Nurses and Physician Assistants: Make Nice and Get Along!

When you think health care, your gut reaction may be to think physician.  This election campaign has once again focused on a lack of family physicians.  You have probably heard NDP leader Jack Layton talking up the suggestion that as many as five million Canadians can't find a family doctor, as quoted in this report by the Fraser Institute on Canada's supply of physicians.  But stats like these miss an important development.  We're starting to see nurses and nurse practitioners (NPs) deliver primary and even specialist care.  More recently, physician assistants (PAs) have started to crash the party.  Turns out at least one provincial union of nurses doesn't like that one bit.

Today, according to a CBC News story, the group representing Ontario nurses said graduates of a new PA program in Ontario are not adequate replacements for trained nurses.  Doris Grinspun, the head of the Registered Nurses' Association of Ontario (RNAO), said Ontario should hire more NPs if it wants to boost healthcare in the province. Grinspun said she believes the training of PAs is inadequate to handle the complexity of what they're asked to do.

Let's back up a bit and explain who's who in this battle over healthcare turf.  NPs are registered nurses who have taken advanced postgraduate training (Master's or Doctorate level) that gives them a much wider scope of practice than the traditional RN.  Unlike RNs, NPs can make diagnoses, order tests and prescribe treatments.  Some provinces place restrictions on what tests can be ordered and what medications prescribed.  The key point is that NPs have an independent scope of practice that permits them - subject to their individual scope of practice - to act outside the authority of a physician.

Enter PAs.  Actually, the PA profession has been around in the US since the mid-1960s when severe shortages of family physicians meant looking for a new type of professional to fill the gap.  The initial ranks of PAs in the US were drawn from battlefield medics who acquired considerable field experience treating sick and wounded soldiers during the Vietnam War.  Nowadays, there are numerous accredited PA programs in the US, and a small but growing number in Canada as well.  The majority of PA training programs in the US and Canada are graduate programs leading to a master's degree.

Unlike the NP, a PA must practice under the direct supervision of a physician.  For that reason, PAs are sometimes referred to as 'physician extenders' because they enhance - but do not replace - the physician.  Under the current system in most provinces in Canada, the PA can't issue orders, perform invasive physical examinations or carry out procedures such as stitching cuts and setting broken bones without direct physician supervision. 

That doesn't satisfy RNAO head Doris Grinspun.  She said she's worried that supervision by a physician does not always require the physician to be physically on site. 

"Actually, the physician can be supervising over the phone," Grinspun was quoted by CBC. "Where are the clinical eyes and ears to support that judgment that these individuals will be making?"

If I could ask Doris Grinspun a question, I'd ask just what is it about PAs that has her so worried?  Is it patient care, or is it NP turf? 

I have a disclaimer to make.  I helped hire the PA who works in the ER at Mount Sinai Hospital under a pilot program set up by the province.  I also work with an NP who works at the ER as well.  I love working with both.  They have different abilities and different skill sets.  I recognize their individual talents and respect the differences in their scope of practice. 

Credentials aside, when we work together, an observer would be hard put to tell the difference. 

The fact is, when it comes to health care, we need to think less in terms of exclusivity and more in terms of the healthcare team.  From what I've seen, I'll take as many NPs and PAs as I can get without showing a preference for one or the other.

There are far too many patients for all of us to look after to worry about who got here first and who deserves the pride of place.  And that includes people like me. 

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