Sermo Exclusive–Solution to the PA-C, NP & ANP Issue in Medicine

The enactment of the Patient Protection and Affordable Care Act (ACA) reflects forces of change in American medicine.  Despite all the politicizing and resistance to the ACA, the public’s misperception about how mandatory health insurance will in fact provide the highest level of access to primary care in the nation’s history, and the medical community’s ambivalence about the coming changes, health care in America has entered a new era that will be transformational for primary care.  Those forces will not only require change in the way Americans use this new medical care, it will also require change in the way primary care is delivered; but before that, it challenges us to revise how primary care practitioners are educated.

I bring a unique perspective to this conversation and debate.  In the spirit of disclosure, I want to state up front that I am an advocate for health care reform and supported the passage of the ACA.

For over thirty years I have served as a professional, first in higher education, and now in a medical setting.

For the past fourteen years I’ve worked as a (Protestant) hospital chaplain at a Regional Medical Center, which is part of a Catholic Health Care System in the Northwest United States.  We operate a Level II Trauma Center and have specialties in cardiovascular medicine, neurosurgery, orthopedics, neonatal intensive care, oncology and palliative care. In addition, we have a Clinical Pastoral Education program to train chaplains

Prior to that, I worked in higher education. For fourteen years I served as a dean of students and vice president for student affairs at a private church-related college. I was responsible for the school’s institutional research for a number of years as well.

In addition to my professional experience, I hold an earned Doctor of Philosophy degree in Higher Education Policy and Management, along with two masters’ degrees, a Master of Divinity and a Master of Arts in Counseling Psychology.

My proposal  in this brief essay, in some respects, is radical.  Medical education has progressed over the past centuries to educate primarily three kinds of  traditional practitioners, one track for medical doctors, one for non-MD specialists such as dentists and optometrists, and the third track for nurses.  As medical technology has progressed, other clinical disciplines have been added, but the customary roles have remained more or less unchanged.

America’s need for good medical care has grown every generation.  As various groups examined the nation’s need for extra practitioners who could be trained more quickly than the average physician (15-20 years), novel programs have been developed that include the Physician Assistant, the Nurse Practitioner and the Advanced Practice Nurses.  From the beginning of these mid-level providers, questions arose over what their role in patient care should really be.

The argument over these practitioners has now gone on for years regarding the quality and standards for their education, clinical preparation and ability to “practice” medicine.  Is the preparation adequate for the practitioner to treat patients without physician supervision?

Those questions remain, but around the country, health reform advocates and state legislators, seeking ways to meet the medical needs of their constituents have warmed to these novel ideas and have passed bills that permit the creation of new categories of medical professionals.  The standards for certification, however, have been set state by state, with little to no coordination.  The result has been a product in the graduates of these programs that lack clinical skills which are the same on a national scale.

Inevitably a debate has erupted from within the physician community about the growing number of novel practitioners that are neither physicians nor nurses, but have been developed attempting to fill the gaps in primary care.  The debate includes Nurse Practitioners (NP) and Advanced Practice Nurses (APN), but I will focus on the Physician Assistant (PA-C).  Although all three categories are questioned on a number of levels, physicians are particularly divided over both the education and the reliability of the PA-C.  The Physician Assistant frequently lacks the undergraduate medical education of a registered nurse, a relevant factor in the two other categories.  Program entrance requirements vary widely.  For example, at least one Physician Assistant school accepts students right out of high school with no college pre-med or nursing prerequisites.  One of my friends who is a primary care physician wrote to me in an email:

Issues doctors have with mid-level providers include the following: not correcting patients when they address them as “Dr.” by mistake, not paying full malpractice rates (the doctor picks up the rest), not taking call, not bearing responsibility for their patients after hours, lack of training leading to ridiculous time-consuming mistakes the doctor has to fix, overconfidence, over ordering tests to compensate for lack of critical thinking skills, don’t know what they don’t know, can never actually be fully supervised unless the doctor is in room with them; some states allow them to practice independently, other states require the PA be “supervised”;  a salary out of proportion to their skills and duration of training.

The inconsistencies revealed through these objections point to a classic example of a well-intentioned but uncoordinated idea that resulted in haphazard standards for the creation of Physician Assistant training programs,  including erratic licensing requirements, and varying state-level rules for practice that lack coherency from a national point of view.  The consequence is a failure of the whole PA-C system to produce a medical provider who can dependably contribute quality primary care medicine regardless of the state’s statutes in which they are licensed to practice.  With the ACA-required mushrooming need for primary care providers, the Physician Assistant programs appear to be completely inadequate and incapable of meeting the obligations placed upon the medical community as a whole.

The most importance shortfall, though, is that due to this lack of capacity, the PA-C is not trusted by the constituents they were created to serve: patients and physicians.   The reality puts America’s health at an even greater risk at a time in which we need the most coordinated medical care in our history.  The same mistrust appears to hold true for the NPs and APNs.

In light of those short-comings, I believe the only viable option is that the Physician Assistant program (along with the NP and APNs) be phased out by 2014 and replaced with a highly trained provider whose focus will almost exclusively be on primary care.  What I present below are a series of ideas on the education and preparation of these practitioners.

I propose the initiation of an entirely new category for the practice of medicine aimed at meeting America’s primary care needs.  The individuals who undergo this training will not be medical doctors, nor will they carry that title.  Figure 1 below provides a diagrammatic presentation of each of the points explained for this new medical provider.

  • This designation for a new medical provider would be created whose title would be Therapian (like “European”); the professional designation would be such as “Susan Smith, TPC”, which would stand for “Therapian of Primary Care,” and the the abbreviation would be “Th” written as Th. Susan Smith.  Therapian is derived from the Greek word for “healer” which also forms the root of our word “therapy.”
  • The education of the TPC would follow a parallel course in Pre-Med, but with some important distinctives:

o   The first two undergraduate years The MD and TPC pre-med prerequisites curriculum would be identical.  This shared track would guarantee that a Therapian would have the same quality pre-med foundation as a Physician.

o   At the end of the sophomore year all pre-med students would take a Junior Qualifying Exam:  One examination would be designed for pursuing a TPC and the other for the MD. Passing the Junior Exam would be the prerequisite for continuing as an upperclassman in either program.

  • The final two pre-med undergraduate years would be differentiated, one for the TPC and another for the MD/DO.
  • At the end of the Senior Year, there would be a qualifying exam for Therapian primary care medical school and as well as the qualifying exam for the established medical schools for those on the MD track.
  • From this point on, the Therapian Primary Care Medical School would be completely its own track.
  • TPC Medical School would be two years (the vast majority of these students would not be specializing).
  • At the end of that second year the therapian would earn a Masters in Therapian Primary Care (MTPC).
  • Therapians would then take their boards, but rather than being fully licensed to independently practice, the person would receive a provisional license.
  • The Therapian would complete a 1 year (12 months) residency.
  • Upon successful completion of the residency, the Therapian would then enter a required three years apprenticeship under the mentorship of a TPC-approved physician who practices primary care.
  • Therapians would receive a federally-funded stipend to cover their salary, not only to cover living expenses but provide for malpractice insurance.
  • TPC mentors would receive compensation for participating in the program.
  • The stipend and malpractice insurance (there might be some additional items to add to this) would be designed to permit a small primary care practice to mentor Therapians without putting a strain on the business’ income stream.
  • At the completion of that three year mentorship the Therapian would be certified as fully licensed and could open a practice in Primary Care Medicine or work in an established clinic.
  • If the Therapian worked in a primary care practice, the a dedicated federal fund would pay off 50% of his or her student loans.
  • The Therapian could also, at this point, apply for a fellowship to study in a specialty other than primary care, working under a physician, but as an incentive to pursue primary care and not specialize in another area of medicine, if the TPC chose to pursue a specialty fellowship, the government would pay off some lesser percentage of his or her student loans.
  • Likewise for physicians,  if the doctor specialized in primary care and went into practice, an identical federal fund would pay off 50% of his or her student loans.  This is based on the assumption that Primary Care Doctors, would, on average, make less than a specialist. The rationale to relieve them of their significant percentage of their indebtedness would provide an incentive to train in primary care (similar to the military paying college tuition as a recruiting device for the armed forces).
  • Doctors choosing specialties, too, would receive a smaller percentage forgiveness of their student loans.  The assumption being that specialists have a higher income potential and would be able to pay off half their student loans without endangering their practice.
  • See Figure 1 below:
  • Figure 1: New Primary Care Provider Model: © 2010, David Waggoner

In summary, the development of the current mid-level provider programs lack the high level of medical expertise, both in their educational preparation and their clinical preparation, to meet the increasing demands for dependable and competent medical care throughout the country.  The ACA only adds to this disparity because of its emphasis on primary care.

However well-intentioned the founders of these programs were, as well as those who have pursued these certifications and work, the programs have ended up as a category of substandard and inadequately trained individuals that place additional burdens on physicians to supervise and increase the risk of incorrect diagnoses, prescriptions and treatments.

Since there appears to be no remedy for the inherent irregularities of those shortcomings, I conclude it is in the best interest of the medical community and the public health to stop training and licensing this sub-category of provider by 2014, and create, on a coordinated, nationwide basis a new practitioner class that eliminates the irregularities while conforming to the highest medical standards to meet Americans’ need for access to medical primary care .  That medical professional is the Therapian.

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