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The Nonphysician Will See You Now

More Americans seek health care from multiple sources

WEDNESDAY, Jan. 8, 2003 (HealthDayNews) -- In the 1990s, the rise of HMOs stoked fears that getting an appointment with a doctor would go the way of house calls -- a luxury not possible in a cost-conscious world.

Instead, doctors' groups warned, we'd be forced to seek treatment from lesser-trained nurse practitioners and physician assistants.

However, a new study finds those fears haven't come to pass. In fact, Americans are going to see more health-care providers of all types.

Between 1987 and 1997, the percentage of patients in the United States who visited nonphysician clinicians rose from 30 percent to 36 percent, says the study. Nonphysician clinicians include nurses, nurse practitioners, chiropractors, midwives, psychologists, social workers, physical or occupational therapists, podiatrists and optometrists. Their training is less rigorous, and they are likelier to face more regulation -- for instance, in prescribing drugs or performing invasive procedures-- than physicians.

That doesn't mean U.S. residents are seeing nonphysician clinicians instead of seeing a doctor with the more traditional education that led to an M.D.

Instead, patients increasingly sought care from both physicians and nonphysicians. Patients who saw both rose from 23.5 percent to 30.9 percent during the decade. And the percentage of people who saw only a nonphysician clinician actually declined, from 7.2 percent to 5.3 percent.

"These findings show how the health workforce has evolved during a time of great change in the U.S. health system," says Dr. Benjamin Druss, an associate professor of public health and psychiatry at Emory University in Atlanta. "Patients are increasingly treated by multiple providers who have a range of training and philosophical approaches to treatment."

The study appears in tomorrow's issue of The New England Journal of Medicine.

At the beginning of the 20th century, physicians accounted for about one in three health-care workers, according to an editorial in the same issue. By the early 1980s, that number had fallen to one in 16.

The dramatic increase in nonphysician clinicians, combined with the "corporatization" of health care that came with HMOs, was seen by some physicians as a threat to their livelihood, says Linda Aiken, author of the editorial and a professor of nursing and director of the Center for Health Policy Outcomes at the University of Pennsylvania.

The new research should be seen as good news for everyone, she says.

"It provides some very compelling evidence that many of the fears of providers and some consumers about the substitution of nonphysician clinicians for physicians were not borne out," Aiken says. "A natural balance seems to be developing, with consumers going to see nonphysician clinicians and retaining their physicians."

The change reflects the greater acceptance of nonphysician clinicians by both patients and physicians, Aiken says.

"The shift couldn't have happened without physician referrals," she says, "which probably reflects a greater recognition by physicians that nonphysician clinicians make an important contribution to health care."

The fact that more people are seeing varied health providers also reflects societal changes. Patients have increased their knowledge about health conditions, in part because of the Internet and other news sources willing to provide the information. The expansion of health insurance and greater disposable income is another reason. Still another factor is the shift in the burden of illness from acute to chronic conditions in an aging population, Aiken says.

As a result, patients seek help from medical professionals for a much wider range of problems. In the past, you might only see a doctor when you were sick, she explains. Now, Americans might seek help for everything from smoking cessation to depression to caring for the elderly to managing diabetes to child development issues.

"These things came to be defined as medical issues and nonphysician clinicians responded to that demand," Aiken says.

The study uses data from two national surveys of more than 40,000 adults interviewed in 1987 and 1997. It was a time of rapid change in the health-care system, Druss says. Examples include: more nonphysician clinicians graduating from training programs; new state laws giving nonphysicians greater autonomy; and the rise of powerful managed-care organizations.

"There had been a prediction that the increase in numbers of nonphysician clinicians and laws allowing them to practice autonomously would create a great deal of conflict with physicians," Druss says. "Physicians worried that it would put primary-care physicians out of work. We really didn't find that."

In fact, fewer nonphysician clinicians practiced independently between 1987 and 1999. It's more common now for physicians and nonphysician clinicians to share a facility, Druss says.

Part of this could be attributed to managed care.

"At its worst, managed care is designed to cut costs," he says. "At its best, it can provide a broader system of care that allows a greater collaboration of care."

What To Do

Find out more about nurse practitioners at the American College of Nurse Practitioners. The American Academy of Physician Assistants has more information about physician assistants.

SOURCES: Benjamin Druss, M.D., M.P.H., associate professor, public health and psychiatry, Emory University, Atlanta; Linda Aiken, Ph.D., R.N., professor, nursing, and director, Center for Health Policy Outcomes, University of Pennsylvania, Philadelphia; Jan. 9, 2003, The New England Journal of Medicine
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