wornts_ The Study of Physician Extenders in Primary Care
The increase in number and kinds of physician extenders in the delivery of primary medical care has led to studies of their roles, functions, and performance in various medical care settings. These studies assess the impact of physician extenders on the cost of health care delivery, examine the quality of their work, ascertain their acceptance by patients, and demonstrate their potential for solving certain health manpower problems. Physician extenders are called by such names as nurse practitioner, physician's assistant, MEDEX, and child health associate. In this article the following definition of physician extender is used: Any care giver (other than a physician) who obtains history or physical examination data which directly influence a decision regarding medical diagnosis, therapy, or disposition. Physician extenders can differ considerably in terms of their past training, experience, and formal credentials. In addition to collecting clinical data which directly influence medical decisions, a physician extender may also make those decisions on the basis of standards . . . agreed upon by the physician ultimately responsible for the patient's care [1].
Studies of physician extenders may be divided into two categories: (1) studies, conducted primarily by physicians and nurses, that emphasize how physician extenders are trained, describe how they perform in clinical settings, or compare their performance with that of physicians in providing certain kinds of care to certain groups of patients [2-141, and (2) studies conducted by operations researchers, systems analysts, management scientists, industrial engineers, and economists that focus on tasks performed by physician extenders, allocation of tasks between physicians and physician extenders, and allocation of tasks among different kinds of physician extenders [15-261. This article is directed to researchers in the second category. It analyzes the approaches they have taken thus far and suggests an alternative approach. Given the long tradition in economics and engineering of the use of task analysis and division of labor to increase productivity and the strong influence of these disciplines in operations research [27-35], it is not surprising that researchers in the second category rely on task analysis and division of labor in 6
Health Services Research
VIEWPOINTS
analyzing the use of physician extenders by physicians giving primary care. A primary care physician has been defined as one who: a) is the physician of first contact for the patient, b) makes the initial assessment and attempts to solve as many of the patient's problems as possible, c) coordinates the remainder of the health care team, including ancillary health personnel as well as consultants, d) provides continued contact with the patient, and often his family, e) acts as the patient's adviser and confidant, and f) assumes continued responsibility for his care [36].
Many studies of physician extenders proceed as follows: 1. Two lists are constructed: a list of technical tasks that a physician usually does in providing primary care and a list of different categories of physician extenders available to do these tasks. One group of researchers identified 263 such tasks [21,22], and another group specified 460 tasks [37]. A technical task may be defined as any task that has been well described and rationalized. For example, interviewing patients to collect historical data is a technical task if the questions to be asked are specified. Similarly, the performance of a particular portion of a physical examination is a technical task if the universe of possible findings is specified. Routine procedures such as drawing blood samples are technical tasks. The important point in the definition is the degree to which one can state in operational terms how to perform the task. Hence, any task that lends itself to written instructions for performance (i.e., a task for which an algorithm can be constructed) is a technical task. 2. The tasks that each category of physician extenders is permitted to do are specified, usually on the basis of kind and level of training. The result is often a hierarchy of competence among the care givers with, of course, the physician at the top. 3. Constraints and goals set by the environment and by the decision makers are stated. 4. Techniques such as linear programming or computer simulation are applied. Linear programming assigns physician extenders to tasks to achieve a goal subject to a set of constraints. (Minimization of the costs of using different categories of physician extenders to meet different levels of demand for different mixes of medical services is an example of a goal.) Computer simulation indicates a feasible way to meet patient care demands with alternative mixes of different kinds of care givers. The studies of Uyeno [23], Golladay and others [21,22], Pondy and his associates [17,20], and Schneider and Kilpatrick [26] are examples of the above approach. Other researchers have not broken down primary care into a set of tasks in their linear programming or computer simulation models [16,24]. In these models the ability of physician extenders to do certain tasks and not others is expressed as a percent of all patient visits that physician extenders are able to handle without physician consultation. Still other researchers have built linear programming and computer simulation models for health manpower planning that allow for the use of physician extenders and for allocation of tasks
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among care givers [15,25]. However, these models are stated in general and aggregative terms. Researchers have studied dentistry in much the same way that they have studied the practice of medicine. As in medicine, recent literature emphasizes problems of efficiency, cost, quality, and accessibility of dental care; discusses new categories of dentist extenders (e.g., expanded-function auxiliaries, expanded-duty dental assistants) developed in response to these problems; presents the results of case studies of the use of dentist extenders in dentists' offices; and demonstrates how analytical techniques such as computer simulation may be used to evaluate the impact of dentist extenders in solving these problems [18,19]. In all of these studies of physician extenders in primary care, by operations researchers, system analysts, management scientists, industrial engineers, and economists, a crucial assumption is made: that certain technical tasks cannot be performed by certain categories of physician extenders. This assumption is open to serious question because there is evidence that physician extenders are capable of performing all of the technical tasks encountered in giving primary care. For example, if all of the technical tasks actually done by physician extenders as reported in different studies were listed, the list would contain virtually all of the technical tasks performed by physicians. As shown in the studies previously cited, physician extenders do many of these tasks as well as or even better than physicians. Further, if no difference exists between physicians and physician extenders in the performance of technical tasks in primary care, then it is doubtful that there are differences in performance among categories of physician extenders. The differences that exist are related directly to whether a particular physician extender has been trained to perform a particular technical task. Once it is admitted that individual physician extenders can be trained to perform competently all of the technical tasks performed by physicians giving primary care, the rationale for operations research studies based on differences in ability of physicians and of different categories of physician extenders to perform those tasks ceases to exist. Other assumptions and aspects of the task approach used by operations researchers in their studies of physician extenders are also open to challenge. One such assumption is that there is a certain basic set of tasks that can be used to describe the activities of primary care givers. However, activities of persons in complex situations may be described in different ways in studies conducted for different purposes. Thus the belief that there is a single set of tasks in primary care that can be used in operations research studies conducted for different purposes is probably incorrect. For example, Massey and Whitehead [38], in a study of time spent by care givers in patient education, reported difficulty in using the list of tasks formulated by Golladay and others [21,22]. Another problem with the task approach is that it does not capture certain important aspects of the provision of primary care such as clinical judgment, patient education, level of patient understanding, and the triage function. For example, for new patients and for old patients with new complaints, who 8
Health Services Research
VIEWPOINTS
determines what is to be done and on what basis is this determination to be made? One reason for the omission of triage in many studies is that in an active private office practice much of this activity is carried out by telephone and thus is not easily analyzed in a time-and-motion study. Clinical judgment, patient education, and level of patient understanding are not included in studies based on the task approach because it is difficult to infer cognitive activity from observed behavior. Another aspect of operations research studies of the use of physician extenders that may be questioned is the way in which operations researchers use empirical data. Data on the activities of physicians and physician extenders are gathered in settings in which no attempt has been made to determine the quality or efficiency of the medical practice. If doctors' offices in which data are collected are not operating optimally, the output of linear programming routines using these data as input will not be optimal. Also, computer simulation studies may replicate unsatisfactory as well as satisfactory methods of practicing medicine. One further characteristic of operations research studies is that they do not recognize continued learning. In effect, the studies are cross-sectional analyses that take as given what physician extenders are able to do at a point in time or what physicians will let them do. They do not include the possibility that physician extenders can be trained to do other tasks than those observed. Many operations researchers are well aware of the limitations in their analytical studies. However, they feel that their studies of office and clinic practice help to determine the skills needed by physician extenders involved in giving primary care and that knowledge gained from these studies in turn influences the content of training programs for physician extenders. Perhaps even more important in their view is that these studies are helpful in dealing with physicians, administrators, and legislators whose understanding and cooperation are needed if the results of their research are to be implemented. That is, the studies are seen as providing a rational framework within which it is easier to deal with the politics of the change process. However, the belief that a rational, scientific approach to problem solving will overcome those aspects of resistance to change in individual and organizational behavior that heretofore have not been handled successfully by operations researchers remains to be demonstrated [39,40]. As pointed out earlier, operations researchers, economists, and engineers who take the task approach to the study of physician extenders in primary care make the crucial assumption that certain technical tasks cannot be performed by certain categories of physician extenders. If, however, they would recognize that physician extenders can be trained to perform all of the technical tasks involved in giving primary care, there would be several new areas for them to explore: 1. If physician extenders can perform all of the technical tasks in primary care, a physician is distinguished from a physician extender by the ability to integrate information from several sources in order to make a diagnosis (in
Spring 1975
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terms of the problem-oriented system [41-44], to formulate a problem list) and by the ability to make plans to treat the condition(s) diagnosed (in terms of the problem-oriented system, to resolve problems on the problem list). Both of these abilities involve skills that may be classified as managerial skills. If a physician uses physician extenders in his practice, then a third managerial skill is required-the ability to supervise effectively the work of others. If one accepts the argument that physicians are to be managers, different studies of the role, functions, and management of physician extenders are needed. 2. The view that physician extenders can do all of the technical tasks in primary care makes imperative the study of the generation and use of information in clinical decision making. The introduction of structure into the practice of medicine as exemplified by the problem-oriented system makes it much easier to assess the data needed and the care process and its outcome. If physician extenders obtain information as part of a problem-oriented system, the relationship of data collected to the resolution of patients' problems will have to be considered explicitly. In brief, operations researchers must incorporate more of the practice of medicine in their studies. 3. There is a need for studies that analyze how physician extenders should function in providing primary care and what the relationship should be between physicians and physician extenders in individual clinic or office settings. Overall, studies conducted in doctors' offices show great variability in how medicine is practiced with or without physician extenders. This variability strongly suggests that no single solution exists to the question of how physician extenders should be used in primary care settings. The organization and administration of such settings is still another area in need of study. 4. The design and evaluation of training programs for physician extenders is an important area of study. Good training programs are needed if physician extenders are to learn to perform competently a large number of primary care tasks. It has been shown that these technical tasks can be taught quickly [1, 8,11-14,45]. Of course, in order to retain competence, physician extenders must use their skills frequently. 5. There needs to be study of why physician extenders are kept from using their skills in certain settings. Some argue that present medical education, current financial incentives, and traditional patterns of behavior inhibit effective use of physician extenders in providing primary care [46]. With some exceptions, medical school curricula do not provide opportunities for medical students to learn to work with physician extenders in giving primary care. At a minimum, medical students should be required to work in clinical settings in which physician extenders are used effectively in the continuing care of patients. Another argument is that changes in medical education are not enough to change physician attitudes toward physician extenders. Present structure and traditions in medical practice have to change too. The impact of changes in the financing and delivery of medical care need to be considered in studies of the use of physician extenders. In summary, physician extenders are an important and growing group of
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Studies have shown that physician extenders can and in many a significant role in providing primary care. These studies have also demonstrated ways to study scientifically certain aspects of the practice of medicine. Acceptance of the view that physician extenders can perform all of the technical tasks involved in primary care generates interesting questions about the nature of medical practice and suggests alternative ways of studying health manpower problems involving physician extenders in the delivery of primary care. care givers.
settings do play
-David H. Stimson and Gerald Charles Veterans Administration Hospital (11C) 4150 Clement San Francisco, CA 94121 REFERENCES
1. Komaroff, A. L. and H. Sherman. Progress Report 11A, Ambulatory Care Project-1I, p. 7. Lincoln Laboratory, Massachusetts Institute of Technology, Lexington, MA, and Beth Israel Hospital, Harvard Medical School, Boston, 1974. 2. Lewis, C. E. and B. A. Resnik. Nurse clinics and progressive ambulatory patient care. New Eng. J. Med. 277:1236 Dec. 7, 1967. 3. Estes, E. H. and D. R. Howard. Potential for newer classes of personnel: Experiences of the Duke physician's assistant program. J. Med. Educ. 45:149 Mar. 1970. 4. Silver, H. and J. A. Hecker. The pediatric nurse practitioner and the child health associate. New types of health professionals. J. Med. Educ. 45:171 Mar. 1970. 5. Lave, J. R., L. B. Lave, and T. E. Morton. The physician's assistant-exploration of the concept. Hospitals, J.A.H.A. 45:43 June 1, 1971. 6. Smith, R. A., G. R. Bassett, C. A. Markerian, R. E. Vath, W. L. Freeman, and G. F. Dunn. A strategy for health manpower-reflections on an experience called MEDEX. JAMA 217:1362 Sept. 6, 1971. 7. Schulman, J. and C. Wood. Experience of a nurse practitioner in a general medical clinic. JAMA 219:1453 Mar. 13, 1972. 8. Sox, H. C., C. H. Sox, and R. K. Tompkins. The training of physician's assistantsthe use of a clinical algorithm system for patient care, audit of performance and education. New Eng. J. Med. 288:818 Apr. 19, 1973. 9. Spitzer, W. D., D. L. Sackett, J. C. Sibley, R. S. Roberts, M. Gent, D. J. Kergin, B. C. Hackett, and A. Olynich. The Burlington randomized trial of the nurse practitioner. New Eng. J. Med. 290:251 Jan. 31, 1974. 10. Taller, S. L. and R. Feldman. The training and utilization of nurse practitioners in adult health appraisal. Med. Care 12:40 Jan. 1974. 11. Komaroff, A. L., W. L. Black, M. Flatley, R. H. Knopp, B. Reiffen, and H. Sherman. Protocols for physician's assistants-management of diabetes and hypertension. New Eng. J. Med. 290:307 Feb. 7, 1974. 12. Greenfield, S., G. Friedland, S. Scifers, A. Rhodes, W. L. Black, and A. L. Komaroff. Protocol management of dysuria, urinary frequency, and vaginal discharge. Ann. Intern. Med. 81:452 Oct. 1974. 13. Charles, G., D. H. Stimson, M. D. Maurier, and J. C. Good. Physician's assistants and clinical algorithms in health care delivery. Ann. Intern. Med. 81:733 Dec. 1974. 14. Vickery, D. M., M. H. Liang, P. E Collis, K. T. Larsen, T. W. Morgan, E. D. Folland, and J. V. Mummert. Physician extenders in walk-in clinics. Arch. Intern. Med. 135: 720 May 1975. 15. Shuman, L. J., J. P. Young, and E. Naddor. Manpower mix for health services: A prescriptive regional planning model. Health Serv. Res. 6:103 Summer 1971. 16. McCormack, R. C. and C. W. Miller. The economic feasibility of rural group practice:
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17. 18. 19. 20. 21.
22. 23. 24.
25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44.
Influence of non-physician practitioners in primary care. Med. Care 10:73 Jan.-Feb. 1972. Pondy, L. R. Utilization and Productivity of the Duke Physician's Associate. Graduate School of Business Administration Paper No. 61, Duke University, Durham, NC, 1972. Dilworth, J. B. and W. J. Pelton. Computer simulation of a dental practice using therapists. J. Dent. Educ. 36:35 June 1972. Kilpatrick, K. E., R. S. Mackenzie, and A. G. Delaney. Expanded-function auxiliaries in general dentistry: A computer simulation. Health Serv. Res. 7:288 Winter 1972. Pondy, L. R., J. M. Jones, and J. A. Braun. Utilization and productivity of the Duke physician's associate. Socio-Econ. Plan. Sci. 7:327 June 1973. Golladay, F. L., K. R. Smith, and M. F. Hansen. Operations Manual: Documentation of an Observation Methodology for Study of Health Manpower Utilization in Ambulatory Care Practice. Health Economics Research Center Research Report Series. University of Wisconsin, Madison, 1973. Golladay, F. L., K. R. Smith, and M. Miller. Allied health manpower strategies: Estimates of the potential gains from efficient task delegation. Med. Care 11:457 Nov.Dec. 1973. Uyeno, D. H. Health manpower systems: An application of simulation to the design of primary health care teams. Mgmt. Sci. 20:981 Feb. 1974. Willemain, T. R. and G. T. Moore. Planning a medical practice using paramedical personnel. Health Serv. Res. 9:53 Spring 1974. Intriligator, M. D. and B. H. Kehrer. Allied health personnel in physicians' offices: An econometric approach. In M. Perlman (ed.), The Economics of Health and Medical Care, p. 442. New York: Wiley, 1974. Schneider, D. and K. E. Kilpatrick. An optimum manpower utilization model for health maintenance organizations. Op. Res. (In press.) Smith, A. An Inquiry into the Nature and Causes of the Wealth of Nations. London: Printed for W. Strahan and T. Cadell, 1776. Gilbreth, F. B. Primer of Scientific Management. New York: Van Nostrand, 1912. Taylor, F. W. The Principles of Scientific Management. New York: Harper, 1923. Dorfman, R. Application of Linear Programming to the Theory of the Firm. Berkeley: University of California Press, 1951. Koopmans, T. C. (ed.). Activity Analysis of Production and Allocation. New York: Wiley, 1951. Dorfman, R. Mathematical or "linear" programming: A non-mathematical exposition. Am. Econ. Rev. 43:797 Dec. 1953. Dorfman, R., P. A. Samuelson, and R. M. Solow. Linear Programming and Economic Analysis. New York: McGraw-Hill, 1958. Baumol, W. J. Activity analysis in one lesson. Am. Econ. Rev. 48:837 Dec. 1958. Rathe, A. W. (ed.). Gantt on Management. New York: American Management Association and American Society of Mechanical Engineers, 1961 Petersdorf, R. G. Issues in primary care: The academic perspective. In Association of American Medical Colleges (ed.), Proceedings of the Institute on Primary Care, pp. 5-16. Washington, DC: Association of American Medical Colleges, 1974. Jacobs, A. R., K. G. Johnson, P. Breer, and E. C. Nelson. Comparison of tasks and activities in physician-Medex practices. Pub. Health Rep. 89:339 July-Aug. 1974. Massey, L. D. and S. F. Whitehead. Measurement of Time Spent Educating Patients in a Physician's Office. Cambridge, MA: Bolt Beranek and Newman, 1974. Stimson, D. H. and R. H. Stimson. Operations Research in Hospitals: Diagnosis and Prognosis. Chicago: Hospital Research and Educational Trust, 1972. Willemain, T. R. Brandeis conference on paramedical personnel. Health Serv. Res. 9:159 Summer 1974. Weed, L. L. Medical Records, Medical Education, and Patient Care. Cleveland, OH: Case Western Reserve University Press, 1969. Bjom, J. C. and H. D. Cross. The Problem-Oriented Private Practice of Medicine. Chicago: Modem Hospital Press, 1970. Hurst, J. W. and H. K. Walker (eds.). The Problem-Oriented System. New York: Medcom, 1972. Hurst, J. W., H. K. Walker, and M. F. Woody (eds.). Applying the Problem-Oriented System. New York: Medcom, 1973.
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45. Andrews, P., A. Yankauer, and J. P. Connelly. Changing the patterns of ambulatory pediatric caretaking: An action-oriented training program for nurses. Am. J. Pub. Health 60:870 May 1970. 46. Bicknell, W. J., D. C. Walsh, and M. M. Tanner. Substantial or decorative? Physician's assistants and nurse practitioners in the United States. Lancet 7891:1241 Nov. 23, 1974.
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The increase in number and kinds of physician extenders in the delivery of primary medical care has led to studies of their roles, functions, and performance in various medical care settings. These studies assess the impact of physician extenders on the cost of health care delivery, examine the quality of their work, ascertain their acceptance by patients, and demonstrate their potential for solving certain health manpower problems. Physician extenders are called by such names as nurse practitioner, physician's assistant, MEDEX, and child health associate. In this article the following definition of physician extender is used: Any care giver (other than a physician) who obtains history or physical examination data which directly influence a decision regarding medical diagnosis, therapy, or disposition. Physician extenders can differ considerably in terms of their past training, experience, and formal credentials. In addition to collecting clinical data which directly influence medical decisions, a physician extender may also make those decisions on the basis of standards . . . agreed upon by the physician ultimately responsible for the patient's care [1].
Studies of physician extenders may be divided into two categories: (1) studies, conducted primarily by physicians and nurses, that emphasize how physician extenders are trained, describe how they perform in clinical settings, or compare their performance with that of physicians in providing certain kinds of care to certain groups of patients [2-141, and (2) studies conducted by operations researchers, systems analysts, management scientists, industrial engineers, and economists that focus on tasks performed by physician extenders, allocation of tasks between physicians and physician extenders, and allocation of tasks among different kinds of physician extenders [15-261. This article is directed to researchers in the second category. It analyzes the approaches they have taken thus far and suggests an alternative approach. Given the long tradition in economics and engineering of the use of task analysis and division of labor to increase productivity and the strong influence of these disciplines in operations research [27-35], it is not surprising that researchers in the second category rely on task analysis and division of labor in 6
Health Services Research
VIEWPOINTS
analyzing the use of physician extenders by physicians giving primary care. A primary care physician has been defined as one who: a) is the physician of first contact for the patient, b) makes the initial assessment and attempts to solve as many of the patient's problems as possible, c) coordinates the remainder of the health care team, including ancillary health personnel as well as consultants, d) provides continued contact with the patient, and often his family, e) acts as the patient's adviser and confidant, and f) assumes continued responsibility for his care [36].
Many studies of physician extenders proceed as follows: 1. Two lists are constructed: a list of technical tasks that a physician usually does in providing primary care and a list of different categories of physician extenders available to do these tasks. One group of researchers identified 263 such tasks [21,22], and another group specified 460 tasks [37]. A technical task may be defined as any task that has been well described and rationalized. For example, interviewing patients to collect historical data is a technical task if the questions to be asked are specified. Similarly, the performance of a particular portion of a physical examination is a technical task if the universe of possible findings is specified. Routine procedures such as drawing blood samples are technical tasks. The important point in the definition is the degree to which one can state in operational terms how to perform the task. Hence, any task that lends itself to written instructions for performance (i.e., a task for which an algorithm can be constructed) is a technical task. 2. The tasks that each category of physician extenders is permitted to do are specified, usually on the basis of kind and level of training. The result is often a hierarchy of competence among the care givers with, of course, the physician at the top. 3. Constraints and goals set by the environment and by the decision makers are stated. 4. Techniques such as linear programming or computer simulation are applied. Linear programming assigns physician extenders to tasks to achieve a goal subject to a set of constraints. (Minimization of the costs of using different categories of physician extenders to meet different levels of demand for different mixes of medical services is an example of a goal.) Computer simulation indicates a feasible way to meet patient care demands with alternative mixes of different kinds of care givers. The studies of Uyeno [23], Golladay and others [21,22], Pondy and his associates [17,20], and Schneider and Kilpatrick [26] are examples of the above approach. Other researchers have not broken down primary care into a set of tasks in their linear programming or computer simulation models [16,24]. In these models the ability of physician extenders to do certain tasks and not others is expressed as a percent of all patient visits that physician extenders are able to handle without physician consultation. Still other researchers have built linear programming and computer simulation models for health manpower planning that allow for the use of physician extenders and for allocation of tasks
Spring 1975
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Stimson & Charles
among care givers [15,25]. However, these models are stated in general and aggregative terms. Researchers have studied dentistry in much the same way that they have studied the practice of medicine. As in medicine, recent literature emphasizes problems of efficiency, cost, quality, and accessibility of dental care; discusses new categories of dentist extenders (e.g., expanded-function auxiliaries, expanded-duty dental assistants) developed in response to these problems; presents the results of case studies of the use of dentist extenders in dentists' offices; and demonstrates how analytical techniques such as computer simulation may be used to evaluate the impact of dentist extenders in solving these problems [18,19]. In all of these studies of physician extenders in primary care, by operations researchers, system analysts, management scientists, industrial engineers, and economists, a crucial assumption is made: that certain technical tasks cannot be performed by certain categories of physician extenders. This assumption is open to serious question because there is evidence that physician extenders are capable of performing all of the technical tasks encountered in giving primary care. For example, if all of the technical tasks actually done by physician extenders as reported in different studies were listed, the list would contain virtually all of the technical tasks performed by physicians. As shown in the studies previously cited, physician extenders do many of these tasks as well as or even better than physicians. Further, if no difference exists between physicians and physician extenders in the performance of technical tasks in primary care, then it is doubtful that there are differences in performance among categories of physician extenders. The differences that exist are related directly to whether a particular physician extender has been trained to perform a particular technical task. Once it is admitted that individual physician extenders can be trained to perform competently all of the technical tasks performed by physicians giving primary care, the rationale for operations research studies based on differences in ability of physicians and of different categories of physician extenders to perform those tasks ceases to exist. Other assumptions and aspects of the task approach used by operations researchers in their studies of physician extenders are also open to challenge. One such assumption is that there is a certain basic set of tasks that can be used to describe the activities of primary care givers. However, activities of persons in complex situations may be described in different ways in studies conducted for different purposes. Thus the belief that there is a single set of tasks in primary care that can be used in operations research studies conducted for different purposes is probably incorrect. For example, Massey and Whitehead [38], in a study of time spent by care givers in patient education, reported difficulty in using the list of tasks formulated by Golladay and others [21,22]. Another problem with the task approach is that it does not capture certain important aspects of the provision of primary care such as clinical judgment, patient education, level of patient understanding, and the triage function. For example, for new patients and for old patients with new complaints, who 8
Health Services Research
VIEWPOINTS
determines what is to be done and on what basis is this determination to be made? One reason for the omission of triage in many studies is that in an active private office practice much of this activity is carried out by telephone and thus is not easily analyzed in a time-and-motion study. Clinical judgment, patient education, and level of patient understanding are not included in studies based on the task approach because it is difficult to infer cognitive activity from observed behavior. Another aspect of operations research studies of the use of physician extenders that may be questioned is the way in which operations researchers use empirical data. Data on the activities of physicians and physician extenders are gathered in settings in which no attempt has been made to determine the quality or efficiency of the medical practice. If doctors' offices in which data are collected are not operating optimally, the output of linear programming routines using these data as input will not be optimal. Also, computer simulation studies may replicate unsatisfactory as well as satisfactory methods of practicing medicine. One further characteristic of operations research studies is that they do not recognize continued learning. In effect, the studies are cross-sectional analyses that take as given what physician extenders are able to do at a point in time or what physicians will let them do. They do not include the possibility that physician extenders can be trained to do other tasks than those observed. Many operations researchers are well aware of the limitations in their analytical studies. However, they feel that their studies of office and clinic practice help to determine the skills needed by physician extenders involved in giving primary care and that knowledge gained from these studies in turn influences the content of training programs for physician extenders. Perhaps even more important in their view is that these studies are helpful in dealing with physicians, administrators, and legislators whose understanding and cooperation are needed if the results of their research are to be implemented. That is, the studies are seen as providing a rational framework within which it is easier to deal with the politics of the change process. However, the belief that a rational, scientific approach to problem solving will overcome those aspects of resistance to change in individual and organizational behavior that heretofore have not been handled successfully by operations researchers remains to be demonstrated [39,40]. As pointed out earlier, operations researchers, economists, and engineers who take the task approach to the study of physician extenders in primary care make the crucial assumption that certain technical tasks cannot be performed by certain categories of physician extenders. If, however, they would recognize that physician extenders can be trained to perform all of the technical tasks involved in giving primary care, there would be several new areas for them to explore: 1. If physician extenders can perform all of the technical tasks in primary care, a physician is distinguished from a physician extender by the ability to integrate information from several sources in order to make a diagnosis (in
Spring 1975
9
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terms of the problem-oriented system [41-44], to formulate a problem list) and by the ability to make plans to treat the condition(s) diagnosed (in terms of the problem-oriented system, to resolve problems on the problem list). Both of these abilities involve skills that may be classified as managerial skills. If a physician uses physician extenders in his practice, then a third managerial skill is required-the ability to supervise effectively the work of others. If one accepts the argument that physicians are to be managers, different studies of the role, functions, and management of physician extenders are needed. 2. The view that physician extenders can do all of the technical tasks in primary care makes imperative the study of the generation and use of information in clinical decision making. The introduction of structure into the practice of medicine as exemplified by the problem-oriented system makes it much easier to assess the data needed and the care process and its outcome. If physician extenders obtain information as part of a problem-oriented system, the relationship of data collected to the resolution of patients' problems will have to be considered explicitly. In brief, operations researchers must incorporate more of the practice of medicine in their studies. 3. There is a need for studies that analyze how physician extenders should function in providing primary care and what the relationship should be between physicians and physician extenders in individual clinic or office settings. Overall, studies conducted in doctors' offices show great variability in how medicine is practiced with or without physician extenders. This variability strongly suggests that no single solution exists to the question of how physician extenders should be used in primary care settings. The organization and administration of such settings is still another area in need of study. 4. The design and evaluation of training programs for physician extenders is an important area of study. Good training programs are needed if physician extenders are to learn to perform competently a large number of primary care tasks. It has been shown that these technical tasks can be taught quickly [1, 8,11-14,45]. Of course, in order to retain competence, physician extenders must use their skills frequently. 5. There needs to be study of why physician extenders are kept from using their skills in certain settings. Some argue that present medical education, current financial incentives, and traditional patterns of behavior inhibit effective use of physician extenders in providing primary care [46]. With some exceptions, medical school curricula do not provide opportunities for medical students to learn to work with physician extenders in giving primary care. At a minimum, medical students should be required to work in clinical settings in which physician extenders are used effectively in the continuing care of patients. Another argument is that changes in medical education are not enough to change physician attitudes toward physician extenders. Present structure and traditions in medical practice have to change too. The impact of changes in the financing and delivery of medical care need to be considered in studies of the use of physician extenders. In summary, physician extenders are an important and growing group of
10
Health Services Research
VIEWPOINTS
Studies have shown that physician extenders can and in many a significant role in providing primary care. These studies have also demonstrated ways to study scientifically certain aspects of the practice of medicine. Acceptance of the view that physician extenders can perform all of the technical tasks involved in primary care generates interesting questions about the nature of medical practice and suggests alternative ways of studying health manpower problems involving physician extenders in the delivery of primary care. care givers.
settings do play
-David H. Stimson and Gerald Charles Veterans Administration Hospital (11C) 4150 Clement San Francisco, CA 94121 REFERENCES
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VIEWPOINTS
45. Andrews, P., A. Yankauer, and J. P. Connelly. Changing the patterns of ambulatory pediatric caretaking: An action-oriented training program for nurses. Am. J. Pub. Health 60:870 May 1970. 46. Bicknell, W. J., D. C. Walsh, and M. M. Tanner. Substantial or decorative? Physician's assistants and nurse practitioners in the United States. Lancet 7891:1241 Nov. 23, 1974.
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