Providing Access to Primary Care in Rural America

Family Physicians Successfully Team With Nonphysician Health Professionals

August 01, 2014 04:08 pm Sheri Porter

Family physicians provide much of the primary care for patients who reside in America's rural towns and communities. And many of those rural family physicians work collaboratively with nonphysician health professionals such as nurse practitioners (NPs), physician assistants (PAs) and certified nurse midwives (CNMs) to ensure that patients get the care they need.

Solo FP Keith Davis, M.D., center, pauses during a busy day at Shoshone Family Medicine Center for a photo with two members of his health care team, certified nurse midwife Mickey Habeck, C.N.M., and physician assistant Russell Singleton, P.A.-C.

Count Keith Davis, M.D., of Shoshone, Idaho, among them.

"I almost hate to say I'm a solo physician because I have such a good team of providers. It doesn't really feel like a solo practice; I can be gone from the practice to go to meetings or take a vacation and the practice is covered very well," said Davis.

Davis, who, coincidentally, is the AAFP's 2014 Family Physician of the Year, has been taking care of patients in "very rural" Shoshone -- a town of about 1,400 people -- since 1985. Davis told AAFP News that the county population numbers about 5,000. "I'm the only physician in a county that's a little larger than Rhode Island," he said.

His practice became an independent rural health clinic in 2002, and Davis serves as the owner, CEO and medical director.

This family physician has had the same NP by his side for nearly 30 years, as well as a certified nurse midwife for close to a decade. He also relies on two part-time PAs to keep his practice running smoothly.

Story highlights
  • Recent research in The Journal of Rural Health found that 60 percent of family physicians sampled for the study worked with nurse practitioners, physician assistants or certified nurse midwives.
  • Two solo family physicians working in rural practices related their personal and positive experiences working with nonphysician health professionals.
  • Physician extenders allow family physicians in small rural communities to ensure that patients have access to primary care even when the physician is away from the office.

Davis enjoys the obstetrical and emergency medicine components of his work, but both take place at a hospital in Jerome, Idaho, 18 miles away.

"The team coverage that I'm talking about is a great relief when I need to be at the hospital -- whether I'm delivering a baby or working in the emergency department -- because there's always a health care professional back at the office," said Davis.

Bottom line, patients have access to the services they need, he said.

Davis' positive experience working with physician extenders is the norm for many family physicians. Research published in the summer 2014 issue of The Journal of Rural Health found that 60 percent of the 3,855 family physicians sampled for the study routinely worked with NPs, PAs or CNMs.

According to an abstract of the article(, authors of that study -- who are associated with the American Board of Family Medicine (ABFM), the Department of Family and Community Medicine at the University of Kentucky in Lexington, and the Robert Graham Center for Policy Studies in Family Medicine and Primary Care -- set out to determine what physician and area-level characteristics were associated with working with midlevel health care professionals.

Research Results

Corresponding author and ABFM Research Director Lars Peterson, M.D., told AAFP News that previous studies had documented a trend showing more physicians were working with midlevels. "We were interested in what the numbers were for family physicians," said Peterson.

"We found that FPs increasingly included other clinicians on their care teams," he said. Furthermore -- in what could be considered an added bonus -- the kind of teamwork undertaken by many family physicians was consistent with foundational principles outlined in the patient-centered medical home (PCHM) model of care, said Peterson.

Lynn Fisher, M.D., a solo family physician in rural western Kansas, conducts a well-baby exam on Grayson Decker, the 4-month-old son of the practice's physician assistant, Emily Decker, P.A.-C.

That PCMH perspective was not lost on Davis. He said that in the past few years, the team approach to care had become very important in his Shoshone practice. "It's really obvious to me that it would be hard to offer the high-level PCMH that I want to have without the midlevel providers or at least one other physician on staff.

And trying to recruit a physician into rural America is increasingly difficult," he added.

One particular point of interest for Peterson, and perhaps, he said, the most important outcome of the study, was the finding that state-level nursing scope-of-practice laws did not impact the number of FPs working with NPs, PAs or CNMs.

"We interpreted that to mean that NPs and PAs prefer to work with physicians in team- based care," said Peterson.

Among other findings, researchers reported that family physicians most likely to work with midlevels

  • worked in a multispecialty group practice,
  • were more likely to provide maternity care and gynecological care, and
  • performed obstetrical deliveries.

Importantly, researchers noted that the "likelihood of working with NPs, PAs, and CNMs increased as the rurality of the practice setting increased."

Many rural areas of the United States consistently experience physician shortages, noted the authors, and many patients in those rural communities have "diminished access to health care providers." Previous research has found that family physicians and NPs who work in primary care are more likely than other health care professionals to practice in rural areas.

In this most recent study, researchers found that family physicians in small rural and isolated areas were "nearly twice as likely to work with NPs, PAs, CNMs as urban-located physicians."

Furthermore, wrote the authors, most of these health care professionals likely are co-locating in the same practice. "If this is true, than rural areas may be benefiting from teams of providers, which may, over time, decrease access problems and increase the quality of health care," they said.

Collaboration Is Key in Kansas

At Lifeline Family Medicine in Plainville, Kan., population 2,000, solo FP Lynn Fisher, M.D., has relied on his PA for nearly four of his eight years in practice there.

Fisher spends some of his time at the local hospital delivering babies and does a fair share of procedures such as screening colonoscopies. He appreciates that fact that someone is back at the practice taking care of patients when he can't be there.

The PA also returns phone messages in Fisher's absence and helps him round on patients in the hospital. "And if my schedule is full, then that offers an opportunity for people to be seen quicker than waiting for my next available appointment," said Fisher.

Having someone with whom to share the night call schedule "helps with the quality-of-life issue," he added.

"I review at least 10 percent of the PA's charts and give her feedback if there are any concerns," said Fisher, who also serves as the medical director at a federally qualified health center in nearby Hays, Kan., where he supervises three NPs.

Fisher said nonphysician health professionals have a very important role as physician extenders in rural communities -- provided collaboration and physician oversight are part of the deal. "When I review charts, I'm not only looking at acute care issues; I'm also looking to see if chronic care issues and preventive care needs such as immunizations and cancer screenings are being addressed," said Fisher.

"I do feel strongly that there is a difference in the level and breadth of training between PAs, NPs and physicians. We are not interchangeable," he said.

From Fisher's perspective, there is one downside to being the leader of the health care team. "It just takes time," he said. Those chart reviews and extra phone calls aren't always convenient, said Fisher, who is available at all times to the midlevel health care professionals he supervises.

Back in Shoshone, Davis and his patients also like team-based care.

"Patients in this practice rarely have experienced a practice closure because I'm unavailable for the day," said Davis. "We also let patients select who they'd like to see whenever possible, and most of our patients are open to seeing whoever is available.

"But we have patients who definitely have a favorite provider and it isn't always me. And I'm OK with that," he added.