Obtaining a medical appointment with a PA or an NP in the United States is not difficult. After a half-century of development and deployment, about 200,000 PAs and NPs are clinically active in the 56 US jurisdictions. Not surprisingly, their presence is greatest in the ambulatory setting, where 98% of medical care takes place. Of an estimated 1.2 billion annual ambulatory visits, almost 20% are managed by a PA or NP.1 Perhaps more important is the duration in time. PAs and NPs have been present in American society for three generations. Many patients are seeing a PA or NP as a health professional who can take a history, order appropriate tests, arrive at a diagnosis, develop a treatment plan, and prescribe an appropriate regimen. In the end, like most of us, what patients want is to have their needs met, and they are largely indifferent as to who delivers it.
Commentary by Roderick S. Hooker
Schappert SM, Rechtsteiner EA. Ambulatory medical care utilization estimates for 2006. National health statistics reports; No 8. Hyattsville, MD: National Center for Health Statistics. 2008.
Although the idea of a systematic review of the roles and contributions of PAs in primary care is appealing, this paper fails to deliver. The authors perpetuate inaccurate information, such as the proportion of PAs in active primary care practice. Coplan showed that no more than a third of American PAs work in primary care.1 The fundamental error: inappropriate criteria for the selection of articles to be analyzed. Specifically, only 46 papers from the US literature were deemed worthy of inclusion, a number that is misleadingly low. The authors use definitions of general practice/family medicine proposed by the European Region of the World Organization of Family Doctors rather than conventional US definitions, which resulted in distortion of the findings and/or the exclusion of relevant papers. In addition, many of the papers analyzed are old. The major inaccuracy: The paper's abstract states, “half of PAs are reported to work in primary care.” Closer examination of this figure reveals that these percentages come from old reports (circa 1991 or older). Systematic reviews by others have used wider selection criteria, employed a more consistent framework, and therefore contain more useful and accurate information.2
Commentary by James F. Cawley
1. Coplan B, Cawley JF, Stoehr JD. Brief report: physician assistants in primary care: trends and characteristics. Ann Fam Med. 2013;11(1):75–79.
2. Hooker RS, Everett CM. The contributions of physician assistants in primary care systems. Health & Social Care in the Community. 2012;20:20–31.
This financial modeling study is what medical and PA students with higher debt obligations may want to consider when entertaining a family medicine career. Working in a nonprofit facility or medically underserved area may put the PA or medical school graduate ahead in the loan debt game. The Association of American Medical Colleges (AAMC) study of 384 debt scenarios included living in high- or medium-cost areas and incorporated various loan forgiveness and loan repayment strategies. In the end, student debt may be a significant limiting factor in career choice and specialty for newly minted PAs.1 A matrix of interest rates and student loan decisions requires the consideration of numerous personal factors such as housing, living expenses, spousal income, level of retirement income, and even anticipated children. Whether crushing debt will affect the choices for PAs and physicians alike remains an area in need of study.
Commentary by Jennifer M. Coombs
Student loan debt affects generations of Americans. US News and World Report. http://www.usnews.com/education/blogs/student-loan-ranger/2012/10/03/student-debt-affects-generations-of-americans. Accessed July 2013.