Physician Assistants Versus Nurse Practitioners: Comparing the Two APP Careers

Physician Assistants Versus Nurse Practitioners_ Comparing the Two APP Careers

Students interested in healthcare careers can find themselves comparing two seemingly similar professions: nurse practitioners (NP) and physician assistant (PA). Both paths lead to well paying careers that involve working closely with patients and performing duties commonly associated with doctors such as performing physical exams and prescribing medicine.

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Both PAs and NPs work closely with other healthcare workers, especially physicians Both are valuable members of an interdisciplinary team.

Despite their many similarities, there are some key differences between these two professions such as their scope of practice, training structure, and certification process. In this article, we will delve into the differences between NPs and PAs.

Physician Assistant vs. Nurse Practitioner Scope of Practice

In general, the scope of practice for the two professions are very similar. Both groups of medical providers can diagnose medical conditions, order tests, and prescribe medicine. Both can practice in a variety of settings. These settings include private practice , nursing homes, hospitals, urgent care centers, and school health clinics.

The exact scope of practice varies and depends on factors such as state law, facility policy, and needs of the practice.

The main difference is that PAs are not able to run a clinic independently of a physician, although there are some efforts to change this. Some PAs do own and manage their own clinics. However, this requires them to hire a doctor who must supervise in some capacity.

In contrast, NPs can practice independently and open up their own practice without a physician. The exact rules vary state by state. Some states are “restricted practice states.” These states require NPs to work closely and consult with a physician. In other states, termed “reduced practice” states, NPs must undergo a transition period before they can work independently. But they must still collaborate with a physician. In states that allow full practice, NPs can work independently of a physician after a transitionary period.

Education

Both careers require a master’s degree in their respective programs. Yet, the actual training path can be quite different.

Physician Assistant Education

PA programs are 2-3 year long graduate programs. To apply to PA school, applicants must complete prerequisites in coursework such as biology, organic chemistry, anatomy, and microbiology and take the GRE.

Applicants must also complete a significant amount of clinical hours. The Central Application for Physician Assistants (CASPA) allows students to list two different types of healthcare experience: patient care experience (PCE) and healthcare experience (HCE).

PCE is defined as experience that requires direct responsibility for some aspect of patient care. HCE is defined as work in the healthcare field where you are not directly responsible for a patient’s care.   PA schools require a significant number of PCE hours. In fact, some of the top schools required between 1000-4000 hours of PCE.

All this clinical work prepare applicants to know how to interact in a healthcare environment prior to matriculating. After starting PA school, students at most programs will spend the first year in an intense preclinical curriculum where they learn the majority of topics covered in medical school. These include anatomy, physiology, microbiology, immunology, pharmacology, and pathophysiology of disease.

After forming a solid scientific foundation, PA students will begin their clinical rotations. According to the American Association of Physician Assistants (AAPA), PA students spend about 2,000 hours in clinical rotation across specialties such as family medicine, surgery, pediatrics, and psychiatry. Students spend most of their time in the clinic, but still need to study outside of clinic hours to pass their shelf exams.

After graduating, PAs complete the Physician Assistant National Certifying Exam (PANCE). This is a multiple-choice exam that assesses fundamental medical and surgical knowledge.. Upon completing the PANCE, PAs get certified and become eligible for licensing.

Some PAs choose to continue their education and pursue residency programs. These programs typically last a year and train PAs in specific subspecialties such as neurosurgery, emergency medicine, urology, orthopedic surgery, and much more.

PAs do not need to go back to school or residency to switch specialties. They are expected to have the general fundamental knowledge to pick up these skills on the job. However, going through residency gives an intense, dedicated training period where they learn in one year what might have taken several years. This training can also help make them more competitive for jobs.

Nurse Practitioner Education 

In contrast, NPs must earn a Master of Science in Nursing (MSN) or a Doctor of Nursing Practice (DNP) from an accredited nursing school. There are many options for pursuing the NP route. Regardless of the option, an NP must complete rigorous clinical training during their training. In total, a nurse practitioner acquires between 500 to 1500 hours of clinical training throughout the course of their program.

The Three Routes to Becoming an NP

The first option is the direct-entry MSN route. This is designed for students who have already completed an associate or bachelor’s degree in nursing. An associate’s degree is only two years and cheaper as it is typically offered at community colleges. Nurses with an associate’s degree can start working sooner and gain nursing experience.

The bachelor’s degree is typically offered at nursing schools associated with universities and is, therefore, longer and more expensive. However, the benefit of the bachelor’s degree is that it is a prerequisite for most NP programs. 

A second option is for candidates who either 1) already have a master’s degree in another nursing program (such as a certified registered nurse anesthetist) or 2) earned a bachelor’s degree in nursing followed by a master’s degree in a relevant field (MPH, MBA). These programs allow students to earn the NP without repeating coursework that they already completed in their previous master’s program.

The third option is a BSN-MSN program. These programs are designed for students who have a bachelor’s degree in a non-nursing focus and are interested in advanced nursing practice, including nurse practitioners. These accelerated programs still require prerequisites such as general chemistry, biology, anatomy and physiology, nutrition, and even statistics. Typically, these programs allow students to earn the BSN at an accelerated pace (around 1.5 years) and then begin their MSN coursework.

In addition to the path flexibility, NP schools can be very different from PA schools on a day to day basis. While some are traditional “brick and mortar” schools with physical campuses and in-person classes, others are online. Some programs (especially BSN-MSN) are designed to be flexible for students who wish to work while in school.

While in school, NPs complete coursework in topics such as pharmacology, health assessment, and pathophysiology. They also must work under preceptors at clinical sites. While PAs are generally trained in surgery, most NP programs do not usually offer surgical training. After completing their coursework and clinical training, an NP must pass a national certification exam in their specific field.

NP Specialization 

Unlike PAs, NPs specialties are defined by patient population and clinical setting. Also, NPs must decide a specialty before they start their program, instead of after graduating. The two main considerations for future NPs are the patient population and clinical setting they would like to work with. NP programs are extremely diverse but generally are divided into these two categories.

Examples of clinical settings include primary care, family medicine, pediatrics, and psychiatry, while examples of patient population include adult, pediatric, and gerontology. For example, if an NP decides that they would like to work in Acute Care, they will have to then choose whether they want to pursue an Acute Care Pediatric or Adult program.

Since these specialties are patient-focused, it means that these providers have a broad base which lets them work in many different traditional medical specialties. For example, a family NP can work in fields such as dermatology, cardiology, or endocrinology. This means it is relatively easy for NPs to switch specialties as long as the patient population and clinical setting are the same.

The same is not true for an NP who wants to switch from an adult specialty to a pediatric one. The NP will have to attend a pediatric NP program and then take the pediatric certification exam. Luckily, some of their original coursework will count towards this new specialty, meaning that the NP can complete their second specialty in a shorter amount of time. 

Certification Renewal Requirements

After becoming certified practitioners, both professions must maintain their certification thru Certification exams which are similar to board exams and make sure that providers are keeping up to date within their respective fields.

For recertification, both are required to complete continuing medical education (CME) credits. These are clinical and professional educational activities intended to improve the knowledge and skills of providers. These courses are made available by many different medical organizations and some courses can be taken online.

PA Recertification

PAs have a 10-year certification maintenance cycle, which can be split into smaller two-year cycles. Within each two year cycle, they must complete 100 hours of CME credits. 50 of these hours must be in CME credits that fall under “Category 1”. Activities that fall under this category include workshops, self-assessment, and teleconferences. The remaining hours can be in Category I or Category II. Examples of Category II activities include lobbying work, post-graduate courses, and journal reading.

In addition to this, PAs must pay a certification maintenance fee of $130 every two years and  take a full recertification exam (known as the PANRE) every 10 years. This is a four-hour, 240 multiple-choice exam that is like the PANCE.

NP Recertification

NPs must renew their certification every 5 years. They have two options to recertify: 

The first is to recertify by both clinical practice hours and continuing education. Specifically, they must have maintained 1,000 hours of clinical practice in any specialty that falls under their population focus.

The second option is to recertify by taking the certification exam again. For both options, the NP must hold a current RN license at the time of recertification.

Occupational Outlook for Physician Assistants and Nurse Practitioners 

Both professions offer many high-paying job opportunities. According to the Bureau of Labor Statistics (BLS), the numbers are similar in terms of median salary, projected growth, and number of jobs. There are currently more NP jobs, however, PAs hold a slight edge in median salary and projected growth.

Salary and Job Growth (Table 1)

Median Salary (2019) BLS Growth (2018-2028) Number of Jobs (2018)
Physician Assistant
$112,260
31%
118,800
Nurse Practitioner
$109,820
28%
189,100

Source: U.S. Bureau of Labor Statistics

Occupational Employment Statistics for 2019 (Table 2)

Office of Physicians General Medical and Surgical Hospitals Outpatient Care Centers Colleges, Universities, and Professional Schools Specialty Hospitals Offices of Other Health Practitioners
Physician Assistant
66,800
29,530
9,540
3,590
1,480
1,870
Nursing Practitioner
95,820
47,420
18,820
6,710
2,320
6,210

Source: U.S. Bureau of Labor Statistics

How Do Their Work Environments Compare?

In general, both work environments are very similar. The differences depend on the actual specialty and clinic that the provider works in. NPs typically work in more diverse settings that include camps, schools, and companies. PAs tend to work in hospitals and doctor’s offices.

Additionally, about 73% of NPs work in primary care whereas 72% of PAs work in medical and/or surgical specialties. While there are surgical NPs, it is not typical as most NP training programs do not include surgical training.

The hours and intensity of work required are completely dependent on the actual field, not the type of provider. If NPs are more likely to work in settings such as schools and camps, then they will generally have less intense work demands. PAs generally have more intense work demands as they  are more likely to work in hospitals and/or surgical fields.

However, if they work in the same clinic or position, the work demands of the NP and PA will be the same. For example, an NP and PA who work in the same emergency department will normally have the same responsibilities and shift options. 

Conclusion

Both professions offer exciting and challenging routes to become a certified health care provider. Both professions offer the opportunity to diagnose and treat patients in many different medical fields. However, due to their similarity, it may be difficult to choose between the two.

When trying to decide between these fields, there are several factors to account for. While the scope of practice is similar, NPs can practice independently in certain states. However, PAs receive more surgical training, may find it easier to fit into surgical roles and switch specialties as they do not need formal training to switch.

Although NPs can switch specialties within their population and clinical focuses, they will have to get recertified if they switch out of them.

In terms of admissions, NP programs require prior nursing experience and education. PA schools require a significant number of clinical hours but are more flexible in terms of education and type of clinical experience (as long as it still includes PCE).

Beyond that, both careers are similar in terms of scope, salary, and job outlook. Either one is a great option for anyone interested in healthcare.

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