Many physician assistants have adhered to a pair of disturbing trends in medical care by going into specialties and avoiding rural America.

A national physician assistant conference last week in Omaha stressed the role those medical providers play both in primary care and in service to rural areas.

Speakers at the conference said primary care providers of all kinds — family physicians, internal medicine physicians, pediatricians, physician assistants and nurse practitioners — are in greater demand because more people have insurance through the Affordable Care Act. With insurance comes more patients in doctors' offices.

And yet physician assistants have gone the way of their physician partners. They are, like medical doctors, gravitating toward surgical centers, skin-care clinics, emergency medicine and other specialties that either pay more or have better hours than primary care.

They are less inclined to go to small towns, speakers and data said.

Dr. Robert Wergin, president-elect of the American Academy of Family Physicians, said the future of American

medicine will emphasize teamwork among primary care doctors, physician assistants, nurse practitioners and other providers.

Primary care doctors who use physician assistants — or PAs — are able to extend their reach and see far more patients. The teamwork in clinics also helps them better coordinate the care of patients, communicate with patients and keep them healthy and out of the hospital, Wergin said.

"Our future is bright," Wergin, who practices in Milford, Nebraska, said of primary care providers. "We just need more of us."

About 100 attended the two-day conference, sponsored by the University of Nebraska Medical Center, Union College in Lincoln, the University of Iowa and other institutions.

Conference materials and speakers said a primary care practice in a rural area can be delightful. PAs in towns have a big part in those communities' care, are respected, assume leadership roles and come to know their patients well. Eventually, some also enter profit-sharing arrangements with clinics, said Michael Huckabee, director of physician assistant education at UNMC.

But most have received training in city academic medical centers and feel more at ease with the support such hospitals provide, Huckabee said. Further, high student-loan debt compels young PAs to seek better-paying jobs in cities. The fact that most Americans today lack familiarity with rural life also contributes to the shortage of rural PAs.

Because physician assistants by law must receive at least some supervision from a doctor, they go where doctors go. And doctors are less likely to practice in small towns. The University of Iowa reported in 2012 that 282 family doctors practiced in small Iowa towns, down from 418 in 1977.

At the conference, speakers estimated 33 percent to 45 percent of PAs practice in primary care with the rest opting for specialties.

According to data from UNMC, 481 of Nebraska's 814 practicing PAs, or close to 60 percent, work in Douglas, Sarpy and Lancaster Counties. Twenty-three of Nebraska's 93 counties have no physician assistants.

Amy Fischer, a PA in three clinics in southeast Nebraska, said she grew up in Utica, Nebraska. Wergin, with whom she works, grew up in Milford. It makes a difference.

"I went back home," Fischer said. "We need to get those PAs to stay rural, or go rural. The reward is the relationships you form."

Wergin said PAs are valuable to primary care doctors who, like him, practice in rural areas.

"You're with us," he told the audience. "You're part of the solution."

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"We need to get those PAs to stay rural, or go rural. The reward is the relationships you form."

Amy Fischer, a PA in three clinics in southeast Nebraska

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