Monday, May 12, 2008

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 get what you pay for!


Anonymous said...

Your comments indicate you think extenders are incompetent. You don't have any proof that a PA wouldn't come to the same conclusion you did. Your comments also lead one to believe that only extenders are capable of missing a diagnoses and in turn becoming a costly and dangerous burden to health care. If you are batting 1.000 then I bow to your greatness. It must be great being able to walk on water. My guess is that is not the case and that you have missed your fair share of diagnoses over the years. If so, where does that leave you compared to the lowly extenders? Hint: How many rocks do you have piled up in that glass house of yours?

Anonymous said...

Lots of PAs and NPs excell in primary care. Heck, the role of the PA was conceived to fill such a role. Perhas you simply see PAs and NPs as more cost-effective competition??

I understand how you could feel defensive given the idea that such extenders can and have effectively cared for such a large proportion of primary care patients. They have such little debt and operational responsibility, but they still get to help patients! It'$ tough to $hare a piece of the pie, e$pecially when you haven't had to for $o long (As a profession, that is).

Anonymous said...

One can only appreciate the KUDOS you give the NP at the start of your sermon. Sadly though, you contrast that with medically narcissistic rhetoric towards the sermon's end.

As an URGENT CARE mid-level NP seeing 30-50 patients a day, your scenarios are all to familiar. In fact most patients that enter our doors are ones that "CANT GET IN TO SEE" their PCPs. I have over 20 years experience, and I have treated all 3 of your senarios, in fact all within the last 2 years. (Though I did refer the thyroid patient to a Endocrinologist.)I work in FL so failure to refer is grounds to sue.

Are there times when I can't figure what the hell is going on?You bet there is! That's why I, like you, have continued to learn everyday while working with patients in my practice. I continue to educate myself through journals, current publications, and seminars. Finally I surround myself with medical professionals from which I can learn from as well as refer patients.

Do I think there are NPs and PAs in my position that are "CLUELESS"? You bet I do. With that said, I think your eyes are "WIDE SHUT" if you think all PCPs practice alike.

Anonymous said...

As a Nurse Practitioner with experience working both in Internal Medicine and family practice, I am familiar with all 3 scenarios you've mentioned, can appropriately diagnose and treat them and yes, also have a good working relationship with specialists so I can also call and get a "curbside consult". I agree that not all PA's/NPs are competent enough to be independent, but I've also known some physicians in my time whom I thought were downright scary in how they practiced. You'd do well to be a little less egotistical and give others the benefit of doubt.

Anonymous said...

I'm sorry to say that you deserve the comments you've received. I, otoh, googled "physician extenders, helpful or not?" and got you first. I have the exact opposite feeling towards them than you do. I find my PA's and NP's to be EXCELLENT at what they do and trust them explicitly. I have even found them to be, in some instances, more thorough and intuitive than some of the newer docs that we have employed throughout the years. The problem I find is the more we have, the more charts i have to sign and review, and the more lab and radiology results that come through that i also have to sign and review. They are part time and not there every day. I do not have time carved into my schedule to sign their charts, and if i am the only doc and there are 3 of them working, that could mean over 30 charts that i have to review just for the morning! I am not sure this is worth it, it probably is but if someone could give me some reassurance, that would be nice.

Anonymous said...

I bet an NP or PA could spell "Salary" correctly! LOL "sallery "

Anonymous said...

I'm an NP in a specialty practice. I see the mistakes made by the PCPs before the patients are referred to us. To think that only NPs and PAs would order unnecessary medical tests and maybe the wrong tests is outrageous. What matters here the most is that people are provided an opportunity to have access to quality care. Let the competent NPs, PAs and doctors share in achieving that goal. There is no room for medical narcissim here, in my humble opinion! Let the individual patient make the choice in who they prefer to receive their care will be surprised.

Anonymous said...

In my humble opinion, I'd like to have a PCP who knows how to spell, AND who doesn't thinking he is God. Your ego is most definitely going to bite you in the a** !
P.S. Your 3 scenarios, to the untrained ear, may make you seem like Dr. House, but to a PA or NP working in primary care like myself they are clearly NOT unusual or difficult to diagnose or treat. I have seen countless patients with complaints that doctors have brushed off, ignored, or failed to work up properly. The pendulum swings both ways my friend.

Anonymous said...

I'm not sure a NP's 1 pathophysiology and pharmacology course is enough didactic education to competently presribe, order appropriate tests, and interpret lab/ imaging data. That said, I hope NP's get full autonomy. It will substantially bring health care costs down! However, their medical malpractice insurance will be the same as a MD's (50-70,000 / year). Insurance companies and are not going to care what the PCP's degree is if they are autonomous providers. Furthermore,medicare/medicaid/PPO's etc... are still going to pay NP's and PA's about half as a doc in reimbursement. Hence, with a NP's 90,000 salary minus 50,000 malpractice leaves 40,000 for the NP. This couldn't happen too soon. Then, finally, a NP's love for providing "patient care" will be truly tested. Let's see if they stay in practice! Or will they take a RN job at $28/hour (60,000/ year) and claim how much they missed being a "good nurse"! LMFAO!!!! You guys are a joke! But, you can spell! You don't need 4 years of straight A's in undergrad taking courses like organic chemistry and physics, 4 years of med school, passing scores on USMLE Steps, 3 years of residency training, etc.. in order to SPELL you idiots!! Most NPs and PAs are MD wannabes. However, they didn't have the grades, intelligence, or diligence to really succeed. So, I know, let's allow these rejects to diagnose and treat our children and loved ones! WAKE UP!!

Anonymous said...

There's a lot of hate being thrown around here. Doctor's and mid-levels are not in competition. The NP/PA was conceived to augment the doctor's services, not compete with him or her. The mid-level is perfectly capable of seeing less complicated primary care cases and, with time, handling more complicated ones. Until that point, and afterward, the NP/PA should be consulting the supervising physician to ensure that appropriate care is given. Check your egos at the door. It's not about who does it better. Each has their own role. It's about working together to provide more quality care for more people.

Anonymous said...

I find the above statement about PA/NPs not having good enough grades to get into med school hilarious. After finishing undergrad with all of the required med school prereqs AND all As...I did enough research to know that return on investment is better for a PA than MD. Sorry, but going that much into debt and putting off a family is not worth it. I'd rather take less debt and still be able to practice medicine, while helping others. It's a personal choice and I didn't go to school so I could feel better than others. There is a place for all three and respect is needed.

Anonymous said...

Anonymous said...

Perhaps before belittling other professions online with conjecture, you could utilize spellcheck. Your write at an eighth grade level.

Anonymous said...

PAs have the experience of everyday cases, they are humble and have wide knowledge of clinical medicine, they were trained very hard, they ran codes, they can manage cases in a more integral way than a physician can do, they have seen and treated all 3 cases you presented and even more they can OPERATE on all of those patients! and their favorite arguement, they are a unique part of the patient care team and deliver evidence-based medicine with high quality standards on a daily basis ... I mean, come on ... it seems now that they know more than doctors, they know they are not doctor but don't mind been called that at all ... I'm sure they are going to create things like "fellow of the american college of physician asssistant" if there are not already ... this is just a joke, US health system is going nowhere because of this

Anonymous said...

Its not about single experiences good or bad with NP.

They are not substitutes for Dr. Something that might seem minor could be serious. If you want to deal with peoples lives, get full MD Education + Internship+Residency, then I have no problem with NP treating people independently.

I am a board certified Internist. I don’t go and practice Obstetrics, just because I have some exposure to it in Med School. But somehow NPs think they should be allowed to practice general medicine, even though they don’t have the training.


Anonymous said...

As long as the NP/PA works within their defined scope of practice, there shouldn't be any issues. I live in a country where we have NP (not yet PAs) and their skill and experience is formidable - they are certainly able to perform many procedures better than junior docs and can teach and supervise docs (again, in the scope of their practice).

Despite this, I've heard some stories from expat British docs who hold the opinion that some PAs do overextend - to the extent that it may compromise patient safety. Of newly graduated PAs who state that they are the equivalent of postgraduate year 3 doctors (i.e. junior registrars) and attempt procedures such as intubation without supervision. Something is a bit off if the junior registrar's 5 years of medical school + 3 PG years in hospital can be equivalent to a newly graduated PA who has completed just 2 years of training.

On the other hand, a PA who has had 3 PG years experience working in hospital? I could believe that, in their scope of practice, they could be experts and equivalents.