Physician associates, physician assistants, and nurse practitioners are playing an ever-increasing role in healthcare. How should we think about the change?
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.
As another physician-scientist, I worry that we are putting ourselves at risk. Many medical schools, including the one where I work, are shortening the years to graduate. This contrasts with many other parts of the world where 5 or 6 years is common. If we require only 3 years, we risk becoming more and more like APPs. I agree completely with this post, that APPs are very valuable and do some things better than physicians. If we want to remain better at complex diagnosis and sophisticated treatment, however, shortening training is not the right way to go.
Do you know what caused this lack of physician access? The EMR. Yes, that’s right the computer. Prior to a universal computer usage and documentation and compliance we could see for EC patients an hour – blood pressure, follow up on Gerd, etc.. after the above burdens and spending all our time typing or dictating we couldn’t see two patients an hour. Then we could pay our staff and our insurance and our rent, but we couldn’t pay ourselves! So we had to all go work for a hospital. They had the same problem only they added more documentation and compliance, etc. Professor Robert Gordon at Northwestern University said, “the Computer has not added anything to productivity of American business since 1995.” he’s a professor of economics. Productivity medicine has dropped essentially 50%. That’s why you can’t see the doctor.
Nurse practitioners do 18 months of a 20 hour week in training after college physicians do a minimum seven years of an 80 hour week. The main reason for their existence is so that the business owners can pay them less, give their clients less experienced “practitioner,” and make a buck.
As a primary care PA, I actually totally agree with this. I entered primary care at a time when PAs were still used to extend/support the docs, not as a replacement to the doctors. I am bothered that now PAs and NPs are expected to function as independent primary care clinicians with no ability to “screen” for appropriate patients who join their panel. I have pushed to not carry my own panel and continue my role as support for my supervising physician and it continues to work so well. There are things I do better and things he does better and our patients have learned that…. And there are times they ask for him, and times they ask for me! By truly functioning as a team we can provide the best care the patients need.
As a retired NP, I would like to share my observations from many years of practice. The original idea for using physician extenders was that if easy and routine conditions were handled by these providers, it would free up doctors to see the more serious and complicated cases. That is how I worked. My patients were high maintenance, but not complicated (pediatric patients with type 1 diabetes and very nervous parents). The doctors I worked with were always available and very helpful if something puzzled me. What I observed in general practice, was that physicians already had a working diagnosis before any tests were ordered, and these tests just confirmed the suspicions or satisfied insurance demands, but NPs and PAs did a million dollar work-up on everyone because they lacked the confidence and the knowledge that the doctors had. If physician extenders are used only for the easy and routine things I think that is fine, but diagnosis and care of all but the most routine things calls for the knowledge and experience of a real doctor.
I get more consults for more minor issues from ‘primary PA’s’ than you can imagine. Every borderline thrombocytopenia in a 265 pound patient with hepatic steatosis displaces one patient with breast cancer who needs to wait that much longer. For a problem one could assess by…maybe reading a book. Or thinking.
NPs are somewhere btwn physicians and PAs as they typically have more experience and are single-specialty.
The use of PAs as primary care ‘fillers’ is not a solution. It’s part of the problem.
Remember that, when your PA sends you to see an expensive ‘ologist for a boo-boo on your thumb.
Exactly right. Half my new consults last week was stable hyponatremia (132 for the past 10-15 years) or a ‘CKD consult’ in an octogenarian with a Cr of 1.0
Everyone keeps harping on about the ‘unmet demand’ that APPs need to fill, no one ever comments on the massive demand APPs create. Any time it’s quantified, it far FAR exceeds any demand they relieve.
Exactly. So when we regurgitate the same talking points about APPs ‘helping with demand’, we’re being intentionally deceptive (whether deceiving oneself or someone else)
My days involve managing euglycemic DKAs, reviewing correct central line placements given the placer doesn’t know how to review them, suggesting better pain regimens, managing hyperthyroidism, and then maybe in the sliver of time I have left I could practice my chosen specialty.
The patient you’re working with as a consultant has not been seen by a practitioner who is as (or better) trained than you. So you end up having to redo everything from scratch given you’re the first physician who saw the patient for a while
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.
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.
As another physician-scientist, I worry that we are putting ourselves at risk. Many medical schools, including the one where I work, are shortening the years to graduate. This contrasts with many other parts of the world where 5 or 6 years is common. If we require only 3 years, we risk becoming more and more like APPs. I agree completely with this post, that APPs are very valuable and do some things better than physicians. If we want to remain better at complex diagnosis and sophisticated treatment, however, shortening training is not the right way to go.
Do you know what caused this lack of physician access? The EMR. Yes, that’s right the computer. Prior to a universal computer usage and documentation and compliance we could see for EC patients an hour – blood pressure, follow up on Gerd, etc.. after the above burdens and spending all our time typing or dictating we couldn’t see two patients an hour. Then we could pay our staff and our insurance and our rent, but we couldn’t pay ourselves! So we had to all go work for a hospital. They had the same problem only they added more documentation and compliance, etc. Professor Robert Gordon at Northwestern University said, “the Computer has not added anything to productivity of American business since 1995.” he’s a professor of economics. Productivity medicine has dropped essentially 50%. That’s why you can’t see the doctor.
Nurse practitioners do 18 months of a 20 hour week in training after college physicians do a minimum seven years of an 80 hour week. The main reason for their existence is so that the business owners can pay them less, give their clients less experienced “practitioner,” and make a buck.
As a primary care PA, I actually totally agree with this. I entered primary care at a time when PAs were still used to extend/support the docs, not as a replacement to the doctors. I am bothered that now PAs and NPs are expected to function as independent primary care clinicians with no ability to “screen” for appropriate patients who join their panel. I have pushed to not carry my own panel and continue my role as support for my supervising physician and it continues to work so well. There are things I do better and things he does better and our patients have learned that…. And there are times they ask for him, and times they ask for me! By truly functioning as a team we can provide the best care the patients need.
As a retired NP, I would like to share my observations from many years of practice. The original idea for using physician extenders was that if easy and routine conditions were handled by these providers, it would free up doctors to see the more serious and complicated cases. That is how I worked. My patients were high maintenance, but not complicated (pediatric patients with type 1 diabetes and very nervous parents). The doctors I worked with were always available and very helpful if something puzzled me. What I observed in general practice, was that physicians already had a working diagnosis before any tests were ordered, and these tests just confirmed the suspicions or satisfied insurance demands, but NPs and PAs did a million dollar work-up on everyone because they lacked the confidence and the knowledge that the doctors had. If physician extenders are used only for the easy and routine things I think that is fine, but diagnosis and care of all but the most routine things calls for the knowledge and experience of a real doctor.
I get more consults for more minor issues from ‘primary PA’s’ than you can imagine. Every borderline thrombocytopenia in a 265 pound patient with hepatic steatosis displaces one patient with breast cancer who needs to wait that much longer. For a problem one could assess by…maybe reading a book. Or thinking.
NPs are somewhere btwn physicians and PAs as they typically have more experience and are single-specialty.
The use of PAs as primary care ‘fillers’ is not a solution. It’s part of the problem.
Remember that, when your PA sends you to see an expensive ‘ologist for a boo-boo on your thumb.
Exactly right. Half my new consults last week was stable hyponatremia (132 for the past 10-15 years) or a ‘CKD consult’ in an octogenarian with a Cr of 1.0
Everyone keeps harping on about the ‘unmet demand’ that APPs need to fill, no one ever comments on the massive demand APPs create. Any time it’s quantified, it far FAR exceeds any demand they relieve.
https://radiologybusiness.com/topics/healthcare-management/healthcare-quality/physician-assistants-order-imaging-rates-higher-primary-care-doctors
Another reason why hospital systems love APPs. They know they drive up demand for imaging, labs, and employed specialist visits. APP=>$.
Sent a 95y/o with MGUS yesterday. PA, of course.
Exactly. So when we regurgitate the same talking points about APPs ‘helping with demand’, we’re being intentionally deceptive (whether deceiving oneself or someone else)
My days involve managing euglycemic DKAs, reviewing correct central line placements given the placer doesn’t know how to review them, suggesting better pain regimens, managing hyperthyroidism, and then maybe in the sliver of time I have left I could practice my chosen specialty.
The patient you’re working with as a consultant has not been seen by a practitioner who is as (or better) trained than you. So you end up having to redo everything from scratch given you’re the first physician who saw the patient for a while
Thank you Bobby, I have enjoyed listening to your podcast on the recommendation of the skeptical cardiologist
If they’re performing the same tasks, then risks are the same. So, why is our malpractice cost 500% more ? Or is it ?
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