Internists

i think the answer for extenders is what is happening anyway, but NOT what those outside healthcare see as the future of primary care.

For example, which of the following scenarios do you think is better suited to a PA than an MD:

(1) 90-year-old woman comes to ER with dizziness. She has a history of diabetes, CHF (ischemic cardiomyopathy, peripheral vascular disease, atrial fibrillation on coumadin, remote history of breast cancer, and "low blood" according to her companion. She sees at least three different MDs, and takes 8 different meds. Her blood pressure is 80s/50s, and her pulse is 140s and irregular. She's not sure where she is, but recognizes her home health aide;

or (2): 45-year-old wall street exec comes in to the cardiologist (directly, without referral or a prior visit with his PCP) has no symptoms whatsoever. Was a smoker in the past but otherwise no cardiac risks. He's about to get tested up the wazoo, with the trifecta ECHO, STRESS, and HOLTER. and will probably not even see the cardiologist, unless of course the tests are equivocal.

You get the point – extenders are MUCH better suited to repetitive easily-learned tasks with little variation in possible outcomes, ie. subspecialty care.

It SO irks me when i get a patient admitted to my nursing home who was in the hospital for 6 weeks, including an ICU stay with intubation, has a history like the patient (1) above, and comes to me with a one paragraph discharge summary signed by a PA with no telephone / pager number and an illegible name.

Extenders should STRICTLY STICK to specialty care, in my opinion. Perhaps that's because of the unfortunate evolution of specialty medicine – somehow 90% of internal medicine training & 75% of cardiology fellowship training goes out the window once a cardiologist decides to only do caths. Same analogy can apply to almost any subpecialist.

In my opinion, extenders have no business running hospital services with sick elderly patients, and little or no physician oversight.