June 2006362 The Journal for Nurse Practitioners - JNP

JNP

LEGAL LIMITS

Carolyn Buppert

Nurse practitioners (NPs) often tell me they are incompetition with physician assistants (PAs) forjobs. NPs want to know how they can sell them-selves, compared with PAs.

The answer depends on state law, the jobdescription, the skills of the individual NP, and thepreferences of the employer. In some jobs and insome states, NPs and PAs may be interchange-able. In that case, they should be paid the same,unless individual productivity or other evaluationmeasures differ. In some states, PAs are going tobe more attractive to some employers than NPs.In other states the legal climate is better for NPs.

Both NPs and PAs enjoy the opportunities theyhave today because of a physician shortage in the1960s. Dr. Eugene Stead of Duke University MedicalCenter put together the first PA program, usingalready trained Navy corpsmen. Stead based his pro-gram on a fast-track training program for physiciansduring World War II. As most of you know, Dr.Loretta Ford, a nursing professor and dean, and Dr.Henry K. Silver, a pediatrician, developed the first NPprogram in 1965 at the University of Colorado.

Although NPs and PAs may function very simi-larly, in most states there are subtle differences indefinition and scope of practice.

Definition and Scope ofPractice of PAsBy definition, a PA is a health care provider whopractices medicine with physician supervision.PAs describe their scope of practice to includetaking medical histories, performing physicalexaminations, ordering and interpreting laborato-

ry tests, diagnosing and treating illnesses, assist-ing in surgery, prescribing or dispensing medica-tion, and counseling patients.1 The scope of aPA’s practice corresponds with the supervisingphysician’s practice, with the understanding thatthe supervising physician will handle the morecomplicated medical cases. PAs are authorizedto prescribe medications in 48 states.1

Physician InvolvementWith PA PracticePAs describe their working relationship with physi-cians as follows: “The relationship between a PAand the supervising physician is one of mutualtrust and respect. The PA is a representative ofthe physician, treating the patient in the style andmanner developed and directed by the supervisingphysician. The physician and PA practice as mem-bers of the medical team.” The AmericanAssociation of Physician Assistants (AAPA) poststhese guidelines on their website.1

Guidelines for Physician/Physician AssistantPractice as adopted by the American MedicalAssociation House of Delegates in 1995 statethe following:

1. Health care services delivered by physiciansand PAs must be within the scope of eachpractitioner’s authorized practice as definedby state law.

2. The physician is ultimately responsible forcoordinating and managing the care ofpatients and, with the appropriate input ofthe PA, ensuring the quality of health careprovided to patients.

3. The physician is responsible for the supervi-sion of the PA in all settings.

4. The role of the PA is the delivery of healthcare that should be defined through mutual-ly agreed upon guidelines that are devel-oped by the physician and the PA andbased on the physician’s delegatory style.

PAs and NPs:What’s the Difference?

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5. The physician must be available for consul-tation with the PA at all times either in per-son or through telecommunication systemor other means.

6. The extent of the involvement by the PA inthe assessment and implementation oftreatment will depend on the complexityand acuity of the patient’s condition and thetraining and experience and preparation ofthe PA as adjudged by the physician.

7. Patients should be made clearly aware at alltimes whether they are being cared for by aphysician or a PA.

8. The physician and PA together shouldreview all delegated patient services on aregular basis, as well as the mutually agreedupon guidelines for practice.

9. The physician is responsible for clarifying andfamiliarizing the PA with his supervisingmethods and style of delegating patient care.

The AAPA site further states: What a PA does varies with training, expe-rience, and state law. In addition, thescope of the PA’s practice corresponds tothe supervising physician’s practice. Ingeneral, a physician assistant will seemany of the same types of patients as thephysician. The cases handled by physiciansare generally the more complicated med-ical cases or those cases which requirecare that is not a routine part of the PA’sscope of work. Referral to the physician orclose consultation between thepatient/PA/physician is done for unusual orhard to manage cases. Physician assistantsare taught to ‘know our limits’ and refer tophysicians appropriately. It is an importantpart of PA training.

DemographicsThe AAPA projects that there are 58,655 PAs in2006.1 Other statistics include the following:

• PAs make about $81,000 per year, on average.• 62% are women.• 47% hold bachelor’s degrees as PAs and 30%

hold master’s degrees as PAs.• 36% work in hospitals, 30% in physician

group practices, 14% in solo practices, and8% in federally qualified health centers.

• 41% work in primary care, 37% manageinpatients, 61% perform minor surgery pro-cedures, and 24% serve as first assistantin surgery.

EducationPAs are educated in programs that use themedical model and are designed to comple-ment physician training. Some PA programs arebachelor’s level; some are master’s level. Thereare residency programs in surgery for PAs.

Licensure RequirementsIn some states, PAs must apply for a license. Inothers, they work under a physician’s license.For a summary of state laws on PAs, visitwww.aapa.org/gandp/statelaw.html. To practiceas a PA, an individual must graduate from anaccredited PA program and pass a national certi-fying examination. To maintain certification, PAsmust log 100 hours of continuing medical edu-cation every 2 years and sit for recertificationevery 6 years.

Nurse Practitioners,ComparedNPs define themselves as nurses with a broad-ened scope of practice and, historically, haveidentified more with the nursing model than themedical model of care. This philosophy may ormay not be attractive to employers, if they arephysicians. Because PAs cannot practice withouta physician, a physician may feel that a PA is lesslikely than an NP to want to break off and start aseparate practice.

As for scope of practice, NPs would includethe same activities in their scope of practice aslisted earlier for PAs, with the exception of assist-ing in surgery. Although some NPs assist in sur-gery, it is not so common an activity that it is uni-versally included in scope of practice of NPs. NPprograms do not teach surgery, and there are noresidency programs in surgery for NPs. In somestates, such as New York, the board of nursinghas determined that surgery is not within thescope of practice of an NP. Practically, if anemployer wants a clinician who is experienced insurgery, the employer probably will seek a PA.Because surgery brings in higher reimbursement

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than office or hospital visits, PAs may have greaterearning potential.

NPs usually include special attention to health caremaintenance and illness prevention in their state-ments of scope of practice. That may be attractive tosome employers.

Finally, because there are more male PAs thanmale NPs, if an employer is more comfortable hav-ing a male colleague, then the successful applicantis more likely to be a PA.

Advice for NPsThe key to getting a job is to fit the needs andpreferences of the employer. An NP who wants tohave the greatest number of opportunities will geteducation and experience with all diagnoses, bothsexes, all age groups, all settings, and all proce-dures, including surgery (unless practicing in NewYork). However, an NP who is interested and expe-rienced in a specialty is going to be very attractiveto employers who have a need for someone inthat specialty.

When looking for a job, research and compareyour state’s law about PAs and NPs. Be preparedto explain why an NP might be preferable. If thelaw is better for PAs, the only courses of actionare to get the law changed, move to another state,or seek a job in which the legal differences do notmatter. In interviews, ask the employer what he orshe needs a clinician to do and why the practice isseeking to hire a clinician. If the practice wantssomeone to conduct office visits, concentrating onprevention and health care maintenance and man-agement of common acute and chronic illnesses,and those are your interests and experience, thenemphasize the fit between you and the employer’sneeds. If the employer is a trauma service, do notexpect to be able to compete with a PA who hascompleted a surgical residency.

Reference

1. American Academy of Physician Assistants. Available at:www.aapa.org. Accessed April 13, 2006.

1555-4155/06/$ see front matter© 2006 Elsevier Inc. All rights reserved.doi:10.1016/j.nurpra.2006.04.002

Carolyn Buppert, CRNP, JD, practices law in Annapolis, MD.She can be reached at cbuppert@buppert.com.

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