Low-cost extenders come at a high price Street Smarts. By Scott Gottlieb, MD, AMNews contributor. May 14, 2001. Last week, late at night, my 2-year-old nephew was stricken with the croup. My sister called her pediatrician, and a physician assistant called her back. He encouraged her to take my nephew into a steamy shower. The next day, my sister called the doctor again. This time a nurse practitioner called in a prescription for prednisone. My nephew got better. He never saw a doctor. These days, more patients are finding that a visit to the doctor may actually mean a visit to a nurse practitioner or a physician assistant. Most of this is due to financial reasons, because nurse practitioners and physician assistants are less expensive for medical practices. Doctors can leverage their time, and boost their incomes, by managing a stable of "physician extenders" rather than seeing all patients individually. The idea is doctors would oversee nurse practitioners handling routine exams, freeing the physicians to focus on diagnostic dilemmas. Economists and Wall Street analysts refer to this as the "industrialization" of medicine. Physicians can streamline their practices by delegating routine exams to cheaper professionals, economizing on their own costly services. Such industrialization, economists say, is the logical next step for a system that has shifted from a healing art based on cradle-to-grave patient relationships to a fragmented, depersonalized delivery system driven by the pressure of medical economics and an increasingly cost-competitive insurance system. In many ways, this was the promise of the practice management craze. These outfits aimed to bring modern managerial techniques into medical offices and apply the corporate fidelity to the daily routine. Physician assistants and nurse practitioners are typically paid less than half what internists and family physicians earn. Practice management firms made heavy use of nurse practitioners to increase patient loads and cut costs, and that trend seemed to catch on. In the short run, physicians have been able to boost their incomes by leveraging their own time off the cheaper professionals. In the long run, they haven't done themselves, or their profession, many favors. For one thing, there's the immediate reprobation from patients who don't want to get a nurse when they go to see their doctor. My grandma said she'd rather get her care from a medical student. That's called consumer backlash. The long-term implications are more troubling. Doctors are conditioning an entire generation to expect RNs instead of MDs and to see inferior care doled out by nurses and physician assistants as being equal to what a physician can provide. Family physicians and internists in particular are making their own crafts obsolete. Chasing a few extra dollars, they're effectively cannibalizing their markets and destroying the perceived value of their training. Nowhere do doctors ask nurse practitioners or physician assistants whether they take their own family members to nurses for medical care. The few anecdotal reports examining the issue are revealing. Doctors would be amazed at how many paraprofessionals seek the best physicians for the care of their own family. The same people will, with a straight face, emphatically state that their care is as good as a medical doctor's. Other industries routinely cannibalize themselves by coming out with newer, faster products that make the old ones relatively more expensive or obsolete. Manufacturers of vacuum tubes didn't balk at the advent of the transistor. Bill Gates doesn't hold back new versions of Windows because it will make all the older versions seem silly. But can you name any service industries that follow this pattern? Accountants aren't out campaigning for a flat tax. Investment bankers recoil when companies say they can execute their own mergers without the help of Wall Street's overpriced prima donnas. The trial lawyers bitterly oppose the golden rule. Not physicians. They eagerly devalue their own degrees to boost their bottom lines. The societies that govern internal medicine and family practice have been wondering aloud in some of the medical journals why more medical students aren't choosing these specialties. I know. Unfortunately, a high debt load isn't the most dramatic disappointment today's graduates face. A 1999 survey of 300 senior residents in family practice, internal medicine and pediatrics found that 40% expected to earn between $101,000 and $125,000 during their first year of practice. Another 26% expected to earn $126,000 to $150,000, and 22% said they expected to earn more than $151,000 in their first year. These expectations were much higher than those expressed in previous years and, more importantly, they are higher than what is realistic. Medical students are instinctive economists. Nurse practitioners are increasingly taking on the role of pediatricians and family physicians. A board certification in one of these specialties isn't as valuable as it once was, and, if some from the current crop of physicians have their way, it will be worth even less in the future. That's because, in the end, having nurse practitioners in your office requires that you blur the distinctions that make physicians special. Doctors dress their nurse extenders up in long white coats and sling stethoscopes around their necks. It works. And by the time patients realize their care has been dumbed down, they've fallen in love with the extenders, who can carve out more moments for the touchy-feely side of medicine. After all, their time is cheap. Dr. Gottlieb is a resident in internal medicine at Mount Sinai in New York and a former analyst for the Wall Street firm Alex. Brown & Sons.