Doctors and nurse practitioners: We’re failing the reality test

Doctors and nurse practitioners: Were failing the reality testA guest column by the American College of Physicians, exclusive to KevinMD.com.

Over the past several months, I have covered some controversial topics, such as electronic health records and the overuse of diagnostic testing. For this month’s column, I will address a less provocative topic: the role of non-physician providers in patient care. (Okay, perhaps we will discuss something non-controversial next month.)

Rather than rehash organized medicine’s position(s) on the topic or attempt an unbiased review of the evidence (what little there is), I will present a practicing physician’s real-life perspective of the issue, and comment on the vitriol that this subject generates. Before I go further, I remind you that my statements do not necessarily reflect official policies of ACP.

I have worked with nurse practitioners or physician assistants since medical school in different settings: resident clinic, a staff-model HMO, and 20 years in private practice. During that time, I have been a colleague, teammate, co- worker, supervisor, and employer of NPs and PAs. For simplicity, I will refer to both types of clinicians as non-physician providers, or NPPs (“mid-level providers” or “physician extenders” are terms that many NPs and PAs find objectionable, by the way).

My practice uses NPPs to increase our patients’ access to care. Our patients can see NPPs for urgent visits, follow up of chronic conditions such as diabetes and hypertension, and preventive services. Our NPPs do not have their own patient panels because we prefer that every patient in the practice have a primary physician. Our preference is based more on logistics than our judgment of the NPPs’ ability to manage a panel of selected patients. However, some of our patients take matters into their own hands and find a way to see the NPP for all of their problems. I don’t view that as a threat but see it as an affirmation that we have a team of providers that patients feel comfortable seeing.  Some patients, on the other hand, refuse to see anyone but a physician. That is their choice. When they request an appointment, we make clear who they can see and what their credentials are.

Our NPPs see patients independently. When they have a question, they ask one of the physicians. In a typical day, that might happen once or twice, usually because the patient is complicated or has an unclear presentation. Often, the NPP will recommend that such patients follow up with one of the physicians. That isn’t surprising given the differences in training and expertise. On the other hand, sometimes one physician will ask another for help with an exam finding or a management question. One of my NPPs worked in a dermatology office for many years, and sometimes I will ask her to look at a rash that I can’t figure out. When we are not sure of something, we ask for help, regardless of our title.

Physicians review and cosign every office note from an NPP visit. There are a few reasons for that, including billing requirements, but it also helps us to keep up to speed with what is happening with our patients. That stated, there are very few occasions that I read an NPP’s note and disagree with the care provided, and most of those disagreements are more over style than substance. I suspect that if I reviewed my physician colleagues’ notes I would have similar disagreements from time to time.

Do our NPPs order more tests or prescribe more antibiotics than the physicians prescribe? Sometimes it seems that way, but then again the NPPs are often seeing acutely ill patients. It varies by NPP, just as physicians differ in their test and antibiotic use. I believe that NPPs welcome education on appropriate use of tests and treatments more than physicians do. I should add that I have hired new physicians straight out of residency who order more tests and antibiotics per capita than any NPP.

On average, our NPPs see fewer patients per day than do our physicians, but in a crunch, the NPPs can see just as many, if not more. The longer visits with the NPPs are by design, for reasons such as patient education and chronic care management. We are a fee-for-service practice, so provider productivity matters, but at the same time, with the longer NPP visits we can provide better care for our patients without hurting the bottom line too much.

From my vantage point, many of the arguments over how to limit what NPPs do fail the reality test. We hear a lot about supervision. One could argue that most of my patients’ visits with NPPs take place without my supervision. While you can call my reviewing the notes “supervising,” by the time I read the note, the prescriptions are written, the tests ordered, and the patient sent home. When my NPPs need help with a patient, they seek help, just as a physician should under similar circumstances. That has nothing to do with regulations or employment status; it is a professional obligation.

Then there is the talk about interchangeability of physicians and NPPs. NPPs can provide many of the primary care and acute care services that I do. That does not make us equivalent, just as my being able to provide much of the care to patients with heart disease does not make me a cardiologist. We work well together when we understand our roles, abilities, and limitations, and we value what each of us brings to the care of our patients.

As to the economic arguments about threats to physician practice, my home state is one of the most permissive for independent nurse practitioner practice, yet there are very few such practices in the state. Perhaps that speaks to the choices that NPPs make, or the fact that a business model that doesn’t work well for physicians wouldn’t work any better for NPPs.

So, when I sit in meetings and listen to angry and frightened physicians or defiant NP leaders discuss “scope of practice,” “restraint of trade,” and who can do what better than the other, I think about what goes on in the real world and wonder if we’re all on the same planet. Why don’t we focus on communication, collaboration, education, and professionalism instead?

Yul Ejnes practices internal medicine in Cranston, Rhode Island, and is the Immediate Past Chair, Board of Regents, American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Dr. Ejnes, could you comment on the NPP staffed retail clinics that are now offering chronic care and accepting insurance, including HMOs? Do you know if HMOs are allowing the selection of a PCP to be a retail clinic NPP?

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

      I read about that about one of the chain retail clinics allowing their staff to care for people with chronic medical problems. When I read that it just made me cringe.

      • http://www.facebook.com/shirie.leng Shirie Leng

        Why did it make you cringe? Because a doctor wasn’t adjusting blood pressure pills or insulin doses? Because no other trained professional can do these relatively simple things? With adequate cross-talk between electronic medical records, the chain retail clinic can help a lot of people. You’re sounding like Buzzkillersmith!

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

          Shire Leng,
          I have used Urgent Care clinics but not the retail ones, and the issue I have with the story about allowing them to manage chronic illnesses in the retail setting is that they aren’t doctors. When I went to the Urgent Care clinics about 10 years ago I was seen by doctors. That’s the way I prefer to get my care is from my own doctor, and if I can’t do that and need something in a pinch I will go to the PAs. I used to get care from a PA for a time about 15 years ago and was glad for her. I will consider a PA any time because their training is in the medical model just like that of a Physician.

          • ProudOkie

            The rest of the story – makes perfect sense now – personal preference.

          • http://www.facebook.com/tlohman2 Theresa Lohman

            Don’t get me started. We both do as well or as poorly. It is very individual. Did you know that NP’s can precept PA’s but not the other way around as they are considered a lower level provider? That may change, and I don’t have a problem with that but that’s the way it is now.

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

            No, I did not know that NPs can precept PAs. And now that I know this information that bothers me just as much as the fact that an NP is trying to be something they are not: a doctor.

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

          Shirie,

          A CRNA can do 100% of what you do. You provide zero value over a CRNA. You should be fired and replaced with a CRNA.

          Why should I pay you 300k per year when a CRNA can do your job for half that cost? Justify your over-inflated salary.

          • Guest

            Jason, really, personal attacks are unnecessary. And if you believe what you post then feel free to have CRNAs do all your and your family member’s anesthetics.

            I personally will do otherwise.

          • http://www.facebook.com/tlohman2 Theresa Lohman

            I know CRNA types that make over $200,000 annually.

        • Noni

          I posted elsewhere that I’ve yet to see a midlevel with the competence of a physician, and I’m a healthy young(ish) person. A PA once recommended an unnecessary surgery for my infant daughter. Thankfully she was supervised by an ENT. What if she hadn’t, and what if I was an unsophisticated, blindly trusting patient? Yikes.

          The thought of primary care being flooded with midlevels makes me nervous, and the thought of pharmacists or optometrists practicing well outside their scope of expertise absolutely makes me cringe too.

          • http://www.facebook.com/tlohman2 Theresa Lohman

            Well, the PA would have had to get a surgical consult. Hopefully, the surgeon would have declined to do the surgery. I personally love pharmacists. They know more about meds than I ever could. I never hesitate to consult with one. Of course, I have my personal favorites that I trust.

          • Guest

            Good point. I just hope we can keep midlevels out of practicing surgery independently. The thought of that is extremely frightening.

      • ProudOkie

        Forget cringing! You would fall over dead if you saw the volume of patients and the chronic problems we manage at our NP clinic. They are so grateful for us and the specialists we utilize and we are so grateful for them…..the cringing and whining and disbelief and astonishment are getting old. But there are those who will continue to do this…..c’est la vie. The patients are still cared for, the outcomes are excellent, the customer service is great and there are only a few unhappy folks on here who continue to cling to patient safety issues.

    • ProudOkie

      Hi Margalit,
      I can’t speak for the retail clinics but my NP only clinic is listed as a PCP for every major insurance company. There are only 3 insurance companies (and two of them aren’t companies – they are physician repricing entities) in Oklahoma that do not allow the selection of an NP as your primary. They are Cigna, the Integris Group of Hospitals (completely managed by physicians), and Preferred Community Care entities (again controlled and owned by physicians). So I would guess the HMOs will allow the retail clinics to be assigned as PCPs. I’m also sure the retail clinics will have specialists available for any family practice issues the provider at the time may have questions about. This is the same with our clinic. We have a specialist in every field in our cell phone – pediatrics, cardiology, oncology, on and on….they are available immediately. I know every PCP does this.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        Yes, I know that NPs and PAs can be HMO PCPs, but I would like to know if an HMO member can pick a retail clinic as his/her PCP.
        My question is not exactly related to the original post. I would like an opinion on longitudinal medical services being delivered in a retail setting, with all that this model implies…. and I don’t really care if it’s NPPs or MD/DO (on screen or in-person eventually) or an ad-flashing self-service kiosk.
        (Confession: working on a blog post and would love some input :-)

        • Ian

          In some states physicians who work exclusively at urgent care centers are listed as PCP’s, especially for referrals to specialists. While it doesn’t quite answer the NP part of the question, urgent care centers in many regards are not that different than the retail clinics in terms of them being a fairly similar setting for conducting longitudinal care of chronic health conditions. That being said it is likely that the beancounters just require a name to assign to the referral. I do not know if a patient can “pick” the urgent care doc as their pcp. They often function as such in regards to follow up and communication for those specialists who do not provide primary care services.

          • http://www.facebook.com/tlohman2 Theresa Lohman

            I work in an urgent care that also does family practice. Great fun trying to see walk ins along with scheduled patients. Urgent care is not the same as retail. If it were, I would be so out of there. I have no problem with retail clinics for acute short term illnesses but I don’t like working there. It’s just not my thing.

    • Yul Ejnes, MD, MACP

      I think there are multiple issues here. One is whether anyone should be getting primary and chronic care at a retail clinic, regardless of who’s staffing it. Ideally, those types of non-acute, non-episodic conditions should be managed in a medical home with a team of physicians, NPPs, nurses, and others. I don’t know how these clinics are set up in terms of continuity, access to specialists (including internists, FPs, and pediatricians), and comprehensiveness of services offered – managing chronic care is more than just checking the BP and the A1c. Personally, I can see retail clinics working with medical homes as an extension of the PCMH, to provide access to patients who cannot go to the office during regular hours for a BP check for example, but I’m concerned that having retail clinics be “the” home shortchanges the patients.Working with a medical home, including exchanging data, would address the fragmentation of care that the retail clinics can increase. Could an NPP-staffed medical home meet the need that the retail clinic intends to address? That’s another discussion altogether, but my problem is more with the setting than anything.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        So is mine, and I don’t believe the chains operating these places are intending to just provide after hours coverage for medical homes.

    • http://www.facebook.com/tlohman2 Theresa Lohman

      I’ve done retail medicine and I can’t imagine doing primary care there.

  • buzzkillersmith

    The comments below are limited to primary care. I make no comment on subspecialty care here.
    Dr. E’s micro view of all this might be interesting to some, but it misses the real point. This is about economic self-protection, which has been a constant in human affairs for centuries, even longer. Patient care concerns are bogus; propaganda by us docs. It is an attempt to deceive, perhaps even self-delusion.
    I expect the tired old arguments, perhaps frothing, about the times the midlevels, are out of their depth. Ho hum. Physicians are also out their depth in many situations.

    Physicians think midlevels, in time, will eat docs’ lunch, and they might be right. How Dr. E runs his shop is merely a reflection of his particular time and place. I expect the world to change. Do you?
    Medical students are very very smart. I will precept one today who went to college at any Ivery League school at is now at the Univ of WA. He could do a lot of things in life. I expect that furture students of his intelligence who also do a lot of things, only that those things will not include medicine.

    • ProudOkie

      Health care crisis or not – enough to go around for everyone….Washington State is an independent NP state and I suspect there are no issues there. Who cares as you say? Do what you do and place the patient first when you do it……completely agree with buzz’s comments. Our clinic is a micro-reflection of our time and space and the need we fill and the gratefulness of those who see us and the expertise I possess and my willingness to take the risk and open up shop and share my knowledge to help people stay healthy and help them back to health when they are sick…..anyone fault me for that?

      • ninguem

        Washington State had a particularly spectacular case with a nurse-practitioner clinic.

        http://www.columbian.com/news/2012/feb/04/vancouvers-former-payette-clinic-a-legacy-of-pain/

        The amount of narcotic drug out of that clinic was staggering. Whole pharmacy chains were ordered to refuse their prescriptions, to where a couple of independent pharmacies would honor their prescriptions, no one else.

        State medical boards, by their nature, are used to judging the judgement calls of physicians. Historically, nursing boards were not dealing with nurses making “medical” judgement calls, you know what I mean. Historically it had been nurses not taking the order properly, as opposed to GIVING the order. Well, now they do have to deal with this, at a regulatory level.

        This is hardly unique to nurse practitioners, there are plenty of physician clinics acting as the candy man. The sheer volume of narcotic coming out of this clinic was staggering. When the DEA raided the place and shut them down, the rain of addicted patients overwhelmed treatment facilities in metro Portland.

        I doubt if the medical board would have let a similar physician practice stay in business, let alone allow them to continue Schedule-2 drugs, but I admit that’s speculation.

        This is just one case, albeit a spectacular one. Don’t say they don’t have issues, if what you mean being are there bad apples. They certainly do have bad apples on the ARNP side, can be as bad as the physicians. I know another one in my town, an independent ARNP taken out in handcuffs over sexual improprieties. In the newspapers, so I’m not revealing any secrets. The independent ARNP’s are in our IPA, same as the physicians.

        So I get to know them, good and bad.

        Don’t interpret this as an attack, you get plenty of that from other quarters. Just reality. ARNP’s practice independently, there will be bad practitioners, same as doctors or anyone else for that matter.

        • Chris

          I just read that article you linked, Ninguem. Astonishing.

          • ProudOkie

            Absolutely. I agree! What a bad apple.

        • buzzkillersmith

          We’ve all worked with NPs who are lunkheads, no doubt. Most are quite good. I haven’t worked with any who are scumbags, but as you documented, they’re out there. I have come across scumbag doctors and I suspect you have too.
          I also suspect that the folks that run healthcare, the insurance companies, CorpMed, and the government, don’t care much about this at all.

        • ProudOkie

          I agree. No offense taken. On the other hand – Florida. NPs cannot write controlled substances, only physicians. Pill mill ground zero. Too many astounding cases to mention. Not surprised at what you say but the cases on the other side are more than there too. Thumbs up here as well.

          • ninguem

            No argument with that either. I’ve met legitimate pain physicians who have left Florida because just saying you practice “pain medicine” leaves people thinking you’re a drug dealer.

            An interesting matter that will come up will be “what is the standard of care”? Same patient, same disease, same circumstances, will there be a nursing standard different from a medical standard? The medical boards have for the most part blended in the D.O.’s to a joint board, and when there remains a separate osteopathic board, they usually cooperate closely with the MD board so there’s little variance.

            The PA’s come under the medical board and/or osteopathic board. Will ARNP’s split off from other nursing and end up in a joint MD/DO/PA/ARNP board?

            Who knows…….

            I say that with the Payette case, in that I’d speculate the Washingron board (MQAC) would have revoked a physician doing that. That’s just a speculation.

        • http://www.facebook.com/tlohman2 Theresa Lohman

          I can give you names of 3 physicians in my area that over prescribe narcotics. One of them has had his license pulled. Does that make all docs bad. I think not.

      • buzzkillersmith

        WA is an independent NP state, but not all is rosy with all that. Our group has had a number of NPs who want to join us because they’re out there all by their lonesome, a cog in the wheel of some evil hospital. In truth, at least in eastern WA, hospitals tend to put them in pretty crappy places where no docs want to go. At first the NPs, an idealistic lot, look forward to it. After a while a lot of them have their “My God, what have I gotten myself into?” epiphany. These out-on-the-range jobs lose their charm.

        Really just another example of an old and not-very-proud tradition in medicine: If there’s something that needs to be done, and if it’s not that fun or glamorous, make the nurse do it.

        Going solo in private practice, at least in these parts, is just as bad for NPs as it is for us. Not much money, not much fun. Most NPs want docs around and most would prefer to group up at least a little bit.

        • ProudOkie

          I understand. What baffles me is there are tons of private rural NP clinics in Oklahoma. Wonder why there is such a difference?

          • buzzkillersmith

            I suspect it’s the money but don’t know.

        • http://www.facebook.com/profile.php?id=1052074130 Kevin Windisch

          having been a solo physician in podunk Nevada, I can say that I felt the same way when given the opportunity to join a small group in a larger city- being alone in the middle of nowhere is a horrible and scarry feeling regardless of your degree.

        • http://www.facebook.com/people/Natalie-Gonzalez/590578764 Natalie Gonzalez

          Who are YOU? You have that you are a “proud Okie” but speak to WA State and what you say is inaccurate. Hospitals cannot be evil for they are buildings. One must presume you mean administration in hospitals are evil. Is that not a gross generality? I work for the WA State Dept. of Health and I have recruited primary health care clinicians to rural WA for the past 12 years. I have placed some physicians and PA-C’s and NP’s and others in what I would call rural communities NOT “crappy places.” Who are YOU to call small towns “crappy places.” Sure there are some rural sites that have some issues and some hospitals that could improve their administration but how dare you reduce rural communities to “crappy places.” Over the years I have found what appeals to one person does not to another. I recruit for retention and many of the folks I have recruited love their work, the area and their patients. One PA-C is still serving an Indian Nation near Forks, a place that gets 10 feet of rain a year. He wrote to me once about the experience, ”
          “It’s a bit stressful at times, being the only provider on site, but the patient load is not heavy…I have time to be thorough and figure things out…I’m able to place a large emphasis on the QUALITY of each patient’s care, rather than on the QUANTITY of patients seen in each day, a rare privilege in medicine these days.”

          And to let you know 11 years later he is still there. I have a physician I helped to find Tonasket, that was 10 years ago. He gets to do COMPLETE family medicine, deliver babies, including c-sections and has a thriving practice with a medical group. And yes they use PA-C’s and NP’s in that practice.
          There are many other stories and quotes I could write to show you that these “crappy places”, as called by you are populated by real people and served by a variety of quality, caring clinicians. So please be careful in your generalizations.

          • ninguem

            What escapes this Washington State employee is the concept that if these rural practices were so great, they would not need a full-time state employee and ancillary staff, to find people willing to work there, and to deal with the turnover.

            No, “crappy” can be quite accurate. It doesn’t have to be the town as much as the nature of the work and the organization of the rural clinics. I would advise anyone looking at a rural practice to look the place over very carefully.

            No it surely isn’t all of them.

            It’s lots and lots of them.

            Who am I? Someone who has actually practiced in the towns where you recruit doctors.

            And good luck selling your house when you leave. Took me years to sell the thing in a depressed rural market.

    • Dave Mittman, PA, DFAAPA

      So big deal. All the smart people will go somewhere else. WOW, talk about self inflation. Give it up. I have worked with physicians for years, some smart-some not so smart-like all other humans. Of course, you would deny that.
      Give me a break.
      Dave

  • trinu

    Maybe part of the reason midlevels can handle so many of the patients is because most of the patients’ problems don’t need medical attention. So many schools and businesses now require doctor’s notes before they’ll let you take a single sick day. You can be sick enough to need to stay home without being sick enough to need a doctor’s visit.

    • ProudOkie

      Yah! That’s it!

  • http://www.facebook.com/shirie.leng Shirie Leng

    Thank You! I’ve posted on this a couple times on KevinMD and a few more on my blog medicineforreal.wordpress.com. The question should not be “who can do wha?t” or “who’s stepping on who’s turf?” but how can we work together. Yes, we doctors have more years of training and supposedly have more expertise, but that should only serve to make us more helpful to the Nurse Practitioners, and they to us. It’s a partnership folks, not a competition.

    • ProudOkie

      So thankful for the specialists/physicians we refer to….could not function without them…..period.

      • ProudOkie

        Why would any sane person give this comment a thumbs down? Amazing, astonishing, expected.

    • http://www.facebook.com/obinna.akunna Obinna Akunna

      Bull crap. The bean counters are paying close attention. As soon as it is safe to get rid of physicians and their “mega salaries”, you will be out a job.

      • Ian

        There is pressure the other way as well. PA’s and NP’s are politically close in the state of Oregon to receiving equal pay of their physician counterparts for their services.

        http://www.thelundreport.org/resource/nurse_practitioner_pay_equity_easily_passes_house

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

          Why in the hell would I pay the same amount to see a nurse if I can get a doctor instead?

          If there is no price difference between a nurse and a doctor then it makes zero sense to use midlevels.

          • Noni

            Unless it’s cheaper to produce nurses and midlevels, which I’m guessing it is. I believe training residents (and paying them their salary, as pathetic as it is) is bloody expensive.

          • http://www.facebook.com/tlohman2 Theresa Lohman

            I will probably not pay off my loans in this lifetime.

          • http://www.facebook.com/tlohman2 Theresa Lohman

            That’s because most NP services are build in a way that is actually under the physician. There is a term for it, I can’t remember. If you look at medicare reimbursement and most other insurances, they do not pay the same amount for the same service, to NPs. Kinda like guys used to, and maybe still do, make more than gals doing the same job.

      • http://www.facebook.com/tlohman2 Theresa Lohman

        Paranoia. I believe it’s treatable. No, NPPs will be out first. If there is a duplication of services, a physician will be the choice because his/her scope of practice is larger. More bang for the buck. I say this because I may well lose a job when hospitalists come in. They need 24/7 coverage to train residents and if we are doing similar duties and don’t have the patient load to pay for all of this, the NPPs are out.

  • Suzi Q 38

    In California, this debate is almost a “done deal.”

  • http://www.mightycasey.com/ MightyCasey

    Scope of practice is determined by states, with the most populous states saying “no” to independent NP clinics. That will undoubtedly change in the coming few years. I’m delighted to hear that a physician at Dr. Ejnes’ level of experience and influence agrees that NPPs should be allowed to practice to the full extent of their license and training.

    Here’s a great visual on scope-of-practice state by state: http://www.bartonassociates.com/nurse-practitioners/nurse-practitioner-scope-of-practice-laws/

    • http://www.facebook.com/tlohman2 Theresa Lohman

      Yes. What she said.

      • http://www.mightycasey.com/ MightyCasey

        Thanks, Theresa.

  • doc99

    Dr. Eines, you answered your own question. Follow the Money.

  • win89

    I have seem many doctors and NPP’s. Some of them were more qualified than others, and it was not delineated based on the letters after their names.

    My symptoms were urgent and seemed simple. An urgent call to my doctor usually resulted in an appointment with a physician extender, usually a different one than last time. Since I only saw my physican when I was symptom free, the recognition of a complex problem was delayed.

    My diagnosis came from a physicians assistant, who knew who I was, see the ups and downs of my care, not read about it in a chart.

    The reality is I have become a chart that anyone can read about and treat.

  • Elvish

    This debate is not going to end.

    If PAs and NPs are practicing out of their scope, then they are dangerous and should be restrained.

    If they are not doing so, then I don`t see why do we keep arguing about it.

    There has to be a higher authority, regulatory body that is formed by a group of senior physicians and surgeons to oversee the practice of medicine in the U.S. .

    If there is such a body, whether it is the NBME, NBOME or the ACP, then they should speak up; loud and clear !

    The problem is, most physicians are profiting out NPs and PAs, hence they are looking the other way.

    Signed by an M.D. .

    • John Smith

      As long as the physicians are on top…

      • Elvish

        Sir, physicians have to be on top.
        Medicine is a hierarchical society, for very good reasons.

        Doctors are forgetting who they are and they are turning into cooperate employee.

        • Guest

          Sir,

          Every organization is hierarchical, for very good reasons.

          Doctors have highly specialized skills for diagnosing individual human illness and administering individual remedies.

          Does that certainly gives them a unique and valuable perspective, but it does not qualify them to be “on top”. Epidemiologists and statisticians also provide a unique and valuable perspective as well. As do people that understand how to read a P&L, or operations folks that understand how to manage a supply chain (of both human and non-human resources).

          Your myopic and unsubstantiated assertion that Doctors, a very well established special interest group should be the ones to rule them all is harmful to this conversation.

          It is easier to argue that your unsubstantiated opinion is actually refuted by experience. Doctors have had the ultimate authority for some time, and look how far we’ve come! Keep those NPs down baby!

          • http://www.facebook.com/tlohman2 Theresa Lohman

            It’s a pyramid scheme. The ones one top get it all.

        • John Smith

          Sir,

          Every organization is hierarchical, for very good reasons.

          Doctors have highly specialized skills for diagnosing individual human illness and administering individual remedies.

          That certainly gives them a unique and valuable perspective, but it does not qualify them to be “on top”. Epidemiologists and statisticians also provide a unique and valuable perspective as well. As do people that understand how to read a P&L, or operations folks that understand how to manage a supply chain (of both human and non-human resources).

          Your myopic and unsubstantiated assertion that Doctors, a very well established special interest group, should be the ones to rule them all is harmful to this conversation.

          It is easier to argue that your unsubstantiated opinion is actually refuted by experience. Doctors have had the ultimate authority for some time, and look how far we’ve come! What’s the estimated shortage of primary care physicians in the coming years? Something on the order of tens of thousands? Yea, nice…

          • Elvish

            Sir :) , I am a fairly young doctor; I recognize the shortage as I work in primary care and I`ve seen the disastrous consequences of our ill health care system.

            Perhaps I misspoke.

            To practice medicine, you have to be a doctor, it takes years of training and hard work.

            Or

            To practice medicine, you have to be authorized by senior physicians. Nowadays, unfortunately, it is the boards with their standardized tests.

            Again as I have mentioned above, if PAs and NPs are qualified to practice independently, then physicians should stop complaining.

            If they are not qualified to practice independently, physicians, should speak up and stop them.

            Either ways, their scope of practice needs to be assessed carefully. Simple.

            Between me and you, many, not everyone, are grumpy because of the $$$$ at stake.

            PS. I don`t have the numbers, but the shortage is closer to 100,000.

          • http://www.facebook.com/tlohman2 Theresa Lohman

            Thank you.

        • http://www.facebook.com/tlohman2 Theresa Lohman

          Yes. I said that.

    • http://www.facebook.com/tlohman2 Theresa Lohman

      I don’t see the problem with this. Many physicians are selling their practices to hospital groups and getting a salary. The hospital makes out. So?

  • http://www.facebook.com/balynn1234 Beverly Ann Lynn

    thank you. a well written article based in reality.

  • http://twitter.com/onlinenursing Terri Schmitt

    Well worded and reasoned. Thank you for writing this piece.

  • http://www.facebook.com/danielle.deutschendorf Danielle Gigler Deutschendorf

    Great article and perspective on the whole debate: Doctors vs NP/PA. I am a independent Primary Care Manager (PCM) for 1200 active duty members, their defendants and military retirees. I never hesitant to consult the appropriate Dr or fellow PA/NP with questions or needs for consultation. I am treated with a great deal of respect by all the PCMs in my military clinic and rarely have a patient who cares what type of provider I am as long as I am competent! Interestingly NPs/PAs function successfully in the military this way but are not paid anywhere near the bonuses Dr. get nor make rank automatically like they do for the same amount of responsibility, liability and LOTS OF HARDWORK! We are expected to be a full-time provider while juggling the requirements for Professional Military Education programs (which can require up wards of 6-9 months of computer based military doctrine training to be completed after hrs at the en if the normal 9-12 hr work day. I think all NPs and PAs would agree we just want the legislative rules for “mid level providers” regarding scope of practice, formal supervision and hoops to jump through to catch up to what we are doing and let us focus on what is most important…great patient care!!!

  • Dave Mittman, PA, DFAAPA

    Dr. Ejnes:
    I just want to say thank you for telling the truth. It’s rare, especially for a physician in a leadership position to do so. There are many good physicians, many who are not threatened, many who realize we are still learning and evolving and who applaud all who want to become good clinicians. I would only ask that you not call us NPPs as it’s hard to be defined by what you are not. It would be like me calling all physicians Non-PAs and NPs. I like Advanced Practice Clinicians (APCs) if you are going to bundle us.
    Again, thank you very, very, much for your kind words.

    • Yul Ejnes, MD, MACP

      Thank you for your comment and your suggestion on terminology. I struggled to find a term that would not offend, like the two I referenced in my post. I did want to cover NPs and PAs, but found mentioning both each time I meant both to be clumsy. So “APCs” it is.

      • Obadiah Oyer

        I’m interested in any comments as to where you think pharmacists fall in the spectrum. My understanding is that pharmacists, PTs, etc would be called “mid-level practitioners.” I struggled with exactly what to write here because I’m trying not to bias the outcome too much. Just for sake of comparison take the medication study and knowledge of NPs and pharmacists. Pharmacists do not focus on diagnosing patients, but I am fairly certain that the study of medications (what NPs are prescribing) is much more advanced. I am very interested in discussion on this and can provide more clarity if needed.

  • http://www.facebook.com/tlohman2 Theresa Lohman

    I am a non-physician provider. I have been a nurse midwife since 1995 and a family nurse practitioner since 2006. I started nursing in 1971. Oh my how things have changed.

    I have worked, in a physician owned practice, as a midwife, doing full scope practice. That is OB/GYN, deliveries etc within my scope of practice. . During that time, when my physician colleague was off call, the docs across the hall were my back-up. I never hesitated to call if there was a problem or I anticipated a problem. I accepted the fact, that if they came in, the patient was theirs. It was in the patient’s best interest. I am back at that hospital in OB triage now and I still have the respect from those physicians that I earned over 15 years ago.

    I have worked in family practice with a doc that spends 10 seconds with each patient and never takes the chart in. Even the patients call him their 1 minute doc. He doesn’t actually visit patients in the nursing home because they won’t remember anyway. Does that mean all physicians are bad. No.

    I also know more physicians that over prescribe pain meds than non-physician providers. Yes, Ohio does allow narcotics to be prescribed by nurse practitioners/midwives.

    My point is that we can all play nice together for the sake of good patient care. I don’t pretend to be a physician even though I am a doctor.(doctor of nursing practice, :-) ) Some are good, some are bad in every facet of medicine/nursing. I don’t want to be a physician. . Some over-step there scope of practice but some physicians do that too. As was said by the author, just because you treat some heart disease does not make you a cardiologist.

    Anyway, we are here. I don’t think we are going anywhere. So, lets all get along and learn from each other. We have to present a smiling united front. Patients, after-all, can complain if they don’t perceive their care to be excellent.Then your reimbursement drops. I think that is a bigger barrier to pay than working with non-physician providers.
    Just sayin.

    Terri Lohman DNP CNM FNP-BC (I tried for the whole alphabet but they started repeating letters. I gave up)

  • Dickson John, RN

    Hey , I have see in your 3rd para ” I have worked with nurse practitioners or physician assistants” . WHO TOLD YOU THAT np AND PA ARE SAME…?????If you dont know the things exactly,,plz dont write it. NP and PA are very very different professional-no .000001% similarity…plz understand that first….

    • cruzfl0w

      I don’t think he ever alluded that they were the same. If you read the article it specifically states he will call them NPPs for simplicity. However, you are right, they are not the same. Both PAs and NPs are great professionals.

    • Yul Ejnes, MD, MACP

      I think you need re-read the article, John. I never stated that the two are the same. All I wrote was that I have worked with both. Of course, they have different training paths and histories. However, I have worked with both NPs and PAs for over twenty years and in my primary care office they play very similar roles. And while much of the discussion of the roles of members of the health care team has focused on NPs, PAs have raised similar issues in some parts of the country, so rather than focus on one group, I broadened my discussion to include both.

  • cruzfl0w

    A truly amazing article. When I read forums and hear the panic/hatred of NPPs it is usually from a med student . When I talk to physicians in the real world they seem to always love their NPPs. Thank you for this article.

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