The Future of Physician Assistants / Nurse Practitioners   6/94

The health care team has become very complicated over the past three decades. There are over a hundred components which not only confuse patients, but also the members of the team.

No one can agree on how to group the members of the team. Let me propose four general levels: The physicians, nurses, allied health specialties, and administrative and clerical support.

The highest trained members are the physicians who are the only ones with an unlimited license to practice medicine and surgery. There are two groups of physicians with such licenses given by two different boards, the California Medical Board and the Board of Osteopathic Examiners. There are several primary specialties (FP, GP, Internist, Surgeon, Pediatrician, Obstetrics, Gynecology, Psychiatry) and dozens of subspecialties. Internal Medicine and Surgery have over a dozen subspecialties each with Pediatrics following the same organ system routine.

The other clinical discipline is nursing with its own practice act and board. Although Nurse Midwives have existed since the 1930's, it wasn't until the 1960's that nursing has developed certified and graduate practitioner and specialty programs. These Nurse Practitioners, now include 5,000 Certified Nurse Midwives (CNM's), 25,000 Family NP's, and 26,000 Nurse Anesthetists. Nursing has also followed the organ system specialties. There are 58,000 Nurse Clinical Specialists, including Respiratory Nurse Specialists, Pediatric Nurse Specialists, Neonatal Nurse Specialists, Cardiac Nurse Specialists, Psychiatric Nurse Specialists, and others.

The third division of the team is the twenty plus Allied Health Specialists, some of which come under the purview of the Medical Board. There are a number of technicians and technologists, including lab techs, med techs, x-ray techs, nuclear med techs, ECG techs, cath lab techs, OR techs, pulmonary function techs, EMT's, and others. There are a group of clinical techs know as therapists. These include Physical, Occupational, Speech, Play, Music, Respiratory, and Rehab Therapists, among others. These allied health specialties can not enter independent practice and can only function on the order of a physician.

A portion of this division can engage in independent practice, but is limited by the Allied Health division of the MBC. These include Optometrist, Podiatrists, and Psychologists, each of which is trying to extend their practice to reach total independent status.

A hybrid, which was developed by physicians, is the 23,000 Physician Assistants. These can only function under the direct supervision of a physician who is responsible for their activities and actions. They are also increasing their independent status, writing prescriptions on their own, ordering laboratory and other expensive tests. PA's are an undergraduate program with much of the initial impetus utilizing the experience of military medical corpsmen by giving them brief academic exposure. This has increased to a full bachelor's degree. Their training program has evolved closely with nurse practitioners, despite the latter being a graduate masters degree program.

The fourth members of the team are the supporting structure including administrators as well as clerical support staff. Of course, there are many levels within this broad category.

In the care of patients, it has been estimated that primary care physicians can manage 75% of the medical problems. It has also been estimated that Nurse Practitioners can handle about 80% of the problems that a primary physician sees. Thus nurse practitioners would be able to take care of about one-half to two-thirds of our nations health care needs. DeAngeles, (JAMA 271:868-71, 1994) a RN who became an MD, gives an excellent analysis of how the patient gets the best care when MD's and NP's work as a complementary team.

The NP and PA programs have been combined at UCD and at other schools despite the fact that NP's are graduate nurses, and PA's are undergraduates. Their job descriptions are nearly identical. However, they function under different boards. PA's have the paradox of trying to function as if they are physicians and thus give orders to nurses even though they are undergraduates to their NP graduate counterparts.

I have interviewed a number of NP's and Nurse Specialists over the past 25 years. I invited a few to write articles for this issue. Many NP's who were in independent practice in other states have returned to California preferring to work with physicians as nurse practitioners, feeling a closer kin to that discipline than to "playing doctor" as many have called it. However, most PA's that I have interviewed not only enjoy playing doctor but are really practicing medicine, some independently in reasonably unstructured situations. Many are making decisions that I would be uncomfortable making which may be hazardous to patients. The costs of the tests they order may be questioned during these times of cost constraints.

It would appear that the initial impetus for PA's no longer exist. It is now appropriate that the PA standards should be increased to have an RN on entry to the program. This would further standardize their training and bring them under the Board of Nursing and total amalgamation. Otherwise they will join the ranks of the psychologists, podiatrists, and optometrists, hanging out their own independent shingle and trying to extend their authority. Our position to protect the public interest in not understood by the public. They will look at it as another turf battle.