Jan 11, 2010

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.


Old MD Girl said...

On my ObGyn rotation, far and away the best deliveries I saw were done by the midwives. I liked the way they interacted with the patients, and their deliveries seems so much more relaxing and low key than the resident's deliveries. If something bad happened the patient was in the hospital so a c-section could be performed by an Ob if necessary. It kind of sold me on the whole midwife thing.

On the other hand, I really don't like being treated by the NPs at student health where I go now. Not sure what it is, they just make me feel defensive and uncomfortable.

Josiah O. Morris said...

Years ago, I saw a PA "in place" of a primary care physician. He was top-notch, thorough, and as an added bonus, quite personable.

I hope this doesn't set off a chain of NP-trashing, but an old girlfriend saw one for a dermatological condition on two occasions, having been punted to her from the MD. The experience was not a good one. In short, the NP recommended a medication to which my girlfriend was allergic. Ha!

Anonymous said...

I've seen good and bad of both.

On the side of bad, there was the PA in the emergency room who actually got mad at me when I was injured in a car accident, and told me the only thing she could do for me was prescribe something I was allergic to. There was also a NP who tried to convince me that tylenol would work for pain when vicodin hadn't been strong enough.

On the good side, the person I prefer to see for my gyn work-ups is a NP who listens well and is very gentle. The PAs at my GP's office do things like weight and taking down my reason to be seen before my doctor sees me, and they're all very nice.

Because of how medically complicated I am, I prefer not to see NPs or PAs unless I can't avoid it. But then, I also try very hard not to see other doctors at my GP's practice, because he knows and remembers my case and it saves a lot of explaining.


Anonymous said...

I am a current PA student with an unusual degree of cynicism about my own chosen profession. I'll concur with Dr. D - a God complex is particularly dangerous in the mid-level provider, and I've met some people whose [over]confidence in their knowledge/competence scared me just a bit. Compared to MDs, we're in [grad] school for half as long, and few PAs/NPs complete a residency (partially because very few residencies are available for us). With that in mind, it would be absurd for me to ever claim I'm as qualified as an MD. As you can see, I am a strong advocate for a large dose of humility.

That being said, I think the PA/NP who is aware of his limits and works closely with the supervising physician can be a wonderful thing. We are able to provide a much-needed service for most patients, but Kali is right - some cases are best managed by an MD - but we can do much more than many people think. The trouble happens when a clinician is unwilling to admit that he is in over his head. We NEED MDs in primary care.

Personally, I get tired of trying to explain how a PA is not the same as a nurse or medical assistant... but that's the result of an unfortunate title. Dr D - How would you feel about the term "Physician Associate" instead? They use the title at Yale and in Connecticut, but it's gotten mixed reviews elsewhere.

Finally, thank you to Dr. D for avoiding the kind of scathing anti-midlevel posts that I see far too often. As someone who is devoting her life to learning the profession, few things are more disheartening to me than reading condescending and venomous words from the physicians who will some day be my comrades, so a level-headed commentary is always a breath of fresh air.


Anonymous said...

It's not smart to generalize on the basis of a few personal experiences, but the NPs I've seen tend to fixate on only the most common interpretation of whatever symptoms are presented. It's not clear to me how an MD was overseeing these visits---I saw the NP, the incorrect diagnosis was made, I later made an appointment to see an MD elsewhere, and then the problem was resolved.

I truly don't mean to insult NPs, because I'm sure there are many excellent ones, but now I would choose to see an NP only for something that seemed to me to be an obvious and limited sort of problem, like an infected cut. The one exception would be NPs who work in gyn offices. The ones I've seen there have been very helpful. Again, I'm generalizing on the basis of just a few appointments.

I get how NPs can handle many sorts of medical problems (probably most of them) very well. I just don't trust them to sort out which ones they can handle. Why should I take the time to see someone less trained and possibly have to make another appointment later?

WarmSocks said...

The NP at my pcp's office (family practice) is great. She ordered my initial bloodwork and gave me the referral to a rheumy, despite my "atypical presentation." There are MDs who miss a sero-negative dx, so I feel fortunate that the NP caught it.

The rheumy to whom I was referred delegated my treatment to a PA. I think that particular PA, working in a very specialized field, knows more about rheumatology than some MDs.

It might depend on age/experience. I'd expect someone who's been in practice for 10-15 years to know more than someone fresh out of school.

Maha said...

I just started to work with two NPs in my emerg dept. They usually see the lower acuity patients. Besides improving wait times, I find that the patients usually respond very well to them because they have a little bit more time to spend with them going over preventative care and follow up care. Haven't seen a God complex - yet. Great post Dr. D - it was nice to read a physician's point of view on the subject.

radioactive girl said...

My son sees a PA quite often for his stomach issues and I love her. I actually prefer her to the doctor because she takes more time to explain things and is just more friendly/chatty in general. She has also impressed me by telling me she isn't sure about something so she will check with the doctor and give me a call. It's nice to know she realizes her limitations and gets help when she needs it.

The only thing I don't care for is when I make an appointment with a particular doctor and then arrive and find that I am not seeing him, but his PA. That has nothing to do with the PA, just that in general I wouldn't be crazy about seeing one doctor when I had made an appointment with a different one.

Anonymous said...

Hi there: I'm a longtime reader, first time poster. :)

I just saw an orthop PA for a relatively uncomplicated knee injury (minor PCL tear), and I felt I was in good hands. Additionally, this PA was personable and had time to explain how things work. I liked working with him.

I knew ahead of time that I was going to see the PA (rather than the MD) for this orthop visit, and that info told me, rightly or wrongly, that, probably, my knee injury was going to be something minor and/or predictable, which I was pleased to hear.

Finally, I agree that you can't really generalize all PAs on the basis of a few.

Interesting post, Dr. D, and nice blog.

WordDoc said...

Check out "The Innovator's Prescription" by Clayton Christensen, of the Harvard Business School and others. He proposes a restructuring of medical care along a business model that would provide affordable access to healthcare in the same way that the computer industry changed in ways that brought down the price and accessibility of their products.

One of many changes that would occur would be taking diagnosis and care of certain conditions such as sore throats from the realm of primary care physicians to venues such as the 'TakeCare' clinics of Walgreen's where algorithms applied by physician extenders make for quick and affordable care. This would free specialists in IM, FP, and Peds to apply their time and training to diagnosing conditions such as abdominal pain, headaches, or fatigue that aren't as amenable to algorithms. The authors also propose that while the diagnosis and initial management of diabetes, hypertension, etc. should remain with MDs, the chronic management of such diseases is better relegated to operations who do nothing but support and monitor such patients, including patient to patient support.

I am impressed by their proposals and curious to hear what you think.

Anonymous said...

I used to have a GP I only met one time, and that was after, over a period of several years, visiting his office for various complaints five or six times. Instead of the GP that was "my doctor," I saw the NP. She was friendly and competent, and I have no complaints. The one time I did finally get to meet "my doctor," he was short, unfriendly and obviously bored to tears by my presence in his office. I was so irked by his borish behavior that I changed doctors soon after. I couldn't imagine having him be in charge of my care should I get really sick.

Helen said...

I did once have an NP walk into my hospital room and just start telling me what I needed to be doing. I'd never seen him before and he had no name tag, nothing. I was just out of surgery and didn't really feel like being polite, and finally just said, "who ARE you?" He wasn't pleased that I asked. I suppose that was an example of an NP with a God complex.

I've also had great experiences with NPs, including one who gave me her email so I could continue to ask questions after my appointment with the doctor.

Anonymous said...

I saw an NP who was really great, but I always had a problem with my prescriptions from this GP office (they wrote them for things that didn't exist or in quantites that didn't exist), so I told her that, and she said if I had a problem with any of the scripts she wrote to call in after hours and the doc on call would fix it. WRONG. I got royally chewed out by the FP on call for "wasting his time" with my "stupid request". I changed Docs after that.

RFazio PA-C said...

I feel like your opinions are focused on the negatives of "midlevels". I am a PA. I don't want to be a doctor and I don't claim to be one. I take pride in my work...much of which is filling in the gaps left by our busy team of doctors. I do assist in surgery also but the patient care is most important. I have the liberty of spending more time with post-op patients and I use this time to explain who I am and what I do...it's all about introduction and communication. "Hi, my name is..." is the first thing out of my mouth when I approach a patient. When surgeons are in and out of the patient's room in 3 minutes, I can go back and "fill in" the blanks" and answer questions. So I agree that team work is the most important thing to have on a service and when appointing your staff, this should be priority. I rely on my surgeons and they rely on me. Some of the routine problems are easily handled by midlevel staff, but it's a great safety net to know your doctors are just a call away when the stuff hits the fan. This is not a job for egomaniacs.

Anonymous said...

The term midlevel, physician extender and non-physician provider are inappropriate and demeaning to individuals who are educated at either the master's or doctoral level. While our training is different than that of a physicians, we are nonetheless well trained and provide excellent care. Some of us are doctors, just not of medicine. Additionally, most, if not all, are great collaborators with our physician colleagues. Please refer to us as either NPs or PAs or advanced practitioners. This, in part, may help us in gaining the respect deserved by our medical colleagues and our patients.

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