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Working with PA's and NP's

Jonathan Bland

Working with Healthcare Professionals/ HSC4060 S01

South University

Professor Nelva Lee

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In the medical field there has been a recent increase in the number of Physician
Assistant (PA) and Nurse Practitioners (NP) that have started working within medical
facilities as primary care managers for patients. The reason is simple this will allow the
increased number a physician can see by giving autonomy to having a PA or NP do the
work for them. Increasing the patients they see a day increases the number patients
and the money they bring in on a daily basis.
In the military medical format, NP and PA's have been treating military personnel
for years, only now has it worked its way to mainstream Medical groups. Main stream
medical groups have seen a rise in patient loads and are able to take care of those
patients with the hiring of an NP or PA. In the military it doesn't matter to the soldiers,
sailors, airmen, or Marines whether they are black, white, Asian, or any other color as
long as that NP or PA takes care of the problem they have for their visit. In the Veterans
Affairs Hospitals, the VA uses NP and PA's as the main person for the level of care the
veterans primary care provider. The NP and PA always have a back up just like in the
civilian side as to having a physician sign off on the medical notes for the veteran.
In the civilian world, people always have a choice on who they want to see and
when they want to see their providers. No matter if that provider is an NP, PA, MD, or
DO. In the United States, when a person walks into the doctor's office for the first time,
they maybe might be seen by any number of races of providers. The stereo typical
white male doctor is slowly going out of style. Now, anyone in America that studies hard
enough can become a Nurse practitioner, Physician Assistant (my personal goal),
medical doctor (MD) or Doctor of Osteopathy (DO). The levels of race tension has
decreased since the 1970's as to whites will only be seen by whites or vice versa. There

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are still racially divided people around the world and in the United States and there will
always be until we are all one races of people. For the most part patients who are
hurting, with disease, with any kind of ailment they will seek out care form the person
who can give it. Take a dying man/woman who hates one race and have that one race
cure them and it changes the mind forever. Patients respond to treatments as long as
their body responds to the medication, no matter who is prescribing it. I have lived in the
South, DEEP South, I have lived in racially divided areas and I have always seen one
color and I am a white man. The color of the skin of an individual doesn't speak to who
the person is or how they will treat you. Most patients seek out medical care because
they need medical help.
Providers of all kinds will keep treating patients no matter what, race has a
deciding factor for many of the smartest minds to go to waste. Charles Drew, M.D. died
outside a hospital in North Carolina in the early 1950's because he was black man who
was injured and the hospital wouldn't treat him. Because of what he did before he died
will allow billions of people from that point in time till we no longer have to transfuse
blood to live, no matter the race. Since his death millions have died because of race
problems. Hopefully no one else will have to die because of the undignified attitudes of
those who treat others because of the color of their skin.
The times have changed patients for the most part no longer see the color of skin
but only the skill behind it to help heal the patient looking into the eyes of the provider. I
think patients are now seeing the betterment of man/woman in the healthcare field.
People get sick and hurt every single second around the world. They don't care who it is
saving their lives as long as that person can help them live.

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There are 83,466 physician assistants in America in 2010. There are a total of 180,233
nurse practitioners in America in 2011. It is estimated that one-fourth of all nurse
practitioners and physicians assistants that are non-white. (Hooker, Potts, & Ray, 1997)
In the United States, in 2006, Hispanics made up 5% of the nations physicians, while
3.5% of doctors were black and fewer than 1% were American Indian or Alaskan
Natives. There are a total of 811,553 physicians in America in 2012. (Distribution of
Physicians by Gender, February 2012, 2012). What does this mean with all of these
numbers? It means that the majority of providers in America are white and there are few
minorities practicing medicine. Patients who seek out care are often met by white
males. Colleges are trying to increase the number of minorities to the ranks of medical,
nurse practitioner, and physician assistant schools.
When some people who seek out medical care find that their provider is nonwhite they have issues. It doesn't mean that they are racist, it just means they may not
understand their providers. In one article following patients with cardiovascular disease.
They notices a low adherence rates of medications can be traced to the quality of the
patient-physician relationship (Maldonado, Maya-Silva, Menefee, & Xiong, 2010). The
patients communication with their provider became the biggest problem with these
patients. The patients didn't feel as if their provider listened and they didn't listen to their
provider so the medications were not taken as they were supposed to be. Another issue
that came up was, Concordance in patient-physician ethnicity, where the patient
identifies as having the same ethnicity as the physician, leads to better communication
and understanding because the patients feel more comfortable and have more trust in
their physician (Taylor, 2010). When there is a breakdown in communication between

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provider and patient, patients don't always have the best outcomes as far as their health
is concerned. No matter the race of the provider, patients must be able to trust them.
Without that trust then there will be a problem in that care.
In 1997, Kaiser wanted to know how the physician, NP, and PA all stacked up to
the patients. They were all equal except in the area of pediatrics, physicians had a
higher rating than NP and PA's. This is to be expected. Since trust in the provider has
been a very big issue when it comes to care the provider gives to the patients. If there is
a good trust then the provider has a better chance of healing the patient. When it comes
to providers and their patients no matter the degree whether it be an MD, DO, NP or PA
patients have to trust the provider.
In the medical field there are many nationalities working within America.
Currently working at one VA medical center in Los Angeles there is an Indian Medical
doctor, a Pilipino nurse practitioner, and a Chinese nurse practitioner. Throughout the
VA system there are a multitude of nurse practitioners and physician assistants that are
non-US citizens at one point in their life. The military personnel that see these providers
are used to change and they understand that their providers are acting on their best
interest so they conform to the care that the providers give. The providers all have
medical training that originated in the United States. When providers arrive to see their
patients for the first time there is always a chance in the VA medical system that the
provider is seeing a patient that at one time was literally shooting a weapon at that
providers nationality at one time. A patient came to our clinic one day and saw our
Chinese nurse practitioner. After the exam he came to check out and requested to see

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another provider because in his words," I killed so many of her kind I don't care to be
taken care of by her". This happens in the VA system, not much in civilian world.
The providers that see patients on a daily basis have to be able to communicate
their medical issues. Providers have come up with interesting ways to make sure the
patients are able to talk to their providers about all of their needs. They hand out forms
that patients fill out while their waiting in the waiting room prior to seeing their provider.
They write down all of their concerns so the doctor can go over each of the problems
prior to the patients leaving. The providers can also write down what the patients
instructions as well as tell them about what they need to do prior to coming back on
their next scheduled visit.
Depending on the patients level of education can depend on the patients are
addressed. The patients with a lower level IQ can be hard on the providers to help them
understand that the care they are providing. Providers can also ask if someone else can
come with the patients to help them understand The patients that are smarter are able
to talk to providers and get the level of understanding needed for the best care. Older
patients present problems with understanding of the way medications and care should
be addressed daily. These patients often take more time in the clinic. Patients with
multiple problems, i.e. high blood pressure, high triglycerides, diabetes, etc. often
present problems when they don't comply with the doctor's orders so they must spend
more time to help the patients understand the need for care. If the patients are disabled,
for example, missing limbs, they may present another problem they must care for the
disability and the patients needs. Patients with reading disabilities may present issues
when trying to follow the medication orders. Patients that are blind need special

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precautions when the medications needed to be taken daily. Politics should be left out
of the medical field. Patients need care not a lesson in politics when visiting the medical
providers.
When providers see patients the providers need to always present themselves as
professionals. With each patient a provider has every patient will be looked after
differently. The provider must understand that their patients ability to communicate
maybe different. The patient's ability to talk may not always be there in the normal forms
that providers use. Patients who are deaf may need a translator to understand.
Providers, no matter the original nationality, should always treat each patient with
compassion and respect.
In the medical field, it's like being the "Highlander", there can only be one person.
That one person makes the decisions about a person's health in a providers office.
What can be especially challenging in the medical field with Nurse Practitioners (NP's)
and Physician Assistants (PA's) are that they have to work with a Medical Doctor to
provide care. Only in 3-4 states is there an instance where Nurse Practitioners can work
on their own and not with a M.D., for the most part these two positions they have to
stand up to providers and tell them this is what is going wrong and that they are going to
treat them with certain medications. Medical Doctors have to verify the patients are
receiving good care. The NP's and PA's must have a motivation in everything they
know. Eventually they will get the respect from the MD that signs off on the care they
give and more then autonomously within the clinic or hospital. Their motivations should
be geared toward satisfaction-performance theory. This can be looked at the way the
provider cares for the patients and in return the Medical Doctors and DO's return their

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admiration of the way the patients are treated by the NP or PA. In the medical field it's
all about what is best for the patient and how the patient is treated.
For example, back when I was just and EMT-Basic. I went to a patients house
who had Chronic Obstructive Pulmonary Disease, (COPD) and he was having an
asthma attack on top. My first instinct was to put the man on high flow oxygen, but the
rules with COPD patients at the time prevented me from doing so. I had the man placed
on a nasal cannula that was blowing out oxygen at 6 liters a minute the recommended
dose for someone with COPD. The patient state he couldn't breathe. I put him on a
mask with the same about of oxygen blowing into it which contradicted the amount the
mask was meant for, when we arrived at the hospital the doctor came to me. He asked
why he was being treated this way. I explain the care that was initiated and followed
through-out our trip to the facility. When I told him the patient felt better after the mask
was in place he said, "as long as the patient felt better and his condition improved he
didn't have a problem with it". From that point on whenever I'd have to call in for an
order he trusted in my skills to acknowledge what the patients needed and would give
me my medication request. This was satisfaction of a job well done and my
performance was right along with what the providers wanted to see.
When it comes to leadership, I've always followed the lead by example. With NP
and PA's they can't lead by example because the care they must do can only be done
by them or the MD over them. A laissez-faire style of leadership can be good for MD's to
have when it comes to working autonomously with NP's and PA's. Although the MD and
DO's working with NP's and PA's must get to a level where laissez-faire style of
leadership can be completed. The NP's and the PA's can have the same level of

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Laissez-faire with the staff below them. They can put orders in or notes for the patients
to be contacted. The care has to be done by the nurses below the NP or PA. There is
also a servant leadership. They do this to better the patients and the nurses below them
must serve the patients while also following the orders of the provider. Patient
satisfaction is being looked at by many professionals. Medical providers are also finding
that running medical clinics is more of a business where keeping the patients happy
often keeps them healthy and coming back when they need care. If a patient is unhappy
with the care they receive they often do not return. They want providers to be servants
to them as well. The provider should be a servant to the patient to ensure the patient
receives and is happy with the care at all times.
When physician assistants and nurse practitioners first start out working within
their respective fields of expertise they are not given much credit. The only credit they
are given is that they finished school. They must prove themselves and their worthiness
to the providers they are working for in that particular setting. Every provider has certain
ways they want patients treated, for example, particular types of antibiotics, certain
preference in sutures and the way sutures are put in patients. When a new NP or PA
starts they must accept that providers will carry towards these practices and make a few
mistakes not taking it to heart that the physician wants things done a certain way. This
can make some NP's and PA's to more stress than others have, depending on where
they are working. Stress can get to new providers just at the onslaught of new patients
or the sheer number of patients they may to see in one day to make their new bosses
happy. Add in some ethnically diverse NP and PA's and the headaches really begin for
everyone. This is saying that NP's and PA's who are ethnically diverse get more stress

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because they have to add in a language barrier that most NP's and PA's do not have to
take in to account for can be really a problem.
The challenge and the extra stress is not just the NP and PA's fault this can
come from the patients problems also. If a provider is seeing a patient that they know to
be difficult they will often have the new providers (NP and PA) see that patient just to
get them out of their hair, so to speak. Stress can be good at times and certainly bad if
there is an over indulgence. Easing new providers into the way the clinics are ran is the
best way to ease the stress a new provider has when they start at a new work place.
Setting up certain medication and protocols to follow for patients is another way to make
life easier on them.
Ethnically diverse PA's and NP's are usually mastering their second language
when they start in the medical field in the United States. Outside the US and Canada,
NP's and PA's aren't really known about. The care that they can give, is often confused
with that of a doctor often times. They must learn a new culture and new language when
coming to America. New PA's and NP's often find that even being as high up as an NP
or PA doesn't give any more status on the social side of life, in many cultures doctors
aren't that big of a deal. This may come to a shock for some providers who have spent
years in school only to come here to the United States and not be identified as a
provider. This can cause some conflict in the work place. Since they see themselves as
much more even the littlest concerns can make them uncomfortable.
In the medical field everyone working knows that there is one doctor in-charge
over a patient for his/her care. When it comes to PA's and NP's as being that medical

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person in-charge for that care it can cause undue stress and conflict when a situation
arises regarding that care. Nurse's, EMT's, Paramedics, respiratory technicians, and
everyone else in the medical field all know that someone is over a patient as far as their
healthcare. Sometimes the respect that NP and PA's over patients aren't always given.
It comes down to patients providers are given the respect that they deserve causing
less stress on the provider in troubling times the patient may be going through. Conflict
in the work place can be best handled by the interorganizational conflict. If there is
conflict within the organization as to what the job responsibilities are when it comes to
the patients of a PA or NP then employee's should be told that they are the overall
person in-charge of that persons care. This will solve many headaches when it comes
to patients and their care within organizations and the care they receive.
Being ethnically diverse in America is not that uncommon since America is made
up of every nation around the globe. When it comes to healthcare being ethnically
diverse can present challenges within the healthcare settings. Providers both NP and
PA should come to realize early on that taking care of the patient is priority number one.
Dealing with the politics is second having a life beyond the work place is a distant 3.
That is the way it is in any healthcare field. Patients die or move on to different areas.
No matter the color of one's skin should make a difference in how patients are treated.
Being diverse has its advantages and disadvantages. Patients need care if they aren't
open to the provider make avenues that make it easier. Even patients who can't speak
find ways to tell their providers what's wrong with them.

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Bibliography
Bodenheimer, T. (2009, Feb). Confronting The Growing Burden Of Chronic Disease: Can The U.S. Health
Care Workforce Do The Job? Retrieved May 28, 2012, from Heal Affairs:
http://content.healthaffairs.org/content/28/1/64.full
Distribution of Physicians by Gender, February 2012. (2012, Feb). Retrieved June 3, 2012, from
Statehealthfacts.org: http://www.statehealthfacts.org/comparetable.jsp?ind=430&cat=8
Dr. Charles Drew. (2012). Retrieved May 28, 2012, from About CDU: http://www.cdrewu.edu/aboutcdu/dr-charles-drew
Hooker, R. S., Potts, R., & Ray, W. (1997). Patient Satisfaction: Comparing Physician Assistants, Nurse
Practitioners, and Physicians. Retrieved June 3, 2012, from The Permanente Journal:
http://xnet.kp.org/permanentejournal/sum97pj/ptsat.pdf
Krupa, C. (2010, Oct 4). New tactics for diversity: Creating doctors from all racial, ethnic groups.
Retrieved June 3, 2012, from Amednews.com: http://www.amaassn.org/amednews/2010/10/04/prsa1004.htm
Lillie-Blanton, M., Rushing, O. E., & Ruiz, S. (2003, June ). Key Facts Race, Ethnicity & Medical Care.
Retrieved June 3, 2011, from The Henry J. Kaiser Family Foundation:
http://www.kff.org/minorityhealth/upload/key-facts-race-ethnicity-medical-care-chartbook.pdf
Maldonado, J., Maya-Silva, J., Menefee, L., & Xiong, S. (2010, July 25). The Effect of Patient-Physician
Ethnicitiy and Communication on Adherence Rates to Cardiovascular Disease Medications. Retrieved
June 3, 2012, from Stanford University:
http://smysp.stanford.edu/documentation/researchProjects/2010/ethnicityAndMedications.pdf
Taylor. (2010). Adherence to Cardiovascular Disease Medications: Does Patient Provider Race/Ethnicity
and Language Concordance Matter? Journal of General Internal Medicine , 1-6.