In recent decades, the number of Nurse Practitioners and Physician Associates* in medicine has increased. From 2010 to 2017, the number of NPs increased from 91,000 to 191,000.1 In 2021, there are now more than 325,000 licensed NPs in the United States.2 For PAs, the growth has been similar. From 2018 to 2019 alone, the number of PAs increased 9% from 130,230 to 141,934.3 These trends are likely to continue in the upcoming years. The United States Bureau of Labor Statistics predicts that NPs and PAs will grow at a rate of 45% and 31%, respectively.4,5 Given these factors, it is important that physicians understand the perspectives of our partners. To better understand how our colleagues view the evolving clinical relationship, I interviewed Emily Schrope and Katlyn Keele. They are both PA students currently in their second year of graduate school. Their views and opinions expressed are purely their own, and do not represent all PAs or the AAPA. All quotes are presented as they originally occurred, unless stated otherwise.
1. What is your ideal working environment with future physicians?
a. Katlyn Keele: “Ideal work environment is to be respected and valued by my physician colleague. My goal is to create a cohesive environment in which our patients’ care can be our top priority.”
b. Emily Schrope: “An ideal working environment revolves around a relationship that focuses on collaboration and growth. PAs should be able to rely on their collaborating physician for a second opinion. Physicians should be able to rely on PAs when they have a booked schedule or need to improve efficiency.”
2. Do you believe that future relationships between PAs and physicians will improve, worsen, or stay the same?
a. Katlyn Keele: “I believe the relationship between PAs and Physicians all depends on the relationship between the two. As long as both parties understand the end goal is to help each other and the practice see and help more patients the relationship should be strong.”
b. Emily Schrope: “I believe the relationship between physicians and PAs will continue to improve as the role of the PA becomes more defined. As physicians learn to utilize and rely on PAs more, it will continue to strengthen the bond between the two professions and benefit both parties.”
3. What are your thoughts on the recent name change from “Physician Assistant” to “Physician Associate” by the AAPA?
a. Katlyn Keele: “I personally like the name change as I feel it better represents our title. Our profession was created to help Physicians and we constantly do that. However, too many times patients don’t understand that we have had valuable schooling and are knowledgeable healthcare professionals.”
b. Emily Schrope: “I think that the name change, although costly, was necessary for the future of the PA profession. While it may be confusing for patients at first, in the long run it will help to define the role of a PA. All too often people are confused about what PAs do and mistake physician assistants for medical assistants. It is important that patients trust PAs as independent providers, not solely as assistants.”
4. What do you believe is the scope of PA autonomy in medical practices?
a. Katlyn Keele: “PA autonomy is determined by the PA and the Physician in the scope of practice agreement. Every PA will have different autonomy based on their relationship and trust with the physician.”
b. Emily Schrope: “PAs are autonomous, and the scope of their practice should reflect this. While it is important to have a collaborative relationship between PAs and physicians, PAs should be able to diagnose, prescribe, and carry-out simple procedures.”
5. What do you believe is the limit of PA autonomy?
a. Katlyn Keele: “I believe PAs are very knowledgeable and well-educated individuals. Our career was created with the aspect of working closely with our collaborating Physician. Personally, I didn’t go to school to become or replace a doctor. I went to school to become a PA. I have no intention of trying to replace or steal jobs from Physicians. I desire to work with Physicians and NPs as a collaborative team. The PA profession was created to increase the efficiency of the Physician and the practice.
b. Emily Schrope: “PAs should not be autonomous when it puts the patient’s health and/or safety at risk. If a PA feels uncomfortable doing a particular procedure, prescribing a specific medication, or taking on a specific case, they should know their limits and be able to rely on their collaborating physician for guidance.”
6. In poor patient outcomes, who is responsible? The PA or MD?
a. Katlyn Keele: “I believe the provider that performs the error should bear the responsibility of his or her actions. However, Physicians do carry some responsibility as they oversee PAs as part of the agreement.”
b. Emily Schrope: “Ultimately, whoever caused the poor outcome should be held accountable for his/her mistakes and should take full responsibility. PAs should be held to just as high of standards as MDs, and are equally as accountable when it comes to malpractice, missing diagnoses, etc. However, it’s my understanding that when a PA makes a mistake, legally, the collaborating physician also shoulders some of the responsibility considering PAs practice ‘under’ physicians.”
7. What are the pros/cons of greater PA autonomy?
a. Katlyn Keele: “The pros of greater PA autonomy include more patients being able to be seen. The cons would be a shift in the amount of people wanting to become Advanced Care Providers (PAs or NPs) due to the difference in schooling and time.”
b. Emily Schrope: “PAs improve efficiency and patient satisfaction. If a PA has greater autonomy and can practice independently (within reason), the office will be able to see more patients, spend more time with each individual patient, and ease some of the burden on the physician. However, greater PA autonomy can theoretically lead to more mistakes, as PAs do not have the same training as MDs.”
8. In your opinion, what field of medicine has the greatest need for PAs?
a. Katlyn Keele: “In my opinion every specialty that wants to see more patients in less time needs to consider hiring a PA. PAs can really help fill the gap in areas of health care disparity as well as in primary care. This allows for more Doctors to specialize while not creating a lack of primary care providers.”
b. Emily Schrope: “I think there is a great need for PAs in all fields of medicine. In fact, I doubt there’s a specialty that PAs are not utilized in. However, with the aging population, recent pandemic, and provider burnout, I think there is a dire need for additional family medicine providers. More physicians are choosing to specialize, so there is a great need for providers in this area, and I think PAs are stepping into this role more and more.”
Perhaps the chief lesson I learned after my interviews was that advanced care providers have a goal of creating an environment that is best for our patients. It is important to note that my interview focused specifically on PAs and not on NPs. There have been studies showing larger differences of opinion between MDs and NPs.6 For example, a New England Journal of Medicine article found that two-thirds of physicians believe that doctors provide higher quality exams and consultations, while three-fourths of NPs disagree.6
I believe the “battle” between medical doctors and advanced care providers stems from systemic issues in the American healthcare system. In my opinion, the two biggest factors driving tension between MDs and NPs/PAs are rising medical costs and physician shortages in certain geographical areas. These two topics are expansive, and I hope to dive into each separately in the future. For now, consider this: NPs cost 30% less on Medicare billing, even when controlling for comorbidities in patients.7 Additionally, it is widely known that healthcare cost in the United States is dramatically increasing. Hospitals must find ways to lower costs into the future, and perhaps advanced care providers are an avenue to cost reduction.
The physician shortage in rural areas could be another factor driving tension between us and our colleagues. Across all specialties, 11% of physicians work in a rural area (population <50,000). Currently, 16% of NPs and PAs work in a rural area (population <50,000).8 Of the entire US population, 20% live in a rural area. This is an issue that needs to be addressed. One of the current solutions is the utilization of PAs/NPs in places where physicians are in short supply.
There are other factors driving this conversation, such as the cost of educating a physician, the time required for medical education, and the increasing specialization of medical doctors. These are no doubt complex issues that will take a collaborative approach to solve. I believe the idea of PAs/NPs “wanting to be doctors” is too simplistic. It is likely a factor for some, but I am not convinced that it is the driving reason for increasing advanced care provider autonomy. In a certain respect, the increased autonomy is due to necessity in a system that desperately needs reform. This reform will require a collaborative approach. I believe it requires the best of NPs, PAs, and MDs to come together to fix our system for patients. As leaders of the healthcare team, we need to be training doctors to lead this reform. The debate between NPs/PAs versus MDs is a symptom of a larger disease. Let us not get distracted. We face these issues together, and together we can fix a healthcare system that has gone awry.
*The American Academy of PAs recently voted to change the title of “Physician Assistant” to “Physician Associate”.
References
1. Auerbach, David I., and David J. Nyweide. “Implications Of the Rapid Growth Of The Nurse Practitioner Workforce In The US: Health Affairs Journal.” Health Affairs, 1 Feb. 2020, www.healthaffairs.org/doi/10.1377/hlthaff.2019.00686.
2. AANP National Nurse Practitioner Database, 2021.
3. “Physician Assistants.” Data USA, datausa.io/profile/soc/physician-assistants.
4. “Nurse Anesthetists, Nurse Midwives, and Nurse Practitioners: Occupational Outlook Handbook.” U.S. Bureau of Labor Statistics, U.S. Bureau of Labor Statistics, 2 June 2021, www.bls.gov/ooh/healthcare/nurse-anesthetists-nurse-midwives-and-nurse-practitioners.htm.
5. “Physician Assistants: Occupational Outlook Handbook.” U.S. Bureau of Labor Statistics, U.S. Bureau of Labor Statistics, 9 Apr. 2021, www.bls.gov/ooh/healthcare/physician-assistants.htm.
6. Donelan K, DesRoches CM, Dittus RS, Buerhaus P. Perspectives of physicians and nurse practitioners on primary care practice. N Engl J Med. 2013;368(20):1898-1906. doi: 10.1056/NEJMsa1212938.
7. Perloff J, DesRoches CM, Buerhaus P. Comparing the cost of care provided to Medicare beneficiaries assigned to primary care nurse practitioners and physicians. Health Serv Res. 2016;51(4):1407-1423. doi: 10.1111/1475-6773.12425.8. Primary Care Workforce Facts and Stats No. 3. (n.d.). Retrieved from https://www.ahrq.gov/research/findings/factsheets/primary/pcwork3/index.html.
Aaron Dowell is a member of the University of Arizona College of Medicine-Phoenix Class of 2024. He graduated from the University of Evansville in 2020 with a degree in Neuroscience. He plans on obtaining his MD/MBA dual degree and is interested in reducing physician burnout, leadership, and healthcare-market trends. In his free time he enjoys hiking with his wife, weightlifting, training Brazilian Jiu-Jitsu, and bowhunting. Contact information: aarondowell@email.arizona.edu