Primary Care being replaced by PA/NP?

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scurred09

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I like to hear from all the D.O.s if midlevels are taking over primary care? For Pre med student who are only interested in primary care, do you recommend that they do not pursue medicine at all? Basically I'm concern about the job market for future D.O.s because I like to go into FP but not if the salary is equivalent to a PA/NP. Not to sound money hungry but I'm sure if Physicians salaries were in the $40K, I'm sure none of you would be practicing medicine.

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I like to hear from all the D.O.s if midlevels are taking over primary care? For Pre med student who are only interested in primary care, do you recommend that they do not pursue medicine at all? Basically I'm concern about the job market for future D.O.s because I like to go into FP but not if the salary is equivalent to a PA/NP. Not to sound money hungry but I'm sure if Physicians salaries were in the $40K, I'm sure none of you would be practicing medicine.

It's a mess, and will continue to slip more to the NPs and IMGs who can't land a residency ... which will lead to subpar care and eventually cause a swing back, but not for a very long time. If you're dead set on PC either:

1. Practice in a ruralish area so you can incorporate a lot into the scope of your practice and bill expensive procedures
2. Practice for a while and transition into a concierge practice
3. Practice normally, be happy doing what you've always wanted and know that you are doing something important ... take the good with the bad.

Good luck.
 
I would be more concerned if PA's and NP's SOLE function was primary care, but they can just as easily subspecialize in ortho, gen surg, cardiothoracic, etc...

That's not to say I'd do primary care; in fact the PA/NP field is one reason I didn't do primary care. My father has been a PA for 20+ years, and from all I gathered form him (working in a rural ER setting), he performed ~85% of the tasks any MD would in the primary care setting. Cookbook medicine is cookbook medicine, whether you're an MD, DO or PA, and the 15% only comes into play when there's legal or really complicated issues involved. Sure, he has no where near the training & basic medicine background as your avg MD/DO grad, but that doesn't matter for a big bulk of stuff you see in primary care, especially after a few years experience.

FP has had their practice rights slowly whittled away over the years, as specialists (GI, OB, surg, etc...) have 'stolen' the business under the notion it's better to be taken care of by a specialist, and consequently have reduced the role of the FP to that of a glorified PA.

The AMA/AOA will fight tooth & nail the DNP (Doctor of Nurse Practitioner), et al, movements, but that's no guarantee, especially when politicians & the public really start to become worried about the escalating costs of healthcare...they may justify annexing even more FP practice rights & risking occasional knowledge-gap-based errors for cheaper costs, who knows.

On the other hand, some physicians really like the PA/NP fields...they can hire one, dump all the scut work/call on him/her, and increase their net income without having to pay the salary of a fully licensed physician.

In any case, it's hard to justify entering a field that an experienced PA can just as easily cover simply on the good-faith that our governing bodies & lobbies will maintain practice rights. Like I said, FPs RARELY perform all the procedures & tasks they historically have because those roles have been deemed more fitting to GI docs, OBs, gen surg, etc...and the malpractice is prohibitively expensive, so as an FP you're relegated to filling Rx's, physical exams, MINOR procedures, and your income is solely (usually) based on volume...ie: how many patients can you get through in a day?
 
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In a somewhat informal way, physicians have given much of primary care--family practice and general IM--over to physician extenders. Like homeboy said, family practice has been whittled away by specialty practice. Would it be feasible to go ahead and formally hand things over to NPs and PAs and create a tiered system of healthcare? The complicated cases like difficult diabetics are already relegated to specialists, or at least should be, by family practice docs. The problem is, you know NPs and DNPs would not stop with primary care - they would eventually want to take over the specialties too.
 
I attended a lecture few months back where they presented on the future of PharmD's. Apparently some states already allow PharmD's to prescribe basic medications. (I think they are still under the supervision of a physician the way NP's are, but not positive) The consensus was that due to the primary care shortage of physicians, that this trend will continue to increase in areas.

So perhaps we could see NP, PA, and PharmD's all receiving basic prescription and treatment privaleges nationwide. With the PCP shortage going the way it is, I could see it happening.
 
I attended a lecture few months back where they presented on the future of PharmD's. Apparently some states already allow PharmD's to prescribe basic medications. (I think they are still under the supervision of a physician the way NP's are, but not positive) The consensus was that due to the primary care shortage of physicians, that this trend will continue to increase in areas.

So perhaps we could see NP, PA, and PharmD's all receiving basic prescription and treatment privaleges nationwide. With the PCP shortage going the way it is, I could see it happening.

What is the purpose of primary care? Without oversimplifying -- treat simple problems and identify complex problems, the systems involved, and refer them to a specialist.

I don't think it takes a physician with 11+ years of training to do this any more. Medicine is becoming fairly standardized with guidelines based on large studies, yes, somewhat cookbook. But it takes a skilled provider to make a diagnosis. PharmDs have minimal training in physical examination and diagnosis. They, instead, fill a different vital role in the system, dispensing medications and providing input on interactions, etc. I don't see why primary care shouldn't be "turned over" to the NPs and PAs.

Also, it worries me when I see NPs and PAs "specializing". Both of their disciplines started to fill the void of PCPs. Why then, should they "specialize" and leave a further void of PCPs. Specialists should be highly trained with residencies and fellowships. The only reason why the current medical system "allows" this specialization is because it increases the supervising doctors revenue, so they aren't complaining.
 
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At my hospital the "cool" thing is for every specialist to have a PA. It's great for the surgeons because the PAs can round on the post-op patients, take the staples and stiches out of the follow-up patients and first-assist during surgeries-- making things go faster. The surgeons do very little except surgeries...so they can fit more of them in and make lots more money in the end. It "pays" for them to have a PA. The cardiologists have them too. They can have PAs rounding on the patients while they do more and more procedures and make more and more money. From a practical stanpoint, where our medical system pays so much more on procedures, it just makes sense.

There's a hospitalist at my hospital who only sees inpatients... but he owns an outpatient clinic staffed by a PA and he picks up a lot of patients for his clinic that way, because a lot of them don't have a PCP. I don't necessarily approve of his tactics, since he only refers patients with good insurance to his practice (the rest are referred to the free clinic) but it makes good business sense.

My point, though, is that it is far more than just primary care that mid-levels are entering. They are changing the way medicine is practiced on many fronts. Medicine, when you get rid of the altruistic desires, is still a business. The smart people will do what they can to survive.
 
Medicine, when you get rid of the altruistic desires, is still a business. The smart people will do what they can to survive.

Beautiful ... honestly, could NOT have said it better myself.
 
At my hospital the "cool" thing is for every specialist to have a PA. It's great for the surgeons because the PAs can round on the post-op patients, take the staples and stiches out of the follow-up patients and first-assist during surgeries-- making things go faster. The surgeons do very little except surgeries...so they can fit more of them in and make lots more money in the end. It "pays" for them to have a PA. The cardiologists have them too. They can have PAs rounding on the patients while they do more and more procedures and make more and more money. From a practical stanpoint, where our medical system pays so much more on procedures, it just makes sense.

That is a comical, but keenly accurate observation on the use of midlevels in current medicine practice. It does seem to be the "cool" new fad, ha ha. Like adopting a child from Africa and having a purse dog.
 
it's a bit ironic that a DO student worries about being replaced by PA/NP mid-levels. Osteopathic physicians can do OMM which pretty much makes them unique, aside from some overlap with orthopaedics, PT's and DC's. It's the DO secret weapon that adds another dimension to patient care and is reimbursable. I think that DO's are well positioned to weather the coming changes in primary care if they apply all of the skills they have been given.

By the way, PA's and NP's rock!
 
Why is there so much concern about DOs/MDs being "displaced" from primary care when most everyone is predicting a massive physician shortage in a decade or so? From what I've read/been told, there should be plenty of room for these other groups to grab a slice of the primary care pie. After all, there aren't even enough physicians being trained to meet forecasted overall physician demand (never mind demand for PCPs, which many medical students don't seem to want to become anyway).

If there aren't enough of us to meet demand, the gap is going to have to be filled somehow.
 
Such bull$hit....you have people who do not have half the training trying to do what doctors do......medicine is over but if I become involved somehow I will fight tooth and nail to prevent this from happening. And now you have the DNP....pathetic
 
it's a bit ironic that a DO student worries about being replaced by PA/NP mid-levels. Osteopathic physicians can do OMM which pretty much makes them unique, aside from some overlap with orthopaedics, PT's and DC's. It's the DO secret weapon that adds another dimension to patient care and is reimbursable. I think that DO's are well positioned to weather the coming changes in primary care if they apply all of the skills they have been given.

I have yet to see too many DOs actually using any omm on their patients. Most of the students I have rotated with have zero interest in learning any omm either.
 
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Why is there so much concern about DOs/MDs being "displaced" from primary care when most everyone is predicting a massive physician shortage in a decade or so? From what I've read/been told, there should be plenty of room for these other groups to grab a slice of the primary care pie. After all, there aren't even enough physicians being trained to meet forecasted overall physician demand (never mind demand for PCPs, which many medical students don't seem to want to become anyway).

If there aren't enough of us to meet demand, the gap is going to have to be filled somehow.

Because like someone above said they wont stop at family practice. Everyone wants money. Specializing is where the money is, so once FP is taken over they will start the same game with other specialties.

We have a shortage thanks to the baby boomers, what happens when the baby boomer generation is gone?

The field of medicine is becoming a very big mess it would seem. Drs need to be thinking about the future of the profession. unfortunately its becoming what most of us have little interest in, business. If we dont start playing the game properly it would seem like were gonna lose.
 
There's a hospitalist at my hospital who only sees inpatients... but he owns an outpatient clinic staffed by a PA and he picks up a lot of patients for his clinic that way, because a lot of them don't have a PCP. I don't necessarily approve of his tactics, since he only refers patients with good insurance to his practice (the rest are referred to the free clinic) but it makes good business sense.

Interesting. At my medical center this practice is STRICTLY forbidden. Don’t know if its cause of conflict of interest or ethical dilemmas or what. Either way, it’s not something that’s frowned upon so much as something that would get you immediately fired.
 
I attended a lecture few months back where they presented on the future of PharmD's. Apparently some states already allow PharmD's to prescribe basic medications. (I think they are still under the supervision of a physician the way NP's are, but not positive) The consensus was that due to the primary care shortage of physicians, that this trend will continue to increase in areas.

So perhaps we could see NP, PA, and PharmD's all receiving basic prescription and treatment privaleges nationwide. With the PCP shortage going the way it is, I could see it happening.

I wouldn't liken a PharmD to the other fields. Many other countries already allow this. It actually makes a lot of sense since it is their job to keep up with the flood of medications. They are much more aware of possible drug interactions, alternatives, etc. Most of the time the other countries have you bring in the symptoms and expected diagnosis, but the Pharmacist is still prescribing the medication.


Also, as somewhat mentioned. If you have a NP or PA in your practice then you are most likely not paying them the same amount you are. You are probably paying them less than you make. If they help you generate income then it isn't much of an issue. You will never see a freestanding office by a PA taking business away.

Every field has its doomesday scenario. Most of the time things get worse and people freak out, but the complete scenario will never happen. How many specialities have you heard of that have completely disappeared and been replaced? They usually just evolve. CT surgery, Radiology, Derm...they all have things to worry about. Part of your job after you choose your particular speciality is to be active and fight for not only your rights as a physician, but for what is safest for the patient. Shortcuts don't pay off in any field. People like to think you can do the money saving in the front end with doctors and offices, meanwhile the middle men (pharmaceuticals, insurance, etc.) are driving up the cost wayyyyyyyyyy more than any individual speciality is. They'll learn their mistakes but it WILL get worse before it gets better....just gotta chug along.
 
I wouldn't liken a PharmD to the other fields. Many other countries already allow this. It actually makes a lot of sense since it is their job to keep up with the flood of medications. They are much more aware of possible drug interactions, alternatives, etc. Most of the time the other countries have you bring in the symptoms and expected diagnosis, but the Pharmacist is still prescribing the medication.


Also, as somewhat mentioned. If you have a NP or PA in your practice then you are most likely not paying them the same amount you are. You are probably paying them less than you make. If they help you generate income then it isn't much of an issue. You will never see a freestanding office by a PA taking business away.

Every field has its doomesday scenario. Most of the time things get worse and people freak out, but the complete scenario will never happen. How many specialities have you heard of that have completely disappeared and been replaced? They usually just evolve. CT surgery, Radiology, Derm...they all have things to worry about. Part of your job after you choose your particular speciality is to be active and fight for not only your rights as a physician, but for what is safest for the patient. Shortcuts don't pay off in any field. People like to think you can do the money saving in the front end with doctors and offices, meanwhile the middle men (pharmaceuticals, insurance, etc.) are driving up the cost wayyyyyyyyyy more than any individual speciality is. They'll learn their mistakes but it WILL get worse before it gets better....just gotta chug along.

Yes - it is an issue because right now it may be about money, but ultimately it will be about maintaining primary care as a viable profession for physicians. Unfortunately, we will see freestanding offices by physician extenders taking patients away, especially with the DNPs. Just look at what is happening with Walmart - clinics within stores staffed by NPs. Especially in rural areas this is a viable option for health care. When you look at the cost to the patients it is even more attractive for them.

Unfortunately, there is no worse before getting better. Many physicians will agree with the simple fact that primary care will be handled primarily by mid level practitioners. The even bigger loss there is that the education for PA and NP students is not equivalent to that of a physician. Sure, they will get the right diagnosis most of the time, but physicians have the benefit of a broader differential diagnosis. I worked in an internal medicine practice and the midlevel providers there would be in talking to the doctors all the time when a difficult or complex case came in because they were unsure how to proceed.
 
Yes - it is an issue because right now it may be about money, but ultimately it will be about maintaining primary care as a viable profession for physicians. Unfortunately, we will see freestanding offices by physician extenders taking patients away, especially with the DNPs. Just look at what is happening with Walmart - clinics within stores staffed by NPs. Especially in rural areas this is a viable option for health care. When you look at the cost to the patients it is even more attractive for them.

Unfortunately, there is no worse before getting better. Many physicians will agree with the simple fact that primary care will be handled primarily by mid level practitioners. The even bigger loss there is that the education for PA and NP students is not equivalent to that of a physician. Sure, they will get the right diagnosis most of the time, but physicians have the benefit of a broader differential diagnosis. I worked in an internal medicine practice and the midlevel providers there would be in talking to the doctors all the time when a difficult or complex case came in because they were unsure how to proceed.
:thumbup:Great post and love the subject. While I think that there are some paths that lead to a bleak outlook for primary care, I also think that primary care could make a comeback with more incentives that it sounds like the new governmental officials are pushing for. This country needs better primary and preventative health care right now, I believe every physician has his place and is equally important. Midlevel providers are also important and I think that the new place for a Physician in primary care needs to be supervisory(with PA's and NP's) and clinical(with your patients).
 
January 27, 2009

AOA President Carlo J. DiMarco, DO, wrote to the Arkansas House Public Health, Welfare, and Labor Committee today to voice the AOA’s opposition to State HB 1134, which would designate advance practice nurses as “primary care providers” and give them prescriptive authority. Essentially, this bill gives nurses the authority to practice without the oversight of a physician. The AOA stance remains firm that the scope of practice should be maintained at a level commensurate with the experience and clinical training of the clinician. As President DiMarco wrote, allowing nurses to widen their scope of practice in this way places patient safety and health care quality in jeopardy. Read a copy of the letter here.
 
I don't really see what Obama's doing to create a larger incentive for medical students to become primary care physicians; maybe he can start at capping tuition and dealing with medical loans, 'cause NHSC won't be enough. His health-care plan will essentially screw over doctors and he's wondering why more don't go into primary care.

Bah, NP's. Just wonderful.

Exactly why it's so frightening...not to mention the reduced quality of care that patients will get in the near future. I love how NPs are being marketed by Obamacare and the Media as a friendlier/more caring/patient centered form of health care. What a friggin' joke.

Patients have historically viewed nurses as being the "good guys" and all-around nicer in comparison to physicians, but that's largely based on the simple fact that, in the hospital, they get much more/extended individual care from their nurse - what a shocker?! It's their job.

Obama has 0 interest in actually helping the physician community. He's a Chicago-bred lawyer, for God's sake!
 
Exactly why it's so frightening...not to mention the reduced quality of care that patients will get in the near future. I love how NPs are being marketed by Obamacare and the Media as a friendlier/more caring/patient centered form of health care. What a friggin' joke.

Patients have historically viewed nurses as being the "good guys" and all-around nicer in comparison to physicians, but that's largely based on the simple fact that, in the hospital, they get much more/extended individual care from their nurse - what a shocker?! It's their job.

Obama has 0 interest in actually helping the physician community. He's a Chicago-bred lawyer, for God's sake!


The man either knows very little about healthcare or simply doesnt care enough. His reluctance to do anything about torte reform is very telling about his commitment towards healthcare reform.
 
In addition to providing many of the same services less expensively, nurse practitioners offer something else that makes them darlings to health reformers: a focus on patient-centered care and preventive medicine. "We seem to be health care's best-kept secret," says Jan Powers, health-policy director for the Academy of Nurse Practitioners. Nurse practitioners may have less medical education than full-fledged doctors, but they have far more training in less measurable skills like bedside manner and counseling. "In the United States, we are so physician-centric in our health system," says Patton. "But it should be about wellness and prevention, not about procedures and disease management."

Really? Really?!

Right. Because bedside manner and counseling will heal a patient. This is all such BS. They're spoon-feeding this crapola to the patient population to mask the fact that they will be cared for by an army of less-qualified medical personnel. "BUT THEY'LL BE NICE!"
 
Really? Really?!

Right. Because bedside manner and counseling will heal a patient. This is all such BS. They're spoon-feeding this crapola to the patient population to mask the fact that they will be cared for by an army of less-qualified medical personnel. "BUT THEY'LL BE NICE!"

Unfortunately, many patients would rather visit a physician who made them feel comfortable even if this physician knew less than lets say a more intelligent but more abrasive physician. I worked with a cardiologist who, during a month I was with him, lost four patients because of lack of bedside manner; these patients literally walked out of room and refused to return. The sad part of this was that this man was most likely the most intelligent physician I have ever worked with; he just sucked as a human being.

But its not the claim of "better bedside manner" that frightens me. Rather it is the assumption that one who has less education and training than a physician can still effectively and safely do the same job. Sitting here as a fourth year student, already with more education and training than a DNP or PA, I know I, for one, do not feel comfortable with all the aspects of medicine. We are putting lives at risk by making the above assumptions and, sadly, I think it will take the loss of several lives to make this apparent to those in charge.
 
By definition, PAs are still required to work under the supervision of a physician, whom should be specialized in the field they're serving anyway. NPs (and if DNP ever comes along) is a completely different matter of course but I doubt you'll suddenly see the field die out in our lifetimes. Primary Care is still the biggest single "specialty" persay and unless we plan on dumping a large majority of future physician population ...we quite frankly dont need so many specialists.
 
By definition, PAs are still required to work under the supervision of a physician, whom should be specialized in the field they're serving anyway. NPs (and if DNP ever comes along) is a completely different matter of course but I doubt you'll suddenly see the field die out in our lifetimes. Primary Care is still the biggest single "specialty" persay and unless we plan on dumping a large majority of future physician population ...we quite frankly dont need so many specialists.

The DNP isnt just a proposed degree, there are already hundreds of schools granting this sham of a degree.
 
By definition, PAs are still required to work under the supervision of a physician, whom should be specialized in the field they're serving anyway. NPs (and if DNP ever comes along) is a completely different matter of course but I doubt you'll suddenly see the field die out in our lifetimes. Primary Care is still the biggest single "specialty" persay and unless we plan on dumping a large majority of future physician population ...we quite frankly dont need so many specialists.

nursing has strong lobbying power and strength in numbers. it blows my mind what nursing has become these days. many states allow nurse anest. to function independently of an anesthesiologist. many states also allow nurse pract to function independently as well.

blows my mind to this day!
 
January 27, 2009

AOA President Carlo J. DiMarco, DO, wrote to the Arkansas House Public Health, Welfare, and Labor Committee today to voice the AOA’s opposition to State HB 1134, which would designate advance practice nurses as “primary care providers” and give them prescriptive authority. Essentially, this bill gives nurses the authority to practice without the oversight of a physician. The AOA stance remains firm that the scope of practice should be maintained at a level commensurate with the experience and clinical training of the clinician. As President DiMarco wrote, allowing nurses to widen their scope of practice in this way places patient safety and health care quality in jeopardy. Read a copy of the letter here.

I'll chime in here as an Arkansan. It doesn't bother me at all that NPs can prescribe medication, see patients, suture, etc. However, I think somewhere there should be a physician not necessarily dictating work hours and so forth but generating protocols with which the NP should practice and thus provide some quality assurance.
 
I'll chime in here as an Arkansan. It doesn't bother me at all that NPs can prescribe medication, see patients, suture, etc. However, I think somewhere there should be a physician not necessarily dictating work hours and so forth but generating protocols with which the NP should practice and thus provide some quality assurance.

So who won? (I'm assuming the NPs?)
 
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