Extending Doctors: Physican Assistants and Nurse Practioners

Question from a reader:

How do you feel about PAs and NPs?

So Physician Assistants and Nurse Practitioners are medical providers who are not doctors, but do doctor-like care for patients with basic problems. NPs and PAs are often called "physician extenders" or "mid-level providers." PAs and NPs don't go to medical school—therefore the care they provide has to be supervised by a physician.

How does Doctor D feel about them?

The Good, the Bad, and the Ugly:

Just like doctors, physician extenders are individuals with different styles of care. Similarly, there are good ones and bad ones. Doctor D is in favor of the good ones.

I have met some excellent physician extenders who work wonderfully with both patients and MDs to provide superb care. My own son, Little D, was delivered by a Nurse Midwife who is like a physician extender for obstetric care. It was an uncomplicated pregnancy, and I was totally comfortable with the midwife caring for my wife and son. It was one of the best deliveries I have ever seen.

Bad PAs and NPs can be trouble. Just like doctors, they can fall prey to the God-complex, which can be even more dangerous when arrogance is coupled with less medical education. D once worked with a NP who was doing some bad care. When Doctor D brought it up he said, "Who the hell are you to tell me how to practice!" And D was like, "Well actually, I'm the doctor assigned to supervise you, dude. It's kind of my job to tell you how to practice."

Just like bad doctors, bad physician extenders are the minority, but they can give all the good ones a bad name. Generally speaking, PAs and NPs are an important part of the healthcare system. Mid-level schooling is shorter which allows excellent people who just don't have the time for medical school to become medical providers.

NPs and PAs in Primary Care:

One place that you will see a lot of mid-level providers is in Primary Care. Since Primary Care is high stress with less pay a lot of medical students just aren't choosing that field. PAs and NPs are helping fill the gaps.

Something that concerns Doctor D is the idea being forwarded by some that all Primary Care can be done solely by physician extenders. The theory is mostly forwarded by politicians eager to save money and Specialist MDs who have no idea how complex Primary Care medicine can be. While there is need for PAs and NPs in Primary Care, physicians must remain intimately involved in this essential part of healthcare.

The Importance of Teamwork:

Patients who see a PA or NP are usually in good hands, but you should be aware that you are being cared for by a team.

Your mid-level provider is working with a physician even if you don't directly see that physician. This team approach has some obvious strengths: you get two providers involved in your care. Two minds can be better than one at spotting problems or unusual diagnoses. You always have the physician as a back-up if the mid-level provider feels your situation needs more advanced attention.

Of course, the flip side of this is that if either the MD or the mid-level are bad, irresponsible, or just don't communicate well your chance of problems increases significantly. Sometimes a really good mid-level provider is stuck with a bad physician. You may not even know you have a bad doctor on your team who is detrimental to your health.

If you are seeing a PA or NP you should understand how the system works, and particularly know about their relationship with the physician that supervises them. If your mid-level provider appears to be competent and has a good working relationship with mutual respect with their physician you can usually rest assured that your care will be done well.

So what do you think? Do you see an NP or a PA? What is your experience with mid-level providers? Any PAs or NPs out there who can tell us more? As always, Doctor D loves to hear your thoughts.