Medical care used to be simple. Patients were treated by a doctor or a nurse. Done.
Today care can also be provided by advanced practice providers, all with their alphabet soup of identifying acronyms: PA, CRNP, CNM and CRNA.
Who are these people, and why are we seeing them instead of a doctor?
“We’ve modified our approach over the years,” said Dr. David Lopatofsky, chief medical officer of UPMC Susquehanna. “We’ve been trying to be all things to all people in all places, and there’s only so much one person can do, so it really helps with the limited bandwidth of physicians to be able to cover an increasing spectrum of patients.”
Melissa Davis, vice president of medical group operations at UPMC Susquehanna, pointed out areas where advanced practice providers (APPs) can bring continuity of care to patients in outlying areas. At UPMC’s Mansfield site, certain physicians see patients twice a month, whereas a nurse practitioner sees patients several times a month. In their Sunbury site, Jennifer Bressler, PA-C, is one of the rheumatology advanced practice providers who treats patients on a regular basis.
“Our patients in Sunbury are very comfortable with our advanced practice providers because they know they’re part of the care team,” Davis said.
“They develop a relationship with the community there and with the referring providers and with the patients,” Dr. Lopatofsky said. “So they develop that collegiality and a trusting relationship.”
UPMC Susquehanna employs more than 100 advanced practice providers in primary care and medical specialty and subspecialty areas, including cardiology, orthopaedics and digestive diseases.
The jobs of Certified Nurse Midwives (CNMs) and Certified Registered Nurse Anesthetists (CRNAs) are fairly easy to comprehend. A midwife is typically trained to assist women in childbirth. A nurse anesthetist provides the same anesthesia services as an anesthesiologist — their main difference lies in the fact that anesthesiologists receive medical education while CRNAs receive nursing education.
As for nurse practitioners and physician assistants, their roles are similar. Their differences, once again, lie in their medical training.
Laura Smith, CRNP of family medicine at Evangelical, explained that all CRNPs are registered nurses who have gone on to obtain a masters or doctorate degree in a specific field, such as family medicine, pediatrics, geriatrics, etc.
“In some states, nurse practitioners can work independently,” Smith said. “In Pennsylvania, they need to have a collaborating physician. I work pretty closely with Dr. (James) Patterson, (family medicine of Evangelical) and speak to him on a daily basis.”
“In physician assistant training you receive education on all aspects of medicine,” said Jonathan Bastian, PA-C with the hospitalist group of Evangelical Community Hospital, adding that PAs do clinical rotations in family medicine, pediatrics, surgery and other areas. “Upon graduation from a physician assistant program you can do just about anything in terms of specialties. And you train constantly throughout your career to expand your knowledge base.”
Fellow physician assistant Georgina Ferriero, with gastroenterology of Evangelical, explained that PAs can prescribe medications but work closely with physicians. A physician must co-sign a PA’s medical notes.
“The doctors don’t see all the patients I see, but they do review our notes,” Ferriero said. Echoing what Lopatofsky said in the UPMC model, she added, “It’s really a team-based approach.”
How closely involved is the physician with the PA? It depends on the doctor, Bastian said.
“We can work very independently of each other or very close to each other,” he said. “From my experience, the level of independence of a physician assistant is largely based on the physician or organization you’re working with.”
Evangelical Community Hospital has more than 80 advanced practice providers on staff at Evangelical in both hospital-based areas and specialty care offices.
Offsetting a shortage
Physician assistants, nurse practitioners, midwives and nurse anesthetists share at least one thing in common: They fill in gaps.
APPs offer one more level of patient care, especially in rural areas like the Susquehanna Valley, where the shortage of physicians can make for long wait times.
“That’s the reason I got into the nurse practitioner career,” Smith said. “As a nurse, I saw patients were having trouble getting in to see their family doctor. They were showing up in the ER with non-emergent situations.”
As a hospitalist, Bastian treats patients admitted to the hospital, freeing up surgeons and coordinating the care of patients.
“I spend a lot of time with all the people involved — patients, families, doctors – to have a positive outcome in the end,” he said.
Today, most patients are comfortable receiving care from an APP.
“I joke that we’re all on ‘Team Patient,’” Ferriero said. “I want people to know, we’re all on their team. We want the best for them.”
Smith agreed, saying, “I always try to think, would I be doing this treatment if this patient was my family member?”
When patients recognize the professionalism and concern of an APP, they respond with trust and appreciation.
“The response we get is that the advanced practice providers are well received,” Lopatofsky said, adding that physicians can tend to be a bit rushed. “Advanced practice providers develop good patient experience and are met with gratitude by our patients.”
“People put their complete trust in us,” Bastian said. “We are all working together collaboratively to provide the best care possible for our patients.”