Should “Advanced Practice Provider” Represent Both PAs and NPs?

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The trend of referring to physician assistants/associates (PAs) and nurse practitioners (NPs) under the blanket term "advanced practice providers" (APPs) is more commonplace nowadays. While this collective label may simplify language for some, it fundamentally misrepresents both professions, diminishing the unique qualifications and medical expertise that set PAs and NPs apart. Recognizing these unique qualifications is crucial in understanding the distinct nature of both professions.

Despite the opposition of the American Academy of Physician Associates (AAPA) to using “APP” to describe PAs, this generic term continues to be applied. Such broad categorization overlooks commitment, discipline, and rigor embedded in the PA profession. This role is defined by years of specialized training and represents a professional identity, education, and trusted partnership with physicians.¹

The American Academy of Nurse Practitioners (AANP) has similar sentiments minus the physician partnership. The AANP emphasizes its distinct position of NPs as independent practitioners who are not extended care providers and only endorses the term “nurse practitioner.” The term APP then only adds confusion to the public.²

Training

Differences mark the path to becoming a PA and an NP. The PA path has intensive, in-person didactic medical training, similar in structure to that of physicians, encompassing diagnosis, treatment, and disease prevention with a strong clinical foundation. This education is distinctly different from that of NP counterparts, who focus their education mainly on the nursing model, which is a different approach to clinical reasoning. Furthermore, the nursing track focuses on a more holistic approach to diagnoses and treatment and emphasizes managing health and disease prevention.²

PA medical-led training is intended to prepare PAs for roles that require nuanced clinical judgment and close collaboration within medical teams, a key aspect of the PA profession. NPs have full practice authority and focus more on independent practice; they have no oversight by medical state boards; instead, they are overseen by the state board of nursing.^3,4 In the end, utilizing clinical reasoning to diagnose and treat a disease may be approached differently between the 2 educational tracks, either focusing on diagnostic or therapeutic reasoning.³ However, it also depends on the individual patient and what is needed to improve them, therefore, comparing clinical reasoning may present a challenge.⁴

Group Consensus

A LinkedIn poll, to which PAs and NPs contributed, found that 42% of respondents preferred not to be referred to as an APP, compared to 18% who did not mind the term. However, 39% of respondents stated they didn't care either way. Most respondents agreed that it is used as an “umbrella” term. Still, the training of the 2 professions differs significantly, and a clear distinction should be made between them to avoid confusion and ensure accurate representation.

Though NPs and PAs have the same clinical patient goals, such as diagnosing, prescribing/treating, managing, ordering, and interpreting tests and educating the patient, training should be recognized as equally valuable. Because our patient goals are the same, it is likely how the “APP” term started in the first place: to create a convenient term to capture both non-physician professions.

In response to the poll, some great points were made, such as the term "physician" lumping medical doctors and doctors of osteopathic medicine together. However, ultimately, they are still physicians, though they have different education tracks.

Nonetheless, nurses and physicians are two distinct titles. Another example is if an NP or PA obtains a doctorate, they still should not be referred to as “physician” or “doctor” at the clinic because they are not technically "medical doctors." Furthermore, "advanced practice" is a nursing term originating from advanced practice registered nurses (APRN) linked to the late 19th century.⁵ When researching the term "advanced practice," it was more associated with nurses, which can confuse the public. Searching the term "advanced practice provider" provided a correct definition by the National Cancer Institute, which included the following and was more accurate for both professions:

"A medical professional who is not a doctor but has special training and is licensed to diagnose, treat, and manage many common medical conditions. Advanced practice providers can perform physical exams, order laboratory tests and imaging tests, review test results, prescribe medications, perform or assist with certain procedures, such as biopsies, and make referrals to other health care providers. They may also provide information about screening tests and give counseling on living a healthy lifestyle, such as changes in diet and exercise and quitting smoking. Examples of advanced practice providers are nurse practitioners and physician assistants."⁶

Organization Perspectives

Though the AAPA and AANP recognize that the “APP” term replaces the outdated terminology of physician extenders or mid-level and non-physician providers, it presents as a diluted term as it could represent other advanced clinicians such as nutritionists, psychologists, APRNs, etc., creating more confusion among the public.^1,2 This resonated with the NPs and PAs who contributed to the poll. However, the term can't be avoided, as many respondents in the survey said. In that case, it's an "umbrella term" for PAs and NPs, and the AAPA suggests that it should clarify who it represents in parentheses after the term APP. Still, at that point, it is better to explain it straight away instead of writing "APP (NPs and PAs)."

However, the AANP suggests if "grouping" providers is necessary for policymakers or other purposes, then groups should use terms such as APP, clinicians, prescribers, and healthcare providers/professionals. Nonetheless, the current trend of lumping PAs with NPs under the term “APP” can have serious consequences. It can lead to a lack of recognition for the unique competencies that PAs and NPs legislatively bring to patient care and undermine the rigorous training and education that they undergo.

Another responder made a valid point about uniting NPs and PAs professionally instead of focusing on the distinguished name. Though many do not disagree, it would be quite a challenge for NPs because an entirely different board governs them compared to PAs. Also, would the nursing board lobby for PAs as they do their own or vice versa? Would that be possible since our paths and governing bodies are so different? PA laws are archaic in comparison to NPs, and for PAs to have equal footing, they would have to mimic those of NPs.

Unfortunately, some professional groups have already resisted such initiatives, making PAs unnecessary discussion targets before NPs, though PAs are trained in the clinic by physicians who hire them. We already recognize our differences in training and accept this by supporting one another by being able to sit at the same table; however, each group has legislative initiatives and should be focused on via collaboration instead of individually, but state laws differ between the 2, and this can present a tremendous challenge. Uniting all professions (PAs, NPs, MDs, DOs) should be the goal as it concerns the patient and the access to care.

In the final analysis, grouping PAs together with NPs with the term "APP" diminishes the essence of each profession, undermining the unique competencies that PAs and NPs contribute to patient care. Because accurate and specific terminology is crucial in healthcare communication and reflects the unique roles and contributions of PAs and NPs, the AAPA and AANP prefer the terms PAs and NPs, respectively, and many PAs and NPs agree. However, we can only move forward by collaborating to make a change, removing the term “APP” altogether, and focusing all efforts on patient access and care.

Renata Block, MMS, PA-C, is a board-certified physician assistant in Chicago, Illinois, a Dermatology Times editorial advisory board member, and the past president of the Society of Dermatology Physician Associates (SDPA) and the Illinois SDPA.

References

1. A guide for writing and talking about PAs. American Academy of Physician Associates. Updated December 2018. Accessed February 3, 2025. https://www.aapa.org/wp-content/uploads/2018/12/How_to_Talk_about_PAs_FINAL_December_2018.pdf
2. Use of terms such as mid-level provider and physician extenders. American Association of Nurse Practitioners. Updated 2022. Accessed February 3, 2025. https://www.aanp.org/advocacy/advocacy-resource/position-statements/use-of-terms-such-as-mid-level-provider-and-physician-extender
3. Wu F, Darracq MA. Comparing physician assistant and nurse practitioner practice in U.S. emergency departments, 2010-2017. West J Emerg Med. 2021 August 21;22(5):1150-1155. doi: 10.5811/westjem.2021.5.51988.
4. Vreugdenhil J, Somra S, Ket H, Custers EJFM, Reinders ME, Dobber J, Kusurkar RA. Reasoning like a doctor or like a nurse? A systematic integrative review. Front Med (Lausanne). 2023 Mar 3;10:1017783. doi: 10.3389/fmed.2023.1017783.
5. Hibbert D, Aboshaiqah AE, Sienko KA, et al. Advancing nursing practice: The emergence of the ole of advanced practice nurse in Saudi Arabia. Ann Saudi Med. 2017 Jan-Feb;37(1):72-78. doi: 10.5144/0256-4947.2017.72.
6. NCI Dictionary of Cancer Terms - Advanced Practice Provider. National Cancer Institute. Accessed February 2, 2025. https://www.cancer.gov/publications/dictionaries/cancer-terms/def/advanced-practice-provider