Tuesday, February 17, 2009

Some More Thoughts On Physician Extenders

I made the mistake here of posting on my thoughts of PA's and Nurse practitioners. Predictably I received a number of not so happy comments. Most of them came from people who had googled phrases such as "physician opinions of nurse practitioners" and fortuitously landed on my blog. I can understand their venom. And maybe I deserve it. Maybe I am a little defensive. A little jealous even.

I mean.... why did I spend so much time and money learning how to be a primary care practitioner? Why did I endure medical school and residency? Why didn't I take the faster route? I could have become a PA or Nurse Practitioner with much less training. I wouldn't have had to spend nearly as much on education. And I would still be able to take care of people and pretty much fill the same role I do today. Right?

I mean you can understand that. Why I would be a little bitter. I guess I do have a jealousy problem. But its not the training or the cost of education that gets me. It something else completely.....

You see I find practicing primary care inexpressibly difficult. Every day I struggle endlessly to balance physiology and psychology, ordinary and uncommon, health and illness. And most days I feel like I do a miserable job. Many nights I sit up worrying that I made the wrong decisions.

I can chart the maturity process of my education. It started early. My first patient.....during gross anatomy. I watched as my cohorts were crass and cocky. How they made fun of the cadavers. In retrospect we were sublimating to protect ourselves. And then we dissected the genitals. And emotionally I fell down. I faced a very sad and scary reality. This was a person that I was cutting open. A human being who had willingly donated their secrets to me.

And then there was medical school. When every patient was a room number or a disease. Until you realized they were people. People who had lives and family. And that was tragic.

Next came residency. After hours of being on call. When no matter what you did your patients got more and more sick anyway. And then there was the day when you sit next to a patient and hold their hand. And watch them die and accept that sometimes even when you can't help by being a physician you can help by being a human being.

With time my attitude towards knowledge also changed. From thinking I knew nothing...to thinking I knew everything....to learning my limitations.

And my knowledge. From anatomy and physiology to disease. To use my senses to evaluate a patient. The visual....the smells...the sounds. To learn to become quiet and listen to myself. To pay attention to what each patient evoked inside and use that to help guide judgement. Seeing sickness over and over again until one could recognize it by the most subtle clues in a half awake state after working 24 hours in a row. Until the gravity of illness was not only a series of lab results and exam signs but an innate feeling that pinches you in the chest before death rears its ugly head.

And overtime I got better. My diagnostic acumen improved. I was better able to wade through the morass of anger, denial, oversimplification, and the useless complexity of the human condition to feel a small level of competence. To appropriately recognize the chest pain that smacked of imminent coronary disaster and direct to the ER as well as comforting the chest pain from anxiety and starting appropriate meds.

But everyday I learn something new. Everyday I return to the literature. Everyday I confront my own inadequacies to imperfectly perform this task that has become my life work. A task that leaves me in awe and humble.

And everyday I wonder if my training has been enough....and I probably will till the day I retire.

So yes I am jealousof you....of anyone who feels that they can do my job with less training. I bow my head to the PA's and Nurse Practitioners who are vying to take my job. I find being a primary care practitioner extremely difficult and wish I could be smart enough to arrive at your level of expertise...

so quickly.


Anonymous said...

Very moving post - I respect you as much as I respect my primary care doctor.Knowledge gained through accumulatedexperience, compounded with common sense to me equals wisdom. I have now (and have had in the past) a wise, compassionate, caring primary care doctor. There may be those odd Minute Clinic-type moments in our lives, but I'd really rather see *my doctor* -or one of her partners - than go to a Minute Clinic.

In no way do I mean to slight or degrade the work of MLPs - long ago, I was in an old-school HMO that used NPs as the front line. They were good at what they did, but escalated appropriately when. necessary.

There is an alternate term I've seen used instead of MLPs - "n'octors" meaning "not doctors". I find that somewhat pejorative, but clearer than all of the alphabet soup that is being flung.

We all have limitations; perhaps some need to learn how to live and work within them, doing what they do well, rather than attempting to be something they're not.

Toni Brayer MD said...

I could not agree more. Physician extenders have their place in medicine and fulfill a valuable role but they are NOT equal in any way to physicians. I work well with physician extenders and respect what they have to offer.

I prefer the term "Comprehensive Medicine" to primary care. It is damn hard work and requires a vast skill set and experience. I believe comprehensive medical care, done well, is difficult and NPs and PAs do not have the expertise to fulfill that role.

Because primary care is so underfunded and overworked, however, I think NPs will be filling the gap. Watch costs go up and quality go down.

tracy said...

Miss you, Dr. Jordan. i hope you are okay.


wolf said...

I totally get what your saying. I respect NP's and I have and do see them when I can't get in to see my PCP but when push comes to shove and bottom line roles around it's my PCP I wait to see for the serious stuff. Even the NP at my office will say your doc knows your history much better and would be better suited to help you figure out the bigger problem but lets see what we can do to get you through this smaller problem till you can get into see her. In my world there is nothing and no one that can replace my PCP not ever.

tracy said...

i miss you so much, Dr. Jordan...have you stopped blogging? i hope not. Are you okay? i hope so.....

Disability Insurance said...

Well written article. You seem to enjoy being a practitioner, and you should work together with PA's and nurses to continue helping your patients.

StorytellERdoc said...

Hey there

Great site. Enjoyed reading your recent posts and enjoyed your writing style. I am a big supporter of PA/NPs--without their hard work, I'm not sure our ER would survive! I did enjoy your perspective on it, though.

Just started my own site last week--checking out other medical sites. I will be following.

Michael Kirsch, M.D. said...

Yes, we have had enough training, but we will never know enough. Beyond the knowledge of anatomy and physiology you noted, we need a tincture of humility if we are to succeed. Nurse pracitioners and other extenders have the great luxury of knowing that all of their advice will be scrutinized by a physician. I wish I had the same oversight. www.MDWhistleblower.blogspot.com

Anonymous said...

@ Toni Brayer MD - Your comments demonstrate a truly short sighted and ignorant view of the role a mid-level can play in the PCP setting. You say you "respect" Physician extenders and "work well" with them, but then go on to say "...NPs and PAs don't have the expertise to fulfill that role." This statement is inherently ignorant and disrespectful. I'm sure a PA or NP who has been practicing in Primary Care for 30 years could teach you more than a few things. You have clearly not done your research on the care statistics of Mid-Levels. Countless reports show that Mid-Levels are capable of filling a PCP role without a decrease in the quality of care. As an MD in a private practice, I find the PAs I work with to be absolutely critical to the success of the practice. I would NEVER be so arrogant or foolish as to think that they are incapable of ever being able to practice medicine at my level, because it is untrue. They learn from me, and I learn from them. We are a team. Your attitude is an embarrassment to physicians and only serves to create a rift between mid-levels and MDs/DOs, which will only end up hurting your patients.