Physician associates, physician assistants, and nurse practitioners are playing an ever-increasing role in healthcare. How should we think about the change?
Steve, I appreciate you commenting on the article and it sounds like you have had a number of personal health challenges and challenging health professional interactions. I was by no means implying that NPs/PAs don't have a very important role in the system. But, rather the broader clinical training in diagnosis and especially differential diagnosis means that for complex patient scenarios, seeing a physician has advantages. Of course a narrowly focused NP who is a nurse anesthetist is very qualified for routine anesthesia and a diabetes oriented NP can well managed the protocols of blood sugar control. Where we may differ is the optimal management of a complex patient.
Dr. Dubois your article could not be further from the truth of what is hasppening in practical medicine in this country. I have been in health care for over 43 years. I have earned a BS degree in Medical Technology (ASCP) from The George Washington University, my BS degree in nursing and my MS degree as a Family Nurse Practitioner. I am a retired USAF Critical Care Nurse who spent nearly a year down range in Afghanistan at Bagram Air Base and have treated more complex injuries than most MD's have ever seen state side. In my former position with Banner Health Care Arizona I was the lead provider ina large Family Practice office. I have worked along side MD's who couldn't make a clinical diagnoses to save their life. In a former role I attempted multiple time to treat a VCU prepared MD on how to perform a TRUSS procedure and he failed miserably. He nearly perforated the colon of several patients. Personally I was diagnosed with Coccidiomycosis in March 2023 at Honr Health Sonran crossings hospital and a "Team" of MD hospitalist nearly killed me because of multiple misdaignoses. They were convinced that I had an atypical pneumonia and flooded me with every IV antibiotic known to man, plus hugh doses of predinose. Why? because the serology studies were negative for Coccidiomycosis. However every practicing provider in Arizona should be knowledgable that you don't rule ut Valley Fever on a negative serology. The test was develped in 1946 and 70% of the time it is a false negative until the titer reaches detectable levels. Then while performing a broncoscopy on me the "MD" Pulmonologist traumatized my vocal chords and necrotized my uvula. I couldn't talk for a year, had to undergo speak therapy and had a uvulectomy. He was a Medical Doctor with his thousand of hours of training. Four months after my hospital discharge I developed a uticarical rash over my entire body, went to my PCP, a NP, and she diagnosed me with Coccidiomycosis. My IgG, IgM titer was then 1:32. She statred me on Fluconazole and Immediately I felt an improvement. Unfortunately due to the intitial misdiagnosis the fungus migrated to my heart causing myocarditis, I suffered three NSTEMI's since and now have a pacemaker not to mention the fungus has also diseminated to my bones and I have lesions on my bones. All of this due to physician error! Your theory has so many holes in it that you don't see the forrest through the trees! What I would like to see is a nationwide strike of every single practicing NP and PA in the United States of America including those in uniform to put down their stethascopes for a period of one month and then maybe this nation will appreciate the role we play in this nations health care. I am on the verge of retirement so I will never see this movement take grass roots. However if physcians such as your self remain on your high horse eventually these providers will advocate for themselves and demand equal rights and equal pay in the health care arena or you can simply try to manage without us!
For the last 30+ years I have been training APPs (nurse practitioners and physician assistants) in general neurology, stroke neurology and headache medicine.
In 2024 we implemented a first of its kind formal 1-year fellowship training program in headache medicine intended for APPs, and our inaugural fellow graduated in September of last year. She now is working – largely independently – as a member of our headache team.
In multiple prospective studies we have demonstrated that in terms of headache diagnosis and management an adequately trained APP can function largely independently at a level of clinical competence approximating that of a subspecialty-trained and experienced MD; in those studies patient satisfaction was recorded as being slightly higher with the “APP paradigm“.
In neurology we have an increasing problem with supply>< demand, and this is particularly true in headache medicine. We have too few providers who possess the expertise and inclination to manage headache optimally, and the volume of individuals with headache requiring medical attention – estimated to be over 25 million in the US for migraine alone– far exceeds existing medical capacity. This problem is not going to solve itself.
There is no question that a properly trained APP can function at a high level of competence in the neurology setting – we and other clinical investigators have established this. It’s time to stop debating and start training.
Thank you for your comment. I agree that focused areas are ripe for APP training. Where I think a physician should be involved is when a presentation doesn't fit a simple category--e.g., fatigue, diffuse pain, AND a headache....the broader approach to differential diagnosis generally requires broader and more involved training. Protocol driven or particular focused symptom (e.g., sore throat, UTI, diarrhea...) can likely be handled well by others. Perhaps even initial seizure w/u and management, post head concussion evaluation/management....
"Where I think a physician should be involved is when a presentation doesn't fit a simple category--e.g., fatigue, diffuse pain, AND a headache....the broader approach to differential diagnosis generally requires broader and more involved training."
Yes, of course.
How do you imagine that physician is going to be paid? And at 22,000 USMGs/year - after 80% of the work is "routine" and done by APPs - what are they all going to do?
For the last 30+ years I have been training APPs (nurse practitioners and physician assistants) in general neurology, stroke, neurology, and headache medicine.
In 2024 we implemented a first of its kind formal one year fellowship training program and hit medicine intended for APP’s, and our inaugural fellow graduated in September of last year. Chanel is working – largely independently – as a member of our headache team.
In multiple perspective studies we have demonstrated that in terms of headache, diagnosis and management and adequately trained a PP can function largely independently at a level of kibble clinical competence approximating that of a sub, specialty trained and experienced MD; in those studies, patient satisfaction was recorded as being slightly higher with the “APP paradigm“.
In neurology we have an increasing problem with supply>< demand, and this is particularly true in headache medicine. We have two few providers with the expertise who possess the expertise and inclination to manage headache adequately, and the volume of individuals with headache requiring medical attention – estimated to be over 25 million in the US for migraine alone– fire exceeds medical capacity. This problem is not going to solve itself.
There is no question that a properly trained APP can function at a high level of competence in the neurology setting – we and other clinical investigators have established this. It’s time to stop debating and start training.
I was referring to some of the symptoms you believe warrant MD intervention: “—think persistent headaches, lingering back pain, unexplained fatigue or mood change—ask to see the doctor or confirm that your NP/PA visit includes same-day physician review.” Don’t think the evidence provides clear support. Back pain is a perfect example. I served for 20 years at the Cochrane Back and Neck Group. During that period, don’t believe I ever saw a compelling study/review showing that MDs do better than other professions in identifying chronic complex, comorbid conditions, interpreting red and yellow flags, and identifying and managing patients at long-term risk of debilitating disability. No profession has a great track record in this area, including physicians. Why make that assertion about back pain without compelling evidence?
You make an excellent point. Where is the evidence that MDs do better with the complex patient than NPs/PAs? There likely isn't rigorous evidence. So, if that is the standard, then we can't disprove the null hypothesis that all of these providers provide equal quality care. Worth reflecting on-although I will personally stick with the guidance I made, albeit with less convincing proof....
Would feel more confident in your essay if there were strong evidence from high-quality clinical trials supporting your position. There doesn't seem to be.
Not sure what aspect of the article you refer to....There are studies comparing MD care with NP/PAs for routine illness management. My concerns relate to the management of complex presentations or multi-comorbid patients. You have also seen the comments about concerns related to increased referrals because the NP/PAs might not feel comfortable handling certain presentations.
Filling in details, history, symptoms. Chatbot will present summary to clinician. Clinician will make some decisions. Chatbot will then present its own decisions. Clinician may then choose to refine their prior decision.
So, the PA vs MD discussion is old. And doesn’t matter as much in the new world we are in.
I have already used the chatbots to fact check my dentist. And was pleasantly surprised by the evidence based, ‘sales’ free recommendation. As of now, I trust the Chatbot to an equal degree, if not more
The healthcare system is placing excess pressures on our wonderful PAs and NPs to do more on their own. They also aren't getting the "supervision" they were promised when they were first hired.
I started practice in 1982 after a lot of training. And I found that I was working alongside a lot of "primary care doctors" a number of whom started work in the 1940s and 50s, and still called themselves "GPs". One of the things I noticed right away, having been trained myself more or less on Mount Olympus, was that it was common for GPs to give patients afflicted by modernity vitamin B12 shots. Why did they do this? Because margins for GPs, even in those days, were so thin that the B12 shots helped to keep the door open.
Wait, wait - what does this have to do with PAs, NPs, primary care in the current year, and Dr. Dubois's article? Hold on, I'm getting there.
I work in a field of medicine with an above average number of complicated cases and diagnostic dilemmas. I don't touch anything sharp, but I'm a good thinker. I like the work, and the pay is OK (although compared to being a radiologist, say, not great). It is said that I am good at hard cases.
But if you took away all my easy cases, which are about 80% of my RVU volume, I couldn't pay the rent or put gas in my car.
All these "supervisions" or "availability for backup" pay zero dollars. What incentive is there for anyone to spend $300K to go to medical school (22,000 USMGs/year, they can't all be Deans and Department Chairs) and then go to work where the need for trained physicians has been reduced by 80% by the means of stopping B12 shots for anxiety/depression and/or giving away all the routine work to NPs and PAs, so the newly minted 22,000 doctors a year can do what, exactly?
Presume their liability for the work of PAs and NPs continues unchanged, while their input into those cases vanishes (already happening) and the compensation for "being available" goes to zero. Will they get to bill $50,000/life saved for 2-3 hard cases/month?
Having practiced (in various clinical settings) with ARNP's & PA's over my entire career, and having served as a pharmacology professor (just one full semester) teaching clinical pharmacotherapuetics to ARNP/MS nursing students, l am in complete agreement with this essay.
Steve, I appreciate you commenting on the article and it sounds like you have had a number of personal health challenges and challenging health professional interactions. I was by no means implying that NPs/PAs don't have a very important role in the system. But, rather the broader clinical training in diagnosis and especially differential diagnosis means that for complex patient scenarios, seeing a physician has advantages. Of course a narrowly focused NP who is a nurse anesthetist is very qualified for routine anesthesia and a diabetes oriented NP can well managed the protocols of blood sugar control. Where we may differ is the optimal management of a complex patient.
Dr. Dubois your article could not be further from the truth of what is hasppening in practical medicine in this country. I have been in health care for over 43 years. I have earned a BS degree in Medical Technology (ASCP) from The George Washington University, my BS degree in nursing and my MS degree as a Family Nurse Practitioner. I am a retired USAF Critical Care Nurse who spent nearly a year down range in Afghanistan at Bagram Air Base and have treated more complex injuries than most MD's have ever seen state side. In my former position with Banner Health Care Arizona I was the lead provider ina large Family Practice office. I have worked along side MD's who couldn't make a clinical diagnoses to save their life. In a former role I attempted multiple time to treat a VCU prepared MD on how to perform a TRUSS procedure and he failed miserably. He nearly perforated the colon of several patients. Personally I was diagnosed with Coccidiomycosis in March 2023 at Honr Health Sonran crossings hospital and a "Team" of MD hospitalist nearly killed me because of multiple misdaignoses. They were convinced that I had an atypical pneumonia and flooded me with every IV antibiotic known to man, plus hugh doses of predinose. Why? because the serology studies were negative for Coccidiomycosis. However every practicing provider in Arizona should be knowledgable that you don't rule ut Valley Fever on a negative serology. The test was develped in 1946 and 70% of the time it is a false negative until the titer reaches detectable levels. Then while performing a broncoscopy on me the "MD" Pulmonologist traumatized my vocal chords and necrotized my uvula. I couldn't talk for a year, had to undergo speak therapy and had a uvulectomy. He was a Medical Doctor with his thousand of hours of training. Four months after my hospital discharge I developed a uticarical rash over my entire body, went to my PCP, a NP, and she diagnosed me with Coccidiomycosis. My IgG, IgM titer was then 1:32. She statred me on Fluconazole and Immediately I felt an improvement. Unfortunately due to the intitial misdiagnosis the fungus migrated to my heart causing myocarditis, I suffered three NSTEMI's since and now have a pacemaker not to mention the fungus has also diseminated to my bones and I have lesions on my bones. All of this due to physician error! Your theory has so many holes in it that you don't see the forrest through the trees! What I would like to see is a nationwide strike of every single practicing NP and PA in the United States of America including those in uniform to put down their stethascopes for a period of one month and then maybe this nation will appreciate the role we play in this nations health care. I am on the verge of retirement so I will never see this movement take grass roots. However if physcians such as your self remain on your high horse eventually these providers will advocate for themselves and demand equal rights and equal pay in the health care arena or you can simply try to manage without us!
Disgusted in America
My apologies for all the typos – the comments fired off prematurely before I could revise them – please see the revised/edited version that follows.
JR
For the last 30+ years I have been training APPs (nurse practitioners and physician assistants) in general neurology, stroke neurology and headache medicine.
In 2024 we implemented a first of its kind formal 1-year fellowship training program in headache medicine intended for APPs, and our inaugural fellow graduated in September of last year. She now is working – largely independently – as a member of our headache team.
In multiple prospective studies we have demonstrated that in terms of headache diagnosis and management an adequately trained APP can function largely independently at a level of clinical competence approximating that of a subspecialty-trained and experienced MD; in those studies patient satisfaction was recorded as being slightly higher with the “APP paradigm“.
In neurology we have an increasing problem with supply>< demand, and this is particularly true in headache medicine. We have too few providers who possess the expertise and inclination to manage headache optimally, and the volume of individuals with headache requiring medical attention – estimated to be over 25 million in the US for migraine alone– far exceeds existing medical capacity. This problem is not going to solve itself.
There is no question that a properly trained APP can function at a high level of competence in the neurology setting – we and other clinical investigators have established this. It’s time to stop debating and start training.
John F. Rothrock, MD
Thank you for your comment. I agree that focused areas are ripe for APP training. Where I think a physician should be involved is when a presentation doesn't fit a simple category--e.g., fatigue, diffuse pain, AND a headache....the broader approach to differential diagnosis generally requires broader and more involved training. Protocol driven or particular focused symptom (e.g., sore throat, UTI, diarrhea...) can likely be handled well by others. Perhaps even initial seizure w/u and management, post head concussion evaluation/management....
"Where I think a physician should be involved is when a presentation doesn't fit a simple category--e.g., fatigue, diffuse pain, AND a headache....the broader approach to differential diagnosis generally requires broader and more involved training."
Yes, of course.
How do you imagine that physician is going to be paid? And at 22,000 USMGs/year - after 80% of the work is "routine" and done by APPs - what are they all going to do?
For the last 30+ years I have been training APPs (nurse practitioners and physician assistants) in general neurology, stroke, neurology, and headache medicine.
In 2024 we implemented a first of its kind formal one year fellowship training program and hit medicine intended for APP’s, and our inaugural fellow graduated in September of last year. Chanel is working – largely independently – as a member of our headache team.
In multiple perspective studies we have demonstrated that in terms of headache, diagnosis and management and adequately trained a PP can function largely independently at a level of kibble clinical competence approximating that of a sub, specialty trained and experienced MD; in those studies, patient satisfaction was recorded as being slightly higher with the “APP paradigm“.
In neurology we have an increasing problem with supply>< demand, and this is particularly true in headache medicine. We have two few providers with the expertise who possess the expertise and inclination to manage headache adequately, and the volume of individuals with headache requiring medical attention – estimated to be over 25 million in the US for migraine alone– fire exceeds medical capacity. This problem is not going to solve itself.
There is no question that a properly trained APP can function at a high level of competence in the neurology setting – we and other clinical investigators have established this. It’s time to stop debating and start training.
John F. Rothrock, MD
I have been training physician assistance, and nurse practitioners in the areas of stroke, neurology, headache medicine
Dear Bobby,
I was referring to some of the symptoms you believe warrant MD intervention: “—think persistent headaches, lingering back pain, unexplained fatigue or mood change—ask to see the doctor or confirm that your NP/PA visit includes same-day physician review.” Don’t think the evidence provides clear support. Back pain is a perfect example. I served for 20 years at the Cochrane Back and Neck Group. During that period, don’t believe I ever saw a compelling study/review showing that MDs do better than other professions in identifying chronic complex, comorbid conditions, interpreting red and yellow flags, and identifying and managing patients at long-term risk of debilitating disability. No profession has a great track record in this area, including physicians. Why make that assertion about back pain without compelling evidence?
You make an excellent point. Where is the evidence that MDs do better with the complex patient than NPs/PAs? There likely isn't rigorous evidence. So, if that is the standard, then we can't disprove the null hypothesis that all of these providers provide equal quality care. Worth reflecting on-although I will personally stick with the guidance I made, albeit with less convincing proof....
Would feel more confident in your essay if there were strong evidence from high-quality clinical trials supporting your position. There doesn't seem to be.
Not sure what aspect of the article you refer to....There are studies comparing MD care with NP/PAs for routine illness management. My concerns relate to the management of complex presentations or multi-comorbid patients. You have also seen the comments about concerns related to increased referrals because the NP/PAs might not feel comfortable handling certain presentations.
The way things are going, patients will be ‘seeing’ an AI chatbot on their own time
Filling in details, history, symptoms. Chatbot will present summary to clinician. Clinician will make some decisions. Chatbot will then present its own decisions. Clinician may then choose to refine their prior decision.
So, the PA vs MD discussion is old. And doesn’t matter as much in the new world we are in.
I have already used the chatbots to fact check my dentist. And was pleasantly surprised by the evidence based, ‘sales’ free recommendation. As of now, I trust the Chatbot to an equal degree, if not more
The healthcare system is placing excess pressures on our wonderful PAs and NPs to do more on their own. They also aren't getting the "supervision" they were promised when they were first hired.
"They also aren't getting the "supervision" they were promised when they were first hired"
But who, exactly, is going to "supervise" them, and how are the supervisors going to get paid?
I started practice in 1982 after a lot of training. And I found that I was working alongside a lot of "primary care doctors" a number of whom started work in the 1940s and 50s, and still called themselves "GPs". One of the things I noticed right away, having been trained myself more or less on Mount Olympus, was that it was common for GPs to give patients afflicted by modernity vitamin B12 shots. Why did they do this? Because margins for GPs, even in those days, were so thin that the B12 shots helped to keep the door open.
Wait, wait - what does this have to do with PAs, NPs, primary care in the current year, and Dr. Dubois's article? Hold on, I'm getting there.
I work in a field of medicine with an above average number of complicated cases and diagnostic dilemmas. I don't touch anything sharp, but I'm a good thinker. I like the work, and the pay is OK (although compared to being a radiologist, say, not great). It is said that I am good at hard cases.
But if you took away all my easy cases, which are about 80% of my RVU volume, I couldn't pay the rent or put gas in my car.
All these "supervisions" or "availability for backup" pay zero dollars. What incentive is there for anyone to spend $300K to go to medical school (22,000 USMGs/year, they can't all be Deans and Department Chairs) and then go to work where the need for trained physicians has been reduced by 80% by the means of stopping B12 shots for anxiety/depression and/or giving away all the routine work to NPs and PAs, so the newly minted 22,000 doctors a year can do what, exactly?
Presume their liability for the work of PAs and NPs continues unchanged, while their input into those cases vanishes (already happening) and the compensation for "being available" goes to zero. Will they get to bill $50,000/life saved for 2-3 hard cases/month?
So happy that you enjoy it! Please let others know.
You captured my concerns completely! Thank you for sharing.
I appreciate the corroboration. thank you!
I appreciate it that you shared your agreement!
Having practiced (in various clinical settings) with ARNP's & PA's over my entire career, and having served as a pharmacology professor (just one full semester) teaching clinical pharmacotherapuetics to ARNP/MS nursing students, l am in complete agreement with this essay.