As the health care system undergoes tremendous change and the primary care physician shortage continues, family physicians are repeatedly being asked to see more patients in less time while providing greater care coordination than ever before. It is therefore not surprising that family physician burnout is on the rise. According to a 2015 Medscape report,1 more than 50 percent of family doctors across all age categories reported symptoms of burnout, making them more likely to abandon the profession or retire early.
One of the reasons for burnout strikes at the very core of the specialty: Family physicians care for everyone and take care of everything. Unfortunately, this “do everything” mantra can be self-destructive when there aren't enough family physicians to go around. Increasingly, resource limitations make it difficult to provide the best possible care for patients.
With the weight of ever-expanding practice demands placed squarely on physicians' shoulders, they need competent, motivated, and passionate colleagues to share the workload. Certified physician assistants (PAs) and nurse practitioners (NPs) can be a cost-effective way to meet this need.
PA and NP abilities, background, and qualifications
Before physicians can empower PAs and NPs to practice to the full extent of their licenses, physicians need to understand what abilities PAs and NPs have, their background, and their qualifications.
Services. In many clinical settings, PAs and NPs perform comparable services – preventive care, care coordination, prescription writing, chronic disease management, etc. They can also help practices address many bureaucratic and regulatory challenges, such as capturing data for quality-based payment programs. Individual interests and experience play a role in the services PAs and NPs perform, as does physician willingness to delegate responsibilities. Allowed services can also vary based on state laws, third-party payer regulations, hospital bylaws, and other factors. Prescription authority, and whether it extends to controlled substances, is one area that varies by location, so check your state's regulations for PAs and regulations for NPs.
Autonomy. One of the main distinctions between PAs and NPs is their relationship with physicians. PAs are licensed by state medical boards and always work as members of physician-led teams. In fact, the PA profession was founded by physicians, based on the principles of team-based care. Although PAs work autonomously, without requiring the on-site presence of a physician, they always work in collaboration with a supervising physician.
Most NPs also work in collaboration with a supervising physician who may or may not be on-site; however, 21 states and the District of Columbia allow NPs to work independently once they have met a requisite number of clinical practice hours.2 In this situation, NPs are neither directed nor supervised by a physician. This means that “state practice and licensure law provides for all nurse practitioners to evaluate patients, diagnose, order and interpret diagnostic tests, initiate and manage treatments – including prescribe medications – under the exclusive licensure authority of the state board of nursing.”2 In states that allow NPs to work independently, practices can still require their NP employees to follow the same collaboration requirements that they have for their PA employees. In any case, you may want to familiarize yourself with your state's current regulations and supervising requirements.
Experience. For many years, PAs and NPs came to their professions as a second career. Many of them were former military medics, paramedics, or registered nurses. This gave them valuable patient care experience. Today, PAs and NPs are increasingly choosing their professions as a first career and enter a graduate program shortly after completing a bachelor's degree. Most NP programs require applicants to have an RN degree, which guarantees that they will have some health care experience. The clinical hours required for an RN degree vary widely by institution but are often 600 hours or more. Most PA programs require health care experience, but again requirements vary. According to the Physician Assistant Education Association, 143 PA programs require applicants to have an average of 587 hours of health care experience, 77 programs prefer or recommend health care experience, and only 11 programs have no preference.
Education. PAs are educated in the medical model, which includes curricula in medical science and behavioral and mental health, with a focus on critical thinking and decision making. Their master's level programs require approximately 1,000 didactic hours and 2,000 clinical hours of training.3 There are no online PA programs in the United States.
NPs are educated in the nursing model, which includes a focus on disease prevention and health education as well as assessment, diagnosis, and treatment. Their programs require approximately 500 didactic hours and 700 clinical hours of training (or more if the NP is pursuing independent practice in an allowed state). Master's and doctoral degree programs are available, and 105 programs are offered online.3,4
Certification and recertification. Both PAs and NPs must pass a national certification exam before being licensed to practice. PAs must recertify by national exam every 10 years and earn 500 CME credits during each 10-year period, including optional performance improvement and self-assessment CME, in a model similar to family medicine's maintenance of certification process.5 NPs must earn 75 to 150 credits of continuing education every five years and log 1,000 hours of clinical work experience to be eligible to recertify.6 NPs must also complete one or more additional activities, such as serving as a preceptor, publishing research, completing academic credits, or volunteering their professional services.
Prevalence in family medicine. NPs outnumber PAs nearly 2:1 in the United States,7,8 and NPs are more prevalent than PAs in family medicine. According to the American Association of Nurse Practitioners, 55 percent of NPs (more than 122,000) specialize as family nurse practitioners (FNPs).7 PAs do not formally specialize in family medicine, but according to the National Commission on Certification of Physician Assistants, 21 percent of PAs (more than 17,090) currently work in family medicine.8
Salaries. PA and NP salaries are comparable. The average salary in 2015 for PAs was $102,163 ($94,613 for PAs in family medicine) and for NPs was $103,819 ($98,532 for NPs working in family medicine).8,9 However, salaries for the two professions vary widely by state. For example, in California annual salaries were $102,800 for PAs and $115,460 for NPs, while in Nevada annual salaries were $112,700 for PAs and $95,450 for NPs.10
Because their salaries are less than a physician's salary, PAs and NPs can be cost-effective members of the health care team if they are empowered to be fully productive.
How to maximize the value of PAs or NPs
As noted earlier, all PAs and most NPs work as members of physician-led teams, not independently. To ensure that PAs and NPs support family physicians in the best way possible and contribute to optimal patient care, consider the following steps:
Define the NP's or PA's role. Some practices choose to give PAs and NPs their own patient panels, with the understanding that the physician will provide regular collaboration and accept referrals of more challenging patients. In other practices, PAs and NPs see some of the physician's patients. Defining this role before you bring a PA or NP on board is important not only for the working relationship but also for patients and for billing purposes.
Hire the right person for you. The person with the best resume may not be the best person for you. Who do you need or want in terms of clinical experience or life experience? Will you do better with a new graduate you can train to work the way you do, or are you looking for someone with years of experience in primary care who can hit the ground running and care for a full panel of patients? Also consider whether the person's interpersonal communication and practice styles complement your own.
Check their certification. All PAs are educated and certified as generalists and take recertification exams in general medicine. Many NPs are educated as specialists (e.g., adult, pediatric, or women's health); only FNPs are trained to treat the entire spectrum of family medicine. To check PA certification, visit NCCPA.net. To check NP certification, visit AANPCert.org.
Make time for training. This is essential to developing a successful relationship with your new colleague. Whether your PA or NP is a veteran or newly certified, he or she will need orientation to your practice style and clinical preferences. Plan some time daily for the first few weeks so the new PA or NP can ask you questions and you can provide feedback on what you've observed that day. Your coaching may be as simple as saying, “That drug you prescribed for Mrs. Smith is an acceptable drug choice, but in our practice setting, this alternative might be preferable because ... .” It is important to discuss everything from individual style preferences to recommended specialists or community resources for referrals. If the PA or NP came from a different practice setting or specialty, you may need to provide orientation specific to family medicine, such as helping the PA or NP consider the current illness in the context of the needs of the whole person.
Adding a PA or NP will also necessitate some staff training. For example, your front desk staff will need to understand what types of problems the PA or NP can treat and should make sure patients are willing to see the PA or NP rather than the physician.
Implement a communication plan. It is important to inform your patients and staff of the PA's or NP's role, any areas of special interest, and how the PA or NP will supplement and enhance patient care. Provide the same information to patients that you would if you were introducing a new physician. You can publish the information in your practice newsletter, make a written introduction available in the exam room, and post a notice in the waiting room.
Take full advantage of their scope. Adding a PA or NP can be an opportunity to expand your practice with extended hours, add a new procedure that a particular PA or NP is interested in pursuing, or experiment with group appointments for patients with chronic illnesses. A PA's or NP's capabilities should not be viewed as competition but as an opportunity to expand access and improve care. Delegate as much as possible so that you and your PA or NP are working to the top of your licenses.
Negotiate call up front. PAs and NPs can help physicians share the burden of taking call at night and on weekends, making work-life balance a bit easier for everyone. Make sure call arrangements are negotiated up front.
Consider expanding your practice to a satellite office. Depending on your location, it may be helpful to place a PA or NP in a small satellite office to broaden access to patients. You can address any questions the PA or NP may have during the day via phone or electronic messaging.
Let certified PAs contribute to your maintenance of certification part IV requirements. Just as family physicians have to complete performance improvement activities to assess and improve quality in their practice as part of their recertification, PAs have the option to complete performance improvement CME for their recertification. Find a project where you can collaborate, and you can both get credit.
Continuing to lead
Given the reality of a perpetually shifting health care landscape, it is increasingly up to physicians to identify innovative approaches to patient care and to lead clinical teams in the delivery of the best care possible. This involves creating, developing, empowering, and managing the care team so its members can participate fully in the patient care process. PAs and NPs have a great deal to offer as part of this team. They can help physicians enhance patient care, expand access and services, create new revenue opportunities, and ultimately maximize clinical outcomes and improve the health of the population.