Monday, March 19, 2012

What's the Difference Between?

Today, I'm pleased to host guest blogger Jason Joyner. Have you ever been confused by certain letters behind health care provider's names? Jason is here to clear that up.

Welcome, Jason!

When I interviewed for the physician assistant program at my university, the program director offered this scenario to me.

"You are working as a PA, and you need to consult with your supervising physician on a patient. You go to the exam room he's in, knock softly, and when you don't hear an answer, you crack the door to see if he's really in there. You find him making love to a patient. You shut the door quietly, apparently escaping detection. What do you do?"

 Recently there was a guest post by Amitha Knight on How To Write A Hospital Scene that described the different levels of medical training from med students to interns, residents, and attending physicians. There are other levels of health care providers that can be in a hospital or clinic setting, with potential for deeper conflict and development in a story.

A relatively new concept is the "mid-level provider," a clinician that is under a doctor but can still see and treat patients. There are three main types of mid-levels: nurse practitioner, nurse midwife, and physician assistant. They function in similar ways and are often indistinguishable to a patient, but there are training, legal, and practice differences.

A nurse practitioner has to be a graduate from an RN (registered nurse) program first, with a bachelor's level degree. Most of the time they will have practiced as a nurse before going back to school. They are trained in the nursing model, with an emphasis on patient care and learning diagnosis and treatment algorithms to treat patients. They often can practice independently - an NP could hang out a shingle and see their own patients, but they are usually working with other physicians. This may vary by state. NP's are often trained in a specific field, such as pediatrics, ob/gyn, or internal medicine.

A nurse midwife is similar in that they are RN's first, but then do advanced training that focuses on ob/gyn. They are an option for uncomplicated deliveries, but have to be able to have back-up in case of complications.

A physician assistant is trained in the medical model like a regular physician, but with a shortened time frame. The average program is two years, and it is mostly a master's level degree anymore. A PA is required to work under the supervision of a physician, but it does not mean that the doc has to see every patient the PA does. It means that the doc has to review a certain amount of the PA's charts and be available for consult. The PA could be hundreds of miles away from their supervising physician in a rural area, if the doc is available by phone. PA's are trained in primary care, not usually specializing at first. They can be trained by their supervising physician for specialties such as orthopedics, cardiology, or urology.

Oh, and my pet peeve? It is physician assistant. No "apostrophe 's'". We're not someone's possession.

Mid-level providers have received a lot of acceptance in the medical field by both patients and professionals alike, but there are still barriers. I get asked when I'm going to finish medical school by patients. Cardiologists in hospitals fight against giving privileges to an NP, because they don't want to be asked to consult by a "lowly" mid-level. PA's and NP's have a friendly rivalry, but there can be sniping between the two groups. Nurses and mid-levels can be partners together against a tyrannical MD, but may have turf battles or issues on their own.

Many patients now prefer to see mid-levels, feeling the PA or NP listens to their concerns better. Doctors are so busy that they may rush through patient visits more (of course this is stereotypical - there are very caring physicians and mid-levels that have the bedside manner of moldy bread). Mid-levels are working more and more in hospitals to help alleviate shortages of physicians, so it is realistic to have one involved in a medical scene.

As my opening hook suggested, there can be a lot of drama created by utilizing a PA, NP, or nurse midwife in a story. What if a doctor orders the wrong medicine for a patient, but the NP sees it in the chart? What if a PA makes a mistake and has to tell their supervising physician?

A good novel has many layers of depth and sub-plots going on that help drive the plot or challenge the characters. I would encourage a writer to use mid-levels in their books to give them a better prognosis.


Jason works as a physician assistant in southeast Idaho, while trying to keep up with three crazy boys and a little princess. He is working on a medical suspense with international flair. Follow him on Twitter @JasonCJoyner or his blog at


  1. Jason,

    I am sure you provide excellent care to your patients as do many "mid-level" providers do, but I must object to the tone of your post as anti-physician. I'm sure that you did not intend it this way. Painting physicians who are tyrannical and spend little time or empathy with patients is stereotypically wrong. I'm an OB/GYN (and by the way not rich) with 17 years of experience who remains caring for patients. I am sorry you have encountered those that you feel do not give you the respect you are due, but I assure you that this is a minority. Please also realize that we are not only liable for are own actions but also those that we "supervise."

  2. Tanya,
    I'm sorry that's the impression you got from my post. I clearly stated that it is stereotypical. I know many doctors that give excellent care and are greatly appreciated by their patients, and I know midlevels who have been awful providers.

    My intent was to show that midlevels can be utilized in stories to heighten conflict. Since there is a level of authority, the PA/NP/physician relationship can be used as a story device. Since this was my purpose, I showed writers some examples of how this can play out. Hopefully if it is read in that light, it will be seen differently.

    As a PA I value working with a physician, and I specifically went this route versus the NP track because I wasn't concerned about independence. If I was just describing the PA or NP profession, I would not have done it this way.

    I hope this helps understanding, because my intent is not anti-physician.


  3. I can empathize with both positions here. I think fiction is all about conflict and Jason highlighted some ways do that for a manuscript. There is likely few ER's, etc.. right now that are not using PA's or NP's to some degreee. So if a novel is heavily set-- these are characters to consider adding. And there is conflict between professions. I have conflict with MD's I work with at times because what I think is best for the pt may not be what they want, etc...

    The issue becomes how do you write about a profession accurately and add conflict but not undermine the profession? Particularly those who work in it so they won't light your book on fire.

    I recently judged a contest entry that had two nurses doing horrible things to a patient-- demeaning things. It made me sick to my stomach. Do I know nurses like this? Not to the extent that was portrayed but I have worked with nurses who don't give nursing the best name.

    That's in any profession.

    Speaking as an author-- I think the best way to handle that is to have one compassionate type (nurse, PA, NP, MD) who points out how awful the behavior is and shows how a good person in that profession would handle it.

    Great comments!!

  4. Jason,

    I understand your intent to educate authors who have no medical background and unfortunately don't quite "get it right". Good job there. As a physician and, by the way, a former ICU RN, I have a perspective of both sides. And I do get calls from ER PA's about OB/GYN patients. My experience with them have all been positive. I wish you success in your medical and writing careers.