In 1965, two revolutionary events occurred in Colorado and North Carolina. In Colorado, Dr. Loretta Ford and Dr. Henry Silver developed the first teaching program for nurse practitioners (NPs). In North Carolina, Dr. Eugene A Stead, Jr. saw an opportunity to train former navy corpsmen to be physician assistants (PAs).
Both no doubt saw an increasing need for health care providers and an inadequate number of physicians. The newly trained professionals were seen as “physician extenders” who could relieve the load from overworked physicians and improve the care of largely underserved patients. It is doubtful either could have foreseen the growth in the numbers of NPs and PAs and the range that advanced practitioners (APs) have experienced.
Today, “extenders” is a pejorative term. APs are found in every specialty from the surgery suite to the delivery room to the hospital ward to the clinic and to the home.
What is the future for APs and in particular, nephrology APs?
Kidney care a tough sell
The future for nephrologists is grim. According to Eric L. Wallace, MD, University of Alabama at Birmingham (UAB), while the number of patients with chronic kidney disease seems to have plateaued, the number of medical residents, both U.S. and international, is declining. This is a dire prediction for the care of a complex population requiring specialized care. The numbers speak for themselves. According to Dan Balkovetz, MD, at the UAB, there are 145 certified programs for nephrology in the U.S. and in 2013, 81 filled all their slots (56%) and 64 (41%) had unfilled positions. For the 403 available slots, there were 380 applicants (see Table 1).
Every nephrologist surveyed cited the shrinking number of future applicants as a concern and looked to the growing number of APs as an important part of their future. Michael Allon, MD, from the UAB, terms the future as the “golden age for APs” and looks for them practicing with more autonomy to meet growing needs.
Seventeen states and the District of Columbia allow nurse practitioners to practice independently and several more are considering the move. While this applies to the general practice and not a specialty, it indicates a trend that we might see in the future. Harvey Feldman, MD, Nova Southeastern University, predicts that in the next 5-10 years, PAs will also have this privilege. Wallace foresees the day APs are directors of dialysis units.
The influence of the MCP
Over the last 10-15 years there has been an influx of APs into nephrology. This move is due in part to CMS’s 2004 decision to “reimburse nephrology practices for four dialysis visits.” Three of these visits can be made by an AP. However, APs have proven their value far beyond dialysis rounds and are increasingly taking on more responsibilities.
Beth Piraino, MD, from the University of Pittsburgh, describes APs as a “God-send.” Having practiced both with and without APs, she finds having another nephrology professional on her staff frees her up to function as a team leader for fellows, residents, and medical students and to focus on more complex cases.
Becoming a nephrology practitioner is no easy task. It poses a steep learning curve and it takes approximately six months before an AP is able to work independently. In the meantime, the practitioners hone their skills not only in nephrology but also endocrinology, internal medicine, psychology, nutrition, and pharmacology. The APs become proficient not only in managing the complexities of dialysis care and the CKD patient, but also learn to coordinate care between the clinic, vascular surgeon, primary care provider, interventionalist, transplant and families. The AP often develops a close relationship with the patient and in many cases their families. They in turn look to the AP for advice and support.
Reamer Bushardt, PA-C, from Wake Forest University and editor of the Journal of the American Association of Physician Assistants, also sees a bright future for APs, particuarly in the CKD clinic where the goals are education and delaying disease progression. The same skills that Dr. Feldman listed for the dialysis practitioner will come into play here. With more people seeking health care and more people diagnosed with CKD, there will be a growing demand for a generalist with a nephrology specialization.
From a practical viewpoint, Bushardt points out that the CKD population is aging even as budgets are shrinking. APs offer a cost effective means of providing care.
Dr. Wallace sees an exciting prospect for medicine—telemedicine. Currently, in some parts of the country, providers spend a significant portion of their time traveling between dialysis units. Legislation, such as the Telemedicine Enhancement Act would allow instant consultation between a clinic and a provider. The AP could serve as a consultant and would be able to offer more timely intervention for a patient issue.
While some welcome the inclusion of APs into the nephrology provider circle, others are not so sure. They see turning more responsibility over to a non-physician as a threat to compromised patient care. However, physicians who have worked with APs do not share this concern.
So why do APs choose nephrology? There are as many answers as there are APs. A survey of approximately 300 nephrology practitioners revealed a number of reasons. Of prime importance is the flexibility. Because dialysis rounds are a large part of most APs work responsibilities, they have the ability to adjust their schedules. Others are attracted by the independence. The challenge of caring for patients with multiple medical and social issues attracts others. 1 Dr. Feldman pointed out that for most patients, CKD is a result of something else, most commonly hypertension or diabetes but also lupus, inherited conditions and a host of other causes.
Cassie Brown, PA-C, has been a nephrology practitioner since 1988 and she has been in a perfect position to watch the opportunities for nephrology APs grow. She says she values her independence but also her close working relationship with her nephrology physicians.
Often, APs are grouped together as though nurse practitioners and physician assistants are interchangeable. In some respects this is true. Both can perform the same duties and fill the same roles. While it is important for the two groups to work together and not against each other, it is just as important for each to maintain its separate identity and not risk being placed together in a category of non-physician providers. Bushardt points to the generalist training of PAs and the perspective that brings to complement patient care. NPs, on the other hand, have a more holistic training. The health care system, in his opinion, needs both what the PA and the NP can bring to provide safe, cost effective patient care. He states the diversity and unique brands of both professions should be preserved and validated.
So the future for APs in nephrology? It is bright and at this point, still wide open. Over the last 10 years, the AP has gone from being a novelty in a physician practice to an accepted member of the health care team.
Davis J, Zuber K. The role of advanced nurse practitioners in nephrology. Dialysis and Transplantation. 2009; 38(12): 488-491.