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Physician assistants working with the medically underserved

Hooker, Roderick S. PhD, PA

Journal of the American Academy of PAs: April 2013 - Volume 26 - Issue 4 - p 12

Roderick S. Hooker, PhD, PA, is an adjunct professor in The George Washington University School of Public Health and Preventive Medicine, Washington, DC.

Following WWII, the percentage of people who were poor and lacked health insurance rose, and access to care became problematic. Half a century ago, the federal government decided that a compassionate society had a mission to serve the poor and launched a series of strategies to address their health care needs. One notable effort was community health centers (CHCs), created in 1965 to provide health and social services access points in poor and medically underserved communities across the nation. CHCs were born in an era of significant social change and designed to offset limited access to care for poor and marginalized populations. PAs and NPs were born in this same era along with the revival of the certified nurse-midwife. That these three providers have been an integral part of CHC teams since the 1970s is no coincidence.1

As of 2013, more than 8,000 CHCs served the primary health care needs of more than 26 million patients across the United States. The mission includes meeting health needs of low-income populations, the uninsured, those with limited English proficiency, migrant and seasonal farmworkers, individuals and families experiencing homelessness, and those living in public housing. CHCs are recognized both for the critical role they play in caring for growing numbers of jobless and uninsured and as model primary care clinics in their communities. Given the local focus of CHCs, a large amount of diversity within the centers is reflected in patient demographics, service provider composition, staff relationships, and resources. No two CHCs are the same.

Unfortunately, little is known about PAs working with the indigent. Anecdotally, we know PAs work with the homeless, in migrant camps, on Indian reservations, and in innercity and free clinics. No survey has assessed PAs working with the poor, but various reports indicate that they are well-represented in these settings. Some PAs have turned to working in volunteer roles after a period of retirement.

Most patients visiting CHCs are either uninsured or Medicaid/SCHIP recipients. Nationally, PAs comprise at least 10% of all CHC medical staff and, on an annual basis, provide care that is divided among new or acute problems (45%), chronic problems (36%), and preventive (17%). The patterns of PA and NP care are similar to that of physicians. Physicians, along with PAs and NPs, serve as the patient's primary care provider 58% to 72% of the time.2

What is missing is what draws PAs and other health professionals to work with the poor. Rabinowitz and colleagues identified four independent predictors of physicians providing care to underserved populations: (1) being a member of an underserved ethnic/minority group, (2) having participated in the National Health Service Corps, (3) having a strong interest in practicing in an underserved area prior to attending medical school, and (4) growing up in an underserved area.3 Eighty-six percent of physicians with all four predictors were providing substantial care to underserved populations, compared with 65% with three predictors, 49% with two predictors, 34% with one predictor, and 22% with no predictors.

In a qualitative analysis of providers working with medically underserved patients, Li and colleagues identified a group of health professionals committed to working with the poor.4 The group included 12 physicians, three PAs, eight NPs, and a dentist. These providers revealed a strong sense of service to humanity and pride in making a difference. Each appeared to thrive on the challenge of creatively dealing with patients' complex human needs with limited health care resources. The authors identified the factors critical to survival in an urban underserved setting: a hardy personality style, a flexible but controllable work schedule, and a multidisciplinary practice team. The camaraderie and synergy of teams generate personal support and opportunities for continuing professional development.

Only a few research studies have outlined the role and dynamics of PAs and NPs working with the underserved.

Grumbach and colleagues found that PAs and NPs in primary care and family physicians have a greater propensity to care for underserved populations than do physicians in other specialties.5

Because of the growing need for medical providers in general and the demands of the medically underserved in particular, a better understanding of the role PAs play in the provision of care to the medically underserved may contribute to health workforce policies for care delivery to disenfranchised populations. Knowing the role they play requires knowing who they are and why they are there. JAAPA

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1. Hawkins DR, Rosenbaum S. The challenges facing health centers in a changing healthcare system: In: Altman SH, Reinhardt UE, Shields AE, eds. The Future US Healthcare System: Who Will Care for the Poor and Uninsured? Chicago, IL: Health Administration Press; 1998.
2. Hing E, Hooker R. Role of nonphysician clinicians in providing medical care in community health centers: United States, 2006-08. NCHS data brief no. 645. Hyattsville, MD: National Center for Health Statistics; 2011.
3. Rabinowitz HK, Paynter NP. The role of the medical school in rural graduate medical education: pipeline or control valve? J Rural Health. 2000;16(3):249-253.
4. Li LB, Williams SD, Scammon DL. Practicing with the urban underserved: a qualitative analysis of motivations, incentives, and disincentives. Arch Fam Med. 1995;4(2):124-133.
5. Grumbach K, Hart GL, Mertz E, et al. Who is caring for the underserved? A comparison of primary care physicians and nonphysician clinicians in California and Washington. Ann Fam Med. 2003;1(2):97-104.
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