Primary care doctors at a competitive disadvantage to midlevels

A primary care resident wrote in one of the journals recently about making the limited time she has with each patient matter the most.

How refreshing, I thought when she concluded that time ultimately is an absolute and finite resource. We often feel as if we are battling time as much as we are battling disease, and we sometimes have trouble admitting when we are losing either one of those battles. Some of us find it more difficult than others to say “no” to unrealistic demands for clinical output per unit of time.

But the writer had another agenda: by teaming up with nurse practitioners or physician assistants, she envisioned having more time to spend with each patient.

This type of new math doesn’t really work in primary care. A physician who performs expensive procedures can maximize his or her time in the operating room by sharing office visits with a less trained and lower-paid “midlevel” practitioner, who could never replace the physician in the operating room.

In primary care, however, physicians, nurse Practitioners and physician Assistants tend to do the same type of work, and if anything, physicians tend to have shorter appointments than “midlevel practitioners,” reflecting their higher level of training and justifying their higher salaries.

Every patient deserves the best care we can give them, and there is no reason to believe that patients who see a physician are so much more complicated that they always deserve more time than patients who see a “midlevel.”

If the young writer expects to have “midlevel providers” somehow subsidize her requirements of time and money, she is not likely to find this in today’s medical environment. She may instead find herself in direct competition with them. In states where nurse practitioners can practice without physician supervision, she might actually be at a competitive disadvantage, should her productivity drop below that of providers making half her salary.

A Country Doctor is a family physician who blogs at A Country Doctor Writes:.

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Comments

cemcbtide3rdmd
If the model of care delivery remains as is, I would concur with Country Doctor’s assessment. However, consider a model where the stable chronically ill develop an agreed upon treatment regimen which is then carried out by mid level practitioners working in collaboration with primary care physicians. This would then free up the physicians to see the unstable chronically ill as well as the acutely ill.
Laurie
I found the physician/midlevel partnership a horrible experience. The midlevels I saw failed to see that a more complicated disease was present. It interfered with the doctor-patient relationship, and the my doctor was quick to diagnose me with mental problems instead of desperation.
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As a patient, I feel at least as comfortable with a nurse practitioner or a physician assistant, as with a doctor. In fact, I prefer a PA or NP, because they do seem able to spend more time with each patient. But I don’t think of them as competitors, but as partners in the same clinic, with each being used most efficiently, and the doctor seeing only the most difficult cases.
Jim Purdy
shane
The question for a patient should be: who provides me the best primary care. I personally prefer NPs for their nursing philosophy and patient experience as my primary care, and a physician for specialty care. From what I understand, NPs have as good or better outcomes than physicians in primary care, and in my experience they tend to be more attentive and holistic, and less dogmatic and prescriptive.
Beginning med student
I should avoid these web sites. They are driving the thought of being a primary care physician out of my mind.

2nd year med student
me too, beginning, me too. or perhaps i should read these web sites daily. one or the other.

3rd year med student
I’ve chosen daily. First you despair, but then you learn. There seem to be a fairly large number of primary care physicians very pleased, and professionally satisfied, with their cash-only practices along something like HelloHealth or other low-overhead cash only practices.

Max
I checked out that hello health website. Pretty interesting. What else can you tell us about it? I have a feeling more and more practices will be moving to a cash-only model.

jsmith
Low-payers will get mostly nurses and PAs if they’re lucky enough to find them, and some high-payers will get concierge care with a doctor. The number of physicians and others doing primary care decreases over time relative to the population, causing a nasty shortage, but the political system does not intervene effectively. Internists almost all become hospitalists and subspecialists Remaining family med docs gravitate towards concierge as the field withers away. America’s HC bill explodes as the country wrings its hands.
Doctors, almost all of whom are now specialists, of course land on their feet, but basic medical needs go unmet.
Nothing unusual really, just the typical pattern of medical care in a third-world country.

Primary care doctors at a competitive disadvantage to midlevels

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