Hospital-based physician assistant staffi ng models outside the United States
The evidence regarding physician staffing of ICUs does not provide a consistent view of the best model to use. Most studies have significant limitations, and are complicated by the fact that optimal ICU staffing may depend on ICU characteristics. The topic with the most data regarding patient outcomes is the intensity of intensivist involvement in care, particularly the value of closed versus open model ICUs; however, the evidence is inconsistent here as well. Also, studies of around-the-clock intensivist presence have not consistently shown that it is associated with superior outcomes. Increasingly, ICU care provided by teams including PAs and NPs appears to be safe and comparable to that provided by other staffing models. Although little is known about the best way to staff ICUs, the conditions of ICU physician coverage will continue to change under shortages of intensivists and increasing duty hour limitations for trainees. Nonphysician providers, innovative physician staffing models, telemedicine, and other technologies will be increasingly used to cope with these realities. This evolution makes it more important than ever to study how staffing affects outcomes.
Garland A, Gershengorn HB. Staffing in ICUs: physicians and alternative staffing models. Chest. 2013;143(1):214-221.
The United Kingdom's National Health Service (NHS) faces substantial staffing challenges arising from reduced working hours and fewer trainees requiring more protected training. One solution is PAs, professionals trained in patient assessment and care who work under the supervision of trained doctors. In 2010, three PAs began working in the pediatric ICU (PICU) at Tooting, a large tertiary hospital. This study used surveys and semi-structured interviews to explore the process and end results of this development. Initially, a large discrepancy existed between expectations and the capabilities of the PAs. Shortly after starting, friction developed from PAs being untrained in PICU activities, and fears that they would take training opportunities from other staff and that their remuneration was disproportionate to their usefulness. At month five, all interviewees stressed the positive effect of PAs on patient care and the running of the unit. Staff found that the PAs had integrated well and there was little evidence of earlier frictions. When surveyed at month 10, PAs were undertaking most PICU procedures with limited supervision. The study shows that PAs can be a valuable addition to the medical workforce, but that predictable problems can complicate their introduction.
White H, Round JEC. Introducing physician assistants into an intensive care unit: process, problems, impact and recommendations. Clin Med. 2013;13(1):15-18.
In the first two decades following the establishment of the PA profession, most graduates were used in primary care and ambulatory care settings, although a sizable minority of PAs practiced in surgery (19% in 1974). Beginning in the 1980s, a gradual shift from primary care to medical specialties occurred. Now at the half-century mark about one-third of PAs enter primary care at graduation. This phenomenon may be due to medical workforce shortages in one form or another that were likely present across most all medical specialties, and PAs tending to respond to higher-paying employment opportunities. This trend appears to be occurring in countries outside the US where the PA profession is in early development but PAs are being used in specialty practices settings.1
The study by Garland and Gershengorn is a literature review describing ICUs by both structural characteristics and available outcomes data. The authors identify different ICU staffing models used in the Western world, and note that the data are not clear on whether any one ICU staffing model consistently provides better outcomes than another. Within this article, the authors also review the use of PAs and NPs in the ICU, in which the outcomes were at least similar to common ICU staffing models using residents. One question raised is whether PAs and NPs will experience the high burnout rates now associated with physicians who have similar responsibilities. Career satisfaction historically has been high for PAs; however, as they enter clinical settings that have historically had high physician burnout rates (for example, emergency medicine), career fatigue may increase for PAs.
The White and Round study describes three PAs in a PICU at a tertiary care center as one solution to address healthcare provider shortages. The experience is well-documented by multiple surveys and interviews of most of the participants involved at various points in the process. Surveys and interviews might appear familiar to pioneering US PAs who in their first jobs often were a totally unrecognized clinician establishing practice in an environment of distrust and lack of professional and legal support.
Commentary by Richard W. Dehn
1. Bohm ER, Dunbar M, Pitman D, et al. Experience with physician assistants in a Canadian arthroplasty program. Can J Surg. 2010;53(2):103–108.
Perspectives of primary care nurse practitioners and physicians
The US healthcare system is at a critical juncture in healthcare workforce planning. The nation has a shortage of primary care physicians. Policy analysts have proposed expanding the supply and scope of practice of nurse practitioners (NPs) to address increased demand for primary care providers. These proposals are controversial.
A national postal-mail survey of 505 physicians and 467 NPs in primary care practice was undertaken in 2011-12. The questionnaire included scope of work, practice characteristics, and attitudes about the effects of expanding the role of NPs in primary care. The response rate was 61%.
Physicians reported working longer hours, seeing more patients, and earning higher incomes than did NPs. 81% of NPs reported working in a practice with a physician, as compared with 41% of physicians who reported working with an NP. NPs were more likely than physicians to believe that they should lead medical homes, be allowed hospital admitting privileges, and be paid equally for the same clinical services. When asked whether they agreed with the statement that “physicians provide a higher-quality examination and consultation than do NPs during the same type of primary care visit,” 66% of physicians agreed and 75% of NPs disagreed.
Donelan K, DesRoches CM, Dittus RS, Buerhaus P. Perspectives of physicians and nurse practitioners on primary care. N Engl J Med. 2013;368:1898-1906.
Controversy seems to be intensifying in various forms about the expansion of supply and roles of NPs in American medicine. Although the NP supply is increasing, the roles they occupy are less understood. This vagueness of roles (for example, the lack of role delineation studies) may be at the heart of some tension between nursing and organized medicine. One major point of contention is that NPs want more autonomy in patient management, prescribing, and treatment. They would also like reimbursement comparable to that of physicians given the same outcomes of care. Discussions between the American Medical Association (AMA) and nursing advocates have not reached détente, and differences are clearly drawn on whether scope of practice laws should be expanded for NPs. The Federal Trade Commission is exploring whether trade restrictions inhibit the independent roles of nurses. The traditional view is for NPs to remain dependent on physicians (as the AMA would like—see accompanying editorial in the same NEJM issue by Blumenthal and an overview of NPs by Iglehardt).1,2 The Donelan and colleagues study, abstracted above, illustrates these differences. At the heart of this matter is independence. Independence of NPs to provide primary care, lead patient-centered medical homes, and hold hospital privileges. The reimbursement issue speaks about substitution of care. Can NPs substitute for physicians? It depends.
Economists are generally indifferent about certain examples of substitution, realizing that Coca-Cola and Pepsi-Cola are perfect substitutes for some soft drinks, but a bicycle is an imperfect substitute for an automobile (although it transports individuals economically). What they are not in agreement about is when advocates believe that education trumps evidence (a card both sides play). The professional degrees of physicians (MD, DO, MBBS) and the clinical doctorate of NPs (DNP) contribute to this tension—who can or should call themselves “doctor” and when does this degree equate to outcomes of care?
While the two sides debate the merits of their tribes, the world is running short of health professionals. The WHO estimated this shortage of doctors and nurses at around 4.5 million in 2006.3 The 2,500 or so medical schools around the world will never catch up with a population gap widening every year, so alternatives are being developed everywhere. The United States also is a limited producer of physicians and has a lean ratio of primary care providers to population, ranking as one of the lowest in developed countries. And it is getting worse, not better, at a time when the number of internationally trained physicians entering this country is dropping. Who will pick up the slack at a time of medical service expansion?
Experiments in delivery of healthcare are needed, and not just for NPs. In the Netherlands, novel legislation has created a 5-year demonstration study of legislation granting the independence of PAs in an effort to improve access to care. Is this substitution? The Dutch are willing to discuss the economics of substitution, realizing there are wide differences in the application of the term. The jury is still out about the Dutch experiment, but this observer believes it is a far more imaginative strategy about society's best interest than drawing a line in the sand about who is in charge. Perhaps there are lessons to be learned when tribes decide to become a team.
Commentary by Roderick S. Hooker
1. Blumenthal D, Abrams MK. Putting aside perceptions—time for dialog among primary care clinicians. N Engl J Med. 2013;360(20):1933–1934.
2. Iglehart JK. Expanding the role of advanced nurse practitioners—risks and rewards. N Engl J Med. 2013;360(20):1934–1941.
Dal Poz MR, Kinfu Y, Drager S, et al. Counting health workers: definitions, data, methods and global results. Geneva: World Health Organization, 2006.