William Cayley: Will mid-level practitioners replace primary care physicians?

bill_cayley_2I 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—since we know that primary care “helps prevent illness and death.”

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 “mid-level” practitioners—for example, nurse practitioners and physician assistants.

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, and a study of women’s healthcare 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 physician assistants “can provide a flexible addition to the primary care workforce,” and in a study of emergency care diagnosis and management, there was no statistically significant difference between nurse practitioners and physicians in terms of missed injuries or inappropriate management.

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. While a study of referral patterns to an academic medical center found that referral quality was higher (in terms of the “clarity of the referral question, understanding of pathophysiology, and adequate pre-referral evaluation and documentation”) from physicians than from mid-level clinicians.

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 and in geriatric care will certainly be a welcome addition to our evidence base.

For several years now, the trend has been to refer generically to primary care “providers”—be 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: “Blast it, I’m a doctor, not a provider!”), this generification undermines an appreciation of the unique roles of each type of professional and their particular contribution to the primary care team.

As argued recently by Dr Allan Goroll:

“Physician 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.”

We need to bolster primary care training and services, both in high resource and low resource settings. The way to do this is not to 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.

I’m not sure how many of us would take on the challenge of Dr McCoy’s job: an “old country doctor” spending five years exploring the “final frontiers” 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.

William E Cayley Jr practices at 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.

Competing interests: I declare that I have read and understood BMJ policy on declaration of interests and I have no relevant interests to declare (although I have been a long time fan of Star Trek!).

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