When contemplating a career in medicine as either a nurse practitioner (NP), physician assistant (PA) or physician, I entered unwittingly into a landmine of opinions tainted with undertones of interprofessional resentment. “Nurses spend more time with their patients,” some would say. Others would retort, “Physicians get the most in-depth experience with the sciences, which is necessary for patient care.” Or, as one PA explained with exasperation, “physician assistants receive the same medical-model of care education as physicians, but without having to deal with the hassles of residency. It’s obviously the best path because, really, who wants to deal with residency?”
The strong-arming among health professions starts with a one-upmanship battle over which path provides the appropriate level of training required to address patients’ health care needs. The American Medical Association (AMA) has often evoked language surrounding the extensiveness of medical training to diminish any efforts to expand NPs’ or PAs’ scope of practice. In response to an attempt to expand NPs’ scope of practice at VA hospitals, the AMA wrote, “[w]ith over 10,000 hours of education and training, physicians bring tremendous value to the health care team. All patients deserve access to physician expertise, whether for primary care, chronic health management, anesthesia or pain medicine.”
The American Association of Nurse Practitioners (AANP) and American Association for Physician Assistants (AAPA) use similar arguments about the unique educational training that they believe enables them to work autonomously. The AANP emphasizes the nurse-model education that allows for a patient-centered approach to health care, while the AAPA leans on their “intensive [educational training] … modeled on the medical school curriculum” noting that PA schools, unlike medical schools, require thousands of hours of clinical training as a prerequisite for matriculation. This debate heightened recently with the American Association of Nurse Anesthetists publishing a statement positioning CRNAs as the solution to issues affecting the healthcare system, causing a firestorm on forums like Reddit and a response from the American Society of Anesthesiologists decrying the statement’s “anti-team based message.”
These arguments are amplified by the siloed nature of our clinical educational system. Although my university has both PA and MD programs, there is no mutual acknowledgement between the two programs. Some days we work side-by-side to save a patient’s life. Other days we walk past each other and sit alongside each other in the libraries without recognizing our shared struggle to complete the intensive coursework and clinical training required to effectively care for patients.
The siloed nature of our medical training does not reflect the reality of the increased importance placed on a team-based approach to medical care. As healthcare moves away from a fee-for-service reimbursement system towards value-based care, hospital systems will increasingly place a premium on collaboration between various healthcare professionals to improve patient outcomes. While there has been success addressing social determinants of health through the partnership between allied professions, such as social workers and community health workers, and with physician-pharmacist collaborations, a search for articles and studies about effective collaboration between PA, NPs and MDs proved more difficult.
Results included terms like “challenges,” “barriers,” autonomy issues, and a slew of comparison studies between the professions (see here, here, and here) that focus on which field “does it better” than the other. Although comparisons among the fields may help us understand gaps in training, we should primarily focus our research efforts on best practices for improving NP, MD and PA collaboration, for the sake of the patients and their health outcomes. Studies that examine best practice team-based collaboration, such as this one, demonstrate that these fields working together can improve patient outcomes and satisfaction.
Given the dire need for an effective health care team that works seamlessly to provide care for patients, the “my level of training is better than your level of training” debate seems at best juvenile and, at its worst, dangerous to patient care. If we truly wish to do no harm and serve patients to the best of our ability, each health care field needs to be honest about its weaknesses and strengths. With this information, we need to develop best practices for collaboration intended to mitigate weaknesses and further sharpen strengths. This requires humility and a recognition that no single field holds all the tools to serving patients.
This also requires that various professional organizations work together on behalf of patients rather than on waging self-serving turf battles that may only result in heightened resentment amongst health care professionals. If we want effective change, we must honestly and unbiasedly lay out the pros and cons of various training paths to prospective students. Furthermore, medical students, PA students, NP students, social work students and other health professionals-in-training should study, take courses and work alongside each other whenever possible throughout the educational process. Early exposure to other fields has been shown to improve empathy and improve team based care.
As Robert Fulghum writes in his famous poem and book on the subject, all our major life lessons were learned in kindergarten. Despite the differences in training between professional fields, I think it is safe to assume that physicians, PAs, NPs and all allied fields have at least completed kindergarten. Therefore, to the AMA, AANP, AAPA and all the special interest health care lobbyist groups with long acronyms—let’s put our swords down, end interprofessional tribalism and focus on team-based approaches to improving patient outcomes … aren’t we all on the patient’s team, anyway?