Is your nurse a doctor? How physician assistants and nurse practitioners are changing primary care

Change is coming.  The world as we, primary care doctors, know it is turning upside down and I don’t think we’re ready.

When I was in college the student health doctor was a doctor.  There were no health clinics in discount stores and your primary care doctor had gone to medical school.  Things have changed.

Physician Assistants and Nurse Practitioners have made a place for themselves in the medical arena and doctors have had to move over to make room.  This new model has plenty of benefits.  It allows physicians to accommodate larger practices and provides medical care, particularly in rural areas, for people who wouldn’t otherwise have any.  In some practices the PA or NP spends more time with patients than the doctor, making them the “primary care doctor” of choice.

Some doctors bash ‘midlevels’ – as PAs and NPs are often called.  I don’t.  I have worked with many great PAs and NPs, and I’ve both taught them and learned from them. Plenty of midlevels are smart and dedicated and some, particularly those with experience, have excellent medical knowledge.  OK, do you get it?  I’m not one of those doctors who stands on my high horse and blindly dismisses what PAs and NPs have to offer.  I see the value.

But still…

Midlevels can augment the offerings of the physician and offer the patient a quicker, richer or more focused experience.  This is a good thing.  But can they really replace the doctor entirely?  Does 2 years of PA school really create the same depth and breadth of knowledge as 4 years of medical school and 3+ years of residency?  More and more people seem to be answering “yes.” 

Doctors were blindsided by the rapid rise of midlevels.  There are rarely student health, STD clinic, or minute clinic positions available to physicians anymore.  PAs and NPs fill those jobs and doctors simply aren’t welcome.  The business men and women in charge seem to believe that the MD simply isn’t worth the extra money.   

As this trend continues, some are wondering where it will end.  Will the primary care of the future be delivered by midlevels?  Will primary care physicians perish like the dinosaurs?  This is not just idle paranoia.  Midlevels are cheaper and our healthcare system is bleeding money.

But I’m concerned.

In primary care, patients arrive without a diagnosis.  Often their problems are minor.  Often, but not always.  It doesn’t take that much experience to treat a cold, but it takes significantly more to evaluate dizzy spells in an older person or recognize a pheochromocytoma.  It is difficult to recognize what you have not seen, and this is why I am worried.  In those 7+ years of training, including countless nights on call, doctors in training see a lot.  They learn to recognize subtle signs of serious illness and they see the results when they are missed. 

PAs and NPs are helpful and valuable.  They are less expensive for a practice to support and patients often love them.  Yes, they are all these things.  But do you know what they aren’t?

They aren’t doctors.
Topics: medical trends