QUOTE OF THE DAY:
“There are absolutely no credible scientific studies that support the safety and efficacy of non-physicians practicing without physician supervision. None.”
This quote is from a new book by Niran Al-Agba, MD and Rebekah Bernard, MD. It is called “Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare”
By Paul Goldfinger, MD, FACC
I was a young doctor in the 1970’s when “physician extenders” (nurse practitioners and physician assistants) appeared on the scene. It was a great idea, but I was certain that it could only succeed if these healthcare professionals would work under the supervision of physicians.
Over the years, these “mid-levels” began to push for the right to open their own practices without supervision by physicians.
They have been growing in numbers and they have gotten permission in an increasing number of states to cast aside physician oversight.
These battles have been won due to politics and not medical wisdom or (see above) scientific proof.
Running parallel to these new mid-level rights to practice alone there is a new revolution which will change the practice of medicine forever.
Coming to a town near you, big corporations such as CVS, Walgreens and Walmart will be opening in-store clinics which will be staffed by nurse practitioners or physician assistants who will be on their own without physician oversight.
They will act like primary care doctors and will mostly see simple everyday disorders such as sore throats, rashes, and musculoskeletal complaints. And they will do well with such complaints, but what happens if a difficult diagnostic problem shows up? They may miss the problem and leave the patient with the risk of dangerous delayed or absent care.
A related phenomenon is the explosive growth of urgicenters which are usually staffed by doctors, but now, more often, are staffed by PA’s and NP’s.
None of these facilities will accept the responsibility of following someone for chronic conditions as doctors’ offices do. One shot diagnosis and treatment is a recipe for trouble.
And in some states mid-levels can open their own offices to diagnose, treat, and prescribe. These “doctors” are sometimes allowed to do and interpret xrays, ecg’s and other critical procedures such as ultrasounds. The PA’s want to jettison the “assistant” name in their title.
I took a relative to a local ER for a painful knee. A young man with a white coat and no name tag came into the room, and I watched him carefully. He did a terrible job of taking a history, ignoring her medications and failing to ask necessary questions.
He barely conducted a physical exam and he quickly ordered an xray. I asked him who he was, and he admitted to be an NP. I asked if a doctor would see her, and he said that he “can do what a doctor does!” His approach was amateurish and he was about to miss a serious and unusual diagnosis and waste time with an unnecessary test until I intervened. An ER doctor came in and corrected the situation.
These mid-levels tend to be delusional over what they are capable of. Their training cannot compare to the years and hours spent becoming a physician, where the depth of inquiry into a situation can only be achieved though years of experience (medical school and residency.)
In some states, mid-levels can get licensed without ever examining a patient—all teaching being done on-line.
Yes they can treat a cold and order a blood test on their own, and they can even order a prescription drug. But they are more likely to make a mistake and threaten a patient’s life than with a physician in charge.
Lately even doctors offices are having mid-levels take their place in certain situations. I have seen that in action including failure to take a blood pressure properly or obtain an appropriately in-depth history.
You will hear more about these issues very soon. We all need to be aware. And these new and unsavory ways to practice medicine will force some primary care doctors out of business.
As a physician, I am horrified. We will soon need more malpractice lawyers.
It used to be said that “doctors bury their mistakes” but there is a great deal of oversight of doctors especially in hospitals. I have long complained about lack of oversight in doctors’ offices, but if I needed an office visit, I will take an appt. with an MD any day over one with a PA or NP.
But turning healthcare over to unsupervised mid-levels will be dangerous to all. Try to obtain your care from physicians. For example if you want an urgicare visit, call ahead and make sure that your care will be supervised by and provided by physicians.
The two physicians who wrote this book open with this:
Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare “exposes a vast conspiracy of political maneuvering and corporate greed that has led to the replacement of qualified medical professionals by lesser trained practitioners. As corporations seek to save money and government agencies aim to increase constituent access, minimum qualifications for the guardians of our nation’s healthcare continue to decline—with deadly consequences. This is a story that has not yet been told, and one that has dangerous repercussions for all Americans.”
So, here’s a truth for those mid-levels in their white coats who want to provide unsupervised care: You can’t be a beacon if your light don’t shine!
THE BLIND BOYS OF ALABAMA: (From the Imus Ranch Record II)
Anyone who is not willing to make the sacrifices required to become a physician is not deserving and should seek out another occupation.
If you want to see the data, the book mentioned in this post is well researched.
You say that you prefer to see mid-level non-physician providers, but you are taking a chance with your life.
But for those of our readers who will be seeing such pseudo-doctors, at least make sure that they are directly supervised by real physicians who are “hands-on.”
And note that just because an NP or PA is employed in a physician’s office doesn’t necessarily mean that a physician will take part in your care.
The new “efficient” procedures in doctors’ offices these days. such as 10 minute visits, are mandated by corporate bottom-line oriented owner-experts resulting in worrisome shortcuts which can be harmful with or without physician oversight. And that is true in ER’s and Urgicare offices, so beware.
And finally, the number of physician practices owned by doctors has dropped from about 70% to 30%, and when doctors become employees, the doctor-patient relationship may be compromised, and quality may decline.
Unfortunately it is difficult for patients to sort it all out.
I would like to have further explanation of the “political maneuvering and corporate greed”. Perhaps this is true, but it is also part of a broader problem of the medical system.
From what I have seen, the problem has also resulted from the difficulties of actually becoming a physician in this country. It is not for the poor or even the middle class, without tremendous sacrifices. They are all very bright and capable and are instead happily becoming NP’s and PA’s.
I would take a qualified, experienced, dedicated NP or PA over what is presently available from qualified doctors.
And while I have always had what would be considered excellent health insurance and pretty good doctors in my years, not all of them were very good.
I have tended to see NP’s because there is easier access (I don’t have to wait 4 months for an appointment!)
Two years ago, I had a medical emergency and was in the local hospital for 5 days. Some changes from an early stay included large IDs for staff with “nurse,” “physician,” etc. in 3/4″ type at the bottom on a color-coded background. One immediately knew their position. At the medical center where I worked prior to retirement, a person with a doctorate other than an MD could not identify themselves as “doctor” to patients without immediately explaining the nature of their degree.