If NPs train under a nursing paradigm, then PAs are educated in a medical school-based model (albeit substantially abbreviated from that which trains physicians). The typical applicant to a PA program has a bachelor’s degree that includes premedical coursework and more than four years of healthcare experience. Their first year of training focuses on classroom and laboratory instruction and includes a research component. The second, or “clinical,” year includes a variety of rotations, including internal medicine. Upon completion of their coursework, graduates must pass a national certification exam. PAs are required to take ongoing medical education classes—at least 100 hours of classroom time every two years—and must retake the certification test every six years to maintain their state licensing eligibility. They do not have to complete a residency or internship, but many do so. PA postgraduate residency training programs are available in internal medicine as well as many other specialties.
Most NPs and PAs get their clinical rheumatology skills from on-the-job training—not their respective training programs. Carlone had no rheumatology experience before she was hired. “When I accepted my current position, I told Dr. Conn that I had no experience in rheumatology and that my knowledge base was sadly lacking,” she says. “Luckily he didn’t find this an impediment. I proceeded to follow our rheumatology fellows and Dr. Conn in clinic, plus I did extensive reading. I really have Dr. Conn to thank for most of what I currently know.”
McDowell was able to do an internship with a rheumatologist during her training, but acknowledged that few NPs have this opportunity. “I attended an adult nurse practitioner program at the University of Florida,” she says. “While there, a rheumatologist/internist recruited me. I did my internship with him during my final year of graduate school and then was employed by him for about two years. There was no formal rheumatology curriculum in my graduate program…Rheumatology training is rarely present during the NP training program.”
Some Reservations Remain
Concerns about mid-level providers’ lack of exposure to rheumatologic diseases, plus their limited general medical training, have prompted some physicians to call for constraints on their utilization. Studies that evaluate the quality of care associated with physician extenders have been performed in the primary care setting, and while end-points of cost-effectiveness and efficacy have been documented, some rheumatologists question whether these results can be applied to their practices.1 Patients with connective tissue diseases may present atypically, be more debilitated, and ultimately have rarer diagnoses, leading to concerns that physician extenders will have a mistaken or missed diagnosis. One group of rheumatologists interviewed for this article found that employing a physician extender created more work for them, as they were now ultimately responsible for the care of more patients. They also expressed concerns about increased liability.
