Below is a copy of an article recently published by a local source here in Knoxville.
Filling the gaps with midlevel health providers
Physician assistants seeing more patients
From right, Danielle Courville, Heather Steepleton and Stephanie Howard are enrolled in South College’s physician assistant program. Many medical practices are relying on physician assistants to administer basic health care needs for patients.
What are …
- Nurse practitioners? Registered nurses who have completed specific advanced nursing education and training in the diagnosis and management of common and complex medical conditions. NPs can provide a broad range of health-care services, but states vary in the amount of autonomy they’re allowed. Don’t confuse with: Licensed Practical Nurses, who have less training and must be supervised by RNs or doctors.
- Physician assistants? Advanced practice clinicians, usually with a graduate-level degree, who can practice medicine under a physician’s supervision. PAs can take medical histories, perform examinations and procedures, order treatments, diagnose illnesses, prescribe medication, order and interpret diagnostic tests, refer patients to specialists when appropriate and first-assist in surgery. Don’t confuse with: Medical assistants, who perform administrative and clinical tasks in hospitals and clinics under the direct supervision of physicians, RNs, NPs or PAs.
That’s because more and more Americans are getting primary care from licensed nurse practitioners and physician assistants, who can do most of what a physician can do but who cost less and often have more time to spend with patients. Some surveys suggest that more primary care patients are seen by a nurse or physician assistant than by a doctor.
Government surveys count more than 140,000 advanced practice nurses and 70,000 physician assistants providing clinical care, compared to just more than 300,000 primary care doctors.
“That ratio is skewing more toward PAs each year since the PA work force is increasing faster than that of physicians,” said Perri Morgan, director of physician assistant research at the Duke University Medical Center. “PAs will be playing a bigger role in the future in primary care and in medical and surgical specialties as well.”
The Tennessee Department of Labor and Workforce Development labels the PA profession “high demand,” projecting the number of PA jobs will increase by anywhere from 15 percent to 70 percent between 2006-2016, depending on the area of the state. Median annual salary is $64,888.
Knoxville’s South College began a PA program in December 2007.
“In East Tennessee, if you look at the statistics, the number of medically underserved (patients) and the need for primary care generalists and physicians is tremendous,” said Ken Harbert, a former practicing physician assistant and dean of South’s School of Physician Assistant Studies.
PAs are “generalists,” trained not only in family practice and geriatrics, but in obstetrics and gynecology, emergency medicine, behavioral medicine, pediatrics and surgery, Harbert said. After training, they can specialize in any of those fields or get further training to work in areas like orthopedics.
South has a mission for most of its PA students to spend at least some time helping the medically underserved, particularly in a primary care setting, where Harbert said a trained PA can do “85 percent” of what a doctor can do.
Collaborative care
In fact, students’ willingness to work with the underserved is part of the competitive application process for the program, he said. Of 675 applicants for this year’s class, 200 will be interviewed and 50 accepted.
Harbert said South looks for applicants who plan to practice in East Tennessee. He estimates more than 65 percent of South PA graduates will stay.
Lincoln Memorial University in Harrogate had a similar mission when it began a PA program this year at its DeBusk College of Osteopathic Medicine.
“Hopefully, it will help alleviate the primary care shortage in this area,” said program director and PA Michelle Heinan, who said LMU also gives precedence to students willing to practice in the area after graduation.
Although state regulations vary, PAs are usually registered to practice after three to four years of training; advanced nurse practitioners go through at least four years of training and usually six or more. While physician assistants work independently in some settings, they’re always under a doctor’s supervision to some extent. Thirteen states let NPs diagnose, treat and prescribe without a supervising doctor, but most, including Tennessee, still require physician oversight.
The Tennessee Nurses Association is advocating letting NPs practice independently, especially in areas with doctor shortages. Nurse practitioner Kimberly Ferguson returned to her hometown of Sneedville, which has a population of about 6,500, to provide care in her own community. State law requires Ferguson be supervised by a doctor, but there’s only one primary-care physician in her county, where 67 percent of residents are medically underserved.
“It is very difficult to recruit physicians in the rural or underserved areas that community health centers care for,” Ferguson said. “As the gap in services have the potential to expand (with) the predicted physician shortage, there is need for our legislators to push for collaborative practice instead of the required supervisory role in the health care setting.”
Midlevel providers
NPs have long filled gaps in care, but although America has had PAs since 1968, they didn’t come to the general public’s attention until the last couple of decades, when television shows “Simon & Simon” and “ER” featured PAs as characters.
These days, most PA students have themselves gone to PAs.
“I like that they’re able to sit and talk to you, not be rushed to the next patient,” said South student Danielle Courville of Columbia, who plans to work in primary care for a few years before specializing in endocrinology. “I like to get to know who I’m treating.”
South PA student Heather Steepleton, from Central Florida, chose PA over other medical careers because PAs “get to educate; they get to spend a lot of time with their patients.”
“I liked the team approach” of working closely with a doctor, she said.
A well-trained PA “knows exactly how you want to practice medicine … (and) helps you see people more effectively and more efficiently,” Harbert said. “Most post-graduate physicians say, ‘I want to see every patient by myself.’ Well, is that the most effective and efficient way to do it? Medicine is changing, and it’s becoming very, very difficult to make that happen.”
Some argue that “midlevel providers,” as practices call NPs and PAs, simply can’t provide the same level of care a physician can.
“The nurse practitioner replacing the family doctor is not good for America,” said Dr. Ted Epperly, president of the American Academy of Family Physicians who runs a multiclinic general practice in Boise, Idaho. “To say a nurse practitioner can fill the shoes of a family physician, in terms of total comprehensiveness, is just not true.”
But proponents point out that not every patient needs that comprehensive level of care at every visit.
“Most of our larger practices employ at least one PA,” said Dr. Randall Curnow, medical director of Summit Medical Group, which includes about 155 primary care physicians and about 50 PAs. “We feel like, given the (primary care physician) shortage, and given the limited resources of our physicians, that we try to provide patients with a team — efficient, overall management of the patient’s care, with physicians dealing with the more complex problems.”
Summit internist Dr. Michael Carlson works in a practice with nine doctors and two midlevel practitioners. When PA Matt Lavelle came on board four years ago, most doctors in the practice weren’t familiar with PAs, Carlson said.
“For years, we did it all,” he said. “To delegate some of that to someone else was very difficult.”
But it soon became apparent to him that the aging population, with its increasingly more complex blend of medical problems, required more people and more time to treat. Lavelle performs a sort of triage, meeting with the doctors daily to discuss the patients he’s seen.
“There’s just not enough time” for doctors to see every patient at every appointment, and PAs “allow a lot of access,” Carlson said. “In this day and age, when people are sick, they don’t really want to wait two weeks to see a doctor.”
Kristi L. Nelson may be reached at 865-342-6434. Scripps Howard News Service medical writer Lee Bowman contributed to this report.
