Introduction

Reviews

When the "Doctor" Isn't a Doctor

Nurse Practicioners and Physician Assistants

Timothy B. McCall, M.D.

When you visit many HMOs and other clinics for a checkup, the chances are the person in the long white coat examining you, ordering tests and handing you a prescription is not a doctor but a nurse practitioner. Nurse practitioners are registered nurses having completed four years of undergraduate nursing school who receive extra training in primary care. There are currently about 50,000 of them in the United States. HMOs use nurse practitioners to save money, since their average pay is around $40,000 per year.

Because they have much less training than primary care physicians—typically nine to 24 months after college compared with seven or eight years for doctors—nurse practitioners cannot be expected to manage some complex medical problems. They may handle more common problems like sore throats and bladder infections and manage some chronic diseases as well or better than some physicians. Due to their training as nurses, many of them practice a more personal brand of care and place more emphasis on prevention than most doctors. On average, they spend 50% longer with patients. In studies, nurse practitioners consistently score better in patient satisfaction than doctors.

As with doctors, the quality of nurse practitioners varies. Since the field is relatively new most of them will be up-to-date. The key thing nurse practitioners must know is when they have sufficient knowledge and skills to handle a situation and when they need help. Ideally, in my opinion, nurse practitioners should work in close collaboration with primary care doctors.

Many HMOs and private doctors’ offices also employ physician assistants (PAs) to function in roles essentially indistinguishable from those of nurse practitioners. The typical PA program requires students to have completed the equivalent of two years of college for admission, although many students enter with undergraduate degrees. PA programs average around two years, the first half devoted to book studies, the second to physician-supervised clinical training.

Whereas nurse practitioners study in nursing schools which place greater emphasis on a holistic approach to patients, the training of PAs more closely resemble a Reader’s Digest version of medical school. PA programs are usually affiliated with medical schools and physicians do most of the teaching. The values and biases of PAs therefore end up being more like those of physicians than those of nurse practitioners. PAs, for example, spend about the same amount of time with patients as do physicians.

There are currently around 25,000 PAs practicing in the United States. Every state except Mississippi recognizes them. Their average annual salary is over $50,000. Since their training is often less than one fourth as long as physicians, PAs have many of the same limitations in their knowledge and skills as nurse practitioners. Unlike nurse practitioners who sometimes work independently of physicians, however, PAs must work at all times under the close supervision of doctors.

Many times when you call up for an appointment at an HMO you will be told that the doctor’s schedule is filled for the next few weeks but that you could get an appointment earlier with a nurse practitioner or a PA. You’ll have to decide how comfortable you feel with that, depending on the nature of your problem and how quickly you need to be seen. For a problem that involves counseling and advice such as when you’re trying to quit smoking or when you’re under a lot of stress, you may prefer to see a nurse practitioner. Other times you may want to hold out to see your doctor.

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