Duke University began a collaborative project with the University of Ruhuna in Galle, Sri Lanka, after the devastating tsunami in 2004. Strand de Oliveira and Østbye traveled to Galle in 2008, to look at the hospital and visit with faculty and university leadership. There, Vijitha De Silva, an internal medicine physician and occupational medicine researcher, told the visitors about the AMOs. Mahinda Liyanage, an AMO and an expert on AMOs, provided more information about training and deployment. Two Duke graduate students followed up with research projects focusing on the AMO perspectives on their profession and physician attitudes toward AMOs. Unfortunately, such information about AMOs in Sri Lanka comes too late. Use of AMOs was discontinued due more to perceptions than evidence. The list of prototype PAs, many defunct, continues to grow. Strand de Oliveira provided the insights to this commentary.
Commentary by Roderick S. Hooker
Clinics housed inside retail outlets such as malls, supermarkets, drugstores, and large corporate retailers have grown from 60 in 2005 to 1,350 in 2012. They have been accepted and used by a mostly insured population for minor or brief episodic medical treatment, yet have encountered substantial opposition from some major physician organizations. Most providers in retail clinics are NPs, although PAs are also involved. Anecdotes suggest independently licensed NPs are easier to employ as standalone providers. The article reports that 61% of retail clinic patients state they do not have a primary care physician, illustrating the shortage of access to primary care providers even among populations served by retail clinics. With retail clinics providing a more convenient form of care for people who likely have access to medical care, an important question is whether the rapidly increasing retail clinic capacity can augment anticipated primary care shortages, particularly in medically underserved and economically disadvantaged populations.
Commentary by Richard W. Dehn
Barriers to practice may affect how fast an emerging profession will grow. In the United States, the NP and PA professions had to overcome various state regulations and restrictions as they matured. In the first 3 decades, the major barriers were thought to be physician and patient acceptance of PAs; research addressed those questions early on.1 Survey research in the 1990s showed that PAs were most limited by insurance reimbursement issues as well as state regulatory restrictions.2 Over time, state regulatory policies have improved, thus enabling PAs and NPs to expand care. Because this occurs on a state-by-state basis, a natural experiment addresses the question of whether regulatory restrictions inhibit a profession's growth. This study by Kuo and colleagues substantiates that growth in NPs delivering outpatient care was greater in states with less restrictive regulations. One might ask whether this study provides evidence that liberalizing practice laws enhances growth in a profession, or whether growth in a profession's numbers increases political pressure for liberalizing practice laws. Nonetheless, the evidence is that practice laws are correlated with participation in the healthcare workforce. The basic message of the study—that the growth of a profession is closely associated with state-mandated scope of practice policies—also applies to PAs. However, the study minimizes the role of PAs in Medicare delivery services, and compares this minimal role to 20-year-old data (more current data document a more substantial PA role in care provided to this study population).3
Commentary by Richard W. Dehn
1. Dehn R. Physician assistant educational research. J Physician Assistant Educ
2. Dehn RW, Asprey DP. Impediments to the practice of medicine in Iowa. JAAPA
3. Hooker RS, Benitez J, Coplan B, Dehn RW. Ambulatory and chronic disease care by physician assistants and nurse practitioners. J Ambulatory Care Manage
. 2013;36(5): in press.