The need for more medical providers: the ABCs of PAs and NPs

Physician assistant David Wood, right, performs an exam on Joe Suttles at KVH Family Medicine in Ellensburg, Wash.

Physician assistant David Wood, right, performs an exam on Joe Suttles at KVH Family Medicine in Ellensburg, Wash. Yakima Herald-Republic photo by Kaitlyn Bernauer


Physician assistants and nurse practitioners can see patients, prescribe medication and treat the majority of complaints or illnesses that people go to their doctor for. In Washington state, they are nearly or entirely independent of licensed physicians.

And with tens of thousands more people here newly covered by health insurance, their services are expected to be in demand more than ever.

That’s why two new programs are starting this year in the Yakima Valley to educate and train advanced-practice clinicians, as physician assistants and nurse practitioners are called. Heritage University is starting a two-year physician assistant degree program, and Yakima Valley Farm Workers Clinic will be hosting a yearlong nurse practitioner residency.

“We’re getting to the point now where a lot of the physician assistants who have been in practice for 30 years are wanting to retire. ... It’s just going to be an unrelenting need for more health care providers,” said Linda Dale, director of Heritage’s new program.

Heritage leaders announced the new program a few weeks ago, but first started talking about it in 2008. The first class of 32 students will start May 16.

Dale’s a PA herself, and taught at the University of Washington MEDEX Northwest physician assistant program until 2007. The UW closed the local branch last year, but even when MEDEX was here, she said, it didn’t turn out enough physician assistants to meet the needs in the Yakima area.

Physician assistants essentially go through the middle two years of a four-year medical school: They get one year of intensive classroom education, and then one year of clinical rotations, where they’re seeing patients and prescribing medications. They complete 120 credits in two years and graduate with a master’s degree.

Once they’ve graduated, physician assistants can go into virtually any medical field or specialty, but must work under the supervision of a licensed medical doctor (MD) or osteopathic physician (DO). Depending on the field, they may require very little contact with or help from their supervising physician.

Nurse practitioners perform nearly identical services, but can own and operate independent practices without physician oversight. (The alternate titles of “advanced practice registered nurse,” or APRN, and “advanced registered nurse practitioner,” or ARNP, refer to the same thing.) Nurse practitioners must first be licensed as registered nurses, then complete a nurse practitioner master’s degree, which can take two to four years depending on the program. Many nurse practitioners have gone back to school for the degree after working as registered nurses.

Dale said the two disciplines approach training and education differently: Nurse practitioners have about 800 hours of clinical training in their chosen specialty, while physician assistants must complete about 2,000 hours, though it’s more generalized, like family medicine tends to be. Physician assistants, like doctors, focus more on procedures; nurse practitioners, like nurses, are more patient-centered with an emphasis on care plans.

Farm Workers’ residency was built on a program from the Community Health Center in Connecticut. The center has started 14 programs so far using its model, though the Farm Workers residency will be its first remote site, along with a similar program at Columbia Basin Health Association in Grant County.

A residency isn’t required to become a nurse practitioner, like it is for doctors, said Kerry Bamrick, program manager in Connecticut. But it’s helpful as a transition from school to the real world.

“The nurse practitioners that are applying to the program are those who are truly committed to working as a primary care provider in a complex setting, really want to serve the underserved population. ... They choose primary care when they’re in school, and are then deterred by the (federally qualified health center) setting,” she said.

Farm Workers’ local program director Graciela Lopez agreed. When nurse practitioners jump straight into community clinics like Farm Workers, they can be overwhelmed by the patient complexity and need.

“You do get burned out, especially with a population that has a lot of needs versus a better-served population,” she said. The residency “allows more time for the nurse practitioner to get more comfortable.”

Currently, Farm Workers employs 56 nurse practitioners and physician assistants. The new residency will have three paid, full-time, 12-month positions, starting in September. The residents will have one classroom session each week, then the majority of their year will be spent seeing patients, either in four-week specialty rotations, independent clinic days, or in “continuity clinic” days, where the residents see their own panel of patients while an established provider looks on as a preceptor.

In their second year at Heritage, PA students will spend two or three days a week in a family medicine practice, and rotate the other days through specialties like emergency medicine, mental health, obstetrics and surgery.

The two programs say they are not in competition, however.

“It’s just all hands to the oars,” Dale said. “From my point of view, we have to train as many as we can to help provide health care. It’s going to get worse before it gets better.”

David Wood is a PA at KVH Hospital in Ellensburg, the first to be hired as a hospitalist there, where he cares for patients sick enough to require hospitalization. The KVH system employs about 12 advanced-practice clinicians, he said.

After working as an Army medic, he chose physician assistant school for the flexibility it offered compared to medical school. He could go into any practice without having to complete a separate residency. But flexibility didn’t mean it was easy.

“The core content of PA school isn’t much different from medical school; it’s just the length of time you have to learn it,” he said. “It’s like drinking out of a fire hose.”

Advanced-care practitioners can help ease the primary care shortage nationwide, and training programs should act accordingly, he said.

“You can train a physician assistant a lot quicker than you can a family doctor. ... There’s definitely still a need for more training programs and more physician assistants,” he said. “The beauty, I think, of being a physician assistant — there’s really no limit of what we can do. As long as we’re working with a physician collaboratively, it’s an open door.”

He doesn’t see advanced-practice clinicians fully replacing doctors, but they should definitely be working to the maximum extent of their training in order to take full advantage of their skills.

“For 99 percent of patients I see, I handle exclusively their problems,” he said. And on cases he has questions about, his supervising physician is usually right there with him. “We’re really finding a more level playing field now in respect and how we’re treated.”

Lopez said PAs and NPs complement to physicians, but they’re still not the same.

“I think definitely the training and knowledge that physicians have is more in depth than what midlevel providers have right out of school,” she said. “I think as the need for health care grows, I think advanced practice clinicians are a good option to keep up with the pace. But I don’t know that the trend would go exclusively to advanced practice clinicians.”


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