One proposed way to control costs is to replace primary care doctors with mid-level providers, like nurse practitioners and physician assistants.
Merely bringing up this idea brings out the worst in turf battles, with most discussions devolving into nurse versus doctor cat-fights.
The ACP comes up with their vision of how nurse practitioners fit within the primary care spectrum. It wisely takes a balanced approach, but, as Bob Doherty writes, will likely disappoint both doctors and nurses on their respective extremes.
For most reasonable people, it’s a good compromise, acknowledging the fact that nurse practitioners play a vital role in primary care delivery, while allowing that physicians are best equipped to lead teams that treat complex medical patients.
In the end, rather that arguing who works for the other, both doctors and nurses have to realize that it’s the patients who come first, and to care best for them, a team-based approach is needed.
Related posts:
- Why nurse practitioners and physician assistants will not solve the primary care shortage
- Why health care savings accounts should play a larger role in reform
- My take: NPs, solving health care, generics vs brand name drugs
- Will nurses solve the primary care crisis?
- Do mid-levels want to take over primary care?
- Does the AMA secretly want to kill primary care?
- Physician assistants and nurse practitioners are staffing rural ERs full time
{ 11 comments }
They shouldn’t even exist. Now matter how you analyze their training they have less when compared to a physician.
NP’s have lowered the threshold for what it takes to have independent practice in an era of increased complexity.
All that has to be done is let medical schools expand and increase like law schools. Once we surpass the number of residency slots per graduates we go back to the days of having intern trained GPs. Would you rather have a NP/PA or a physician GP?
When it becomes clear to rotating medical students that the line between mid-levels and physicians in the outpatient setting has been blurred, the MD flight from primary care will be complete.
Despite all the lofty rhetoric of collaboration, this is really about a conceptual shift that you either believe or you do not: most primary care can be delivered by mid-levels.
Having a few MDs (those remaining in primary care for now) loosely supervise midlevels(”supervise” being more the theory than reality)is the new model being put forward. And I’m sure if there are no lapdog MDs willing to do this job in any given area, there will soon be a push for experienced midlevels to supervise the younger midlevels. Which shouldn’t bother anyone, because remember, you don’t need an MD to do most primary care. And you can just refer the difficult cases to specialists.
So when med students rotating through these new exciting Medical Home collaborative models see that midlevels are doing pretty much the same thing as the docs when it comes to the nuts and bolts of caring for patients, the nail will be firmly planted in the coffin.
Why go through medical school, residency, call nights, debt, etc. to do a job that is little different from an NP/PA? that would just be stupid. And most med students aren’t stupid.
How are physicians doing primary care supposed to make the case for increased payments for their services (a recurring theme on this blog) if there is increasing agreement that much of what happens in primary care settings can be handled by midlevels?
Either it’s complex, important work that a physician should be doing, or it’s relatively straightforward algorithm driven work that a midlevel can handle most of the time. If we think it’s the latter, then good luck getting the government or any insurance company to pay MORE for the physcians doing the work that could be done by cheaper providers.
They shouldn’t even exist…..
No matter how you analyze it, less training…..
First of all, with the shortage of Primary Care Providers that currently exists, not considering the impending exacerbation of the shortage that the babyboomers will bring, who do you propose should provide primary care for our patients Doctor?
Second, why is it that Physicians assume that the only place one can learn medicine, is in medical school? This might be shocking to some physicians, but pharmacology, anatomy, physiology and pathophysiology can be, and is currently taught to non-physicians. Doctor, this might also be shocking, but they probably are teaching those nurses out of the very same text books that you used.
It is time to acknowledge what Nurse Practicioners bring to the table.
Experience. Before they were NP’s, they were nurses. The same nurses who teach interns how to start IVs and take blood pressures. Education. The curriculum for all advanced practice nurses is getting longer, and more comprehensive. Thus the progression to Doctorate prepared advanced practice nurses.
It is time to stop wasting our resources on medical turf wars while the insurance companies are sticking it to patients and providers alike.
Problem is all too many docs in Primary Care are not much better than a nurse practitioner. Part of the problem is, of course, the docs themselves. Big chunk of the blame goes to the programs that emphasize woo and psychobabble to the detriment of real-live medicine.
They dumb down their teaching to a NP level.
I am growing my own practice. I moonlight in an Urgent Care for the cash flow ’till the practice grows. It’s instructive ’cause I see all the shitty practices from some primary care clinics.
Patient calls office at 9-AM during weekday with, say, bronchitis. Cough, fever, the usual. “I need to see the doctor”.
They get “Go to the ER” or “Go to Urgent Care”, and they end up in my office. Minor cuts and scrapes. Cerumen impactions. So many primary care offices book so heavily they won’t accomodate these patients.
I just had someone with lab testing and imaging reports for a chronic painful condition. Annoying but not dangerous. So patient, as part of workup, gets these tests. Patient calls doc’s office. “How did test reports come back?” OK, I prefer to do these face-to-face. Yes, I bill the counseling. Some may argue with that.
But this office gives patient the raw data. A lot of “maybe it’s this, maybe it’s that” stuff from the radiologist. Yes, that’s the radiologist’s job, no problem. But the patient is now freaked. “Maybe it’s this, maybe it’s that” is interpreted by patient as “I have this, I have that”.
And patient has specific concerns. Traveling on business, is it safe? Answer is yes.
But doc’s office does not accomodate. No I don’t mean 3-AM or Saturday afternoon, I mean Tuesday at 9-AM request, and now I’m seeing patient on Saturday.
Patient’s doc does not accomodate. Patient’s doc’s associates do not accomodate (assuming doc was not around that week). So patient stews, and next thing I know, patient is in Urgent Care for explanation of tests.
Yes, I know, two sides of story, just take my word for it, I checked it out.
But hey, doc is salaried. Big box clinic. No motivation do do this.
So, I find myself counseling patient, as best as I can, not being primary physician. I gave them the usual caveats.
Actually, knowing parties involved professionally, it’s not the docs, it’s the organization they work in.
Seeing that, I know what NOT to do in my own solo private practice. Patient gets long, detailed explanation from me (when long detailed explanation is needed, like in patient with chronic painful condition and workup in progress but so far unrevealing). So patient can be told “we don’t know what you have but we know you don’t have a whole bunch of dangerous things, you don’t have this, you don’t have that, so maybe you have a whole bunch of other annoying but less dangerous stuff, so go on with your life and let’s keep looking, and yes, it’s safe to go on that business trip, they have docs smarter than me where you’re heading, blah, blah….”
Difference maybe, I do charge for the counseling, doc in question is salaried. You get what you pay for.
But yeah, I see practices where the patient might as well see a midlevel ’cause the doc practices at the midlevel’s standard anyway.
The doc needs to make sure he/she is offering something better.
It is not just the primary care involvement of the NP/PA’s that will show the medical students that “midlevels” are doing nuts and bolts of caring for patients.
I call for specialty consults [cardiology, ortho, derm] and get a note in the chart from a PA. The note gets reviewed by an MD….whenever. Does the specialist MD ever see the patient? Beats me.
Oh, as as for NP/PA’s being willing to stay in their “midlevel” designated roles? Have you seen the “medical wellness spas” in the malls where along w/your massage you can get dermabrasion, Restylane, Botox, etc? Lots of them are run by NP/PA’s. Sure, subsidize their schooling w/M’care $ and watch them flock to be useless.
Not to say that MD’s don’t do useless cosmetic high income stuff, but the fiction is that it benefits the health care system to have “midlevels” do primary care. They won’t.
Differential Diagnosis
Any questions?
Medical school is not replaceable. There are tangible and intangibles associated with medical school. You have a group of people who face hard work, long hours, and constant beradement with the question, “why?” A nurse practitioner isn’t surrounded for 7+ years in an environment of asking and seeking the solution to the question “why?” A NP applicant spent their time teaching interns how to draw blood as you pointed out. NP degrees exist in part because the NPs were too LAZY to go back and do a post bacc to obtain the necessary pre-requisites to get into medical school or even PA school. The whole degree exists as a result of not wanting to spend the TIME AND EFFORT to become a real doctor, a physician.
Nurses strive to make themselves a profession, unique from medicine to gain respect for the services and their greatest irony is making an advanced degree to become a ‘doctor.’ They insult themselves with this degree. Applicants who choose NP school do so because they aren’t as rigerous. They are offered online. You can still work while you are learning advanced nursing theory. I don’t want my family treated by some one who doesn’t have the heart/desire/devotion and work ethic to do something right the first time. How many MD/DO/MBBS went back to be a NP for the special training of Nursing theory? How many NPs go on to be physicians?
Primary care has been neudered. It has been so by the entitled attitude of our country for specialists and enforced by the poor reimbursements of insurance companies for selective procedures and regimens by a PCP. FP and general IM training is capable of a lot of medicine, including the inpatient management of illnesses. As medicare collapses and people once again are reluctantly forced to pay cash for medical care in our failing economy a comprehensive care physician will be the best bang for your dollar. Cash/retainer/concierge physicians are already illustrating this point.
12:16 Anonymous: the argument that these same NPs trained the doctors in procedures such as taking blood pressures and starting IVs doesn’t imply to me that the NPs are competent to do the doctor’s job. I can teach you how to do a lot of routine motorcycle maintenance, but that doesn’t mean I can diagnose and repair a complex mechanical problem. I’m more sympathetic to the idea that advanced practice nursing education imparts the skills for primary care…to a point.
I’m pretty torn on this issue because, frankly, there are a lot of bad primary care physicians. If all I can expect from an MD is a dull-eyed stare, some checking of check-boxes on an EMR screen, and a lab slip for this year’s lipid and fasting blood glucose screening…well, an NP can easily do all that, and probably adopt a less vacant expression while doing it. If my primary care MD is actually a *doctor* who is intellectually engaged with his work, that is a different matter entirely, and I don’t think an NP will easily fill those shoes. Unfortunately quite a few MD’s currently practicing as PCPs don’t, either.
As things are, replacing bottom-of-the-class MDs with high-achieving NPs is probably a win for average quality of care, although it would also drive out or up the good doctors and pretty much ensure no more enter the field. Finding some way to make primary care medicine more attractive to more good doctors would be a lot better, IMO.
NP training is enough to serve most patients–only because most patients recover without treatment and only need to receive treatment that doesn’t kill them.
NP training is inadequate to reliably detect the unusual exceptions that call for prompt intervention to prevent catastrophe–but then so is a well-trained MD who is burned-out, lazy, or careless as many that I observe are.
I used to be fine with the whole NP idea but have observed too many specific anecdotes of patients permanently serverely disabled or dead due to the critical eval being left up to the NP who missed the smoking gun. I am talking about cases where they got the critical data and documented but just didn’t realize it’s importance. Not knowing that severe vomiting and diarrhea in a patient on lithium is life threatening and calls for lithium levels to be checked. Not knowing that heavy drinking calls for thiamine on admission to prevent permanent neuropyschiatric impairment. Not knowing that acute developement of regional lymphadenopathy might be a fungal infection rather than cancer.
But, since sometimes good NP’s outperform sloppy docs, people should have a choice. It is after all, their life and their health at stake. Let them choose their gamble as long as they are competent and free to do so. But the law should require everyone to always make it clear who and what they are too all patients. All healthcare personnel should be clearly labeled as to content, as much as food. And irregardless of how well earned a persons doctorate, the title should be restricted to the usual “doctors” in healthcare settings, so as to avoid confusion. Also, in settings where people do not have the freedom to choose by reason of competence or context (such as an emergency), the use of mid-levels should be strictly limited–the law should protect those who can’t protect themselves.
If , a patient is electively admitted to the hospital, and has a workup by a midlevel instead of a physician, they should have given their prior consent to that, and should have the right to object with no prejudice to be attatched to them and provided with a physician.
There’s been a couple posts on the idea that good midlevels are probably as good (or better) than bad doctors. That’s probably true, but irrelevant. Dont forget, midlevels can be lazy, burned out, whatever, also.
The real question is how does the training/knowledge/skills differ between an average midlevel and an average MD, and which level is needed for the proper delivery of primary care.
Comments on this entry are closed.