The success of physician assistants and nurse practitioners in delivering quality, cost-effective patient care has much to do with their relationship with physicians.

Because duties overlap and because advanced level providers are growing in numbers and influence, hospitals must be clear before an NP or PA is hired as to how the relationship with physicians will work—everything from what duties will be performed to how schedules and billing will be handled.

"Generally the physicians will welcome the help, but you need to have a very frank conversation up front," says Tricia Marriott, director of reimbursement policy for the American Academy of Physician Assistants. A physician needs to be aware that if a PA or NP is assigned a task, they will bill for it. Some physicians will not be comfortable with that and will decide to do a task themselves. Others will happily delegate.

Learning together is one way to increase teamwork, Marriott says. "We only practice what the physician delegates to us and what the physician knows how to do. If he learns a new procedure he should be bringing his PA along, and in my experience, that's what happens."

Even when advanced practice nurses know what needs to be done, physicians must be engaged in the decisions and be respected as "captain of the ship," she says. Mutual respect, she says, has grown now that physicians are starting to receive more training alongside PAs and NPs.

Penny Kaye Jensen, president of the American Academy of Nurse Practitioners, says interprofessional teams learning together, rather than in parallel but separate tracks, is crucial to patient-centered care. A pilot program to establish Centers of Excellence in Primary Care at five selected Veterans Administration centers starts later this year and is an example of that kind of training, she says. Each center will be federally funded at a level of approximately $1 million per year for five years.

"Our system will have a nurse practitioner student actually co-managing panels with medical residents and working as a team. Within the VA system it's called patient-aligned care teams, but on the outside it's called the medical home model," Jensen says.

Ron Byerly, a physician assistant at Geisinger Health System in Danville, Pa., says he sees turf wars not so much between physicians and advanced practice nurses but between NPs and PAs, who traditionally have competed for jobs and salaries. Twenty years ago, he says, PAs made more than NPs for doing the same job, but that has since leveled out.

Byerly helps lead the Advanced Practice Council at Geisinger, a group established almost two years ago to help resolve such issues. Collaboration starts with having three directors—one each for NPs, PAs and certified registered nurse anesthetists—with equal access to the administration.

"We decided right from the start that we were going to close that chasm to recognize our differences and recognize that 90-plus percent of what we do, especially between nurse practitioners and PAs, is so similar that it's not worth an argument," he says.