On the Front Line: Physician Assistants, Nurse Practitioners Take on Primary Care Duties That Were Once the Exclusive Domain of Physicians

Article excerpt

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"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.

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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. …