
By Paul V. DeMarco
Guest Columnist
In 1993, as a new physician fresh from residency, I joined an internal medicine practice composed of three doctors and one physician assistant in Marion. The next year, one of the doctors left the practice and our call schedule went from every fourth to every third night. I was the father of two young children, and this sudden increase in my workload threatened to overwhelm me. I would have left the practice and probably the Pee Dee if we hadn’t hired another PA. She enabled me to remain living and practicing in Marion.
I tell you this to underscore how important physician assistants (PAs) and nurse practitioners (NPs), collectively known as advanced practice providers (APPs), are to the practice of medicine. In my 30-plus years of practice I have worked closely with six APPs in two different internal medicine practices. Practicing with them as colleagues has been a privilege and of great benefit to me and my patients.
However, despite my love and respect for APPs, I oppose the current bills in the SC Legislature that would allow them to practice independently (S 45 and H 3580). The bills would allow APPs to see patients independently after only a year (2,000 hours) of working with a physician.
I have a host of reasons for my opposition. I will offer two here. First, training matters. Medical school is more rigorous and almost twice as long (4 years vs. 2 to 2.5 years) than APP training. But the most important difference is clinical experience. NPs need only complete 500 hours of clinical training to satisfy their national governing body. The PA national minimum standard is higher, at 2,000 hours, which are divided into multiple rotations in different medical specialties. At best, a PA doing an internal medicine rotation might get 8 weeks (about 300 hours) of IM training. An NP would likely get even fewer hours.
In contrast, physicians come from a tradition in which training was so grueling that it had to be scaled back. I finished my residency in the early 1990s before the Accreditation Council for Graduate Medical Education put a work hours requirement in place. In those days, every other night call was allowed, which meant residents could work more than a hundred hours a week. In 2003, an 80 hours-a-week maximum was instituted. Even if we use a more conservative estimate of 60 hours a week for an IM resident, over a three-year residency internists begin practice with approximately 9,000 hours of clinical experience, 30 times as much as the best case for an APP. It is a deficit that is very difficult for an APP to make up.
It’s not only the hours, but the intensity of the training. Physician residency training is remarkable for its depth and breadth. In the first (intern) year, physicians are intimately involved in their patients’ care. We perform histories and physicals, order labs and imaging, and create differential diagnoses and treatment plans. As second- and third-year residents, we remain closely involved, but also supervise the interns. Experienced attending physicians make rounds mornings and sometimes evenings, do bedside teaching, and are available for advice, but the residents are entrusted with significant responsibility and are the patients’ primary doctors.
By the end of our residencies, we have managed a vast array of clinical problems in the office and the hospital, from the trivial to the life-threatening. An exhaustive residency is the best way to prevent knowledge gaps, which are a common source of medical errors. If a provider’s training is too short or too narrow, they may not be able to recognize a condition they have never seen.
Second, the primary argument for independent practice is that it will increase access for underserved patients. But these bills will not remedy that problem. In about half the states, APPs have independent practice authority, so there is a record to examine. But different lenses produce different conclusions. Nursing researchers have produced papers claiming that independent practice does increase patient access; unsurprisingly, data from American Medical Association refutes this, concluding that APPs tend to practice in the same areas as physicians.
Current state law allows APPs to work alone if the supervising physician is “readily available,” although that term is not defined. Specific requirements for supervising physicians’ distance (45 miles) and travel time (60 minutes) to APPs’ practice locations were eliminated in 2018. Many of these solo APPs are only lightly supervised. Eliminating supervision entirely is a step in the wrong direction. We need more collaboration with our APP colleagues, not less.
Given the demands of modern medical care, the likelihood that a private solo APP or even a small group APP practice could offer affordable care, generate acceptable revenue, and sustain bearable working conditions is low. Rural practice can be grueling and lonely, and the burnout rate is high.
The best option for APPs to offer this type of care is through a community health center like HopeHealth, where I have worked for the past 14 years. CHCs receive enhanced Medicaid reimbursement and can offer a sliding scale for uninsured patients. If they are like HopeHealth, they offer competitive salaries and benefits, strong leadership, and educational and social opportunities for all providers, physicians and APPs alike.
I urge the legislature to focus on incentivizing doctors and APPs to collaborate. APPs have rightly argued that not enough physicians are willing to work in rural areas. But there are still some of us who will. In SC, physicians can supervise up to six APPs, so a single willing physician could catalyze a large rural clinic, or several smaller ones. This model, in which the physician and APPs work together, sharing the burdens and rewards of caring for rural patients, is the best way forward.
A version of this column appeared in the August 20th edition of the Post and Courier-Pee Dee. Dr. DeMarco’s opinions are his own and do not necessarily represent those of HopeHealth.


































