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Not All NPs and PAs Choose to Work in Primary Care; What's the Problem?

Posted Aug 22 2013 12:00am

Nurse practitioners (NPs) and physician assistants (PAs) play very important roles in our healthcare delivery system (see: Future Key Role of Nurse Practitioners in Primary Care ). They work across the entire spectrum of care from primary care to specialty practices. A recent article caught my attention with the provocative assertion that NPs and PAs "may not be the answer" to something. Below is an excerpt from it (see: Primary Care Shortage: NPs and PAs May Not Be the Answer ):

Relying on nurse practitioners (NPs) and physician assistants (PAs) to relieve the primary care shortage may not be the answer, as many NPs and PAs work outside of primary care, according to a Graham Center Policy One-Pager published in the August 15 issue of American Family Physician. Stephen M. Petterson, PhD, from the Robert Graham Center for Policy Studies in Family Medicine and Primary Care , and colleagues analyzed data from the National Provider Identifier file, which identifies the locations of NP and PA clinics and identifies physicians who work in the same location. NPs and PAs practicing in clinics without a primary care physician are assumed to be practicing primary care. Those data show that only about half of NPs (52.4%) and PAs (43.2%) work in primary care, with the others choosing subspecialty areas.....NPs and PAs may be influenced by similar factors that encourage physicians to choose subspecialties, such as student debt and income gap disparities. Strategies used to encourage physicians to choose primary care, including training in rural and underserved areas and student debt reduction, may also be effective with NPs and PAs, but more research is needed to know for sure, the authors write. "Relying on NPs and PAs to solve the problem of a growing shortage of primary care physicians may not be an option, and policy makers should not abandon policy solutions designed to increase the number of primary care physicians, NPs, and PAs," [according to the report].

Here is a description of the Graham Center copied from its web site . Its a branch of the American Academy of Family Practice (AAFP):

In July 1997, the AAFP Board of Directors approved the development of a "Center for Policy Studies in Family Practice and Primary Care" to be located in Washington, DC. It was envisioned that the Center would be responsible for research and analysis to inform deliberations of the Academy in its public policy work and to provide a family medicine perspective to policy deliberations in Washington, D.C.

We learn from this article that about half of NPs and PAs work in primary care. I think that this is admirable and probably what I would have predicted. We also learn that the remainder of them work in subspecialty areas and are motivated in their choices by factors similar to those affecting physicians. No surprise here. Physicians working in specialty practice have the same need as primary care physicians for skilled healthcare professionals to assist them. I also agree with the conclusion of the report that we can't rely on NPs and PAs to solve the problem of too few primary care physicians in the pipeline.

However, where I differ from the position of the AAFP is that I think that many physicians are too highly trained to function as PCPs. Hence, some sort of a triage function needs to be introduced into many PCP practices. This triage function could be filled by NPs or PAs. For example, if more primary care physicians were to introduce email into their practices, they could also operate more efficiently and handle more patients (see: Will Accepting Patient Email Make Physicians More Productive? ). NPs and PAs could handle many of these incoming emails. In fact, some of this email triage could be managed remotely. 

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