Dr. Whatever

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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.
 

juddson

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Interesting article. I wonder if it is true that NP's and PA's do NOT take thier own family members to other NP's and PA's. I DO think this has had an effect on the number of students going into primary care.

Judd
 

emedpa

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I am a pa. my pcp is a pa. my wife sees an ob nurse practitioner. a midwife delivered our kids. when a family member injured their knee I refered them to an ortho pa who did the initial screening exam and arranged follow up for ortho surgery with an orthopedist I respect. most midlevel providers(pa/np) I know are happy to have their care delivered by other midlevels with apropriate referals to specialty care as needed.
 

juddson

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Well, there's one at least.

Perhaps physicians are overtrained to do what they have traditionally done in primary care. Maybe young doctors need to look at this issue from another tac. Rather than lament the loss of practice scope to mid-level practioners, they should instead petition their regulatory boards to permit them to skip the last two years of medical school and residency if they agree to practice in primary care.

Judd
 

Homunculus

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from the patient side of the fence, i've seen this firsthand. my son has been to his pediatrician probably around 12 times, counting sick visits and well visits. how many times has he seen his actual pediatrician? 1. every other time was a nurse practitioner. i understand PA's and NP's doing routine care, but i'm not paying my insurance premiums and co pays for a nurse when my kiddo is sick. my latest favorite from the NP-- my son presents with a history of 104 degree fevers, runny nose, cough, and irritibility. her diagnosis? allergies, lol.

i think for me it comes down to peace of mind.
 

rad_one

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It's your right to determine who you/ your spouse or kid will see as a healthcare provider. I tell my wife that when she is asked if she is OK w/ seeing an NP/PA, that it is OK only if we get charged half price. Primary care providers are not overtrained, they need to be able to recognize a large variety of problems. These practices are hiring midlevels in order to boost revenue in the face of declining reimbursement and rising malpractice. It is up to the younger physicians to maintain the foothold that they have earned through 12+ years of education.
 
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Blade28

While I'd argue that, for many routine visits, a PA or NP may be able to do an equally proficient job as an MD/DO (having been seen by a NP quite a few times myself, growing up)...I do believe patients should have a choice. They should be able to specify who they want to see, and not just be assigned to someone OTHER than their doctor without their knowledge.
 

DocWagner

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If you go to chic high priced cafe, you don't expect to be served a Big Mac. Yeah, it tastes good...but I DID pay for a filet, and it damn well better be cooked by a chef.

If you work at McDonalds and you want Big Macs then go for it...I'll take the filet.
 

Freeeedom!

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Many of the PA's I have worked with were fantastic at suturing, but many of the new ones are kids with zero experience. The well is drying up and I just don't trust the unknown midlevel...to much variance in training and skill. Just no standards. Many times you are rolling the dice.
Today, I just tell my parents SPECIFICALLY who I want them to see "board certified cardiologist, internist, FP, etc".
Let us not start a flame war, this has been played to death and simply brings the Trolls out from underneath the bridges (MacGyver etc).
I stand firm that DO FP's use skills not found in any other degree (except maybe PT)...hard to reproduce those skills by a midlevel.
 
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Blade28

Originally posted by DocWagner
If you go to chic high priced cafe, you don't expect to be served a Big Mac. Yeah, it tastes good...but I DID pay for a filet, and it damn well better be cooked by a chef.

If you work at McDonalds and you want Big Macs then go for it...I'll take the filet.
Very well put! :laugh: :thumbup:
 

16846

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Originally posted by Freeeedom!
Many of the PA's I have worked with were fantastic at suturing, but many of the new ones are kids with zero experience. The well is drying up and I just don't trust the unknown midlevel...to much variance in training and skill. Just no standards. Many times you are rolling the dice.
Today, I just tell my parents SPECIFICALLY who I want them to see "board certified cardiologist, internist, FP, etc".
Let us not start a flame war, this has been played to death and simply brings the Trolls out from underneath the bridges (MacGyver etc).
I stand firm that DO FP's use skills not found in any other degree (except maybe PT)...hard to reproduce those skills by a midlevel.
I have to agree w/ the above statement...

Some years ago I was doing some DIY and incurred a 2-inch gash on my index finger that went to the sub-Q and wouldn't stop hemorrhaging. When I went to the ER they sent me to the fast-track and I was seen by a PA who said that it couldn't be sutured. She just wrapped it and said to come back if an infection sets in, I never saw an actual MD. I didn't question her treatment because at that time I didn't know any better, and believed she knew what she was talking about. As a result I have a rather large, unpleasant scar on that hand...

A very similar incident happened more recently and I had a friend who was a plastic surgeon do me a favor and suture it. Being a very talented surgeon, after the stitches came out, there was absolutely no scar, totally impossible to tell I was ever injured...

I strongly believe that the scar on my left hand could have been minimized/avoided if it had been properly sutured. Ever since I specifically ask to only be seen by a physician whenever I need treatment of any kind.
 

amdap

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Going into a primary care specialty, this really worries me. I am already leaning toward fellowship, but I feel like this issue will drive others to consider further training if things continue as is. This is a sad situation for those who have dreamed of going into general primary care office practice their whole life - as opposed to those who are cashing in on a relatively new way to make money.

But, that's how business works, I guess.

I liken this to the rise of CRNAs and the time when anesthesiology was all full . . . how did the gas MDs take it?

For what it's worth, I will insist on seeing only physicians and not nurses or PAs. I have not had particularly great impressions about these extenders.

The fact is, if I am too busy to accomplish everything in one day, I would MUCH rather cut out the unnecessary paperwork that will be thrown my way and see more routine visits. That is what I like to do and have spent 20+ years in school preparing for - to see patients. I think these extenders should do the other work and see what doctors deal with everyday.

I don't mean to sound bitter, but I think what angers me most is how out-of-hand this whole thing has gotten, and how none of our so-called medical organizations have taken a stand on anything to help out future physicians who may very well be facing a substantial decrease in job security. I have been told not to join these organizations and, instead, just look out for myself. Sad.