One remedy for the looming shortage of physicians in the United States is expanding the caregiver workforce to include nurse practitioners (NPs) and physician assistants (PAs). These health professionals come from fairly disparate backgrounds, yet over the years, increasing numbers of them have practiced side by side with physicians in primary care and specialty settings with varying levels of autonomy, depending on the regulations in the state where they practice.
As professionals from various disciplines have become more common in Community Health Centers around the nation, Drs. Ellen Kurtzman and Burt Barnow, of The George Washington University, set out to compare the quality of care that NPs, PAs, and physicians deliver to patients in that setting. Their study was recently published ahead of print in Medical Care.
Using 5 years of data (2006-2010) from the National Ambulatory Medical Care Survey–an annual survey of care providers administered by the National Center for Health Statistics–Kurtzman and Barnow were able to gather data about the care provided by 1,139 clinicians (a mixture of MDs, PAs, and NPs) in up to 30 patient visits in a randomly assigned 1-week period during those 5 years. They examined the quality of care using the following outcomes: 3 quality indicators, such as smoking cessation or treatment for high cholesterol; 4 service utilization measures, such as imaging services and physical exam; and 2 referral pattern measures, such as specialty referral.
The authors found that for 7 of the 9 outcomes studied, there was virtually no difference in the quality of care provided between providers of the 3 disciplines. Patients seen by NPs rather than MDs or PAs, however, were more likely to receive recommended smoking cessation counseling. Also, patients seen by NPs or PAs received significantly more health education and counseling services than patients seen by physicians.
Aside from smoking cessation counseling and a few others, the outcome measures may not necessarily be the best for determining high quality practice patterns; unfortunately, the authors were limited to what information was available from the survey. Clearly, measuring healthcare quality is challenging and the subject of rich debate in the health policy world.
The big lesson from this study, and from my own personal and professional experience, is that medicine is a team sport. Professionals from every discipline can add indispensable perspectives and input about a patient’s care – nurses, nurse practitioners, physician assistants, physical therapists, social workers, interpreters, medical assistants – every team member can add to the quality of a patient’s care – if we listen to one another and value one another’s experience and knowledge.
Fortuitously, I learned this lesson early. As a medical student, I became involved in HAVEN, the student-run free clinic that is held every weekend in a Community Health Center nearby the Yale campus. There, I had the opportunity to work with PA students, NP students, and other medical students on clinical teams and in administrative capacities. Notably, this was my only inter-disciplinary experience as a medical student – I never had rotations or didactic experiences with my PA and NP colleagues. But now I work with NPs every day, and they are a crucial part of our clinical team.
It does not surprise me in the least that the aspects of patient care where NPs and PAs outstripped the physicians was in counseling and patient education. Most NPs have a background in nursing, some working for years as a registered nurse and gaining invaluable experience learning how to counsel patients effectively in language free of medical jargon. I learned some of these skills from my nursing colleagues at HAVEN. Similarly, PAs have a great breadth to their training, and while I don’t have as much personal experience working with them currently, surely many of them have copious skills and knowledge to share.
If we are to advance primary care as a field, both in the quality of care that is delivered to patients and in making it a sustainable career choice for health professionals of any stripe, we have to move toward the ideal practice patterns that Margolius and Bodenheimer described in a 2010 Health Affairs paper:
- Physicians see about 8 patients per day with complex or acute medical issues and have the time and autonomy to focus on those cases.
- Meanwhile, allied health professionals and nursing colleagues manage more of the routine chronic disease, such as hypertension and obesity with assistance and supervision from the cooperating physician.
- Lastly, outreach and population health management can be shifted to other practice staff trained in those specific tasks.
Learning to trust one another and let go of parts of our work that we are accustomed to doing is very hard for physicians, and indeed all health professionals – but it is a change that is coming and will make primary care and our health system better for patients and providers alike. In order to get there, however, we do need more evidence and understanding of our workforce strengths and weaknesses, and in that vein, this paper is a step forward and a welcome addition to the primary care transformation literature.
Audrey Provenzano
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