Who is the Enemy?

Over the past year, we’ve seen ongoing relentless rhetoric, in the medical and lay press, besmirching the competence of PAs and NPs. The motives behind this unsettling trend can be viewed either as a veiled attempt to diminish our standing in patients’ eyes or even constrain our scope of practice. For years, we have tried to stay above the fray and avoid weighing in. However, we now feel compelled to address this rising negative tide.

Recently, Louis J. Goodman, PhD, President of the Physicians Foundation and CEO of the Texas Medical Association, stated, “The idea that nurse practitioners or physician assistants can fill the vacuum [in primary care] is not accurate.” He continued, “They can do some things, but someone needs to make the unequivocal diagnosis, and the person who is best qualified to do that is a physician.”¹

According to a recent white paper from the American Academy of Family Physicians (AAFP),² “Physicians offer an unmatched service to patients and without their skills, patients would receive second-tier care.” This report also recommended the establishment of more patient-centered medical homes in which a physician leads a team of “allied health professionals,” particularly PAs and NPs, as the way to provide optimal care. It is interesting to consider that the AAFP statement flies in the face of evidence to the contrary from credible and powerful organizations, including the Institute of Medicine and the National Institutes of Health.

Even a well-meaning 2011 article in American Medical News, entitled “Bringing PAs and NPs on Board: What to Do if You’re Hiring,”³ had inaccurate assertions about PA and NP practice—for example, that PAs tend to carry out more procedures, while NPs are better suited to provide evaluation and management.

So the question has to be asked: Who is the enemy here? There are plenty of fingers to go around if we are pointing—physicians, administrators, regulators—even ourselves! Truth be told, the enemy is, of course, ignorance. Why, in this world of evidence-based practice, do we so often write, post, and verbalize inaccurate information about each other? Even in light of the fact that in 2009, 49.1% of office-based US physicians worked alongside NPs and PAs, the misconceptions persist.⁴

The concept of patient satisfaction with health care has only recently received the attention it deserves in the medical literature; concurrently, there has been increased interest in patient satisfaction measurements among hospitals and health plans as they compete to attract and retain members. Analysis based on data from an adaptation of the “Art of Medicine” survey (an eight-item, patient-reported measure of clinician style of encounter) supports the finding that patients are indeed satisfied with their care, regardless of the type of practitioner who delivers it. The study found no statistically significant differences between scores for physicians and PAs or NPs, whether provider practice was differentiated by specialty or data were combined for statistical purposes. In addition, it was reported that some patients perceive PAs and NPs as somewhat indistinguishable from physicians.⁵

Regarding the quality-of-care issue, a number of studies—generated by nonbiased authors and entities and available online—have concluded that the quality of care provided by NPs and PAs is comparable to that given by physicians, in terms of functions that all these clinicians usually perform. Case in point: A seminal 1986 policy analysis from the congressional Office of Technology Assessment documented that NPs and PAs provide care of quality equivalent to that provided by physicians.⁶ The researchers found that NPs are more adept than physicians at providing services that depend on communicating with patients and taking preventive action. The evidence also indicated that PAs perform better than many physicians do in supportive care and health promotion activities. 

In addition to communicating more effectively, PAs and NPs have been found to be more proficient than many physicians at managing patients who require long-term and continuous care. Extending early studies, researchers have repeatedly demonstrated the high-quality care delivered by these professionals. 

Since the 1960s, the priority of health policy initiatives has been to make health care accessible to all Americans. As a means to this end, programs were developed to educate future clinicians (maybe even potential patients!) about the NP and PA professions, with the purpose to improve access to care. That, we have done. We have made important contributions to meeting the nation’s health care needs, especially by improving the geographic distribution of care, because we have been willing to practice in underserved rural and inner-city areas. And we will continue to do so, as meeting the health care needs of the nation has always been our priority—more important than disabusing those with misconceptions about our value and competence. 

Bottom line? Health care reform will bring numerous challenges for stakeholders over the next few years. It is imperative that we all focus on what matters most: a collaborative model of care that delivers improved patient outcomes through qualified providers, with access to health care for all Americans. And just as it “takes a village” to raise a child, it will take all of us, working collegially and cooperatively, to meet those challenges.

Our professions have been studied to death. If we continue to focus on the wrong problems, notes health analyst Brian Klepper, PhD, “primary care will continue to flail.”⁷ Let’s get on with the work of providing that care and researching better methods of preventing and treating diseases. Our discussions should be about the patient!

Are we overreacting? Are you tired of the inaccuracies perpetuated about both of our professions? Tell us what you think at PAeditor@qhc.com or NPeditor@qhc.com.                  

REFERENCES
1. Hertz BT. Primary care and the keys to its success: newer revenue and practice models to gain in popularity as primary care skills increase in value. Modern Medicine. Aug 25 2012. www.modernmedicine.com/modernmedicine/Modern+Medicine+Now/Primary-care-and-the-keys-to-its-success/ArticleStandard/Article/detail/785800?contextCategoryId=40158. Accessed October 11, 2012.

2. American Academy of Family Physicians. Primary care for the 21st century: ensuring a quality, physician-led team for every patient (2012). www.aafp.org/online/etc/medialib/aafp_org/documents/membership/nps/primary-care-21st-century/whitepaper.Par.0001.File.dat/AAFP-PCMHWhitePaper.pdf. Accessed October 12, 2012.

3. Elliott VS. Bringing PAs and NPs on board: what to do if you’re hiring. Am Med News. January 10, 2011. www.ama-assn.org/amednews/2011/01/10/bisa0110.htm. Accessed October 12, 2012.

4. Park M, Cherry D, Decker SL. Nurse practitioners, certified nurse midwives, and physician assistants in physician offices. NCHS Data Brief. 2011:69. www.cdc.gov/nchs/data/databriefs/db69.htm. Accessed October 11, 2012.

5. Hooker RS, Potts R, Ray W. Patient satisfaction: comparing physician assistants, nurse practitioners, and physicians. Permanente Journal. 1997;1(1). http://xnet.kp.org/permanentejournal/sum97pj/ptsat.html. Accessed October 11, 2012.

6. US Congress, Office of Technology Assessment. Nurse Practitioners, Physician Assistants, and Certified Nurse-Midwives: A Policy Analysis (1986). www.fas.org/ota/reports/8615.pdf. Accessed October 12, 2012.

7. Klepper B. Care and cost: the wrong battles. http://boards.medscape.com/forums?128@591.ZSwVamdalRA@.2a35001c!comment=1. Accessed October 12, 2012.

Over the past year, we’ve seen ongoing relentless rhetoric, in the medical and lay press, besmirching the competence of PAs and NPs. The motives behind this unsettling trend can be viewed either as a veiled attempt to diminish our standing in patients’ eyes or even constrain our scope of practice. For years, we have tried to stay above the fray and avoid weighing in. However, we now feel compelled to address this rising negative tide.

Recently, Louis J. Goodman, PhD, President of the Physicians Foundation and CEO of the Texas Medical Association, stated, “The idea that nurse practitioners or physician assistants can fill the vacuum [in primary care] is not accurate.” He continued, “They can do some things, but someone needs to make the unequivocal diagnosis, and the person who is best qualified to do that is a physician.”¹

According to a recent white paper from the American Academy of Family Physicians (AAFP),² “Physicians offer an unmatched service to patients and without their skills, patients would receive second-tier care.” This report also recommended the establishment of more patient-centered medical homes in which a physician leads a team of “allied health professionals,” particularly PAs and NPs, as the way to provide optimal care. It is interesting to consider that the AAFP statement flies in the face of evidence to the contrary from credible and powerful organizations, including the Institute of Medicine and the National Institutes of Health.

Even a well-meaning 2011 article in American Medical News, entitled “Bringing PAs and NPs on Board: What to Do if You’re Hiring,”³ had inaccurate assertions about PA and NP practice—for example, that PAs tend to carry out more procedures, while NPs are better suited to provide evaluation and management.

So the question has to be asked: Who is the enemy here? There are plenty of fingers to go around if we are pointing—physicians, administrators, regulators—even ourselves! Truth be told, the enemy is, of course, ignorance. Why, in this world of evidence-based practice, do we so often write, post, and verbalize inaccurate information about each other? Even in light of the fact that in 2009, 49.1% of office-based US physicians worked alongside NPs and PAs, the misconceptions persist.⁴

The concept of patient satisfaction with health care has only recently received the attention it deserves in the medical literature; concurrently, there has been increased interest in patient satisfaction measurements among hospitals and health plans as they compete to attract and retain members. Analysis based on data from an adaptation of the “Art of Medicine” survey (an eight-item, patient-reported measure of clinician style of encounter) supports the finding that patients are indeed satisfied with their care, regardless of the type of practitioner who delivers it. The study found no statistically significant differences between scores for physicians and PAs or NPs, whether provider practice was differentiated by specialty or data were combined for statistical purposes. In addition, it was reported that some patients perceive PAs and NPs as somewhat indistinguishable from physicians.⁵

Regarding the quality-of-care issue, a number of studies—generated by nonbiased authors and entities and available online—have concluded that the quality of care provided by NPs and PAs is comparable to that given by physicians, in terms of functions that all these clinicians usually perform. Case in point: A seminal 1986 policy analysis from the congressional Office of Technology Assessment documented that NPs and PAs provide care of quality equivalent to that provided by physicians.⁶ The researchers found that NPs are more adept than physicians at providing services that depend on communicating with patients and taking preventive action. The evidence also indicated that PAs perform better than many physicians do in supportive care and health promotion activities. 

In addition to communicating more effectively, PAs and NPs have been found to be more proficient than many physicians at managing patients who require long-term and continuous care. Extending early studies, researchers have repeatedly demonstrated the high-quality care delivered by these professionals. 

Since the 1960s, the priority of health policy initiatives has been to make health care accessible to all Americans. As a means to this end, programs were developed to educate future clinicians (maybe even potential patients!) about the NP and PA professions, with the purpose to improve access to care. That, we have done. We have made important contributions to meeting the nation’s health care needs, especially by improving the geographic distribution of care, because we have been willing to practice in underserved rural and inner-city areas. And we will continue to do so, as meeting the health care needs of the nation has always been our priority—more important than disabusing those with misconceptions about our value and competence. 

Bottom line? Health care reform will bring numerous challenges for stakeholders over the next few years. It is imperative that we all focus on what matters most: a collaborative model of care that delivers improved patient outcomes through qualified providers, with access to health care for all Americans. And just as it “takes a village” to raise a child, it will take all of us, working collegially and cooperatively, to meet those challenges.

Our professions have been studied to death. If we continue to focus on the wrong problems, notes health analyst Brian Klepper, PhD, “primary care will continue to flail.”⁷ Let’s get on with the work of providing that care and researching better methods of preventing and treating diseases. Our discussions should be about the patient!

Are we overreacting? Are you tired of the inaccuracies perpetuated about both of our professions? Tell us what you think at PAeditor@qhc.com or NPeditor@qhc.com.                  

REFERENCES
1. Hertz BT. Primary care and the keys to its success: newer revenue and practice models to gain in popularity as primary care skills increase in value. Modern Medicine. Aug 25 2012. www.modernmedicine.com/modernmedicine/Modern+Medicine+Now/Primary-care-and-the-keys-to-its-success/ArticleStandard/Article/detail/785800?contextCategoryId=40158. Accessed October 11, 2012.

2. American Academy of Family Physicians. Primary care for the 21st century: ensuring a quality, physician-led team for every patient (2012). www.aafp.org/online/etc/medialib/aafp_org/documents/membership/nps/primary-care-21st-century/whitepaper.Par.0001.File.dat/AAFP-PCMHWhitePaper.pdf. Accessed October 12, 2012.

3. Elliott VS. Bringing PAs and NPs on board: what to do if you’re hiring. Am Med News. January 10, 2011. www.ama-assn.org/amednews/2011/01/10/bisa0110.htm. Accessed October 12, 2012.

4. Park M, Cherry D, Decker SL. Nurse practitioners, certified nurse midwives, and physician assistants in physician offices. NCHS Data Brief. 2011:69. www.cdc.gov/nchs/data/databriefs/db69.htm. Accessed October 11, 2012.

5. Hooker RS, Potts R, Ray W. Patient satisfaction: comparing physician assistants, nurse practitioners, and physicians. Permanente Journal. 1997;1(1). http://xnet.kp.org/permanentejournal/sum97pj/ptsat.html. Accessed October 11, 2012.

6. US Congress, Office of Technology Assessment. Nurse Practitioners, Physician Assistants, and Certified Nurse-Midwives: A Policy Analysis (1986). www.fas.org/ota/reports/8615.pdf. Accessed October 12, 2012.

7. Klepper B. Care and cost: the wrong battles. http://boards.medscape.com/forums?128@591.ZSwVamdalRA@.2a35001c!comment=1. Accessed October 12, 2012.

Over the past year, we’ve seen ongoing relentless rhetoric, in the medical and lay press, besmirching the competence of PAs and NPs. The motives behind this unsettling trend can be viewed either as a veiled attempt to diminish our standing in patients’ eyes or even constrain our scope of practice. For years, we have tried to stay above the fray and avoid weighing in. However, we now feel compelled to address this rising negative tide.

Recently, Louis J. Goodman, PhD, President of the Physicians Foundation and CEO of the Texas Medical Association, stated, “The idea that nurse practitioners or physician assistants can fill the vacuum [in primary care] is not accurate.” He continued, “They can do some things, but someone needs to make the unequivocal diagnosis, and the person who is best qualified to do that is a physician.”¹

According to a recent white paper from the American Academy of Family Physicians (AAFP),² “Physicians offer an unmatched service to patients and without their skills, patients would receive second-tier care.” This report also recommended the establishment of more patient-centered medical homes in which a physician leads a team of “allied health professionals,” particularly PAs and NPs, as the way to provide optimal care. It is interesting to consider that the AAFP statement flies in the face of evidence to the contrary from credible and powerful organizations, including the Institute of Medicine and the National Institutes of Health.

Even a well-meaning 2011 article in American Medical News, entitled “Bringing PAs and NPs on Board: What to Do if You’re Hiring,”³ had inaccurate assertions about PA and NP practice—for example, that PAs tend to carry out more procedures, while NPs are better suited to provide evaluation and management.

So the question has to be asked: Who is the enemy here? There are plenty of fingers to go around if we are pointing—physicians, administrators, regulators—even ourselves! Truth be told, the enemy is, of course, ignorance. Why, in this world of evidence-based practice, do we so often write, post, and verbalize inaccurate information about each other? Even in light of the fact that in 2009, 49.1% of office-based US physicians worked alongside NPs and PAs, the misconceptions persist.⁴

The concept of patient satisfaction with health care has only recently received the attention it deserves in the medical literature; concurrently, there has been increased interest in patient satisfaction measurements among hospitals and health plans as they compete to attract and retain members. Analysis based on data from an adaptation of the “Art of Medicine” survey (an eight-item, patient-reported measure of clinician style of encounter) supports the finding that patients are indeed satisfied with their care, regardless of the type of practitioner who delivers it. The study found no statistically significant differences between scores for physicians and PAs or NPs, whether provider practice was differentiated by specialty or data were combined for statistical purposes. In addition, it was reported that some patients perceive PAs and NPs as somewhat indistinguishable from physicians.⁵

Regarding the quality-of-care issue, a number of studies—generated by nonbiased authors and entities and available online—have concluded that the quality of care provided by NPs and PAs is comparable to that given by physicians, in terms of functions that all these clinicians usually perform. Case in point: A seminal 1986 policy analysis from the congressional Office of Technology Assessment documented that NPs and PAs provide care of quality equivalent to that provided by physicians.⁶ The researchers found that NPs are more adept than physicians at providing services that depend on communicating with patients and taking preventive action. The evidence also indicated that PAs perform better than many physicians do in supportive care and health promotion activities. 

In addition to communicating more effectively, PAs and NPs have been found to be more proficient than many physicians at managing patients who require long-term and continuous care. Extending early studies, researchers have repeatedly demonstrated the high-quality care delivered by these professionals. 

Since the 1960s, the priority of health policy initiatives has been to make health care accessible to all Americans. As a means to this end, programs were developed to educate future clinicians (maybe even potential patients!) about the NP and PA professions, with the purpose to improve access to care. That, we have done. We have made important contributions to meeting the nation’s health care needs, especially by improving the geographic distribution of care, because we have been willing to practice in underserved rural and inner-city areas. And we will continue to do so, as meeting the health care needs of the nation has always been our priority—more important than disabusing those with misconceptions about our value and competence. 

Bottom line? Health care reform will bring numerous challenges for stakeholders over the next few years. It is imperative that we all focus on what matters most: a collaborative model of care that delivers improved patient outcomes through qualified providers, with access to health care for all Americans. And just as it “takes a village” to raise a child, it will take all of us, working collegially and cooperatively, to meet those challenges.

Our professions have been studied to death. If we continue to focus on the wrong problems, notes health analyst Brian Klepper, PhD, “primary care will continue to flail.”⁷ Let’s get on with the work of providing that care and researching better methods of preventing and treating diseases. Our discussions should be about the patient!

Are we overreacting? Are you tired of the inaccuracies perpetuated about both of our professions? Tell us what you think at PAeditor@qhc.com or NPeditor@qhc.com.                  

REFERENCES
1. Hertz BT. Primary care and the keys to its success: newer revenue and practice models to gain in popularity as primary care skills increase in value. Modern Medicine. Aug 25 2012. www.modernmedicine.com/modernmedicine/Modern+Medicine+Now/Primary-care-and-the-keys-to-its-success/ArticleStandard/Article/detail/785800?contextCategoryId=40158. Accessed October 11, 2012.

2. American Academy of Family Physicians. Primary care for the 21st century: ensuring a quality, physician-led team for every patient (2012). www.aafp.org/online/etc/medialib/aafp_org/documents/membership/nps/primary-care-21st-century/whitepaper.Par.0001.File.dat/AAFP-PCMHWhitePaper.pdf. Accessed October 12, 2012.

3. Elliott VS. Bringing PAs and NPs on board: what to do if you’re hiring. Am Med News. January 10, 2011. www.ama-assn.org/amednews/2011/01/10/bisa0110.htm. Accessed October 12, 2012.

4. Park M, Cherry D, Decker SL. Nurse practitioners, certified nurse midwives, and physician assistants in physician offices. NCHS Data Brief. 2011:69. www.cdc.gov/nchs/data/databriefs/db69.htm. Accessed October 11, 2012.

5. Hooker RS, Potts R, Ray W. Patient satisfaction: comparing physician assistants, nurse practitioners, and physicians. Permanente Journal. 1997;1(1). http://xnet.kp.org/permanentejournal/sum97pj/ptsat.html. Accessed October 11, 2012.

6. US Congress, Office of Technology Assessment. Nurse Practitioners, Physician Assistants, and Certified Nurse-Midwives: A Policy Analysis (1986). www.fas.org/ota/reports/8615.pdf. Accessed October 12, 2012.

7. Klepper B. Care and cost: the wrong battles. http://boards.medscape.com/forums?128@591.ZSwVamdalRA@.2a35001c!comment=1. Accessed October 12, 2012.