Memo From the Editor

Who are those guys?

By Jeff Forster, Editor  

The thundering hooves you hear in the distance are those of a new generation of clinicians, racing to assume their places in tomorrow's health care system—and today's, for that matter. As the hooves thunder on, there's more than a fair amount of jockeying for position: Nurse practitioners, physician assistants, certified nurse midwives—where will they all fit in? And what about those other folks, the physicians?

Now please, please, good people of the NP, PA, and CNM communities, don't clog my phone line, rattle my in-box, or inundate my e-mail with complaints about unflattering comparisons to herds of cattle or wild horses. Everybody is just a tad too touchy about image and perception and terminology these days. I'm not going to use the terms "physician extender," "midlevel provider," or "nonphysician practitioner" except to acknowledge how much they are loathed by the people so labeled.

What really matters is the fabric that these well-trained, highly motivated, and dedicated professionals will add to the patchwork we call our health care system. How can their energies and skills help most in furthering the interests of quality patient care?

To gain some insight into that issue, turn to the special section that begins on page 156. Anita J. Slomski, our Chicago-based Group Practice Editor, thoughtfully orchestrated a team effort that looks at the exponential growth of these professions, the turf battles that have ensued, and the liability questions that arise for any physician who hires a PA, NP, or CNM (that's three fewer keystrokes than "midlevel provider"). We also provide a set of tables detailing, state by state, these professionals' prescribing rights and the level of physician supervision required of their work.

Those provisions will continue to change as the jockeying continues in the halls of Congress and our state capitols. Down the stretch run of any legislative session, the bumping and jostling among the various professions can get downright intense.

Out of this conflict, however, may come a more coordinated approach to patient care. "NPs, PAs, and CNMs know that what they offer is invaluable—the time for educating patients to make more-informed choices about health," says Anita. "They argue persuasively that by working together—physicians, PAs, advanced-practice nurses—they can best meet the needs of patients and keep them healthier."

Over time, however, what will matter most to patients is how all the health professions mix and match in the real world of day-to-day clinical practice. In our 1998 Continuing Survey, we reported that about one in five medical practices had already hired a PA or NP. Those numbers will keep rising, a sure daily double bet if there ever was one.

I'd like to think that the collaborative model, not the contentious one, will prevail. To be sure, there will be disagreements between physicians and their new "partners," particularly over the desire of some NPs to practice as independent primary care providers. But, as an eternal optimist, I'd also like to think that our gap-ridden health system can use all the properly deployed man- and womanpower it can get.

I do pass along one caveat: PAs, NPs, and CNMs deservedly win high praise for the time and attention they're willing to devote to patients. While that can provide physicians with relief from certain tasks, time and attention paid to patients are precisely what physicians can least afford to relinquish. Any doctor who is concerned that one of the "new" practitioners will usurp his or her role had better not lose touch with, or sight of, the patient. The survival cry of the future may very well be "Physician, extend thyself!"

Jeff Forster. Memo from the Editor.

Medical Economics

2000;6:8.