Shifting procedural work to midlevel providers

It is entirely clear that too few medical graduates go into primary care.

Although the number of family physicians is increasing modestly, there are very few internal medicine residents becoming primary care doctors. This year there will be only about 200 new internal medicine doctors entering the workforce from training programs, which will not even begin to cover the attrition of older and more efficient physicians, and due to improvements in access with the affordable care act, demand will be increasing significantly.  The main reason that very few physicians are choosing primary care is that specialty fields are just about as rewarding personally and way more rewarding financially.

Insurance companies in our present, primarily fee for service, payment system, pay generously for operations and procedures, but much less for complex interactions such as counseling patients on their multiple medical problems, medications, and managing their many diseases. A cataract operation is reimbursed at around $1500 or more, and an ophthalmologist can perform one of these in less than an hour. A similar hour of seeing patients will net a physician a small fraction of that amount of money, and will require many more decisions and neuron firings. Many other procedures have similar high reimbursement for very low amounts of work. If a physician specializes in a field that involves many procedures, he or she can make truly absurd amounts of money if there are sufficient numbers of patients who need that procedure.

Because of the shortage of primary care doctors, more and more people are getting their primary care from nurse practitioners and physician’s assistants, who have many fewer years of education than a physician. These providers are paid less than physicians and are more plentiful. Many of them are very competent, but patients often prefer an MD over a PA because the MD has a greater depth of knowledge. A primary care visit is often a combination of counseling about psychological issues, medications and interactions, review of tests, recommendations about prevention and careful examination (at its best). MDs can be very good at this.  Midlevel practitioners are often quicker, having been trained to treat urgent problems more than chronic ones.

Training to be a primary care physician requires at least 7 years after completing a bachelors or higher level college degree. The first year is spent learning basic science and physiology, the second involves absorbing huge amounts of information about human beings in health and disease. The third and fourth years bring the student in direct contact with patients, providing supervised clinical care along with classes and individual teaching by practicing physicians and academics. After these 4 years we have an MD degree, and must pass a licensing exam that assures a certain level of competence in all fields of medicine. At this point we can still choose to become surgeons, radiologists, pathologists or go on to academic medicine or research.  Those of us who intend to be primary care docs then spend at least 3 years in residency, taking care of patients under the supervision of more experienced physicians, with an increasing level of independence. When we finish these residency years we are broadly competent in taking care of most of what can go wrong with a human, with fresh and extensive knowledge of psychiatry, critical care, well patient care and the vast variety of other illnesses we have been exposed to.  After those residency years we have the opportunity to take another year or more of specialty training in fields such as cardiology, oncology, infections disease or rheumatology. Most physicians who specialize limit their practices to specific diseases and no longer do general medicine.

Nurse practitioners and physicians assistants must complete 2-3 years of training after getting their undergraduate degrees and in most states are then certified to practice independently. Although they are often gifted and become increasingly capable with years of practice, they do start out with considerably less training than physicians and the programs that train them are significantly less competitive.

So what would a midlevel practitioner be really excellent at doing? In what kind of a situation would a provider with less extensive experience and education really shine? Procedures. A midlevel such as a nurse practitioner or physicians assistant could learn to do an excellent cataract extraction or colonoscopy. Advanced level nurses already act as surgical assistants and have been providing anesthesia services at a high level for longer than MDs have done. In developing countries with less medical regulations, it is often the janitors or former patients who learn to do operations and act as surgeons when the foreign trained doctors are not available. I have read that some of the most skillful surgeons for vaginal fistulas, a very delicate and specialized condition of women who have had disastrous labors, are lay people.

What else would midlevels really excel at? Already much of diabetes care is delivered by nurse practitioners who limit themselves to issues related to that disease. They do an excellent job, often better than MDs. Specific disease states, as are now managed by subspecialists, would be perfect for nurse practitioners and PAs. In fact, this is already starting to gain momentum.

How would shifting procedural work to midlevel providers affect the health care equation? If less well paid providers did this work market forces would drive down costs, which would make procedure rich specialties less desirable. Health care costs would also go down, and if cognitive specialties such as primary care were even somewhat better reimbursed it would increase the number of talented folks choosing those careers.

A recent article in the New England Journal of Medicine obliquely addressed this question.

In this article authors looked at the success of treatment of hepatitis C by specialists vs primary care doctors after an online course in treating this common and deadly disease.  Primary care providers were slightly more successful than the gastroenterology clinic which trained them in curing the disease. This does, of course, involve MD providers in both cases, but gives very strong support for the idea that specialization can be taught effectively and quickly.

A move in this direction will be very unpopular among just those who are most needed to make it work, the MDs who make their livings doing procedures. These folks have years of practical experience and have skills that are not available in books or videos. Excellent surgeons will always be necessary and appreciated. A supremely skilled surgeon is an artist and deserves money and acclaim. Wise subspecialists will always be needed and appreciated in taking care of patients with diseases that are rare or so complicated that primary care physicians are just not enough. But we are now grossly out of balance, with a truly inadequate number of primary care physicians to take care our our growing needs, and appropriate use of midlevels could be a solution to the problem.

Janice Boughton is a physician who blogs at Why is American health care so expensive?

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  • Joe

    That scenario doesn’t sound like a roundabout way to increase the primary care physician stock. It sounds like a direct way to drive existing physicians away from practicing clinical medicine and very significantly decrease the quality of future medical school applicants.

    Physicians are not (yet) indentured servants, nor are prospective medical students. The comparative attractiveness of different medical specialties may seem like a zero sum game, but that is not the case – people can and will quit the game entirely.

    I happen to think most prospective medical students are not unaware of the reasons behind the primary care shortage. The fact that a career as a specialist is still viewed as worth the investment has kept medical school admissions competitive.

  • Tim Richardson

    Another cost saving mid-level provider are physical therapists treating lower back pain – a huge cost driver in most metropolitan healthcare systems.

    The medical model emphasizes treatment of pathology, such as a herniated disc, but many, many people with this problem are also underfit, overweight, anxious, fearful and unsure of what therapies can help vs. harm.

    Medical examinations may often lead to unwarranted x-rays or MRI’s which identify disc changes associated with aging. These changes may be assumed to cause the patient’s pain and, often, unwarranted surgery results.

    Physical therapists are trained at 215 doctor-level university programs around the USA to treat lower back pain using a biopsychosocial model, rather than a medical model, and to elicit factors in the examination that predict future disability and healthcare resource use.

    Screening algorithms can be used to identify low-frequency insidious events, like cancer or blood clots, that can mimic lower back and leg pain.

    Treatment of lower back pain is a well-defined process-of-care that can be safely performed by physical therapists.

    Patients are well satisfied by physical therapist treatments and their cost is considerably lower than physician costs.

    Tim Richardson, PT

    • Kevin

      Agreed! I would guess that outcome rates for LBP would be better for PT’s than it has been for PCMs (and even orthopedists!)

    • Bianca B

      Although I agree with the value to physical therapists, I do not agree with the categorization of them as mid-level providers. I have worked extensively with PT and OT as an Orthotist/Prosthetist and think that when it comes to evaluation-they often do a better job than the physicians. I am currently a PA student and firmly believe that mid-level providers should be reserved for PAs and NPs since they are physician extenders with much of the same scope of practice. PTs, OTs, etc are axillary healthcare – their scope of practice is not in line with MD/DO/PA/NP.

      • Carrie (@LizzPiano)

        I hate to beat a dead horse, but I would not lump NPs in any group referred to as physician extenders. That’s not the NP role or philosophy in any way. It’s a collaborative role and NPs work under their own license, with the scope of practice determined by the state. Once again, mid-level provider is not a term that should be used for anyone, IMHO…

        I do agree with Tim’s post on PTs and lower back pain, however. They can definitely prevent some of the over testing and quick response to surgical intervention.


    The easiest way to get more people to do primary care is to pay them more. We have all these roundabout ways of enticing people but I think in the end if you raise the lower paying specialities starting pay to around $200k your shortage will diminish.

    Payments to MDs make up only 5-10% of the total healthcare cost. Until primary care is paid what they deserve you will see a shortage.
    See my post on this below:

  • EmilyT

    >>>”In developing countries with less medical regulations, it is often the janitors or former patients who learn to do operations and act as surgeons when the foreign trained doctors are not available. ”

    I’m sensitive to the lack of medical care available today in some developing countries. And I’m aware that in days of old, barbers, adept at holding sharp instruments, often moonlighted as surgeons. But I’m curious what background skill would a janitor bring to the operating table?

    • JC

      We know how to keep a sterile environment! :)

      Seriously, very few people wake up one morning saying, “I want to be a janitor!” Like everyone else, there is usually a story that is either ending or developing as people transition through life, even in TWC’s.

      Some people missed the point the author was trying to make. I do not think that she was saying that we should adopt the practice of letting lay people perform procedures but rather that the idea that you need the type of training specialists have to be qualified to perform these procedures is erroneous. Dr. Boughton is simply pointing out the inequitability that exists in a system that rewards doctors by procedure and its effects on the quality and sustainability of our country’s current health care environment.

      This is a real issue that is directly tapping into a deeper problem in American society. Fortunately for us, there are some shining stars among our MD’s, NP’s, and others who genuinely care about more than the bottom line.

  • Margalit Gur-Arie

    I don’t understand why we are looking at developing countries when we are attempting to find solutions to our health care problems. They are using lay people to do surgery and other things because they have nothing better.
    This is not the problem we are having here, so why use the same solution?
    Are we aspiring to developing country status when it comes to health care?

    Specialists are paid too much and PCPs too little. That’s our very simple problem. The equally simple solution is to increase PCP pay, leave specialty pay alone and educate to reduce utilization of unneeded procedures. Things will even out in time.

  • pat

    Well, PAs by law always practice within the context of a doctor/PA team, even if the doctor is not directly at hand. Nurse practitioners are independent in only 13-17 states, depending on the exact definition you useThe current ratio of applicants to accepted students at the Portland Oregon PA programs (OHSU and Pacific University) is roughly 1000/40, which is more competitive than many DO programs and some MD programs. As a matter of fact, for the past few years, stats of PA applicants have compared favorably to those of DO applicants and are slightly higher than US students applying to medical schools outside the US (US IMGs)

    I agree that many PAs can and do handle procedures/ they first assist at more cardiothoracic and bypass cases in the US than anyone else (this includes vein harvesting independently). Some PAs at Duke do angiography from beginning to end; many do chest tubes and intubations in the ED. I had a student who, as a graduate PA, ended up placing more than 300 chest tubes in his first deployment to Iraq. PAs are now battalion medical officers in Afghanistan; two PAs have commanded FSTs (Forward Surgical Teams) in the operating theater. These teams also contained physicians as well as CRNAs. I think both their procedural and primary care skills are pretty advanced and it is an error to consider them, as a group, less qualified at entry to professional school.

    There is an interesting commentary on the training and philosophy of PAs in today’a JAMA.

  • Carrie (@LizzPiano)

    This argument is really struggling on many levels. To begin with, I agree with above comments that looking to underdeveloped countries to solve our own medical problems by returning surgery and procedures to the hands of lay people is absolutely absurd. This argument as stated above also compares nurse practitioners and physician assistants to lay people.

    Now, I am a human being first and foremost, then a patient, and then a nurse. I actually suffer from several complex chronic health conditions. When more acute situations arise, I tend to want to see physicians. When I’m in chronic disease state, I prefer to see nurse practitioners for exactly the opposite of what you’ve written above. Whereas the neurologist has 15 minutes (at best) to spend with me and is running 2 hours late, the nurse practitioner runs on time, spends a solid half hour and actually attends to me in a holistic way that does not ignore the fact that I’m a person and not just a disease entity. If there is any question whatsoever about my care during that appointment, she consults with the physician and at times even brings him in to discuss issues with me. In fact, seeing nurse practitioners from the patient role is what made me want to become one.

    I’m about 8 weeks away from finishing a Pediatric Acute/Chronic Nurse Practitioner program, and I’ve worked as a nurse in neonatal intensive care for 6 years. While there is some variation by state, nurses are required to have 2 years of nursing experience in the area they are seeking further education in before beginning the clinical rotations of their programs as advanced practice nurses. That’s different than both physicians and physician assistants actually.

    Nurse practitioners and physician assistants differ in many ways, not the least of which is a requirement of practice with patients prior to earning an advanced practice degree. Also, the role of the physician assistant was developed by physicians and was designed to actually help take care of the more procedural based tasks that physicians were unable to cover due to the needs of patients outweighing the availability of providers. Hence, most physician assistants work in surgical subspecialties such as orthopedics. While I have run into excellent ones in primary care and also know of several who work in other areas, it is definitely a profession that was designed with a certain purpose in mind.

    The nurse practitioner role developed out of the body of nursing literature, theory, and history. It is a role steeped in caring for the whole patient, educating patients and families on an endless number of topics, supporting the psychosocial needs of patients and families and fostering the professional development of the nursing profession, including that of nurses at the bedside, among many other things.

    The phrase “mid-level provider” originated from the Texas Medical Association amongst physicians who wished to keep NPs and PAs out of their realm. It is a terrible term that has unfortunately been assimilated into vernacular in other areas of the country. When used, it demonstrates a lack of understanding of the differences and strengths provided by both of these professions.

    The ultimate thing to remember here is that all of us who work in the medical profession in these capacities are here to work together as a team for the good of the patient. Nobody practices in a vacuum. As a nurse practitioner, I hope to provide comprehensive care for my patients, but I also am tremendously looking forward to the relationship I will build with physicians with whom I will collaborate in caring for the needs of my patients. As a patient, I appreciate the interplay between the physicians and nurse practitioners that I see. I value both of the roles tremendously but for different reasons. Any opportunity for patients to experience care by competent providers of any sort (there are incompetent physicians just as there are incompetent nurses) is a good one as the needs of our communities are tremendous. We must work together to fill these needs and not antagonistically. Yes, the primary care shortage needs to be addressed, but what you have proposed above is not the solution.

    Carrie Preston, BSN, RN, MSN Candidate, Master of Bioethics Candidate

  • Janice Boughton

    I’m not suggesting that PAs and NPs are similar to lay people, but that the years of general training required before an MD gets his or her degree are more suited to general practice than to procedural practice, and that providers can become adept at procedures in less time than they can become adept at primary care. I have worked with both NPs and PAs and find that they particularly shine when they are in positions where they specialize, and especially in procedural fields, both of which are paid particularly highly if the provider is an MD.

    The janitor story was told to me by a nurse who had second hand knowledge of the situation, but I have read other accounts of lay surgeons having excellent skills. The janitor in question developed his skills by assisting at surgery for many years. Most of good medicine is learned through practice, though formal education can be an excellent background. I don’t propose that we train lay surgeons in the US, but I do believe that we can learn from developing countries.

    There does seem to be some consensus that specialists are paid disproportionately to PCPs among commenters. It would be nice to allow the market to even this up a bit rather than try to mandate it, which sets physician against physician. Even though most health care providers agree that primary care should be paid more, we seem to be unable to do anything substantial about it. Legislated fixes don’t come near to evening out the differences.

    What I am proposing, as some of the commenters have noted, is nothing new. Already NPs and PAs are making inroads into the highly reimbursed provinces of MDs. I only suggest that we embrace the trend.

    As far as reducing the number of capable med school applicants, Joe, I don’t really think so. I do think that something needs to be done to reduce the debt burden of med school graduates, but if that is taken care of, I think we will get better med students if we are not trying to attract folks who choose medical careers because they pay so well.

  • Ugh

    It’s insulting that you believe intraocular surgery (cataract extraction) could be safely and competently performed by so-called midlevel providers. Would you trust your own eyes to these so-called “surgeons?” The whole point of medical and surgical training (residency) is not only to be able to perform these procedures, but to recognize when they are appropriate to perform, as well as manage complications that may (and do) arise.

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