Physician Extenders : An Invitation from the Family Physician Family physicians are quite excited and invigorated with the concept of converting our specialty to one which is responsive to the needs of patients and family doctors across the nation. We embrace the idea of being the first to transform our discipline to one which is functional and allows for high quality care in a variety of settings. The family physician will have access to resources which permit state-of-the-art performance in the private office setting, residency training program, hospital environment, and any other arena which the family physician designates as their practice. We have long recognized that our daily work is not accomplished in a silo, but often in combination with other professionals who assist in the delivery of care. The management of the individual patient typically requires assistance from ancillary professionals such as diabetic educators, wound care specialists, physical therapists, occupational therapists, and a host of others who have the same goal to provide comprehensive medical treatment. We recognize that these professionals are often utilized for a short period of time and when the goal is accomplished, the patient is discharged from their services, thus ending the physician communication. This is not the case with physician extenders who practice in alliance with the physician for the long-term. Physician assistants and nurse practitioners are invited professionals in the family physician team approach to care. Family physicians have long recognized the valuable services which these two disciplines provide in our daily work. Physicians who work in the underserved areas of our state appreciate the valuable work of the physician extenders. The “Future of Family Medicine� clearly recognizes the need for family physicians to maintain the relationship with nurse practitioners as we redevelop our discipline. It is evident that Physician Assistants will also be part of the new plan. As we proceed in structuring our profession it is important for family physicians in the state of North Carolina to ana4
lyze our current relationship and define the role of the Physician Extender in the new practice of family medicine. Family physicians are often on the frontier, establishing practices in areas where other subspecialties may not be well suited. The comprehensive approach to the care of the entire family makes the discipline well suited for these communities. As a result, we often establish practices which are small group or solo and consist of large patient populations with numerous high co-morbidities, are remote from established healthcare systems; and possess economics which do not attract wealth. The practice business model may be fortunate to attract other family physician partners after establishing a strong financial base. This can take many years to achieve even in the busiest settings. Family physicians invite Physician Assistants to come into the practice under the guidance and supervision of the doctor and they assist with providing care to patients after establishing a defined management plan. Nurse Practitioners are found to be quite useful with providing comprehensive education with a compassionate approach that’s well- received by most patients. The discipline somehow lost this approach and began to allow the physician extender to provide care without the close guidance of the physician. It is suspected that patient volume may have been the driving force causing this breakdown in the relationship. The family physician of a typical practice is required to spend more time with documentation including completion of patient-generated forms and reviewing payment claims while miraculously taking care of the patients who present for care. Physicians who are participating in both the inpatient and outpatient setting are called upon to perform the duties for these two arenas respectively. Some family physicians have also witnessed the establishment of Physician Extender-Only practices where the physician is not only removed from the physical location of the practice, but in
some instances, are not even practicing in the state of North Carolina! There are several problems which family physicians are now recognizing due to our absence from taking care of business in the practice of the discipline. The erosion of the family physician relationship with the physician extender is reflected as less than optimal patient quality of care for many situations. The medical education for a family physician is not equivalent to the education for a physician assistant or nurse practitioner. The comprehensive education and training of the doctor allows medical problems to be addressed with the goal of resolution after evaluation, in-depth review of pathophysiology, and establishing a management plan with defined treatment. There are several instances of confusion noted when discussing the role of a physician and the physician extender. The most striking level of confusion is with public perception. There are medial offices which offer only the services of a physician extender and the public perceives these offices as family physician practices. Despite the North Carolina Medical Board publications encouraging physician extenders to clearly identify their title to patients, the layperson may not to comprehend the difference in care. It is recognized that these offices have a defined scope-of-practice in the communities in which they serve, but it is not equivalent to a physician-based practice. The idea of establishing physician extender offices in underserved areas does not address the problem of PHYSICIAN SHORTAGE. There are examples where hospital systems are assuming a similar position. In the event of hiring for remote practices, the physician extender is offered a salaried position with a minimal differential noted in comparison with a physician salary. Both physicians and physician extenders are often paid for their services based on production or volume with less emphasis on outcome of care. In settings of this nature, supervision is counterproductive since it requires time
North Carolina Academy of Family Physicians