We write in response to the September 2019 commentary, “Are PAs and NPs interchangeable?” by Roderick S. Hooker, PhD, PA, and Benjamin McMichael, JD, PhD, and appreciate the spirit of collegiality with which Dr. Hooker brought this to our attention and invited a response.1 We speak here not as experts on the physician assistant (PA) role but as observers, from the NP point of reference, of the changing healthcare landscape. Our view is that the subject matter of the commentary is not inclusive enough and misses a more important question. That is: To what extent are healthcare providers interchangeable? This question is inclusive of each of the major types of healthcare providers practicing today in the United States: PA, NP, and physician.
We do not concur that NPs and PAs are interchangeable. We support the distinct recognition of each type of clinician for the competence and expertise brought to the patient care setting. This includes referencing each clinician by the license held and not comingling titles or using bucket terms to reference some types of clinicians. Identifying the two professions as interchangeable has the potential to diminish both roles.
Hooker and McMichael made several good points about parallels that are commonly drawn between NPs and PAs. They also make the argument that the two types of licenses are functionally substitutable in many practice settings in the United States. We do not disagree that these statements apply in some clinical practice roles. A strength of the similarities between our two professions is that there are multiple opportunities for us to align and synergize for the betterment of both.
Many members of the public tend to view NPs and PAs similarly, for reasons varying from a general lack of knowledge of the various types of healthcare providers to unclear language used in healthcare settings to overlap of patient care functions, among others. Today, in fact, there is quite a bit of overlap in the roles of the major types of clinicians. These areas of overlap are worthy of ongoing discussion and examination if we are to move each of our professions forward.
Virginia Hass previously noted this lack of interchangeability in JAAPA.2 Hass, who is certified as both a PA and an NP, made the excellent point that the two professions have distinct education, certification, and licensure.2 This is undisputed. However, we also appreciate the pragmatic viewpoint of Hooker and McMichael that both perceptions of the lay public and current healthcare reimbursement schemes blur these distinctions. We acknowledge that in some roles, NP and PA practice is similar and that both achieve high-quality outcomes. However, similar is not the same as interchangeable.
In our national healthcare culture, the health outcomes measured generally focus on disease management and interval screening. Outcomes studies are lacking and there are few insights about either differences in clinician style or outcomes from specific interventions. Even less is known about differences between clinicians for outcomes of health promotion activities that are a primary focus of nursing, such as immunizations, breastfeeding, avoidance of sexually transmitted infections, and many other behaviors related to lifestyle and culture. These areas have not been a funding priority in our national tertiary care-focused medical culture.
Starr's classic text on the historical and sociological development of physicians in the United States explains the ascendance of allopathic medicine in the US social structure that led to our current culture.3 Legislative changes made decades ago at the behest of organized medicine prohibited other qualified clinicians from delivering healthcare despite their possession of appropriate education and skills. Parochial battle lines were quickly drawn and conflicts ranging from skirmishes to all-out warfare have existed since.
Examples of these conflicts can be found in the early days of the NP movement, when state boards of medicine repeatedly accused NPs of practicing medicine without a license. The first PAs were similarly charged, as were chiropractors and osteopathic physicians at one time. Now, graduates of PA programs routinely take a professional oath committing to the practice of medicine, and the physicians who direct these programs endorse the graduates and their oath.
NP practice is rooted in nursing theory. NPs are first educated as registered nurses, which encompasses basic science, nursing science, and direct patient care promoting healing of the body, mind, and spirit.4 What difference this makes in health outcomes for NP graduates is less clear.
A deeper look at the differences in the professions, which are derived from their respective educational preparation, is needed. The observation of the tasks or jobs performed may not fully elucidate the similarities or differences. A simple distillation of tasks misses critical differences in the approach to care that can affect patient outcomes.
Although statutory differences exist between states, which in some cases legislate practice and collaboration requirements with physician colleagues, a growing number of states allow NPs independent practice. Less-restrictive practice models are associated with improved access to healthcare.5,6
We have often heard physicians cite their more time-consuming educational programs as a rationale for prohibiting those following other educational paths from delivering many types of healthcare. Unfortunately for the people arguing this position, no studies have identified an ideal length of training for any particular type of patient care, and we all know the broad range of patient care needs that we face each day. Academic physicians now seem to be recognizing this. Although the 4-year model for basic medical education went unchallenged for decades, there now are about 150 3-year medical education programs in the United States, with numerous other medical schools considering such programs.7,8 In addition to illustrating the ability to transform medical education, this fact may also help to raise some important questions about how to evaluate actual differences in curriculum plans between disciplines and what implications these differences have for providing patient care along the vast continuum of possible scenarios.
Recently, progress has been seen in moving the discussion of educational comparisons between NPs, PAs, and physicians away from a discussion of clock hours of clinical training and toward relevant questions of competencies and outcomes.9 Still, little is known about the influence of the patient-provider interaction on knowledge and behavior change in self-management of health. As noted above, the nature of physician training is evolving with the healthcare environment as NP and PA education also evolves. Each profession can and should respect differences in background, education, clinical training, and practice and be able to acknowledge the evolution in each role and the contributions each makes to the healthcare team.
Further highlighting the question of broader interchangeability between multiple professions is the recent executive order to the US Department of Health and Human Services from the executive branch. This order demands proposals to remove barriers that keep other clinicians such as NPs and PAs “from practicing at the top of their profession” and seeks to ensure that PAs and NPs are reimbursed in accordance with the work performed rather than basing reimbursement on occupational title.10 As healthcare delivery has become both more costly and complex, the bigger issues of our current delivery models, including the most cost-effective ways of teaching critical knowledge, skills, and abilities, should be the focus of more research.
We have deep respect for our PA, physician, and other colleagues who have chosen healthcare careers. It is time for old rhetoric, such as the promotion of the physician as the gold standard of healthcare of any type, to be put aside. Publications in the PA and NP literature unfortunately support this mystique when they propose our professions as potential solutions for the “physician shortage,” rather than recognizing our own colleagues as qualified independent clinicians who are needed in their own right. Our shared goals should include teaching colleagues and students to accurately characterize their professional role and its value. By allowing ourselves to view the sacred cows of our career field with clearer eyes, we can all move forward with the patient as the center of our concerns.
1. Hooker RS, McMichael B. Are PAs and NPs interchangeable. JAAPA
2. Hass V. Physician assistants and nurse practitioners are not interchangeable. JAAPA
3. Starr P. The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry
. New York, NY: Basic Books; 1982.
4. Frisch NC, Rabinowitsch D. What's in a definition? Holistic nursing, integrative health care. J Holist Nurs
5. Neff DF, Yoon SH, Steiner RL, et al. The impact of nurse practitioner regulations on population access to care. Nurs Outlook
6. Yang BK, Trinkoff AM, Zito JM, et al. Nurse practitioner independent practice authority and mental health service delivery in U.S. community health centers. Psychiatr Serv
8. Weiner S. Med school in 3 years: is this the future of medical education? Association of American Medical Colleges. www.aamc.org/news-insights/med-school-3-years-future-medical-education
. Accessed March 20, 2020.
9. Warm EJ, Kinnear B. What can the giant do? Defining the path to unsupervised primary care practice by competence, not time. Acad Med
10. Young K. Trump executive order seeks proposals on Medicare pay for NPs, PAs. www.medscape.com/viewarticle/919415
. Accessed January 21, 2020.