Can Physician Assistants Save Primary Care?

If you set foot in the emergency department in Adirondack Medical Center in Saranac Lake, N.Y., you'll probably see a physician assistant.


As per state law, AMC is allowed to staff its emergency room with independently practicing physician assistants, which it does in abundance. At AMC, those PAs are allowed to practice like attending physicians.

"There's an extremely high level of functioning. In certain cases, an internist can even ask a PA to do a spinal tap. We're proud of that," says Anthony Dowidowicz, MD, medical director for emergency services at AMC. He oversees the emergency department's 12 physician assistants.

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Mary Rittle, manager of public relations at the National Commission on Certification of Physician Assistants, agrees that PAs can be a valuable asset. There are several certifications for PAs offered through the NCCPA, which helps PAs become educated in various medical specialties to increase their ability to provide increasingly complex care. "These are voluntary credentials, which show extra commitment and dedication," she says of PAs who decide to go that route.

Even with extra education, PAs seem to be a value-based choice for primary care provision. "As we look for less expensive solutions for healthcare, they're a natural choice," says Dr. Dowidowicz, referring to PA's lower reimbursement rates for insurers and federal health programs. "Depending on the skill level of a PA and their experience, you can entrust them with complicated patients. They play a great role in primary care."

While Dr. Dowidowicz says the physicians assistants at AMC do great work, as of yet they are more of an exception than a rule. Suggesting mid-level providers be entrusted with greater responsibilities tends to receive a lukewarm response. However, while some providers may prefer a physician-only approach, others advocate for a model in which physicians take on a metaphorical "air-traffic controller" role, directing lower-level providers toward patients in order to optimize the ability to handle patient volumes.

PAs are especially useful in rural areas, which tend to have lower concentrations of higher level providers. After all, according to one analysis, more than 20 percent of Americans already live in areas, most of them rural, that are short of primary care physicians.

However, according to Ms. Rittle, the tables are beginning to turn as the PA-supplemented model of primary care gains interest as a viable model for urban centers. In 2012 there were 86,700 PAs in the United States. By 2022, within the next decade, the U.S. Department of Labor estimates the number of PAs will be closer to 120,000. In contrast to that 38 percent increase in positions, the average job is only expected to grow between 10 and 11 percent within the decade.

Dr. Dowidowicz says more research is needed on just how many PAs can work under one physician and still provide safe care. "It's hard to give a number, but I think it's more than most people think," he says. Currently he supervises PAs based on their personal comfort zones. "We practice in a supervised fashion as long as they need. There's no prescriptive standard. They self-report when they're comfortable," he adds. In Dr. Dowidowicz's four years at AMC, this approach has proven safe.

Plus, he adds, when it comes to customer satisfaction rates at AMC, PAs have better statistics. "PAs blow physicians out of the water," he says. "Patients like PAs. They're more down to earth, and they connect more with patients, because they're trained in patient care and communication skills."

Despite rave reviews, physicians need not worry about job security. They may, however, have to worry about the changing face of what it means to be a physician. Dr. Dowidowicz predicts the role of the physician will change in a few ways. "It'll be more about designing treatment algorithms, the effects of which will be greatly magnified through the use of midlevel providers," he says.

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