General Comments by Dr Tim

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 underwriter of the conference a priori advocates increasing the ratio of non-physician to physician training enrollment (p 66)
   
   
2. There is no definition of primary care
   
   
3. There is no physician specialty representation indicated in these discussions (Board Certification)
   
   1. Anesthesiology
      
   2. Emergency Medicine/ Trauma/ ICU
      
   3. Internal Medicine
      
   4. Obstetrics and Gynecology
      
   5. Pathology/ Cytology
      
   6. Surgery
      
      
4. Obstetrics and Gynecology CNM and midwifes are vaguely included in the discussions of outpatient care, yet OBGYN is not defined as primary care. In fact, much of OBGYN does not fit within the primary care models discussed in this work. ER, short admissions and inpatient services which are intimately tied to out patient services (particularly in obstetrics) is not included. For example, a patient that does not have a problem addressed in the office commonly shows up at the hospital- this would not appear in the statistics cited.
   
   
5. The displacement of the roles of nurses (LPN, RN) by these other practitioners has not been discussed. That is, in many settings nurses themselves already provide many of the roles that NP/PA's can.
   
   
6. The skills necessary for independent practice status in medicine are not defined.
   
   
7. In medicine, an elaborate evaluation process has been put into place over time. What is required and what is different about the evaluation and supervisory system for NP/PA's that will fill this need?
   
   
8. The most efficient system may not be the best system for human beings: the most efficient system is no care at all and to let people suffer the consequences.
   
   
9. The federal government, thru incentives, created more specialists in the first place to meet an anticipated shortage. Now, 30 years later, they say that this was wrong, and so will discard all this effort. I contend that the government has not shown the ability to acurately predict the need for practitioners any better than the professional agencies themselves.
   
   
10. 'There really has not been any systematic discussion about the appropriate roles of various physician and non-physician health care personnel in providing primary care services or health care services generally' (p125)