Outside of a few estimates here and there, there is a lack of formal information about the role of physician assistants (PAs) and nurse practitioners (NPs) in rheumatology practices.

However, in a study of physician members within the American College of Rheumatology (ACR), those in the upper quintile of income all employed a PA or NP. Additionally, the Association of Rheumatology Health Professionals (ARHP), a non-physician membership of the ACR, identifies 157 NP and 69 PA members. The Society for Physician Assistants in Rheumatology (SPAR) lists 75 PAs as members. In a recent role delineation study of rheumatology PAs, researchers were able to accumulate names of 120 PAs who work in a rheumatology role.¹

I am a clinical rheumatology PA and health policy analyst, and am mindful of how little we know of this unique workforce. This is especially pertinent given the 2005 ACR panel study, which predicts a diminishing number of rheumatologists by 2020. The panel recommends considering PAs and NPs as additional team members to improve patient access to rheumatology services.²

I recently attended a July 2007 meeting of 75 rheumatology PAs and NPs in Dallas. The meeting’s intent was to obtain information concerning the function of rheumatology NPs and PAs, and how they perceive the value of different biologic inflammatory disease treatments.

These types of consultant meetings are not new to the industry. They have been conducted for over two decades. What is new is the focus on PAs and NPs as prescribers and influencers of medical management. Physician assistants have prescribing rights in all states and NPs can prescribe in most. With an estimated 1.1 billion prescriptions written annually, it is a small wonder more attention is not paid to these clinicians.

I recorded what I heard during focus group sessions, over meals, in the halls, during breaks and after the meeting. None of the attendees I encountered were self-employed and all worked at least halftime. All were assigned patients to manage. A doctor saw most of these patients during the same or a separate visit. Almost all evaluated the patient on their own. The majority recommended initiating medication if needed.

Some mentioned taking on roles beyond diagnosing and treating patients with inflammatory diseases. These roles were described as follows.
• Medical orthopedics. This was defined as injecting corticosteroids and viscosupplements, and using splinting and bracing.
• Disability assessment. This involved documenting residual injuries and chronic disease effects, and performing disability evaluations.
• Metabolic bone disease. This involved assessing bone mineral density, interpreting bone density findings and labaratory results, and initiating treatments with minerals and bisphosphonates.
• Pain management. This involves treating patients with central pain syndromes such as fibromyalgia and chronic fatigue syndrome.
These roles are a reflection of only some of the diverse patient conditions NPs and PAs have seen in their clinics and practices. Others said they see more patients per week than their employing doctor.

None of the clinicians were partners in their doctor’s corporation. All were salaried employees and some received quarterly bonus incentives based on billing receipts.

While the information from this informal gathering is limited, it suggests the employment of NPs and PAs is broader than appreciated. The roles of NPs and PAs in rheumatology may be larger than literature suggests. Additionally, the industry is increasingly cognizant of the PA and NP roles in medical management. Companies who recognize this should be commended. At the same time, we should assume they understand what targeting PAs and NPs will most likely yield.

Physician assistants and NPs have worked in rheumatology for over 40 years. Yet how well they perform in these roles is poorly understood. After four decades of experience, we should know more than we do. Exploring the deployment of NPs and PAs throughout rheumatology would provide opportunities to examine methods for greater economies of scale and improve access for patients with inflammatory disease.