The Misuse of Physician Assistants and Nurse Practioners in Modern American Medical Practice
By far, the most popular blog posting I wrote was the series entitled 5 Things I Can't Stand About Going to the Doctor. The series has been posted on numerous medical blogs and has received a fair amount of commentary, particularly on the issue of the misuse of nurse practitioners. In today's posting, I wanted to expand on my thoughts about this topic.
First of all, I want to again clarify that nurse practitioners (and physician assistants) serve a very valuable role in the medical setting. As one anonymous poster correctly pointed out, they improve access to healthcare because there are not enough physicians to see all the patients. If a patient knowingly makes a choice to see a nurse practitioner or a physicians assistant over a physician, that is fine by me. That is the free market at work.
Where I have a problem is when patients are unknowingly and essentially forced to see a physician's assistant or a nurse practitioner. What do I mean by "forced?" Well, take the example of a patient who waits for months for a doctor appointment. The patient shows up and after waiting for a long time because the office is double-booked, is then told that he or she will be seeing the physician assistant or nurse practitioner. I have had patients tell me that they are sometimes told there is no big difference and that it's pretty much the same thing, which is outrageous. I have also had patients tell me that they are told they can reschedule to see the physician if they prefer, but that this will take another few months. So if you are the patient and you have a medical problem, and you waited months for an appointment, what are you going to do? Most people are going to go ahead with the appointment. Sure, the patient could technically leave, but then he/she goes another three months without any medical attention. Therefore, the way I see it, the patient in this scenario is essentially forced to see someone he or she did not plan to see. This is why I use the word "misuse" because it is the responsibility of the physician to make sure this does not happen.
Another thing to keep in mind if you are a physician or nurse practitioner is that many patients have no idea about all of the different medical professions and if you do not tell them who you are they will think you are a doctor, especially if you wear a white lab coat and have a stethoscope. The introduction when meeting the patient should not be "So Jim, what brought you in to see me today?" There NEEDS to be an introduction of who you are. Every week, I wind up needing to correct patients that the person they are calling Dr. Smith is really a physician's assistant or nurse practitioner. Full disclosure is the best policy and would solve all of these problems.
posted by MedFriendly | 8:55 PM
16 Comments:
Dominick, as a patient I agree with your gripe. As a physician, I see both sides of the argument. Personally, I think it is OK for an established patient to see a physician extender, if the physician tells the patient ahead of time and if the extender is qualified to handle the visit. An initial encounter is never an acceptable time for a patient-extender only visit.
Otherwise, nice post.
IU: I totally agree with you. My main point is the patient needs to be informed and agree in advance but to many places are pulling a bait and switch.
I work in a practice were we utilize nurse practitioners, who see twice as many patients a day as a physician. While I agree that patients should be notified ahead of time that they will not be seeing the physician,we make EVERY attempt to have the physician "peek" into every exam room to "bless" the visit and assure the patient that they are recieving the best care. We bill "incident to" which calls for oversight by a physician. Unlike many office, we literally follow this guideline. As you have already stated, the problem occurs when too many physicians find ways around this requirement. It's very amusing to see how many ways regulations can be interpreted by a single group of individuals.
I cannot agree more. I know that PA's and NP's are capable and wonderful but, when I make an appointment with the Dr., it's because I want to see the Doctor. I am paying full premium for my own health insurance and have a high deductible. I want my moneys worth so to speak. I personally know of a PA who does not introduce himself to patients and (we believe) he takes great pleasure in being mistaken for a Doctor.
I am a ED Nurse who is a little older than most of the ED Physicians (and sometimes dress more professionally). Despite introducing myself as a RN and having my nametag clearly visible I am called Doctor all the time. Really pisses off the younger female MD's who get called Nurse by the same people. Full disclosure works to a point but does not always overcome peoples stereotypes
Greetings. I agree that the patient should be told whom they are seeing in advance. I do disagree however with the first responder that a first encounter should never be with a midlivel as I think a midlevel in a specialty practice can carry their own patient load and are not there just to see follow ups. Different strokes for different folks and different practices. Its too bad for those people that "take pride" in fooling people- I'm pretty excited about my role as an fnp and would hope others would be just as proud to introduce themselves as who they are and what their educational background is but again. .. different strokes for different folks and different practices.
This is my first time visiting this site and I felt that the comments were thought provoking. I do feel that it is important to introduce yourself as an NP or PA on initial introductions to patients. I always introduce myself as a nurse practitioner and correct my patients when they call me doctor. I have found that some of them will call me doctor anyway, as if they are doing me a favor. I even have to remind some of my established patients that I am a nurse practitioner, but I do not mind. I work in an office with four anesthesiologist and one other nurse practitioner. On a given day, if an MD is overbooked, I am asked if I can see one or two of his/her patients. I always tell the staff to ask the patient if they would like to see the NP prior to "forcing" them to see me. I never thought of it this way, however, it does make me feel that my skills and expertise are being misused because I know that after waiting for an hour for the MD, the only reason that the patient would like to see the NP is to get their prescriptions and go home.
I've had better care with NP, so i would rather see him/her than the MD in most cases. Lots of MDs are only in it for the money and have less-than-caring attitude, which is why I applied for med school. I want to be a caring physician who lives in a modest home, drives a stripped Toyota Camry and cares for the human lives that are under my charge, with no thought for expensive material things.
I agree with the last two comments. I would rather see a PA than a doctor. After shadowing people in both professions, I feel that PAs and NPs are more able to provide patients with quality care. Doctors I shadowed seemed to be on the phone with other medical professionals, either taking a referral or giving one. I saw doctors leave patient's rooms to answer pages quite often. On the other hand, the mid-levels that I've shadowed tend to lead a more low-key profession. They are able to focus on each patient they see. Competent PAs and NPs know when they need to refer a patient to a physician. After a certain amount of time in the medical profession, PAs and NPs will end up with the same real life experience as Physicians... sometimes this experience is just as, if not more important than the years and dollars spent at Medical School.
That being said, patients should be informed of who they are seeing, and mid-levels should be proud of what they are and introduce themselves as such - they've earned it!
The sad thing about the nurse practitioner profession is its philosophy regarding independence. The nurse practitioner philosophy has disguised their relationship with physicians for years by using words such as collaboration. In reality nurse practitioners have always wanted to push themselves into an independent role free from any medical over site. This philosophy rings loud and clear with their most recent push for the development of the "Doctor Nurse" (DNP) program. Why would a profession that already has two pathways (PhD & DNSc) that allow a person to obtain a doctoral degree with an emphasis in nursing want to develop another doctoral degree? One does not have to look far to find out their ulterior motives. Just go to some of their webs sites (AANP, ANA, and accrediting agencies CCAC...). Greed and arrogance are two reasons that initially come to my mind. It is egotistical and despicable to think that anyone with two years of extra training (whether it be at the masters or doctoral level) would be aloud to hang their own shingle up and practice on their own without any physician oversight. This only does one thing, but place the general population in harms way. I find it deceptive when people make a comment like this, NP's are quick to mention the numerous studies that have been performed comparing the quality of care between physicians and NP's that report little to no difference in the quality of care that NP's provide. Unfortunately, no one mentions that the majority of these studies were performed when the NP was working with a group of physicians and had close over site or direct collaboration with a physician as well as including data obtained from the PA profession. Working as a PA I find it absolutely deplorable the practice of hospitals hiring NP's simply because it is cheaper to higher an NP than it is an MD and they do not have to worry about finding or paying anyone extra to supervise them. Word to the wise, any NP or PA worth their salt will tell you they would never want to practice without physician over site.
I am a regular person: a patient/consumer.
What some of the medical folk on this blog have to say INFURIATES ME.
Here is an example from one poster above using the handle "Jennifer."
She says: "While I agree that patients should be notified ahead of time that they will not be seeing the physician,we make EVERY attempt to have the physician "peek" into every exam room to "bless" the visit and assure the patient that they are recieving the best care."
HOW DARE YOU! You make "EVERY" attempt?
Dearheart, WE AREN'T PAYING FOR YOUR "ATTEMPTS." This is health and well-being we're talking about...
That goodness that MedFriendly is a GOOD doctor who beleives in quality.
The bottom line is everyone is looking to cut costs...and it doesn't work when it comes to top-notch healthcare.
So "Jen," feel free to keep working in your ghetto medical practice with shoddy standards.
You would NEVER get my business and I hope others are smart enough to quit going to the practice where you work as well...they are being done a serious and dangerous diservice!
The last comment is just ridiculous. You are paying for health insurance- so that you have the ability to find good health practioners who can take care of you. If that person is PA or NP who cares? As long as you are having your needs meet and medical issues resolved. That last comment about "ghetto" medical practice is idiotic.
Am I incorrect in my understanding that MedFriendly is a PhD not an MD? I don't intend to be pejorative but I wonder how much experience he has had with the MD-PA/NP relationship. PAs and NPs fill an extremely unique niche in the medical field and the nuances of being a midlevel practitioner cannot be understood from the outside.
Not all NP's desire to be independent practitioners seen as "on par" with a physician. I am a Women's Health NP and as such am qualified to handle many health care concerns for pregnant women and women with gynecologic concerns. I work very closely with an OB/GYN and any questions concerns are run by her on a weekly if not daily basis. If I find something that is out of my scope I have her examine the patient. I want what is best for the people I work with. Personal glory etc really has no place in my care of patients. However, this does not mean that I am not fully capable and equipped to handle many problems that gynecology patients seek care for. All our patients are informed that they may see the MD or the NP and if the Doc has to run to the hospital to deliver a baby and a woman wants to get in and out I have no problem doing her pap. Smart and informed use of NP's/PA's is not detrimental to healthcare, rather it increases efficiency. Keep in mind I won't see anyone who hasn't been asked and agrees to see me....
I have been a nurse for 43 years and an NP for 15 years. I carry my own full patient load and have a wonderful relationship with my collaborating physician. He refers patients to me in areas that I am more educated than he, and I refer patients to him that are out of my scope of practice. Twenty two states need no physician supervision or collaboration whatsoever. There private practices are thriving. There are good and bad NP's, PA's, and MD's. Many patients request that they never see the physician and many leave the practice to follow an NP to wherever they go within the commmunity. I have had hospital privileges in the past, although not admitting privileges, and I have been invited to present grand rounds, speak publically and also privately for pharmaceuticals. Education is important but all of us learn more in the field than we ever learned in school. I have volunteered in Africa, Russia, Guatemala, Mexico and met aids who have more knowledge in tropical diseases and other entities than any Dr. or NP who was there. We all learn from each other. I always introduce myself as an NP and if a patient asks what the difference is, I tell them how long each went to school and that the physician focus is on the treatment of disease and the NP focus is on health maintenance. Most are satisfied, as proven by the high return rate. We all need to give up our egos and do the best job we can to meet our patients needs. That is the only thing that is important.
So...the standard is. Send all medicare patients to a PA. MD is to be reserved for those paying as the Doctor charges. Those worrisome medicare rules just get in the way of real profit. The Physician Assistant should take a cut, or see twice as many patient for more money. I know the game. I've played the game.
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