The recognition that NPs and PAs—so-called (if reluctantly) midlevel providers—are enormously beneficial to the functioning of the US health care system has led to the introduction of similar practitioners in specialty areas such as dentistry, EMS, and radiology. Unlike PAs and NPs, with their broad areas of expertise and primary care focus, this new generation of health care professionals tends to have a more limited scope of practice.
What impact their presence may ultimately have on NPs and PAs is, for the moment, mostly hypothetical; resistance to these new professional categories has limited their use and acceptance in this country. But their positions within the health care team—and their struggles to practice and prosper—may remind PAs and NPs of their own professional journeys.
Dental Health Aide Therapists
Dental health aide therapists (DHATs) were introduced in Alaska in 2003 to meet a very specific need: dental care among Alaska Natives. This population experiences tooth decay at 2.5 times the national average, creating a substantial burden on both children and adults.
Further complicating matters, an estimated 85,000 people live in small villages (population 400 or below) in rural areas, according to the Alaska Native Tribal Health Consortium. Many cannot afford health or dental insurance and find that high travel costs prohibit them from seeking care in more developed, populous areas. (Sound familiar?)
So how can the dental health needs of this underserved population be met? Enter the DHAT, which was developed under the auspices of the Community Health Aide/Practitioner Program (CHAP). Since the 1960s, this federal program—a collaboration of the Indian Health Service with Alaska Native tribes—has brought more than 550 midlevel medical providers to work in small community clinics.
Taking its cue from more than 40 other countries in which DHATs or their equivalent are fairly common, CHAP conferred upon DHATs a rather broad therapeutic mandate. These practitioners are trained to do cleanings, fillings, and uncomplicated extractions, as well as to provide preventive services, under the general supervision of dentists who work at regional hospitals in the state.
Ironically, DHATs currently must complete their two-year education program through a New Zealand university, because there are no midlevel dental practitioner training programs in the US. While state licensure is not a requirement for DHATs, federal certification, continuing education, and biannual recertification are.
DHATs have been seen as an important solution to Alaska’s dental health problems and have earned praise from organizations involved in Native American health (as well as from former US Department of Health and Human Services Secretary Tommy Thompson).
But—cue the development that PAs and NPs may recognize from their own professional experiences—the American Dental Association (ADA) has been less than enthusiastic. In fact, the ADA and the Alaska Dental Society sued to abolish DHATs, insisting that their very existence violated state law regarding dental licensing. They were unsuccessful.
Despite this setback, opponents to the DHAT model persisted. Their lobbying efforts began to pay off in late February, when the reauthorization of the Indian Health Care Improvement Act—with amendments—passed the US Senate. (It is currently languishing in the US House of Representatives.)
If the act becomes law in its current form, the amendments would prevent DHATs from performing any oral or jaw surgeries and would allow extraction and pulpal therapy only in an emergency and only after consultation with a licensed dentist. The idea is that DHATs would not be allowed to engage in irreversible procedures—and while this would not entirely negate their purpose, it would certainly limit their utility.
Further keeping a lid on these midlevel practitioners, the Senate version of the bill would also prevent—at least for the time being—any expansion of the DHAT program to other states. But a similar concept is already in development in the lower 48 states.
Advanced Dental Hygiene Practitioners
Advanced dental hygiene practitioners (ADHPs) resemble DHATs both in their therapeutic role and in the necessity of slugging it out in the political arena just to be allowed to exist. The Minnesota legislature is the first state political body to consider bestowing official sanction upon the ADHP and has made itself a battleground in a drawn-out fight. The primary combatants are the Minnesota Dental Hygienists’ Association (MNDHA), which supports the new designation, and the Minnesota Dental Association, which (surprise!) opposes it.
According to Mary Beth Kensek, RDH, RF, President of the MNDHA, the idea for the ADHP originated from the American Dental Hygienists’ Association in response to the Surgeon General’s 2000 report that highlighted issues of access to dental care in the US. In other words, much like the situation in Alaska, a lot of people who need dental care are not getting it for a variety of reasons, and the midlevel practitioner has been seen as part of the solution to that problem.
In describing the new professional designation, Kensek was at pains to distinguish the ADHP from the traditional dental hygienist. “It’s a new level of practitioner, and so, at least in our state, it’s not [simply] expanding the role of the dental hygienist,” Kensek explained. “It’s creating a whole different level of practitioner—a midlevel practitioner.”
When asked whether she thought the ADHP was akin to an NP or a PA, Kensek said, “The specifics are different, but in a very broad sense, yes, it’s a fair comparison. They’re both midlevel positions—that’s a good way to put it.”
To be more specific, ADHPs will not be independent practitioners; like DHATs, they will work under general supervision in collaboration with a licensed dentist. ADHPs will be trained to the master’s level in a curriculum developed by MNDHA in collaboration with the Minnesota Safety Net Coalition. The program will be similar to that for dental hygienists but will include additional qualifications.
“In addition to being able to provide any of the preventive services that traditional hygienists do, we’re also looking at doing different types of therapeutic activities, like some extractions that aren’t very involved, in order to relieve patients’ discomfort,” Kensek elaborated, “doing pulpotomies, and doing minimal prep and restorative work.” Limited prescribing privileges, within well-defined parameters, would also be available to the ADHP.
At the moment, “We’re looking at doing a pilot study so that we can examine this concept a little bit more and establish that it’s safe and effective,” Kensek said. “That way we can alleviate some of the fear and show that there is a need for this practitioner.”
Advanced Practice Paramedic
It is ironic that while PAs were virtually unheard of in the United Kingdom until a few years ago, and NPs are still a relatively recent phenomenon there, midlevel practitioners of other kinds have been thriving. One is what the Brits call an emergency care practitioner (ECP; or paramedic practitioner) and what Americans call the advanced practice paramedic (APP)—or at least they would if such a thing existed.
In the UK, the ECP delivers “unscheduled care” with a defined set of available interventions and medications. For example, therapeutic scope includes defibrillation, intubation, and thoracostomy, while prescriptive authority is granted for drugs such as adrenaline, naloxone, heparin, and hydrocortisone. Perhaps the most significant privilege given the ECP is the ability to treat-and-release or treat-and-refer.
In the US, the APP was originally proposed in the first draft of the National EMS Scope of Practice Model (2005), a semiformal “constitution” for the world of emergency medicine. The proposal was met with considerable con-sternation when its intended audience realized that the introduction of the APP would mean an entirely new class of emergency practi-tioners.
The American Ambulance Association, for example, noted in their position paper in response to the draft, “We take exception to the creation of [the APP] as defined in the document. The reasons for the creation of such a certification level seem to be far-reaching and only vaguely connected.…
“Further, we believe the educational requirement necessary for a paramedic to advance to the APP certification would severely constrain a local medical community from implementing creative and innovative integrated delivery systems that allow for referral/transport to alternative health care facilities.”
The APP was not to be—at least then. Some emergency medicine leaders continue to express support for the concept itself or for the idea of treat-and-release/refer privileges.
This support may receive a boost from a pilot program conducted in Arizona earlier this year, in which a Mesa fire department replaced their EMS technician with a PA who could evaluate patients on the scene and determine whether they should be treated, transported to a hospital, or referred to their usual health care provider. The idea was to free up the EMS team for response to true emergencies—but it could point to a need for a practitioner like the APP.
How many practitioner designations does one specialty need? The radiologist assistant (RA)—first recognized by the American College of Radiology and the American Society of Radiologic Technologists in 2003—should not be confused with the radiology practitioner assistant (RPA), which was introduced in the 1990s as a way to address a shortage of radiologists in the armed forces.
The therapeutic scope of RAs depends on their level of education and training and which certifying body they are associated with. That said, RAs typically assist with patient management, radiology exams, and preliminary image evaluation—although image interpretation is not within their purview.
The RA may be the one to prepare patients for radiologic exams, obtain patient consent for the injection of diagnostic agents, address patient questions—in short, serve as a patient advocate. The RA might assist with invasive procedures or perform fluoroscopy for noninvasive procedures under the supervision of a radiologist.
RAs can also undertake certain peripheral venous diagnostic procedures and place feeding tubes in patients without complications. Once the examination has taken place, the RA may be involved in determining image quality and may also provide preliminary observations—but purely in the context of assisting the radiologist and not for presentation to the patient.
While a certain amount of controversy inevitably surrounds their emergence as distinct midlevel practitioners, RAs are currently recognized in 10 states, each with its own requirements for education and accreditation. RAs must obtain at least a bachelor’s degree, and master’s degrees are fairly common.
It should be noted that PAs frequently perform many of the tasks for which RAs are trained. PAs, of course, have a broader educational background than RAs and possess certain advantages in the breadth of their capabilities and privileges as health care practitioners. However, within the narrower scope of radiologic duties, the RA may be regarded as having more specific training than the PA. What impact this will have on PAs who practice in radiology remains to be seen.