Am Fam Physician. 2014 Jan 15;89(2):74-76.
Original Article: Relying on NPs and PAs Does Not Avoid the Need for Policy Solutions for Primary Care
Issue Date: August 15, 2013
See additional reader comments at: http://www.aafp.org/afp/2013/0815/p230.html
TO THE EDITOR: This Graham Center Policy One-Pager points out that using nurse practitioners (NPs) and physician assistants (PAs) to relieve the primary care shortage may not work because many of them, like physicians, tend to practice in specialty areas. However, this piece suggests that the authors oppose the idea of NPs independently practicing in primary care. I argue that unless training programs for primary care physicians are shortened and made more practical, expanding the scope of practice of NPs remains an essential part of the solution.
The Institute of Medicine supports the idea of NPs providing aspects of primary care within the scope of their training and education.1 Furthermore, the National Committee for Quality Assurance recognizes patient-centered medical homes that are led by NPs.2
The increasing burden of administrative and clinical tasks is associated with job dissatisfaction and high burnout rates in primary care physicians.3 However, if this workload were spread out among more clinicians, including NPs, job satisfaction might improve.
Although adding NPs to the workforce will help, clinicians need to be trained more quickly to make the primary care work-force sustainable. This can be done through accelerated three-year medical degree programs4 or by combining college and medical school. I would not be surprised if future primary care clinicians are hybrids, being trained in ways that would be considered heretical today.
1. Institute of Medicine. The future of nursing: Leading change, advancing health. October 5, 2010. http://www.iom.edu/Reports/2010/The-future-of-nursing-leading-change-advancing-health.aspx. Accessed September 10, 2013.
2. National Committee for Quality Assurance. PCMH eligibility. http://www.ncqa.org/Programs/Recognition/PatientCenteredMedicalHomePCMH/BeforeLearnItPCMH/PCMHEligibility.aspx. Accessed September 10, 2013.
3. Shanafelt TD, Boone S, Tan L, Dyrbye LN, Sotile W, Satele D, West CP, Sloan J, Oreskovich MR. Burnout and satisfaction with work-life balance among US physicians relative to the general U.S. population. Arch Intern Med. 2012;172(18):1377–1385.
4. Krupa C. Med school on the fast track: A 3-year degree. American Medical News. May 7, 2012. http://www.amednews.com/article/20120507/profession/305079951/2/. Accessed September 10, 2013.
IN REPLY: We appreciate Dr. Volpintesta's willingness to read and respond to our brief. Having said that, we must correct his assumption that it somehow implies anything about NP or PA practice independence. The brief sticks strictly to the finding that most NPs and PAs are not currently practicing in primary care—similar to physicians. This finding is supported by another recent study showing that just 33% of NPs and 22% of PAs in New York are practicing in primary care.1
Our message is clear and narrow: there are no easy solutions to the growing work-force shortage in primary care, and policy and training innovations are desperately needed to produce the primary care work-force that America needs now and in the future.
Such innovations should not impair the ability of primary care clinicians to deliver comprehensive, complex, and continuous care. Nearly two-thirds of family physicians currently work with NPs, PAs, or certified nurse midwives, and robust primary care will undoubtedly add other functionalities to these clinical teams.2
1. University of Albany Center for Health Workforce Studies. New York's primary care workforce. August 2013. http://chws.albany.edu/archive/uploads/2013/09/nypricare2013.pdf. Accessed November 11, 2013.
2. Peterson LE, Phillips RL, Puffer JC, Bazemore A, Petterson S. Most family physicians work routinely with nurse practitioners, physician assistants, or certified nurse midwives. J Am Board Fam Med. 2013;26(3):244–245.
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