1140
THE PHYSICIAN EXTENDER: HIS ACHIEVEMENT AND POTENTIAL* BELLA STRAUSS, M.D. Associate Professor of Medicine Dartmouth Medical School Director, MEDEX-New England Hanover, N.H.
T 1lE majority of physician-extender programs have been described in the news media, in the official physician-assistant's journal, and in numerous standard medical journals-especially the New England Journal of Medicine. For this audience, a descriptive narrative about the program I represent, MEDEX-New England, would be inappropriate. Therefore, I shall summarize MEDEX-New England and then address myself to the physician or physician assistant (PA) here in terms of his achievement and potential. PA programs, their achievements and potential-whether MEDEX, physician associate, or physician assistant and so on-certainly bear upon medical manpower, its problems, and, perhaps in part, on their solution. These form our common concern today. MEDEX-New England has trained approximately 125 PAs since 1970 to work with primary-care physicians thoughout the six New England states, predominantly in rural communities in the northern tier (northern New Hampshire, Vermont, and Maine). In a number of ways this training has departed from traditional modes of paraprofessional education despite the fact that it has been provided within the setting of a conventionally oriented teaching hospital and regional medical center, where a variety of medical technicians are given specific, task-oriented training and where there is a heavy commitment to the training of medical students and house officers in specialty medicine. MEDEX is 12 months in duration and is biphasic. Phase I is composed *Presented in a panel, The Contribution of Other Members of the Health Team to the Solution of Medical Manpower Problems, as part of the Fourth Annual Symposium on Medical Education, Prospective Medical Manpower Requirements-How Are They To Be Met? held by the Committee on Medical Education of the New York Academy of Medicine October 9, 1975.
Bull. N. Y. Acad. Med.
THE PHYSICIAN EXTENDER
THE PHYSICIAN
EXTENDER
1141
of three months at the Dartmouth- Hitchcock Medical Center; here an intensive, task-oriented curriculum occupies eight to 10 hours per day for at least five days per week. Phase II comprises the succeeding nine months spent in the field: the community of the PA candidate's physician-preceptor, who is a primary-care physician. The goal of the first three months is to provide the candidate with an orientation, a frame of reference. Mastery of skills, it is anticipated, will evolve over the nine months in the field and beyond, after certification. The physician-preceptor is the key to the success of the program, since he carries 75% of the teaching load during the training year; more important, his teaching is on a 24-hour basis in terms of the actual practice situation and his over-all responsibility. He provides an entree for the PA into the community. Departure from tradition has been twofold: 1) in the manner in which the curriculum is implemented in Phase I and 2) in the manner in which the program has monitored its candidates in Phase II. The curriculum is task-oriented rather than memory-based. It teaches skills considered requisite for the field in a unique manner; the skill is taught first, and thereafter only the pertinent basic information adjudged essential to its competent execution is imparted. One example will suffice: the components of the physical examination-head, eyes, chest, abdomen, etc.-are taught as they are taught to medical students, but with this difference: after the specific procedural component has been taught, only the essentials of anatomy and physiological function are provided. A roughly parallel course for a medical student would be to undertake physical diagnosis first and to study basic science thereafter. (Similar experiments are being tried in medical education on several campuses today, most notably at Stanford University School of Medicine.)* Candidates are monitored closely during the nine-month preceptorship in the community; they are judged within the frame of the problemoriented medical record on acquisition of data, definition of the basic clinical problem (at the PA's level of training), and formulation of diagnostic plan, therapeutic regimen, and patient-education plan for review with the physician before implementation. One structural tool for monitoring is the clinical algorithm system, whose utility relates to common, acute illnesses. The algorithm is a kind of clinical flow sheet or protocol which indicates step by step how a PA *Wasson, J. Personal communication.
Vol. 52, No. 9, November 1976
1142 1142
B. STRAUSS
B.
who has been trained to differentiate between normal and abnormal and to perform a standard physical examination can define a clinical problem safely and competently, up to and including the review of the assembled data by a physician for ultimate decision. The system incorporates the clinical algorithm itself, a checklist medical record form, and a sophisticated computer program to audit the performance of the PA. The objective measurement of performance of the PA is obtained via the computer so that the physician-preceptor can obtain a profile of MEDEX reliability and thoroughness. The printout displaying numbers and kinds of algorithm errors month by month can be used by MEDEX, the program, and the preceptor as a basis for corrective growth. In the setting of our common interest today, have the achievements of PAs so trained and otherwise trained implemented the solution of medical manpower problems? The answer is yes and no. First the yes. Statistics from many sectors of the national PA effort (whether MEDEX, nurse-practitioner, pediatric nurse-practitioner, or other physician extenders) indicate that these professionals have increased the access to medical care by formerly unreached populations of patients. That has been a prime goal, hoped for by the Congress, the National Institutes of Health, the programs, and the potential populations of patients. Increased access constitutes an important asset. Now for the no. Our data and the data of others point to a mounting problem: in the best practice sites across the United States, those where there is maximum total professional staff organization, the effective PAs, trained in problem-oriented medical records, are generating in the course of their contacts with patients lists of problems so much longer than those compiled prior to their employment that even the most efficient physicians are unable to investigate them all. Thus, it is common for a practice site, within a year of having incorporated a PA, to be forced to consider the option of 1) inviting an additional physician or 2) bringing another PA into the fold. The latter, as you can guess, then may compound the problem. A further drawback is that the legal fabric, state by state, generally relates a PA by definition and by specific law to a physician, without whom the extender cannot function. Since a maldistribution of physicians is a thorny fact of life, it follows that the presence on the American professional scene of 2,000 certified PAs in and of itself hardly can serve to lessen the skewing. According to the New England Journal of Medicine, PAs tend to follow the same distribution patterns as profes-
Bull. N. Y. Acad. Med.
THE PHYSICIAN EXTENDER
THE
PHYSICIAN
EXTENDER
1143
sionals in general-partly for the same reasons, partly because the impetus of the law so dictates.* Also part of the no is the fact that the maldistribution of physicians (given the present legal framework) can be lessened only by physicians, not by PAs. Also, practices having PAs show a significant increase in the rate of hospitalization and, therefore, an element of the increase in the cost of medical care may be laid, in a sense, at their collective door (although, of course, that increase may be wholly justified in terms of good medicine). As we search for a solution to shortages of medical manpower, it appears that at least one area of professional help has been exploited insufficiently: the fabric of professional support at the level of the community agency. A Veterans Administration program now underway utilizes physician extenders in conjunction with the Visiting Nurse Association, home health aides, and discharge-planning nurses from regional hospitals in the upper Connecticut River valley-predominantly Vermont plus some contiguous areas of New Hampshire. This program has been able to provide multiple levels of professional support and extensive services for patients characterized by continuity and appropriate monitoring (i.e., physician responsibility) where heretofore few or no services were available. In this functional unit several hundred thousand square miles are encompassed and a new dimension of medical care has become a reality; the key to the viability of this effort is the PA or physiciansurrogate. This template-despite vast difference in geographic terrain and, perhaps, some differences in cultural patterns-suggests itself as a means of obtaining a measure of relief from our common problem. It is feasible and it has proved practicable to establish functional relations among three principals: 1) a regional hospital, 2) community agencies, and 3) PAs of several types. The traditional pattern of utilization of these principals is tripartite. Realignment into a unit structure and abandonment of the traditional divisive state of affairs, at least functionally, can lessen significantly the pressure for manpower; this is especially true in areas experiencing a paucity of primary-care physicians and its attendant ill: a paucity of access to care.
*Nelson, B. C., Jacobs, A. R., Cordner, K., and Johnson, K. G.: Financial import of physician assistants on medical practice. N. Engl. J. Med. 293:527-30, 1975.
Vol. 52, No. 9, November 1976
THE PHYSICIAN EXTENDER: HIS ACHIEVEMENT AND POTENTIAL* BELLA STRAUSS, M.D. Associate Professor of Medicine Dartmouth Medical School Director, MEDEX-New England Hanover, N.H.
T 1lE majority of physician-extender programs have been described in the news media, in the official physician-assistant's journal, and in numerous standard medical journals-especially the New England Journal of Medicine. For this audience, a descriptive narrative about the program I represent, MEDEX-New England, would be inappropriate. Therefore, I shall summarize MEDEX-New England and then address myself to the physician or physician assistant (PA) here in terms of his achievement and potential. PA programs, their achievements and potential-whether MEDEX, physician associate, or physician assistant and so on-certainly bear upon medical manpower, its problems, and, perhaps in part, on their solution. These form our common concern today. MEDEX-New England has trained approximately 125 PAs since 1970 to work with primary-care physicians thoughout the six New England states, predominantly in rural communities in the northern tier (northern New Hampshire, Vermont, and Maine). In a number of ways this training has departed from traditional modes of paraprofessional education despite the fact that it has been provided within the setting of a conventionally oriented teaching hospital and regional medical center, where a variety of medical technicians are given specific, task-oriented training and where there is a heavy commitment to the training of medical students and house officers in specialty medicine. MEDEX is 12 months in duration and is biphasic. Phase I is composed *Presented in a panel, The Contribution of Other Members of the Health Team to the Solution of Medical Manpower Problems, as part of the Fourth Annual Symposium on Medical Education, Prospective Medical Manpower Requirements-How Are They To Be Met? held by the Committee on Medical Education of the New York Academy of Medicine October 9, 1975.
Bull. N. Y. Acad. Med.
THE PHYSICIAN EXTENDER
THE PHYSICIAN
EXTENDER
1141
of three months at the Dartmouth- Hitchcock Medical Center; here an intensive, task-oriented curriculum occupies eight to 10 hours per day for at least five days per week. Phase II comprises the succeeding nine months spent in the field: the community of the PA candidate's physician-preceptor, who is a primary-care physician. The goal of the first three months is to provide the candidate with an orientation, a frame of reference. Mastery of skills, it is anticipated, will evolve over the nine months in the field and beyond, after certification. The physician-preceptor is the key to the success of the program, since he carries 75% of the teaching load during the training year; more important, his teaching is on a 24-hour basis in terms of the actual practice situation and his over-all responsibility. He provides an entree for the PA into the community. Departure from tradition has been twofold: 1) in the manner in which the curriculum is implemented in Phase I and 2) in the manner in which the program has monitored its candidates in Phase II. The curriculum is task-oriented rather than memory-based. It teaches skills considered requisite for the field in a unique manner; the skill is taught first, and thereafter only the pertinent basic information adjudged essential to its competent execution is imparted. One example will suffice: the components of the physical examination-head, eyes, chest, abdomen, etc.-are taught as they are taught to medical students, but with this difference: after the specific procedural component has been taught, only the essentials of anatomy and physiological function are provided. A roughly parallel course for a medical student would be to undertake physical diagnosis first and to study basic science thereafter. (Similar experiments are being tried in medical education on several campuses today, most notably at Stanford University School of Medicine.)* Candidates are monitored closely during the nine-month preceptorship in the community; they are judged within the frame of the problemoriented medical record on acquisition of data, definition of the basic clinical problem (at the PA's level of training), and formulation of diagnostic plan, therapeutic regimen, and patient-education plan for review with the physician before implementation. One structural tool for monitoring is the clinical algorithm system, whose utility relates to common, acute illnesses. The algorithm is a kind of clinical flow sheet or protocol which indicates step by step how a PA *Wasson, J. Personal communication.
Vol. 52, No. 9, November 1976
1142 1142
B. STRAUSS
B.
who has been trained to differentiate between normal and abnormal and to perform a standard physical examination can define a clinical problem safely and competently, up to and including the review of the assembled data by a physician for ultimate decision. The system incorporates the clinical algorithm itself, a checklist medical record form, and a sophisticated computer program to audit the performance of the PA. The objective measurement of performance of the PA is obtained via the computer so that the physician-preceptor can obtain a profile of MEDEX reliability and thoroughness. The printout displaying numbers and kinds of algorithm errors month by month can be used by MEDEX, the program, and the preceptor as a basis for corrective growth. In the setting of our common interest today, have the achievements of PAs so trained and otherwise trained implemented the solution of medical manpower problems? The answer is yes and no. First the yes. Statistics from many sectors of the national PA effort (whether MEDEX, nurse-practitioner, pediatric nurse-practitioner, or other physician extenders) indicate that these professionals have increased the access to medical care by formerly unreached populations of patients. That has been a prime goal, hoped for by the Congress, the National Institutes of Health, the programs, and the potential populations of patients. Increased access constitutes an important asset. Now for the no. Our data and the data of others point to a mounting problem: in the best practice sites across the United States, those where there is maximum total professional staff organization, the effective PAs, trained in problem-oriented medical records, are generating in the course of their contacts with patients lists of problems so much longer than those compiled prior to their employment that even the most efficient physicians are unable to investigate them all. Thus, it is common for a practice site, within a year of having incorporated a PA, to be forced to consider the option of 1) inviting an additional physician or 2) bringing another PA into the fold. The latter, as you can guess, then may compound the problem. A further drawback is that the legal fabric, state by state, generally relates a PA by definition and by specific law to a physician, without whom the extender cannot function. Since a maldistribution of physicians is a thorny fact of life, it follows that the presence on the American professional scene of 2,000 certified PAs in and of itself hardly can serve to lessen the skewing. According to the New England Journal of Medicine, PAs tend to follow the same distribution patterns as profes-
Bull. N. Y. Acad. Med.
THE PHYSICIAN EXTENDER
THE
PHYSICIAN
EXTENDER
1143
sionals in general-partly for the same reasons, partly because the impetus of the law so dictates.* Also part of the no is the fact that the maldistribution of physicians (given the present legal framework) can be lessened only by physicians, not by PAs. Also, practices having PAs show a significant increase in the rate of hospitalization and, therefore, an element of the increase in the cost of medical care may be laid, in a sense, at their collective door (although, of course, that increase may be wholly justified in terms of good medicine). As we search for a solution to shortages of medical manpower, it appears that at least one area of professional help has been exploited insufficiently: the fabric of professional support at the level of the community agency. A Veterans Administration program now underway utilizes physician extenders in conjunction with the Visiting Nurse Association, home health aides, and discharge-planning nurses from regional hospitals in the upper Connecticut River valley-predominantly Vermont plus some contiguous areas of New Hampshire. This program has been able to provide multiple levels of professional support and extensive services for patients characterized by continuity and appropriate monitoring (i.e., physician responsibility) where heretofore few or no services were available. In this functional unit several hundred thousand square miles are encompassed and a new dimension of medical care has become a reality; the key to the viability of this effort is the PA or physiciansurrogate. This template-despite vast difference in geographic terrain and, perhaps, some differences in cultural patterns-suggests itself as a means of obtaining a measure of relief from our common problem. It is feasible and it has proved practicable to establish functional relations among three principals: 1) a regional hospital, 2) community agencies, and 3) PAs of several types. The traditional pattern of utilization of these principals is tripartite. Realignment into a unit structure and abandonment of the traditional divisive state of affairs, at least functionally, can lessen significantly the pressure for manpower; this is especially true in areas experiencing a paucity of primary-care physicians and its attendant ill: a paucity of access to care.
*Nelson, B. C., Jacobs, A. R., Cordner, K., and Johnson, K. G.: Financial import of physician assistants on medical practice. N. Engl. J. Med. 293:527-30, 1975.
Vol. 52, No. 9, November 1976
![[The physician and his environment (author's transl)].](/assets/img/hold.png)
