LAUREL COUNTY, Ky. — On a busy Thursday morning, Rebecca Kraftick made her rounds in Saint Joseph-London’s cardiothoracic vascular unit. With her crisp lab coat on and a stethoscope around her neck, Kraftick moved fast, writing in patient charts, consulting X-rays, and making assessments.

When she arrived to see Florene Grubb, who had open heart surgery a few days before, Kraftick looked pleased.

“She looks a million times better,” she said of the 70-year-old. “She may get to go home today.”

That call ultimately was not Kraftick’s to make. Though she looks every bit the doctor, she is instead a physician assistant.

People who have gone to the doctor or been treated in the hospital lately have likely been seen by someone like Kraftick. In today’s hospitals and doctor’s offices, physician assistants have become part of the medical landscape. Nurse practitioners are also part of the picture these days. Like physician assistants, they perform duties that, historically, were done by a doctor.

In researching the wellness of Laurel Countians, access to health care — which means how easy or difficult it is to get medical treatment — consistently fell short. The Kentucky Institute of Medicine’s comparative county assessment shows the primary care physician-to-population ratio is 2, “which means there are two full-time equivalent primary care physicians for every 3,500 people in the county,” said Elmer Whitler, director of the Office of Rural Health Policy Research.

Statewide, the ratio is 2.5. Nationwide it is 3.7.

The University of Wisconsin Population Health Institute highlights a similar shortcoming, showing there are 98 primary care providers per 100,000 people in Laurel. Statewide, the number is 110.

Saint Joseph-London’s emergency room is feeling the pressure, with patient visits up by 10,000 this year over 2007.

“Part of the growth is because more and more patients are not able to see a doctor,” Chief Financial Officer Robert Brock said. “It’s not only because they don’t have insurance. It’s because, in many cases, doctors can’t accept new patients — they’re overburdened.”

In order to relieve the stress on the ER, Saint Joseph-London opened its own primary care clinic.

“We have three full-time physicians there and a fourth is joining soon,” Brock said.

While access to health care appears to be an issue in Laurel County, as is the case in fighting tobacco use, there are systems in place to address the problem.

Adding physician assistants and nurse practitioners to the medical community is one of those. In 1988, there were just 49 PAs and 796 nurse practitioners practicing in Kentucky. In 2009, there were 3,613 nurse practitioners licensed in Kentucky and another 917 physician assistants.

Dr. James Norton, administrator of the University of Kentucky’s Area Health Education Center in Lexington, said these medical professionals, who are also called physician extenders, are increasing access.

“Having physician assistants and nurse practitioners has considerably increased the number of access points,” he said. “If you have a physician that has two physician assistants,  you have three people who can see patients, rather than just one person. It’s pretty much the math.”

Teresa Renner, a nurse practitioner who practices at the London Pediatric & Adolescent Medicine Clinic, agreed.

“A lot of the time, the physicians are so booked up, they can’t see any more patients,” she said. “I’m here as an extra provider. I’m willing to work. A lot of us nurse practitioners are willing to work late hours outside of your 9 to 5 schedule, where a lot of the physicians are not.”

The work of physician extenders varies greatly. Before Kraftick became a cardiovascular surgery PA, she worked in an internal medicine practice.

“I basically did everything he did,” she said of her attending physician. “I diagnosed, I treated. He did not necessarily follow behind me for everything I did.”

Kraftick did and does receive supervision, however, and her attending physician is required to sign off on her charts. As a PA, she also cannot practice without the oversight of a physician.

That is not the case with nurse practitioners, however, who, like Wendy Fletcher of Morehead, can practice independently.

“We diagnose and treat all kinds of health problems,” Fletcher said. “We do all sorts of acute care management, as well as treat chronic conditions such as diabetes and hypertension.”

In Kentucky, physician extenders are limited when it comes to prescribing drugs. A physician assistant is not allowed to prescribe narcotics. A nurse practitioner must have collaborative agreements for controlled substances, such as narcotics, and for non-controlled substances like blood pressure medication.

“It basically means there is a physician aware that we are writing prescriptions,” Fletcher said.

That, too, may change. In 18 states nationwide, Fletcher said nurse practitioners are “completely independent in every way.”

In their patient visits, Fletcher and Kraftick contend physician extenders spend more time with patients than physicians typically do.

“As a general rule, I do think nurse practitioners are pretty famous for (that),” Fletcher said, adding those visits focus heavily on prevention.

While that may be the case, physician assistants and nurse practitioners are not as extensively trained as doctors. At the University of Cumberlands’ physician assistant program, which opened in January, students must have a bachelor’s degree in order to apply. Once accepted, the master’s degree program is two years.

The requirements are similar for nurse practitioners, though as of 2015, the American Association of Colleges of Nursing will strongly recommend that new nurse practitioners be educated at the practice doctorate, as opposed to the master’s, level — a process that will take seven years.

Providing a wide variety of care without the same degree of education has some physicians questioning what the prevalence of nurse practitioners and physician assistants will mean for the quality of health care.

But Dr. Kevin Kavanagh, a retired ear, nose and throat specialist in Somerset, is not one of them.

“Right now, I think it’s working very well for the system,” he said. “There is a shortage of primary care physicians across the nation and it’s especially prevalent in rural areas. Physician assistants and nurse practitioners are picking up the slack in primary care, though they do not alleviate the access issues to specialists in rural areas, which continues to be a problem.”

Kavanagh added he does not worry about the fact that a physician extender’s education is less extensive than a physician’s.

“I think you’re trained in what you do, though certainly they should practice in the scope of their training,” he said, adding the same true for physicians. “I was an ear, nose and throat doctor and I wouldn’t think of treating someone for a heart attack.”

Kavanagh did say the prevalence of nurse practitioners and physician assistants may one day decrease the number of students who choose to go to medical school.

“That’s the big question,” he said. “If you earn the same income then you might not do the extra training. Because it’s expensive to go through medical school. That’s the thing you have to be careful of.”

He added the increasing numbers of PAs and NPs will also increasingly cause competition for physicians — particularly if they are permitted to prescribe all types of drugs.

“In that case, they’ll have to find how they distinguish themselves from their competitors,” Kavanagh said of physicians. “It’s a free marketplace. You have to distinguish yourself for price and quality like you do for any business.”

Regardless of how physicians feel, it seems clear physician extenders are here to stay. In fact, the demand is what prompted the University of the Cumberlands to start its PA program, which already has 28 students.

“Kentucky is losing a lot of primary care docs,” said Kathleen Flynn, clinical coordinator and associate professor at the University of the Cumberlands department of physician assistant studies. “It’s our hope and one of the goals of the profession to put physician assistants in underserved areas where there is not enough doctors ... It seems like with the demands of the future, in order to meet them, they’re going to need physician extenders.”



Staff writer Tara Kaprowy can be reached by e-mail at tkaprowy@sentinel-echo.com.