Honestly, I personally think it will HAVE to be both. I've seen awesome PAs and NPs - but general practice is difficult (despite its reputation) - family practice has a daunting number of diagnoses, conditions, illnesses that the physician has to be aware of. When you compare how much training PAs and NPs have compared to the years of training involved in a M.D. and the FP residency (or any residency for that matter), it's difficult to imagine PAs and NPs serving as the sole providers (or as the majority of sole providers) of primary care. The position where I have seen NPs and PAs function the most autonomously is actually as PART of a specialist's practice - like the ortho PA or the plastic surgery NP - they are trained to perform a specific function in the clinic or hospital (wound checks) but have some background in medicine to recognize if something is nor the way it should be. I've seen the other end, with PAs and NPs in family practice clinics who just don't have the experience or training to provide the full-spectrum of care that a family physician can (hypertension and diabetic checks are one thing - but delivering a baby or doing some procedures (colonoscopy) or caring for patients with complicated illnesses). However, I think PAs and NPs are important to FP - but do need to be closely supervised. I'll never forget working with a physician in the ER, and a patient with a list of meds a page long (you know the patients I'm talking about) and multiple medical and social issues came in - and her primary was a PA (a well respected one in the community) - and the ER physician said "Geez, I really wish Dr. X (the supervising physician of the PA) wouldn't farm these kinds of patients out to his PAs." But everyone is happy when the PAs take care of the urgent care stuff in clinic - colds, etc. I guess - where to draw the line??
One other thing - whenever a health care company or HMO is selecting one kind of provider over the other because it helps them make more money, whether it's requiring a certain number of referrals to specialists to make more money or adding NPs and PAs so that they can pay them less and save money rather than hiring physicians, who really wins??? Not the patient....the corporation. Something to think about.
I would like to add, please don't flame me - this message was NOT meant to be a slam to PAs and NPs. Everyone has a role in the health care system, it's just figuring out what that role is so a patient can receive the best care possible (at the least cost).