What a doctor is good for.

Over the years I have served as both a preceptor and colleague for more than a dozen physician assistants and nurse practitioners. All the while I wondered: are they as good as they seem, and are doctors as indispensable as we’d like to believe? When my daughter became a physician assistant I was forced to respond. I share a small practice with six family physicians. Each of us works closely with a designated medical assistant. Around us, personal service representatives greet our patients and schedule their visits; billing associates ensure our financial survival. We also rely on a physical therapist, pharmacist, behavioral therapist, triage nurse, care manager, health coach, laboratory technician, medical records clerk, clinical coordinator, and practice director. Thus, you can forgive the doctor, let alone his or her patients, for sometimes getting lost in the shuffle. Increasingly, advanced nurse practitioners and physician assistants will join the clinical team. One of each is now on our staff. In the United States, more than 165 training programs have educated the 95 000 certified physician assistants in practice today. There are over 180 000 nurse practitioners trained in 92 programs. Numbers in the United Kingdom are less accessible, but at least six physician assistant schools are listed online. Like physicians, mid-level practitioners have gravitated toward the higher paying specialties, despite the design of their programs and needs of society. In the US, barely a quarter of physician assistants work in family medicine, general internal medicine, and pediatric settings. Our nurse practitioner and physician assistant are skilled communicators, detail oriented clinicians, and evidence based practitioners. They care for 90% of the problems I see routinely and are proficient in many of the procedures I perform. They have reached this level of proficiency in a quarter of the training time. Their metrics of clinical performance match or surpass the doctors who supervise them. That they command half our salary is surely not lost on those who employ us. Thus, it is not only justified but critical to ask: what is a doctor good for? Framing the clinical question