More medical caregivers don’t have an M.D.

When Flora Piatti goes to the doctor these days, she doesn’t deal directly with an MD. The Douglasville woman’s medical needs at the YourTown Health clinic in Palmetto are handled by a physician assistant — a PA, as they’re often called — and that’s fine with her.

“I don’t see any difference. They do basically the same thing,” the 61-year-old said. “It just doesn’t say ‘doctor’ before their name.”

Not everyone would go that far. But the numbers and the role of physician assistants as well as nurse practitioners, another type of mid-level health care provider, are growing to meet the increasing demands of the patient population, and that has them taking on jobs that some patients might view as the traditional domain of doctors.

There may be a need for more PAs and NPs in the future. America’s population is aging and requiring more care, and the number of people with health insurance is expected to rise because of the Affordable Care Act. The need is expected to be greatest in primary care.

The American Academy of Physician Assistants said there are more than 100,000 practicing PAs, double the number in 2000. A third are are in primary care, but they also practice in all medical and surgical settings and specialties, including emergency medicine, surgery, oncology, orthopedics, psychiatry, radiology and pediatrics.

There are about 192,000 NPs, with about three of four practicing in at least one primary care setting, the American Association of Nurse Practitioners said. The number of NPs has doubled since 2000.

According to a study from the Health Resources and Services Administration of the U.S. Dept. of Health and Human Services, “If the system for delivering primary care in 2020 were to remain fundamentally the same as today, there will be a projected shortage of 20,400 primary care physicians.”

The study said, however, that, “Under a scenario in which … (NPs) and … (PAs) are fully integrated into health care delivery, such as patient-centered medical homes that emphasize team-based care, the projected shortage of primary care practitioners in 2020 could be somewhat alleviated.”

As the number of PAs and NPs has grown, so have their responsibilities. There is debate, however, among some providers over their appropriate “scope of practice:” how far their responsibilities should go.

Some PAs now have their own set of patients, and patients seek to schedule appointments with them directly, not with the doctor.

Some nurse practitioners own and operate their own clinics.

Margaret Hinson-Williams, a PA who is senior director of Piedmont Heart Institute Physician Extenders, oversees more than 100 PAs and NPs at the cardiology center.

Both PAs and NPs are trained in numerous areas to take on responsibilities that go far beyond obtaining patient histories and conducting physical exams, she said.

For example, a physician extender might extract a vein needed for heart surgery from another part of the patient’s body for use during the procedure, then assist with other aspects of the surgery including closing.

Years ago, all this would have been performed by a second surgeon in the operating room. Extensive training and supervision has allowed PAs and NPs to assume the role, she said.

Jeff Lefeber, a PA at the heart institute, said, “I have a great deal of latitude.”

PAs do what their supervising physicians request and what is allowed by state law, they say. They are seeking greater authority, though, in areas such as writing prescriptions. In Georgia, for example, PAs cannot prescribe drugs that are deemed to be the most highly addictive or abused.

For their part, NPs say they only want to practice according to their education and skills.

But 19 states, not including Georgia, don’t require nurse practitioners to have a supervising physician or collaborative relationship with a doctor. And the NPs say it’s not necessary in Georgia, either.

NPs are sufficiently qualified, they say, because most worked for many years as a registered nurse before receiving the additional training required to become an NP. Typically, that takes about two more years.

An Atlanta doctor says the role of NPs should be limited, however.

Physician Brian Nadolne, owner of Nadolne Family Medicine & Preventive Care in Marietta and president of the Georgia Academy of Family Physicians, said, “I do believe there is a role for physician extenders. There’s no question that there’s a physician shortage.”

But a physician needs to be the head of a medical team, he said, and, “The problem is nurse practitioners want to be the leader.”

Patients, he said, don’t want that. They want someone who put in the many years of training required to become a physician.

“Some people say NPs are as good as a doctor. They’re not,” he said. Comparing the training, he said, “It’s like a running a 10k versus taking six steps.”

Despite their differences over scope of practice, providers agree that coordinated care is the best way to deal with modern health matters. Integrating care and utilizing providers in the most efficient way holds down costs and ensures that patients get treated fast and don’t end up in costlier care later.

And there are places it works well.

Dr. Tom Bat heads North Atlanta Primary Care, a group of family practice centers with 24 doctors and 12 physician assistants but no NPs. He brought in his first PA about 15 years ago to help handle heavy patient volume. Things worked out.

“It opened my eyes,” he said. “The PAs take the burden off us so we can get through our days.”

Bat added, “I hear my peers argue about what we should and should not let mid-levels do. My conclusion is that generally they haven’t worked with mid-levels a lot. We’ve never had a problem with a PA trying to push to do more than their skill set allows. They are playing an appropriate role.”