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Who's really in charge? Physician assistants and nurse practitioners are common in health care facilities. But how much responsibility do they have? If a patient is injured, you need to find out who - the midlevel provider, the supervising doctor, the facility, or all of them - is responsible.

Article Excerpt
Once upon a time, a person seeking medical care walked into a doctor's office, hospital, or clinic expecting to see a doctor who would perform the examination. Not anymore. Most patients seeking primary care today will leave the office, clinic, or hospital without ever being seen by a doctor. They will be examined, possibly get some tests and even a prescription or two, and be discharged with instructions from a midlevel provider.

The role of physician assistants and nurse practitioners--collectively called midlevel providers--in health care is growing. Once they gained statutory recognition and licensing, their ranks expanded to meet patient needs for health care--particularly in primary care, where physicians have become scarce. Health care facilities save money by employing midlevel providers to see patients in place of doctors, because the physician can bill for supervisory functions and still see and treat other patients. (1)

Not to be confused with medical assistants, who perform routine clinical and clerical tasks, physician assistants (PAs) are formally trained to provide diagnostic, therapeutic, and preventive health care services, as delegated by a physician. Working as members of a health care team, they take medical histories, examine and treat patients, order and interpret laboratory tests and X-rays, and make diagnoses. They also treat minor injuries by suturing, splinting, and casting. PAs record progress notes, instruct and counsel patients, and order and carry out therapy. In 48 states and the District of Columbia, PAs may prescribe medications.

Nurse practitioners (NPs) are independent advanced-practice nurses who provide ambulatory, diagnostic, clinical, and primary care. NPs have graduate education and clinical training beyond their preparation as registered nurses. They are licensed to practice in all states and in the District of Columbia under statutes that define their scope of practice. (2)

Clinically practicing physician assistants and nurse practitioners are always supervised by physicians, and the number of PAs or NPs one physician can legally supervise is limited by statute. (3)

Formal training of midlevel providers dates back to 1965, when the University of Colorado offered the first nurse practitioner courses and Duke University Medical Center offered the first physician assistant class. All states require NPs and PAs to complete accredited, formal education programs and pass national exams to obtain licenses.

Full-time PA programs last at least two years. Most programs are in schools of allied health, academic health centers, medical schools, and four-year colleges; a few are in community colleges, the military, and hospitals.

All states and the District of Columbia have legislation governing the qualifications or practice of physician assistants. All jurisdictions require PAs to pass the Physician Assistant National Certifying Examination, administered by the National Commission on Certification of Physician Assistants and open only to graduates of accredited PA education programs.

In 2005, more than 135 education programs for PAs were accredited or provisionally accredited by the American Academy of Physician Assistants (AAPA). More than 90 of these programs offered the option of a master's degree, and the rest offered either a bachelor's or an associate degree. Most applicants to PA educational programs already have a bachelor's degree. More than 325 colleges and universities educate nurse practitioners, and more than 115,000 NPs practice across the country. (4)

Now, in the 21st century, midlevel providers' domain has expanded beyond primary care to every aspect of health care delivery in the United States. PAs and NPs practice not only in primary care specialties, such as general internal medicine, pediatrics, and family medicine, but also in areas such as emergency medicine, obstetrics, and geriatrics. PAs specializing in surgery provide preoperative and postoperative care and may work as first or second surgical assistants. (5)

The problem

While the increased use of midlevel practitioners has had many salutary effects, extending access to health care and ostensibly relieving physicians...

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