Physician Extenders in Hospital Medicine

To use or not to use, that is the dilemma being faced by a lot of hospitalist programs when it comes to employing “physician extenders” in hospital medicine. The ever increasing demand in the field of hospital medicine and static supply resulted in the classic answer expected by a market in any trade: tap into alternate resources. Since their inception in the mid sixties, Nurse Practitioners (NPs) and Physician Assistants (PAs) are extensively used in outpatient practices across the country. But because of the nature of higher acuity of illness and complex life-threatening illnesses, the deployment of physician extenders in hospital medicine has been slow and reluctant. So far, the Society of Hospital Medicine has encouraged their supervised use, but there are presentations and panel discussions in the pipeline for the 2009 annual meeting on this issue as well.

Just to review their history, Drs. Loretta Ford and Henry Silver developed the first NP program at the University of Colorado in 1965. Mostly, these were registered nurses, until Boston College initiated a Masters program for Nurse Practitioners in 1967. Now, NPs have their own association, peer reviewed journals, a fellowship program and a national certification started in 1974. According to the American Association of Nurse Practitioners, there were 10,600 NPs by 2005. Physician Assistants came around the same time as well. Dr Eugene Stead of Duke University in North Carolina put together the first class of PAs in 1965, relying on navy corpsmen as his first class recruits. They received considerable medical training during the Vietnam War, when they were enrolled in the first batch, given formal training according to the newly established curriculum, and given PA certificates. There are presently 68,124 PAs across the country. Like physicians, both NP and PA licenses are awarded by state education departments and thus, their scope of practice and degree of independence varies from state to state.

I have taught both NP and PA students. I have also worked with both PAs and NPs in out-patient as well as hospitalist settings, and have found that physician extenders can be very useful team members in a hospitalist program. In our practice setting, we restricted their use to non-ICU patients and did not use them as the initial provider for new consults or new admissions. With their nursing background, NPs in particular have the “niche” when it comes to care, passion, patience and perseverance when dealing with chronically ill but stable patients. We have seen a dramatic rise in physician extender utilization in our organization. I know programs where extenders are used as first on for emergency rooms as well, with equal efficacy. Remember, the whole premise of starting physician extender programs was a physician shortage, and more importantly, their unequal distribution between urban and rural settings. We are facing the same work force shortage in our specialty today, and extenders can be a reliable and tested solution. Perhaps the next step is for SHM to coordinate a short refresher course or certification of extenders who want to specialize in hospitalist medicine.