Since the physician assistant profession’s founding at Duke University in 1965, the scope of PAs’ work has grown steadily, along with an increased need for health care services in the United States. A March 2017 Association of American Medical Colleges report shows the demand for physicians will grow faster than the supply through 2025, and physician assistants are needed to fill the gap.
PAs are especially important in underserved communities. According to the National Rural Health Association, about 20 percent of Americans live in rural areas, but only 9 percent of physicians practice there. However, 17 percent of PAs practice in these areas.
“The role of physician assistants is really critical,” says Benjamin Money, Jr., MPH, president and CEO, North Carolina Community Health Center Association. “They’re critical to health centers actually being a medical home that’s readily accessible to the community. We’re proud of the fact that Duke University is the home of the PA program and we are grateful to their support of the training and encouragement of PAs to continue their careers in underserved areas within the state of North Carolina.”
While the number of projected PA jobs and practicing PAs is increasing nationwide, it is a rarity for physician assistants to own and operate their own practices; some states won’t even allow PAs to have proprietorship over a practice.
However, these Duke Physician Assistant Program alumni have worked to establish themselves as primary care providers as well as leaders in business, owning and operating flourishing clinics in underserved communities of North Carolina.
Elizabeth Buno, Roxboro Family Medicine
Elizabeth Buno, MHS, PA-C, was a medical social worker with plans to work in a big trauma center, as an emergency room PA, when she began Duke’s program in 2002. She worked with Duke Cardiology after graduating in 2004 but soon found herself following her heart into primary care.
“I realized that I didn’t get to follow up with my patients,” she says. “I didn’t realize how much that would mean to me. I never had my own panel of patients and I found that frustrating.”
She joined Roxboro Family Medicine, a clinic that cares for patients in a medically underserved community, in 2005. Three months later, she was told the practicing physicians were leaving and that she had three options: help find another physician to take over, get out of her contract, or figure out a way to buy the practice herself.
“I was nine months out of PA school at that point and I really loved and had a strong connection with the patients I was seeing,” she says. “I realized what an underserved community it was and the last thing I wanted to do was leave. So I just thought, ‘Why not? Let’s do this. Let’s see if I can own a practice.’”
Buno became part-owner in 2006 and in 2010 became the majority owner. Tami Lee, MHS, PA-C, came on a short time later as her partner in the business.
“I had never even contemplated owning my own practice,” Buno says. “When I was in school, it was, and still is, very rare and, I think as of about three years ago, less than one percent of PAs were in ownership of their practice. Coming out of school, if I was really not prepared clinically, there is no way I could have handled it.”
Her practice has earned certification as a Patient-Centered Medical Home, which indicates that the practice and its providers meet high requirements and standards as they deliver all-encompassing care to patients and families.
Tami Lee, Roxboro Family Medicine
A graduate of Duke’s PA program in 2004, Tami Lee, MHS, PA-C, knew primary care was for her.
“Terrific professors, instructors and mentors all contributed to my journey and influenced the fact that I wanted to go into primary care in a rural area,” she says. “I did many of my rotations in rural communities and fell in love with the patient population in those small, rural settings.”
For several years after graduating, Lee worked in Roxboro. Eventually she and Buno discussed merging their clinics. The two decided to join together in 2010 at Roxboro Family Medicine.
“We have similar hearts for what we’re trying to do in Roxboro and the services we’re trying to bring there,” Lee says. “I think the wide spectrum of what we see and treat every day, cradle to grave, and getting to know generations of people—treating sometimes four generations in the same family—that makes us better.”
Lee says the practice works with the loan repayment program through the North Carolina Medical Society to bring providers to Roxboro Family Medicine to help with services.
“The problem is many providers will stay in the county for five years and, once that loan repayment is done, they’ll move on,” she says. “We’ve seen that time and time again with some of the other clinics and specialists. I think people have to be passionate about the people there to stay.”
Lee says her motivation stems from her desire to provide services for patients who might not otherwise have them and to ensure patients know they can come to their clinic rather than going to an urgent care or to the emergency room.
“We know our patients, their home circumstances, their extended circumstances,” she says. “We try very hard as a Patient-Centered Medical Home to make sure if someone walks in off the street that they see their normal provider to the extent possible. Having that knowledge of someone’s whole history, which might be subtle nuances that another provider might not know in a five-minute skim of their chart, goes a long way in making sure we provide the best care possible for our patients.”
Miguel Pineiro, FamHealth
Miguel Pineiro, MHS, PA-C, was 35 years old when he enrolled in PA school at Duke. After he graduated in 2004, he worked in mental health as a Spanish-speaking PA for a Latino doctor in Raleigh and as a full-time PA in the emergency room.
Three years ago, Pineiro got a call that the Latino doctor he worked for had passed away and that her clinic was in need of a full-time provider. He sent a message on Facebook to his now-colleague, Enid Tallmer, asking if she’d be interested in buying the practice with him.
The two opened FamHealth, a bilingual primary care clinic that focuses on serving the Latino population in Raleigh, in September 2016.
“Our clinic is low cost,” Pineiro says. “We want to provide care, not only to the Latino community, but to people who don’t have insurance. We do everything possible to be a resource for the community.”
FamHealth is a part of Project Access of Wake County, a program that coordinates and connects patients needing specialty care with specialists that provide those services for free. The program has yearly pledges from physicians and clinical staff to provide care to patients that are referred due to medical necessity.
“Enid and I are older, so we have seen what’s important in life,” Pineiro says. “When you leave this earth, you have to be able to ask how you helped your fellow man. Were you able to help somebody in a meaningful capacity? That’s what drives our business. We want to affect positive change in the population that we serve. We’re not trying to get rich; we’re here to be of service.”
Pineiro says he believes the trend of PAs opening their own practice will continue to grow because the need is there.
“Most doctors go to specialty care and leave this huge vacuum of primary care,” he says. “People are getting older because medicine is fortunately making people live longer. That means people live longer with more medical problems and you need to have somebody in the middle to coordinate whatever advanced care people need.”
He also credits Buno, Lee and Roxboro Family Medicine with being the future of what a sustainable primary care clinic should be and how other clinics should strive to operate.
“Their practice is a perfect example of something that’s worked for 10 years now,” he says. “It’s a model for where most of us in primary care would like to end; a place where you can come in and get all your health care needs taken care of at one place, or at least figure out where you need to go if you need to go elsewhere.”
Enid Tallmer, FamHealth
A 2005 Duke PA program graduate, Enid Tallmer, MSW, MHS, PA-C, found her favorite rotations during PA school to be in primary care, working with underserved communities. She feels it’s where she belongs.
“I was born in Puerto Rico and I’ve always been very aware of what not belonging feels like,” she says. “My parents didn’t have any money. My mother would go to the doctor and they’d always have to find an interpreter and never understood what she was saying. That led me to want to be in health care.”
Tallmer first began her career working in mental health and was the first bilingual clinical social worker in Wake County.
“As I started working with Latinos and realizing again that the mind, soul and body are so interlinked, I became more aware of the physical health part and was very interested in looking at labs and knowing what they meant,” she says.
At 40 years old, Tallmer enrolled in Duke’s PA program and, after completion of the program, initially worked in urgent care.
“I was never satisfied,” she says. “In urgent care, you have no continuity. Patients would ask me if I had my own practice and if they could come see me and I’d have to say, ‘No, I’m so sorry.’”
She says when Pineiro asked her to join FamHealth as his partner that was the sign she needed to make the switch.
“It was an incredible risk, and still is,” she says. “But whenever I have doubts about doing what I do, I see a patient or two come in and they’re so grateful and are so glad I’m there. They hug me and send me a zillion blessings. When they do that, that’s when I say, ‘This is where I belong.’”Leah Komada is a freelancer writer based in Charlotte, N.C.