Blog | Monday, January 16, 2012

Filling the void (... the young docs, vol. 2)


The CDC released a recent report ("data brief") on the subject of physician assistants (PAs) and advanced practice nurses (APNs).

Physician assistants are a growing cadre of professionals who practice medicine under the supervision of doctors. Advanced practice nurses are registered nurses with advanced training, who work independently (but in collaboration) with doctors.

PAs and APNs are often referred to in health care-speak as "physician extenders," a term I loathe. To me it implies that these professionals are somehow not fully formed human beings, but rather mere appendages of almighty doctors.

There was a lot of initial resentment toward PAs and APNs by doctors. I can still hear some of the claims:

--They will take our patients, thus stealing our business.
--They don't have enough education.
--Will patients really want to see them, with their "lesser" education and experience?
--They can't be trusted to prescribe mediation independently.
--They're not doctors.

Those cries have greatly diminished as their numbers have grown. Doctors in the private world relish working with "extenders," because they help improve volume (i.e. patients seen) which brings in additional revenue. And because they earn less (presumably because they have less in the way of education [two years vs. four for medical school] and experience [one year internship vs. three years-and-beyond residency training periods], they are in fact quite economical for private physicians who hire them, or the larger groups (especially hospitals) that employ doctors.

In a prior brief, the CDC demonstrated that nearly 50% of office-based physicians work with PAs and APNs. The larger the practice, the more likely this is to be true.

The most recent brief, highlighted courtesy of V.S. Elliott in American Medical News, looked at "allied health workers" (PAs and APNs) working specifically in hospital-affiliated medical practices. The data shows a 50% increase in visits to these office sites in which a patient saw only a PA or APN over the most recent eight years.

I find this important for a couple of reasons. As we inch closer to health care reform, with several million uninsured people expected to enter the insured pool, allied health workers will be more frequently counted on to pick up the load, as the number of primary care doctors isn't growing enough to meet demand.

In addition, under health care reform it's expected that one of the formats for improving delivery of health care will be the Accountable Care Organization (ACO). In this model, doctors will supervise teams consisting of nurses, PAs and APNs, who will see most of the patients. It is argued that this will be the most efficient, cost effective, and highest quality deployment of health care personnel.

Some beg to differ on those assumptions. My own feeling is that doctors don't go to medical school to learn to manage teams of other professionals. Some of us may actually like it or have talent for it, but current medical education models don't have any bearing on these skills.

It's a tumultuous time to be in health care. Stay tuned.

This post by John H. Schumann, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.