If you want to work as a mid-level practitioner, you have two choices: nurse practitioner or physician assistant. Nurse practitioners work under a nursing model, while physician assistants practice under a medical model. Both career tracks are rewarding and both have pros and cons.
The differences between the medical model and the nursing model have been hotly debated for years. As you’re making a decision about the direction you want your career to take, let’s examine the differences and similarities in the models of care, and the way they may impact your practice.
Models of Care
Both professions began in 1965 and have similar histories. They both developed as a master’s program in response to a need for a greater number of healthcare providers in primary care. But here is where the similarities diverge. One developed under the umbrella of nursing care and the other was developed under a medical model.
Your model of care helps define the care you give to your patients. Although both mid-level practitioners focus on establishing and providing excellent patient care, the underlying philosophy of (and approach to) care is different.
What Is the Nursing Model?
In 1965, Dr. Loretta Ford and Dr. Henry Silver developed the first program for nurse practitioners at the University of Colorado. By 1979, there were 15,000 nurse practitioners in the U.S. and nearly 200 programs available. By 1999, there were approximately 68,300 nurse practitioners, and by 2018, the number more than doubled to 248,000.
The nursing model of care, which nurse practitioners follow, is based on nursing theory. This is a framework that defines what nurses do and why they do it. These principles guide the nursing practice. Nursing theory includes the nursing process, which provides the steps nurses use to care for patients. The steps in the nursing process include assessment, diagnosis, plan, implementation, and evaluation.
Under the nursing model of care lay several sub-models of care, including the family-centered model, the patient-centered model, the primary care model, and the chronic care model. Nursing theory and the nursing process are the keys to every model of patient care. While they appear to be the same as a medical model, the underlying focus is slightly different.
Holistic Approach
At the very core of the nursing model is a focus on the whole person, including their social circle and support system. The initial emphasis on diagnosis really focuses on how the symptoms or conditions will affect the individual, their ability to remain independent, and their support system. The nurse practitioner considers how the plan and implementation of care will affect the individual, taking into account the person as a whole.
Additionally, a nurse practitioner in primary care is focused on health promotion and disease prevention. Once the presenting condition is treated, the focus is on sharing information to help individuals make smart and healthy lifestyle choices. The goal is to use a holistic approach.
Ultimately, patient care is based on an education of disease processes and evidence-based practice, integrating family-centered and patient-focused primary care. In the real world, this means a treatment plan may be altered to fit the individual’s needs and desires (after they have a full understanding of the consequences of their decision).
What Is the Medical Model?
In 1965, Dr. Eugene Stead from Duke University Medical Center was the first to put together a class of physician assistants. By 1980, the American Academy of Physician Assistants’ membership was nearly 7,000. By 1995, there were 61 accredited programs, 4,850 PA students, and over 29,000 graduates. By 2019, the number of accredited PA programs quadrupled reaching 254.
Physician assistants are educated in the same method and manner as doctors, and both healthcare professions use the medical model.
When the PA program was first developed in 1965, it was a straightforward approach to the medical model. The goal was to provide patient care based on the disease process without considering the psychosocial ramifications. However, that soon changed.
By the late 1960s, George Engel, an internist and psychoanalytic psychiatrist from the University of Rochester, began critiquing the medical model of care. His critiques brought focus to the traditional approach that assumed health is the absence of disease. This disease-focused model of care left no room for social, psychological, or behavioral elements.
Engel proposed broadening the medical model to include psychosocial factors. If patients provided additional information, physicians could evaluate all factors contributing to a person’s illness.
Despite some criticism of the model, it reached mainstream acceptance, shifting the traditional medical model from an “absence of disease” to a broader understanding of health and wellness.
Disease-Focused and Evolving
Physicians and physician assistants are educated to seek out the basis of the disease process first. They employ an emphasis on pathology, biology, assessment, diagnosis, and treatment of a single symptom or disease process. This set of principles has defined the breadth and scope of practice with a primary focus on disease.
Even though the primary focus is on the disease, the medical model definitely takes into account a broader understanding of health and illness. That’s why, in your PA practice, you have the option to add prevention information, health education, and counseling.
Scopes of Practice
The medical model and the nursing model have significant similarities and differences in their views on patient care. And those similarities and differences continue to change with each passing year.
However, your scope of practice is not really defined by the model of care. The scope of your practice is actually defined by your state’s medical board and your supervising physicians for those states that mandate them.
In the past decades, events have raised the complexity of clinical practice and patient populations. This has impacted the arrangement of the healthcare system, including raising the value of mid-level practitioners and expanding their scope of practice. From a patient care standpoint, the role of the NP and PA may look similar, but the scope of their practice differs from state to state.
Nurse Practitioner Care and Scope of Practice
Nurse practitioners have lowered the overall cost of healthcare. Those getting primary care from an NP have fewer visits to the emergency room and shorter hospital stays. Nurse Practitioners also have comparable patient care outcomes when measured against physicians’. Patients who saw an NP had fewer medications prescribed, were less likely to suffer falls and had improved functional status.
Nursing State Law and Regulations
Since state medical boards do not regulate nurse practitioner practices the same across the U.S., it is imperative you understand the laws and regulations that impact your practice. There are three levels under which an NP may practice: full practice, reduced practice, and restricted practice.
Full Practice
Under full practice the law allows you to evaluate, diagnose, interpret tests, start treatments, and manage treatments (including medications and controlled substances). This happens under the authority of the State Board of Nursing without a supervising physician. As of April 2020, there were 23 states, plus the Federal district of D.C., where an NP has full practice capability.
Reduced Practice
Under this licensure, the NP is limited in at least one element of practice. If you practice under this license, you are required to have a collaborative agreement with another healthcare provider to furnish care. If you don’t have that agreement, the law limits the setting in which you may practice. There are 16 reduced practice states and the majority are in the northeast.
Restricted Practice
Under this licensure, the law restricts at least one element of practice AND requires supervision, delegation, or team management by another health provider. California is the lone restricted practice state in the western U.S. There are 12 states that enforce restricted practice for NPs.
Physician Assistant Care and Scope of Practice
As we’ve covered in the past, the day-to-day activities of a physician assistant are much the same as a nurse practitioner or physician. However, while NPs focus on primary care, as a PA you’re able to do procedures. Depending on your specialty, you may also assist in surgery.
Medical State Laws and Regulations
The scope of practice for a physician assistant may be defined by the state medical board. Therefore, it’s necessary to be sure you know the law in the state where you practice. According to the American Academy of Physician Assistants (AAPA):
“Although there is some variation in state law, the majority of states have abandoned the concept that a medical board or other regulatory agency should make decisions about scope of practice details for individual PAs. Most states allow the details of each PA’s scope of practice to be decided at the practice level.”
However, the physician assistant has another hurdle to independent practice: the American Medical Association (AMA). While PAs are highly valued and sought after, AMA policy states:
“…physician assistants should be authorized to provide patient care services only so long as the physician assistant is functioning under the direction and supervision of a physician or group of physicians.”
Education Requirements and Clinical Experience
To practice as an NP or PA, you must get your master’s degree, but each program’s preparation is different. Additionally, education is based on the model of care under which you will eventually practice. So, suffice to say, nursing school and PA school curriculums vary.
Nurse Practitioner Education
A nurse practitioner begins their education with a Bachelor of Science in Nursing (BSN). This offers a general education in nursing, after which a nurse usually chooses a specialty through on-the-job training and continuing education. Most nurses choose to practice as a registered nurse (RN) for several years. This offers healthcare experience before moving on to a master’s degree in nursing (MSN).
The master’s program is 2 years long and is specialty-specific. In other words, your classroom education and clinical rotations are based on specialties However, the nurse practitioner usually plays a role in the office setting for surgical specialties, such as cardiovascular and orthopedics. The physician assistant is also trained to assist during surgery. Specialties a nurse practitioner may enter include:
- Pediatrics
- Acute Care
- Midwifery
- Family Practice
- Women’s Health
- Gerontology
- Emergency Medicine
- Neonatal
- Oncology
- Adult Psychiatric/Mental Health
- Family Psychiatric/Mental Health
Once you graduate as a nurse practitioner, you sit for a certification examination in your specialty area. Re-certification and continuing education credits are dependent on the specialty and the state where you practice.
Physician Assistant Education
A physician assistant’s education also begins with a bachelor’s degree. Some schools offer a pre-PA program and others allow PA candidates to choose to follow a pre-med track or major in one of the biological sciences, such as biology or physiology. Before applying to a PA program, you must have 2,000 hours of healthcare experience.
Physician assistants may choose to get their healthcare experience in a variety of fields, such as an EMT, Paramedic, Medical Assistant, EKG technician or respiratory therapist.
Your PA program is broad-based. Students receive a general medical education over 24 to 27 months. This includes class time and clinical training. The program is rigorous and challenging. Once you graduate, you must sit for a certification examination in order to practice as a PA-C. After becoming certified, you’re required to get 100 continuing medical education (CME) credit hours every 2years and be recertified every 10 years.
Becoming a Well-Rounded Provider
If you choose to become a PA or an NP, you’ll be prepared to offer quality patient care. The choice you make will depend on how you want to focus your career. Nurse practitioners are educated in a specialty and may be able to practice independently, depending on the state where you live. PA education is broad, which allows you to change specialty during your career.
Whether you choose to practice as an NP or PA, it’s gratifying to know both professions have reduced the use of acute care services and lowered costs in those who have chronic diseases, such as diabetes. And both professions are helping to meet the growing demand for patient care during a physician shortage. Whichever path you choose, you must focus on becoming a well-rounded provider to ensure patients and your community are offered the best care possible
