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.

The Battle Against Incompetence

A while back Nurse K asked a really good question:

How do doctors deal with colleagues that they know are incompetent? Keep your mouth shut? Frank discussion with the medical director? Anonymous letter?

Doctor D has two ways of answering this question. One makes him look really awesome, and the other exposes him a part of the problem. Doctor D will start out all the heroic stuff and then tell you more in the next week:

Doctor D once worked at a place called Crayzee Clinic, because he really wanted to practice primary care in an underserved community. (What a saint! Let's give Doctor D a Nobel Prize or something!) Unfortunately the clinic came with a partner we shall call "Crayzee Colleague."

Now Crayzee Colleague was pleasant enough, but the medicine she practiced didn't even remotely resemble proper standards of care. Doctor D, being the totally nice dude that he was, thought maybe Crayzee Colleague was just behind the times and hadn't heard of the cool new stuff doctors have been doing for these last fifty years. D mentioned his concern in the gentlest possible way, but would you believe it, Crayzee went nuts! She called D a "young doctor who doesn't know shit."

So Doctor D printed out some info for Crayzee Colleague on how medical care is done in this century to prove that he isn't the only one who believes in things like vaccines, mammograms, and such. Unfortunately nothing changed about Crayzee Colleague's incompetent care.

Doctor D was worried because he shared patients with Crayzee Colleague and the stuff she did wasn't exactly safe. From time to time he sent her pleasant little notes reminding her about sensible medical care as he was cleaning up her disastrous work. After a few months of this our hero realized Crayzee Colleague had no interest in changing anything.

Since Crayzee Clinic was federally funded, Doctor D figured he should go up the ladder and speak to "The Man." The Man isn't a doctor, but he has a fancy title, sits behind a big desk, and supervises a whole lot of doctors. D figured his colleague would surely listen to The Man. So D informed The Man that he was very worried about Crayzee Colleague's care. The Man said "Doctor D you are right. Crayzee should step up her game."

And then nothing happened.

Crayzee Colleague kept providing downright dangerous care, ignoring D's still friendly but increasingly firm reminders to at least try to practice something resembling primary care.

Finally, Doctor D had enough of Crayzee Colleague doing dangerous shit to his patients. He blew the whistle as loud as he could. He warned every healthcare bureaucrat he could find, "Look, if Crayzee Colleague keeps doing this stuff that endangers patients I will resign from Crayzee Clinic and tell every patient I see on my way out that I'm leaving because the care here is a treat to public safety!" And still nothing happened.

So Doctor D did exactly as he had threatened he would.

At the end of our story The Man's bureaucracy remained intact, Crayzee Colleague was still at the clinic, and Doctor D had all his principles but no job in the middle of the Great Recession.

...but Doctor D is still proud he opened that can o' whoopass on medical incompetence as well as The Man and his Crayzee Clinic.

Please feel free to praise the fearless Doctor D in the comments section! Get his ego good and inflated because next week he has to make some confessions that will disappoint you.

Why Not Call? (Exhaustion and Economics of Phone Calls)

A reader writes:

Why do I have to take time off of work and make an appointment for my doctor to explain test results? Wouldn't it be much easier to do over the telephone?

It would be easier to discuss this over the phone, and cheaper. Your doctor isn't paid for talking to you over the phone. Getting info over the phone is always a win for patients and a loss for doctors.

Primary Care Doctors (like Doctor D) for whom much of the job is educating you about your health are making a less and less every year (we're the green line) and we started out as the lowest paid physicians. Primary Care clinics are just barely scraping by, so when it comes to discussing your labs they can either do it over the phone for free, taking time away from seeing patients, or bring you in and get paid by your insurance to have the same discussion. The economic solution usually beats the common sense solution.

Now, I don't want this to sound like one of those Happy Hospitalist I-don't-get-reimbursed-for-all-I-do posts. Primary Care is still a good job and Doctor D doesn't have to worry about keeping food on the table.

But when Doctor D worked at Crayzee Clinic he spent many hours every day getting patients results, refills, and forms without pay. He did his best to call patients when he could, but if he knew it was going to be a long talk he usually had you come to the office. Doctor D had to keep some work during office hours—as it was he barely saw his wife or son while working primary care. Of course, some docs avoid phone calls because of greed, but most in primary care are just exhausted having to see more patients faster and faster while doing more paperwork in the evenings. An appointment to follow up tests was usually pleasant and easy, and didn't keep Doctor D in the office later at night after office hours.

But for the patient, it sucks! You have to get off work and drive to the doctor's office, just to get information you could have gotten over the phone. You can and should ask if your doc can call you the results without an appointment. Your heathcare is already too costly without extra visits. But please realize that this is harder on you doc, so don't abuse it. If you are the sort that needs to ask lots of follow up questions please schedule a visit instead of tying up your doc on the phone for 20 minutes!

Okay, after a long blog post about money and reimbursement Doctor D feels dirty and must go bathe the Happyishness off of himself.

This is one of those annoying situations that forces either you or your doc into a financially frustrating situation. The solution proposed on most doctor blogs is billing for phone calls.

What do you think? Would you be comfortable being billed for phone calls? It would save you costlier office visits. Or do you want to keep phone contact free?

Primary Care: The Best and Worst Job in Medicine

Shawn the medical student asked Doctor D:

As a medical student, I am constantly wondering what type of physician I will become. So my question is, what kind of doctor are you, and how did you decide that field?

Doctor D is a Family Medicine doctor. He chose this career because he is a glutton for punishment! Actually, D chose Family Med because he likes people much more than he likes the technical aspects of medicine. As a jack-of-all-trades doctor I can usually help anyone no matter their age, gender, or medical history, but my knowledge on any specific subject is limited. I can sew up lacerations, give end of life care, deliver babies, prevent future illness, and educate people on how to handle most common medical problems. I did this because I enjoy working with human beings and want to help people with their physical needs.

Should you choose Family Medicine as your specialty you will be constantly looked down upon by other physicians. Even though you probably store more knowledge in your brain than any other doctor, specialists assume you are slow-witted because you don't know as much about their particular disease of choice as they do. You will make much less money than other doctors because insurance doesn't think keeping someone healthy is nearly as worthwhile as doing big tests and procedures. You will constantly be pressed to see more patients in less time because the reimbursement for your work is continually dropping.

After his training Doctor D chose to work in a community health clinic to provide primary care for underserved patients. He absolutely loved his job and the amazing people he cared for. He also learned to hate the medical system and the bean counters that were constantly pushing him to cut corners on patient care. In the end the bureaucrats won and Doctor D quit that clinic rather than choose to hurt the patients he cared about. He is currently working odd shifts as an ER doctor in a tiny hospital in the middle of nowhere to pay the bills till he returns to Primary Care. He blogs about patient-doctor relationships because he misses having patients of his own and still has those crazy ideas about "helping people" with his medical knowledge.

Of Course there are days Doctor D wishes he would have never signed on to be a general doctor (or a doctor at all for that matter). But when I realize I can help nearly every person that walks through my door I am certain that I chose the right career. Family Medicine is one of the most frustrating and rewarding paths in all of medicine. I advise med students to seriously consider general primary care—it is the fullest embodiment of the ideal of doctoring—but only select it as your specialty if you are certain you will love it, because it will probably get harder for primary care doctors before it gets better.

Wow, that was a touchy-feely post! I'm afraid Nurse K is failing to make a good hard-ass ER doc out of me. Quick, someone ask a question that will awaken my god-complex angry doctor side!