Abstract
The U.S. primary-care assistant seems lost in a vicious circle: problems in the American health-care system (high cost and hospital orientation, lack of satisfaction for patient and provider with primary-health-care services, and the related maldistribution of physicians)—problems which might be mitigated by utilising physicians' assistants and nurse practitioners—themselves militate against effective use of such assistants. Financial incentives, educational systems, and traditional patterns of behavior and expectation all work in the opposite direction; all favour decisions which virtually preclude good primary care—maximum hospital usage, short physician visits, minimal delegation to non-physicians. There will have to be a substantial change in the U.S. system before physicians' assistants and nurse practitioners can begin to function well, and can hope to contribute to the quality, accessibility, and cost-effectiveness of primary care.
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