The Roles of Physician Assistants and Nurse Practitioners in Primary Care
D. Kay Clawson, MD, and Marian Osterweis, PhD, editors
Association of Academic Health Centers, Washington, DC
128 pp., free (plus postage) (paperback)
This collection of papers on the roles of physician assistants (PAs) and nurse practitioners (NPs) in primary care provides a wealth of information on the two professions, their origins, educational requirements, and demographics. The papers were provided as background for a workshop conducted April 13, 1993, in Washington, DC, by the Association of Academic Health Centers. The workshop was requested by Thomas H. Meikle, Jr., MD, president of the Josiah Macy, Jr. Foundation. The Macy Foundation has shown great interest in the future of PAs and their potential for providing primary medical care, particularly to underserved populations.
Much of the material in this book naturally focuses on how these two professions are likely to affect healthcare delivery in this country as primary care assumes a higher priority. Clawson notes in the preface that "while health reform proposals are placing greater emphasis on the delivery of primary care services, they do not appear to adequately address human resource issues, particularly questions related to nonphysician practitioners." In other words, who is going to be providing all this new primary care?
The purpose of the workshop was to "examine the educational, professional practice, and public policy issues that impact the ability of physician assistants and nurse practitioners to deliver primary care services." Participants were "challenged to recommend actions to help meet the nation's primary care needs, particularly in underserved areas."
The first chapter briefly summarizes the day's proceedings and the participants' recommendations. Not surprisingly, the 35 participants — who included PAs, NPs, registered nurses, physicians, public and private policymakers, researchers, educators, and 15 chief executive officers from academic health centers — could not agree on much. They did, however, agree that (1) health reform is on a fast track, (2) more information is needed on these two professions and their potential roles, and (3) the short-term priorities for study should be supply, scope of practice, practice, and reimbursement policies.
The chapter that stands out particularly for me is "Meeting the Needs of the Underserved: The Roles of Physician Assistants and Nurse Practitioners" by Virginia Fowkes. Fowkes is the director of the Primary Care Associate Program in the Stanford University School of Medicine, an unusual program in that it educates both NPs and PAs. Her paper is based on a recent, federally funded study that she and three colleagues did of 51 PA, NP, and certified nurse-midwife programs that focus on underserved areas.
Fowkes describes strategies found to be successful in recruiting and retaining students interested in caring for the underserved. These include providing financial aid, having flexible admission requirements, offering part-time or extended programs, admitting student-preceptor pairs together (the Medex model), providing extra academic support for targeted students, offering outreach baccalaureate completion programs for rural nurses, having ethnic minority faculty members, and recruiting in underserved areas.
Fowkes also identifies a number of barriers to success, the most striking being the current tendency of nurses to seek advanced degrees. Fowkes's arguments on this point are most compelling.
My summary is just the tip of the iceberg. Fowkes demonstrates that there are considerable data about who goes to underserved areas and about the educational strategies that work to get them there.
Other chapters examine:
- The lack of current information about the actual roles and functions of PAs and NPs in the workplace
- The economics of PAs in the work force, including costs and productivity, distribution by specialty, supply and demand, and the politics of replacing physician residents with PAs as hospital residency programs are cut
- NP educational issues, practice styles, and practice barriers
- The roles of PAs and NPs in managed care, including information from nearly two decades of PA and NP work at Kaiser Permanente in Portland, OR
- PA institutional sponsorship, program budgets, curricula, personnel, applicants, students enrolled, student expenses and attrition, minority representation, and graduate employment
- Government policies (especially those involving reimbursement) and how they affect PA and NP distribution and their ability to practice most effectively
A chapter by E. Harvey Estes, Jr., MD, a founder and longtime proponent of the PA profession, offers his insights into its success. The PA educational model is both radical and practical, Estes argues. He thinks physician educators might make use of it, too.
I have two complaints about this otherwise excellent and useful collection of papers. The first involves my current pet peeve and is certainly not limited to this book. When writers use such broad terms as "midlevel providers," "nonphysician practitioners," or, heaven help us, "paraprofessionals" in referring to healthcare providers, they often confuse the reader. Healthcare writers ought to be specific. PAs, NPs, clinical nurse specialists, certified nurse-midwives, and direct-entry midwives — to name a few — are distinct types of providers with different types of training, scopes of practice, and political and clinical issues. Writers who attempt to conserve ink by lumping them together just muddle discussion of an already immensely complex issue. Not all the authors represented in this book commit this offense, but many do.
I also wish the book provided more background information about its authors. But, in general, I found the quality of the papers to be quite good and the content valuable. The papers are thoughtful and filled with historical information about the evolution of these two professions, with remarkably little redundancy. The references are very good, too.
Ellen Rathfon
Director of Professional Affairs
American Academy of Physician Assistants
Alexandria, VA
Copyright © 1995 by the Catholic Health Association of the United States
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