One of greatest problems with today's health care system is access to medical care in underserved populations. In 1988, 34 million people lived in these underserved areas and the number continues to grow. The physician-to-patient ratio in these areas averages 0.9 active physicians per 1000 population, of which, only 33 percent are primary care physicians (De Lew 156). For the purpose of this paper, the "medically underserved" encompass rural populations, minority groups, homeless clinics, and the inner-city poor that are in need of medical services. Physician Assistants (PAs) are health care providers that perform general primary care and with proper recruitment and retention strategies in these underserved areas, have the ability to improve the access of primary medical care to medically underserved populations.

The history of the PA begins in the 1960's with a program started by Dr. Eugene Stead, chairman of the department of medicine at Duke University. The first people chosen to participate in the PA program were former Navy medical Corpsmen. These individuals were trained in anatomy, physiology, pharmacology, first aid, venipuncture, and nursing skills at a Hospital Corps School. They were then assigned to a preceptorship in a medical or surgical unit at a naval hospital for a minimum of one year (Condit 58). However, these individuals could only become technicians in the world outside the Navy because they had credentials that were not acknowledged by the American Medical Association(AMA). Dr. Stead was interested in recruiting individuals with "good intelligence and motivation who might have been doctors if the turn of the wheel had given their families a social and financial structure to support the long general and special education needed to produce the doctor", which in his opinion was the epitome of the military medical corpsmen(Condit 58). The PA concept quickly became adopted across the country as the word of Duke's program spread. Today, there is approximately 30,000 PAs in the U.S. and by the year 2000, an estimated 3500 will be trained each year(Cooper 683).

The PA today makes approximately $45,000 to $55,000 a year, only one third of the salary of another doctor. However, one PA can increase the efficiency of primary care by 50 percent, which creates a real economic value by allowing the doctors to do more complicated and remunerative tasks(Terry 57). The cost effectiveness, ability to provide comparable care to that of physicians, and patient satisfaction of the PA have been well documented over the past decade. However, their possible role as a solution to access of care is just beginning to be researched. Currently, only 53 percent of PAs practice in primary care settings and only 20 percent practice in towns with populations of less than 10,000, and these numbers are decreasing(Larson 266). According to Larson et al., "As the number of roles that PAs can fill in medicine expands, it is likely that rural communities will find that financial and lifestyle push and pull factors that contribute to the chronic shortage of physicians in rural areas will make recruitment and retention of rural PAs a problem too"(266). This problem of recruitment and retention will be further discussed later.

Although the percentage of PAs in rural settings appear to be decreasing, the differences in practices between rural and urban settings are few. MEDEX Northwest, a PA program which focuses on promoting rural practicing to relieve access to care problems, completed a study comparing the differences in demography, satisfaction with practice and community, practice history, and practice content between rural and urban settings(Larson 266). The analyses of all studies were strictly limited to primary care providers and involved the comparison of PAs currently practicing in urban places with PAs currently practicing in rural places. The significant differences in demography were few. Minorities were more likely to practice in rural locations and PAs with advanced educational degrees tended to practice more in urban settings. Surprisingly, there was no significant difference in average salaries, average number of hours spent practicing primary care, and in other characteristics of practices and communities. However, there were large differences in the scope of medical practice performed by PAs in these two areas. Urban PAs spent a significant amount of time more with their physician sponsors compared to rural PAs. This suggests that rural PAs have a greater degree of autonomy and spend more time with supervisory and administrative activities. The final statistical data they found to be significant was that the practicing rural PAs tended to have grown up in rural areas themselves(Larson 266-73).

If rural PAs have comparable salaries and hours spent practicing care with urban PAs and have a greater degree of autonomy, then why are PAs leaving rural settings for urban ones? It seems that underserved areas lack the effectiveness of recruitment, educational, and deployment strategies necessary to retain PAs. These "lifestyle push and pull factors" in which Larson refers include less educational benefits for family, higher crime in inner-city areas, and sacrifice of professional acknowledgement and respect for the PAs themselves. According to Donald Barr, M.D., Ph.D., the factors that are driving people toward specialties and more affluent, urban areas are prestige and the ability to use high technological advances, frustration within primary care due to its repetitive and boring nature, and lack of good primary care role models. Today, most PA programs focus their requirements towards those individuals that have grown up in a rural area or have had clinical experience in these areas.

Therefore, the recruitment and training activities in underserved sites needs to be examined further and improvements must be made. Senior Research Scholar and Director at Stanford University's School of Medicine, Virginia Fowkes, and her colleagues completed a qualitative study on the effectiveness of educational strategies preparing PAs for underserved areas. Their study found that the programs with a strong dedication to underserved communities had several distinctive features that other PA programs did not. For example, they publicly professed this dedication in a "mission" statement; they have changed their educational structure to meet this "mission"; they have strong ties to community oriented education and services; and they are more likely to attract rural and minority students(Fowkes 680). The study was able to conclude "that older students with well-conceived practice goals of working and living in underserved areas and background experience in such areas are the most likely candidates". And furthermore, "Programs need to recruit ethnic minorities actively and to have retention strategies to help students surmount academic barriers"(Fowkes 681). To parallel the recruitment of these students, PA programs need focus on the recruitment of professional and ethnic minority faculty which provide students with role models.

Further implications suggest that state prescriptive privileges, reimbursement policies, and increase in responsibility and autonomy all have a strong relationship with recruitment of rural practice. According to Terry, in the 35 states with prescriptive privileges for PAs, 17 percent of practicing PAs are in rural areas; this compared to only 8 percent of PAs in those states without such laws(60). Reimbursement policies have undergone drastic change in the past couple of years. The problem of how close physicians supervise the PAs is under close scrutiny. Medicare and Medicaid will no longer reimburse PAs that were once allowed to legally treat patients without the doctor's attendance. The exception to the government's policy is specially designated rural "health professional shortage areas"(HPSAs). This exception is expected to attract more PAs to rural settings(Stevens 175). These combined efforts, along with efforts to increase PA's responsibility and autonomy at the federal, state, and facility levels, should work together to improve the recruitment and retention of PAs in underserved areas.

One dilemma that current clinics are facing is Medicare and Medicaid reimbursement. It seems that Medicare is enforcing strict supervisory regulations and is refusing to reimburse most Medicare claims(Stevens 175). The new rule states that a physician must be on site anytime a PA treats a Medicare patient. This seems a bit extreme since the purpose of the PA program is to treat patients were physicians are extremely limited. These clinics, without the reimbursement, are being forced to shut down, increasing the need for more medical care. This problem needs to be looked into further and is most likely a result of the cut-backs resulting from the Medicare crisis. Another possible solution to the recruitment and retention of PAs in underserved areas is the active interest of an inner-city clinic exposing already qualified individuals, like the Navy Medical Corpsmen, to a PA program by giving financial support in return for future service. According to Dr. Oscar Cervantes, a Hispanic American with a Ph.D. in Clinical Psychology, many doctors from his country are driven out to America, where they work blue-collar jobs for less than our minimum wage(lecture). These individuals are highly trained in anatomy, physiology, pharmacology, and the list goes on. However, when in America, the AMA prohibits them from practicing any kind of formal medicine, and wastes talented individuals that could possibly solve the underserved dilemma.

However, if an inner-city clinic in an underserved hispanic area could seek these individuals out and provide them with the opportunity to attend a PA program, partially or fully funded, when the individual completes the program, he can now come back to the same clinic and provide his services for one-third the cost of a physician. These qualified Hispanic individuals could provide excellent service to the underserved areas to replace our physicians and PAs that leave rural areas for prestige and the "lifestyle push and pull factors". The Hispanic individuals are from these underserved areas and are currently working at construction sites for minimum wage or less. It is hard to believe that these factors that affect our physicians will have the same affect on these individuals.

Therefore, PAs appear not only to be cost effective, have the ability to provide comparable quality of primary medicine, and receive equal patient satisfaction, but it also appears they can significantly ameliorate the obstacle of access to care in underserved areas. However, changes in recruitment and retention need to be made at all levels; federal, state, community, and the facility if we are to see a change in the current trend of PAs leaving rural practice for the prestigious specialties in urban areas.