One of the more modern developments of modern medicine is the proliferation of non-physicians getting into the business of healthcare delivery. In the old days you had doctors and nurses. The distinction was clear, and the roles each played were understood by those in their care. How things have changed.
If you’ve been to your primary care doctor’s office recently, especially if you are covered by an HMO, chances are you were not seen by your primary care physician. Most likely you were seen by the Physician’s Assistant, or perhaps by a Nurse Practitioner. Your recent health history was reviewed, you received something of a physical exam, lab tests ordered the previous week were back and you were informed of the results. Based on all of this you were either given a pat on the back or some recommendations about lifestyle changes you might want to consider if longevity is one of your goals.
In these ways the visit was like any other you’ve had in the past. Except the doctor wasn’t really a doctor. Just who this person was, and how he or she got there, is what I’d like to discuss.
Over the past couple of decades, as the demand for healthcare has grown, the fact that there are too few physicians to meet this demand has become increasingly obvious. Various solutions to this problem were proposed. These included allowing foreign-trained physicians easier entrée to the American healthcare market, increasing the size of the medical school student body, and creating new classes of healthcare professionals to help with the clinical workload.
Each of these three solutions has had consequences, intended and otherwise. In the case of the foreign medical graduates we’ve enjoyed an influx of bright, well-trained and eager physicians excited by the opportunity to work within the American system of healthcare. That was the intended consequence. The unintended one was the depletion of physician talent in foreign countries that could little afford the loss. This has been especially noticeable during the recent Ebola outbreak in West Africa where the need for non-African physicians to help with the fight has become acute.
Increasing the medical school student body has, in fact, produced larger numbers of graduating physicians. This increase, though, has not been sufficient to meet the growing demand and many of these new physicians eschew primary care in favor of other, more lucrative, specialties. Given the economic realities of getting a medical education this should be no surprise—and something we can discuss in greater detail in another installment.
This brings us to your recent doctor visit, and the person behind the white coat. As I mentioned earlier, this person was likely either a Physicians’ Assistant or Nurse Practitioner, commonly referred to as a “Midlevel Provider”. Both of these individuals have a certain amount of medical training and both can function well in certain clinical environments.
The Physicians’ Assistant, or PA, has a college degree and somewhere between two and four years of post-graduate training depending on the state in which the training took place and the specific role the PA expects to assume. PA’s practice under the direct supervision of a physician and usually specialize in a particular area of medicine. There are surgical PA’s who work in the operating room alongside a surgeon, and subspecialty surgical PA’s who work with orthopedists and neurosurgeons. There are family practice PA’s working in medical clinics and private doctors’ offices. They do an excellent job of managing the established patients, making sure treatment plans are adhered to and “best practices” followed. The majority of physicians working with PA’s in these types of situations find them to be indispensible.
Nurse Practitioners, or NP’s, have graduate nursing degrees and additional training, sometimes up to the point of a Ph.D. in nursing. They, too, tend to specialize, but unlike the PA a Nurse Practitioner can work independently. No physician supervision required. Like PA’s, NP’s can be found in a variety of practice settings, but their ability to practice independently makes them especially valuable in the primary care setting. They can also provide care that might otherwise be unavailable to certain patients in areas with few physicians.
Though PA’s and NP’s have less training than a doctor, when working as part of a medical team they make the doctor more efficient. This is good for patients who can get more hands on attention than might be possible were the doctor working alone. And because both PA’s and NP’s typically earn less than physicians, they help keep the cost of healthcare delivery down.
Though it seems unlikely that PA’s or NP’s will replace physicians, their roles will expand over time. Improved metrics, such as “best practices” and “core measures”, and their integration into clinical teams will allow them to use their training and experience most effectively, and provide a more robust patient care environment.