NURSE PRACTITIONERS and PHYSICIAN ASSISTANTS–THE FUTURE OF MEDICINE
In 1963, as a neurosurgeon on the faculty at Western Reserve Medical School, I became aware that Internists were not significantly interested in caring for the medical problems in my neurosurgical patients. Internists did not give my patients with diabetes, hypertension and other major medical problems the careful attention I expected. Indeed, throughout my clinical experience as a neurosurgeon, I was often discouraged that Internists did not want to take responsibility for the medical problems in a patient with neurological disorders. Somewhere in the hierarchical development of specialization, where organ/disease specialists replaced the general physician, it seemed that specialists were supposed to take care of their designated organ of choice and other specialists were supposed to become part of the team for total patient management. Indeed, I often had patients admitted to my care when they had had a minor head injury but much more serious other injuries, such as a ruptured spleen, fractured leg, contused lung, etc. Surgeons took out the spleen; orthopedists nailed the fractured leg; and I was expected to be the primary physician because of the head injury.
Although I interned in Internal Medicine and had a year of General Surgery before entering Neurosurgery, neurosurgical patients with major diseases, such as brain tumors, aneurysms, etc require considerable attention by the neurosurgeon. With frequent emergencies requiring that I go o the operating room, I learned that I needed a nurse to help manage the day to day medical needs of my patients. After leaving Western Reserve, I always had my own nurse to assist with these essential medical problems. By 1966, I was convinced that good nurses were the backbone of Medicine! Then along came Nurse Practitioners and Physician Assistants. I have been blessed to work with several outstanding Nurse Practitioners. I believe they can serve well 90+% of all patient problems not requiring super-special needs like surgery.
A recent study compared the quality of care delivered to HIV patients by Nurse Practitioners, Physicians and Physician Assistants (Ann. Int. Med., 2005: 143: 729-736.) The results are striking! NP's and PA's performed AS WELL AS or BETTER than physicians on all 8 measures analyzed! Indeed on 6 of the measures NP's and PA's performed better than physicians without specific expertise and as well as those with expertise! On no measure were the NP's or PA's inferior.
In some states both Nurse Practitioners and Physician Assistants can practice independently. In most states they must have official ''supervision'' by a physician. Target, Wal-Mart and CVS Pharmacies are beginning to establish in-store facilities for patients to receive ''walk-in'' acute care. They will essentially take over the Doc in a Box type facility and may begin to decrease visits to hospital emergency wards. The future is beginning to be obvious—I predict that sometime in the next 50 years, Nurse Practitioners and Physician Assistants will become the mainstay of patient care. I pray that they do not lose their attention to detail which often surpasses that of physicians—and that they do not become the pawns of the PharmacoMafia, as have so many physicians. If 85% of all illnesses are the result of unhealthy lifestyle, NP's and PA's have the opportunity to practice REAL medicine—education and prevention. The principles of Integrative, Complementary and Alternative Medicine are essentials for quality care.
The challenge for America, where 16% of Gross National Product is spent on medical care, is to improve the quality of health. In 1964, the cost of medical care was only 4.5% of GNP. Health has not improved significantly while cost of medical care has exploded almost four-fold. The Medical DEBT load in the US far exceeds every other country in the world but health here is grossly inferior. The American Public Health Association reports a ''sickly rate of improvement'' in health in the U.S. In comparison to other nations, the U.S. ranks number 13th in infant mortality, behind even the Czech Republic and Cuba! The U.S. is number 29 in healthy life expectancy. The PharmacoMafia will not improve health. Indeed well over 100,000 people die each year because of prescription drugs. We can hope that Nurse Practitioners and Physician Assistants will stem the red ink tide, the essential hemorrhaging of the current American Medical System.