Currently, in America, there are only three legal groups of prescribers, the physicians (which include MDs, DOs, DPMs), the nurse practitioner (NPs), and the physician assistant (PAs).
The first class of physician assistants, in 1965, was also the year of the first class of nurse practitioners. Today there are nearly 300,000 NPs In America and 123,000 PAs.
PAs are outnumbered almost three to one, and the trend, with the rapid rise, and push, by NP organizations for more accessible, primarily online, schools, will soon reach four to one. The two have existed for the same number of years, yet, in most states, including my beautiful state of Utah, nurse practitioners have a status that allows them independent practice in all or to some degree.
The benefit to them is the ability to practice unencumbered without a “supervising physician” that they are required by state statutes to report to. They can simply get a job without having a supervising physician to practice. They can also start their own practice. In all states, they answer to a nursing board and are not under the purview of the medical board.
Contrast this with the career of the physician assistant. In all 50 states and territories, the PA is required to have a supervising physician. This means that the hiring process for a PA is always a 2:1 requirement, and the newer trend, due to the liability and responsibility of having to supervise a PA, a stipend is to be made to the physician.
The nurse practitioner simply can be “hired” as a 1:1 acquisition.
This has created a severe hindrance to physician assistants and has created many closed opportunities for PAs, and our job market has shrunk dramatically. Why hire and pay two when we can just hire one? And where, as in Utah, a physician can only supervise two FTE PAs at once, this also severely inhibits the number of PAs in any given place of employment.
I highlight this with a common and real example. In many states, a clinic will utilize both PAs and NPs as part of their staff. Yet, for example, there may only be one single retired physician on staff who does not see patients and who serves as the medical director and supervisor of the PAs, which, by state mandate, only allows her to supervise 2 FTEs. This means only two PA’s can work there.
There are six full-time nurse practitioners on staff, and there could be 100. They can hire as many NPs as they desire because they have no supervising constraints. If there is no extra doctor to supervise them, no additional PAs could work there. We are finding far too many instances where hiring managers do not even consider a PA at all in order to avoid paying to have a physician on staff. They have become simple to hire.
Now, this is not a personal attack on any honest, conscientious NP, but an outline of how the current rules have created a serious issue for PAs.
Our concerns as PAs are the closing doors on our job market due to the issue of having a supervisor, when we are on average, trained better, and longer, in all cases than the NP. One only needs to do a quick internet search, and this will become clear. Where NP programs once required nursing experience to enroll in an NP program, many now just encourage their students to continue from RN to NP. No experience necessary. All PA programs require health care experience to enter.
There is also a misconception that we need supervisors while they do not. This is certainly not based on our training paths, which are quite very different. To highlight this, all PA programs in the U.S. require the PA, after a minimum of a year of full-time didactic in a classroom (there are some experimental online programs). Per accreditation standards intern in emergency medicine, surgery, OB/GYN, pediatrics, and family or general medicine.
Contrast this with the NP, the PA’s sole competition in the job market. Many simply are required to put in 500 hours in some general practice, and that’s it. Many NPs, as many now attend online, often “find” their own student site. According to MidlevelU, the NP averages 500 to 700 hours of clinical time, again often in a single setting, while the PA averages over 2,000 hours with many, like my program at the University of Utah, approaching 4,000 hours.
We, as PAs, are not against NPs as they are a very vital part of the health care landscape, and much needed. We are against losing jobs because we are required to have a supervisor, without an adequate understanding of our training, or that we have proven ourselves to be competent, strong providers, and professionals. Of course, we all have anecdotal stories of good and bad PA’s, good and bad NP’s, but this consideration is on a grand scale and not directed at the individual level.
We PAs duly, and rightfully, acknowledge that we are not physicians, we are not trained to the same overall standards and requirements physicians are. We are not claiming to be able to replace physicians — who we need as much as the patients do. As a solitary group, the primary PA organization (AAPA) is deeply committed, with the overwhelming consensus of the constituents and members to the medical “team concept” in performing optimal team practice (OTP) with the physicians who have been our mentors and guides since day one of our inception.
The desire and need for the loss of the supervisor rule is to allow the PA to remain competitive in the job market that is shrinking by the day due to the meteoric rise of the NP profession and the opening of new programs at a rate never seen before. It is primarily being driven urgently by the economics of the business – not a desire to separate from the physician – physician assistant relationship.
Dale J. Bingham is a physician assistant.
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