Respect Show

Nurse practitioners (NPs) are registered nurses who take Masters or Doctoral training that permits them to make diagnoses, order tests and prescribe treatments - subject to restrictions that vary with the provinces - without being supervised by a physician.  Physician Assistants (PAs) are yet another kind of health professional making inroads into health care.  PAs also receive Master's degrees at Canadian universities - and can be trained to do anything from stitching cuts to assessing patients and assisting surgeons in the operating room. 

But unlike NPs, PA's can only work under the direct supervision of a physician.  Picky difference?  Not if you're jockeying for a place in health care system, as NPs and PA's increasingly are these days. Both are looking for respect from each other, the health care team and you.  But to get that, you have to make people understand how you differ from everywhere else.  

I had a fascinating conversation on the roles and public perceptions of NPs and PAs with Laura Servage, a doctoral student at the University of Alberta who focuses on post-secondary education and how that applies to health care.  She's a keen observer of "who's who in the hospital zoo".  Most important, she calls it as she sees it because she isn't tied to any vested interests.  Some of her observations are both startling to me and likely threatening to some.  I asked her about the emerging role of NPs and PAs in the health care system.

"They are essentially competing for the same position within that system," she told WCBA.  "They're competing for a certain level of status.  They're competing to own a body of knowledge and skills that will be highly valued within the system."

"They won't tell you that," she adds.  "But that's what it really comes down to."

 So, how important is it that NPs can practice independently of physicians while PAs cannot?  That depends on who's asking, says Servage.

"As a physician, you want somebody who will - I don't wait to call it that - do your bidding," says Servage. "They want somebody who will extend the work that physicians do without fundamentally challenging the physician's approaches to the care that they give."

On the other hand, Sevage argues that nurses and physicians have traditionally held different views regarding patient care.  She says it's critical to understand those differences when considering why nurse practitioners might feel it important to have an independent scope of practice.

"If a physician works with an NP with an autonomous scope of practice, there's a lot more room to butt heads there," says Servage.

 The social scientist notes that nursing organizations have been drawn into the conflict between NPs and PAs.

"You've got a little bit of squabbling with nurses defending the nurse practitioner role versus these upstart physician assistants," she told WCBA.

"They're saying that PAs don't have the same education.  They're quite right, and I think they're making the case that on balance NPs have greater expertise and education and are more qualified to do this work."

"That's a way of saying the NP is the bigger fish in the pond."

To an expert who takes a bird's eye view of health care, the actual differences between NPs and PAs don't seem quite so important.

"Let's say there's a legitmate place in health care for somebody who is not quite a doctor but is more than a nurse," says Servage.  "We could say in a lot of ways that physician assistants and the nurse practitioners are competing for this position just underneath the doctor."

Servage believes it's important for the public care to be aware about the jockeying for position because she thinks it's damaging to the effectiveness of the health care system.

"This competing for status doesn't make us look at the real issues in terms of patient care," she concludes.  "I see lots of room in the system for both NPs and PAs as excellent innovations. 

Servage believes that a rational health care system would look at the number of orphan patients in Canada and try to find as many ways as possible to serve them. 

"And yet, we have these odd, irrational, status-driven symbolic dynamics," concludes Servage.

I think Laura Servage is right.  Understanding that jockeying for status doesn't help patients is one thing.  But dealing with it is another.  One way is to increase the competition.  Let them all practice and you can decide which of MD, NP or PA you prefer. Another way is to work within the system - patiently explaining what you do - until you earn the respect of your competing colleagues.

I'll have more to say about that in my next blog.

Happy Thanksgiving!