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.
Radiologist Assistant
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.