1) Nurse practitioners are taking over primary care in the UK. Today, Dr. Crippen describes NP-focused clinics that promote provider access and short wait times.
My take: There are calls for using mid-levels as a means to solve the primary care crisis in the United States. Two problems with that. First, mid-levels aren’t stupid. They see the problems that are afflicting primary care, ranging from the bureaucracy and paperwork, emphasis on volume and quantity, and the lack of professional respect. Like medical students, surveys show physician assistants are increasingly shying away from primary care and entering medical and surgical sub-specialties. Who’s to say that mid-levels even want to take up the primary care slack? Why board a sinking ship?
Next, will patients accept having the majority of primary care handled by PAs and NPs? Yes, there are numerous anecdotes of appropriate care and patient satisfaction, but I have also experienced significant pushback when patients are “forced” to see a mid-level. Will provider access supersede the desire to see a physician? That unanswered question will go a long way in determining if the mid-level PCP movement will gain traction Stateside.
2) Boston mayor Tom Menino convenes a group of academic physicians to find ways to reduce waiting times for appointments and expand access to urgent-care services.
My take: What a joke. The academic setting is precisely the wrong place to start if you want solutions. Look no further than our leaders at the ACP and AMA who have done very little to save primary care. The ivory tower is shielded from the issues facing private practice, leading them to be out-of-touch with the majority of physicians in the country.
If you want solutions, reach out primarily to physicians in the community, and don’t get blinded from the high-powered titles of academic physicians.
Related posts:
- Foreign medical graduates and mid-levels will provide the majority of tomorrow’s primary care
- My take: Mid-levels, cost-shifting, IMGs
- Boston’s primary care summit
- My take: Mid-levels, health consultants, blogging
- Mid-levels for primary care, but not for surgery?
- When do mid-levels help in the ER?
- Do mid-levels want to take over primary care?
{ 8 comments }
very well put Kevin.
My feeling about the expansion of e.g. minute-clinics as the answer to primary care: It’s a RIDICULOUS stretch to say that NPs & PAs treating “simple stuff” like URI’s, strep throat, etc. will fill the primary care void that will grow as the elderly medicare population grows.
The majority of those folks using minute-clinics will inevitably be young & healthy overall, between jobs & therefore uninsured. These guys will get over their colds within a few days anyway, with or without the z-pak & robitussin.
For the 75-yr-old on 10 meds with chf, uncontrolled diabetes, and pneumonia, it’ll be a different story, and the minute-clinic will only be a useless $50 stopover on the way to the ER (hopefully).
I have no problem seeing an NP once in awhile. They definitely serve a purpose. I want to be an NP eventually.
However, if I never saw the doctor, I’d be pissed. NPs were never meant to replace doctors, nor do they want to in my experience.
I think Dr. Crippen was way off the mark when he said that they don’t know when to get the doctor involved though. That hasn’t been my experience at all.
When I did a number on my ankle playing basketball I was quite satisfied to see a PA. Had the bone been sticking out of my skin I probably would have gone to the ER. Since I could hobble home I did, and called my health plan.
I got in with a PA promptly, saving me the indignity of the ER. He wiggled it around in a gentle way and send me on for an Xray. Nothing broken, wrap it up and stay off of it.
Had it been broken I would have expected to see an MD. Had it not improved in a few days I would have called back and seen an MD.
All in all I’d rather see and NP or PA promptly at my health center where my records are than sit among the unwashed in the ER.
So right Dr. Kev. It’s the docs in the trenches who have their finger on the pulse—literally and figuratively. When it comes to any meaningful change in American medicine, if you don’t get their buy in, it’s really not going to happen. Just as it should be.
And you do great work representing that group. Keep up the outrage.
Greg Kelly
Physicians’ Financial News
http://www.pfnlive.com
I think using mid-levels for primary care is an inexorable trend, particularly as it seem that prpimary care will continue to decline in numbers and influence.
What I see is the efficacious use of mid-levels in specialists’ offices to perform primary care. The added advantage is that if a true specialty need arises the specialist is on the premises available for prompt consultation. It’s pretty hard to argue against instant access.
That does not take the place of comprehensive health care, but since patients are self-referring for a specific problem anyway, the comprehensive part of it is not a concern of the specialist.
Hmmm. Interesting. I know several PCP’s who use midlevels to do a lot of their work in the office. I am sure that most patients are happy with them since they have been working there for many years. Some people however, are just snooty and refuse to even be examined by PA. I guess as they encounter more good ones, that attitude may change.
“What a joke. The academic setting is precisely the wrong place to start if you want solutions.”
100% true. Which is precisely why the politicians are avoiding dealing with real clinical physicians like the plague. The sorry excuses for Presidential candidates, third rate hacks like Tom Menino, the insurance companies, and various power-hungry bureaucracies are instead busy scheming on various ways to (excuse my language) screw us royally.
There are many, many billions of dollars to be made by unscrupulous insurance companies with government monopoly contracts. There’s big money also to corrupt politicians (Think Bill Clinton’s recent influence peddling for mega-millions).
Ed Sodaro MD
Kevin, you mention anecdotes of NP-rendered patient staisfaction and “appropriate” care. Well, I’d just like to provide you with some peer-reviewed evidence to perhaps shift your mindset a little: http://www.cochrane.org/reviews/en/ab001271.html, http://jama.ama-assn.org/cgi/content/abstract/283/1/59, http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&uid=16282871&cmd=showdetailview&indexed=google (I have more if you’d like to see them). The fact is that NP’s have been providing high-qulaity cost-effective care for years.
NP’s will be willing and able to fill these voids in primary care.
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