With heavier patient loads than ever and a physician shortage looming, the demand for physician extenders is increasing. Nurse practitioners and physician assistants are doing more than just filling the gap-they're adding tremendous value to the medical team. Expect continued changes as new laws pass to address the roles and responsibilities of physician extenders.

Oncologist Linda Bosserman, MD, and nurse practitioner Traci Young are a well-oiled medical machine. Young assists Dr. Bosserman daily with medical histories, patient exams and follow-up visits at Wilshire Oncology Medical Group Inc. The pair utilizes the medical team approach to care for hundreds of oncology patients in the group's Pomona and Rancho Cucamonga locations.

"Without Traci, patients experience longer wait times, and I am plagued with mounting emergency visits and mounting phone calls," says Dr. Bosserman, president and managing partner of Wilshire Oncology Medical Group. "With Traci, I treat twice the amount of patients, get emergency visits in faster and patients receive much more personal attention."

Relationships like the one between Dr. Bosserman and Young are a growing trend in medicine, where physicians rely on other health professionals to extend their abilities to serve increasing numbers of patients. These physician extenders are typically nurse practitioners (NPs) and physician assistants (PAs), but may include certified nurse midwives and other allied healthcare professionals as well. Physician extenders often work in primary care settings, such as family medicine, internal medicine, pediatrics, and obstetrics and gynecology. However, they are also found in emergency medicine, oncology, dermatology and surgical specialties, too.

"With the current and future primary care physician shortage, the demand for physician extenders is expected to increase," says Ronald Bangasser, MD, director of external affairs at Beaver Medical Group in Redlands, a multispecialty practice that utilizes PAs. "It's a way physicians can create extensions of themselves who can take care of patients and get things done in the medical practice. Extenders do very many of the things that physicians do, and they expand what our primary care capabilities would be otherwise."

Power of a Nurse Practitioner
As owner of Wilshire Oncology, Dr. Bosserman struggles to keep her medical practice afloat financially. Because of decreasing reimbursement, she must see 16 patients a day to stay in business. And she can't afford to hire another physician because the money isn't there.

"The Medicare Modernization Act of 2003 has cut so much [reimbursement] out of oncology--four to five times more than the Senate projected," Dr. Bosserman says. "In 2006, 400 oncologists retired and only 180 came into medical practice. Physicians aren't entering the field of oncology anymore."

So Dr. Bosserman works with Young, who provides patient care at a substantially lower salary than a physician. However, Young's medical expertise and training are well above average. She is a registered nurse and possesses a UCLA master's degree in nursing with an oncology nurse practitioner certification.

In California, an NP cannot practice independently without a collaborating or supervising physician. The scope of practice for an NP is determined by a document called standardized procedures, which is developed by the medical practice where he or she will work. State law requires physician supervision for the purposes of prescriptive authority only. The physician is not required to be on-site, but simply available through phone or electronic means.

"If I am with another patient or working on another project, Traci can examine my patients, review their treatment plans, collect data and answer questions about medications," Dr. Bosserman says. "In my opinion, she can do everything that a physician does except for determine an oncology treatment plan. Once the plan is determined, she oversees it, implements it, manages the side effects and maintains the quality of life of the patient. Traci helps the patients with emotional and long-term survival issues."

Young also brings compassionate, patient-centered care to the medical practice, which capitalizes on her specialized nursing training. "Traci does a super job at educating patients and answering questions about their cancer diagnoses," Dr. Bosserman says. "She is very in tune with their emotions, quality of life and symptom management, which is essential in oncology. We can't handle the complexity of what we're doing without a team. And each of us is important in contributing to the patient's care."

"I take a lot of stress off of Dr. Bosserman," Young says. "In oncology, there are always new treatments, new research and new data developing. In order for her to stay up to date and on the cutting edge of cancer care, she must be free to attend CME events and meetings on clinical trials. When this happens, she is ultimately able to provide better care."

Physician Assistant Partner
Michael Koshak, MD, finds it difficult to get through a typical day without physician assistant Larry Rosen. As medical director of Noble Community Medical Associates Choice Providers in Reseda, Dr. Koshak manages eight clinics in cities from Granada Hills to North Hollywood and supervises three convalescent homes. With such a busy practice, Rosen's assistance is crucial.

"Larry and I have very good communication and we really respect each other," Dr. Koshak says. "He knows his capabilities and his limitations. He is very versatile: He sees adults, children, seniors and workers' compensation patients. I am in the office most of the time, but sometimes I go to meetings or visit nursing homes, and he is just a phone call away."

PAs must practice under the supervision of an active licensed physician. When their relationship was first formed, Dr. Koshak and Rosen signed a delegation of services agreement outlining the duties that fall into Rosen's scope of practice.

"Since Wednesday is the day Dr. Koshak visits the convalescent homes, I run the clinic," says Rosen, who completed his PA program at the Keck School of Medicine of USC. "I saw 30 of his patients this morning. We share information about patients, I see and read his chart notes, his patients know who I am, and they are very comfortable with me. Rather than patients waiting a few days for appointments, I can see them right away."

Although Dr. Koshak is very satisfied with Rosen's work, he knows that relationships between doctors and physician extenders aren't always rosy. If a physician extender does not communicate with the supervising physician or ask for help when he needs it, healthcare and patient safety can be severely compromised.

"If physician extenders participate in any activities that are outside of the delegation of services agreement or outside of their scope, patient conditions can be undiagnosed or misdiagnosed," Dr. Koshak says.

When physician extenders don't follow protocol, liability issues can also result. "PAs operate under the physician's license and malpractice coverage," Dr. Koshak adds. "So if a mistake is made by the PA and the patient decides to sue, he is actually suing the doctor."