Nurse practitioners,(NPs),  physician assistants (PAs) and clinical nurse specialists (CNS’s), collectively called advanced practitioners (APs), can be found in every aspect of health care.

Their popularity and wide spread use is in response to the need for more providers and the growing ranks of underserved population groups.

The Feldsher, a surgeon-barber of the Russian Army, a position created in the mid 1600’s, is the first recorded organized effort of training personnel to assist physicians. The army medic first emerged in the 1890’s.

In response to the shortage of primary care providers and the increasing needs of the population, Eugene Stead, MD, at Duke University Medical Center in Durham, N.C., established the first PA training program.


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He capitalized on the number of Navy corpsmen returning from Vietnam who were unable to find civilian jobs that made use of their field training. Dr. Stead employed many principles learned from World War II when physicians were being fast tracked through training.

Meanwhile, at the University of Colorado in Denver, Loretta Ford, EdD, and Henry Silber, MD, were also faced with the dilemma of providing care to underserved populations. They looked to the training and skills of public health nurses and trained the first NPs. The early graduates were pediatric NPs whose mission was to provide pediatric care to rural areas.

Today, APs are frequently found in urology and nephrology practices in both the inpatient and outpatient setting. While use of APs has been primarily in North America, the concept is catching on internationally and these professionals are playing a larger role in health care world wide.

A practice enhancement

APs enhance a practice, according to Michael Allon, MD, Professor of Medicine University of Alabama in Birmingham. “APs  have become an integral part of outpatient nephrology practice,” he said, adding that they serve as “the eyes and ears of the nephrologists in the outpatient dialysis unit ensuring optimal medical care.” In addition, they enable nephrologists to bill for the highest level of MCP visits.”

In CKD clinics, Dr. Allon noted, APs provide close oversight and management of complications of kidney disease and education of patients and families. “The AP can facilitate the transition to dialysis,” he said.

APs also play a large role in treating the renal transplant clinic both in the hospital and outpatient setting. A growing number of programs use advance practitioners as transplant coordinators, capitalizing on their abilities to make medical judgments, order tests, and prescribe medications.

Nearly half of the practicing PAs work in surgery. Recognizing the need for well trained first assistants, surgeons have utilized PAs at higher rates than expected.  PAs also are found working as hospitalists as well as in primary care and specialty practices.  Many teaching hospitals are looking to APs to fill the gap created by reduced resident hours.

States regulate the scope of practice so there are some differences from state to state and even among institutions. In all cases, however, the AP is a graduate of an approved program and has national certification.

Numerous studies and surveys have supported and underscored the value of APs. A 2008 study at Duke University suggested the efficiency of the health care system was positively impacted by PAs. Health Economics included PAs in its list of recession-proof jobs and they were listed in US News and World Report’s top 10 jobs for the coming decade.

Likewise, there are studies attesting to the economic feasibility of advanced practice nurses. They have shown adding NPs to a practice decrease patient cost and increased practice revenue. The Renal Physician Association (RPA)’s 2009 benchmarking survey noted that practices with an AP were more likely to be in the top performers in their region for income generation.