Providers who want the authority of doctors: Let them have it

California doesn’t have enough doctors to provide healthcare to newly insured patients.

California state senator Ed Hernandez asks, “What good is it if they [state citizens] are going to have a health insurance card but no access to doctors?”

Wait. Health care insurance doesn’t mean that patients will have access to health care? Where have I heard that being said for more than 3 years?

The government is going to give patients their medical “insurance,” but access to physicians is limited by government policies, payment cuts, and administrative red tape — which are driving many doctors from the primary care business and are, in effect, rationing care to patients.

California’s grand plan is to allow physician assistants, nurse practitioners, optometrists, and pharmacists to provide primary care services. I liked one of the commenters who said that he went to see the doctor, but was referred to the janitor who gave him a bag of medications for $5. These other health professionals and their organizations seem to naively think that the patients they will treat only require management of simple medical problems. In reality, most patients have multiple interrelated chronic medical problems that must be managed together.

Take diabetes, for example. Will it really be cost effective to have an optometrist manage a patient’s diabetes and perhaps monitor the patient’s diabetic retinopathy while the patient still has to be assessed and monitored for diabetic nephropathy, diabetic wounds and wound care, diabetic neuropathy, the increased risk of heart disease, oh and the impotence that often accompanies diabetes? Should the optometrist prescribe Viagra for a diabetic patient with heart disease or not?

If the optometrist refers the patient to a bunch of physicians to make those decisions, then the government has just created an additional layer of bureaucracy which will cost more money.

If the optometrist just blissfully monitors the patient’s glucose levels, prescribes insulin and doesn’t regularly evaluate the patient for diabetic complications, then the patients are receiving government-sanctioned poor medical care. That should make the trial lawyers happy … if the optometrists have insurance for the millions of dollars in damages when bad outcomes occur.

These health care providers are begging to get in over their heads and we need to let them do so. The medical establishment should really stop fighting this idea.

Allowing governments to implement a system that reduces access to doctors, increases complexity in medical care, and that will likely increase bad outcomes will eventually create patient outrage with government officials who adopt the idea.

We all should be part of a team, but not everyone is able to play quarterback.

I predict that these types of policies, if implemented, will ultimately increase the demand for physicians.

Unfortunately, the underlying problem is that most of us will be expected to pay more in “taxes”, insurance premiums, and other fees … for less medical care.

But remember that everyone will be insured, so things will be OK.

In anticipation of hate mail from nurse practitioners, physician assistants, optometrists, pharmacists expressing outrage at my unprofessional stance because there aren’t any studies showing worse outcomes in medical care provided by those with less medical training, I’ll quote a comment that I posted a couple of months ago in response to a nurse practitioner who asserted that he had “the same ability to provide patient care [as physicians] based on the evidence.”

You’re right about all the studies, I’m sure. In fact, I bet there aren’t any studies showing that treatment rendered by grade schoolers is any worse than that rendered by nurse practitioners, so next down the line to help patients save money will be gifted grade school student phone advice and then Shaman Skype toddlers with their magical rattles of health. Goo goo ga ga.

I don’t care how good you think you are, if you can’t pass a doctor’s board exam, you shouldn’t be [independently] treating patients, so lose the ego. Actually, the law says that you can treat patients, but you damn well better tell the patients that you aren’t a doctor and then let the patients decide whether they trust you with their lives. But lose the ego, anyway. It’s a team sport and you don’t get to be the captain just because you think you’re better than everyone else. When there’s an emergency in the hospital, no one goes running to find the nurse practitioner.

“WhiteCoat” is an emergency physician who blogs at WhiteCoat’s Call Room at Emergency Physicians Monthly.

Comments are moderated before they are published. Please read the comment policy.

  • kpagliai@hotmail.com

    Actually, as an NP in the ER, people do look for me when there is an emergency, especially when the physicians are tied up with other emergencies. I think the real issue is not what degree you hold, but knowing your strengths and limitations as a provider, and practicing accordingly. I would never try and treat someone with multiple, chronic health issues but I can treat most acute care illnesses and injuries with confidence. Maybe its you who needs to drop the ego. I know plenty of providers who can pass a test but aren’t worth the paper it was printed on.

    • Close Call

      “I think the real issue is not what degree you hold, but knowing your strengths and limitations as a provider, and practicing accordingly”

      But that’s so nebulous! Unless you want to do away with all accreditation bodies, there must be some standards involved. For example, family physicians must have a certain number of clinic visits by the time they graduate, do a certain number of supervised procedures, deliveries, community projects, a certain number of hours of didactic sessions, carry a certain number of patients on a service during each rotation, etc…. plus take the 3 step tests and pass the board exam.

      They’re measurable objectives.

      Most physicians aren’t familiar with what measurable objectives a freshly minted NP has had to accomplish. I’ve looked, and I can’t figure out how many patients they’re supposed to follow in the hospital, or how many EKG’s they’re supposed to interpret, or how many clinic visits have they had to perform before they’re allowed to graduate?

      It would be very helpful if these were made plain so that an accurate comparison can be done.

      • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

        I have to agree with post, especially on the part that there has to be some standards involved when it comes to scope of practice. If not, then we are setting ourselves up to go back to the way it was prior to the turn of the 20th century. Do we really want the next generation to have to see what those of previous generations before us had to experience?

    • WhiteCoatRants

      I’m glad that people look to you in emergencies. However, the assertion that some people look to you in emergencies does not mean that your emergency department is the yardstick by which all other emergency departments in this country should be measured. Similarly, the assertion that you know providers who aren’t worth a piece of paper does not mean that you are smarter than a preponderance of providers or that all other NPs are as smart as you are.
      Like I argue in the article, have at it. Do brain surgery with a screwdriver if you want. I *want* you to have all the privileges that doctors have. Breaking down the barriers to access will ultimately help patients be better consumers of medical care. You just better inform the patients about the amount of your training, that’s all.
      So are you upset because someone wants NPs to have more privileges or do you just want to arbitrarily berate those with more training than you?

      • kpagliai@hotmail.com

        I’m not sure why you think I don’t let my patients know exactly who I am and what my training is. I’m proud to be an NP and don’t understand why you assume we are all parading around pretending to be doctors. What we want is the ability to provide access to healthcare to those who would otherwise be without. I also work at a rural health clinic that provides free healthcare to individuals with no insurance or ability to pay. Right now, we pay a physician $2000 to come sign our charts once a month. That is all he does. At the same time, I am paid less per hour there than I was as an RN. I do it because I love it. And why is everyone assuming we will “shy away” from the responsibility that ensues? Please don’t make general assumptions about NP’s based on a few bad apples.

        • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

          It’s good that you are proud to be an NP, but the issue here in part is that you have been trained to do things that should only be done by doctors. Two examples of that are: 1. prescribing medications, and 2. analyzing test results such as for routine labs. Not that doctors can’t make mistakes because we know they can, but they have more training to know when the result indicates that the patient is in trouble.
          Alot of people have the idea that they get better care from an NP because they spend more with the patient than the doctor does (yes, I know that NPs in various specialties may not always get that opportunity but this is a perception that many have). There are many people out there who have very complicated health histories because of multiple health problems. Some of those problems are not just the common ones seen in many Primary Care Physician offices. How many hours do you get both in the classroom and in the clinical setting in how to deal with those who have complicated medical histories as part of your training before you can graduate from school whether at the MSN or DNP level? I met an NP last week that made the comment to my relative when we were at this clinic to follow up after hospitalization that she knew as much as the doctor did. And that the information she just gave us the doctor would have given to us. Ok, fine but that comment really bothered me a lot.
          May I please ask why it is that you chose not to go to Medical School or Osteopathic Medical School? Also, what can you do for the patients as far as helping with their care that is different from the doctor that many (myself included) would prefer to see? I am in Nursing School now going through my General Education classes, and wil start my core classes in May. I am very excited about that, but it bothers me very much that there are those in the Nursing profession that want to duplicate what has already been established by doctors. Basically, re-inventing the wheel. This bothers me very much because of the liability factor when it comes to scope of practice. I know it has been said that there have been studies done to show that the satisfaction rate among patients is high, and same for the safety factor. Have any of these studies been published in the medical journals too so that we can all see? If not, why not?

          • kpagliai@hotmail.com

            First of all, I did not go to medical school for a number of reasons. Not only did I not have the finances, but also because I wanted to have a family and knew that a nursing profession would fit that lifestyle. After 7 years in the nursing profession, I knew I wanted to do more. I returned to school part-time (because I had a one-year-old at home) and finished my Master’s degree. This is the story most of my classmates had as well. Most of us have spent many years in the nursing profession before going back for an advance practice degree.I know the question has been asked many times about how much clinical experience we complete in school. Schools require a minimum of 500 hours.

            And to address your comment about how NP’s should not write prescriptions…I think that statement is laughable. Not only have I completed extensive training in pharmacology, I stay up-to-date with current recommendations and guidelines and complete numerous continuing education credits on pharmacology each year. I practice under my own DEA license and malpractice insurance.

            The bottom line is, if you don’t feel comfortable seeing an NP then don’t do it. That’s ok. But there are plenty of people who love their mid-level provider.

          • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

            I am sorry that you feel that the issue of that NPs should not write prescriptions is laughable. Thing is that this is something myself and many others take very seriously. The reason we do take it that seriously is because of the fact that we know just like our doctors that lives are at stake. How many hours of Pharmacology did you have in the classroom setting? Also, who takes care of your patients if you lose your ability to practice, or even when it comes to prescribing certain types of medications?
            As for the number of hours in the classroom being a minimum of 500, wow. What is the maximum trainees are allowed to have in the classroom? How many of the patients that love their midlevel provider actually know that they are not the doctor? The reason I ask this is because in the clinic where I go they have an NP that some of the patients use I happened to overhear something interesting when I was there last week. The lady that came in told the receptionist that she needed to get a hold of her doctor but she couldn’t think of the doctor’s name. The receptionist told her the NP’s name. Now, with that said how many of the patients that you see are still comfortable with letting you care for them when they find out that you are not an actual doctor? I ask because I am trying to understand this since I know I will hear more about this when I go to in to core for my Nursing program.

          • kpagliai@hotmail.com

            You have so much to learn. NPs are not trying to be doctors. We are trying to fill a void in the healthcare system in which there are too many patients and not enough primary care physicians to see them. Good luck in the future. I hope you will have a more open mind once you see the complete picture.

          • Suzi Q 38

            I encouraged our DD to become an NP.
            I could see the future need.
            I don’t mind you being there to see patients that need health care.
            Good Luck.

        • WhiteCoatRants

          I don’t assume anything, I’m glad you’re proud, and I’m glad you love your job.

          I can tell you from experience that many of the patients coming to emergency departments state that they have been treated by “DR. Smith” when the practitioner in question is an NP. So patient confusion exists whether or not you care to admit it.

          You argue that NPs should be able to treat patients who would otherwise be without care. Using that logic, should high school students be able to treat patients in remote locations who would otherwise be without care of MDs or NPs? If not, where should the line on independent medical practice be drawn? That’s the crux of the issue I’m trying to raise. No one in these comments is willing to draw that line, but everyone is eager to assert how they are competent to treat patients independently.

          • kpagliai@hotmail.com

            First of all, I admit that there is confusion. I have explained to patients many times that I am an NP. I’ve explained my training, the difference between myself and a physician, etc. I can tell people until I am blue in the face and some of them still don’t understand or care. That’s life.
            I’m not understanding this logic of letting high schoolers treat patients. NP’s have been granted the permission to legally assess and treat patients because we have been found safe and effective. We have completed the required amount of school and clinical hours, have passed a national certification exam, and complete required continuing education to maintain a license to practice. The line should be drawn at proven safe and effective care. It’s that simple.

  • David Lawrance

    In quite a few states, the battle over nurse practitioners was long ago won. Some docs just need to get over it. Everyone else has moved on.

    • http://www.facebook.com/cabrerakathy Kathy Cabrera

      There is plenty of work for everyone. I would never pretend to be a Doc. I know when I need help, but we all need to pitch in and Doc’s can have their pecking order.

    • Suzi Q 38

      I agree.
      I thought that there was this huge shortage of doctors. If so, why wouldn’t help from NP’s and PA’s be welcomed?

      • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

        Suzi Q, PAs have been welcomed and have helped out a lot over the last 2 or 3 decades especially. And I prefer to use the PAs as back up if I have something urgent. But as far as the NPs this bothers me because of the liability issue. As I said before we need to find a way to work together, but to take on a role doing some of the things that doctors do like prescribing medicine and such that really bothers me. You mentioned that your daughter is going to school to become an NP. Could she give you any links to some of the studies (both good and bad) about the work and results of the work that NPs do?

        • Suzi Q 38

          Yes.
          I remember asking her about this and she did come up with studies that were positive.
          I kind of took it for whatever it was worth, because you could always find studies that were contrary.
          It really depends on who is conducting the study.

          • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

            Did you notice with any of the studies that you read how many people were surveyed and how long the studies were done for? You mentioned about the Nursing groups doing the studies. Makes me wonder now if anything has been put in the medical journals too with regard to studies like this. Interesting indeed. But like you supporting your doctor I will be behind my doctor as well. I have his back as well as the other doctors that do Primary Care, and especially Family Medicine.

      • ProudOkie

        Suzi, our help IS welcomed….always everywhere. As long as we understand we are a “mid-level” and the MD/DO is the El Capitan. Trust me, in this type of setting, you will not hear one gripe from any physician. After all, this is “just the way it should be!”

  • John

    I say let them have their cake as well. What we will find out of course is everyone wants the freedom to practice independently yet will shy away from the responsibility that ensues.

    • ninguem

      Exactly. They want the authority, but not the responsibility.

  • John Henry

    Dunning-Kruger will have out.

    • ProudOkie

      Yes, yes it will…..but you will never be able to see you don’t know what you don’t know. Unfortunate.

  • drd

    This article is about healthcare specifically mentioned about California. I think we need to focus on that.

    I am a physician in California. Everywhere I go I see private practices swallowed up faster than the guy in Florida who fell in a sinkhole. I am utterly disillusioned here not only as a physician but the fact I have been unable to get access to care myself out here I find frightening. I can see that different parts of the country can be much different as far as access to care and practice opportunities.

    California in my experience has got to be one of the worst. It is so bad it is driving me away between the difficulties with keeping a private practice and the poor access to care.. i find it vicious and there is no place to really turn to. Today I went to see a physician for my own self– only to find out that his practice is being overtaken in a month. I would gladly fight but there is no group here to advocate for physicians in a true sense. I am frightened where things are headed here.

    • Suzi Q 38

      “As an example–ok worst case scenario–I tried to get in myself to see a doc. There was a –ok are you sitting down? NINE MONTH WAiT.”

      I can call my PCP and get an appointment the same day if I need it.
      They just try to fit me in between their scheduled patients.

      As far as a specialist, it depends. Private practice: 2 weeks.

      Teaching hospital: 3 weeks to one month.

      If the specialist is very, very good and busy, 2 1/2 or 3 months.
      Yes, I could be paralyzed or dead by then.

      I am just curious..why a 9 month wait?

      I have PPO. I pay $850.00 a month for the freedom to choose who I want to see.

      I have never had to wait 9 months.
      Yes, I live in California.

      I have got to admit that I like the choices of doctors and hospitals here. For some reason, I have not had a problem yet.

    • Suzi Q 38

      “Everywhere I go I see private practices swallowed up faster than the guy in Florida who fell in a sinkhole.”

      This is a huge problem, but probably because the corporation groups of doctors are stronger. They advertise on radio and T.V. now.
      They are very agressive with their marketing and referrals from other doctors and hospitals.
      The new physician is going to have a difficult time at first, because of all the competition.
      This is sad.

  • Katherine

    OM Gosh-I am still laughing. I’m a cardiologist in Kentucky and my partner loathes the notion of independently practicing NP’s. We do have very excellent NP’s but just as physicians have limitations, so do all providers. My partner often points out that an NP education, nor experience can approximate the four years post university, three years of specialty and then two to three more years of sub-specialty training that physicians receive.

  • Anon

    Lawyers have much less training than doctors, yet you don’t see lawyers letting paralegals practice law. You don’t see paralegals clamoring to practice law either because they know there’s a snowball’s chance in hell of lawyers letting anyone other than lawyers practice law.

    I’m sure paralegals (or NPs) are just as effective as court-appointed lawyers regarding outcomes of traffic court cases, but when’s the last time any lawyer admitted that?
    When will physicians start advocating for themselves?

    • drd

      now there’s a good question i would love to know the answer to. Does not seem anyone fights back or organizes. So sad.

      • Suzi Q 38

        The reason is that physicians are too busy treating patients.
        At the end of the day, you are too tired to donate your free time to “the cause.”

        • Anon

          Lawyers work just as hard as physicians. The nature of legal work and competition for clients who can pay $200+/hr. is contentious, so lawyers are used to fighting off encroachment.

          The medical training culture is about keeping your head down, jumping when told to, and not rocking the boat. Physicians who come out of that tunnel aren’t likely to fight.

          It’s also easier to earn a good income as a physician than a lawyer, and most physicians become complacent. The $300,000+ specialist isn’t concerned about decreasing reimbursements for primary care until the cuts come for him. By then, it’s too late.
          A significant percentage of physicians are also foreign. They happy just to have a job in America because they have no student loans and make 2-3 times what they would make at home. There’s no motivation to act, and they are less familiar with the American concept of having to fight for everything.

          • Suzi Q 38

            Agreed.
            It is sad that a group of PCP’s got together, hired lawyers and lost. They were the first to do so, they shouldn’t be the last.

    • http://www.facebook.com/cabrerakathy Kathy Cabrera

      Well you can thank Obama care for this start of an Avalanche.

      • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

        This avalanche that is now being dealt with started long before Obamacare. There has been a concern about making sure there’s enough Primary Care Physicians to go around for most of my lifetime of 41 years, and from what I read it apparently goes back even further than that. And some of them asked the same questions that are still being asked today.

    • WhiteCoatRants

      “When will physicians start advocating for themselves?”
      The problem is that when physicians advocate for themselves on this topic, those with ulterior motives complain that the physicians are being elitist and cite some vague studies alleging similar quality care.

      That’s the underlying issue in the post — how much training is necessary to competently (not “confidently”) treat a medical patient?

  • http://www.facebook.com/brenda.tsuchiya Brenda Tsuchiya

    As a family nurse practitioner, I find it highly insulting that you would compare NPs to children. Talk about ego!

    Do I pretend that I am a physician and have the same training? No. Do I know my limits and when to ask for help? Yes. But, am I able to manage a patient with multiple chronic medical issues (i.e. the typical patient with DM, HTN, CKD, hyperlipidemia, depression, and obesity) and do it well? Yes, I am. Why can’t we work together?

    • http://www.facebook.com/people/Jason-Simpson/100001631757606 Jason Simpson

      Your AANP organization DOESNT WANT to “work together” they want solo/independent practice with doctors out of the loop.

      Get your story straight.

      • ninguem

        ^^^ What Jason said. ^^^

        The organizations have been quite explicit about it lately. They are showing their true colors.

      • ProudOkie

        Yes Jason, get your story straight. Full practice authority for NPs does not change their ability to work with physicians, work in “physician – led teams” or increase their ability to perform certain procedures. The only thing that changes? If they want to open a private clinic, they can, without the need for a private business agreement in which they pay a physician $2,000 per month for a signature. As is already being done in 17 states, it also allows the NP to practice without relying on an individual from another profession. You shouldn’t have an issue with any of this. It does not change the way you practice one bit either.

        • Close Call

          ProudOkie,

          I don’t think doctors really know how NPs and PAs are trained, which makes them leery of them prescribing medicines, doing procedures and just about anything an family physician or internal medicine doc can do right out of residency.

          ACGME has their own requirements for FM and IM docs – numbers of procedures, patient visits, deliveries, EKGs read, minimum number of patients carried on service, etc – for what they need to have before they’re allowed into the “real world”.

          Where can someone find similar measurable requirements for a PA to graduate and who in theory, will be granted full practice authority right after graduation?

          I’ve been looking for that info, but probably not in the right places.

          • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

            Very well said.

    • WhiteCoatRants

      I find it highly insulting that you change the argument I make and then become highly insulted by it. Apparently family nurse practitioners are not well-versed in what is known as “reductio ad absurdum”. Google it.

      How do you *know* that you competently manage patients with multiple medical issues? What criteria do you use?

      As I mentioned above, I want you to be able to practice independently. Do anything you want. Just inform the patients about your qualifications and accept the responsibility of paying for millions of dollars in damages if a jury doesn’t think you are as good at managing those multiple medical issues as you think you are.

      • ProudOkie

        As I have mentioned 12,000 times before, I have a private practice and treat patients without physician involvement. I have been accepting full responsibility for over 10 years. So, as I always do, I will fully disclose there are no physicians in our clinic and they are being treated by an NP. Also, I have my own liability insurance. Why do you and others continue to make an issue of liabilty? Stop talking about it…..we understand. We worry about it just as much as you do – it’s part of practice but we are covered. So – I am (and already have for years) meeting your criteria. So make it so WhiteCoat!

        • ProudOkie

          And while I’m thinking about it….first you wanted us to make sure patients knew we were an NP and not an MD or DO. Perhaps once they knew this, they wouldn’t want to see us. Well, we did, and they STILL came to see us. Now, since that didn’t work for you, you want us to spend 30 minutes giving them a breakdown of the educational requirements for both professions? When will you stop? As I stated in another post, this is starting to take on a circus flavor surrounded by organ grinders with little monkeys.

        • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

          The reason that the doctors make such an issue about liability is because these are people’s lives at stake. The stakes are super high when it comes to the care of patients especially with multiple medical problems, especially chronic ones. And if something goes wrong such as that the person dies that family may not be very forgiving as well as angry that a doctor was not involved in their loved one’s care as they should have been.

      • Suzi Q 38

        I see a PA 50% of the time, at my dermatologist’s office.
        My mother has a favorite PA at her PCP’s office.
        Sometimes, the doctor is not there.

  • Suzi Q 38

    Our daughter is studying to become an NP.
    She works unter the supervision of a physician, any day she works in a clinic setting.
    One doctor is very, very strict, and lets her see only 40% of his patients.
    She also helps him with most charting and paperwork.
    The other clinic that she works at is a free clinic for the poor that pay very little.
    The doctors in charge allow her to do a lot more, because there is so much going on that she has to treat on her own and tell them what happened later. If she runs into a problem, the doctors are there for her.
    Patients are waiting to be seen all day long.

    She is fortunate to have these doctors train her.
    They have told her that she is good at what she does, and appreciate the assistance that she gives them. None of this attitude that you convey on paper has ever been conveyed to her in person from any doctor that she has worked with.

    She doesn’t think that she is a doctor. She knows she isn’t.
    The patients at the FREE clinic are not particular about who they see.
    They are thankful for the care, and start lining up for such at 6:30 or 7:00 AM. She has not told her patients that she is a doctor; as in reality she is still a nurse. When she becomes an NP in a year, she will still be a nurse.

    Articles like the author’s with his/her angry overtones about NP’s and PA’a show the fear for a group of professionals that are merely there to provide a much needed service.

    California is full of people that are uninsured. Many are legal and illegal immigrants. Many are just poor, or have no insurance.

    Heathcare for all is the plan. In order to do this, they at least have a plan.
    If you have a better one, let Governor “Moonbeam” Brown know.

    • http://warmsocks.wordpress.com/ WarmSocks

      The plan is not “healthcare for all.” The plan is “insurance for all.” Huge difference. California and Massachusetts are making the point quite effectively: insurance doesn’t do much good if there’s nobody available to provide the care.

      • Suzi Q 38

        Thanks for the clarification. Hence, the PA’s and NP’s are going to be needed.

        • http://warmsocks.wordpress.com/ WarmSocks

          I read it more as suggesting that doctors quit fighting NP/PA requests for autonomy, the idea being that if PAs and NPs practice on their own without any physician oversight, eventually patients will see a difference in quality of care, which will lead to an increased demand for physicians.
          PPACA really is not helping the situation. It’s driving doctors out of business, not increasing access to care :(

          • Suzi Q 38

            Your ideas have merit, but in California, there is supposedly going to be a huge physician shortage.
            As it is Medicare pays very little to a PCP.
            If I were a physician and needed to see a lot of patients, I would get an NP to help out.
            I am not sure if it will drive physicians out of business if there is a huge shortage as it is. In this case, it would help a physician stay in business.
            Also, I will not see an NP visit after vist.
            I would ask to see the doctor in charge, especially if it is complicated.

      • drd

        so well put!!

    • WhiteCoatRants

      You guys get my point exactly.

      Kevin changes the titles to the articles, so I don’t have control over that aspect.

      WarmSocks – haven’t seen you around in a while. Hope you’re doing OK.

      • http://warmsocks.wordpress.com/ WarmSocks

        Thank you, I’m doing well. Life has been busy.

  • SHodge

    One of the reasons that I became a PA was that I noticed that most PAs had more time to work with patients than doctors, as the nature of insurance reimbursement and patient volume keeps doctors from spending the time they used to with each patient (which I think is a shame, and a testament to a generally failing system, not a fault of the physicians). I see my profession as what it was intended to be: an extension of the physician. In a world where doctors now need to see 40+ patients daily to make a decent living (and repay their loans) having an allied health professional allows for patients to get the treatment and health education they need while the physician can focus on the sicker patients with multiple medical problems. Having been in Orthopedics for 5 years, and having a great relationship with the surgeon with whom I work, we have developed a process that works for our practice. It allows many patients more access to our time, and as I gained more on-the-job training I took on more treatment responsibility. In the end, it’s that relationship that allows our patients to be seen quickly and efficiently. If there are problems, the surgeon is readily available.

    In many places around the country, access to physicians is very limited. These patients need access to care. Just as MDs must pass a board exam, so must PAs. Yes, our training is shorter, but if we can work alongside physicians to provide quality care for those who can’t or don’t have easy access to care, don’t we have that responsibility? If Californians don’t have good access to MDs, shouldn’t the MDs, NPs, and PAs work together to come up with a solution to improve access to care?

  • http://twitter.com/Clinician1 Dave Mittman, PA

    Since WHITECOAT you refuse to sign your name and refuse to stand by evidence based medicine and believe studies that show certain clinicians are good, please do this.

    Please write a column and ask the people who test family docs to allow PAs and NPs to sit for the family practice boards. NOT SO WE CAN BE PHYSICIANS, but if we pass maybe then you will say we are OK enough to practice primary care. Funny, PAs in the armed services have been practicing family medicine (yep, they call it that) and advanced trauma, ortho and other specialties generally on a very collaborative basis for 40 years. The outcomes are there, go look at them. Thousands of clinicians, battle tested, thousands and thousands. Same in the civilian world but outcomes harder to gather.

    We don’t want to be family physicians, just want you to admit some of us are really good and passing the Boards it seems would be the only way to get you to stop complaining. We don’t shuffle papers nor turf patients all over the place, so stop saying we do.

    Also stop being so negative and realize some of the barriers on PA and NP practice you love so much were put there for economic reasons.
    Some of them need to be removed as they drive up costs and help no one.
    When can we see your column?

    Dave

    • Close Call

      It’s not just about boards.. and it’s not even about medical school.

      It’s about residency.

      There should be a minimum number of procedures, hospitalized patients carried each day, deliveries, office visits, etc. that anyone wanting to practice independently should have.

      I can’t find the requirements for NPs or PAs anywhere… are there a certain number of patients they’re required to carry on an inpatient service? Minimum number of peds? Xrays read? EKGs interpreted? Athletic events staffed? Community projects done? ACGME lays all this out for a family medicine resident.

      There probably are discrete requirements and actual numbers for PAs and NPs, and I just can’t find them. If you know please share a link.

      If there are not discrete requirements… and it’s just taking classes and doing “clinical hours”.. then there should be some requirements. That’s just as important as the boards – and probably more so.

      • http://www.facebook.com/randall.b.sexton Randall B. Sexton

        I had to workup 70 psych patients per quarter…plus all the other “homework” .

    • WhiteCoatRants

      Funny that I keep hearing about all this “evidence based medicine” and
      about all these nebulous “studies” showing how physician extenders are
      just as competent as physicians.
      But I never see the “evidence” or the “studies” documenting these assertions
      Then
      I hear about “outcomes” comparison, but I never see the data and
      the “outcomes.” With such an extensive number of patients and the
      government’s penchant for data, one would think that there should be
      many studies to support your assertions.
      If you re-read my article,
      I’m not “complaining” about anything. I want you and everyone else to
      have all the practice privileges you want. Why bother
      licensing? If a high school kid can pass a medical
      board exam and wants to independently treat patients, maybe that high
      school kid should be able to do so. After all, the data shows that patient outcomes are similar.
      What is the minimum amount of
      medical training that should be required to treat patients, Dave? Why
      can’t we push the envelope even further based upon some nebulous
      “studies”?
      You’re so caught up in your “woe is me” mentality and your feelings of outrage that you miss the point.

    • Diagnosus

      I don’t think Whitecoat or anyone who can decide based on a survey of some arbitrary patients as to their satisfaction or outcome between visits to PAs and MDs are comparable or not. I think the very thought that NPs and PAs are even suggesting such an approach is indicative that they have misunderstood the process and context of clinical
      decision making. A resident takes 100s of calls a week, presents them to the faculty and improves on the process continually for 3-4 straight years. The reason to do this is in part to learn to manage a situation about which no
      information/science currently exists. These shows up every day. It is very easy to learn a few norms (and apply them independently when situation suits) but it takes a lot of training to know what is unknown- which is why routine clinical work will not be outsourced any time soon. If you can boil everything down to protocols, the patients might as well use Skype and get cheaper care from more
      trained physicians abroad.

  • Doug Capra

    You’re describing the current “de-professionalization” of medicine, and too many doctors and have been going along with it for years. I’m not at all suggesting that there is no place for mid-levels and all kinds of nurse assistants and patient techs. They can and do play a valuable role. But scopes of practice are being extended and extended; training is becoming more and more merely task oriented with little focus on patient psychological, emotional, and spiritual needs; oversite of these newly minted cna’s and med assistants is sometimes non existant or inadequate. Doctors can complain, but how often to you see a nurse in a private practice or doctor’s office today? They’re all medical assistants, most with no licence but working under the doctor’s license — thus, able to do whatever the doctor is willing to risk training them to do. And why is all this happening? Follow the money. Certainly, we need to reduce the cost of medical care, and all these different positions have their place. But at what point does profit, efficiency, and cost become the primary motive for reducing the role of licensed doctor and nurses and replacing them with those less qualified and trained? I don’t have the expertise to know the answer to that, but I think it’s a valid question.

  • Physicaltherapize

    I know this blog didn’t mention PT whatsoever, though I do feel like it’s directed at our field as much as towards the NPs and PA’s. Yes we want direct access and it’s because most MD’s have no idea when it comes to orthopedic injuries. Any idea how often I get a patient with a prescription for PT with a diagnosis of “low back pain” or “knee pain”? It happens a lot, so I ask- what was the purpose of that visit to the doctor? The visit accomplished nothing whatsoever other than to boost the MD’s billing.

    • http://www.facebook.com/randall.b.sexton Randall B. Sexton

      Aren’t PTs in some countries independent practitioners?

  • http://www.facebook.com/deanna.tolman Deanna Tolman

    Dr. Whitecoat,
    SUCH a chicken, not to use your real name. Here’s mine: Deanna Tolman, DNP, FNP-BC, DCC. That’s a lot of initials. They stand for Doctor of Nursing Practice, Family Nurse Practitioner-Board Certified, and Diplomate of Comprehensive Care. The last set says that I took a test that is equivalent to the USMLE step 3 exam and passed it. I’m sure any NP or PA could do the same.
    I own my own family practice. I frequently uncover problems for patients that physicians have missed. I don’t know why physicians miss those problems—maybe it’s because they’re so busy seeing 4-10 patients an hour to make a higher salary that they don’t take the time to listen to the whole story and do a proper investigation. I don’t know. I’m not there in the exam room when they see those patients. But almost every patient that comes to me says the same thing, and has the same result—we find a problem, sometimes serious, that has taken them from doctor-to-doctor for years. This year I’ve had three patients with unidentified hereditary hemochromatosis, one with achalasia treated improperly for years as acid reflux, two (mother and daughter) with neurofibromatosis, several with various forms of cancer, a dozen with celiac disease (all had been told “you’re just depressed and you have IBS – take this anti-depressant), and one very grateful young lady on disability for 10 years for explosive diarrhea. She had already seen 4 physicians and a gastroenterologist, who had performed an EGD and a colonoscopy, and then told her she was depressed. A little Questran fixed her post-cholecystecomy diarrhea. She now has a boyfriend, a job, and is a happy woman again. So, what about these patients makes physicians more capable of taking care of them? They all had to leave their MD practice and come to me for an accurate diagnosis. I’m sorry you don’t like us—but your statements are slanderous and wrong. You should be ashamed of yourself.
    By the way, I don’t wear a white coat. It frightens the children and carries germs.

    • WhiteCoatRants

      Ahhhhh. Name calling. How professional. I’m sure your patients benefit from your professionalism in addition to your self-described razor sharp clinical acumen. I’ve been blogging for 7 years, so if people want to find me, it is easy to do so. I use a pseudonym so that when I write stories about patients, there is less possibility that the patients would be identified based on my identity.

      So why did you do the additional training to get the extra “initials” behind your name? Do you think that it improved your ability to independently care for patients or were you more concerned with just having more “initials”? If you did think that the training improved your clinical skills, then you’ve essentially agreed that more training improves patient care. The question then becomes what should be the minimum amount of training necessary to independently treat patients – which was the underlying point of the post.

      Your generalizations about your practice, your ability to catch diagnoses that doctors have missed, and how doctors are much too busy “earning money” to provide adequate care for their patients are needlessly demeaning, contribute little to the discussion on the topic, and further demonstrate your unprofessionalism.

      You take my argument in favor of providing other medical professionals with the same rights conferred upon doctors and you twist it into some false-logic diatribe about how you are a DNP FCC DCC RN and therefore anyone who isn’t a doctor must also be smarter and better at treating patients than doctors.

      You express outrage, accuse me of slander, and impute shame on me without basis. Again, how “professional” of you. Degrees don’t make the person and your comment has clearly demonstrated that.

      Oh, and by the way, if you look at your avatar, you *are* wearing a white coat. Maybe it’s your lack of professionalism and not the white coat that “frightens the children.”

  • Diagnosus

    From the back and forth between MDs and NPs in this forum it appears that there are two monologs going on instead of a dialog. Enjoying it. In a nutshell, I feel like the physicians are emphasizing the value of extensive training and the NPs are demanding evidence for its impact on outcome.

    Since this is my first post let me introduce by angle. I am not a provider but am affiliated with lab tests, a clinical chemist if you will. My work space is implanted into a residency program in a teaching hospital and I work closely with attending and residents in correctly interpreting test results.

    Testing is an area that is seeing significant changes. I can see how residents are being trained to recognize the validity of a test results, what is presumptive, what is confirmatory etc., In our hospital, in the last year, we have made changes to the way we interpret certain toxicological and other results. We are moving to new technologies with a different level of sesnitivity and specificity and needs to be interpreted differently by the provider. Definitions are changing fast. I am curious as to how NP get trained in these complex, evolving diagnostic techniques. I am very ignorant of NP training process. I would appreciate if anyone would list the key training areas that allow an NP to be up-to-date on fast changing clinical/diagnostic landscape. Thanks in advance,

    • http://www.facebook.com/randall.b.sexton Randall B. Sexton

      What do you mean by “key training areas?” We get the same updates all other providers receive.

  • Diagnosus

    If a large part of the job of a primary care physician can now be done with shorter training, what is to prevent some smart automation guys from developing a complex algorithm to rule in and rule out conditions based on patient filling out an on-line form? Insurance companies would love it and offer cheaper rates to patients and perhaps outsource any interactions to professionals from other countries. An NP in US is still more expensive than a physician who lives in say India. I think of medical training like an onion. You keep peeling the layers to get to the root cause. For a given patient, the root cause may lie be dispersed in several layers. A type and interval of training is like the ability to peel a layer. I suspect we will miss some layers when we replace MD training with lesser training.