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TRIPOLI, Iowa --- Erin Ott doesn't want to be a doctor, so she does what she thinks is the next-best thing: She is a physician assistant.

Ott, who treats patients at Covenant clinics in Tripoli and Fairbank, is one of a growing number of medical professionals who choose a so-called "mid-level" path between MDs and nurses and become PAs and nurse practitioners.

Contrary to common belief, PAs and NPs are distinct from each other. The latter fall into a broader category of advanced practice nurses.

"The majority of employers use APNs and PAs interchangeably," said Roger Tracy, assistant dean and director with the University of Iowa's Carver College of Medicine, which trains both. "Let's take an urgent care center or emergency department, for example. Most likely they'll fill an opening with either. NPs and PAs will tell you they're different from one another. They don't take lightly the fact that employers think of them interchangeably."

NPs have a nursing and education component that PAs don't.

Nurse practitioners can work without the supervision of a physician, Tracy said.

"There's more effort for patient information, education and patient counseling and less so on the PA side," Tracy said. "Not that they don't do that, but it's just not as pronounced in their training as with NPs."

But there are plenty of similarities, particularly in filling roles in rural clinics, said Dr. Nasredin Dalil, a family-practice physician at a Covenant clinic attached to Mercy Hospital in Oelwein.

"The need for medical services in small towns and rural areas is just growing," Dalil said.

"That cannot be filled by physicians at all times, and that's the main reason for the need for all the mid-levels to fill these provisions."

A shortage of physicians combined with doctors' preference for practicing in urban areas has created the need for mid-level practitioners, said Dr. Paul Franke, vice president of medical affairs for Wheaton Franciscan Healthcare - Iowa.

"Most people in small towns don't have access to physicians," he said. "There's just kind of a major trend everywhere, a tendency for people and professionals of all sorts to kind of migrate to more urbanized areas, which leaves rural areas trying to scramble for resources and expertise."

PAs and NPs are answering the call with distinction, Franke said. He singled out Ott in that vein.

"I'm really very impressed with the training that she obviously got, the level of understanding of the problems she confronts and the way she works her way through it," he said.

Ott, a 2005 graduate of Columbus High School in Waterloo, worked through a 25-month program at Des Moines University that, along with the U of I, trains most mid-level medical personnel in the state.

Two years of training

The training is rigorous from start to finish, she said.

"The first year most of the time is all classroom work, with all system courses with pharmacology," she said. "We're kind of being trained with medical students at PA school,. It's kind of different from nursing. The second year is all clinical rotations. We have so many months of family practice and internal medicine, some emergency room, some specialties."

Ott said she had rotations in Waterloo in such fields as cardiology, dermatology and women's health.

Splitting her time between the two rural Covenant clinics fills an essential role.

"We go places where other providers often don't want to settle. It's really an important opportunity to reach out and serve patients here. That's kind of what the PA program is all about: to serve areas that normally wouldn't draw physicians and specialists and such. It's a good connection to have that health care at home. It's a good access for them."

Having access to a mid-level practitioner and not a doctor sometimes creates misconceptions, but those are generally cleared up with ease, Ott said.

"Most of the clinics are long-established, and in these areas they're used to who we are and what a PA is. But other times it's a good question to ask. A lot of people are misinformed as to what a PA or nurse practitioner can provide."

A growing field

Mid-level medicine is a growing field, said Tracy, who tracks statistics on PAs, NPs and doctors.

"In 2000, we had 706 APNs in Iowa, and at the end of 2010, we were at 1,250, which is a 77 percent increase," he said.

The NP field has grown even more dramatically.

"For every two APNs, we have one PA," he said.

According to Tracy, Iowa's population of PAs has grown from 467 in 2000 to 679 at the end of last year, a 45 percent increase.

"The rate of increase is steeper for APNs, but both are increasing pretty substantially," he said.

Allen College in Waterloo graduates about 50 nurse practitioners each year, according to Ruselle DeBonis, a doctor of nursing practice who teaches several nurse-practitioner courses and is clinical coordinator for NPs at Allen College School of Nursing.

"Obviously, they are practicing registered nurses with bachelors (degrees) when they come to us, and they have to have a 3.0 in order to get into the program," she said of her program, which confers master's degrees.

"Basically, the nurse practitioners, once they've graduated, are independent practitioners who can write prescriptions and see and manage patients," DeBonis said. "Part of the reason they're becoming more popular is they can fill that role themselves."

PAs, by comparison, require the supervision of a physician, DeBonis said.

But both provide necessary functions, particularly in small towns.

"A lot of that is because it's been hard to recruit providers into those rural areas," she said. "NPs have kind of answered the call, willing to go to some of those areas that a physician might not be necessarily enticed to go. They fill that need quite well."

Ott said she is kept busy.

"I'm new, but I see 15 to 25 patients on average," she said. "We have patients that ask for us particularly."

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