etween the worlds of physicians and patients in the United States there is at the moment an intermediate layer of health care professionals collectively referred to as physician extenders (PEs) or mid-level providers (MLPs). The two most prominent are the Nurse Practitioners (NPs) and the Physician Assistants (PAs). Who are they and how are the performing is the topic for today.
How it all began: In the delivery of health care nurses have traditionally been the closest professionals to the physician. The official origin of Nurse Practitioners took place when the first class of NPs graduated at the University of Colorado in 1965. As of today there over 120,000 practicing NPs. Close to 6,000 new NPs are prepared each year at over 325 colleges and universities. Beyond the RN, which requires a bachelor's degree, NPs have an additional 2-3 years of training which, in the early years, led to a required Master's degree in Nursing. Physician shortages in the 60s and 70s led to optional pathways leading to either an associate degree or a hospital-based diploma degree or other modifications.
The Physician Assistant profession also began in the mid-1960s when the previously mentioned physician shortages created an uneven shortage of primary care physicians in the US. Dr Eugene Stead of the Duke University Medical Center in North Carolina put together the first class of PAs in 1965curiously, when the NPs were graduating their first class in Colorado. The first PA class consisted of Navy corpsmen who received considerable medical training during their military service and during the Vietnam War. He based his PA curriculum, in part, on his knowledge of the fast-tracking training of doctors during World War II.* The rest is history, as the saying goes. There are a number of training centers for PAs in the US. Currently, I belong to a faculty who trains PAs and can vouch for their excellent training and performance as well as acceptability by the public at large.
Mid-level providers are here to stay and there is a move to facilitate their entrance into medical school and become full fledged MDs for those who so desire.
Current status: Both NPs and PAs have similar pathways following graduation. They are licensed to practice in all States and the District of Columbia under the supervision of a practicing physician and must abide by the governing rules of the State and the medical organizations therein. They can prescribe medications to include narcotics, they carry malpractice insurance and are recognized for payment by Medicare and Medicaid. Both groups have national organizationsThe American Academy of Physician Assistants and the American Academy of Nurse Practitioners. Both NPs and PAs have progressed into specialty and subspecialty areas of medicine.
Military experience: All military services have NPs and PAs on active duty as Medical Specialist Corps officers in combat and non-combat roles within the continental US, Hawaii and other overseas duty areas, to include Special Forces units. They serve as the "front line" of Army medicine and, along with combat medics, are responsible for the total health care of soldiers assigned to their units, as well as of their family members. PAs in the Air Force and Navy serve as clinical practitioners and aviation medical specialists. PAs are also required to meet the officer commissioning requirements and the physical readiness of the respective military services.
Patient acceptability: Patients are generally pleased with the quality of care delivered by Physician Extenders. A survey conducted by MGMA, Medical Group Management Association, showed that 429 out of 663 practices employed PEs and 200 out of 222 practices surveyed were satisfied with their performance. It's been my observation that since NPs and PAs don't have the full "white coat effect" of the physician who raises your blood pressure just by his presencethe so-called 'white coat hypertension effect', their interactions with patients are less stressful, more comfortable and they are capable of gathering more detailed information in less time.
How close must PEs be supervised? This has been the problematic area. In Pennsylvania, for example: "Constant physical presence of the supervising physician is not required so long as the PA supervisor and the PA are or can be in contact with each other by radio, telephone or telecommunications". However, the rules for reimbursement in the same State require the physical presence of the Supervisory Physician. Under Medicare regulations, services provided by a PA in most physicians' offices are reimbursed as incident to a physician's service and, thus, paid the same as if a physician had provided them. Also, services located in a designated rural health professional shortage area, or outside the office setting, for example a Skilled Nursing Facility or as an assistant in surgery are reimbursed. States vary in payment practices.
In short, mid-level providers are here to stay and there is a move to facilitate their entrance into medical school and become full fledged MDs for those who so desire.
Other mid-level providers: Besides PAs and NPs there are other well known mid-level providers such as the Certified Nurse Anesthetist, the Certified Nurse Midwife and others. Radiologists are currently training their own Radiology Technicians.
For further information consult the following internet sites:
- American Academy of Nurse Practitioners (AANP) http://www.aanp.org.
- American Academy of Physician Assistants (AAPA) www.aapa.org/.
- National Commission on Certification of PAs (NCCPA) www.nccpa.net>.
- Journal of the American Academy of PAs (JAAPA) www.jaapa.com/.
Adding a Physician Extender. Physician's News Digest
* I was a resident at Walter Reed Medical Center when Dr Stead visited during his US tour of medical centers explaining his proposed idea of creating a PA curriculum. I remember the feedback he got then was not favorable.