{"id":36459,"date":"2016-04-05T16:25:06","date_gmt":"2016-04-05T15:25:06","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmj\/?p=36459"},"modified":"2016-04-05T16:29:10","modified_gmt":"2016-04-05T15:29:10","slug":"william-cayley-will-mid-level-practitioners-replace-primary-care-physicians","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmj\/2016\/04\/05\/william-cayley-will-mid-level-practitioners-replace-primary-care-physicians\/","title":{"rendered":"William Cayley: Will mid-level practitioners replace primary care physicians?"},"content":{"rendered":"

\"bill_cayley_2\"<\/a>I recently asked<\/a> whether, in light of the relative drop in the number of trainees entering family medicine in the US compared to other specialties, we can continue to find ways to bolster the strengths of primary care, both in medical education and practice\u2014since we know that primary care \u201chelps prevent illness and death<\/a>.\u201d<\/p>\n

Some have suggested that the best way to strengthen primary care systems, if physicians are in short supply, is to focus on further development of training for \u201cmid-level\u201d practitioners\u2014for example, nurse practitioners and physician assistants.<\/p>\n

There is certainly evidence that mid-level practitioners are an asset to a primary care team. Inclusion of nurse practitioners in a primary care team may enhance management of chronic disease<\/a>, and a study of women\u2019s healthcare<\/a> actually found that mid-level clinicians are more likely than physicians to adhere to guidelines for preventive screening services. A mixed methods study concluded that<\/a> physician assistants \u201ccan provide a flexible addition to the primary care workforce,\u201d\u00a0and in a study of emergency care diagnosis and management<\/a>, there was no statistically significant difference between nurse practitioners and physicians in terms of missed injuries or inappropriate management.<\/p>\n

Nevertheless, there remain concerns that care by mid-level practitioners is not the same as care given by physicians. In outpatient practice, mid-level clinicians appear to have a higher rate of antibiotic prescribing<\/a>. While\u00a0a study of referral patterns<\/a> to an academic medical center found that referral quality was higher (in terms of the \u201cclarity of the referral question, understanding of pathophysiology, and adequate pre-referral evaluation and documentation\u201d) from physicians than from mid-level clinicians.<\/p>\n

The larger point to all of this is that the best way to address needs for primary care is not to focus on one category of training or another. Rather, we need to develop all parts of the primary care team. Further research on the role of mid-level clinicians in caring for infectious diseases in under-resourced settings<\/a>\u00a0and in geriatric care<\/a>\u00a0will certainly be a welcome addition to our evidence base.<\/p>\n

For several years now, the trend has been to refer generically to primary care \u201cproviders\u201d\u2014be they physicians, nurse practitioners, physician assistants (perhaps even midwives). Setting aside for now the de-personalization and de-professionalization this implies (to paraphrase the admirable, if fictitious, Dr McCoy<\/a>:\u00a0\u201cBlast it, I\u2019m a doctor, not a provider!\u201d), this generification undermines an appreciation of the unique roles of each type of professional and their particular contribution to the primary care team.<\/p>\n

As argued recently<\/a> by Dr Allan Goroll:<\/p>\n

\u201cPhysician participation, if not leadership, in the multidisciplinary team effort remains essential to effectively delivering the full spectrum of high performance primary care demanded by society. Because the greatly expanded agenda and responsibilities of modern primary care necessitate an evolution from the revered solo-physician model to a multidisciplinary team based effort, care must be taken to specify competencies, responsibilities, and working relationships of team members while maintaining the traditional commitment to a high level of professionalism.\u201d<\/p><\/blockquote>\n

We need to bolster primary care training and services, both in high resource and low resource settings. The way to do this is not<\/em>\u00a0to replace physicians with mid-level clinicians. Rather, the way to do this is to promote education and appropriate placement for all members of the healthcare team.<\/p>\n

I\u2019m not sure how many of us would take on the challenge of Dr McCoy\u2019s job:\u00a0an \u201cold country doctor\u201d spending five years exploring the \u201cfinal frontiers\u201d of space. Nevertheless, now more than ever, we need professionals at all levels of training who are willing to take on the ongoing mission of bringing primary care to our patients.<\/p>\n

William E Cayley Jr<\/strong>\u00a0practices\u00a0at the Augusta Family Medicine Clinic; teaches at the Eau Claire Family Medicine Residency; and is a professor at the University of Wisconsin, Department of Family Medicine.<\/em><\/p>\n

Competing interests:<\/strong> I declare that I have read and understood BMJ policy on declaration of interests and I have no relevant interests to declare\u00a0(although I have been a long time fan of Star Trek<\/a><\/em>!).<\/p>\n","protected":false},"excerpt":{"rendered":"

I recently asked whether, in light of the relative drop in the number of trainees entering family medicine in the US compared to other specialties, we can continue to find ways to bolster the strengths of primary care, both in medical education and practice\u2014since we know that primary care \u201chelps prevent illness and death.\u201d Some […]<\/p>\n

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