So, have you heard about the physician shortage—how by 2020, it is estimated that the United States will have approximately 200,000 fewer practicing physicians than the nation will require to meet the increasing needs of a growing, aging, chronically ill population? The Association of American Medical Colleges (AAMC) has already called for a 30% increase in medical school enrollment, but “even with that increase, demand is going to be significantly higher than the supply,” says Edward S. Salsberg, MPA, Director of AAMC’s Center for Workforce Studies.
It may please NPs and PAs to know they are not alone in considering their professions an important part of the solution to the problem. Both groups “play a major role in our thinking about the future,” Salsberg says. “The only way we can balance the need for services and assure access [to care] is if we use more PAs and NPs, and use them more effectively.”
And the Numbers Are …
There is no doubt that the NP and PA professions are thriving. Data from the National Commission on the Certification of Physician Assistants indicate that the number of newly certified PAs in the US has increased from about 1,000 in 1990 to nearly 5,000 last year. “That fivefold increase is enormous,” Salsberg says, “and it means the number of PAs will be rising significantly over the next several decades.”
Data on NPs are a little harder to gather, since there are multiple training models and certification programs; if you consider advanced practice nurses as a group, there are nearly 10,000 new APNs each year. Geraldine Bednash, PhD, RN, FAAN, Executive Director of the American Association of Colleges of Nursing (AACN), says, “For the last decade, we’ve seen enormous growth in the number of individuals who have been educated as NPs and who are practicing as NPs.”
Salsberg is uncertain as to what impact the switch to the Doctor of Nursing Practice (DNP) degree will have on the NP supply. “That does have the potential to slow up the pipeline for several years. So I don’t know what [NPs’] growth rate will be,” he says. “I’m sure it will be significant. I just don’t know whether there will be a delay in the growth.”
Bednash considers that “a reasonable question” but says AACN believes the DNP will actually attract more candidates to NP programs. “We’re seeing people choose graduate school earlier in their careers, so it should expand the number of people who are entering the programs,” she observes. “The big issue for us will not be whether it takes longer [to get NPs educated and into the workforce] but whether we can continue to graduate the same or larger numbers of people every year.” So far, she says, the numbers have continued to rise.
Tweaking the Data
But sheer volume may not be enough to offset the physician shortage. Much like clinical trial results, the NP/PA workforce supply is subject to a number of variables. Roderick S. Hooker, PhD, PA, Director of Rheumatology Research at the Dallas Veterans Affairs Medical Center, who has done extensive analysis of health care supply and demand, tries to be conservative in his own estimates.
“When I look at what the outpatient productivity in the US is on an annual basis, it’s about 1.2 billion outpatient visits,” he explains. “And when we look at who’s minding the store—who’s seeing those patients—the provider of record in about 11% to 13% of cases is a PA or NP. So, while the head count is larger for both camps, the productivity number is small.”
Furthermore, Hooker notes, not all PAs or NPs who are certified (the basis on which most estimates are generated) may be seeing patients. They may have chosen an academic or leadership role that keeps them out of the clinic. Hooker estimates that the number of PAs who are in active practice could be as much as 12% lower than the stated figures.
Both Salsberg and Hooker say more research is needed to determine whether there will be enough NPs and PAs available to offset the physician shortage. “What is the optimal number?” Hooker asks. “Only when we have an optimal number, what people think is the right ratio of ‘doctor to population,’ will we be able to answer that question.”
Salsberg says “better information on the numbers and types and locations of practitioners … would help us do a lot more forecasting. Both professions are growing very rapidly, [but] I don’t know whether we need more [PAs and NPs] or whether the growth we’ve seen in the last 15 years is going to be sufficient.”
Faculty, Funding, and Preceptors
Then there are the practical obstacles to NP and PA education programs maintaining, let alone ramping up, “production.” These are the same problems that have plagued the nursing and medical education systems for years: faculty, funding, and preceptors.
AACN’s Bednash says her organization sees the DNP as part of the solution to the nursing faculty shortage: “To some extent, the work that’s being done to prepare people at the doctoral level for advanced practice will both produce a very high-quality clinician and expand the ability to have people who can serve in faculty roles.”
Foundations, individual institutions, and employers are also developing ways to support graduate nursing education; for example, AACN is working with the California Endowment to provide funding for minority nurses in California to pursue higher education. “The funding they receive from us is based on their commitment to us that they will stay in California and serve as a faculty member for several years,” Bednash says.
Meanwhile, “the bottleneck for the PA programs tends to be clinical sites, not the classroom,” Hooker notes. “You can teach a classroom of 200 people the same way you can teach a classroom of 20. It’s getting people dispersed into preceptorship sites that I think is the conundrum.”
Solutions to that problem have been slow in developing. Hooker, who describes himself as “more of an observer than an activist” (ie, he does not advocate for particular solutions but points out different ways of doing things as food for thought), notes that in Canada and Australia, preceptor sites are purchased as part of the tuition for a program. “They give some remuneration to the mentor, and while it’s not much, it is a very important price signal,” he says. “And that price signal says, ‘We value the time that you spend, and we’re willing to compensate you for it.’”
Whatever solutions are proposed or pursued, the bottom line involves funding: more of it. “[Policy makers] need to focus on graduate education,” Bednash says. “They need to fund the programs so that they can hire additional faculty to expand, and they need to understand that doctoral-level education is the only way somebody is going to be able to have a long-term career in a university and serve as a faculty member.”
Generation Next and the Evolution of Team Care
Finally, there is one other factor—a more sociological one—that could have an impact on the health care workforce supply. That is the younger generation’s desire for a better work/life balance than their parents and grandparents had. As Bednash observes, “The expectation [used to be] that you would work morning, noon, and night, weekends, ’round the clock, forget your family.”
That attitude toward work appears to be changing, regardless of profession. “So the question there is, who’s going to work those nights and weekends?” Salsberg asks. “Someone is going to need to be available, and it remains to be seen [who it will be].”
Bednash says practices will have to consider how to balance work schedules and patient care needs “so no one profession ends up having the right to preferential expectations about how that work life should play out. It probably means there will need to be more physicians and more nurses so that all the care needs can be met.”
Besides a greater interest in a 9-to-5 job (or close to it), Hooker also detects a growing sense of wanderlust among people in their 30s and younger. “These people, to me, seem to be delaying marriage, delaying commitment, very interested in going abroad,” he observes. “I wouldn’t be surprised if over the next 10 years we find young Americans emulating Canadians, Australians, the Swiss, and others, and wanting to go abroad—with their skills. I’m wondering if American PAs won’t want to bring their newly honed skills to the world stage and say, ‘I’m a PA, and I’d like to work in the Netherlands for two years’ or ‘I’d like to work in Australia for a few years. It’s a great country, and I want to see the world.’”
The chance that any or all of these factors could impact the supply of NPs and PAs in the coming years brings us back to Salsberg’s original point about creating a more effective health care team. Here, too, he says, research is needed. “I’m a very strong believer in expanding the use of NPs and PAs,” he says, “but I do believe that should really be driven by evidence. What kind of services does it make sense for someone with, say, six years of post–high school [education] to do, and what do you really need those 12 or 13 years of post–high school education for?”
Both Bednash and Hooker provide examples of how NPs and PAs already expand a practice’s capabilities. “You might have a cardiology practice with cardiologists providing the high-level, specialized care for patients with heart disease, and then have a team of NPs working with those physicians to oversee the other kinds of issues that patients have besides the cardiac ones,” Bednash says. “They are able to make sure that the care is very comprehensive and coordinated in a way that the other needs are not forgotten.”
Hooker describes a hypothetical urology clinic of four doctors who hire a PA. “The PA may say, ‘I’m a surgical PA’ but is never in the operating room,” he says. “He or she is taking care of the patients in the office. That either helps maintain continuity of care or tends to offload somewhat from primary care: ‘Oh, your blood pressure is up, let me get an ECG…. It looks like the ECG shows an ST depression. I think we’d better get you into your primary care doctor, but I’m going to start you on some antihypertensives today.’”
For Bednash, the larger issue involves “making sure that reasonable people in both disciplines [medicine and nursing] understand that there are tremendous access and care needs in this country that can only be met when physicians and nurses are allowed to practice to the highest level of their education, knowledge, and skills.
“To some extent, at some point, people are going to have to confront some of the biases about limiting scope of practice for NPs so they can do everything they are capable of doing,” she adds. “The old biases of some physicians have got to be laid to rest. The good news is, in a lot of places, they have been—but it needs to be more uniform.”
For his part, Salsberg agrees that mutual respect and understanding will be key. “We need to do more to prepare our practitioners, our physicians, to work in collaborative practice,” he says. “PAs, NPs, and physicians need to be educated and trained to work together, so that everyone coming out understands and respects the skills of all the other professions.”