Turf Wars: Can MDs, NPs, and PAs Learn to Get Along?

Brandon Cohen

Disclosures

May 17, 2018

A recent session presented at the 2018 Society for Hospital Medicine annual meeting offered some quick facts regarding physician assistants (PAs) and nurse practitioners (NPs), using the catchall phrase advanced practice providers (APPs). This led to lively and often contentious discussion in the comments section from APPs, physicians, and other healthcare providers.

An outspoken nurse practitioner stirred up controversy right away:

I do not see any difference between myself and an MD. I have the same responsibilities, authority and requirements. I can diagnose, prescribe and admit to the local hospital. [I could also] open my own clinic.

An emergency room physician shot back quickly:

You may not see any difference between yourself and an MD, but there is a substantial difference in terms of training and, generally, experience. No one expects you to be a physician, but not knowing what you don't know can be a significant limitation. You may feel that you have adequate training for eighty to ninety percent of what you see, but if you don't recognize the corners around which you don't see . . . you are doing a disservice to your patients.

An anesthesiologist made an unflattering comparison:

McDonald's perfected the idea that you don't need a trained chef in every retail outlet and teenagers and warm bodies off the street could be trained . . . effectively. That is the kind of singularity we are trying to achieve in medicine. There will, by necessity, then have to be a two-tier system where the masses will get the McDonald's and people who can pay the premium prices get the Michelin-rated restaurants.

A psychiatrist scoffed: "Should we scrap med schools and have everyone become a nurse and then do an online degree to become NPs?"

But the original controversial nurse practitioner did not back down, countering with an educational suggestion:

I believe all MDs should have to first get their four-year RN degree and work about four years [in the field] before starting medical school.

Many saw this sort of verbal jousting as counterproductive. A registered nurse wrote:

There is no reason for patients to view these professions as competing against each other . . . It's up to us as providers of care to reassure patients that our colleagues are competent and caring, and that each has a role as part of the healthcare team.

Another healthcare provider was even more impassioned:

I am shocked at the degree of antagonism and arrogance reflected in the various MD specialists' comments on this forum. Many sound extremely overprotective of a perceived positional superiority.

An oncologist also sought to diminish competitiveness, but from a different point of view:

There should not be competition between physicians and non-physicians because only one is a physician. When patients see a physician they expect said physician to know everything. Is that the expectation with an NP? Because . . . it won't be met.

A registered nurse responded:

I sure hope that you do not present options to your cancer patients with the attitude that you know everything . . . As an experienced RN I have saved a newbie doc, and I have learned a ton from all of the wonderful collaborative physicians I have worked with. So instead of guarding our turf, how about we each contribute as best we can to the care of the patient?

And it should be noted that there were also physicians who voiced great respect for colleagues. One wrote:

I've worked with PAs and NPs since my days in the Navy 35 years ago and have overall had very positive experiences. I've had a couple PAs/NPs that the patients absolutely loved—their schedules were always full. They knew their limits and knew when to refer or get guidance. There are good and bad in all professions. There are good and bad doctors also.

An internist was similarly collegial:

I personally enjoy collaborating with them [APPs] and serving as a resource for the super challenging patients. Many patients actually prefer the PA or NP to myself.

But many still believed in strict hierarchies. A nurse practitioner thought it was important to make clear the lines between doctor and nurse, but also between nurse and assistant:

I tell all my patients that my MA is an assistant, not a nurse . . . I've seen many medical assistants step outside their scope because they are called nurses and think they can do . . . what nurses do.

A physician assistant wanted further distinctions:

I wish everybody would stop lumping PAs and NPs together for every argument. The education and training of the two professions differ in that PAs are licensed by the medical board whereas NPs are licensed by the nursing board.

The final word goes to a nurse practitioner who, after diving deep into the fray, had a change of heart:

It is sad to see physicians and [APPs] . . . go at each other's throats. I'm guilty myself of putting down my colleagues online . . . But . . . at the end of the day, what people say online [is unimportant.] What matters is . . . the outcomes I have with my patient.

The full discussion of this topic is available at Experts Bust Myths About Working With NPs and PAs.

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