Can Midlevels Save Primary Care?

mittmanpa (11/24/2008 at 1:40 PM)
Dear Mr. Bakhtiari: Thank you for your thoughts regarding using NPs and PAs to help ease the problem of an ever decreasing number of primary care physicians in the future. Truly, thank you for thinking of us. The reality is is we are already providing this care, have been for years and we do it well. Look at the Army, Navy, Air Force and the entire VA system. Look at New York State and California which has over 40,000 of us providing care in all corners of our state. I have been a PA for many years. I was treating my own panel of patients at a medical group in Brooklyn, NY in 1976. I was providing what we would now call family practice (without pediatrics) to thousands of patients that after meeting me felt just fine that I was their clinician. Now we have more than 200,000 PAs and NPs in practice. Sadly to me though, many of us are also not in primary care. Family Nurse Practitioners and PAs need to be brought back to primary care in larger numbers for any plan to work. To do this, some barriers both professions face need to be broken down (reimbursement, ultra-restrictive laws passed 40 years ago before PAs and NPs proved themselves, physician resisitance). Teaching hospitals should start one year residencies in primary care that will allow PAs and NPs to practice with much more autonomy upon graduation. This would allow us the flexability to truly go where we are needed and make even more of a difference. I know this would be threatening to some but to most consumers that have seen NPs and PAs for their care and those physicians that work with us as colleagues or employ us would love to have us practice in a system where we would be utilized in a much more significant way. There is much work to be done to attract even the NPs and PAs needed but it can be done. We all must work as members of a team with the patient foremost in the equation for it to work. Too often, the equation centers around turf or money. That will no longer work. Also, two more things if you are going to write about our professions. One is we do not practice with algorythims or "standardized care plans". If you have seen an NP or PA as a long term patient you would see that our clinical decision making skills are generally quite sophisticated and our quality generally quite good. We do welcome evidence based "protocols" not as flow charts but as any good clinicians would, materials that make us think, question old assumptions and by doing that allow us to provide better care. Also the term "midlevel" connotates that there is an upper and a lower level of healthcare provider. It just does not work that way anymore. Where does the pharmacist or physicial therapist fit in? How about the ICU nurse with a PhD in electrophysiology? Or the fact that many specialty NPs and PAs are evaluating and treating patients for family physicians/internists and others who refer their patients. If you want to group us together using one name, many of us prefer "advanced practice clinician" or APC to be the term to use. Or you can just say PAs and NPs. That's also good. Again, I thank you for your very well intentioned thoughts about utilizing NPs and PAs to provide a higher proportion of primary care in the future. Many of us would welcome the opportunity to become a greater solution to this ever growing problem in our nations healthcare delivery. Sincerely, Dave Mittman, PA President-Elect American College of Clinicians www.amcollege.org --------------------------------------------------------------------------------