Risk stratify patients to best use non-physician providers

“There are two diagnoses you will never make: those you didn’t think about, and those you have never heard of.”

This quote, ascribed to many an attending physician over the years, underlies what has become on some levels a vitriolic discussion of primary care delivery in the United States today. It was recently highlighted by a study published in the New England Journal of Medicine.

This article showed a real chasm between what physicians and nurse practitioners think of themselves and think of one another. Nurse practitioners were more likely than physicians to believe that they should lead medical homes, be allowed hospital admitting privileges, and be paid equally for the same clinical services. When asked whether they agreed with the statement that “physicians provide a higher-quality examination and consultation than do nurse practitioners during the same type of primary care visit” 66.1% of physicians agreed and 75.3% of nurse practitioners disagreed. The authors did not include physician assistants in the study.

Let’s start here as way of background to make sure we are all on the same page: physicians, nurse practitioners and physician assistants are all trained to provide medical care. Their training and background differ significantly. Physician assistants (PAs) have 6 years post-secondary education; nurse practitioners (NPs, or APRNs: advanced practice registered nurses) have 5-8 years post-secondary education; primary care physicians (MDs) have 11-12 years post-secondary education.

The number of hours worked in those years differs substantially too. Physician assistants can work upon completion of school, and require no internship or residency. Some nurse practitioners do 1 year of residency training in outpatient medicine, though 99% do not. Physicians have residency training that requires 12-30 hour shifts across their time in residency.

As one organization, the American Academy of Family Physicians, which has a huge percentage of its doctors serving in primary care roles, has recently reported, the educational and training differences among these groups of providers profound: nurse practitioners complete 2,300 to 5,350 hours of education and clinical training during five to seven years, compared to physicians’ standardized path of 21,700 hours over 11-12 years.

If medicine really wants to solve the primary care shortage, improve quality and decrease cost, the key is to risk stratify patients and stop wasting resources of human capital.  In no other industry do people with staggeringly different levels of education, training, expertise all do the same job – except in primary care medicine.

Take a look at the “average” education of some of our country’s educators:

High school teacher: 4-6 years of post-secondary education

University professor: 6-10 years of post-secondary education

Would we allow our high school teachers and university professors to work interchangeably? It hasn’t happened on a large-scale yet, and would be unlikely to in the near future.

Alternatively, look inside the world of science and medicine.  We have amazing discoveries that advance science and the public health of our nation that make news every day. Many labs have one or more scientists working with and supervising a cadre of lab technicians. Most lab technicians have a 4-year college degree. Most PhDs have an extra 6-8 years of education and training beyond their college degree. While the PhD scientists can do the technical work that a lab technician does, it doesn’t make sense for them to do this all day. They can do more than this, and they do indeed do far more than this in almost every single laboratory across the globe.

Let me give you a glimpse into the environment where I work, a federally qualified health center that is a level 3 patient-centered medical home. The clinical care delivered on par with the rest of the United States, and is the perfect set-up for a fully-integrated healthcare team. There are 6 providers that deliver primary care: 2 physicians, 2 nurse practitioners, and 2 physician assistants. Perfect team based care, right? Not really.

Where I work now, if you walk in the door, you could have an appointment with a physician, nurse practitioner or physician assistant, and all clinicians are expected to provide the same care, achieve the same quality metrics, and ensure the same high levels of patient satisfaction delivering evidence-based care. A patient with end-stage liver and kidney disease with uncontrolled diabetes could just as well be seen by a PA, an NP or an MD.

Indeed, in many clinics, receptionists with little to no medical training book patients with “the next available slot” regardless of the complexity of the patient or their symptom. So, on a typical day, I can see a 25-year-old health female with a cough while a nurse practitioner sees a 72-year-old lady with heart failure, Sjorgen’s syndrome and intersitital lung disease. The NP may well do a fine job caring for this patient, too, but there are days when this scenario is the norm, and not the exception, and that just doesn’t seem to make much sense from a systems utilization point of view.

As I have argued prior, if nurse practitioners and physician assistants can see 80-85% of the patients I see, and require only 4 or 5 years of post-graduate training – and not the 7 or 8 that most primary care physicians receive – then we need to develop systems that select the 15-20% of patients that need to see a physician.  If however, all clinicians – MDs, NPs and Pas perform similarly, then we should cut primary care physicians training by 4 years and several thousand hours.

There are several validated methods that have been used to classify patients as “medically complex” based on diagnoses and combinations of conditions. These systems should be more broadly employed to preferentially direct the more complex to those providers with increased training. It would have the potential to provide more efficient care and also provide a more thoughtful, appropriate distribution of limited resources.

I work with several nurse practitioners and physician assistants, and they all do a great job, and many function tremendously well as primary care clinicians for their panel of patients. Some of them are also more likely than physicians to have the skill set necessary to lead medical homes. Patients need all of us, and we all need to work together to make sure we support one another. It is this spirit in which I propose risk stratification.

In no other industry would three groups with very different levels of training and expertise be asked to provide the same level or service and adhere to the same professional standards. If all groups of clinicians are doing the same job, they should all be licensed the same way, require maintenance of certification, and all be required to take and pass the exact same licensing board exam. Otherwise, roles and responsibilities should be more thoughtfully distributed.

There are some areas in the country where there are no choices, and NPs and PAs must work independently. And I realize that we as physicians do not get fairly reimbursed for providing complex versus non-complex care. But this does not mean the whole situation is appropriate.

In places where there is a mix of PAs, NPs and MDs, their job responsibilities, descriptions and levels of care should reflect the 6, 7 and 11 or more years of training they have had. It is not a quick fix for a stressed primary care system, but it may well be a more judicious use of limited human resources.

Doug Olson is a primary care physician.  He can be reached on Twitter @doctorolson.

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  • Ed Rodgers

    So, just for the sake of argument, how do you risk stratify patients when your office has an MD fresh out of residency and an NP with 15 years of experience and ongoing medical education. Who would you rather see if you were the patient with end-stage kidney disease if these were the only options?

    Seems to me that training alone as a basis for distributing risk is lacking at least one other important dimension – experience in practice.

    • Greg Dursteler

      The physician, obviously.

    • buzzkillerjsmith

      MDs fresh out have seen a zillion cases of ESRD in residency. I know I did.

    • Cyndee Malowitz

      The nurse practitioner, obviously.

    • Cardionp

      The experienced one. The NP.

  • Noni

    I’m starting to think Kevin is just trying to bait us with these articles…

  • Elvish

    On what basis do you want to cut back Primary care training for physicians ??

    Just because an MD`s performance has declined to that of a NP or PA, it does not mean primary care training should be cut down.

    The Royal College of General Practitioners in the UK has recommended to extended the GP training to 4 years, after the 2 foundation years !

    It is a crime that you let “”72-year-old lady with heart failure, Sjorgen’s syndrome and intersitital lung disease.” to be treated by an NP !

  • Nobody

    You seem to imply that a PhD never teaches in high school while all everyone at a university has a PhD.

    Perhaps primary care physicians are overqualified instead of your premise that nurse practitioners are under qualified.

    My spouse works as a software engineer with a man with a degree a BS in physics and one with a degree an MS in mathematics. Your premise that education is uniform is also incorrect. Do you think they should be paid the same for similar work?

    Perhaps nurses have skills not taught in medical school that is valuable for primary care.

    During that extra time training, primary care physicians learn things they never use in practice.

    I was that patient with a cough…it wasn’t simple. My primary care physician was unable to make a correct diagnosis. Does that mean primary care is inferior to specialists and they should not be paid the same or have the same responsibilities?

    My primary care physician often refers for anything complex. Of the five major diagnosis I have received, all five of them were referred to a specialist. Of those five, only two of them are now treated in primary care…for the others, I continue to see specialists. Any changes and I would consult a specialist. A nurse practitioner could ask the same questions and refer just as competently as a primary care physician.

    • Guest

      Bill Gates and Steve Jobs did very well for themselves and neither finished college ; )

    • Cyndee Malowitz

      My daughter has a Master’s in Computer Science yet she doesn’t make anything close to Bill Gates, who dropped out of college. Oh, life is so unfair!

    • Cardionp

      That was beautifully stated!

  • southerndoc1

    Nothing says “patient-centered” more than “You’re simple, you’re not allowed to see your doctor.”

    • Mengles

      Of course where does Doug Olson work? According to Twitter, a “federally qualified health center”. Yeah, no wonder he has the view that “a patient with end-stage liver and kidney disease with uncontrolled diabetes could just as well be seen by a PA, an NP or an MD.” So scary.

      • Elvish

        It is unethical and should be criminalised.

        I don`t know how such doctors sleep at night !

      • Dr. Drake Ramoray

        When I was in medical school I had a patient call 911 from his inpatient bed at the VA with chest pain because the nurses weren’t answering his call bell. Dispatch called the floor after he gave his room number. True story.

      • Cyndee Malowitz

        Mengles – are you stalking people again? Why don’t you use your real name so we can find out where YOU work.

  • goonerdoc

    Sigh….another MD vs. NP article where we all get to rip each other unproductively. Kevin, please stop the madness.

    • Dr. Jess

      Ladies & Gentlemen, ready your spitball shields ;-)

  • Greg Dursteler

    It sounds like you need to alter your scheduling process so that this workflow outcome can occur. It is certainly achievable to schedule patients more intelligently so that you are not seeing someone with sniffles while a NP or PA deals with a complex patient.

  • buzzkillerjsmith

    Cutting back training for PCPs would cause our numbers to plummet even faster.

    Have the NPs run the medical homes. It has always been my dream to work for a nurse, how about you?

    It does not matter to CorpMed what you have after your name. No one cares whether you can diagnose Waldenstrom’s macroglobulinemia and your NP or PA can’t. It does not matter that a clinically rational system would include a mix of midlevels and MDs who would manage the more complicated outpts and be available for immediate consultation. No one cares about this.

    We are expensive factors of production and we will be eliminated, although perhaps mainly through the decisions that med students make. Few will pay for expensively tailored clothes when Walmart suffices.

    The med students will do fine. They just won’t do primary care. Wave the white flag, give up the fight. If you’re an older doc like me, run out the clock. I don’t expect to be fired, just deprofessionalized.

    • Dr. Drake Ramoray

      Do an endocrine fellowship. It’s only two years. Almost exclusively outpatient (for now). With obesity rates in this country you will always have a job. Just go in with eyes open and know CMS will grade you on the hardest, most non-compliant, most difficult to manage diabetes patients for the rest of your life. Oh wait……

      • buzzkillerjsmith

        I’m a FP so they won’t let me in. Dang it. Otherwise it sounds really sweet.

    • Cardionp

      Buzzkillerjsmith…what’s wrong with working for a nurse? You sound like a pig. Also, a bigger pig for referring to PAs and NPs as midlevels. You clearly need to retire. Your thinking is outdated.

      • buzzkillerjsmith

        I’m actually more of a dog than a pig….

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

    Maybe we can change the focus here a little bit, and ask how come that people with less education seem to be able to practice “primary care”, and seem to be convinced that they should do so independently. Maybe we should be asking what “primary care” is, or has become.

    Going back to an article Kevin posted here a year ago, http://www.kevinmd.com/blog/2012/01/primary-care-doctors-referring-patients-specialists.html (which also disintegrated partially into NP/MD comments), I would argue that too many “primary care” docs are not practicing to the “full extent of their license” (present company excluded), whether by choice, or forced by ugly realities, and therefore non-physicians figured out that their own “license” is perfectly fine for this diluted “primary care”.

    Until and unless “primary care” reclaims its status as comprehensive medical care, which is most likely paramount to both quality and cost containment, you will have to contend with these foolish “wars”.

    • buzzkillerjsmith

      Primary care will not reclaim that status because it is not in the short-term best interest of individual PCPs to do so. And we have no confidence that even if we were to organize we would be able to resist the forces compelling us to not practice to the full extent of our licenses, especially the economic forces. To my mind that lack of confidence is simply bowing to reality.

      The solution, the only sensible solution, is to get out or, even better, to avoid this cluster@#$% in the first place. Then the med students will not have to contend with the wars.

      No matter how much we want something, and no matter how just it is the we should have it, we still might not get it.

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

        Forever the realist…. :-)
        It may be just my self-destructive tendency, but I’d rather go out in a big ball of fire, than march silently into the night.

  • http://www.facebook.com/twila.noble.3 Twila Noble

    Hello…. NP responding here. 9 years post- secondary years, two masters’ thirty years RN and six years as NP. I was a home health and hospice nurse for 15 years. We managed patients using a team approach. RN saw pt first and every two weeks or as needed per acuity level, LVN/LPN saw Pt in between as needed. It seems that this model might be used for chronic patients.

  • SenorMiamiBeach

    Risk stratify just doesnt work in real world busy practices. Way too many variables..give up on the idea. If physicians are so focused about all their increased training and knowledge then why do they do they set up so many prim care practices where we Non physician providers are often left to do almost all the urgent walkins. These are usually the more complex patient situations than the routine f/u patients but they seem to prefer we NPs and PAs do all these visits. They lose some credibility with me with this practice.

  • Luz Zenaida Jorge-Rodriguez

    The problems for me do not reside in the amount of training each discipline had or had not but in the way the practice chooses to interact. what happened to collaboration among team members? As per MD seen the cough patient..train your schedulers. Had similar situation while working home health and had to train scheduler to understand why this patient needed to be seen by RN and who could be seen by LVN/LPN. When trained properly and when collaboration exist among all providers in the practice the workflow is smooth and everybody is more content…and the winner is THE PATIENT who really do not care about the degree of the practitioner who provide care for him/her when sick. Please make sure no matter what your initials after your name are: MD, NP, PA that you take time to really and actively listen to your patient concerns, take time to build a relationship with them and build that so much lost trust in the medical community. I hear many patients complain that my doctor is to busy and when I am in his/her office I have no time to talk to them because they rush into their room and rush out of it as fast as they can. I do understand the era of manage care and all that insurance bull…but remember the patient is a human been with unique and complex needs. also please speak to us patients in plain English avoid all those medical terms that most do not understand and just make them to feel scared when they leave your office. Use term that they will understand.

    • Suzi Q 38

      Thank you. My feeling exactly.

  • meyati

    I was hospitalized to get IV antibiotics. I was released without enough -antibiotics at home. I kept telling everyone that I had only 5 pills. They told me that I was on painkillers, and the pills were home. My wounds stopped healing on the weekend. I called the primary care clinic that I desperately needed more antibiotics. The receptionist told me to use the electronic chart-which has a 48 hour turn around-and says-non-urgent- I asked again to leave a message for my doctor and nurse. Then I told her that I’d keep calling until I got somebody else and I’d tell them about her. 10 minutes later, the nurse called, and I went right there, got a shot in the rear, and a big bottle of horse pills. The nurse was by the reception desk waiting for me when I checked in—Indeed, in many clinics, receptionists with little to no medical training book patients with “the next available slot” regardless of the complexity of the patient or their symptom.– Many receptionists are very good, but they have little training beyond smiling, knowing federal guidelines for privacy, and how to run a computer. I sometimes go to PAs when my doctor is booked up, and I have praise for them. The receptionists have a rough job, but a clinic or doctor has to invest time in training the front line of medical care-the receptionists. By the way, I finished radiation and said that at the ER. My sleeping dog woke up and bit me. I never did see a doctor at the ER. PAs and nurses were trying to figure out what to do-and what they did was wrong-I had pus coming out of each puncture by 50 hours and was hospitalized. I kept calling and calling, leaving messages, but my doctor was gone-and nobody had the sense to fit me in with another doctor, which I did ask for. When he saw my arm, he had all of the nurses come in and look at my arm. The communication needs to include the receptionists and nurses.

  • meyati

    And doctors don’t continue to learn? They just work at a higher level, when given the opportunity. Fortunately most patients don’t have complicated medical problems, and whomever does preventive care to keep that strep throat from becoming rheumatic fever, followed by a bad heart.

    • Dave Mittman, PA, DFAAPA

      Wow.
      The autor was talking about PAs and NPs seeing the easier things. I don’t believe it can happen. The author was not talking about MDs seeing the easier things. That’s why I made the point that we continue to learn on the job. That would be how most people keep learning and getting better.

      • meyati

        Yes, I understand, but life doesn’t often work the way we would like for it to be. I had a wonderful flight surgeon-full colonel, because I had severe IBS, and almost died. The staff-Sgts. PAs, etc thought that I’d die from it. He pulled aces out of his sleeve and found experimental meds that worked on me. But when it was time for a thyroid screen, he had to have a crash course on the TSH, I was out of range on the bottom, and he thought that I had low thyroid. I explained the TSH doesn’t make sense-low is hyper, high is hypo. His real speciality was the circulatory system of wart hog and F 16 pilots, but he was the head of the clinic. He was the go to man for the attached VA, bc he was an excellent surgeon and diagnostician. Even fairly small clinics that have ample specialists and medical staff of all types get a patient that doesn’t seem to fit their medical expertise. Some of the best help I got was from PAs in the AF. But back to my statement, everyone keeps learning, even MDs and DOs.

  • Climber

    I have a question for all those with more wisdom than I. My son is going to nursing school right now and plans on becoming an NP but has lately been wishing he’d gone to be an MD instead. As a patient, I personally would rather see an MD and I haven’t found in my experience that the NP’s are better listeners as I’ve heard some people say. It all depends on the MD or the NP.

    My question is that of education. I hear in all these debates that MD’s get far more schooling, and yes, I understand that is true. But what about the fact that the first 4 years of college for an MD are not any different than for most any other bachelor’s degree except being heavy on the science. While in nursing from the first semester they are doing clinicals and their education is much more specific to their career and not so much fluff as in other bachelor degrees. Doesn’t that balance the scales a little on the education. Most of what an undergraduate bachelor’s degree entails has nothing to do with medicine. For that matter why don’t we streamline education more so everyone isn’t wasting their time during those 4 year bachelor degrees just becoming a “well rounded” person. I appreciate that nursing has cut out a lot of those extra classes, thought not all. Why can’t we be more like Europe where young people spend more time focusing on learning what they will actually be using in their carreers.

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