Let’s uncover the key differences and similarities between Physician Assistants and Nurse Practitioners to better understand their unique roles in healthcare.
Physician assistants and nurse practitioners are both Advanced Practice Providers (APPs) or “mid-level practitioners” who hold specialized degrees and are licensed to diagnose and treat medical diseases. Each program was founded during the 1960s as a means to expand healthcare access to an underserved population. Since its inception, both have developed exponentially and currently are amongst the fastest-growing professions in the United States. Now cemented as professions, they are an integral part of the modern healthcare structure in all 50 states.
With an aging population, a looming physician shortage, and the overall increasing complexity of medical care, the need for mid-level providers is more crucial than ever. Filling in gaps left by physicians, nurse practitioners, and physician assistants have taken on prominent roles to continue providing quality care by expanding attainability, alleviating physician workload, and reducing the burnout burden. All this equates to more time for physicians to donate to highly complex and sub-specialized care.
The similarities between physician assistants and nurse practitioners often lead to the idea that they are interchangeable positions. While it is true they compete for similar jobs and perform comparable clinical responsibilities, there are important differences that need to be recognized
Education and Licensure:
The initial fundamental separation between a physician assistant and a nurse practitioner begins with education. Each program offers a master’s degree, however the curriculum is substantially different.
The nurse practitioner program focuses on the nursing model or a holistic approach to the wellness of a patient. This initially includes preventive medicine and later, how a medical condition affects the patient and their support system. There is less reliance on anatomical or pathophysiologic causes of disease, and more focus on nonphysical elements, such as spirit and emotions, and how they interact with the body to cause ailment. Students are required to complete 1,000 hours of supervised training and they choose to focus on ONE SPECIFIC health population (Family, Adult/Gerontology, Neonatal, Pediatrics, Women’s Health, or Psychiatric/Mental Health) as well as CARE SETTING (inpatient/acute or outpatient). The program can be done part-time.
The physician assistant program utilizes the medical model of training similar to medical school. Considered a disease-specific approach, the human body is viewed as a complex mechanical system with abnormalities of anatomy, biochemistry, and physiology causing medical conditions. Students are trained to utilize clinical sciences and an emphasis on pathology to assess, diagnose, and treat. They need to complete 2,000 hours of supervised training in SEVERAL disciplines including family medicine, internal medicine, general surgery, pediatrics, obstetrics and gynecology, emergency medicine, and psychiatry. Educated as medical generalists, they learn skills in all areas of medicine and for all patients, regardless of age or gender. The program is only full time speaking to its rigorous nature. There are postgraduate fellowship programs available in most subspecialties of medicine and surgery to further advance training and experience.
Following graduation and licensure, both professions need to continually recertify to maintain the ability to practice. Nurse practitioners need to complete 100 hours of continuing education (CE) and 1,000 clinical hours every FIVE years. There is NOT a required recertifying exam. Physician assistants are obliged to complete 100 hours of continuing medical education (CME) every TWO years and pass a recertifying exam every 10 years.
Scope of Practice
Ultimately, the model of education and recertification requirements do not define the scope of practice. This is done by each state’s legislature and is the second biggest difference between the professions. Nurse practitioners DO have the ability to independently practice without supervision in 27 states under the authority of the state board of nursing. They have restricted and reduced practice authority in the other states and require a collaborative agreement or supervision by another healthcare provider. Physician assistants need to practice under the direction and supervision of a physician. They have recently been pursuing optimal team practice (OTP) or a system where physician assistants, physicians, and other healthcare professionals work together to provide quality care without burdensome administrative constraints.
The American Academy of Physician Associates defines Optimal Team Practice as a way to eliminate the legal requirement of a relationship between the physician and physician assistant:
“Physician Assistants can practice to the full extent of their medical education, training, and experience. PAs continue to collaborate, consult, and refer to the healthcare team’s appropriate member(s) as indicated by the patient’s condition, the PA’s competencies, and the standard of care. The healthcare team, and/or their employer, may establish guidelines for collaboration, consultation, and/or referral beyond state laws and regulations”.
Physician assistants currently have independent practice authority in 3 states: Wyoming, North Dakota, and Utah. In all other states, a physician must supervise a physician assistant, as well as nurse practitioners in the states where they do not have independent practice capabilities.
Role of the Supervising Physician
In regards to physician assistants, a physician may supervise up to four physician assistants. They do not need approval from the state board to perform this task.
The physician and physician assistant create a PRACTICE AGREEMENT where the supervising physician oversees and accepts responsibility for the medical services rendered by the physician assistant. The physician MUST be available by telephone or other electronic communication at the time the physician assistant is evaluating a patient, however, does not need to be on-site.
The practice agreement is a legal document that includes the following provisions:
- The supervising physician has evaluated the education, state licensure, experience, knowledge, and competency of a physician assistant before allowing them to practice.
- It addresses the types of medical services the physician assistant is authorized to perform. This includes the ability to perform surgery under anesthesia.
- Establishes policies to ensure adequate supervision of the physician assistant during procedures.
- Allows authorization to prescribe medications including class II-V controlled substances. A physician assistant must register with the Drug Enforcement Administration (DEA).
- Requires the physician to be “immediately” available during a surgical procedure requiring anesthesia.
- Delegates the supervisory position over medical assistants and other office staff to the physician assistant when the physician is not on site.
- It mandates the physician must co-sign a specific percentage of orders and charts from care delivered by the physician assistant. Typically this is 10%. Initially, a method to objectively verify physicians were overseeing physician assistants, this policy no longer is required by most states given the historic success of collaboration between physicians and physician assistants.
Work Environments and Specialization
A THIRD key difference between nurse practitioners and physician assistants revolves around the work environment and specialty practices. Nurse practitioners are trained in advanced roles for a specific patient demographic, such as neonatal nurse practitioner, family nurse practitioner, or adult-gerontology nurse practitioner. They obtain certifications within these specialties and can NOT switch to a different field or level of patient acuity (medical office versus hospital) without acquiring more formal education and licensure.
Physician assistants, on the other hand, are trained as generalists under the medical model. Through their education, they acquire knowledge in all the foundational aspects of medicine and surgery, thereby allowing them to transition to different specialties or work environments without the need for further training.
Salary and Career Outlook
Given the similarities of the roles and the rising demand for healthcare providers, the future for both professions is bright. They both consistently rank in the top 10 overall jobs per the U.S. News and World Report which rates a profession based on salary, work-life balance, job satisfaction scores, and prospective growth.
The U.S. Bureau of Labor Statistics reported the following statistics from 2022:
Physician Assistant | Nurse Practitioner |
Median Annual Salary: $126,010 | Median Annual Salary: $125,900 |
Job Outlook (until 2032): 27% growth | **Job Outlook (until 2032): 38% |
Additional Jobs: 39,300 | **Additional Jobs: 123,600 |
**also includes projected positions for nurse midwives and nurse anesthetists
Impact on Patient Care
At the advent of the physician assistant and nurse practitioner professions, there was fear amongst physicians that mid-level providers would impinge upon their jobs as well as negatively impact the level of care delivered to patients. Numerous studies have debunked these ideas and overall, the research has helped formulate more progressive thinking of how to utilize physician assistants and nurse practitioners in roles that can reduce medical costs, share patient workload by acuity, and recruit providers to areas of need.
By achieving their degree in a shorter time frame, physician assistants and nurse practitioners can more quickly enter the workforce and begin treating patients. This alleviates the physician shortage in healthcare organizations. Additionally, this labor increase comes at a financial benefit considering the discrepancy in pay between physicians and mid-level providers. Often seeing similar patient loads, physician assistants and nurse practitioners can generate significant revenue at a reduced expense. Furthermore, physicians would now have more time to dedicate to higher-grossing procedures and services.
This scenario of production can accommodate the increasing patient population plagued with chronic disease while maintaining a high level of patient satisfaction. Typically attributed to improved access, increased time spent with the patient, and better health education via answering questions, physician assistants and nurse practitioners exceed in these areas. The generalist education of a physician assistant is especially helpful given their versatility to assume many different positions and expand clinical services without the need for further certifications. This can include walk-in clinics, providing surgical procedures, or having the flexibility to care for patients in other specialties. Overall, physician assistants and nurse practitioners complement, rather than impede, physicians to improve healthcare for the general public.
Legal and Malpractice
Physician assistants and nurse practitioners can, and do, get sued. It is incorrectly assumed that since the physician assistant, and typically the nurse practitioner (the majority do not practice independently), are supervised by a physician then it is not their responsibility if an error occurs. Although logical, there are exceptions. If a mid-level provider consults their supervising physician and fails to carry out orders or the medical plan, then they are liable. Additionally, in a malpractice suit, several providers can be named, especially if they are directly involved in the care of the patient. Therefore, physician assistants and nurse practitioners need insurance.
The cost is often covered by their employer which begs the question if this negates the cost-effectiveness of mid-level providers. It would depend largely on whether physician assistants and nurse practitioners had more malpractice suits targeted at them. Jeffrey Nicholson (PA-C, PhD) and the American Academy of Physician Associates conducted a study of malpractice and safety comparing PAs to physicians and nurse practitioners. Examining 17 years of data, the abstract proved physician assistants are not more likely to make significant medical errors warranting a malpractice suit.
My Choice
A student has the option to choose which path they want to take based on the direction of the field’s education and each state’s practice laws. For me, the decision was based on the following:
- The medical model was more appealing as it is not truly limited to disease-specific training. Students learn social, behavioral, and psychological elements as well as how to interact with ancillary medical staff, like therapists, to provide full care.
- The physician and PA share a familiarity enabling improved communication and collaboration.
- -Working under physician supervision, physician assistants can expand the limits of practice beyond independent nurse practitioner restrictions, including being the first assist for surgeries.
- The “more is better” philosophy: physician assistants are required to do more clinical hours and take more medical classes. Additionally, they offer post-graduate fellowship programs to continue training. All this translates into more experience and improved patient care.
- Physician assistants are educated in ALL areas of medicine and patient populations with a focus on anatomy and pathology as opposed to a limited scope of training for nurse practitioners. Given the complexity of medicine, having a streamlined clinical science and patient cohort education seems insufficient.
- More job opportunities for physician assistants given their diverse background of training including the setting (outpatient, inpatient, acute) and different specialties.
- Medicine is dynamic and constantly progressing. To stay up to date, having more frequent continued education as well as the need to recertify by exam, is important to provide modern evidence-based care.
The optimal team approach is gaining ground and offers an exciting future for physician assistants where independent practice in the majority of the United States is a possibility.
Conclusion
In summary, physician assistants and nurse practitioners are both valuable assets to the healthcare industry with an excellent job outlook, high salary, and quality life-work balance. Although they often occupy similar roles, there are foundational differences between the professions and they are not identical. The distinctions lie within education and training, as well as the type of available work environments and flexibility to specialize.