By Kenrick Lam

Note: PA = Physician Assistant. NP = Nurse Practitioner.

Dear Forebrain,

I hate PAs and NPs on a visceral level. This hate is completely illogical and would never hold weight in any argument. But here are the reasons why I cry every time on the wards when I work with NPs and PAs (which from now on I will refer to lovingly as PANPs).

• PANPs are way too qualified. I need some subservience in my life. A fresh PA graduate is just as, if not more, qualified than a fresh MD graduate when it comes to taking care of patients.  The same can be said about NPs. I mean, is there a difference between what MDs and PANPs do (operationally) in most specialties in their first three years of residency? In patient outcomes? Answer to both questions: Nothing. (1, 2).
• PANPs are gunning for my IQ. I must be smarter than PANPs because a) I chose to pursue a life-sucking, buzz-killing occupation that will undoubtedly wreck at least one of my close relationships. And b) I took the MCAT, that’s got to count for something right? Instead of a standardized test, the PA program at UTSW requires applicants to have at least 200 hours of professional health care experience (nurse, phlebotomist, ER technician, etc.), which is paltry to Duke’s medical school requirement of 1,000 hours. Standardized tests always trump clinical experience.
• PANPs are my competition … and they look really competitive right now. Over the past 35 years there has been a growing body of evidence that PANPs deliver equivalent care in the primary care setting (3, 4). Plus, their role in subspecialty, emergency, and acute care settings is expanding as well, though the outcomes in these areas are not as well-validated (5, 6, 7, 8). And now, many states are giving PANPs significantly more autonomy; Washington State, for instance, enables PA’s to open their own practices.
• The PANPs’ curriculum is too clinically relevant. Only pansies bypass the year of heartbeat-robbing minutia in lieu of practical courses such as “Clinical Decision Making.”

Unfortunately, I am only an incensed, pen-wielding ego of a medical school student, and I can’t do anything to stop this. In fact, it would only limit access to health care if I tried to restrict the practices of PANPs. These men and women have the same skill and knowledge as residents do. And if residents can pass the boards and go on to practice on their own, then why not qualified NP’s and PA’s? Maybe it’s time we drop the letters ‘N’ from NP and ‘A’ from PA.

Yours truly,

Your sulking ego

Works Cited

• Singh, S., Fletcher, K. E., Schapira, M. M., Conti, M., Tarima, S., Biblo, L. A. and Whittle, J. (2011), A comparison of outcomes of general medical inpatient care provided by a hospitalist-physician assistant model vs a traditional resident-based model. J. Hosp. Med., 6: 122–130. doi: 10.1002/jhm.82
• Miller, W., Riehl, E., Napier, M. Barber, K., & Dabideen, H. (1998). Use of physician assistants as surgery/trauma house staff at an American College of Surgeonsverified level II trauma center. The Journal of Trauma, 44(2), 372–376
• SOX HC. Quality of Patient Care by Nurse Practitioners and Physician's Assistants: A Ten-Year Perspective. Ann Intern Med. 1979;91:459-468. doi:10.7326/0003-4819-91-3-459
• Horrocks, S, Anderson Elizabeth, Salisbury Chris. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors BMJ 2002; 324:819
• Nevidjon B, Rieger P, Miller Murphy C, et al. Filling the gap: development of the oncology nurse practitioner workforce. J Oncol Pract. 2010 Jan;6(1):2-6.
• Warriner, IK, Meirik, O, Hoffman, M, et al (2006). Rates of complication in first-trimester manual vacuum aspiration abortion done by doctors and mid-level providers in South Africa and Vietnam: a randomised controlled equivalence trial. The Lancet, 368(9551), p1965–1972
• Doan, Q., Sabhaney, V., Kissoon, N., Sheps, S. and Singer, J. (2011), A systematic review: The role and impact of the physician assistant in the emergency department. Emergency Medicine Australasia, 23: 7–15. doi: 10.1111/j.1742-6723.2010.01368.x
• Newhouse J, Stanik-Hutt J, White KM, et al. Advanced practice nurse outcomes 1990-2008: A systematic review. Nurs Econ 2011;29:230-250

Kenrick Lam, M.D., Class of 2016, is a third-year medical student curious about the hierarchy in medicine. He wrote this piece after observing the opinions of some physician assistants and nurse practitioners squashed by M.D.s. He does not understand why they are considered to have less expertise and is still trying to find out.