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The Laryngoscope
V
C
2011 The American Laryngological,
Rhinological and Otological Society, Inc.
Contemporary Review
Effective Use of Physician Extenders in an Outpatient
Otolaryngology Setting
Byron Norris, MD; Tristen Harris, MPAS, PA-C; Scott Stringer, MD, MS
Physician extenders may be a valuable asset to an outpatient otolaryngology practice. The adjunctive care pro-
vided by physician extenders appears to be cost effective and has the advantages of increasing patient education,
promoting physician productivity, and improving management of chronic conditions. Practice types that may benefit
from advanced practice providers include group or solo practices with high demand or who need improved efficiency.
We discuss five different practice models for incorporation of advanced practice providers in an outpatient otolaryn-
gology practice. These models include scribe, collaborative, limited independent, partial independent, and near com-
plete independent practice and are based primarily on the autonomy level of the physician extender. In additon, we
examine available literature discussing the cost effectiveness of physician extenders used in an outpatient setting.
Key Words:
Physician extender, midlevel providers, practice management, cost–benefit.
Level of Evidence:
5.
Laryngoscope,
121:2317–2321, 2011
INTRODUCTION
Physician extenders have an increasing presence in
the healthcare workforce. Based on data from 2007,
there are approximately 120,000 active nurse practi-
tioners (NPs) and physician assistants (PAs) in the
United States, and the use of midlevel providers is
increasing in specialty and subspecialty aspects of medi-
cine.
1
Despite the increase, the field of otolaryngology is
currently underrepresented.
2
According to the 2008
American Academy of Physician Assistant’s Census
Report there were 251 PAs working in otolaryngology
practices, representing 0.9% of the total workforce.
3
The
percentage of NPs in otolaryngology is even fewer, being
reported as less than 0.2% of all active NPs.
4
The
increase in advanced practice providers is needed in
part to offset the relative decline in practicing otolaryng-
ologists. According to the American Association of
Medical Colleges 2006 data, there are only 9,077 active
otolaryngologists in the United States, with 42% of these
physicians aged 55 years or older.
5
Physician extenders, including NPs and PAs, refer
to health professionals who are trained and licensed to
practice medicine under the supervision of or in collabo-
ration with a physician. The background, education, and
level of autonomy differ between NPs and PAs.
6
NPs
are governed by the state boards of nursing and may
have greater autonomy than PAs.
6
In addition, the
requirements for education, prescribing practices, and
credentialing vary between state for NPs.
2
For example,
as of 2008, only 30 states required NPs to collaborate
with a physician for diagnosis and treatment.
2
PA’s
training and education are centered around physician
collaboration and are governed by state medical boards.
6
Although the training, scope of practice, and background
education may differ between NPs and PAs, this manu-
script groups the two subsets together to focus on
similar roles in relation to an outpatient otolaryngology
practice.
This manuscript is intended to highlight the chang-
ing face of healthcare with respect to the increasing
presence of advanced practice providers, specifically
regarding specialty practices such as otolaryngology.
Pertinent literature is reviewed and five models are dis-
cussed relating to the incorporation of advanced practice
providers into the outpatient otolaryngology sector. Cost
analysis, impact on patient care, and future healthcare
directions are reviewed. Although there are many appli-
cations of advanced practice providers for inpatient
management and assisting with surgical procedures,
this manuscript focuses solely on the application in the
outpatient clinic setting.
From the Department of Otolaryngology and Communicative
Sciences, University of Mississippi, Jackson, Mississippi, U.S.A.
Editor’s Note: This Manuscript was accepted for publication June
27, 2011.
This research was presented at the Annual Meeting of the Acad-
emy of Otolaryngology September 29, 2010.
The authors have no financial disclosures for this article.
The authors have no conflicts of interest to disclose.
Send correspondence to Scott K. Stringer, MD, MS, Department of
Otolaryngology and Communicative Sciences, University of Mississippi,
2500 North State Street, Jackson, MS 39216. E-mail:
sstringer@umc.eduDOI: 10.1002/lary.22192
Laryngoscope 121: November 2011
Norris et al.: Physician Extenders in Otolaryngology
Reprinted by permission of Laryngoscope. 2011; 121(11):2317-2321.
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