Doctors turning to assistants for primary care
Not enough doctors: As shortage worsens, other health professionals increasingly asked to step in
Published 7:53 pm, Wednesday, April 11, 2012
Allen, a 55-year-old Ansonia resident, came to the center complaining of arm pain. Her blood pressure was taken. She was asked to move her arm to determine how the pain was affecting her range of motion.
She was asked whether she participated in any activities that could have led to her pain. And she was given a prescription for anti-inflammatory medication and referred for X-rays.
But the health professional Allen saw wasn't a doctor. It was Holly Major, a nurse practitioner. Major holds one of two midlevel health care positions becoming increasingly important as the national physician shortage grows.
The other is physician assistants. Though these are two different types of jobs, caregivers in these fields can do many of the things a doctor can, such as prescribe medications and treat certain diseases and illnesses.
With the possibility that health care reform may lead to 32 million more people with access to care by 2014, the physician shortage is set to get even worse. Thus, doctors will likely become more dependent on people like Major to give patients the care they need.
Nurse practitioners are basically registered nurses with more training -- including a master's degree -- and responsibilities. They are able to diagnose many common illnesses, prescribe some medications and even perform certain procedures and minor surgeries. Nurse practitioners can work independently, without the support of a physician, and can even have their own practices. Many, however, work with a doctor, like Major does. She said, oftentimes, doctors looking to take on additional staff prefer to hire a nurse practitioner over another doctor.
"They're more cost-effective for one thing," Major said. "And nurse practitioners are known to spend more time with patients. Physicians like that because they often don't have as much time to spend with patients."
Unlike nurse practitioners, physician assistants do need to work with a physician. However, they can have some degree of autonomy, depending on their experience and the willingness (or need) of the doctor they work with to delegate.
Physician assistants follow the medical model for training, and many have master's degrees. Like nurse practitioners, they have many of the same capabilities as doctors. They can write prescriptions, conduct medical exams and take on a host of other responsibilities.
Both professions began in the mid-1960s, mainly to help offset physician shortages then. The physician assistant profession was also developed to find a spot for an untapped resource -- military medics coming home from the Vietnam War whose options in the health care field were mainly limited to becoming orderlies.
Today, many doctors in the state employ a physician assistant or nurse practitioner. In a 2009 survey by the Connecticut State Medical Society of 498 physicians statewide, 25 percent of those polled said they employed a physician assistant and 46 percent employed an adult nurse practitioner.
The relationship between doctors and these midlevel professionals, however, hasn't always been harmonious, said Margaret Grey, dean and professor at the Yale University School of Nursing. Grey said there has been muttering from doctors in the past that PAs and NPs are trying to replace doctors. That's never been true, she said.
"We're not trying to replace them -- we're trying to fill the gap," she said. "There's increasing recognition that if we're going to meet the primary care needs of our country we're not going to meet them (just) by training more physicians. It's time to start talking about how we work together and less about, `You're taking my job and I'm taking yours.' "
Indeed, the shortfall of doctors in the country has been a nagging concern for some time. In 2010, there was a shortage of 13,700 physicians nationwide, according to the Association of American Medical Colleges, a nonprofit representing faculty members, medical students, and resident physicians at medical schools and other institutions. If the major pieces of the Affordable Care Act go into effect in 2014 as scheduled, the gap will continue to grow, reaching a shortfall of 62,900 by 2015 and 91,500 by 2020.
As a result, many in the health care field are scrambling to figure out how to provide care to all who seek it. Daniel Cervonka, director of the physician assistant training institute at the University of Bridgeport, said the possibility of a huge influx of insured Americans will alter the way health care is delivered.
"If you're going to create a situation where there's more access, we need to create a two-tier system, where NPs or PAs see patients initially, then possibly refer them to a physician (if they need more intense care)," he said.
Other health professionals also see NPs and PAs as essential to the future of health care. As director of primary care development at St. Vincent's Medical Center in Bridgeport, Frank Scifo said filling the gaps caused by the physician shortage is a huge concern for him.
"The cadre of primary care physicians is definitely shrinking," he said. "We want to make sure we have a succession plan in place to serve the needs of the community. We're going to have to tap into these pools of midlevel clinicians more. It's an essential part of meeting health care needs in the coming years."
Martha Shouldis, chief executive officer for St. Vincent's, which has its own nursing college, said doctors will be increasingly reliant on midlevel health professionals moving forward.
"We have doctors retiring (at a high rate)," she said. "We will have to learn how to continue to deliver quality care."
But some in health care question the growing importance of nurse practitioners and physician assistants in health care at a time when a nursing shortage is also on the horizon. The American Medical Association attributes this potential nursing gap to many of the same factors causing the physician shortage. Nurses, like doctors, are aging. Nurses in their 50s are expected to become the largest segment of the nursing workforce, accounting for almost one-quarter of the registered nurse population.
Another factor is that nursing colleges can't accommodate everyone who wants to attend. According to the American Association of the Colleges of Nursing, nursing schools in the country turned away 75,587 qualified applicants from baccalaureate and graduate nursing programs in 2011 due to an insufficient number of faculty, clinical sites, classroom space and other factors.
Given that, the increased reliance on nurse practitioners is alarming, AMA President Peter W. Carmel said.
"There are currently shortages of both nurses and physicians, and increasing the responsibility of nurses is not the answer to either problem," Carmel said. "Training more physicians and nurses so patients have access to the quality care they need is the answer. Patients benefit when all members of the health care team work together with each playing the role they were educated and trained to play."
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