Scope of practice for PCP vs PA in primary care

[osjl]

Hi,
I am considering becoming a MD in primary care or PA in primary care. Any thoughts on the scope of practice between a physician working in primary care vs a physician assistant working in primary care?* Is it reasonable to say that if a patient needs care that extends much beyond the scope of a physician assistant they are referred to a specialist? In other words, I am under the impression that although primary care physicians have a wider breadth of knowledge than a PA they generally don't get a chance to apply it because of how specialized the medical field is. Thank you in advance for any thoughts on this! And I apologize if my assumptions are completely inaccurate - I do not have any family in the medical field and am simply trying to figure things out as I go along.

* I am familiar with the legalities surrounding the physician supervision of a PA. I am more interested in what patient care and patient interactions look like.

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[Psai]

Patient care is inferior from PAs or NPs. They don't know as much as they think they do. They will miss things and misdiagnose things at a higher rate than physicians because their knowledge base is so much more limited. I think primary care physicians should have the broadest knowledge base but the reality of our system makes it so that the people who go into primary care are either foreigners or people towards the bottom of the class. Many patients seem to like having mid levels as they get the impression that they tend to spend more time with the patients while the realities of poor insurance force doctors into 15 minute time slots (now going towards 7.5 minutes). But I have also seen many patients switch doctors because they were tired of seeing the mid-level instead of the doctor.

 

[deleted718115]

the reality of our system makes it so that the people who go into primary care are either foreigners or people towards the bottom of the class.

Really? I don't think you can see a specialist any time without seeing a PCP first, even when you have private insurance..............

 

[Dr. Death]

Really? I don't think you can see a specialist any time without seeing a PCP first, even when you have private insurance..............

This isn't true and has nothing to do with the topic at hand. What psai said is definitely the case. When I was looking for a Doctor for my daughter we bounced around to a few before we found a good physician who self selected for primary care.

 

[SSSMDt]

Really? I don't think you can see a specialist any time without seeing a PCP first, even when you have private insurance..............

Thats not the point.. Its how much PCPs are reimbursed for their services by insurance..

Side note: Patients with original Medicare dont need a referral to see a specialist. Although Med Adv patients do need one

 

[Holmwood]

PCPs are like the gatekeepers of the healthcare system. With greater medical advancement, their roles will likely expand.

Will PA/NPs be able to catch up in time? I don't know. But in my opinion, we wouldn't have that great of a need for PA/NPs if we adopted models similar to European countries where pharmacists can also manage certain kinds of patients. Heck, California is heading into that direction soon... Someone enlighten me.

 

[LizzyM]

The scope of practice is no different in primary care. The wages are diffierent, even for the same hours in the same setting (basing this on people I know who work in university-based closed panel HMO). As a PA with 20+ years experience you may come to resent the position you're in. Proceed accordingly. (I am not a PA but my sibling is.)

As long as they are treated with respect, patients seem to like their providers regardless of the initials after their names. John Lantos in his book The Lazarus Case describes the attitudes of women and their partners toward lay midwives even in light of poor OB outcomes.

 

[Yadster101]

As a PA with 20+ years experience you may come to resent the position you're in. Proceed accordingly. (I am not a PA but my sibling is.)

Jc but has your sibling ever said anything about "resenting" their position?

 

[LizzyM]

Jc but has your sibling ever said anything about "resenting" their position?

Yes, my sib has voiced this to me. Getting paid a fraction of what another clinician with similar senority is making for the same work (same case load, same types of patients) is demoralizing. (Not a case of gender bias, either).

On the other hand, the training was 5 years less than med school plus internal medicine residency so my dear sib has worked 5 years longer and with less student loan debt than someone who started med school the year Sib started PA training. That said, long after the student loans are paid off, making a lower salary for the same services is grating.

 

[Psai]

Yes, my sib has voiced this to me. Getting paid a fraction of what another clinician with similar senority is making for the same work (same case load, same types of patients) is demoralizing. (Not a case of gender bias, either).

On the other hand, the training was 5 years less than med school plus internal medicine residency so my dear sib has worked 5 years longer and with less student loan debt than someone who started med school the year Sib started PA training. That said, long after the student loans are paid off, making a lower salary for the same services is grating.

Well yeah that's because they're under the impression that they do the same work and offer the same services. This is not so

 

[LizzyM]

Well yeah that's because they're under the impression that they do the same work and offer the same services. This is not so

Right. Because you know so much about it.

Patients come into an urgent visit clinic and are randomly assigned to one clinician or another. How is what is offered for a complaint of sore throat, burning on urination or a laceration from a collision on a sports field going to be any different in terms of services rendered? How is the work of diagnosis and treatment of minor self-limited illnesses in this type of setting going to be different if provided by an MD or a PA?

You must be taking seconds of that med school Kool-Aid.

 

[TaroBubbleTea]

Right. Because you know so much about it.

Patients come into an urgent visit clinic and are randomly assigned to one clinician or another. How is what is offered for a complaint of sore throat, burning on urination or a laceration from a collision on a sports field going to be any different in terms of services rendered? How is the work of diagnosis and treatment of minor self-limited illnesses in this type of setting going to be different if provided by an MD or a PA?

You must be taking seconds of that med school Kool-Aid.

However, when something goes awry, the supervising physician will be the one help responsible, not the PA or NP.

 

[Moose A Moose]

Yes, my sib has voiced this to me. Getting paid a fraction of what another clinician with similar senority is making for the same work (same case load, same types of patients) is demoralizing. (Not a case of gender bias, either).

On the other hand, the training was 5 years less than med school plus internal medicine residency so my dear sib has worked 5 years longer and with less student loan debt than someone who started med school the year Sib started PA training. That said, long after the student loans are paid off, making a lower salary for the same services is grating.

Short term pain, long term gain.

Also, it comes down to the source of authority, which a PA is not.

C'mon now.

 

[IAhawkeye]

Patient care is inferior from PAs or NPs. They don't know as much as they think they do. They will miss things and misdiagnose things at a higher rate than physicians because their knowledge base is so much more limited. I think primary care physicians should have the broadest knowledge base but the reality of our system makes it so that the people who go into primary care are either foreigners or people towards the bottom of the class. Many patients seem to like having mid levels as they get the impression that they tend to spend more time with the patients while the realities of poor insurance force doctors into 15 minute time slots (now going towards 7.5 minutes). But I have also seen many patients switch doctors because they were tired of seeing the mid-level instead of the doctor.

Where are your statistics to support this?

 

[Psai]

Right. Because you know so much about it.

Patients come into an urgent visit clinic and are randomly assigned to one clinician or another. How is what is offered for a complaint of sore throat, burning on urination or a laceration from a collision on a sports field going to be any different in terms of services rendered? How is the work of diagnosis and treatment of minor self-limited illnesses in this type of setting going to be different if provided by an MD or a PA?

You must be taking seconds of that med school Kool-Aid.

The difference comes when that cough is not just a cough. Knowing the common presentations for common diseases is not difficult. Knowing the treatment for common diseases is not difficult. But do you know the uncommon presentations of common diseases? Or the common presentations of uncommon diseases? Or the uncommon presentations of uncommon diseases? Of course the work of diagnosis and treatment of minor illnesses will be similar. But I see people coming in because of something thought to be minor that someone missed plenty of times. Anyone can miss something. In my few months of being in the healthcare environment, I have seen many inexcusable misses or mistakes coming from midlevels that I have to speak out when someone tries to conflate mid-level work with physician work. It is not the same. The difference is also obvious when you look at the documentation. When someone puts down pyelonephritis as a differential in a person with abdominal pain, yet the patient has not had urinary symptoms, no fever, no nausea, vomiting, no cva tenderness, etc. that tells me that they don't know anything about pyelonephritis except that the kidneys are in the belly and that an infection can hurt. To be fair, it's the NPs that are the main problem, most PAs seem to work well with doctors and it's a good relationship.

But what is this about med school kool-aid? Medical schools are all about working together in teams with other professions etc. There is nothing denegrating other fields. My views are my own that came from my experience, as limited as you may think it is. There is no propaganda in medical school on the level of nursing schools.

 

[Mad Jack]

Really? I don't think you can see a specialist any time without seeing a PCP first, even when you have private insurance..............

While you don't need a referral to see most specialists, many specialists would prefer not to waste their time with self-diagnosing patients and thus won't see you if you have not first been referred by your PCP.

 

[Mad Jack]

Right. Because you know so much about it.

Patients come into an urgent visit clinic and are randomly assigned to one clinician or another. How is what is offered for a complaint of sore throat, burning on urination or a laceration from a collision on a sports field going to be any different in terms of services rendered? How is the work of diagnosis and treatment of minor self-limited illnesses in this type of setting going to be different if provided by an MD or a PA?

You must be taking seconds of that med school Kool-Aid.

It's the rare times things aren't routine that people end up suffering. Many serious illnesses can be missed and have their symptoms written off by an undertrained provider. Cancer is a great example of a disease where certain subtleties of presentation can easily be overlooked, and a good clinician could end up being the difference between life and death.

 

[LizzyM]

It's the rare times things aren't routine that people end up suffering. Many serious illnesses can be missed and have their symptoms written off by an undertrained provider. Cancer is a great example of a disease where certain subtleties of presentation can easily be overlooked, and a good clinician could end up being the difference between life and death.

Missing a cancer diagnosis is the #1 reason internists are sued.

 

[deleted718115]

Yes, my sib has voiced this to me. Getting paid a fraction of what another clinician with similar senority is making for the same work (same case load, same types of patients) is demoralizing. (Not a case of gender bias, either).

On the other hand, the training was 5 years less than med school plus internal medicine residency so my dear sib has worked 5 years longer and with less student loan debt than someone who started med school the year Sib started PA training. That said, long after the student loans are paid off, making a lower salary for the same services is grating.

I don't agree that PA/NP are on the same level as MD/DO. Truth is NP/PA schools do not teach these providers to handle complex cases. Besides reading about it, I personally have experienced 2 NP's mistakes, one involves simple but important thing like antibiotic dosing! My infection went on because of that, which caused me to visit a doctor's office a 2nd time, and a doctor at first thought I did not follow antibiotic instruction!
And I personally would not want to be anesthetized & monitored by a CRNA...

 

[Mad Jack]

Missing a cancer diagnosis is the #1 reason internists are sued.

And they've got a much more solid base of knowledge and training. That's the point.

 

[Ad2b]

I've been seen by NPs, PA's, DOs, and MDs.

1 NP in university setting = excellent
1 NP in city setting (recent) = average; prescribed mupricin for 50+ ant bites as a topical and cephalexin; during follow up visit to my own doc, she raised an eyebrow and said she thought it odd that I was treated as an infection rather than an allergic reaction especially combined with the CHEST PAIN I was having

PA's = solid; good; nothing remarkable; asked him why PA v MD and he said if he had to do it over again, he would go MD; he resents not being MD now

 

[allantois]

While you don't need a referral to see most specialists, many specialists would prefer not to waste their time with self-diagnosing patients and thus won't see you if you have not first been referred by your PCP.

Mmmm, specialists love patients with PPOs.

 

[medic86]

I don't agree that PA/NP are on the same level as MD/DO. Truth is NP/PA schools do not teach these providers to handle complex cases. Besides reading about it, I personally have experienced 2 NP's mistakes, one involves simple but important thing like antibiotic dosing! My infection went on because of that, which caused me to visit a doctor's office a 2nd time, and a doctor at first thought I did not follow antibiotic instruction!
And I personally would not want to be anesthetized & monitored by a CRNA...

Lol.

 

[Perrotfish]

Right. Because you know so much about it.

Patients come into an urgent visit clinic and are randomly assigned to one clinician or another. How is what is offered for a complaint of sore throat, burning on urination or a laceration from a collision on a sports field going to be any different in terms of services rendered? How is the work of diagnosis and treatment of minor self-limited illnesses in this type of setting going to be different if provided by an MD or a PA?

You must be taking seconds of that med school Kool-Aid.

You are definitely right that, in many clinics and hospitals I have rotated through, midlevels are allowed the same scope of practice as a physician. Even though I am in a state where they haven't yet won the right to practice under their own licenses their 'supervision' is frequently a legal fiction that has no basis in reality. They see the same scope of patients as an FP and are not signing off their management with anyone.

To me, as a doctor, there are two reasonable responses to this

1) Anger at the Midlevels. This response assumes that 2-3 years of training leaves midlevels completely unqualified to do what they do. They are endangering their patients, and the reputation of medicine as a profession, because completing appropriate medical training is inconvenient. Its no different that a third year medical student stealing his attending's prescription pad and setting up a 'clinic' in his apartment.

2) Anger at Medical Schools and Residencies. This response assumes that 2-3 years of training is completely adequate to do what most physicians do for a living, and that the entire system of medical training is, at least for most kinds of physicians, just a form of regulatory capture where a handful of non-practicing physicians leech of the next generation while giving nothing of value in exchange. Maybe, this response argues, you could make an outpatient Pediatrician without Surgery, OB, or even NICU rotations.

I can understand and respect either response.

 

[cbrons]

Patient care is inferior from PAs or NPs. They don't know as much as they think they do. They will miss things and misdiagnose things at a higher rate than physicians because their knowledge base is so much more limited. I think primary care physicians should have the broadest knowledge base but the reality of our system makes it so that the people who go into primary care are either foreigners or people towards the bottom of the class. Many patients seem to like having mid levels as they get the impression that they tend to spend more time with the patients while the realities of poor insurance force doctors into 15 minute time slots (now going towards 7.5 minutes). But I have also seen many patients switch doctors because they were tired of seeing the mid-level instead of the doctor.

PA or NP practice independently is largely dangerous (regardless of fake studies showing "equivalency" in outcomes for very specific conditions. Have heard/seen NPs who didn't know basic things that even a 3rd year medical student would know. Would not recommend seeing on as my primary care "Provider."

 

[medic86]

And they've got a much more solid base of knowledge and training. That's the point.

This brings up an interesting question:

Missing/delayed diagnosis of cancer is a big issue in medicine (obviously). How can this be reconciled without contributing to another big issue in medicine - the over-treatment of patients?

 

[Mad Jack]

This brings up an interesting question:

Missing/delayed diagnosis of cancer is a big issue in medicine (obviously). How can this be reconciled without contributing to another big issue in medicine - the over-treatment of patients?

Diagnose and treat accurately the first time. This issue will resolve itself in the near future, most likely, as very finely tuned and inexpensive blood and urine tests become available that are highly sensitive for particular diseases.

 

[medic86]

Diagnose and treat accurately the first time. This issue will resolve itself in the near future, most likely, as very finely tuned and inexpensive blood and urine tests become available that are highly sensitive for particular diseases.

But that's the problem. If you suspect cancer for every non-specific ache and pain, you will overtreat your patients on average.

 

[Mad Jack]

But that's the problem. If you suspect cancer for every non-specific ache and pain, you will overtreat your patients on average.

I said accurately- overtreatment requires an initial diagnosis that is inaccurate.

 

[medic86]

I said accurately- overtreatment requires an initial diagnosis that is inaccurate.

So you're telling me that it's possible to accurately diagnose a patient 100% of the time?

Good lord, there must be ****ty doctors all over the country practicing medicine.

 

[Mad Jack]

http://www.meddeviceonline.com/doc/new-urine-test-can-detect-cancer-in-minutes-0001

So you're telling me that it's possible to accurately diagnose a patient 100% of the time?

Good lord, there must be ****ty doctors all over the country practicing medicine.

Not 100% of the time, but as often as possible. And, as I said, I believe this issue will resolve itself within our working lifetimes, so it isn't one that I find particularly interesting. What we do know, however, is that physicians order less unnecessary tests than midlevels, so, if you're looking to save some money, hire more doctors. They utilize less resources, diagnose accurately more often, and will miss fewer rare cases. I will concede, however, that as technology moves forward, a physician's unique skills will be less and less of importance as they are replaced by diagnostic tests that take the art out of diagnosis and replace it with science.

http://ecp.acponline.org/novdec99/hemani.htm