Randy D. Danielsen, PhD, PA-C, PA

This month, our country welcomes a new administration to Washington. Among the many challenges President Obama will face is our broken health care system.

“There is no plan for health care reform that can succeed without adequate numbers of physicians,” Richard A. Cooper, MD, said in the September 2007 issue of Academic Medicine, “and it will not be possible to ensure the adequacy of physician supply unless major portions of the work that physicians now do are undertaken by other skilled professionals, principally PAs and NPs.”

Efforts at health care cost containment will also increase the demand for a cost-effective complement, such as an NP or PA. The continued high regard for these providers is evidenced by the fact that there are now more than 300 NP educational programs in this country and more than 140 programs for PAs. According to Dr. Cooper, this is still not enough. He has stated: “The United States has failed to ramp up the training of NPs or PAs to the extent that will be needed by a technologically advanced and accessible health care system.”

Market forces are shaping integrated health care delivery networks, yet we face increasing numbers of uninsured Americans. This only adds to the financial burden our country faces with delayed health care and inappropriate use of medical services. According to Sultz and Young in their book Health Care USA, “Managed care organizations have been particularly successful in using nurse practitioners and physician assistants to bolster their complement of staff physicians. Rural hospitals, with limited reserves of physicians, make substantial use of nurse practitioners and physician assistants.”

A number of landmark studies have claimed that PAs and NPs are qualified substitutes for primary care physicians, and researchers have also found that they are able to perform a great many of the tasks currently done by physicians. This is important, since NP and PA salaries are significantly lower than those of primary care physicians. The mean salary for a family practice NP in 2007 was $69,410, compared to $74,270 for a PA. A primary care physician in 2007 made approximately $149,850, according to the US Department of Labor’s Bureau of Labor Statistics. 

Based on that data, the average NP/PA salary is about half that of a primary care physician. With a substitution ratio for PAs and NPs of approximately 85% (based on PA data, at least), the cost of producing an NP or PA is about 20% of the cost for a physician. NPs and PAs can be in practice for four to six years before a physician is functioning postresidency. As a complement, PAs and NPs do, in most cases, offer a service that would not be available in the absence of a physician. They provide care that is of comparable quality and with comparable outcomes to that provided by physicians in similar settings.

While there has been a dearth of global studies in the last four decades on the cost-effectiveness of NPs and PAs, many studies have demonstrated cost-effectiveness in a number of specific practice settings. The impact of PA and NP practice continues to be positive, both in anecdotal and scientific research, although the actual demonstration of productivity across all practice settings is still being researched. There is no doubt that the analysis of the cost-effectiveness of NPs and PAs, because of the diverse clinical settings in this country, is complex. In addition to setting, it is also important to consider whether the PA or NP is a physician substitute or a physician complement—or both—to the practice.

Our country is at a critical juncture. The opportunity for change has never been greater. But there’s a lot that needs to be done, and we have to decide where we should focus first. As our health care system undergoes fundamental changes in structure and processes in the years to come, NPs and PAs must continue to be an important part of the workforce.

How do we do that? I have a few suggestions:

1. We should explore all avenues that will allow us to contribute to the health care reform debate on state and national levels.

2. We need to find innovative ways to increase the number of PA and NP graduates in the near future by recognizing alternative pathways in education, previous experience, and combinations of these to satisfy entry-to-practice requirements for licensure, while preserving the integrity of our clinical education sites.

3. We need to work with our regulatory boards in removing barriers to the full use of our scope of practice, particularly by eliminating entry-to-practice standards that are not based on the competence, skills, training, or knowledge of the NP or PA.

4. We need to continue the ongoing research into the cost-effectiveness and productivity of PAs and NPs in all practice settings, as well as the role they can play in reducing medical errors and malpractice.

5. We need to develop a national metric for the NP and PA that can be used for comprehensive workforce and health policy planning.

I agree with Marie-Eileen Onieal, PhD, CPNP, FAANP, Clinician Reviews’ NP Editor-in-Chief, who wrote in her editorial last month that “NPs and PAs still wear a virtual cloak of invisibility.” Now is the time to find ways to throw off that cloak. We in both professions must be vocal advocates for our role in a time of change. We are the architects of our future.

I would love to hear your thoughts on how we can accomplish that mission. E-mail me at [email protected].

This month, our country welcomes a new administration to Washington. Among the many challenges President Obama will face is our broken health care system.

“There is no plan for health care reform that can succeed without adequate numbers of physicians,” Richard A. Cooper, MD, said in the September 2007 issue of Academic Medicine, “and it will not be possible to ensure the adequacy of physician supply unless major portions of the work that physicians now do are undertaken by other skilled professionals, principally PAs and NPs.”

Efforts at health care cost containment will also increase the demand for a cost-effective complement, such as an NP or PA. The continued high regard for these providers is evidenced by the fact that there are now more than 300 NP educational programs in this country and more than 140 programs for PAs. According to Dr. Cooper, this is still not enough. He has stated: “The United States has failed to ramp up the training of NPs or PAs to the extent that will be needed by a technologically advanced and accessible health care system.”

Market forces are shaping integrated health care delivery networks, yet we face increasing numbers of uninsured Americans. This only adds to the financial burden our country faces with delayed health care and inappropriate use of medical services. According to Sultz and Young in their book Health Care USA, “Managed care organizations have been particularly successful in using nurse practitioners and physician assistants to bolster their complement of staff physicians. Rural hospitals, with limited reserves of physicians, make substantial use of nurse practitioners and physician assistants.”

A number of landmark studies have claimed that PAs and NPs are qualified substitutes for primary care physicians, and researchers have also found that they are able to perform a great many of the tasks currently done by physicians. This is important, since NP and PA salaries are significantly lower than those of primary care physicians. The mean salary for a family practice NP in 2007 was $69,410, compared to $74,270 for a PA. A primary care physician in 2007 made approximately $149,850, according to the US Department of Labor’s Bureau of Labor Statistics. 

Based on that data, the average NP/PA salary is about half that of a primary care physician. With a substitution ratio for PAs and NPs of approximately 85% (based on PA data, at least), the cost of producing an NP or PA is about 20% of the cost for a physician. NPs and PAs can be in practice for four to six years before a physician is functioning postresidency. As a complement, PAs and NPs do, in most cases, offer a service that would not be available in the absence of a physician. They provide care that is of comparable quality and with comparable outcomes to that provided by physicians in similar settings.

While there has been a dearth of global studies in the last four decades on the cost-effectiveness of NPs and PAs, many studies have demonstrated cost-effectiveness in a number of specific practice settings. The impact of PA and NP practice continues to be positive, both in anecdotal and scientific research, although the actual demonstration of productivity across all practice settings is still being researched. There is no doubt that the analysis of the cost-effectiveness of NPs and PAs, because of the diverse clinical settings in this country, is complex. In addition to setting, it is also important to consider whether the PA or NP is a physician substitute or a physician complement—or both—to the practice.

Our country is at a critical juncture. The opportunity for change has never been greater. But there’s a lot that needs to be done, and we have to decide where we should focus first. As our health care system undergoes fundamental changes in structure and processes in the years to come, NPs and PAs must continue to be an important part of the workforce.

How do we do that? I have a few suggestions:

1. We should explore all avenues that will allow us to contribute to the health care reform debate on state and national levels.

2. We need to find innovative ways to increase the number of PA and NP graduates in the near future by recognizing alternative pathways in education, previous experience, and combinations of these to satisfy entry-to-practice requirements for licensure, while preserving the integrity of our clinical education sites.

3. We need to work with our regulatory boards in removing barriers to the full use of our scope of practice, particularly by eliminating entry-to-practice standards that are not based on the competence, skills, training, or knowledge of the NP or PA.

4. We need to continue the ongoing research into the cost-effectiveness and productivity of PAs and NPs in all practice settings, as well as the role they can play in reducing medical errors and malpractice.

5. We need to develop a national metric for the NP and PA that can be used for comprehensive workforce and health policy planning.

I agree with Marie-Eileen Onieal, PhD, CPNP, FAANP, Clinician Reviews’ NP Editor-in-Chief, who wrote in her editorial last month that “NPs and PAs still wear a virtual cloak of invisibility.” Now is the time to find ways to throw off that cloak. We in both professions must be vocal advocates for our role in a time of change. We are the architects of our future.

I would love to hear your thoughts on how we can accomplish that mission. E-mail me at [email protected].

This month, our country welcomes a new administration to Washington. Among the many challenges President Obama will face is our broken health care system.

“There is no plan for health care reform that can succeed without adequate numbers of physicians,” Richard A. Cooper, MD, said in the September 2007 issue of Academic Medicine, “and it will not be possible to ensure the adequacy of physician supply unless major portions of the work that physicians now do are undertaken by other skilled professionals, principally PAs and NPs.”

Efforts at health care cost containment will also increase the demand for a cost-effective complement, such as an NP or PA. The continued high regard for these providers is evidenced by the fact that there are now more than 300 NP educational programs in this country and more than 140 programs for PAs. According to Dr. Cooper, this is still not enough. He has stated: “The United States has failed to ramp up the training of NPs or PAs to the extent that will be needed by a technologically advanced and accessible health care system.”

Market forces are shaping integrated health care delivery networks, yet we face increasing numbers of uninsured Americans. This only adds to the financial burden our country faces with delayed health care and inappropriate use of medical services. According to Sultz and Young in their book Health Care USA, “Managed care organizations have been particularly successful in using nurse practitioners and physician assistants to bolster their complement of staff physicians. Rural hospitals, with limited reserves of physicians, make substantial use of nurse practitioners and physician assistants.”

A number of landmark studies have claimed that PAs and NPs are qualified substitutes for primary care physicians, and researchers have also found that they are able to perform a great many of the tasks currently done by physicians. This is important, since NP and PA salaries are significantly lower than those of primary care physicians. The mean salary for a family practice NP in 2007 was $69,410, compared to $74,270 for a PA. A primary care physician in 2007 made approximately $149,850, according to the US Department of Labor’s Bureau of Labor Statistics. 

Based on that data, the average NP/PA salary is about half that of a primary care physician. With a substitution ratio for PAs and NPs of approximately 85% (based on PA data, at least), the cost of producing an NP or PA is about 20% of the cost for a physician. NPs and PAs can be in practice for four to six years before a physician is functioning postresidency. As a complement, PAs and NPs do, in most cases, offer a service that would not be available in the absence of a physician. They provide care that is of comparable quality and with comparable outcomes to that provided by physicians in similar settings.

While there has been a dearth of global studies in the last four decades on the cost-effectiveness of NPs and PAs, many studies have demonstrated cost-effectiveness in a number of specific practice settings. The impact of PA and NP practice continues to be positive, both in anecdotal and scientific research, although the actual demonstration of productivity across all practice settings is still being researched. There is no doubt that the analysis of the cost-effectiveness of NPs and PAs, because of the diverse clinical settings in this country, is complex. In addition to setting, it is also important to consider whether the PA or NP is a physician substitute or a physician complement—or both—to the practice.

Our country is at a critical juncture. The opportunity for change has never been greater. But there’s a lot that needs to be done, and we have to decide where we should focus first. As our health care system undergoes fundamental changes in structure and processes in the years to come, NPs and PAs must continue to be an important part of the workforce.

How do we do that? I have a few suggestions:

1. We should explore all avenues that will allow us to contribute to the health care reform debate on state and national levels.

2. We need to find innovative ways to increase the number of PA and NP graduates in the near future by recognizing alternative pathways in education, previous experience, and combinations of these to satisfy entry-to-practice requirements for licensure, while preserving the integrity of our clinical education sites.

3. We need to work with our regulatory boards in removing barriers to the full use of our scope of practice, particularly by eliminating entry-to-practice standards that are not based on the competence, skills, training, or knowledge of the NP or PA.

4. We need to continue the ongoing research into the cost-effectiveness and productivity of PAs and NPs in all practice settings, as well as the role they can play in reducing medical errors and malpractice.

5. We need to develop a national metric for the NP and PA that can be used for comprehensive workforce and health policy planning.

I agree with Marie-Eileen Onieal, PhD, CPNP, FAANP, Clinician Reviews’ NP Editor-in-Chief, who wrote in her editorial last month that “NPs and PAs still wear a virtual cloak of invisibility.” Now is the time to find ways to throw off that cloak. We in both professions must be vocal advocates for our role in a time of change. We are the architects of our future.

I would love to hear your thoughts on how we can accomplish that mission. E-mail me at [email protected].

Within the competencies espoused by the PA and NP professions, critical thinking is a paramount issue. In fact, the scope of practice for NPs and PAs is defined by an educational program’s competency standards and by state requirements for licensure—all of which demand critical thinking.

Despite these good intentions, medical errors remain prevalent. Even after the 1999 Institute of Medicine report To Err Is Human, there are concerns that our health care system lacks a firm commitment to patient safety. State regulatory boards are questioning the critical-thinking skills of clinicians in both ethical and medical problem solving. While medical science has been successful in extending life expectancy, our patients present with more severe illness than ever before, requiring the use of multiple medications, procedures, and treatments—all of which makes critical thinking more critical than ever.

In the face of this complexity, we find younger NP and PA students with less health care and life experience than their mentors had. Those who are accepted into highly competitive PA or NP programs have demonstrated an ability to retain and recall information, especially with multiple-choice questions that have a single correct answer. Anecdotally, however, many educators say that one of the biggest obstacles facing today’s students is learning how to be a critical thinker. I too have concerns about students who are passing all of their courses, including clinical rotations, when I hear comments such as “but they can’t think for themselves.” 

Clearly, not all PA and NP students are equipped with the critical-thinking skills needed in today’s complicated health care system. Even evidence-based medicine must be coupled with an equally rigorous argumentation process. As Jerome Groopman, MD, points out in How Doctors Think, “today’s rigid reliance on evidence-based medicine risks having the doctor choose care passively, solely by the numbers.”

Critical thinking in modern medicine is not something that can be instantly mastered; it must be learned though experience. According to Scott Weber, EdD, MSN, RN, FACHE, FHIMSS, in his article “Promoting Critical Thinking in Students” in the Journal of the American Academy of Nurse Practitioners, “the focus during clinicals should be on critical thinking (clinical reasoning) first and foremost…. A student should be a good entry-level critical thinker by the end of clinical education—for example, clear, accurate, precise, and relevant in his or her approach to practice, and able to link theory and practice in decision making, intervention planning, and even spontaneous modification of ongoing intervention processes.”

Weber adds that “a clinical student who is striving to become a good clinical thinker will:

“1. raise relevant, precise questions during clinical education, demonstrating the use of past experiences blended with knowledge;

“2. analyze and interpret clinical experiences from the assessment of relevant information;

“3. provide reasoned conclusions and intervention recommendations based on practice frames of reference and standards for professional performance;

“4. modify thinking based on practical implications that demonstrate self-correction of thinking in atypical or unique situations; and

“5. communicate effectively with others in negotiating complex problems.”

The most concise definition of critical thinking may be that of Dr. Richard Paul, Chair of the National Council for Excellence in Critical Thinking, who suggested that it is “the art of thinking about your thinking while you are thinking, in order to make your thinking better: more clear, more accurate, or more defensible.”

The pressing need to promote critical thinking among our students requires us to reevaluate our curricula and teaching methods. Critical thinking cannot be taught by lecturing. The relevant intellectual skills (analysis, synthesis, and reflection) must be learned through use. However, these skills can be cultivated through:

Clinical examinations. Students inevitably practice critical thinking with objective structured clinical examinations (or practical laboratories) developed to address the identified medical and behavioral problems.

Reflective papers. Reflective thinking refers to the processes of analyzing and making judgments about what has happened, then writing them down. It is increasingly important to prompt reflective thinking during learning to help students develop strategies to apply new knowledge to the complex situations they will confront in their day-to-day activities. Reflective thinking helps students develop higher-order thinking skills by prompting them to relate new knowledge to prior understanding, to think in both abstract and conceptual terms, to apply specific strategies in novel tasks, and to understand their own thinking and learning strategies.

Journal clubs. The journal club, an established teaching modality in many educational programs, improves students’ reading habits, knowledge of epidemiology and biostatistics, and critical appraisal skills.

Clinical case studies. Small-group interactions in which clinical cases are presented and discussed promote analysis and critical thinking.

Simulation. The best predictor of future performance is practicing in a simulated situation. Today’s sophisticated computer-based simulations of clinical problems can test a wide range of competencies. 

If we require NP and PA students to learn critical thinking, then how do we assess it? How can we know that our students have acquired this important skill?

Several standardized tests are available to assess critical thinking skills. The California Critical Thinking Skills Test (CCTST) is a challenging, discipline-neutral measure of actual cognitive skills used in critical thinking. The standardized and validated 34-item multiple-choice test targets the core skills considered essential in a college education. An older but frequently used test is the Watson-Glaser Critical Thinking Appraisal. It too is a multiple-choice tool with text-based questions; however, it uses a more limited response format than the CCTST.

No consensus exists, however, concerning the best test. And an individual’s results on one test cannot be assumed to indicate what he or she would score on a different test.

Discipline-specific national board examinations are another option for assessing critical thinking. Today’s computerized multiple-choice tests comprise questions that assess basic medical and surgical knowledge. Some testing of reasoning skills should be required of these high-stakes examinations.

NPs and PAs need to analyze, evaluate, and synthesize information from many sources in order to make appropriate decisions about a patient’s diagnosis and treatment plan. A lack of critical thinking can be dangerous—and perhaps even fatal.

I invite your responses on best practices for teaching and assessing critical thinking. Please e-mail me at [email protected].

Within the competencies espoused by the PA and NP professions, critical thinking is a paramount issue. In fact, the scope of practice for NPs and PAs is defined by an educational program’s competency standards and by state requirements for licensure—all of which demand critical thinking.

Despite these good intentions, medical errors remain prevalent. Even after the 1999 Institute of Medicine report To Err Is Human, there are concerns that our health care system lacks a firm commitment to patient safety. State regulatory boards are questioning the critical-thinking skills of clinicians in both ethical and medical problem solving. While medical science has been successful in extending life expectancy, our patients present with more severe illness than ever before, requiring the use of multiple medications, procedures, and treatments—all of which makes critical thinking more critical than ever.

In the face of this complexity, we find younger NP and PA students with less health care and life experience than their mentors had. Those who are accepted into highly competitive PA or NP programs have demonstrated an ability to retain and recall information, especially with multiple-choice questions that have a single correct answer. Anecdotally, however, many educators say that one of the biggest obstacles facing today’s students is learning how to be a critical thinker. I too have concerns about students who are passing all of their courses, including clinical rotations, when I hear comments such as “but they can’t think for themselves.” 

Clearly, not all PA and NP students are equipped with the critical-thinking skills needed in today’s complicated health care system. Even evidence-based medicine must be coupled with an equally rigorous argumentation process. As Jerome Groopman, MD, points out in How Doctors Think, “today’s rigid reliance on evidence-based medicine risks having the doctor choose care passively, solely by the numbers.”

Critical thinking in modern medicine is not something that can be instantly mastered; it must be learned though experience. According to Scott Weber, EdD, MSN, RN, FACHE, FHIMSS, in his article “Promoting Critical Thinking in Students” in the Journal of the American Academy of Nurse Practitioners, “the focus during clinicals should be on critical thinking (clinical reasoning) first and foremost…. A student should be a good entry-level critical thinker by the end of clinical education—for example, clear, accurate, precise, and relevant in his or her approach to practice, and able to link theory and practice in decision making, intervention planning, and even spontaneous modification of ongoing intervention processes.”

Weber adds that “a clinical student who is striving to become a good clinical thinker will:

“1. raise relevant, precise questions during clinical education, demonstrating the use of past experiences blended with knowledge;

“2. analyze and interpret clinical experiences from the assessment of relevant information;

“3. provide reasoned conclusions and intervention recommendations based on practice frames of reference and standards for professional performance;

“4. modify thinking based on practical implications that demonstrate self-correction of thinking in atypical or unique situations; and

“5. communicate effectively with others in negotiating complex problems.”

The most concise definition of critical thinking may be that of Dr. Richard Paul, Chair of the National Council for Excellence in Critical Thinking, who suggested that it is “the art of thinking about your thinking while you are thinking, in order to make your thinking better: more clear, more accurate, or more defensible.”

The pressing need to promote critical thinking among our students requires us to reevaluate our curricula and teaching methods. Critical thinking cannot be taught by lecturing. The relevant intellectual skills (analysis, synthesis, and reflection) must be learned through use. However, these skills can be cultivated through:

Clinical examinations. Students inevitably practice critical thinking with objective structured clinical examinations (or practical laboratories) developed to address the identified medical and behavioral problems.

Reflective papers. Reflective thinking refers to the processes of analyzing and making judgments about what has happened, then writing them down. It is increasingly important to prompt reflective thinking during learning to help students develop strategies to apply new knowledge to the complex situations they will confront in their day-to-day activities. Reflective thinking helps students develop higher-order thinking skills by prompting them to relate new knowledge to prior understanding, to think in both abstract and conceptual terms, to apply specific strategies in novel tasks, and to understand their own thinking and learning strategies.

Journal clubs. The journal club, an established teaching modality in many educational programs, improves students’ reading habits, knowledge of epidemiology and biostatistics, and critical appraisal skills.

Clinical case studies. Small-group interactions in which clinical cases are presented and discussed promote analysis and critical thinking.

Simulation. The best predictor of future performance is practicing in a simulated situation. Today’s sophisticated computer-based simulations of clinical problems can test a wide range of competencies. 

If we require NP and PA students to learn critical thinking, then how do we assess it? How can we know that our students have acquired this important skill?

Several standardized tests are available to assess critical thinking skills. The California Critical Thinking Skills Test (CCTST) is a challenging, discipline-neutral measure of actual cognitive skills used in critical thinking. The standardized and validated 34-item multiple-choice test targets the core skills considered essential in a college education. An older but frequently used test is the Watson-Glaser Critical Thinking Appraisal. It too is a multiple-choice tool with text-based questions; however, it uses a more limited response format than the CCTST.

No consensus exists, however, concerning the best test. And an individual’s results on one test cannot be assumed to indicate what he or she would score on a different test.

Discipline-specific national board examinations are another option for assessing critical thinking. Today’s computerized multiple-choice tests comprise questions that assess basic medical and surgical knowledge. Some testing of reasoning skills should be required of these high-stakes examinations.

NPs and PAs need to analyze, evaluate, and synthesize information from many sources in order to make appropriate decisions about a patient’s diagnosis and treatment plan. A lack of critical thinking can be dangerous—and perhaps even fatal.

I invite your responses on best practices for teaching and assessing critical thinking. Please e-mail me at [email protected].

Within the competencies espoused by the PA and NP professions, critical thinking is a paramount issue. In fact, the scope of practice for NPs and PAs is defined by an educational program’s competency standards and by state requirements for licensure—all of which demand critical thinking.

Despite these good intentions, medical errors remain prevalent. Even after the 1999 Institute of Medicine report To Err Is Human, there are concerns that our health care system lacks a firm commitment to patient safety. State regulatory boards are questioning the critical-thinking skills of clinicians in both ethical and medical problem solving. While medical science has been successful in extending life expectancy, our patients present with more severe illness than ever before, requiring the use of multiple medications, procedures, and treatments—all of which makes critical thinking more critical than ever.

In the face of this complexity, we find younger NP and PA students with less health care and life experience than their mentors had. Those who are accepted into highly competitive PA or NP programs have demonstrated an ability to retain and recall information, especially with multiple-choice questions that have a single correct answer. Anecdotally, however, many educators say that one of the biggest obstacles facing today’s students is learning how to be a critical thinker. I too have concerns about students who are passing all of their courses, including clinical rotations, when I hear comments such as “but they can’t think for themselves.” 

Clearly, not all PA and NP students are equipped with the critical-thinking skills needed in today’s complicated health care system. Even evidence-based medicine must be coupled with an equally rigorous argumentation process. As Jerome Groopman, MD, points out in How Doctors Think, “today’s rigid reliance on evidence-based medicine risks having the doctor choose care passively, solely by the numbers.”

Critical thinking in modern medicine is not something that can be instantly mastered; it must be learned though experience. According to Scott Weber, EdD, MSN, RN, FACHE, FHIMSS, in his article “Promoting Critical Thinking in Students” in the Journal of the American Academy of Nurse Practitioners, “the focus during clinicals should be on critical thinking (clinical reasoning) first and foremost…. A student should be a good entry-level critical thinker by the end of clinical education—for example, clear, accurate, precise, and relevant in his or her approach to practice, and able to link theory and practice in decision making, intervention planning, and even spontaneous modification of ongoing intervention processes.”

Weber adds that “a clinical student who is striving to become a good clinical thinker will:

“1. raise relevant, precise questions during clinical education, demonstrating the use of past experiences blended with knowledge;

“2. analyze and interpret clinical experiences from the assessment of relevant information;

“3. provide reasoned conclusions and intervention recommendations based on practice frames of reference and standards for professional performance;

“4. modify thinking based on practical implications that demonstrate self-correction of thinking in atypical or unique situations; and

“5. communicate effectively with others in negotiating complex problems.”

The most concise definition of critical thinking may be that of Dr. Richard Paul, Chair of the National Council for Excellence in Critical Thinking, who suggested that it is “the art of thinking about your thinking while you are thinking, in order to make your thinking better: more clear, more accurate, or more defensible.”

The pressing need to promote critical thinking among our students requires us to reevaluate our curricula and teaching methods. Critical thinking cannot be taught by lecturing. The relevant intellectual skills (analysis, synthesis, and reflection) must be learned through use. However, these skills can be cultivated through:

Clinical examinations. Students inevitably practice critical thinking with objective structured clinical examinations (or practical laboratories) developed to address the identified medical and behavioral problems.

Reflective papers. Reflective thinking refers to the processes of analyzing and making judgments about what has happened, then writing them down. It is increasingly important to prompt reflective thinking during learning to help students develop strategies to apply new knowledge to the complex situations they will confront in their day-to-day activities. Reflective thinking helps students develop higher-order thinking skills by prompting them to relate new knowledge to prior understanding, to think in both abstract and conceptual terms, to apply specific strategies in novel tasks, and to understand their own thinking and learning strategies.

Journal clubs. The journal club, an established teaching modality in many educational programs, improves students’ reading habits, knowledge of epidemiology and biostatistics, and critical appraisal skills.

Clinical case studies. Small-group interactions in which clinical cases are presented and discussed promote analysis and critical thinking.

Simulation. The best predictor of future performance is practicing in a simulated situation. Today’s sophisticated computer-based simulations of clinical problems can test a wide range of competencies. 

If we require NP and PA students to learn critical thinking, then how do we assess it? How can we know that our students have acquired this important skill?

Several standardized tests are available to assess critical thinking skills. The California Critical Thinking Skills Test (CCTST) is a challenging, discipline-neutral measure of actual cognitive skills used in critical thinking. The standardized and validated 34-item multiple-choice test targets the core skills considered essential in a college education. An older but frequently used test is the Watson-Glaser Critical Thinking Appraisal. It too is a multiple-choice tool with text-based questions; however, it uses a more limited response format than the CCTST.

No consensus exists, however, concerning the best test. And an individual’s results on one test cannot be assumed to indicate what he or she would score on a different test.

Discipline-specific national board examinations are another option for assessing critical thinking. Today’s computerized multiple-choice tests comprise questions that assess basic medical and surgical knowledge. Some testing of reasoning skills should be required of these high-stakes examinations.

NPs and PAs need to analyze, evaluate, and synthesize information from many sources in order to make appropriate decisions about a patient’s diagnosis and treatment plan. A lack of critical thinking can be dangerous—and perhaps even fatal.

I invite your responses on best practices for teaching and assessing critical thinking. Please e-mail me at [email protected].

Over the past two decades, our changing health care environment has increased both interest in and the need for NPs and PAs as providers. Nursing and PA educators have responded by significantly increasing class sizes. This, in turn, has led to a greater demand for quality clinical preceptors. The preceptor/student relationship is at the very core of the growth and development of NP and PA students. Most clinical preceptors are unpaid volunteers, despite the fact that the time they spend teaching students can lengthen their workday and decrease their productivity as clinicians.

The other day, I was shocked by the response from a potential clinical preceptor for our students. He asked, “What’s in it for me?” Now, I realize that the daily demands of clinical practice are quite overwhelming. With admissions, emergencies, and complications, not to mention the daunting business aspects of managing a practice, even the most skilled and efficient clinicians are seriously challenged. That’s certainly one explanation for the response I received.

But perhaps there’s another explanation. Could it be that the insidious commercialism or deprofessionalism of medicine has changed clinicians’ attitudes? Do we have a new generation of providers who either by choice or by burnout have become jaded and given up on the “pay it forward” philosophy? Tell me it ain’t so.

Even under the best of circumstances, time is a major factor in the clinician’s world. It would be an understatement to say that clinical preceptors who have volunteered to train a PA or NP student have their work cut out for them. Still, I would hope that this potential preceptor’s self-serving question is not a typical response. And yet, to be frank, I keep hearing similar comments. There is even a movement afoot for group practices, hospitals, and HMOs to start charging for precepting a student to recoup lost revenue. Word is that this will soon become standard practice.

Could it be that precepting will soon become a lost art? Is it realistic to think otherwise? Is there anything that could possibly replace it? If we assume that paying for clinical rotations is inevitable, do we ignore it and avoid it as long as possible? Or do we jump in now and try to create the best deal possible for our students?

Of course, entering into a financial contract with a preceptor brings a new level of obligation for both parties. There is also the worry that the cost of future clinical rotations may roll over into increased tuition for students.

I can’t help but think back (yes, it was another century) to my student days and the dedication demonstrated by physicians and NP and PA preceptors. They all wanted to give something back to their profession for the benefit of their patients and society as a whole. They all spent the time needed to make sure the student received the best experience possible—and all of this without asking for compensation. What has changed over the years?

It’s true that clinical preceptors today often don’t have the means or the workload with which to create an ideal environment for student learning to take place. In fact, they may have no control over that if they are employees or contractors. In a perfect system, clinical preceptors would have less work to do themselves and more time to prepare for the teaching process. Unfortunately, that is not a realistic expectation in today’s health care system.

Educators feel that precepting students exemplifies the highest principles of clinical education. Clinical preceptors must be confident in their clinical and teaching skills and generous with their time. Perhaps learning how to better utilize their time will enhance the precepting experience.

An article entitled “A Five-Step ‘Microskills’ Model of Clinical Teaching” was published in the Journal of the American Board of Family Practice in 1992. This article formed the basis for what became known as the “One-Minute Preceptor” approach to effective clinical precepting, and it has been modified and changed over the years. In general, this model offers the following tips for efficient instruction:

1. Get a verbal commitment from the student to an aspect of a case. Ask questions such as “What do you think is going on with this patient?” or “What other diagnoses would you consider in this setting?” The act of stating a commitment pushes the student beyond his or her comfort level and makes the teaching encounter more interactive and personal.

2. Probe for a rationale. Determine if there is an adequate rationale for the student’s answers to your questions. Encourage an appropriate reasoning process.

3. Reinforce what was done well. Positive comments should focus on specific behaviors that demonstrated knowledge, skills, or attitudes that you value as a preceptor. At the same time, it is important to tell the student what areas need improvement in as specific a manner as possible.

4. Teach a general principle. Take the information and data gleaned from an individual learning situation and apply them as a broader concept to other situations.

5. Provide closure. Time management is a critical function in clinical precepting. This final step serves the very important function of ending the teaching moment and defining what the role of the student will be in the next precepting opportunity.

Busy clinical preceptors have welcomed this strategy. The problem with clinical precepting, some say, is that too much time is spent on the nonteaching aspects of preceptorship and the whole process isn’t structured to facilitate effective teaching.

While precepting students can be an enjoyable activity, there are pitfalls that can be anticipated and perhaps even avoided to enhance the experience. Paulman, Susman, and Abboud, editors of Precepting Medical Students in the Office (2000), make the following suggestions:

• Don’t agree to precept a student when you are overcommitted and stressed.

• Don’t hesitate to discuss mutual expectations for the preceptorship.

• Don’t try to teach too much.

• Don’t have students just follow you around. Give them specific tasks to do while you see other patients. This tends to stimulate and vitalize them.

• Don’t make assumptions about your students’ knowledge.

• Don’t assume that documentation by students is adequate or appropriate.

• Avoid subtle putdowns of a student in front of the patient.

• Don’t hesitate to mention issues that are a source of significant annoyance. (For example, a student’s behavior, dress, or personal hygiene may cause irritation or frustration. Deal with it early on.) 

With the number of NP and PA students on the rise, there is a greater need than ever for more qualified and dedicated preceptors. If you are not currently a clinical preceptor, I hope that you will consider calling your local NP or PA school and volunteering. If you are already a preceptor, thank you. And let us know what can be done to make your experience better.

I would love to hear from you on the issue of clinical precepting. Please e-mail me at [email protected].

Over the past two decades, our changing health care environment has increased both interest in and the need for NPs and PAs as providers. Nursing and PA educators have responded by significantly increasing class sizes. This, in turn, has led to a greater demand for quality clinical preceptors. The preceptor/student relationship is at the very core of the growth and development of NP and PA students. Most clinical preceptors are unpaid volunteers, despite the fact that the time they spend teaching students can lengthen their workday and decrease their productivity as clinicians.

The other day, I was shocked by the response from a potential clinical preceptor for our students. He asked, “What’s in it for me?” Now, I realize that the daily demands of clinical practice are quite overwhelming. With admissions, emergencies, and complications, not to mention the daunting business aspects of managing a practice, even the most skilled and efficient clinicians are seriously challenged. That’s certainly one explanation for the response I received.

But perhaps there’s another explanation. Could it be that the insidious commercialism or deprofessionalism of medicine has changed clinicians’ attitudes? Do we have a new generation of providers who either by choice or by burnout have become jaded and given up on the “pay it forward” philosophy? Tell me it ain’t so.

Even under the best of circumstances, time is a major factor in the clinician’s world. It would be an understatement to say that clinical preceptors who have volunteered to train a PA or NP student have their work cut out for them. Still, I would hope that this potential preceptor’s self-serving question is not a typical response. And yet, to be frank, I keep hearing similar comments. There is even a movement afoot for group practices, hospitals, and HMOs to start charging for precepting a student to recoup lost revenue. Word is that this will soon become standard practice.

Could it be that precepting will soon become a lost art? Is it realistic to think otherwise? Is there anything that could possibly replace it? If we assume that paying for clinical rotations is inevitable, do we ignore it and avoid it as long as possible? Or do we jump in now and try to create the best deal possible for our students?

Of course, entering into a financial contract with a preceptor brings a new level of obligation for both parties. There is also the worry that the cost of future clinical rotations may roll over into increased tuition for students.

I can’t help but think back (yes, it was another century) to my student days and the dedication demonstrated by physicians and NP and PA preceptors. They all wanted to give something back to their profession for the benefit of their patients and society as a whole. They all spent the time needed to make sure the student received the best experience possible—and all of this without asking for compensation. What has changed over the years?

It’s true that clinical preceptors today often don’t have the means or the workload with which to create an ideal environment for student learning to take place. In fact, they may have no control over that if they are employees or contractors. In a perfect system, clinical preceptors would have less work to do themselves and more time to prepare for the teaching process. Unfortunately, that is not a realistic expectation in today’s health care system.

Educators feel that precepting students exemplifies the highest principles of clinical education. Clinical preceptors must be confident in their clinical and teaching skills and generous with their time. Perhaps learning how to better utilize their time will enhance the precepting experience.

An article entitled “A Five-Step ‘Microskills’ Model of Clinical Teaching” was published in the Journal of the American Board of Family Practice in 1992. This article formed the basis for what became known as the “One-Minute Preceptor” approach to effective clinical precepting, and it has been modified and changed over the years. In general, this model offers the following tips for efficient instruction:

1. Get a verbal commitment from the student to an aspect of a case. Ask questions such as “What do you think is going on with this patient?” or “What other diagnoses would you consider in this setting?” The act of stating a commitment pushes the student beyond his or her comfort level and makes the teaching encounter more interactive and personal.

2. Probe for a rationale. Determine if there is an adequate rationale for the student’s answers to your questions. Encourage an appropriate reasoning process.

3. Reinforce what was done well. Positive comments should focus on specific behaviors that demonstrated knowledge, skills, or attitudes that you value as a preceptor. At the same time, it is important to tell the student what areas need improvement in as specific a manner as possible.

4. Teach a general principle. Take the information and data gleaned from an individual learning situation and apply them as a broader concept to other situations.

5. Provide closure. Time management is a critical function in clinical precepting. This final step serves the very important function of ending the teaching moment and defining what the role of the student will be in the next precepting opportunity.

Busy clinical preceptors have welcomed this strategy. The problem with clinical precepting, some say, is that too much time is spent on the nonteaching aspects of preceptorship and the whole process isn’t structured to facilitate effective teaching.

While precepting students can be an enjoyable activity, there are pitfalls that can be anticipated and perhaps even avoided to enhance the experience. Paulman, Susman, and Abboud, editors of Precepting Medical Students in the Office (2000), make the following suggestions:

• Don’t agree to precept a student when you are overcommitted and stressed.

• Don’t hesitate to discuss mutual expectations for the preceptorship.

• Don’t try to teach too much.

• Don’t have students just follow you around. Give them specific tasks to do while you see other patients. This tends to stimulate and vitalize them.

• Don’t make assumptions about your students’ knowledge.

• Don’t assume that documentation by students is adequate or appropriate.

• Avoid subtle putdowns of a student in front of the patient.

• Don’t hesitate to mention issues that are a source of significant annoyance. (For example, a student’s behavior, dress, or personal hygiene may cause irritation or frustration. Deal with it early on.) 

With the number of NP and PA students on the rise, there is a greater need than ever for more qualified and dedicated preceptors. If you are not currently a clinical preceptor, I hope that you will consider calling your local NP or PA school and volunteering. If you are already a preceptor, thank you. And let us know what can be done to make your experience better.

I would love to hear from you on the issue of clinical precepting. Please e-mail me at [email protected].

Over the past two decades, our changing health care environment has increased both interest in and the need for NPs and PAs as providers. Nursing and PA educators have responded by significantly increasing class sizes. This, in turn, has led to a greater demand for quality clinical preceptors. The preceptor/student relationship is at the very core of the growth and development of NP and PA students. Most clinical preceptors are unpaid volunteers, despite the fact that the time they spend teaching students can lengthen their workday and decrease their productivity as clinicians.

The other day, I was shocked by the response from a potential clinical preceptor for our students. He asked, “What’s in it for me?” Now, I realize that the daily demands of clinical practice are quite overwhelming. With admissions, emergencies, and complications, not to mention the daunting business aspects of managing a practice, even the most skilled and efficient clinicians are seriously challenged. That’s certainly one explanation for the response I received.

But perhaps there’s another explanation. Could it be that the insidious commercialism or deprofessionalism of medicine has changed clinicians’ attitudes? Do we have a new generation of providers who either by choice or by burnout have become jaded and given up on the “pay it forward” philosophy? Tell me it ain’t so.

Even under the best of circumstances, time is a major factor in the clinician’s world. It would be an understatement to say that clinical preceptors who have volunteered to train a PA or NP student have their work cut out for them. Still, I would hope that this potential preceptor’s self-serving question is not a typical response. And yet, to be frank, I keep hearing similar comments. There is even a movement afoot for group practices, hospitals, and HMOs to start charging for precepting a student to recoup lost revenue. Word is that this will soon become standard practice.

Could it be that precepting will soon become a lost art? Is it realistic to think otherwise? Is there anything that could possibly replace it? If we assume that paying for clinical rotations is inevitable, do we ignore it and avoid it as long as possible? Or do we jump in now and try to create the best deal possible for our students?

Of course, entering into a financial contract with a preceptor brings a new level of obligation for both parties. There is also the worry that the cost of future clinical rotations may roll over into increased tuition for students.

I can’t help but think back (yes, it was another century) to my student days and the dedication demonstrated by physicians and NP and PA preceptors. They all wanted to give something back to their profession for the benefit of their patients and society as a whole. They all spent the time needed to make sure the student received the best experience possible—and all of this without asking for compensation. What has changed over the years?

It’s true that clinical preceptors today often don’t have the means or the workload with which to create an ideal environment for student learning to take place. In fact, they may have no control over that if they are employees or contractors. In a perfect system, clinical preceptors would have less work to do themselves and more time to prepare for the teaching process. Unfortunately, that is not a realistic expectation in today’s health care system.

Educators feel that precepting students exemplifies the highest principles of clinical education. Clinical preceptors must be confident in their clinical and teaching skills and generous with their time. Perhaps learning how to better utilize their time will enhance the precepting experience.

An article entitled “A Five-Step ‘Microskills’ Model of Clinical Teaching” was published in the Journal of the American Board of Family Practice in 1992. This article formed the basis for what became known as the “One-Minute Preceptor” approach to effective clinical precepting, and it has been modified and changed over the years. In general, this model offers the following tips for efficient instruction:

1. Get a verbal commitment from the student to an aspect of a case. Ask questions such as “What do you think is going on with this patient?” or “What other diagnoses would you consider in this setting?” The act of stating a commitment pushes the student beyond his or her comfort level and makes the teaching encounter more interactive and personal.

2. Probe for a rationale. Determine if there is an adequate rationale for the student’s answers to your questions. Encourage an appropriate reasoning process.

3. Reinforce what was done well. Positive comments should focus on specific behaviors that demonstrated knowledge, skills, or attitudes that you value as a preceptor. At the same time, it is important to tell the student what areas need improvement in as specific a manner as possible.

4. Teach a general principle. Take the information and data gleaned from an individual learning situation and apply them as a broader concept to other situations.

5. Provide closure. Time management is a critical function in clinical precepting. This final step serves the very important function of ending the teaching moment and defining what the role of the student will be in the next precepting opportunity.

Busy clinical preceptors have welcomed this strategy. The problem with clinical precepting, some say, is that too much time is spent on the nonteaching aspects of preceptorship and the whole process isn’t structured to facilitate effective teaching.

While precepting students can be an enjoyable activity, there are pitfalls that can be anticipated and perhaps even avoided to enhance the experience. Paulman, Susman, and Abboud, editors of Precepting Medical Students in the Office (2000), make the following suggestions:

• Don’t agree to precept a student when you are overcommitted and stressed.

• Don’t hesitate to discuss mutual expectations for the preceptorship.

• Don’t try to teach too much.

• Don’t have students just follow you around. Give them specific tasks to do while you see other patients. This tends to stimulate and vitalize them.

• Don’t make assumptions about your students’ knowledge.

• Don’t assume that documentation by students is adequate or appropriate.

• Avoid subtle putdowns of a student in front of the patient.

• Don’t hesitate to mention issues that are a source of significant annoyance. (For example, a student’s behavior, dress, or personal hygiene may cause irritation or frustration. Deal with it early on.) 

With the number of NP and PA students on the rise, there is a greater need than ever for more qualified and dedicated preceptors. If you are not currently a clinical preceptor, I hope that you will consider calling your local NP or PA school and volunteering. If you are already a preceptor, thank you. And let us know what can be done to make your experience better.

I would love to hear from you on the issue of clinical precepting. Please e-mail me at [email protected].

In addition to the longstanding issues of patients’ lack of access to health care and the increasing costs of that care, there continue to be concerns about the safety and quality of care being delivered in the United States. This is especially true as more information on the nature and extent of errors in health care has been brought to the forefront.

Since 1990, the National Practitioner Data Bank (NPDB) has been collecting information on health care practitioners, including NPs and PAs, with regard to disciplinary actions such as monetary judgments (both by settlement and jury decision), loss of licensure, and limitation of practice. Over the years, PAs and NPs have experienced increased liability (mostly as a result of their expanding scope of practice), greater patient care responsibilities, and more autonomy. However, according to an article in the March 20, 2000, edition of Medical Economics, “Judging from the actual number of malpractice cases settled, PAs and NPs are in court much less often than their doctor colleagues.”

Information from the NPDB, in fact, reveals that NPs and PAs still incur a remarkably low rate of malpractice judgments. Moreover, anecdotal data support the possibility that hiring a PA or NP may even reduce the risk of malpractice liability.

The Health Care Quality Improvement Act, passed by Congress in 1986, requires that all malpractice payments made on behalf of any clinician who is licensed, registered, or certified by the state must be reported to the NPDB. Since the data bank began collecting statistics, it has recorded a total of 235,797 paid claims for all physicians of every type, with an average paid claim (inflation adjusted) of $282,782. During that same period, the NPDB recorded a total of 1,130 paid claims for PAs, with an average paid claim of $86,568. The total number of NP claims was 470, but average claim data were not available.

You can get some perspective on these data by keeping in mind that in 2006, there were 633,000 physicians, 125,000 NPs, and 70,000 PAs practicing in the US. There are five physicians for every NP in the country; nine physicians for every PA. Can we surmise then that the number of physician-related paid claims should be five times that of NP-related paid claims and nine times that of PA-related claims? 

In reality, the number of physician-related paid claims approaches 100 times that of PA-related paid claims. A further disparity is noted when mean losses are compared: The 2006 mean physician-related losses are 33% higher than PA-related losses ($312,000 for physicians vs $234,000 for PAs). Unfortunately, it should be noted that the mean rate for PAs is approaching that of the physician.

Another way of examining the differences among the malpractice experiences of NPs, PAs, and physicians is to calculate how many providers of each type exist for each malpractice paid claim. Data from 2006 show that one claim was paid for every 2.68 physicians, compared to one for every 210.43 NPs and one for every 619.5 PAs.

It is true that we don’t know for sure how accurate the data reported to the NPDB are. Variations in NP practice—whether independent, collaborative, or phys-ician-supervised—exist from state to state, which may affect the reliability of the data. Also, differences exist among states in the way NPs are licensed. In some states, an NP is licensed as a nurse while in others he or she would be licensed as an NP, which can similarly alter the reporting. And because prescriptive authority by PAs and NPs varies from state to state, it may be true that states are not on an equal footing when it comes to their settlement of claims against NPs or PAs.

Lastly, NPs are reported to the NPDB separately from certified nurse midwives (596 paid claims) and advanced practice nurses (1,181 claims including CRNAs). If they were reported as one group, that would also affect the numbers.

It must be remembered that each health care provider is responsible for his or her own negligent acts. Even if you are a dependent practitioner with a supervising physician who is responsible for your actions, that does not exonerate you from the risk of individual liability.

To win a negligence case and recover damages from an NP or PA, a patient must prove three things: that the PA or NP owed the patient a duty of care, that he or she breached that duty, and that the patient was harmed as a result of the NP’s or PA’s action or failure to act. Conduct that may lead to liability includes failure to properly diagnose, failure to refer, exceeding one’s scope of practice, negligent monitoring, failure to question a physician’s abnormal order, or failure to properly follow up.

In most cases, PAs and NPs are covered under their employer’s policy. In spite of that, they may still be liable for their own negligence and for all or part of a plaintiff’s award or settlement. It is important, in my experience, that NPs and PAs maintain their own personal medical liability insurance.

There are plenty of articles and handbooks that discuss methods to avoid medical liability, such as the Physician Assistant Legal Handbook by Aspen Health Law and Compliance Center and The Advanced Practice Nurse’s Legal Handbook by Rebecca F. Cady, RNC, BSN, JD. But in my opinion, they all boil down to the following basic principles:

• Know and understand your scope of practice under state law.

• Know and understand your hospital or institutional policies.

• Know and understand the importance of communicating honestly with your patients and your supervising or collaborating physician.

Ensuring patient safety and improving quality of care are steadfast goals for all NPs and PAs. We need to continue our discussions on best practices for preventing medical errors as well as finding ways to remove barriers to effective practice. I would love to hear from you about these matters. Please e-mail me at [email protected].         

In addition to the longstanding issues of patients’ lack of access to health care and the increasing costs of that care, there continue to be concerns about the safety and quality of care being delivered in the United States. This is especially true as more information on the nature and extent of errors in health care has been brought to the forefront.

Since 1990, the National Practitioner Data Bank (NPDB) has been collecting information on health care practitioners, including NPs and PAs, with regard to disciplinary actions such as monetary judgments (both by settlement and jury decision), loss of licensure, and limitation of practice. Over the years, PAs and NPs have experienced increased liability (mostly as a result of their expanding scope of practice), greater patient care responsibilities, and more autonomy. However, according to an article in the March 20, 2000, edition of Medical Economics, “Judging from the actual number of malpractice cases settled, PAs and NPs are in court much less often than their doctor colleagues.”

Information from the NPDB, in fact, reveals that NPs and PAs still incur a remarkably low rate of malpractice judgments. Moreover, anecdotal data support the possibility that hiring a PA or NP may even reduce the risk of malpractice liability.

The Health Care Quality Improvement Act, passed by Congress in 1986, requires that all malpractice payments made on behalf of any clinician who is licensed, registered, or certified by the state must be reported to the NPDB. Since the data bank began collecting statistics, it has recorded a total of 235,797 paid claims for all physicians of every type, with an average paid claim (inflation adjusted) of $282,782. During that same period, the NPDB recorded a total of 1,130 paid claims for PAs, with an average paid claim of $86,568. The total number of NP claims was 470, but average claim data were not available.

You can get some perspective on these data by keeping in mind that in 2006, there were 633,000 physicians, 125,000 NPs, and 70,000 PAs practicing in the US. There are five physicians for every NP in the country; nine physicians for every PA. Can we surmise then that the number of physician-related paid claims should be five times that of NP-related paid claims and nine times that of PA-related claims? 

In reality, the number of physician-related paid claims approaches 100 times that of PA-related paid claims. A further disparity is noted when mean losses are compared: The 2006 mean physician-related losses are 33% higher than PA-related losses ($312,000 for physicians vs $234,000 for PAs). Unfortunately, it should be noted that the mean rate for PAs is approaching that of the physician.

Another way of examining the differences among the malpractice experiences of NPs, PAs, and physicians is to calculate how many providers of each type exist for each malpractice paid claim. Data from 2006 show that one claim was paid for every 2.68 physicians, compared to one for every 210.43 NPs and one for every 619.5 PAs.

It is true that we don’t know for sure how accurate the data reported to the NPDB are. Variations in NP practice—whether independent, collaborative, or phys-ician-supervised—exist from state to state, which may affect the reliability of the data. Also, differences exist among states in the way NPs are licensed. In some states, an NP is licensed as a nurse while in others he or she would be licensed as an NP, which can similarly alter the reporting. And because prescriptive authority by PAs and NPs varies from state to state, it may be true that states are not on an equal footing when it comes to their settlement of claims against NPs or PAs.

Lastly, NPs are reported to the NPDB separately from certified nurse midwives (596 paid claims) and advanced practice nurses (1,181 claims including CRNAs). If they were reported as one group, that would also affect the numbers.

It must be remembered that each health care provider is responsible for his or her own negligent acts. Even if you are a dependent practitioner with a supervising physician who is responsible for your actions, that does not exonerate you from the risk of individual liability.

To win a negligence case and recover damages from an NP or PA, a patient must prove three things: that the PA or NP owed the patient a duty of care, that he or she breached that duty, and that the patient was harmed as a result of the NP’s or PA’s action or failure to act. Conduct that may lead to liability includes failure to properly diagnose, failure to refer, exceeding one’s scope of practice, negligent monitoring, failure to question a physician’s abnormal order, or failure to properly follow up.

In most cases, PAs and NPs are covered under their employer’s policy. In spite of that, they may still be liable for their own negligence and for all or part of a plaintiff’s award or settlement. It is important, in my experience, that NPs and PAs maintain their own personal medical liability insurance.

There are plenty of articles and handbooks that discuss methods to avoid medical liability, such as the Physician Assistant Legal Handbook by Aspen Health Law and Compliance Center and The Advanced Practice Nurse’s Legal Handbook by Rebecca F. Cady, RNC, BSN, JD. But in my opinion, they all boil down to the following basic principles:

• Know and understand your scope of practice under state law.

• Know and understand your hospital or institutional policies.

• Know and understand the importance of communicating honestly with your patients and your supervising or collaborating physician.

Ensuring patient safety and improving quality of care are steadfast goals for all NPs and PAs. We need to continue our discussions on best practices for preventing medical errors as well as finding ways to remove barriers to effective practice. I would love to hear from you about these matters. Please e-mail me at [email protected].         

In addition to the longstanding issues of patients’ lack of access to health care and the increasing costs of that care, there continue to be concerns about the safety and quality of care being delivered in the United States. This is especially true as more information on the nature and extent of errors in health care has been brought to the forefront.

Since 1990, the National Practitioner Data Bank (NPDB) has been collecting information on health care practitioners, including NPs and PAs, with regard to disciplinary actions such as monetary judgments (both by settlement and jury decision), loss of licensure, and limitation of practice. Over the years, PAs and NPs have experienced increased liability (mostly as a result of their expanding scope of practice), greater patient care responsibilities, and more autonomy. However, according to an article in the March 20, 2000, edition of Medical Economics, “Judging from the actual number of malpractice cases settled, PAs and NPs are in court much less often than their doctor colleagues.”

Information from the NPDB, in fact, reveals that NPs and PAs still incur a remarkably low rate of malpractice judgments. Moreover, anecdotal data support the possibility that hiring a PA or NP may even reduce the risk of malpractice liability.

The Health Care Quality Improvement Act, passed by Congress in 1986, requires that all malpractice payments made on behalf of any clinician who is licensed, registered, or certified by the state must be reported to the NPDB. Since the data bank began collecting statistics, it has recorded a total of 235,797 paid claims for all physicians of every type, with an average paid claim (inflation adjusted) of $282,782. During that same period, the NPDB recorded a total of 1,130 paid claims for PAs, with an average paid claim of $86,568. The total number of NP claims was 470, but average claim data were not available.

You can get some perspective on these data by keeping in mind that in 2006, there were 633,000 physicians, 125,000 NPs, and 70,000 PAs practicing in the US. There are five physicians for every NP in the country; nine physicians for every PA. Can we surmise then that the number of physician-related paid claims should be five times that of NP-related paid claims and nine times that of PA-related claims? 

In reality, the number of physician-related paid claims approaches 100 times that of PA-related paid claims. A further disparity is noted when mean losses are compared: The 2006 mean physician-related losses are 33% higher than PA-related losses ($312,000 for physicians vs $234,000 for PAs). Unfortunately, it should be noted that the mean rate for PAs is approaching that of the physician.

Another way of examining the differences among the malpractice experiences of NPs, PAs, and physicians is to calculate how many providers of each type exist for each malpractice paid claim. Data from 2006 show that one claim was paid for every 2.68 physicians, compared to one for every 210.43 NPs and one for every 619.5 PAs.

It is true that we don’t know for sure how accurate the data reported to the NPDB are. Variations in NP practice—whether independent, collaborative, or phys-ician-supervised—exist from state to state, which may affect the reliability of the data. Also, differences exist among states in the way NPs are licensed. In some states, an NP is licensed as a nurse while in others he or she would be licensed as an NP, which can similarly alter the reporting. And because prescriptive authority by PAs and NPs varies from state to state, it may be true that states are not on an equal footing when it comes to their settlement of claims against NPs or PAs.

Lastly, NPs are reported to the NPDB separately from certified nurse midwives (596 paid claims) and advanced practice nurses (1,181 claims including CRNAs). If they were reported as one group, that would also affect the numbers.

It must be remembered that each health care provider is responsible for his or her own negligent acts. Even if you are a dependent practitioner with a supervising physician who is responsible for your actions, that does not exonerate you from the risk of individual liability.

To win a negligence case and recover damages from an NP or PA, a patient must prove three things: that the PA or NP owed the patient a duty of care, that he or she breached that duty, and that the patient was harmed as a result of the NP’s or PA’s action or failure to act. Conduct that may lead to liability includes failure to properly diagnose, failure to refer, exceeding one’s scope of practice, negligent monitoring, failure to question a physician’s abnormal order, or failure to properly follow up.

In most cases, PAs and NPs are covered under their employer’s policy. In spite of that, they may still be liable for their own negligence and for all or part of a plaintiff’s award or settlement. It is important, in my experience, that NPs and PAs maintain their own personal medical liability insurance.

There are plenty of articles and handbooks that discuss methods to avoid medical liability, such as the Physician Assistant Legal Handbook by Aspen Health Law and Compliance Center and The Advanced Practice Nurse’s Legal Handbook by Rebecca F. Cady, RNC, BSN, JD. But in my opinion, they all boil down to the following basic principles:

• Know and understand your scope of practice under state law.

• Know and understand your hospital or institutional policies.

• Know and understand the importance of communicating honestly with your patients and your supervising or collaborating physician.

Ensuring patient safety and improving quality of care are steadfast goals for all NPs and PAs. We need to continue our discussions on best practices for preventing medical errors as well as finding ways to remove barriers to effective practice. I would love to hear from you about these matters. Please e-mail me at [email protected].         

I have received many positive responses to my comments regarding a pathway for PAs and NPs to become physicians in our March cover article, “Degrees of Latitude: Real Issues Behind Clinical Doctorates.” In essence, I advocated for medical schools to recognize the training and clinical experience of NPs and PAs and provide an advanced and accelerated pathway for these clinicians. As we all know, the need for affordable and accessible health care is growing rapidly in tandem with our increasing population and the aging of America. To meet this challenge, more health care practitioners are needed, especially in the primary care setting.

One solution is to increase the number of PAs and NPs, particularly since we already know that their education is less costly and time-consuming than traditional physician education. Unfortunately, this alone will no longer meet the demand for primary care providers. 

Then there is the proposal I brought up in March—to allow NPs and PAs to become physicians through the process called “fast tracking.” Is this an idea whose time has come? Although further studies are needed, it is my opinion that there is definitely interest in the opportunities that could be offered by such a program.

A big difference between the education of NPs and PAs and that of physicians is not so much the curricula’s core content but the amount of time spent in school. While curricula vary somewhat between educational institutions, PA and NP programs run between 80 and 110 weeks, compared to the typical 155 weeks of a medical school program. At the end of the didactic component, most NP and PA programs will have covered 70% of what a medical school program would have covered.

NPs and PAs, of course, complement their didactic education with clinical rotations in various medical specialties. Although they do not have to serve an internship or residency, the clinical education for PAs and NPs amounts to 1,500 to 2,000 hours of direct patient contact. In addition, many NPs and PAs have up to several years of clinical experience before they even begin their educational programs.

Thus, in designing a fast-track program, perhaps some portion of the didactic and/or clinical years of medical school could be shaved off for PAs and NPs, since they have already invested so many hours in both of those areas. Such an approach would leverage the education and skills NPs and PAs currently have and allow them to build on that foundation to complete the education and training necessary to become a physician. It may also have the advantage of maintaining the current workforce of PAs and NPs while those who are interested in becoming physicians attain additional education in a time-efficient and cost-effective manner.

Another difference in training between PAs and NPs and physicians is the autonomy they have as providers. Although NPs and PAs are trained to give optimal health care, they are taught to do so within either a dependent framework (PAs) or an advanced practice paradigm (NPs), while physicians enjoy more autonomy. However, experienced NPs and PAs do function at various levels of autonomy, depending on their practice setting. Such autonomy, coupled with appropriate clinical training, may minimize the disconnect and facilitate the retraining of PAs and NPs in the role of physicians.

Fast tracking, it should be noted, is not a new idea. In a 2001 article in Clinician News, George Lundberg, MD, former editor of JAMA and Editor-in-Chief Emeritus of Medscape, explained that fast tracking NPs and PAs into medical school could be evaluated case by case, according to their education level and assuming there was a standardized way to measure knowledge and competence.

And Eugene A. Stead Jr, MD, considered the father of the PA profession, in a 2001 article in the North Carolina Medical Journal, outlined a program in which PAs and NPs could progress to the level of physician through an accelerated academic program. His proposal prescribed distance-learning curricula for community-bound PAs and NPs, thereby building on the talents of these nontraditional but seasoned clinical veterans.

Dr. Stead reminded us that 35 years ago, a medical school in Florida observed the market for PhD science graduates plummeting while the market for MDs remained strong. The school jumped at the opportunity to accept these PhD students into their medical program and accepted them as third-year medical students, deciding that the first two years of their PhD program fulfilled the scientific requirements for medical practice. As physician-in-chief, Dr. Stead appointed a few of these fast-tracked medical residents at Duke Hospital and found they performed as well as, and in some instances better than, the students who had spent four full years in medical school.

He also advocated an online program that would consist of 20 health care professionals–turned–medical students. The students would be required to spend one to two weeks on the medical school campus before starting their online coursework. During that time, they would undergo a series of written and oral tests, clinical trials, and other evaluation methods to determine the additional courses they would need to pass the qualifying examinations for medical practice. Each student would then begin an individualized online course of study. At the end of the program, the students would take both the basic sciences and qualifying examinations in the same week, and their scores would be compared with those of traditional four-year medical students. If the nontraditional students performed at the same or higher levels as the traditional students, the program would have been deemed a success and primed for implementation.

Dr. Stead listed some requirements for those entering the program. Applicants would need to be NPs or PAs with a master’s degree from an accredited educational program, already working in areas of medical need. They should have completed at least three years of practice, and they must have a physician mentor once they are accepted into the distance-learning program.

To sum up, there can be no doubt that the need exists for fast-track programs. And we have various models to draw on to fine-tune these programs.

A key question remains, however: Is there enough interest among PAs and NPs to pursue further education to become physicians? Would they consider leaving their profession for medical school, especially when recent job satisfaction surveys show PAs, at least, are very happy with their positions? (Only 65% of NPs, on the other hand, actually stay in practice as NPs.) In their textbook Physician Assistants in American Medicine, Hooker and Cawley suggest that only 4% of PAs move on to medical school, although others believe that number could be as high as 8%. It is not known what percentage of NPs make this move.

Equally important, is there enough interest among medical school administrators in offering fast-track programs? While opinions may vary as to the efficacy of an accelerated medical school program, it seems the only way to really know for certain is through a pilot program. Would medical schools be interested in conducting such studies?

Other unanswered questions relate to public policy. Would society ultimately benefit from these programs? Would they indeed improve primary care delivery? Or would PAs- and NPs-turned-physicians follow the same maldistribution patterns currently seen among traditional physicians today, toward specialization and urban practices and away from primary care in rural settings? Could NPs and PAs who enter fast-track programs be compelled to practice in rural and/or primary care settings?

Obviously, there is much to discuss here. And to further the dialogue and the debate, I would love to hear from you on this intriguing issue. Send your comments to [email protected].

I have received many positive responses to my comments regarding a pathway for PAs and NPs to become physicians in our March cover article, “Degrees of Latitude: Real Issues Behind Clinical Doctorates.” In essence, I advocated for medical schools to recognize the training and clinical experience of NPs and PAs and provide an advanced and accelerated pathway for these clinicians. As we all know, the need for affordable and accessible health care is growing rapidly in tandem with our increasing population and the aging of America. To meet this challenge, more health care practitioners are needed, especially in the primary care setting.

One solution is to increase the number of PAs and NPs, particularly since we already know that their education is less costly and time-consuming than traditional physician education. Unfortunately, this alone will no longer meet the demand for primary care providers. 

Then there is the proposal I brought up in March—to allow NPs and PAs to become physicians through the process called “fast tracking.” Is this an idea whose time has come? Although further studies are needed, it is my opinion that there is definitely interest in the opportunities that could be offered by such a program.

A big difference between the education of NPs and PAs and that of physicians is not so much the curricula’s core content but the amount of time spent in school. While curricula vary somewhat between educational institutions, PA and NP programs run between 80 and 110 weeks, compared to the typical 155 weeks of a medical school program. At the end of the didactic component, most NP and PA programs will have covered 70% of what a medical school program would have covered.

NPs and PAs, of course, complement their didactic education with clinical rotations in various medical specialties. Although they do not have to serve an internship or residency, the clinical education for PAs and NPs amounts to 1,500 to 2,000 hours of direct patient contact. In addition, many NPs and PAs have up to several years of clinical experience before they even begin their educational programs.

Thus, in designing a fast-track program, perhaps some portion of the didactic and/or clinical years of medical school could be shaved off for PAs and NPs, since they have already invested so many hours in both of those areas. Such an approach would leverage the education and skills NPs and PAs currently have and allow them to build on that foundation to complete the education and training necessary to become a physician. It may also have the advantage of maintaining the current workforce of PAs and NPs while those who are interested in becoming physicians attain additional education in a time-efficient and cost-effective manner.

Another difference in training between PAs and NPs and physicians is the autonomy they have as providers. Although NPs and PAs are trained to give optimal health care, they are taught to do so within either a dependent framework (PAs) or an advanced practice paradigm (NPs), while physicians enjoy more autonomy. However, experienced NPs and PAs do function at various levels of autonomy, depending on their practice setting. Such autonomy, coupled with appropriate clinical training, may minimize the disconnect and facilitate the retraining of PAs and NPs in the role of physicians.

Fast tracking, it should be noted, is not a new idea. In a 2001 article in Clinician News, George Lundberg, MD, former editor of JAMA and Editor-in-Chief Emeritus of Medscape, explained that fast tracking NPs and PAs into medical school could be evaluated case by case, according to their education level and assuming there was a standardized way to measure knowledge and competence.

And Eugene A. Stead Jr, MD, considered the father of the PA profession, in a 2001 article in the North Carolina Medical Journal, outlined a program in which PAs and NPs could progress to the level of physician through an accelerated academic program. His proposal prescribed distance-learning curricula for community-bound PAs and NPs, thereby building on the talents of these nontraditional but seasoned clinical veterans.

Dr. Stead reminded us that 35 years ago, a medical school in Florida observed the market for PhD science graduates plummeting while the market for MDs remained strong. The school jumped at the opportunity to accept these PhD students into their medical program and accepted them as third-year medical students, deciding that the first two years of their PhD program fulfilled the scientific requirements for medical practice. As physician-in-chief, Dr. Stead appointed a few of these fast-tracked medical residents at Duke Hospital and found they performed as well as, and in some instances better than, the students who had spent four full years in medical school.

He also advocated an online program that would consist of 20 health care professionals–turned–medical students. The students would be required to spend one to two weeks on the medical school campus before starting their online coursework. During that time, they would undergo a series of written and oral tests, clinical trials, and other evaluation methods to determine the additional courses they would need to pass the qualifying examinations for medical practice. Each student would then begin an individualized online course of study. At the end of the program, the students would take both the basic sciences and qualifying examinations in the same week, and their scores would be compared with those of traditional four-year medical students. If the nontraditional students performed at the same or higher levels as the traditional students, the program would have been deemed a success and primed for implementation.

Dr. Stead listed some requirements for those entering the program. Applicants would need to be NPs or PAs with a master’s degree from an accredited educational program, already working in areas of medical need. They should have completed at least three years of practice, and they must have a physician mentor once they are accepted into the distance-learning program.

To sum up, there can be no doubt that the need exists for fast-track programs. And we have various models to draw on to fine-tune these programs.

A key question remains, however: Is there enough interest among PAs and NPs to pursue further education to become physicians? Would they consider leaving their profession for medical school, especially when recent job satisfaction surveys show PAs, at least, are very happy with their positions? (Only 65% of NPs, on the other hand, actually stay in practice as NPs.) In their textbook Physician Assistants in American Medicine, Hooker and Cawley suggest that only 4% of PAs move on to medical school, although others believe that number could be as high as 8%. It is not known what percentage of NPs make this move.

Equally important, is there enough interest among medical school administrators in offering fast-track programs? While opinions may vary as to the efficacy of an accelerated medical school program, it seems the only way to really know for certain is through a pilot program. Would medical schools be interested in conducting such studies?

Other unanswered questions relate to public policy. Would society ultimately benefit from these programs? Would they indeed improve primary care delivery? Or would PAs- and NPs-turned-physicians follow the same maldistribution patterns currently seen among traditional physicians today, toward specialization and urban practices and away from primary care in rural settings? Could NPs and PAs who enter fast-track programs be compelled to practice in rural and/or primary care settings?

Obviously, there is much to discuss here. And to further the dialogue and the debate, I would love to hear from you on this intriguing issue. Send your comments to [email protected].

I have received many positive responses to my comments regarding a pathway for PAs and NPs to become physicians in our March cover article, “Degrees of Latitude: Real Issues Behind Clinical Doctorates.” In essence, I advocated for medical schools to recognize the training and clinical experience of NPs and PAs and provide an advanced and accelerated pathway for these clinicians. As we all know, the need for affordable and accessible health care is growing rapidly in tandem with our increasing population and the aging of America. To meet this challenge, more health care practitioners are needed, especially in the primary care setting.

One solution is to increase the number of PAs and NPs, particularly since we already know that their education is less costly and time-consuming than traditional physician education. Unfortunately, this alone will no longer meet the demand for primary care providers. 

Then there is the proposal I brought up in March—to allow NPs and PAs to become physicians through the process called “fast tracking.” Is this an idea whose time has come? Although further studies are needed, it is my opinion that there is definitely interest in the opportunities that could be offered by such a program.

A big difference between the education of NPs and PAs and that of physicians is not so much the curricula’s core content but the amount of time spent in school. While curricula vary somewhat between educational institutions, PA and NP programs run between 80 and 110 weeks, compared to the typical 155 weeks of a medical school program. At the end of the didactic component, most NP and PA programs will have covered 70% of what a medical school program would have covered.

NPs and PAs, of course, complement their didactic education with clinical rotations in various medical specialties. Although they do not have to serve an internship or residency, the clinical education for PAs and NPs amounts to 1,500 to 2,000 hours of direct patient contact. In addition, many NPs and PAs have up to several years of clinical experience before they even begin their educational programs.

Thus, in designing a fast-track program, perhaps some portion of the didactic and/or clinical years of medical school could be shaved off for PAs and NPs, since they have already invested so many hours in both of those areas. Such an approach would leverage the education and skills NPs and PAs currently have and allow them to build on that foundation to complete the education and training necessary to become a physician. It may also have the advantage of maintaining the current workforce of PAs and NPs while those who are interested in becoming physicians attain additional education in a time-efficient and cost-effective manner.

Another difference in training between PAs and NPs and physicians is the autonomy they have as providers. Although NPs and PAs are trained to give optimal health care, they are taught to do so within either a dependent framework (PAs) or an advanced practice paradigm (NPs), while physicians enjoy more autonomy. However, experienced NPs and PAs do function at various levels of autonomy, depending on their practice setting. Such autonomy, coupled with appropriate clinical training, may minimize the disconnect and facilitate the retraining of PAs and NPs in the role of physicians.

Fast tracking, it should be noted, is not a new idea. In a 2001 article in Clinician News, George Lundberg, MD, former editor of JAMA and Editor-in-Chief Emeritus of Medscape, explained that fast tracking NPs and PAs into medical school could be evaluated case by case, according to their education level and assuming there was a standardized way to measure knowledge and competence.

And Eugene A. Stead Jr, MD, considered the father of the PA profession, in a 2001 article in the North Carolina Medical Journal, outlined a program in which PAs and NPs could progress to the level of physician through an accelerated academic program. His proposal prescribed distance-learning curricula for community-bound PAs and NPs, thereby building on the talents of these nontraditional but seasoned clinical veterans.

Dr. Stead reminded us that 35 years ago, a medical school in Florida observed the market for PhD science graduates plummeting while the market for MDs remained strong. The school jumped at the opportunity to accept these PhD students into their medical program and accepted them as third-year medical students, deciding that the first two years of their PhD program fulfilled the scientific requirements for medical practice. As physician-in-chief, Dr. Stead appointed a few of these fast-tracked medical residents at Duke Hospital and found they performed as well as, and in some instances better than, the students who had spent four full years in medical school.

He also advocated an online program that would consist of 20 health care professionals–turned–medical students. The students would be required to spend one to two weeks on the medical school campus before starting their online coursework. During that time, they would undergo a series of written and oral tests, clinical trials, and other evaluation methods to determine the additional courses they would need to pass the qualifying examinations for medical practice. Each student would then begin an individualized online course of study. At the end of the program, the students would take both the basic sciences and qualifying examinations in the same week, and their scores would be compared with those of traditional four-year medical students. If the nontraditional students performed at the same or higher levels as the traditional students, the program would have been deemed a success and primed for implementation.

Dr. Stead listed some requirements for those entering the program. Applicants would need to be NPs or PAs with a master’s degree from an accredited educational program, already working in areas of medical need. They should have completed at least three years of practice, and they must have a physician mentor once they are accepted into the distance-learning program.

To sum up, there can be no doubt that the need exists for fast-track programs. And we have various models to draw on to fine-tune these programs.

A key question remains, however: Is there enough interest among PAs and NPs to pursue further education to become physicians? Would they consider leaving their profession for medical school, especially when recent job satisfaction surveys show PAs, at least, are very happy with their positions? (Only 65% of NPs, on the other hand, actually stay in practice as NPs.) In their textbook Physician Assistants in American Medicine, Hooker and Cawley suggest that only 4% of PAs move on to medical school, although others believe that number could be as high as 8%. It is not known what percentage of NPs make this move.

Equally important, is there enough interest among medical school administrators in offering fast-track programs? While opinions may vary as to the efficacy of an accelerated medical school program, it seems the only way to really know for certain is through a pilot program. Would medical schools be interested in conducting such studies?

Other unanswered questions relate to public policy. Would society ultimately benefit from these programs? Would they indeed improve primary care delivery? Or would PAs- and NPs-turned-physicians follow the same maldistribution patterns currently seen among traditional physicians today, toward specialization and urban practices and away from primary care in rural settings? Could NPs and PAs who enter fast-track programs be compelled to practice in rural and/or primary care settings?

Obviously, there is much to discuss here. And to further the dialogue and the debate, I would love to hear from you on this intriguing issue. Send your comments to [email protected].

I would like to address an issue this month that is perhaps a little sensitive, yet extremely important in today’s complex health care system. And that is the issue of creating professional networks between PAs and NPs.

It is clear that NPs and PAs fill parallel niches in the health care system. Both groups seek to provide consumers with greater access to health care. Their expanded scope of practice indicates a shift in primary care responsibility away from physicians. Patients and third-party payers should be made aware of who delivers primary care, who writes prescriptions, and who controls referrals. In addition, many PAs and NPs provide specialty care.

For all these reasons, I believe now is the time for the two professions to communicate with each other more than ever before.

Of course, there are clinicians on both sides of the aisle who believe just the opposite—that the two professions should stay as far apart as possible because of perceived differences in regulations, supervision policies, overall philosophies, and so forth. However, there are many others who feel, as I do, that we should strive to be as close as possible in areas that affect the quality of our patient care, such as continuing medical education, professional practices, and patient teaching. I suggest that we find ways to increase the networking opportunities between our professions, not only to get to know each other better but also to become more familiar with our various specialties and more comfortable with patient referrals. 

There can be no doubt that networking is the most powerful way to build collegial relationships, foster contacts, and disseminate information. In fact, networking is now considered to be a fundamental business skill.

So how do we build and maintain a professional network between our professions? Most NPs know many PAs—and vice versa. Harvey Mackay, a well-known author and speaker, suggests keeping a Rolodex of colleagues’ names and contact information and jotting down a little something about each person on his or her card. Of course, with PDAs and iPhones, we can now do that on the fly.

The point is simple: Get to know your PA and NP colleagues. Get involved in local CME opportunities, whether they’re NP- or PA—oriented. Go out of your way to meet these colleagues when the opportunity presents itself. If this kind of networking is hard for you, then start on a smaller scale. But start!

It’s important to be genuine, to be yourself. And beware of common networking errors, such as payback expectations, not being respectful of other people’s time, and not following through on promises.

One of the more interesting sayings I’ve heard is, “It is not what you know; it is not who you know; it is what you know about who you know.” Another one is: “They don’t care what you know until they know that you care.”

I’m reminded of the movie Erin Brockovich, starring Julia Roberts. The reason the title character was so successful as an investigator in that movie was because she really cared for others. She could relate to people, and people trusted her.

The respect you extend to your PA or NP colleagues in your networking efforts will enhance each of our professions and help make you a better provider. We can—and should—be partners in pursuing the common good for our patients.

I hope you agree. If so, what ideas do you have for accomplishing this? If not, why not? I’d love to hear from you. E-mail me at [email protected].

I would like to address an issue this month that is perhaps a little sensitive, yet extremely important in today’s complex health care system. And that is the issue of creating professional networks between PAs and NPs.

It is clear that NPs and PAs fill parallel niches in the health care system. Both groups seek to provide consumers with greater access to health care. Their expanded scope of practice indicates a shift in primary care responsibility away from physicians. Patients and third-party payers should be made aware of who delivers primary care, who writes prescriptions, and who controls referrals. In addition, many PAs and NPs provide specialty care.

For all these reasons, I believe now is the time for the two professions to communicate with each other more than ever before.

Of course, there are clinicians on both sides of the aisle who believe just the opposite—that the two professions should stay as far apart as possible because of perceived differences in regulations, supervision policies, overall philosophies, and so forth. However, there are many others who feel, as I do, that we should strive to be as close as possible in areas that affect the quality of our patient care, such as continuing medical education, professional practices, and patient teaching. I suggest that we find ways to increase the networking opportunities between our professions, not only to get to know each other better but also to become more familiar with our various specialties and more comfortable with patient referrals. 

There can be no doubt that networking is the most powerful way to build collegial relationships, foster contacts, and disseminate information. In fact, networking is now considered to be a fundamental business skill.

So how do we build and maintain a professional network between our professions? Most NPs know many PAs—and vice versa. Harvey Mackay, a well-known author and speaker, suggests keeping a Rolodex of colleagues’ names and contact information and jotting down a little something about each person on his or her card. Of course, with PDAs and iPhones, we can now do that on the fly.

The point is simple: Get to know your PA and NP colleagues. Get involved in local CME opportunities, whether they’re NP- or PA—oriented. Go out of your way to meet these colleagues when the opportunity presents itself. If this kind of networking is hard for you, then start on a smaller scale. But start!

It’s important to be genuine, to be yourself. And beware of common networking errors, such as payback expectations, not being respectful of other people’s time, and not following through on promises.

One of the more interesting sayings I’ve heard is, “It is not what you know; it is not who you know; it is what you know about who you know.” Another one is: “They don’t care what you know until they know that you care.”

I’m reminded of the movie Erin Brockovich, starring Julia Roberts. The reason the title character was so successful as an investigator in that movie was because she really cared for others. She could relate to people, and people trusted her.

The respect you extend to your PA or NP colleagues in your networking efforts will enhance each of our professions and help make you a better provider. We can—and should—be partners in pursuing the common good for our patients.

I hope you agree. If so, what ideas do you have for accomplishing this? If not, why not? I’d love to hear from you. E-mail me at [email protected].

I would like to address an issue this month that is perhaps a little sensitive, yet extremely important in today’s complex health care system. And that is the issue of creating professional networks between PAs and NPs.

It is clear that NPs and PAs fill parallel niches in the health care system. Both groups seek to provide consumers with greater access to health care. Their expanded scope of practice indicates a shift in primary care responsibility away from physicians. Patients and third-party payers should be made aware of who delivers primary care, who writes prescriptions, and who controls referrals. In addition, many PAs and NPs provide specialty care.

For all these reasons, I believe now is the time for the two professions to communicate with each other more than ever before.

Of course, there are clinicians on both sides of the aisle who believe just the opposite—that the two professions should stay as far apart as possible because of perceived differences in regulations, supervision policies, overall philosophies, and so forth. However, there are many others who feel, as I do, that we should strive to be as close as possible in areas that affect the quality of our patient care, such as continuing medical education, professional practices, and patient teaching. I suggest that we find ways to increase the networking opportunities between our professions, not only to get to know each other better but also to become more familiar with our various specialties and more comfortable with patient referrals. 

There can be no doubt that networking is the most powerful way to build collegial relationships, foster contacts, and disseminate information. In fact, networking is now considered to be a fundamental business skill.

So how do we build and maintain a professional network between our professions? Most NPs know many PAs—and vice versa. Harvey Mackay, a well-known author and speaker, suggests keeping a Rolodex of colleagues’ names and contact information and jotting down a little something about each person on his or her card. Of course, with PDAs and iPhones, we can now do that on the fly.

The point is simple: Get to know your PA and NP colleagues. Get involved in local CME opportunities, whether they’re NP- or PA—oriented. Go out of your way to meet these colleagues when the opportunity presents itself. If this kind of networking is hard for you, then start on a smaller scale. But start!

It’s important to be genuine, to be yourself. And beware of common networking errors, such as payback expectations, not being respectful of other people’s time, and not following through on promises.

One of the more interesting sayings I’ve heard is, “It is not what you know; it is not who you know; it is what you know about who you know.” Another one is: “They don’t care what you know until they know that you care.”

I’m reminded of the movie Erin Brockovich, starring Julia Roberts. The reason the title character was so successful as an investigator in that movie was because she really cared for others. She could relate to people, and people trusted her.

The respect you extend to your PA or NP colleagues in your networking efforts will enhance each of our professions and help make you a better provider. We can—and should—be partners in pursuing the common good for our patients.

I hope you agree. If so, what ideas do you have for accomplishing this? If not, why not? I’d love to hear from you. E-mail me at [email protected].

While I was visiting family in southern Idaho over the holidays, I received word that my uncle had been rushed to the regional hospital about 60 miles from my hometown. An 84-year-old Army veteran who landed on Utah Beach on D-Day +1, he had recently been placed in an assisted living center, where he was having trouble sleeping. He was already taking glyburide (10 mg/d) for his type 2 diabetes, and two days before admission to the hospital his family physician had prescribed zolpidem (10 mg at bedtime) for insomnia and hydrochlorothiazide (50 mg) for blood pressure control.

Within 24 hours, he became agitated and combative, at which point he was transported to the emergency department of the hospital. There, he continued to be combative, to the point where admission to the psychiatry unit was considered. His CT scan showed the expected cerebral atrophy for an 84-year-old. Random glucose was 300 mg/dL, serum potassium was 3.1 mmol/L, and a chest x-ray revealed a right lower lobe infiltrate. Vital signs were within normal limits.

He was admitted to the medicine floor, where IV antibiotics, injectable insulin, and potassium supplements were given. The zolpidem was discontinued. So was the hydrochlorothiazide; in its place an ACE inhibitor was prescribed. Within 24 hours, he returned to normal behavior and was sitting up and eating well. He subsequently returned to the assisted living center without any problems.

In reviewing this case, I came to the conclusion that at least three medication errors were made in my uncle’s treatment. The first was the concomitant use of a thiazide diuretic with the sulfonylurea glyburide. Thiazides can exacerbate type 2 diabetes by raising glucose levels, resulting in loss of glycemic control if the sulfonylurea dosage isn’t increased. According to the guidelines from the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, ACE inhibitors should be the first choice for blood pressure control in type 2 diabetes; not only do they lower blood pressure effectively but they also protect the kidneys.

The second mistake was the use of a thiazide diuretic without potassium supplementation. (It is not known if baseline electrolyte levels were ever checked at the assisted living center.) And thirdly, the side affects of agitation and combativeness with the use of zolpidem, particularly in patients older than 60, apparently were not foreseen.      

All PAs and NPs are familiar with the five rights of safe medication use: the right patient, the right drug, the right time, the right dose, and the right route of administration. In his book Medication Errors, Michael Cohen, RPh, MS, ScD, FASHP, President of the Institute for Safe Medication Practices in Huntingdon Valley, Pennsylvania, suggests that these rights focus only on a health care professional’s performance. They don’t take into account system/management errors, such as poor lighting, inadequate staffing, handwritten orders, doses with trailing zeros, and ambiguous drug labels.

Nearly half of all adverse drug events are preventable. Many do not represent errors of commission but errors of omission. This suggests a failure on the part of someone (pharmacist, physician, PA, NP, or nurse) to recognize certain factors that most likely led to the adverse event. These factors include failure to:

• detect a contraindication to the drug therapy

• detect a significant drug interaction

• detect a history of a significant drug allergy

• prescribe the correct dose for a specific patient

• monitor drugs with narrow therapeutic windows

• be aware of or identify patient knowledge deficits.

Many of these errors can be avoided by spending the appropriate amount of time counseling the patient and family. Communication, obviously, is key. Barriers to effective communication include the use of too many abbreviations, illegible handwriting, verbal or ambiguous orders, and fax or Internet prescribing problems.

My uncle was lucky. The medication errors that led to his hospitalization were caught in time. He was able to return to the assisted living center without any long-term deficits. But that won’t always be the case in the aftermath of a medication error—and that is a risk we can’t afford to take.

While I was visiting family in southern Idaho over the holidays, I received word that my uncle had been rushed to the regional hospital about 60 miles from my hometown. An 84-year-old Army veteran who landed on Utah Beach on D-Day +1, he had recently been placed in an assisted living center, where he was having trouble sleeping. He was already taking glyburide (10 mg/d) for his type 2 diabetes, and two days before admission to the hospital his family physician had prescribed zolpidem (10 mg at bedtime) for insomnia and hydrochlorothiazide (50 mg) for blood pressure control.

Within 24 hours, he became agitated and combative, at which point he was transported to the emergency department of the hospital. There, he continued to be combative, to the point where admission to the psychiatry unit was considered. His CT scan showed the expected cerebral atrophy for an 84-year-old. Random glucose was 300 mg/dL, serum potassium was 3.1 mmol/L, and a chest x-ray revealed a right lower lobe infiltrate. Vital signs were within normal limits.

He was admitted to the medicine floor, where IV antibiotics, injectable insulin, and potassium supplements were given. The zolpidem was discontinued. So was the hydrochlorothiazide; in its place an ACE inhibitor was prescribed. Within 24 hours, he returned to normal behavior and was sitting up and eating well. He subsequently returned to the assisted living center without any problems.

In reviewing this case, I came to the conclusion that at least three medication errors were made in my uncle’s treatment. The first was the concomitant use of a thiazide diuretic with the sulfonylurea glyburide. Thiazides can exacerbate type 2 diabetes by raising glucose levels, resulting in loss of glycemic control if the sulfonylurea dosage isn’t increased. According to the guidelines from the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, ACE inhibitors should be the first choice for blood pressure control in type 2 diabetes; not only do they lower blood pressure effectively but they also protect the kidneys.

The second mistake was the use of a thiazide diuretic without potassium supplementation. (It is not known if baseline electrolyte levels were ever checked at the assisted living center.) And thirdly, the side affects of agitation and combativeness with the use of zolpidem, particularly in patients older than 60, apparently were not foreseen.      

All PAs and NPs are familiar with the five rights of safe medication use: the right patient, the right drug, the right time, the right dose, and the right route of administration. In his book Medication Errors, Michael Cohen, RPh, MS, ScD, FASHP, President of the Institute for Safe Medication Practices in Huntingdon Valley, Pennsylvania, suggests that these rights focus only on a health care professional’s performance. They don’t take into account system/management errors, such as poor lighting, inadequate staffing, handwritten orders, doses with trailing zeros, and ambiguous drug labels.

Nearly half of all adverse drug events are preventable. Many do not represent errors of commission but errors of omission. This suggests a failure on the part of someone (pharmacist, physician, PA, NP, or nurse) to recognize certain factors that most likely led to the adverse event. These factors include failure to:

• detect a contraindication to the drug therapy

• detect a significant drug interaction

• detect a history of a significant drug allergy

• prescribe the correct dose for a specific patient

• monitor drugs with narrow therapeutic windows

• be aware of or identify patient knowledge deficits.

Many of these errors can be avoided by spending the appropriate amount of time counseling the patient and family. Communication, obviously, is key. Barriers to effective communication include the use of too many abbreviations, illegible handwriting, verbal or ambiguous orders, and fax or Internet prescribing problems.

My uncle was lucky. The medication errors that led to his hospitalization were caught in time. He was able to return to the assisted living center without any long-term deficits. But that won’t always be the case in the aftermath of a medication error—and that is a risk we can’t afford to take.

While I was visiting family in southern Idaho over the holidays, I received word that my uncle had been rushed to the regional hospital about 60 miles from my hometown. An 84-year-old Army veteran who landed on Utah Beach on D-Day +1, he had recently been placed in an assisted living center, where he was having trouble sleeping. He was already taking glyburide (10 mg/d) for his type 2 diabetes, and two days before admission to the hospital his family physician had prescribed zolpidem (10 mg at bedtime) for insomnia and hydrochlorothiazide (50 mg) for blood pressure control.

Within 24 hours, he became agitated and combative, at which point he was transported to the emergency department of the hospital. There, he continued to be combative, to the point where admission to the psychiatry unit was considered. His CT scan showed the expected cerebral atrophy for an 84-year-old. Random glucose was 300 mg/dL, serum potassium was 3.1 mmol/L, and a chest x-ray revealed a right lower lobe infiltrate. Vital signs were within normal limits.

He was admitted to the medicine floor, where IV antibiotics, injectable insulin, and potassium supplements were given. The zolpidem was discontinued. So was the hydrochlorothiazide; in its place an ACE inhibitor was prescribed. Within 24 hours, he returned to normal behavior and was sitting up and eating well. He subsequently returned to the assisted living center without any problems.

In reviewing this case, I came to the conclusion that at least three medication errors were made in my uncle’s treatment. The first was the concomitant use of a thiazide diuretic with the sulfonylurea glyburide. Thiazides can exacerbate type 2 diabetes by raising glucose levels, resulting in loss of glycemic control if the sulfonylurea dosage isn’t increased. According to the guidelines from the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, ACE inhibitors should be the first choice for blood pressure control in type 2 diabetes; not only do they lower blood pressure effectively but they also protect the kidneys.

The second mistake was the use of a thiazide diuretic without potassium supplementation. (It is not known if baseline electrolyte levels were ever checked at the assisted living center.) And thirdly, the side affects of agitation and combativeness with the use of zolpidem, particularly in patients older than 60, apparently were not foreseen.      

All PAs and NPs are familiar with the five rights of safe medication use: the right patient, the right drug, the right time, the right dose, and the right route of administration. In his book Medication Errors, Michael Cohen, RPh, MS, ScD, FASHP, President of the Institute for Safe Medication Practices in Huntingdon Valley, Pennsylvania, suggests that these rights focus only on a health care professional’s performance. They don’t take into account system/management errors, such as poor lighting, inadequate staffing, handwritten orders, doses with trailing zeros, and ambiguous drug labels.

Nearly half of all adverse drug events are preventable. Many do not represent errors of commission but errors of omission. This suggests a failure on the part of someone (pharmacist, physician, PA, NP, or nurse) to recognize certain factors that most likely led to the adverse event. These factors include failure to:

• detect a contraindication to the drug therapy

• detect a significant drug interaction

• detect a history of a significant drug allergy

• prescribe the correct dose for a specific patient

• monitor drugs with narrow therapeutic windows

• be aware of or identify patient knowledge deficits.

Many of these errors can be avoided by spending the appropriate amount of time counseling the patient and family. Communication, obviously, is key. Barriers to effective communication include the use of too many abbreviations, illegible handwriting, verbal or ambiguous orders, and fax or Internet prescribing problems.

My uncle was lucky. The medication errors that led to his hospitalization were caught in time. He was able to return to the assisted living center without any long-term deficits. But that won’t always be the case in the aftermath of a medication error—and that is a risk we can’t afford to take.

This issue debuts Clinician Reviews in its new, expanded format. Several months ago, when Group Publisher Gary Falcetano, PA-C, announced that Clinician Reviews was being redesigned, I was—as many of you may be now—concerned about this publishing decision. I was concerned that the change in format would lead to less quality in a publication that has been innovative and continually meeting the needs of practicing PAs and NPs. I am now convinced that is not the case. In fact, the larger format will enable us to do more.

Medical publishing has been revolutionized in the past decade. With the explosive growth of online publishing, the Internet, and the advent of electronic printing technology, it is critical that the most recent medical articles, health care news, and professional updates be published as soon as possible. The editors and reviewers of Clinician Reviews will continue to work hard to fill each page, each issue with accurate, relevant, and instructive information for NPs and PAs. Since not every word on every page is of equal interest to all readers at all times, a format that helps readers quickly spot what they want to scrutinize, skim, skip, or save is essential. I believe this new format will meet these challenges and enhance the integrity and quality of the journal.

Please take the time to turn every page of this issue and enjoy reading all of the high-quality clinical content that you have trusted for 17 years. You’ll find your favorite departments: Clinical Pearls, DermaDiagnosis, Literature Monitor, ECG Challenge, Radiology Review, and Malpractice Chronicle. And this month’s CE activity, “Office-Based Spirometry,” written by Gwen Carlton, is a strategic follow-up to our November CE article, “Key Messages in the New Asthma Guidelines,” which strongly endorses spirometry as the “gold standard” for diagnosis and monitoring of asthma (as well as other respiratory conditions). “Spirometry is underutilized in primary care,” says Carlton, “because most providers are not taught how to obtain and interpret results in their training programs.” With minimal training, PAs and NPs can administer this test and give more accurate diagnoses, provide effective management, and make appropriate referrals.

In keeping with our commitment to advocate for and serve the NP and PA professions, Clinician Reviews now will also feature professional news and information relevant to your practice. For instance, this month’s lead news article discusses why you need to keep informed about, and be an active participant in, your state and national legislative issues. To quote AAPA’s Ann Davis, “If you don’t participate, then you are at the mercy of those who choose to—and they may not make decisions that you like.”

It is my wish that we use Clinician Reviews as a vehicle to share medical information and experiences with our peers to enhance and enrich our opportunities to be better clinicians. I look forward to your partnership in making that happen. I encourage you to send us your comments about the new format and other suggestions you might have to [email protected].

Clinician Reviews began in 1990 as the only publication serving both physician assistants and nurse practitioners—and it still is.        

This issue debuts Clinician Reviews in its new, expanded format. Several months ago, when Group Publisher Gary Falcetano, PA-C, announced that Clinician Reviews was being redesigned, I was—as many of you may be now—concerned about this publishing decision. I was concerned that the change in format would lead to less quality in a publication that has been innovative and continually meeting the needs of practicing PAs and NPs. I am now convinced that is not the case. In fact, the larger format will enable us to do more.

Medical publishing has been revolutionized in the past decade. With the explosive growth of online publishing, the Internet, and the advent of electronic printing technology, it is critical that the most recent medical articles, health care news, and professional updates be published as soon as possible. The editors and reviewers of Clinician Reviews will continue to work hard to fill each page, each issue with accurate, relevant, and instructive information for NPs and PAs. Since not every word on every page is of equal interest to all readers at all times, a format that helps readers quickly spot what they want to scrutinize, skim, skip, or save is essential. I believe this new format will meet these challenges and enhance the integrity and quality of the journal.

Please take the time to turn every page of this issue and enjoy reading all of the high-quality clinical content that you have trusted for 17 years. You’ll find your favorite departments: Clinical Pearls, DermaDiagnosis, Literature Monitor, ECG Challenge, Radiology Review, and Malpractice Chronicle. And this month’s CE activity, “Office-Based Spirometry,” written by Gwen Carlton, is a strategic follow-up to our November CE article, “Key Messages in the New Asthma Guidelines,” which strongly endorses spirometry as the “gold standard” for diagnosis and monitoring of asthma (as well as other respiratory conditions). “Spirometry is underutilized in primary care,” says Carlton, “because most providers are not taught how to obtain and interpret results in their training programs.” With minimal training, PAs and NPs can administer this test and give more accurate diagnoses, provide effective management, and make appropriate referrals.

In keeping with our commitment to advocate for and serve the NP and PA professions, Clinician Reviews now will also feature professional news and information relevant to your practice. For instance, this month’s lead news article discusses why you need to keep informed about, and be an active participant in, your state and national legislative issues. To quote AAPA’s Ann Davis, “If you don’t participate, then you are at the mercy of those who choose to—and they may not make decisions that you like.”

It is my wish that we use Clinician Reviews as a vehicle to share medical information and experiences with our peers to enhance and enrich our opportunities to be better clinicians. I look forward to your partnership in making that happen. I encourage you to send us your comments about the new format and other suggestions you might have to [email protected].

Clinician Reviews began in 1990 as the only publication serving both physician assistants and nurse practitioners—and it still is.        

This issue debuts Clinician Reviews in its new, expanded format. Several months ago, when Group Publisher Gary Falcetano, PA-C, announced that Clinician Reviews was being redesigned, I was—as many of you may be now—concerned about this publishing decision. I was concerned that the change in format would lead to less quality in a publication that has been innovative and continually meeting the needs of practicing PAs and NPs. I am now convinced that is not the case. In fact, the larger format will enable us to do more.

Medical publishing has been revolutionized in the past decade. With the explosive growth of online publishing, the Internet, and the advent of electronic printing technology, it is critical that the most recent medical articles, health care news, and professional updates be published as soon as possible. The editors and reviewers of Clinician Reviews will continue to work hard to fill each page, each issue with accurate, relevant, and instructive information for NPs and PAs. Since not every word on every page is of equal interest to all readers at all times, a format that helps readers quickly spot what they want to scrutinize, skim, skip, or save is essential. I believe this new format will meet these challenges and enhance the integrity and quality of the journal.

Please take the time to turn every page of this issue and enjoy reading all of the high-quality clinical content that you have trusted for 17 years. You’ll find your favorite departments: Clinical Pearls, DermaDiagnosis, Literature Monitor, ECG Challenge, Radiology Review, and Malpractice Chronicle. And this month’s CE activity, “Office-Based Spirometry,” written by Gwen Carlton, is a strategic follow-up to our November CE article, “Key Messages in the New Asthma Guidelines,” which strongly endorses spirometry as the “gold standard” for diagnosis and monitoring of asthma (as well as other respiratory conditions). “Spirometry is underutilized in primary care,” says Carlton, “because most providers are not taught how to obtain and interpret results in their training programs.” With minimal training, PAs and NPs can administer this test and give more accurate diagnoses, provide effective management, and make appropriate referrals.

In keeping with our commitment to advocate for and serve the NP and PA professions, Clinician Reviews now will also feature professional news and information relevant to your practice. For instance, this month’s lead news article discusses why you need to keep informed about, and be an active participant in, your state and national legislative issues. To quote AAPA’s Ann Davis, “If you don’t participate, then you are at the mercy of those who choose to—and they may not make decisions that you like.”

It is my wish that we use Clinician Reviews as a vehicle to share medical information and experiences with our peers to enhance and enrich our opportunities to be better clinicians. I look forward to your partnership in making that happen. I encourage you to send us your comments about the new format and other suggestions you might have to [email protected].

Clinician Reviews began in 1990 as the only publication serving both physician assistants and nurse practitioners—and it still is.