education - key components of reduced healthcare costs and higher patient satisfaction rates.

Multiple studies show the cost effectiveness and patient acceptance of those in the PA and NP professions. A report by the Office of Technology, for example, showed that their cost per care episode was at least 20% less than that of physicians with the same patient population. One study found that NPs had a 21% reduction in hospital inpatient rates, and another reported a satisfaction rating of 89% to 96% by patients of PAs and NPs.

"Our findings suggest that patient satisfaction with care appears to depend on the communication skills and style of the provider, and not on the type of the provider itself," explained Roderick Hooker, PA, of Northwest Division of Kaiser Permanente, a group practice health maintenance organization. "Policies to incorporate PAs and NPs in healthcare seem to be justified."

The authors of the study also reported that the lines between physician assistants, nurse practitioners and physicians are becoming blurred. "Some patients perceive PAs and NPs as somewhat indistinguishable from physicians," they noted. "This perception may persist in spite of combined efforts by support staff and providers to differentiate between physicians, PAs and NPs, which could suggest that they provide quality care equally well as primary care providers."

The fact that patients sometimes confuse PAs and NPs with physicians could also have something to do with increased legal authority and the subsequent surge in prescription privileges.

According to a study by Newtown, PA-based Scott-Levin, nurse practitioners wrote 15 million prescriptions in the United States last year, up 66% from 1997. Physician assistants wrote 12 million prescriptions, reflecting a 33% increase.

"The jump in prescriptions corresponds with the increasing number of nurse practitioners and physician assistants working with doctors," said Thomas Reardon, president of the American Medical Association.

Physician assistants now have the authority to write prescriptions in 47 states - nearly twice as many as a decade ago. Only Ohio, Indiana and Louisiana have yet to grant them legal authority (see chart). Conversely, NPs have prescribing privileges in all 50 states, although in Pennsylvania, Georgia, Michigan and Ohio, a physician is required to co-sign the order.

"Prescribing privileges have definitely grown in recent years. States are coming to realize the benefits of allowing [these professionals] to handle more of these responsibilities," Hughes said. Although some have questioned whether the caregivers' educational backgrounds are sufficient for prescribing medications, the AAPA believes allowing them to do so makes sense.

"PAs have undergone extensive training and perform physician duties. Given their background, providing them with more [prescribing] authority seems quite logical," added Hughes.

But PAs and NPs aren't just writing prescriptions. They are also forging relationships with pharmaceutical representatives and acting as liaisons between drug companies and physicians, sources noted. In fact, about 96% of these caregivers see pharmaceutical reps, according to Scott-Levin's pilot survey of more than 900 NPs and PAs. Most participating in the survey said they see between one and ten sales reps per week - independently of physicians 95% of the time.

Roughly two-thirds of sales calls to nurse practitioners and 52% of calls to physician assistants occur in office environments, the firm observed. Most NPs surveyed said reps leave behind nutritional information, coupons and drug pricing charts, while PAs typically receive pamphlets, literature and dosing charts.

Said Scott-Levin's Theresa Regan, "More and more often, reps are calling on nurse practitioners and physician assistants. These professionals are gaining much more authority and could have a significant influence over pharmaceutical-related decisions." PR