New health care providers emerge

3. Florida

4. Georgia

5. Illinois

6. Hawaii

7. Massachusetts

8. Michigan

9. North Carolina

10. Maryland

Source: The American Journal for Nurse Practitioners

Going to a doctor's office in Georgia will increasingly be an experience that doesn't actually involve seeing a doctor.

Within just a few years, an emerging doctor shortage in Georgia is expected to be so critical that the only way to provide health care to the state's growing and aging population will be to rely more than ever on someone in a white coat who is not an M.D.

Nurse practitioners and physician assistants --- so-called "mid-level" health care providers --- will relieve doctors from seeing every earache and sprained ankle. Many health care experts say patients should embrace the change. The mid-levels may have more time to spend with patients, and they can free up doctors to focus on patients needing more complex care.

Already, medical schools are preparing for the transition, training a range of professionals to employ a team-based approach to health care.

"We have to choose to do what I think the numbers demand, " said Dr. Wright Caughman, Emory University's executive vice president for health affairs.

By some estimates, the nation will be short 90,000 doctors by 2020.

To meet demands for care, Georgia will be under pressure to loosen its tight restrictions on nurse practitioners and physician assistants. But many doctors oppose easing limits on mid-levels in Georgia. They fear patient care could be jeopardized if these mid-level providers don't have enough oversight by doctors.

"My big concern is that what we're beginning to see is more mid-level providers and people will not see physicians as often --- if at all, " said Dr. John Moore, an Atlanta ob-gyn. "They are not trained as well as doctors and they're going to miss some stuff, and that's a scary thing to me."

Georgia restricts mid-level providers

When Ben Taylor joined the ranks of Georgia health providers after more than two decades of practicing medicine in the Army, the physician assistant was shocked to find more limits on how he could care for his patients.

Suddenly, he needed a doctor's OK to send a patient home with a prescription for Percocet.

"It hampers our ability to practice efficiently, comprehensively and at a faster pace, " Taylor said.

Georgia has some of the most restrictive regulations in the country for mid-levels. Unlike Georgia, some states allow nurse practitioners to order an MRI or prescribe a narcotic without a doctor's approval. Georgia also requires a formal written agreement with a doctor that spells out medical tasks a nurse practitioner can perform. Other states, including Washington and Arizona, allow nurse practitioners to practice independently without a doctor's oversight.

How states choose to regulate nurse practitioners and other providers is going to be the critical difference in how states make sure their residents have care, said Tay Kopanos, director of health policy for state affairs at the American Academy of Nurse Practitioners.

"Unfortunately, a lot of states have not kept pace, " Kopanos said. "Provisions put in place decades ago are really no longer protecting the public."

Many doctors in Georgia disagree and have fought for years against state legislation aimed at giving nurse practitioners greater autonomy.

Although Moore uses nurse practitioners and midwives at his metro Atlanta practice, the ob-gyn has lobbied against expanded privileges that would allow more independence for mid-level providers.

Doctors aren't perfect and sometimes miss things, but they have a higher level of training, said Moore, a Medical College of Georgia graduate who has practiced for more than 25 years. Mid-level providers are not M.D.s and need oversight to avoid mistakes that could hurt patients, he said.

"If you want to be a doctor and play doctor, then you go to school and get your doctor degree, " he said. "If you don't want to do that, then you work for somebody."

On top of earning a bachelor's degree, doctors must complete four years of medical school and residency programs that usually last between three and seven years, depending on their specialty.

Nurse practitioners must complete a master's degree that usually takes two years after earning a bachelor's degree in nursing. Physician assistants must earn a graduate degree in a miniature version of medical school that usually last about 27 months. Most have a bachelor's degree that includes training in the sciences.

In the years to come, nurse practitioners will push to practice independently, says Dr. Sandra Reed, president of the Medical Association of Georgia, a trade group for physicians. Reed opposes that, even with the looming doctor shortage.

"In my practice, we have nurse practitioners and certified nurse midwives and we practice as a collaborative group, " said Reed, an ob-gyn in Thomasville. "The important thing is the physician oversight piece."

Earlier this year, the association, which represents more than 7,000 members, opposed a state senate bill that would have allowed advanced practice registered nurses to order radiographic imaging tests, such as MRIs. It ultimately failed. On the association's website, the group's government relations director, Marcus Downs, said the bill "would have subjected patients in Georgia to unnecessary levels or radiation, and it would have increased costs as a result of the additional tests."

The group has also opposed legislation allowing pharmacists to give certain vaccinations.

Many in medicine, though, believe the new health care model will improve quality --- not detract from it --- while meeting demand.

Doctors need to get over feeling threatened by mid-level providers and, instead, see themselves as leaders of primary care, said former U.S. Surgeon General David Satcher, now with the Morehouse School of Medicine.

Two years ago, the Institute of Medicine recommended that all states allow nurses to practice to the full extent of their training and adopt national scope-of-practice regulations.

"I would hate to think that the posture of primary care providers will continue to be resistant, " Satcher said.

Some patients embrace convenience of mid-levels

Already ranked 41st in physician supply, Georgia is projected to fall roughly 5,000 doctors short of the number it will need by 2030 with doctors retiring, baby boomers aging and hundreds of thousands of Georgians expected to gain insurance under the federal health law.

It can already be difficult to get in to see a doctor quickly, and many patients have embraced the convenience of seeing an advanced nurse or a PA.

Chelsey Tabakian, for one, sometimes wishes her PA was her main doctor.

For months after her knee surgery, the 18-year-old did everything right, going to physical therapy and refraining from her passion --- dance. But the pain remained agonizing.

Tabakian said that at a follow-up appointment, she ended up seeing a physician assistant who took a personal interest in trying to understand the ongoing pain --- and who listened to her frustration.

The PA wrote up a new therapy plan and gave the student her email and personal phone number.

"We're on a road where I feel like we're going to get somewhere, " Tabakian said. "It's not a dead end anymore."

In Georgia, numbers of PAs and nurse practitioners have both jumped by close to 40 percent in the past five years.

The number of nurse practitioners nationwide has risen steeply in the past decade as the physician shortage has worsened, said David Auerbach, a policy researcher at the nonprofit research group RAND Corp. In general, he said, nurse practitioners are qualified to handle roughly 85 percent of patients who come into a typical primary care office.

Mid-levels play an especially crucial role in the increasingly popular "medical home" model, he said. The model uses a physician-led primary care team to promote wellness and coordinate all of a patient's care. The mid-levels can help free up physicians to see complicated patients who have multiple ailments and need more attention.

Some physicians are finding a new kind of excitement in seeing themselves more as the quarterback of the team, Auerbach added.

"The demand is only going in one direction, " he said. "All these new models ... are really going to need people to coordinate care, to manage patients, all the stuff nurses are doing."

While studies have shown that mid-levels can provide high quality care, surveys have also shown patients are just as satisfied --- sometimes even more so --- seeing a mid-level rather than a doctor.

Some experts say that's because PAs and nurses simply have more time to spend with patients and listen to their needs.

But that doesn't mean all patients are ready to accept spending less time with their doctors.

Stan Citron, a 73-year-old from Atlanta, said he's uncomfortable with mid-level providers handling too much of his medical care. He said he went to see a specialist and assumed the appointment was with a doctor, only to be greeted by a nurse practitioner.

Citron said that wasn't appropriate. Patients "should see an M.D. for at least the initial diagnosis --- whatever the problem may be, " Citron said. "I wouldn't be comfortable where a nurse practitioner makes any diagnosis."

Gabriel Najarro, a PA who recently graduated from Emory's program, said patients should realize that PAs are trained to work very closely with physicians as part of a team.

"Even though you may only be seeing a PA at a primary care office or clinic, the physician is always right behind that PA in one sense or another, " Najarro said.

Taylor, who practices as a PA in Georgia and South Carolina, said his patients gladly ask for him by name.

Doctors often have very little time to spend with patients because their schedules are so packed, Taylor said, but physician assistants can sit and listen. They take time to answer questions and explain things.

Most Americans have little patience to sit around and wait to be seen, he added.

"If my doctor's schedule is really full and mine is not, " he said, "nine times out of 10 they'll say, 'yes, let me see Ben.' "