Instead of seeing the doctor...

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Ralph
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Instead of seeing the doctor...

Post by Ralph » Sun Aug 10, 2008 7:38 am

I have mixed feelings about the trend to having non-MDs engage in primary care although I recognize the economics of the emerging reality.

In the cardiology practice that takes care of me there are some terrific nurse practitioners and physician assistant who work directly with the top-flight MDs. That's fine. What I'm leery about is private practices, loosely if at all supervised. At least around here there are drug stores and supermarkets where nurse practitioners can work seeing walk-ins.

Anyone interested in this development in health care?

*****

From The New York Times:
By CHRISTINE LARSON
Published: August 9, 2008

EVER since he was a hospital volunteer in high school, Adam Kelly was interested in a medical career. What he wasn’t interested in was the lifestyle attached to the M.D. degree. “I wanted to treat patients, but I wanted free time for myself, too,” he said. “I didn’t want to be 30 or 35 before I got on my feet — and then still have a lot of loans to pay back.”

When Mr. Kelly was in college, his older brother, then a medical student, mentioned the role of physician assistant — a “midlevel” health care provider with two to three years of medical training, who is licensed to examine and treat patients, make diagnoses and write prescriptions, under a doctor’s supervision. Mr. Kelly, 26, now works as a physician assistant in the neonatal unit of St. Francis Hospital and Medical Center in Hartford.

In an aging population, a shortage of doctors has created new demand for care providers like physician assistants and nurse practitioners — nurses with advanced training who can also examine and treat patients, make diagnoses and write prescriptions.

From 2001 to this year, the number of nurse practitioners in the United States has grown to 125,000 from 82,000, according to the American Academy of Nurse Practitioners, and the number of P.A.’s to 68,000 from 43,000, says the American Academy of Physician Assistants.

To patients, the two roles can seem very similar. Salaries can be similar, too. The average total income for physician assistants in full-time clinical practice is about $86,000, according to the P.A. academy. The average total income for nurse practitioners is $92,000.

But there are important differences. Physician assistants must practice under a physician’s supervision. Nurse practitioners are licensed as independent health care providers, without mandated physician supervision, although some states require them to have a supervising or collaborating physician to whom they can turn for advice. Some nurse practitioners have private practices.

Another important difference is that P.A.’s are generalists, while nurse practitioners train in a specialty like family medicine or women’s health. As a result, P.A.’s can switch fields more easily.

Linda Gale, 51, of Fairfield, Conn., worked as a physician assistant in orthopedics for 18 months after graduating from the physician associate program at Yale in 2005. In 2007, she switched to a urology office, where she sees patients and assists doctors in the operating room, suturing incisions and operating the tiny camera used in laparoscopic surgery.

P.A.’s are licensed by state boards of medicine. Like doctors, they initially take classroom lecture classes emphasizing science and diseases, then continue with clinical rotations. Ninety percent of P.A. schools offer master’s programs. After finishing a program, candidates must pass a national certifying exam. The programs have an average total cost of $46,000, the P.A. association says.

Nurse practitioners are licensed by state boards of nursing, and typically are registered nurses with bachelor’s degrees as they begin their advanced training. To become licensed, they must hold a registered nurse’s license, earn a master’s in nursing science or a doctorate of nursing practice, and pass a certification exam in a specialty area. Both master’s and doctoral programs are offered by nursing schools, which integrate classroom instruction and clinical teaching throughout two or more years of advanced training.

To date, most nurse practitioners hold master’s degrees, which can cost $20,000 to $45,000 to complete. But that standard is changing. In late 2004, the American Association of Colleges of Nursing recommended that new nurse practitioners earn a doctorate of nursing practice by 2015, and nursing schools are responding rapidly.

Since the first such doctorate was awarded in 2005 by the Columbia School of Nursing in New York, 74 nursing programs have added the degree, and 63 other programs are in the works, the association says. Doctoral programs take an additional 18 months to three years and may cost $20,000 to $40,000.

Rachel Lyons, 33, of New York, was a nurse practitioner for five years at an emergency room in Rhode Island before joining the Columbia doctoral program. After finishing it in 2005, she took a new job at NewYork-Presbyterian Hospital, running two clinics in pediatric orthopedics. Next year, she will start seeing private patients.

She also introduces herself as “Dr. Lyons”; doctors of nursing practice can use the title, though they must also introduce themselves as nurse practitioners. “I’ve worked hard to obtain this degree and I make no false pretenses about who I am,” she said. “I’ve earned it.”

Some physicians voice concern at use of the doctor title. “It may cause patient confusion and misunderstandings,” said Jim King, president of the American Academy of Family Physicians.

But nurse practitioners say they are clear about describing their role — as are physician assistants, who don’t use the title “doctor” but are often mistaken for physicians.

“Because I’m wearing a white coat or scrubs, patients call me ‘doctor’ and I have to correct them,” Mr. Kelly said. “It’s a great opportunity to educate them about my role.”

Fresh Starts is a monthly column about emerging jobs and job trends.
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"Only two things are infinite, the universe and human stupidity, and I'm not sure about the former."

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Teresa B
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Re: Instead of seeing the doctor...

Post by Teresa B » Sun Aug 10, 2008 8:11 am

Ralph, I share your concern. I would not trust a NP in a drug store to do my medical care--possibly if it were a blood pressure check or a cold, but the problem is, with no supervision, what does the NP do when he/she is faced with something more challenging?--hopefully refer the patient immediately to a physician--but my biggest concern would be about missing a serious diagnosis.

These ancillary providers can be super-competent and conscientious, but their training is simply nowhere close to as extensive as an MD's. This point was made clear to me some years ago when I was working with a superb PA at the VA hospital. He was so good, I sort of forgot he wasn't a dermatology resident, and started rattling off something about how we should treat some patient based on his unusual biopsy findings, and the PA gently said "Um, I'm not really familiar with dermatopathology"--which was not a fault of his, of course--but it reminded me of the limitations of PA training and experience.

I have resisted using PA's but recently hired one, because it is a reasonable way to handle routine medical problems and make ends meet without burning the candle at both ends. (Not that PA's come cheap, mind you, but if they work full time they can help the physician bring more patients in and have more time spent with each one.) Needless to say, my PA is supervised, with access to me in the office or by phone, and is able to have any patient see me within a day if necessary. Key is to allow the PA to do all she is capable of, but in that very regard, she must not go beyond her comfort level on her own.

Teresa
"We're all mad here. I'm mad. You're mad." ~ The Cheshire Cat

Author of the novel "Creating Will"

Madame
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Re: Instead of seeing the doctor...

Post by Madame » Sun Aug 10, 2008 11:24 pm

Caveat emptor.

Evelyn Laden
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Re: Instead of seeing the doctor...

Post by Evelyn Laden » Mon Aug 11, 2008 1:07 am

I agree with Teresa on a number of points, but not on others. First, PAs, trained either 12 or 18 months, came into being because physicians, mostly surgeons at that, in mainly rural areas where few nurses were available, needed technical aides to assist in the operating room and follow up with postoperative care, such as dressings, all strictly technical work. They know nothing about nursing care as it is taught today. They are not allowed in many hospitals to do anything except assist the surgeons who employ them with technical work in the OR. As time went on, many physicians saw PAs in other medical specialties as a convenient way to increase their practice, ie, profitability. Patient benefit was (and is) a secondary reason for employing PAs.
In fact, in earlier days physicians intended to use PAs to replace nurses entirely wherever possible. Obviously, nurses and nursing organizations did not appreciate this, pointing out that their education provides them with skills of assessment and patient care no technically trained PA possesses. Example: A PA would not know a pressure ulcer (decubitus) if he saw one, much less how it is caused and treated.
Contrast this with advanced nursing education. It provides nurses from the MA level on up with many skills PAs after the usual 18 months training don't have. Among many others, these nursing skills include Intensified physical assessment, physical exams, in-depth knowledge of wellness (of no interest to physicians generally since not profitable), disease, anatomy and physiology, knowledge of pharmacology, and more. This is true at the MA level and more so at the doctorally trained level of NP education. Moreover,NPs, except for family practitioners, usually specialize in one field, such as orthopedics, oncology, pediatrics, all the way down the line.
To compare a PA's knowledge with that of an NP who has minimally five years of education, or doctorally trained NP (add another several years) points out ignorance concerning these different healthworkers' education - there simply is no comparison. That said, any NP, at whatever level of academic education, would not advise or treat a patient whose diagnosis is problematic, if only for legal reasons. So, to say an NP might be allowed to perform "blood pressure checks or treat a cold" is absurd. Any lay person can learn to do that after a few weeks or less of simple instruction.
Not all PAs working in physicians' offices are properly (or at all) supervised either. I know of several cases of PAs assigned to patients in physicians' offices, who advised wrong treatment after making an inaccurate diagnosis (sorry, Teresa, one was in a dermatologist's office).
Regrettably, some physicians' diagnostic skills are not always accurate, either, the accusation made here against NPs. And nobody supervises them! Case in point: A female acquaintance, age early to mid-70s, was recently diagnosed as having "genital herpes." Not knowing this is a sexually transmitted disease she didn't think it necessary to keep the information private. Knowing the woman's age, lifestyle, and hearing a general description of her symptoms, I delicately told her that the dermatologist's diagnosis seemed rather unlikely. The greater likelihood, sight unseen, was possibly some form of excema. (I am neither a dermatologist nor an NP, and have worked as a writer for many years since my RN education, but this was just too obvious). After treating the poor woman unsuccessfully for several weeks with antiviral medication, a biopsy was performed. Result: A type of eczema. No NP I can think of would have made such an error in diagnosis.
To sum up: Just as GPs (physicians) and family practice physicians would send patients whose problems exceed their practice skills to a specialist, an independently practicing NP would do the same. Of course, an intelligent patient who has that option would choose a specialist right away. PAs and NPs have their uses. PAs should always be supervised by a physician. Many NPs are, and those practicing independently don't want to lose their license. I haven't heard of many who have.

Teresa B
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Re: Instead of seeing the doctor...

Post by Teresa B » Mon Aug 11, 2008 6:49 am

Evelyn, I had no intention of trashing NP's in my post! I have the utmost respect for them, and considered hiring one for my practice rather than a PA. It just so happened I was impressed by this particular PA.

I would still not necessarily trust a NP who is practicing unsupervised in a drug store, and despite the many knowledgeable NP's out there, they do not have the medical training to diagnose and treat complex illnesses. (Nor would I want a PA unsupervised.) In retrospect, I apologize for the "blood pressure and cold" comment, which was off-the-cuff (no pun intended) and meant as a synechdoche for "all minor illnesses". Of course I know that NP's can do much more than just that.

Your remark that a PA would not know a decubitus ulcer makes no sense. And no physician I know would replace an RN with a PA, either, as they serve entirely different functions.

Your case of the dermatologist who misdiagnosed the lady is irrelevant. Anyone can point out a misdiagnosis made by anyone else. Also, just to elucidate a few things about the case you cite--the dermatologist who made the incorrect diagnosis knew that genital herpes may lie dormant for many years, so it is not at all unusual for an older person, even if they were sexually inactive for some years, to manifest symptoms at some point. If the patient actually had eczema, it's good it was eventually diagnosed correctly. However, and not to diss NPs, it is expressly not true that an NP (or a PA, or a family practice MD, or an ophthalmologist, etc) is likely to be a better diagnostician of rashes than a dermatologist.

All the best, and no ill will to NP's,
:) Teresa
"We're all mad here. I'm mad. You're mad." ~ The Cheshire Cat

Author of the novel "Creating Will"

Evelyn Laden
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Re: Instead of seeing the doctor...

Post by Evelyn Laden » Mon Aug 11, 2008 10:09 am

Dear Teresa,

Thank you for your reply. No dissing of dermatologists intended either! However, referring to the example cited earlier, anyone with functioning eyesight trained - even if not in dermatology - in medicine or nursing, would know that an excematous lesion doesn't remotely look like H. genitalis however long dormant that may have been. And PAs being technically trained really do not know what a decubitus is or what its causes are, unless specifically taught by their employers after they finish PA school. It is not part of the PA's technical training. It is fundamental, however, at any level of nursing education.
Finally, no well educated NP, whatever the area of specialization, would undertake to treat a complicated illness. A generalist physician most likely wouldn't either. Unfortunately, particularly in the area of dermatology but also in others, some generalist physicians make (incorrect) diagnoses either because they think they can or because they don't want to lose the patient. Specialists know best (or should, no guarantees!) about their areas of expertise. That's why we have them. Thanks again for your comments.

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Re: Instead of seeing the doctor...

Post by living_stradivarius » Mon Aug 11, 2008 11:41 am

So it all comes out... I didn't know Teresa was a dermatologist :D. I know a dermatologist in SF who works with at least one PA in a private practice. I can certainly say from observation that the PA sometimes has no idea what's going on, and if the doc weren't present with him, I wouldn't trust the PA at all.

I think the next question for Ralph is whether he would trust a non-J.D. to handle his tort cases for him.
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Ralph
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Re: Instead of seeing the doctor...

Post by Ralph » Mon Aug 11, 2008 2:48 pm

living_stradivarius wrote:So it all comes out... I didn't know Teresa was a dermatologist :D. I know a dermatologist in SF who works with at least one PA in a private practice. I can certainly say from observation that the PA sometimes has no idea what's going on, and if the doc weren't present with him, I wouldn't trust the PA at all.

I think the next question for Ralph is whether he would trust a non-J.D. to handle his tort cases for him.
*****

Obviously, there is no parallel between a nurse practitioner or physician assistant with regard to practicing medicine and a paralegal with regard to practicing law. N.P. and P.A.s are licensed to provide certain services while paralegals have no equivalent standing.

On the other hand, while a nonlawyer may not represent others, he/she has a constitutional right to self-representation while nonphysicians are never given hospital privileges to operate on themselves.
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"Only two things are infinite, the universe and human stupidity, and I'm not sure about the former."

Albert Einstein

Teresa B
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Re: Instead of seeing the doctor...

Post by Teresa B » Mon Aug 11, 2008 4:58 pm

Ralph wrote: On the other hand, while a nonlawyer may not represent others, he/she has a constitutional right to self-representation while nonphysicians are never given hospital privileges to operate on themselves.
:lol: :lol: :lol:

And I will reiterate, I respect the points of view here, and guarantee any CMG'er who wishes to come to my office will not be relegated to the PA! (And if anything I probably over-supervise, but that's the safest.)

Teresa
"We're all mad here. I'm mad. You're mad." ~ The Cheshire Cat

Author of the novel "Creating Will"

Ralph
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Re: Instead of seeing the doctor...

Post by Ralph » Mon Aug 11, 2008 8:35 pm

Teresa B wrote:
Ralph wrote: On the other hand, while a nonlawyer may not represent others, he/she has a constitutional right to self-representation while nonphysicians are never given hospital privileges to operate on themselves.
:lol: :lol: :lol:

And I will reiterate, I respect the points of view here, and guarantee any CMG'er who wishes to come to my office will not be relegated to the PA! (And if anything I probably over-supervise, but that's the safest.)

Teresa
*****

Don't be surprised if I show up. :)
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"Only two things are infinite, the universe and human stupidity, and I'm not sure about the former."

Albert Einstein

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