On The Front Line of Health Care

“Depending on how you look at it, there are either 90,000 or 30 million reasons why someone might see me rather than a physician,” says Kevin Lohenry, Ph.D., PA-C (physician assistant — certified), director of the Primary Care Physician Assistant Program at the University of Southern California. “The 90,000 is the projected shortage of medical doctors by 2020. The 30 million is the number of Americans who don’t have ready access to health care.”

The question of how to provide everyone with access to health care was a major issue in the 2008 presidential campaign yet is not new and has been debated for almost 50 years. In 1965, when the Medicare and Medicaid laws were passed in response to the need to provide care for women, children and the elderly, the issue wasn’t only how to pay for it, but who would actually provide services, particularly outside of big cities.

“The crisis in primary care is even more acute today,” says Lohenry. “It’s not just a function of money, but also the distribution of doctors by geography and specialty. If you live in a rural area, even a middle class person with good insurance might have a hard time getting in to be seen.”

“In fact, if you live in the wrong neighborhood in a big city full of doctors, you can still have a hard time getting an appointment,” notes Laura Worby, FNP, a family nurse practitioner who sits on the Board of Directors of the Nurse Practitioners Association of Washington, D.C., and works with impoverished patients. As a result, when more and more people go to “the doctor,” they are more likely to be treated by a licensed clinician who isn’t a medical doctor but is most likely a physician assistant or a nurse practitioner.

Both of these professions got their start at the same time.

In 1964, then-Surgeon General William Stewart assigned an African-American physician, Dr. Richard Smith, to the Pacific Northwest — which had very few doctors — to develop a training program for physician assistants later called MEDEX (medicine extension) to provide care in underserved communities. At the same time, Dr. Eugene Stead of Duke University proposed a pilot project to test the viability of a two-year nurse clinician program. A year later in 1965, Duke approved Stead’s training program, but instead of enrolling nurses, four experienced Navy hospital corpsmen became the first students in the physician assistant training program at Duke Medical Center. At the University of Colorado, Dr. Henry Silver and Dr. Loretta Ford established the first pediatric nurse practitioner program to provide primary care for children.

Growing Pains

One of the interesting aspects of the development of physician assistants is that Stead only decided to build the program around medical corpsmen because the idea of giving nurses advanced training in primary care techniques was originally resisted by nurses and doctors. Nurses feared that this development would subsume nursing education and practice and many physicians opposed giving nurses greater authority and autonomy. Today, all that has changed.

Across the country, nurse practitioners and physician assistants can perform almost all of the duties previously carried out by primary care physicians. Nurse practitioners and physician assistants make up the largest number of clinicians within a growing group of advanced practitioners — including nurse anesthetists, licensed midwives, and others who are not physicians, but who have extensive medical training. In most states, PAs and NPs have been licensed to carry out many tasks that had previously been performed only by doctors, such as writing prescriptions, diagnosing diseases, and performing minor surgery.

In almost half of the states, nurse practitioners can operate completely independent of physicians. (Legally, physician assistants must be “supervised” by an M.D.; however, in many cases, the doctor can do this from miles away by phone or even through the Internet.) “It has been a slow but forward-moving process over the past … years,” says Jan Towers, Ph.D., NP-C (nurse practitioner — certified) who is director of government affairs for the American Academy of Nurse Practitioners. Nurse practitioners and non-M.D. practitioners often have had to fight every step of the way — particularly when it came to being eligible for direct third-party payments from government agencies and insurance companies. Their major weapon has been research on their quality of care.

One of the earliest confirmations that non-M.D. practitioners can do the job came in 1986 when the U.S. Office of Technology Assessment published Case Study 37, Nurse Practitioners, Physician Assistants and certified Nurse-Midwives: A Policy Analysis. It determined that, within “their defined areas of competence, NPs, PAs and certified nurse-midwives generally provide care that is equivalent in quality to the care provided by physicians for similar problems.”

In 1994, The New England Journal of Medicine came to the conclusion that, “when measures of diagnostic certainty, management competence, or comprehensiveness, quality and costs are used, virtually every study indicates that primary care provided by nurse practitioners is equivalent to or superior to that provided by physicians.” Then, in 2000, The Journal of the American Medical Association published the results of a major randomized clinical trial showing that, in providing primary care, M.D.s and NPs achieved the same results.

How can nurse practitioners and physician assistants deliver the same quality of services as medical doctors who are required to have more than twice as much formal training during their four years of medical school and three-year residencies?

According to Dawn Morton-Rias, Ed.D., PA-C, dean and professor at the College of Health Related Professions at SUNY Downstate, and the first African-American elected president of the Physician Assistant Education Association, the answer is that “most patients present with ordinary routine conditions and require common interventions so they don’t need to be seen by a person with the maximum amount of expertise and training.”

The secret is having access to appropriate technology, tests and diagnostic tools and understanding your limitations. “With good skills, a reasonable level of training and appropriate supervision, we can provide high quality care for most common conditions,” Morton-Rias adds.

Side-by-side Comparison

According to Worby, “the biggest difference” between physician assistants and nurse practitioners “is that, in many states, NPs can function completely independently. However, in reality, everyone works in teams and consults physicians and other experts whenever necessary.”

Robert Wooten, PA-C, president of the American Academy of Physician Assistants, or AAPA, thinks that the biggest advantage of becoming a physician assistant is the flexibility of entry into the profession. The training typically takes between 24 and 27 months. However, he notes that most programs only admit people with 1,000 to 2,000 or more hours of previous patient-care experience. In many cases, the students received their medical training in the armed services.

But it is open to quite a wide range of other health professionals such as certified personal trainers, physical therapy aides and emergency medical technicians.

“The health care profession is huge and growing, so of course at the organizational level there is some professional competition and conflict between NPs and PAs, but it’s easy to make too much of the differences between us,” Wooten said. “On the local level, I see PAs, and NPs, working well together at HMOs, rural clinics, and other settings every day. The bottom line is that both groups are becoming the frontline soldiers in providing primary care to the millions of people who are having a hard time getting in to see anyone.”

But it is open to quite a wide range of other health professionals such as certified personal trainers, physical therapy aides and emergency medical technicians.

“The health care profession is huge and growing, so of course at the organizational level there is some professional competition and conflict between NPs and PAs, but it’s easy to make too much of the differences between us,” Wooten said. “On the local level, I see PAs, and NPs, working well together at HMOs, rural clinics, and other settings every day. The bottom line is that both groups are becoming the frontline soldiers in providing primary care to the millions of people who are having a hard time getting in to see anyone.”