' Indian Health Manual (IHM) - Circular 76-04
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     Indian Health Manual

Circular 76-04

Public Health Service
Health Services Administration
Indian Health Service
Rockville, Maryland


Effective Date:  April 25, 1979



    IHS Memorandum dated August 20, 1975, entitled "Recommended IHS Policy on Physician Extenders."

    IHS Publication dated April 1971 entitled "Community Health Medic of the Indian Health Service."


    1. Physician Extenders-  A generic term for health professionals or paraprofessionals qualified by professional instruction and formal precepteeship training to provide a particular health service or services to patients.  These services are of a level including diagnosis and therapy that in many cases would other wise be provided by physicians.

    2. Classification of Physician Extenders.

      1. Physician Assistant -  A skilled person qualified by academic and practical experience, to provide patient services under supervision and direction of a licensed physician who is responsible for the performance of that Assistant.

      2. Community Health Medic -  A person trained as a physician assistant by the Indian Health Service.

      3. Nurse Practitioner -  A registered nurse who, by virtue of added knowledge and skills gained through an organized program of study and clinical experience which adheres to ANA guidelines, has extended the limits of practice to include responsibility for physical assessment, evaluation, and management of therapeutic and preventive health care within established regimes.

      4. Family Nurse Practitioner -  A nurse practitioner with special background knowledge and skills to effectively provide a broad range of basic personal health care services to individuals, families and communities.

      5. Pediatric Nurse Practitioner -  A nurse practitioner who has completed a pediatric nurse associate or pediatric practitioner course and provides primary health care to children and adolescents.

      6. Midwife -  A nurse practitioner who has completed a program of study and clinical experience leading to certification in nurse midwifery.

      7. Pharmacist Trained in Primary Care -  A pharmacist who has received additional training in history taking, physical examination and patient assessment for the treatment of patients with selected acute diseases and for the management of patients with selected chronic diseases.  The training also improves the pharmacist's skills for all outpatient and inpatient drug review, monitoring and counseling, and advising on the rational use of drugs.

        The pharmacist retains all of the traditional duties and responsibilities of a practicing pharmacist.  The training prepares the pharmacist for a role expansion, not a role change, and the expanded role activities are conducted from a pharmacy based program in a pharmacy setting.  Such pharmacist is not intended to serve on remote duty.

      8. Ambulatory Care Nurse Specialist -  A registered nurse who has received selected training to provide limited physician extender functions, under standing orders of physician, but without nurse practitioner certification.

    3. Remote Duty -  Assignment of a Physician Extender to a facility without immediate on-site supervision of a physician.  The terminology, Independent Duty, shall not be used as it implies the physician supervision.

  3. PURPOSE.  To outline IHS policy concerning the utilization of physician extenders and the training of IHS Community Health Medics.

  4. POLICY.  The Indian Health Service, recognizing the need for continually improving the quality of health services to American Indians and Alaska Natives, accepts and utilizes physician extenders to extend professional services to more people, and to make possible the more effective utilization of the higher level skills possessed by the physician and other health specialists by relieving them of less complex duties.


    1. Utilization of Physician Extenders.

      1. Each IHS Area and Program Office will assure that billets or positions for physician extenders are identified by type and organizational location, and conform to accepted classification (ref. 2B).

      2. No individual may be appointed to a physician extender billet unless he/she has received prior training and instruction recognized through professional organization accreditation (such as the AMA) as qualifying for such appointments.

      3. All physician extender billets should clearly differentiate between expanded functions of the health professional specialists and physician extender type duties which specifically require a licensed physician's direct supervision and written standing orders.

      4. All Service Units shall assure that each station employing physician extenders has a written functional statement concerning the utilization of physician extenders together with appropriate written standing orders.

      5. A person serving as a Physician Extender may only provide health services to people while under the supervision of a designated physician supervisor, who must have received specific training or instruction in the supervision of physician assistants and who has agreed in writing to accept the responsibilities for such supervision.

      6. Physician Extenders are urged to seek and to keep current professional certification or accreditation.

      7. Physician Extenders are expected to maintain a current professional log or record on proficiency certification and continuing education.

    2. Training.
      1. No full-time IHS-wide training activity for physician extenders may be established without the approval of the National Council of Clinical Directors, the IHS Training Committee and the Director, Indian Health Service.

      2. The IHS Community Health Medic Program is recognized as an established professional training activity of the Indian Health Service under local management.

      3. The Community Health Medic Program including continuing education programs, will be evaluated on the same basis as other training activities with criteria established for evaluating training activities in the Training Management Program.

      4. Until such time as supplemental positions and funding become available CHM classes, beginning with Class VI in 1976, will be limited to a maximum of 10 students, who will be trained at the Gallup training activity site.

      5. The Phoenix CHM training activity site will be utilized to provide continuing education for CHM's and other physician extenders, and to provide field evaluation of graduate CHM's, and supplemental training for physician extenders and M.D.'s.  The name of the Phoenix Program is changed to the IHS Clinical Continuing Education Center.

      6. Position announcements for admission to CHM training shall be standardized and specific on the qualifications for selection.

      7. The CHM training sites shall maintain accreditation by the Council of Medical Education of the American Medical Association.  CHM students shall receive academic instruction comparable to at least an AA Degree.

      8. CHM preceptees shall be carried as trainee positions, with authorized ceiling, by the Area providing primary training.

      9. CHM physician preceptors must receive specific training instruction in the continued training and supervision of CHM trainees.  The CHM Program Directors shall be responsible for the selection and instruction of preceptors and for providing technical assistance throughout the training year.


    1. Snyder Act 25 USC 13.

    2. P.L. 90-425 dated 7/26/69 IHS appropriations.  Included appropriation for physician assistant programs p. 15.

    3. "The Physician Assistant" U.S. Civil Service Commission Announcement No. 48, dated March 1971.

    4. P.L. 93-638 "The Indian Self-Determination and Education Assistance Act".

/Emery A. Johnson, M.D./
Emery A. Johnson, M.D.
Assistant Surgeon General
Director, Indian Health Service

NOTE:  Description of Pharmacy Practitioner has been revised.  Change is indicated by lines on page 2, section 2.B(7).  No. 76-4 Amendment 1 dated 4/25/79.

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