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A move toward team-based care has increased collaboration among health care professionals.

Roles of nurse practitioners and physician assistants in medicine still under debate

With shortages of doctors across Canada, many health authorities are looking for ways to fill gaps that don’t require training or hiring new physicians. Nurse practitioners and physician assistants are two professions that can help relieve the strain. Generally, there is amicable collaboration between these professionals and doctors, but there are times when minor turf wars break out.

In Nova Scotia, the College of Registered Nurses of Nova Scotia plans to merge with the College of Licensed Practical Nurses of Nova Scotia. The plan has wide support, but one provision in the enabling legislation has raised eyebrows among some doctors. Currently, nurse practitioners are required to enter a formal partnership with a doctor or group of doctors and submit written proof of the agreement to the college. After the merger, that will no longer be the case.

“We are told that the change is to reduce onerous paperwork,” said Dr. Tim Holland, president of Doctors Nova Scotia. “But we’re concerned it is a move away from collaboration.”

The change could, in theory, allow nurse practitioners to set up independent practices, said Holland, which seems at odds with the push by the provincial government over the past decade for health care workers to work in teams. “If [independence] is the goal, that’s a different discussion to have,” said Holland. “We’re open to that, but it’s not the discussion we’re having. We’re guessing at motivation here.”

According to Mary Jane Hampton, a health care consultant in Nova Scotia, many family doctors fear they will be replaced by nurse practitioners. “They feel that their very existence as a profession is being evolved out of the health care system in a process of extinction fuelled both by clumsy planning and insidious policy,” she wrote in an opinion article in The Chronicle Herald.

In the United States, the turf war has been waged more openly. The American Medical Association opposes allowing nurse practitioners to practise independently, and some doctors feel that collaborating with nurse practitioners devalues their medical training.

Increasingly, however, patients appear more willing to receive care from health professionals who aren’t doctors. Visits to primary care physicians have been falling in the US, while visits to nurse practitioners and physician assistants are on the rise. There are no comparable data for Canada, but the number of nurse practitioners in the country rose from around 1300 in 2007 to almost 5000 in 2016.

Physician assistants are another group that can do some of the work typically performed by doctors, but they are not as common as nurse practitioners. They are used extensively in the Canadian military but are licensed to practise in only four provinces: New Brunswick, Ontario, Manitoba and Alberta. Physician assistant programs are typically two years in duration, and graduates must pass an exam to be designated as a Canadian Certified Physician Assistant.

The Canadian Association of Physician Assistants is pushing to have the government in British Columbia recognise physician assistants and integrate them into the health care system. According to Patrick Nelson, executive director of the association, wherever physician assistants have been used, the reception from doctors and patients has been positive, and they help save money. An analysis by the Conference Board of Canada found that greater use of physician assistants could save the Canadian health care system up to $1 billion by 2030. “It’s mystifying why progress in Canada has been so slow,” said Nelson.

Kevin Dickson, a physician assistant in the emergency department of the Dr. Everett Chalmers Regional Hospital in Fredericton, New Brunswick, said at first some doctors were resistant to the introduction of physician assistants, but they quickly came around. “Now they see the benefit and are happy to have a shift with them,” he said.

In Australia, though, the introduction of physician assistants raised fears that they would take clinical training opportunities away from medical students. There is also some strain occasionally between physician assistants and nurse practitioners. But Nelson said that is mostly restricted to the higher levels, where the politics of divvying up health care budgets comes into play. “When nurse practitioners work with physician assistants, the relationship is great,” he said. “There is enough work for everybody.”

With the move toward more team-based care, all health care professions will have to work out how best to collaborate for the benefit of patients. “We want to see a world where we have the right service for the right patient at the right time,” said Holland.

Photo credit: Cecilie_Arcurs/iStock

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