how do you feel about mid-level practitioners

[vikary]

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Hey,
I was searching the allopathic forum and came across a post by Macgyver that had evolved into this huge discussion of how NPs and PA and CRNAs in some rural areas can practice without supervision of an MD, and how this may result in the disappearance of primary care doctors because of the cost benefit of hiring skilled mid-level practitioners. I wanted to ask you future doctors how you feel about mid-level practioners and their role. I personally have no objection to NPs, PAs, and CRNAs, and their expanded roles that they play in the hospital. We should all work as a team, and if you can provide quality care and it is at a fraction of the price, why not?

 

[upitt]

As long as people have the need to see a doctor there will be a need for FP's. You cannot replace a physician with an RN, PA, or a rocket scientist. There's a reason why we go to med school for 4 years and then do atleat 3 years of residency. An RN or a PA taking care of patients without being supervised by a medical doctor will be very dangerous to the patient. I'm not trying to put down RN's or PA's, they are great and contribute a lot to the field of healthcare. However, medical doctors go through more training and are more knowledgeable about medicine.

 

[asama527]

I agree. There's always going to be something the mid level health care professionals just aren't going to be prepared or trained to deal with. Occasionally these providers just aren't going to have the skills and experience that a FP/Rural doc is going to have.

 

[benelswick]

I disagree with the assesment that NP's and PA's don't have the skills. I've seen doctors and residents that are freakin scary and I've seen NP's (my mother included) that have been working in healthcare for more than some residents/doctors have been alive and who have better instincts for what direction a patient is heading.
What is unique about the physician in my mind is not the training in biochemistry and what not but the training in the use of decision making skills including the development of the confidence to do so.
As healthcare costs continue to skyrocket and the access to healthcare continues to diminish its not unlikely that expanded roles for NPs and PA's will be on the rise.
It is, however, likely that the AMA will continue to defends its territory at the expense of the greater good which is perhaps ironic....a bunch of aging archaic doctors unable to pay for their own healthcare being seen by the same NP that they cumudgeonly restricted the practice rights of.

 

[ornis4]

Well, you're clearly biased on the matter too...let's not forget that. I'm sure your mom is great as an NP, but you're trying to tell me that ALL NP's and PA's should have the same range of responsibilities of FP's? That's absurd, and frankly pretty insulting to FP's who go through the same training as every other doctor. I believe there are more differences between them than merely confidence, and if you tried to introduce some measure that enabled PA's and NP's of a certain level those responsibilties, you'd have a mess on your hands. Which nurses and assistants would be considered good enough to perform those duties? How would the malpractice insurance work for that? Why even have FP's at all? Don't you think that the NP's and PA's would eventually demand the money to match their responsibilities?
The need for FP's is most always going to be greater than any other discipline, and continues to rise every day. I know experience is possibly the most important part of training and learning in the medical world, but still...no offense, but I'll take a FP over a PA or NP any day when it comes to the duties meant to be performed by the doctor. And I would think to the laypeople, who seem to be concerned at least to a certain degree about the MD/DO on the coat(unfortunately), they would feel more comfortable with a doctor as well. And you can bet that should something go wrong they would probably be a little quicker to file a lawsuit against a practice if they let the nurse do something out of their normal range of duties and it went wrong.
Just my opinion...I have great respect for NP's and PA's, but they're not doctors, and blurring that distinction would cause a mess in many ways, not to mention put a damper on the career aspirations of many future docs.

 

[skypilot]

My sister is a Nurse Practitioner and the ObGyn's she works with would rather work with her than with a Family Practice doc on a birth.

The reason is that as a Nurse Practitioner she knows the limits of her abilities and won't wait till the last minute to call in the expertise of the ObGyn (for an emergency C section for example). The Family Practice docs sometimes think they can handle it and won't call the ObGyn until the baby is crashing.

 

[jdg222]

I think that due to the shortage of FPs and the fact that most of us seem to be more interested in specializing, society may have no choice but to look to NPs, PAs, and CRNAs.

My girlfriend is from a rural area in Missouri, and believe me, in some of these small towns, there aren't many doctors who are willing to serve a small client base in the middle of nowhere. Instead of driving 1-2 hours to the nearest FP, alternate care providers may step in.

I don't think it's good that doctors be completely replaced for these purposes, but it is an access to care issue that needs to be addressed.

 

[twinklz]

When my dad (an internist) worked on the air force base, they used NPs and PAs as sieve to weed out the "easy" cases. This works in 95% of cases. However, he says he had at least a dozen patients who he found in physical rehabilitation because the NPs or PAs thought the patient's left shoulder pain was merely a sore joint as opposed to angina...

The point being that midlevel practioners are a great and inexpensive way for most day in and day out cases to be treated. However, being treated by someone who doesn't have as large a knowledge base always carries additional risks.

 

[Supadupafly]

I don't like the idea of mid-levels taking too much of the patient load. Sure, some of the best clinicians I know and work with are PA's and NP's. That's not the point. From a labor perspective, we need to advocate for members of our profession: physicians. This doesn't need to be devisive; it just means to keep boundaries clear. If there aren't enough physicians for rural areas, schools need to graduate more docs. As a P.C. doc, it's going to take me years to pay off my loans. I don't need the pay cut that would come from competing in a labor market saturated with mid-levels. As a medical technologist, I saw wages freeze then decline, as technicians with associate's degrees took over high complexity testing. I fear a similar scenario in medical practice.

 

[skypilot]

Originally posted by Supadupafly
That's not the point. From a labor perspective, we need to advocate for members of our profession: physicians. This doesn't need to be devisive; it just means to keep boundaries clear. If there aren't enough physicians for rural areas, schools need to graduate more docs.

There was so much fear of an oversupply in the past that we are in a pickle now. A huge portion of the slack is being taken up by FMGs and another part by the mid levels.

As a patient I think it is not a good direction. On the other hand I see physicians rushing patients so they can get the volume to support their huge debt, salary, and overhead loads. Those aren't good things either.

I would rather have a mid level practitioner who cares and would spend lots of time with me than a extremely harried physician who is practicing defensive medicine and only worried about seeing as many patients as possible.

 

[benelswick]

There is little conclusive evidence that I'm aware of that demonstrates better patient outcomes at the hands of FP's than NP's. If you're going to say this the burden of proof should be on you to justify it in a world where millions don't have access to healthcare.
And as far advocating for the physicians' cornering the market on providing healthcare you won't have my support...and yes I will also be faced--if I'm lucky--with exiting medical school with HUGE debt but so what. If it means having less constituents who clearly are their for their own interests, ie. ego, pocket book etc. , then let the plea for all those whose families have suffered with no access to healthcare be the victor in this clear and impending crisis.

 

[ornis4]

Well, altruism sounds all warm and fuzzy on an SDN forum as well...but when we get out of med school, I sincerely doubt I'll see too many of us running off to Africa or other severely underprivelaged parts of the world. And I also don't understand the distinction between the monetary motivation for doctors and mid-level practitioners. Certain posts on this thread have implied NPs and PAs go into their professions with more interest and compassion for patients, simply because they make less money? Sure, patient volume is directly related to income in FP...but personally I'd rather have a harried physician take a look at me for 2 minutes than a PA who cares for 5 minutes. It's nothing personal...and in my experience, I've met far more rude, impersonal NP's in my life than physicians...but maybe that's just me.
Regardless of my preferences though, I can at least see a time in the future where this may be an option for solving the enormous primary care demand that is always increasing. One option would be a couple more DO schools...there is a thread in the pre-DO forum right now on this same topic. Although it would further dilute the applicant pool, it would at least help to quell the problem to some extent.

 

[skypilot]

Originally posted by ornis4
personally I'd rather have a harried physician take a look at me for 2 minutes than a PA who cares for 5 minutes. It's nothing personal...and in my experience, I've met far more rude, impersonal NP's in my life than physicians

Sad that the choice is between 2 minutes and 5 minutes and then they charge you $80 for 15 minutes isn't it?

Some ob/gyn patients do choose nurse practitioners (certified nurse midwives) because they are given far more time in the office and during their delivery.

Of course there is always an Ob/Gyn standing by (usually sleeping in the call room) in case something goes drastically wrong.

 

[vikary]

posted by ornis4
It's nothing personal...and in my experience, I've met far more rude, impersonal NP's in my life than physicians...but maybe that's just me.



I have had quite the opposite experience. Some of the doctors at the hospital here think they are God's gift to the world and they are so consumed with themselves that they don't even bother to acknowledge anyone else. One of my favorite docs though is just great. Ironically she told me when I asked for her opinion in medicine today that if medicine was what it was ten years ago, she would say go ahead and do it. Now, she says, she would never encourage anyone she loved to enter the field. She told me to become a well prepared nurse.

 

[Alleria]

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[woolie]

Well, in the interest of full disclosure I have to add that I was a contributor to the PA/FP thread. I asked about the nurses, as well, who I often like more than the PA-c's.

I think it's a very murky field sometimes, like today when I called my ob/gyn to ask her a question and I was told to speak to her "nurse," Mary. "Nurse?" I said, "or is she a medical assistant?" Well, the receptionist said, she really is an MA. Now, I knew that, which is why I wanted to drive home the difference. To me, that is dishonest and is misrepresenting the situation.

On the same level, I have seen some murkyness with PA-c's who seem to encourage being called "doctor." Interesting phenomenon .... (*ahem *)

But back to the main idea, yes - the PA-c's and NPs can be great aides in a medical practice, each in his/her own professional way. But absolutely they should not be confused for a full medical practitioner or even a med student. It's just a completely different ball game and a very different level of knowledge and accuity. But in a really rural area, I really don't care who stitches me up - just as long as there's somethere there who's actual able to do it.

 

[skypilot]

Originally posted by Alleria
as the Deans were concerned, almost all the Deans said that there was either no shortace of FPs, or at the most, a very mild shortage (three out of 70, I believe.)

Hey, great article!

Although there is not a shortage of FPs according to the article, there is a severe shortage in General Internal Medicine as well as many of the subspecialties of Internal Medicine.