A guest column by the American College of Physicians, exclusive to KevinMD.com.
Over the past several months, I have covered some controversial topics, such as electronic health records and the overuse of diagnostic testing. For this month’s column, I will address a less provocative topic: the role of non-physician providers in patient care. (Okay, perhaps we will discuss something non-controversial next month.)
Rather than rehash organized medicine’s position(s) on the topic or attempt an unbiased review of the evidence (what little there is), I will present a practicing physician’s real-life perspective of the issue, and comment on the vitriol that this subject generates. Before I go further, I remind you that my statements do not necessarily reflect official policies of ACP.
I have worked with nurse practitioners or physician assistants since medical school in different settings: resident clinic, a staff-model HMO, and 20 years in private practice. During that time, I have been a colleague, teammate, co- worker, supervisor, and employer of NPs and PAs. For simplicity, I will refer to both types of clinicians as non-physician providers, or NPPs (“mid-level providers” or “physician extenders” are terms that many NPs and PAs find objectionable, by the way).
My practice uses NPPs to increase our patients’ access to care. Our patients can see NPPs for urgent visits, follow up of chronic conditions such as diabetes and hypertension, and preventive services. Our NPPs do not have their own patient panels because we prefer that every patient in the practice have a primary physician. Our preference is based more on logistics than our judgment of the NPPs’ ability to manage a panel of selected patients. However, some of our patients take matters into their own hands and find a way to see the NPP for all of their problems. I don’t view that as a threat but see it as an affirmation that we have a team of providers that patients feel comfortable seeing. Some patients, on the other hand, refuse to see anyone but a physician. That is their choice. When they request an appointment, we make clear who they can see and what their credentials are.
Our NPPs see patients independently. When they have a question, they ask one of the physicians. In a typical day, that might happen once or twice, usually because the patient is complicated or has an unclear presentation. Often, the NPP will recommend that such patients follow up with one of the physicians. That isn’t surprising given the differences in training and expertise. On the other hand, sometimes one physician will ask another for help with an exam finding or a management question. One of my NPPs worked in a dermatology office for many years, and sometimes I will ask her to look at a rash that I can’t figure out. When we are not sure of something, we ask for help, regardless of our title.
Physicians review and cosign every office note from an NPP visit. There are a few reasons for that, including billing requirements, but it also helps us to keep up to speed with what is happening with our patients. That stated, there are very few occasions that I read an NPP’s note and disagree with the care provided, and most of those disagreements are more over style than substance. I suspect that if I reviewed my physician colleagues’ notes I would have similar disagreements from time to time.
Do our NPPs order more tests or prescribe more antibiotics than the physicians prescribe? Sometimes it seems that way, but then again the NPPs are often seeing acutely ill patients. It varies by NPP, just as physicians differ in their test and antibiotic use. I believe that NPPs welcome education on appropriate use of tests and treatments more than physicians do. I should add that I have hired new physicians straight out of residency who order more tests and antibiotics per capita than any NPP.
On average, our NPPs see fewer patients per day than do our physicians, but in a crunch, the NPPs can see just as many, if not more. The longer visits with the NPPs are by design, for reasons such as patient education and chronic care management. We are a fee-for-service practice, so provider productivity matters, but at the same time, with the longer NPP visits we can provide better care for our patients without hurting the bottom line too much.
From my vantage point, many of the arguments over how to limit what NPPs do fail the reality test. We hear a lot about supervision. One could argue that most of my patients’ visits with NPPs take place without my supervision. While you can call my reviewing the notes “supervising,” by the time I read the note, the prescriptions are written, the tests ordered, and the patient sent home. When my NPPs need help with a patient, they seek help, just as a physician should under similar circumstances. That has nothing to do with regulations or employment status; it is a professional obligation.
Then there is the talk about interchangeability of physicians and NPPs. NPPs can provide many of the primary care and acute care services that I do. That does not make us equivalent, just as my being able to provide much of the care to patients with heart disease does not make me a cardiologist. We work well together when we understand our roles, abilities, and limitations, and we value what each of us brings to the care of our patients.
As to the economic arguments about threats to physician practice, my home state is one of the most permissive for independent nurse practitioner practice, yet there are very few such practices in the state. Perhaps that speaks to the choices that NPPs make, or the fact that a business model that doesn’t work well for physicians wouldn’t work any better for NPPs.
So, when I sit in meetings and listen to angry and frightened physicians or defiant NP leaders discuss “scope of practice,” “restraint of trade,” and who can do what better than the other, I think about what goes on in the real world and wonder if we’re all on the same planet. Why don’t we focus on communication, collaboration, education, and professionalism instead?
Yul Ejnes practices internal medicine in Cranston, Rhode Island, and is the Immediate Past Chair, Board of Regents, American College of Physicians. His statements do not necessarily reflect official policies of ACP.
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