Do most surgeons think mid-level providers can replace primary care physicians?
That much was implied during recent testimony by the American College of Surgeons’ John Preskitt, who said, “With trauma care and surgical emergencies, there are no good substitutes or physician extenders for a well-trained general surgeon or surgical specialist.”
The ACP’s Bob Doherty took that to mean that there were good substitutes for primary care doctors.
That may, or may not, be true, and it’s obvious we are seeing the seeds planted for a vicious turf war that will inevitably erupt as we move forward in health reform.
There is a school of thought that mid-level providers, like physician assistants and nurse practitioners, can be trained to do minor surgical operations and procedures. In fact, some think that may be a more appropriate venue for them, rather than managing a complex patient with multiple chronic issues.
In any case, the incentives that sway physicians towards procedure-based specialties affect mid-levels as well, and I would not be surprised to see them start training to do procedures like colonoscopies and minor operations soon.
So, if I was a subspecialist or general surgeon, I wouldn’t get too comfortable thinking that only primary care doctors could be so easily replaced.
Related posts:
- Is general surgery the primary care of specialties?
- Foreign medical graduates and mid-levels will provide the majority of tomorrow’s primary care
- Do mid-levels want to take over primary care?
- Should specialists be re-trained as primary care physicians?
- Work-hour restrictions in surgery?
- Why nurse practitioners and physician assistants will not solve the primary care shortage
- What role should nurse practitioners play in primary care?
{ 8 comments }
Mid-levels should be used more for prevention and care coordination. Physicians are not a cost-effective way of delivering either of those aspects of a thoughtfully reformed healthcare system.
They shouldn’t even exist. All that has to be done is increase the number of medical schools and slots within each school. To the exact degree that law schools have expanded. Once the graduates have flooded the market, insure that there are enough transitional/traditional intern years for all these graduates to essentially bring back general practitioners. It will be understood that they have passed the same level of competencies to be called a doctor rather than lobbying for it.
A PA and NP both have less medical training than a 3rd year medical student. Why would we let them perform surgeries or even be primary care providers when we wouldn’t trust a fresh medical graduate? We have lowered the bar for minimum standards in our country.
Midlevels should be used for simple repetitive tasks that can be learned quickly & easily, e.g. endoscopies, nuclear stress tests, perhaps even simple "lumps & bumps" surgeries.
This is not a far cry from CRNAs taking the place of anesthesiologists.
Personally I would rather have well-paid doctors for all of these making clinical decisions for myself, if i were the patient. Midlevels should play an ancillary nursing / secretarial / coordination role. But if that's impossible then substituting midlevels for the guy running the whole show (ie. primary doctor) seems totally ridiculous.
As a primary care (internist) MD myself, it really pisses me off when i send a patient for recurrent hematuria to a urologist for consultation, and i get a note from a urology PA telling me that "a UTI can cause hematuria, please check a urinalysis/urine culture and treat appropriately". Then when i try to call him back to explain that the patient needs a cystoscopy, he's only available on tuesdays & thursdays!
Stuff like that makes me feel that if i could just order e.g. a midlevel to DO THE CYSTOSCOPY under my orders, and bypass the idiotic judgment part of the equation, the patient would be better off. Same holds true for echocardiogram, upper endoscopy, colonoscopy, and a whole array of other procedures which require "specialty consultation" first. What a bunch of BS.
What are you talking about?? There’s a difference between performing a laparscopic cholecystectomy and treating a cold. There’s a difference bewteen doing a colonoscopy and dipping urine for a possible infection.
Will the mid-level take the patient to surgery after he or she perforates the colon?
I doubt mid-levels will be doing surgical procedures….if nothing else, the public won’t have it.
obgyn has already had this for a long time with cnms. they can do deliveries but supervised and no operative deliveries or surgeries. So I don’t think this is too far off especially if this is becoming the era of midlevel providers.
The MD is becoming a endangered species.
John Preskitt is simply defending his field.
Unfortunately, for those of us in primary care, there seems to be a lack of people speaking up to defend us. I guess we need to speak up for ourselves.
As far as the above story about a urology consultation done by a mid-level, I could not agree more. We referring doctors have got to insist that our patients are seen by attending physicians, or do not send your patients to those practices.
A family practitioner
I want to leave everyone with this concept. Surgery is a medical discipline that encompasses the care of patients with the potential need for surgical intervention. This is apart from the technical aspects of an operation. A good surgeon is one who is trained to recognize who should, and who should NOT have an operation. Additionally this translates into an individual who can perform excellent preoperative management as well as postoperative care. This person needs to understand all the ins and outs of the complications that may arise because of performing surgical procedures and how to reduce the risk of those complications and finally how to manage said complications.
I honestly do not have any concern that midlevel practitioners will endager my career. If they do… maybe my work week will go from 100 hours to 80. How scary would that be.
JFS
I think the original idea of PAs was to extend MDs, no? In my first-hand experience, this seems to work well–e.g., cardiac surgery performed by the MD while the PA is available to re-insert chest tubes that come out in recovery, answer late-night phone calls, etc. I have also been on the receiving end of poor physical exam and incorrect diagnosis from a PA. My uneducated guess is that mid-levels are more appropriately trained into performing narrow specific tasks rather than primary care, although I could see management in a preventive context as well.
While I understand why MDs are concerned about less educated providers, I have also experienced the situation in which hospital RNs calling MDs can predict the MDs’ orders with a high level of accuracy. I’m not sure what to make of this, but when someone with an associate’s degree and someone with a doctorate and residency training can come to the same conclusions 90% of the time, something is amiss in the system.
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