Question

The wisdom of depending on International Medical School Graduates (IMGs) to fill gaps in physician supply, while US medical schools hold class size constant, is questionable. In addition, the aging of the physician workforce, the decreasing hours worked by both physicians in practice and physicians in residency, and a 20 percent reduction in the effort of the increasing proportion of female physicians, will result in a significant decrease in the “effective” supply of physicians. Should the gap be filled by a major substitution of nurse practitioners, physician assistants, chiropractors, acupuncturists, and others, or are there alternatives?

Answer 1

As the nation shifts through proposed solutions to the shortage of primary care physicians, one option would be to fill the gap with so-called physician extenders -- nurse practitioners (NPs) and physician assistants (PAs).

That was the option promoted in a 2010 Institute of Medicine report, which also suggested expanding nurses' scope of practice.

Hospital medicine is a growing field with an increasing demand for additional healthcare providers, especially in the face of an aging population. Reductions in resident duty hours, coupled with a continued deficit of medical school graduates to appropriately meet the demand, require an additional workforce to counter the shortage.

A major dilemma of incorporating nonphysician providers such as nurse practitioners and physician assistants (NPPAs) into a hospital medicine practice is their varying academic backgrounds and inpatient care experiences. Medical institutions seeking to add NPPAs to their hospital medicine practice need a structured orientation program and ongoing NPPA educational support.

The big differences between these physician-extenders and physicians are the amount of time spent in training and autonomy once in practice. It takes 6 years to train an NP or a PA -- 4 undergraduate and 2 in grad school. PAs must always practice under physician supervision, while NPs can practice autonomously in 17 states.

PAs and NPs are excellent at diagnosing and treating illness, and believes they are essential in solving the primary care shortage problem. However, that it is important for them to continue to work under physician supervision.

The NPPA-physician model serves as an alternative care practice, and we believe that with the institution of modalities, including a structured orientation program, didactic support, hands-on learning, and professional growth opportunities, NPPAs are capable of fulfilling the gap created by provider shortages and resident duty hour restrictions. Additionally, the use of NPPAs in hospital medicine allows for patient care continuity that is otherwise missing with resident practice models.

References

1.Spychalla MT, Heathman JH, Pearson KA, Herber AJ, Newman JS^. Nurse practitioners and physician assistants: preparing new providers for hospital medicine at the mayo clinic. Ochsner J. 2014 Winter;14(4):545-50.

2.Kleinpell RM, Ely EW, Grabenkort R. Nurse practitioners and physician assistants in the intensive care unit: an evidence-based review. Crit Care Med. 2008 , Oct;36(10):2888-97