Introduction 
Comparing notes with an NP educator/clinician at a national consultants' meeting inspired this veteran PA to consider ways the 
PA and NP professions can team up to address their shared challenges.
 

For me, this has been an exciting two years. I've had the opportunity to travel to sites around the country, comoderating at national consultants' meetings for a major pharmaceutical company. It was great to meet and befriend so many practitioners from so many places. 

This also was my first chance to meet Margaret Fitzgerald, MS, APRN, BC, NP-C, an NP educator and practicing clinician-and my comoderator. Margaret and I enjoyed the opportunity, together with some of the meeting participants, to dismantle many of the walls that exist between the PA and NP professions. Throughout our dialogue, I was reminded that we share common dilemmas and common opportunities-and reflected that together, we can find common solutions.

Our Shared Dilemmas
NPs and PAs share the issue of credibility, thanks to our powerlessness to be properly tracked by the pharmaceutical industry. How can we be credible when so many pharmacists unilaterally override us as the prescriber?

Apparently, doctors experience this, too. I recently had a prescription filled at a chain drug store. Printed on my medication bottle, to my amazement, was the name of the first physician on the prescription slip-not the name of my cardiologist. The pharmacist had not made this choice because of a bias about my cardiologist's credentials (she is not a PA or an NP), and hopefully, not because of her gender; it was simply because another physician was listed first on her prescription pad.

We first addressed this issue at the 1994 Clinicians' Conference in Connecticut, but to this day it remains a seemingly insurmountable problem. Would it be possible for our two professions to take on this issue-and perhaps come up with a satisfactory solution? Remember, there is strength in numbers.

Our reimbursement problems, too, persist. I applaud the American Academy of Physician Assistants for its fine work in getting PAs approval for Medicare reimbursement-and the American Academy of Nurse Practitioners, the American College of Nurse Practitioners, and other NP organizations for diligently pursuing these matters on behalf of NPs. Yet until we have universal reimbursement, until every insurance company in the land is mandated to pay for services provided by an NP or a PA, then we remain restricted and our professions are weakened.

This coming year will bring increased malpractice insurance rates for both PAs and NPs. Here, because of dramatic increases in our numbers, our patient loads, and our vulnerability, we shall share a fate similar to that of our physician colleagues. 

The Opportunities
During the rapid metamorphosis of health care, each new challenge can be translated into an opportunity to promote ourselves and extend our overlapping roles. The burden of higher malpractice insurance premiums has impacted all of us-particularly the ob/gyn physicians. There is an acknowledged need for tort reform and a lowering of the malpractice ceiling. And yet, at the same time that we "nonphysician" clinicians partner with our physician colleagues to help, we must also consider the opportunity this situation presents. For instance: In cases where NPs and PAs share insurance companies, perhaps we could offer to help create a top-notch risk reduction course or program that will include a 10% premium reduction for each PA or NP who attends it.

With the growing shortage of physicians and declining enrollments in medical schools, a dark cloud is forming on the horizon. Like Dave Mittman, publisher of this journal (and my contemporary, friend, and colleague), I shudder to look into the crystal ball. There, 20 or 30 years in the future, we see ourselves sharing a geriatric suite at University Medical Center. Who will be caring for us, and with what credentials? Will they be compassionate toward us in our motorized wheelchairs, or will they consider us a burden? And who will be staffing critical care areas? Will their roles change? Clearly, we must move together toward a vision of health care as we hope to see it!

An additional opportunity arises with the proposed maximum 80-hour workweek for physician residents. It will be nice for residents to "have a life," but they will pay for it in experience-or the lack thereof. I can only reflect on my personal knowledge in surgery and emergency medicine; but after you've worked grueling hours and been pressed to the max, it's that ruptured abdominal aortic aneurysm at 3 AM that defines you and shows just how far you can really go. I've been there; I've felt that adrenaline surge. And I've found within myself the ability to run yet one more mile-to find gold at the end of the rainbow when the patient emerges from the hospital 10 days later. 

"We pay a price to gain a prize." It concerns me that despite the potential payoff of reduced errors, residents may pay the price of lost experience. 

Common Solutions
How does all this affect each of us, personally and professionally? And how do we respond?

Regarding the ob/gyn crisis, we can demonstrate our commitment to the health care team by extending our hands and becoming active partners with our physician colleagues in the realm of tort reform and other malpractice issues. By doing so, perhaps we can dispel the medical societies' fears and doubts concerning "midlevel providers." Of course, this may take time. 

Meanwhile, if ob/gyn physicians continue to drop obstetrics, this could be catastrophic for the many women who need prenatal and complete ob/gyn care. NPs and PAs will be affected, too-but they can choose to become part of the solution. The care needed for women to bear healthy babies may well be provided by certified nurse-midwives and by PAs and NPs who practice in ob/gyn. These NPs and PAs may then be motivated to pursue postgraduate studies, further qualifying them to take up the slack and fill in the holes-as we have so often done in the past.

Likewise, we must find our fit in the shortfall of medical care that will result from the 80-hour workweek for residents. Residency programs are closing almost as rapidly as malpractice companies. Hospitals, medical centers, and government-funded agencies will all need to reach out to other qualified providers. 

We are those qualified providers. 

Surgical PAs function as first assistants and perform well in surgical intensive care. The new role of hospitalist has been successfully filled, thanks to board-certified internists and other physicians working in teams with NPs and PAs; this model has proven itself. In emergency departments, experienced PAs and NPs performing in a resident-like role successfully meet the challenges of overcrowding, dumping, and unnecessary visits.

Conclusion
Nurse practitioners and physician assistants are still the answer to the American health care crisis. We have the education, the experience, the commitment, the passion, the tools, the enthusiasm-and the numbers-to make a difference. If we each take one step forward, America will soon hear the marching steps of thousands from both of our professions, with thousands of voices expressing the urgent medical care needs across our country. Maybe then, people will no longer ask, "What is a PA?" or "What is an NP?"-because they will have experienced firsthand the excellent treatment that defines our roles.
Where do we fit in the vision that I have described? Where do we see our respective and collective professions in the next three years? The next ten? 
Are we ready to risk becoming proactive, working toward a healthier America-starting today? I, for one, vote yes. Together, let's make the years 2001 to 2010 known as the Decade of Progress, forged by our professions! 
 
 

Robert M. Blumm has practiced in plastic surgery for 30 years and owns a private first assistant business. He acts as a preceptor to PA students from the State University of New York-Stonybrook, the New York Institute of Technology in Westbury, and Touro College in New York City. Currently Chairman of the Surgical Congress of the American Academy of Physician Assistants (AAPA) and the AAPA Liaison to the American College of Surgeons, Mr. Blumm is a past president of the New York State Society of Physician Assistants and the American Association of Surgical Physician Assistants.

Copyright 2002 Jobson Publishing, LLC. Reprinted with permission by Clinician Reviews.