Midlevel Providers Fill Primary Care Doctors' Shoes Physician assistants, like Jim Love, and nurse practitioners can prescribe medicine, and many operate almost completely independently of physician supervision. And unlike physicians in primary care, the number of physician assistants and nurse practitioners is on the rise.

Midlevel Providers Fill Primary Care Doctors' Shoes

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From NPR News, this is ALL THINGS CONSIDERED. Im Melissa Block.


And Im Robert Siegel.

Within 10 years, there could be a shortage of 45,000 primary care physicians -thats one prediction, at least. And one possible solution is to increase the number of highly trained nurses and physician assistants who do primary care.

We've been focusing on this most basic health care this week. And once again, Im joined by NPR's Julie Rovner.

Hi, Julie.


SIEGEL: The shortage of primary care professionals is particularly bad in large rural states. Yes?

ROVNER: Absolutely. You know, people are having trouble all over the country finding someone to give them primary care, but it is definitely worse in rural areas. According to the journal Health Affairs, 21 percent of the nation's population lives in rural America, but only 10 percent of the doctors practice there.

SIEGEL: Earlier in the week, you talked about the fact that the new federal health law will extend health insurance to tens of millions more people. So does that law do anything about boosting the supply of primary care doctors?

ROVNER: You know, it really does. Lawmakers knew that there was going to be this shortage, and that they were going to add to it with the people who are getting insurance. So the law increases payments for health professionals who provide primary care now. The law doubles funding for community health centers that provide care in areas where there are shortages of health services. And it also increases fundings for programs that train students to become health professionals in the future.

SIEGEL: You're using the phrase health care professionals, health professionals - not doctors. You mean more than just doctors.

ROVNER: That's right. As American patients, most of us are used to getting our primary care from someone we call doctor. But increasingly, primary care is being delivered by whats called midlevel professionals. These are people like physician assistants and nurse practitioners. They have more training than a registered nurse but less than a full-fledged doctor.

There are just over 200,000 P.A.s and N.P.s practicing today around the country. And in many states, they can practice on their own. They can write prescriptions and do many of the things that a doctor does.

SIEGEL: And thats what today's story is about?

ROVNER: Yes, I spent a day with a physician assistant in rural Maine - a part of rural Maine where it's been very difficult to attract doctors, I might add.

SIEGEL: Okay. Thanks, Julie.

And here is the concluding part of Julie Rovner's series this week, about the crisis in primary care.

(Soundbite of a roadway)

ROVNER: It's a little before 6 a.m., and Jim Love is taking the long way to work. Most of the tiny town of Pittsfield, Maine, population 4,200, is still asleep as he peddles his bike through the cool, tree-lined streets.

He stops at the local park to check on a mother loon that nests every year at the foot of the same dam.

Mr. JIM LOVE (Physician Assistant, Sebasticook Family Doctors): See the loon...

ROVNER: Mm-hmm.

Mr. LOVE: ...sitting in the grass?

ROVNER: Ever the caregiver, he's worried that no eggs have hatched yet.

Mr. LOVE: A chick, it's going to be hard to get raised and get out of here in time, before cold weather.

ROVNER: Love, who looks younger than his 62 years, gets back on his bike and heads up the hill to his office, just down the street from the local hospital. He knows these will be the last quiet moments of what he expects will be a very long day.

(Soundbite of a door closing)

ROVNER: Once inside, he checks out the schedule on his computer.

Mr. LOVE: So far today, we're booked for 22 patients, and the phone line hasn't opened up yet.

ROVNER: When it does open, he says, the remaining slots at his clinic, Sebasticook Family Doctors, will fill quickly.

Mr. LOVE: My inbox just turned red, so that means two patients are now scheduled in for the 7 o'clock slot. And looking ahead, starting at 9 o'clock, Im booked pretty solid from 9 a.m. right through noon. Five of those are new patients that I haven't seen before.

ROVNER: That's because the doctor who used to practice with him in the clinic quit a week earlier. So Love is seeing many of that doctor's former patients, as well as his own.

Mr. LOVE: Good morning. How are you?

Unidentified Woman #1: My ears have been (unintelligible)...

ROVNER: But Love isnt a doctor himself. He's a physician assistant - though most of his patients ignore the distinction between a P.A. and an M.D.

Mr. LOVE: Ninety-nine percent of them call me doctor, just because it's easier that way.

ROVNER: Of course, to watch Love in action, it's easy to forget he's not an M.D.

Mr. LOVE: Now, how often are you checking your sugars at home?

Unidentified Man: Twice a day.

Mr. LOVE: Twice a day?

Unidentified Man: Yeah, morning and night.

Mr. LOVE: Whats the lowest youve gotten?

ROVNER: And most of his patients, at least on this day, dont seem to care what his title is. Robert Marshman is from nearby Exeter, Maine.

Mr. ROBERT MARSHMAN: Tell you what, I think he's better than any medical doctor I've been to. And I've said that to everybody I've talked to.

ROVNER: Love planned to become a doctor. But he couldn't get into medical school out of college. He worked for several years as a registered nurse instead. When he decided to go back to school in the mid 1970s, he was urged to go to medical school. But with a wife and child, he was put off by the financial obligation that would mean.

Mr. LOVE: It just simply was not, at that stage in my life, feasible. I didn't have the money.

ROVNER: So he became a physician assistant. P.A.s get training that's similar to what doctors get, just less of it. The average P.A. program lasts just over two years. And he's good at what he does, in part because he knows his limits.

Mr. LOVE: I'm good. Im experienced and I'm confident, and all that kind of good stuff. I'm not an internist. And I tell my patients that. I just don't bring the same sophistication that a really skilled internist - and I shouldn't.

ROVNER: Love says he thinks people like him - P.A.s and other so-called midlevel practitioners - are a big part of the solution to the nation's shortage of primary care providers.

Mr. LOVE: We are ideally suited for it. And it's so cost-effective compared to any other form of medical provider. So we need to be educating a lot more of us.

ROVNER: And not just in rural areas but increasingly, everywhere.

Dr. MICHAEL MCDONALD (Sebasticook Family Doctors): You know, whether it's P.A.s or nurse practitioners, they're going to be an integral part of this - sort of the new horizon in medicine.

ROVNER: That's Michael McDonald. He's the primary care doctor who supervises Jim Love. But they dont work in the same building. McDonald works at another branch of Sebasticook Family Doctors, about 25 miles up the road in Dexter, Maine.

They communicate primarily by phone and email, and each has his own, separate group of patients.

Dr. MCDONALD: It works out well. It helps our patients get access to care and you know - and provides good, quality medicine.

ROVNER: It's already a pretty typical arrangement in rural America. And as the number of primary care doctors goes down and the number of midlevel practitioners rises, it's becoming more common in urban areas, too.

But McDonald hopes his midlevel providers dont start streaming to the city. He says he couldnt run his primary care practice without the services of his physician assistant and nurse practitioners.

Sebasticook Family Doctors serves some 8,000 patients from 20 rural towns in four counties in central Maine.

Dr. MCDONALD: It's been very difficult to get M.D.s to come to the area. Or if they do, they don't stay for very long, and they leave. All of our nurse practitioners and P.A.s have been here almost since the beginning, since we started.

ROVNER: Jim Love, in fact, has lived in Pittsfield for more than 20 years, and he says he has no intention of leaving - at least not until he retires.

Mr. LOVE: I really am dedicated to this practice and taking care of the people we take care of. I really want this to succeed.

(Soundbite of door opening)

Mr. LOVE: Hey, there. How are you doing this morning?

Unidentified Woman #2: Oh, Im doing better.

ROVNER: It's now nearing 11 a.m. in Pittsfield. Jim Love is greeting his 11th - or maybe 12th - patient of the day.

Mr. LOVE: Okay. You're taking the 400 and the 200, both at bedtime?

Unidentified Woman #2: Yeah. Yeah.

ROVNER: And no matter how dedicated you are, some patients are more challenging than others, like this new patient he's seeing for the first time.

Mr. LOVE: She's truly above my pay grade. She's got a whole host of serious psychological and physical ailments. Im really not comfortable treating her.

ROVNER: But Love says he'll continue being her primary care giver because she has no place else to go. He'll consult with his supervising doctor and specialist, as needed. It's what makes his life both so rewarding, and so overwhelming.

He's hoping the practice will find a replacement for the doctor who just left, and he's hoping it will be a doctor. But even if it's another P.A. or a nurse practitioner, he'll be glad to have another set of hands to share the load.

Julie Rovner, NPR News.

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