Chapter Six ('Underserved')

Non-Physician Practitioners in Primary Care
by
Timothy Bilash MD, MS
June 17, 1994
www.DrTimDelivers.com

based on
"The Roles of Physicians Assistants and Nurse Practitioners in Primary Care"
D. Kay Clawson and Marian Osterweis, Eds, 1993

1. The physician assistant (PA) and nurse practitioner (NP) professions were developed for two main reasons:
   
   1. 'expand the availability of primary care services'
      
   2. 'improve access to these services for medically underserved'
      
      1. note: cost savings was not the priority.
         
         
2. PA background
   
   1. '55% of PA's have baccalaureate or higher degrees at the time of program admission.' (p70)
      
   2. 'PA's average 52 months of health care experience at program entry' (p70)
      
      
3. NP background (p70,71)
   
   1. 'NP's are the most numerous and diverse group of midlevel providers.'
      
   2. '56,043 have NP training, 20,838 are in current practice.'
      
   3. 'The distribution of NP's is heavily skewed in favor of metropolitan counties (91%).'
      
   4. '98% are female, and the mean age is 42.'
      
   5. 'The non-masters NP's are more likely to be employed in primary health care and to practice in rural areas than were the masters NP's.'
      
   6. 'No reliable summary information about the clinical or academic backgrounds of NP students is available.'
      
      
4. 'There were proportionally more PA programs with comprehensive strategies and evidence of successful outcomes than NP program. Many did not submit data because they had none.' (p75)
   
   
5. 'In relation to the needs of the underserved, the numbers of the practitioners being graduated from these programs are small.' (p77)
   
   
6. 'Some NP programs may not provide sufficient clinical training for practice in underserved areas.' (p78)
   
   
7. 'Programs most likely to deploy their graduates among the underserved use expensive strategies to produce that result, such as decentralization, outreach, and dispersal of students over a wide geogrphic area for clinical training.' (p79)
   
   
8. 'PA's have been called upon to function as house staff in teaching hospitals that have reduced the size of residency programs or in inner city institutions losing the services of foreign medical graduates.' (p79)
   
   
9. "Diversion of students from primary care to subspecialties is an increasing problem that is exacerbated by training in tertiary care institutions. The higher salaries offered by subspecialties are attractive to students who have incurred debts during their training." (p80)
   
   
   1. 'One third of the NP's who have been trained to care for underserved patients are practicing.'
      
   2. 'Nurses can often make higher salaries by returning to previous roles in hospital nursing than by practicing in primary care.'
      
   3. 'Academic medicine and nursing pursue professional interests at the expense of community service.' (p81)
      
   4. 'Medical schools value the research interest of faculty and the training of subspecialists. Academic nursing may be making some of the same mistakes made by academic medicine.' (p81)
      
   5. "The struggle for professionalism has been equated with higher degrees and has resulted in divisiveness in many areas of nursing education and practice. Some suggest that the higher the degree, the further away from the client the practitioner becomes. Faculty in schools of nursing with NP programs are preferred at the doctoral level. In many nursing schools, faculty are valued (as shown by requirements for tenure) first for their ability to do research, second for their skills as teachers, and third for their skills as clinicians. NP's who have doctoral degrees and are skilled clinicians are extremely scarce. Clinical teachers for most NP's in our study poulations were master's prepared clinicians who have 'lower status' in their schools or who are community-based and have clinical reather then tenured appointments in order to comply with university requirements." (p82)
      
      
10. How is this different from MD patterns?