On Nurse Practitioners and Physician Assistants

There is a nurse practitioner that works at my hospital. She is employed by the pulmonology group and helps run the intensive care. She is good. She is better then good...great even. She probably knows more then seventy five percent of the docs in the hospital. She is one of a kind. Hand trained by the pulmonologists she has spent every day in the hospital taking care of the sickest ICU patients. For years. Even so she is closely monitered by the attending staff and and each patient is seen by the covering physician daily. Sometimes it makes me wonder......It works for them.....could it work for us?

There is a primary care shortage in this country. No doubt about it. As access is getting more dificult there have been many cries to enahnce the responsibilities of physician extenders. After all if a a nurse practitioner can work in the ICU, A PA can work for the surgeons, why not staff primary care clinics with physician extenders. Afterall, compared to those specialities....primary care requires the least training....Doesn't it.

Maye.....maybe not.

Last week was a typical week. Maybe a little slow. But I took a look back at some of my interesting cases in the office to consider how a physician extender would have fared. None of these cases were particularly earth shattering, none of them were even life threating (at least for the most part). But they do highlight the way in which a primary care physician is trained. A training that actually is quite extensive.

Patient A was a young lady under a lot of stress. She recently had given birth and already was back at work. She was juggling a busy careeer, a busy family life, and quite a bit of stress. Starting the week before she came to see me she developed shortness of breadth. It was episodic. Lasted for 15 minutes at a time and was accompanied by dizziness and hand tingling. On further questioning she described the shortness of breadth as a strangling sensation around her neck which would cause her respiratory rate to go up and this would then be followed a few minutes later by dizziness and tingling.

At first I was convinced that she was having panic attacks. But her exam made me consider an alternate possibility. Her anterior neck was mildly tender. I ordered thyroid tests and an ultrasound. Thyroid functions were normal but the thyroid on ultrasound was heterogenous with some nodularity. The findings were consistant with thyroiditis. Likely the dizzines and hand tingling occured because the sensation of strangulation which caused her to hyperventilate. I prescribed first alleve and when that didn't work a medrol dose pack. She will see me monthly for repeat thyroid tests to make sure she doesn't become hypothyroid.

So how would a physician extender have done ont his one. Would the patient have been started on antianxiety medication? Would they have been sent for a head CT to work up dizziness? To a pulmonologist to work up dyspnea?

Patient B is a 50 year old Gym teacher with a sore calf. While teaching his students he demonstrated a sprinting technique and developed acute pain. It occured while pushing off the ground at the start of a sprint. He heard a pop and then developed sharp pain in the calf below his knee. Over the next day the calf became swollen and painful. He developed quite a bit of bruising and came to see me.

Based on the history I felt relatively certain the patient had developed an acute gastrocnemius tendon rupture. I examined him and sent him for a stat doppler to r/o DVT and also asses the tendon. Althought the tech told me he didn't see a rupture my suspicion was high so I called an orthopeadist for a curbside consult who confirmed my suspicions. Yes it was likely a ruputre, no the patient didn't need consultation. Yes the patient would likely recover with physical therapy only. Coincidentally the tech callled me back a few days later. He ammended his report. The ultrasound showed a free floating gastroc consistent with a tendon rupture.

Would a PA have caught this one? Would the patient have gotten and unnecesaryand costly orthopeadics consult or an MRI?


Lastly Patient C is a 65 year old female on dilaysis for end stage renal disease. While in dialysis her renal doctor noticed that she had a fever of 101. When the fever continued for multiple days she was sent to the ER for blood and urine cultures and a chest xray. They were all negative. The kidney docotor asked the patient to call me for an eval. The patients exam was completely normal ecxept.....she had anterior neck pain a few inches above a recently placed IJ dialysis catheter. It was mild pain and she had been told by the ER to use a heating pad. Given the fevers and otherwise normal exam I was worried there could be something more sinister going on. Ultrasound/Doppler revealed an acute DVT in the Right Internal Jugular vein and a chronic DVT in the LEft IJ. The patient was hospitalized and coumadinized.

I bring up these cases because they are examples of the wide and varied nature of a primary care physician's job. My ability to recognize and treat these problems comes from years of studying, training, working in hospitals, and overall experiance. I fear that physician extenders will not have as deep experiance. They will not have spent long hours in hospitals like we did in residency. They will never have been confronted by do or die situations in which vital decisions have to be made in the middle of the night without anyone around to help. Becoming a physician has been a life long process. I still have soo much to learn. I read vorasciously, I learn from each patient. I discuss cases with specialists daily. Yet even I often feel humbled by the vast sea of knowledge necessary to treat my patient's appropriately.

If you were really going to go through all the trouble and training necessary to be good at primary care....why the heck would you become a physician extender. Why would you accept a lower sallery for all this hard work?

The simple answer is you wouldn't. You get what you pay for my friends...you get what you pay for!