KevinMD Blog: Shifting Procedural Work To “Midlevel” Providers
Posted 1 year, 7 months ago by Dave Mittman in Adult Health, Anesthesiology, Cardiothoracic Surgery, Colorectal Surgery, Dermatology, Family Medicine, Gastroenterology, Internal Medicine, Surgery and Women's Health
This doc is well intentioned but still sees us as super technicians
or something akin to that?
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Shifting procedural work to midlevel providers
by JANICE BOUGHTON, MD
It is entirely clear that too few medical graduates go into primary care.
Although the number of family physicians is increasing modestly, there are very few internal medicine residents becoming primary care doctors. This year there will be only about 200 new internal medicine doctors entering the workforce from training programs, which will not even begin to cover the attrition of older and more efficient physicians, and due to improvements in access with the affordable care act, demand will be increasing significantly. The main reason that very few physicians are choosing primary care is that specialty fields are just about as rewarding personally and way more rewarding financially.
Insurance companies in our present, primarily fee for service, payment system, pay generously for operations and procedures, but much less for complex interactions such as counseling patients on their multiple medical problems, medications, and managing their many diseases. A cataract operation is reimbursed at around $1500 or more, and an ophthalmologist can perform one of these in less than an hour. A similar hour of seeing patients will net a physician a small fraction of that amount of money, and will require many more decisions and neuron firings. Many other procedures have similar high reimbursement for very low amounts of work. If a physician specializes in a field that involves many procedures, he or she can make truly absurd amounts of money if there are sufficient numbers of patients who need that procedure.
Because of the shortage of primary care doctors, more and more people are getting their primary care from nurse practitioners and physician’s assistants, who have many fewer years of education than a physician. These providers are paid less than physicians and are more plentiful. Many of them are very competent, but patients often prefer an MD over a PA because the MD has a greater depth of knowledge. A primary care visit is often a combination of counseling about psychological issues, medications and interactions, review of tests, recommendations about prevention and careful examination (at its best). MDs can be very good at this. Midlevel practitioners are often quicker, having been trained to treat urgent problems more than chronic ones.
Training to be a primary care physician requires at least 7 years after completing a bachelors or higher level college degree. The first year is spent learning basic science and physiology, the second involves absorbing huge amounts of information about human beings in health and disease. The third and fourth years bring the student in direct contact with patients, providing supervised clinical care along with classes and individual teaching by practicing physicians and academics. After these 4 years we have an MD degree, and must pass a licensing exam that assures a certain level of competence in all fields of medicine. At this point we can still choose to become surgeons, radiologists, pathologists or go on to academic medicine or research. Those of us who intend to be primary care docs then spend at least 3 years in residency, taking care of patients under the supervision of more experienced physicians, with an increasing level of independence. When we finish these residency years we are broadly competent in taking care of most of what can go wrong with a human, with fresh and extensive knowledge of psychiatry, critical care, well patient care and the vast variety of other illnesses we have been exposed to. After those residency years we have the opportunity to take another year or more of specialty training in fields such as cardiology, oncology, infections disease or rheumatology. Most physicians who specialize limit their practices to specific diseases and no longer do general medicine.
Nurse practitioners and physicians assistants must complete 2-3 years of training after getting their undergraduate degrees and in most states are then certified to practice independently. Although they are often gifted and become increasingly capable with years of practice, they do start out with considerably less training than physicians and the programs that train them are significantly less competitive.
So what would a midlevel practitioner be really excellent at doing? In what kind of a situation would a provider with less extensive experience and education really shine? Procedures. A midlevel such as a nurse practitioner or physicians assistant could learn to do an excellent cataract extraction or colonoscopy. Advanced level nurses already act as surgical assistants and have been providing anesthesia services at a high level for longer than MDs have done. In developing countries with less medical regulations, it is often the janitors or former patients who learn to do operations and act as surgeons when the foreign trained doctors are not available. I have read that some of the most skillful surgeons for vaginal fistulas, a very delicate and specialized condition of women who have had disastrous labors, are lay people.
What else would midlevels really excel at? Already much of diabetes care is delivered by nurse practitioners who limit themselves to issues related to that disease. They do an excellent job, often better than MDs. Specific disease states, as are now managed by subspecialists, would be perfect for nurse practitioners and PAs. In fact, this is already starting to gain momentum.
How would shifting procedural work to midlevel providers affect the health care equation? If less well paid providers did this work market forces would drive down costs, which would make procedure rich specialties less desirable. Health care costs would also go down, and if cognitive specialties such as primary care were even somewhat better reimbursed it would increase the number of talented folks choosing those careers.
A recent article in the New England Journal of Medicine obliquely addressed this question.
In this article authors looked at the success of treatment of hepatitis C by specialists vs primary care doctors after an online course in treating this common and deadly disease. Primary care providers were slightly more successful than the gastroenterology clinic which trained them in curing the disease. This does, of course, involve MD providers in both cases, but gives very strong support for the idea that specialization can be taught effectively and quickly.
A move in this direction will be very unpopular among just those who are most needed to make it work, the MDs who make their livings doing procedures. These folks have years of practical experience and have skills that are not available in books or videos. Excellent surgeons will always be necessary and appreciated. A supremely skilled surgeon is an artist and deserves money and acclaim. Wise subspecialists will always be needed and appreciated in taking care of patients with diseases that are rare or so complicated that primary care physicians are just not enough. But we are now grossly out of balance, with a truly inadequate number of primary care physicians to take care our our growing needs, and appropriate use of midlevels could be a solution to the problem.
Janice Boughton is a physician who blogs at Why is American health care so expensive?
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Discussion
Between my bursts of laughter I am literally crying at the igonorance of this physician. So, she wants PA’s to do catarct surgery? and lay people do vaginal fistula surgery. Physicians will go into “cognitive” specialties, WHAT??? What is a cognitive specialty? WHAT?? PA’s and NP’s can’t think? Huh! LOL and crying at the same time!
Paragraph #3: Midlevel practioners are often quicker...etc. What? I just spent an hour with a DM pt. with multiple other problems, did a thorough physical exam, and found a new problem, not detected by anyone else...... I reviewed tests, labs, adjusted medications, referral for further testing....counseled.
I have to log on to KevinMD and see what the comments are to this post. What planet does Dr. Boughton live on.
Then again....if I could extract 5 cataracts a day at $1500 per procedure and if I even made 50% of the $1500 I could make $18750 in a week, or $975,000 in a year and become part of the 1% club. Yeesh, I’m in the wrong specialty...where do I sign up to learn cataract removal?
I can’t find her post, Dave can you provide the link? Thanks.
KevinMD Blog tends to irritate me - this physician is another example of why I am irritated by the bloggers on the website.
Her comments are akin to what a specialist MD might say to a primary care MD. “While we know that there are many talented primary care MDs out there, none of them can manage condition X,Y,Z as well as a specialist can”. This hierarchical and divisive thinking pervasive throughout the medical community is one of the reasons many of the problems we face exist.
Her comments, while probably well intentioned are fairly condescending. She misses the point completely of what PA and NP providers should be and can be doing.
Maybe PA/NPs need to align themselves with the AAFP? Family medicine tends to feel a lot like the “red headed step child” of medical specialities - maybe we can find some common ground and get some work done. Primary care residencies get less funding, generally get cut and are under staffed, under funded with preference given to specialist programs and departments. The AAFP needs to get together and start their own medical schools with a blended school/residency program and allow PA/NP providers to have advanced standing if they choose to get their MD.
Screw AMA, screw specialists, screw “well intentioned” physicians like this one.
There are so many inaccurate statements in her post that I don’t know where to begin.
The one thing she did get right was in the last paragraph:
“A move in this direction will be very unpopular among just those who are most needed to make it work, the MDs who make their livings doing procedures.”
I would add little to the above posts. The first sign of trouble was her comment that Physician Assistants can practice independently. Where does she gather information. I would hate to think that her comments are accepted as fact by those who may naive about PA’s. I hope she reads these responses and rethinks what she has set forth as truth. C’mon Doc, you CAN do better.
so the fact that i just had to “educate my SP” about the dangers of Seravent as a stand alone agent in asthma management (5+ years of having a block box warning) or what is the correct Abx for sinusitus or UTI’s (still using low dose Amox for both) means that I am “faster” and he is smarter?
What the heck - this physician is oblivious to the real world - doc’s don’t stay up to date any more then anyone else - they can be lazy and not interested in learning and in effect be very unskilled providers.
Time and time again I take the time to read through a chart and find new things that PCP never foud - I am not faster, I am a little bit slower but still seeing 22-25 patients per day, and generating 300,000 in receipts a years - It comes down not to the title after your name but instead the desire to continue to learn and help. The large “factories of medicine” that are run by doctors are going to be in for a rude awakening when pay for performance is fully implemented and they realize they are not providing the level of care to the patients that they think they are.....
As for specialist making the big bucks - it is just to excessive - why should a Radiology 1-2 yrs out of residency be getting 300K on a partnership track for a 40 hour work week and 12 weeks of vaction when a IM doc working 48 weeks a year (45-50 hours per week + call) be at 160-180K? Makes no sense
This is amusing.
“Primary care providers were slightly more successful than the gastroenterology clinic which trained them in curing the disease. This does, of course, involve MD providers in both cases, but gives very strong support for the idea that specialization can be taught effectively and quickly. “
Actually, this study on the management of hepatitis compared care delivered by specialized NPs and PAs to that delivered by primary care MDs. The “midlevel” care resulted in significantly higher level outcomes. There are already well-documented similar findings describing improved clinical outcomes in the management of HIV/AIDS, heart failure, diabetes, asthma/COPD, and other chronic disease states by APNs when directly compared to care provided by MDs. This evidence then disproves her opinion that “Midlevel practitioners are often quicker, having been trained to treat urgent problems more than chronic ones.”
The author states with some confidence: “A primary care visit is often a combination of counseling about psychological issues, medications and interactions, review of tests, recommendations about prevention and careful examination (at its best). MDs can be very good at this.”
I agree - it may be that MDs CAN BE very good at this. But regrettably, there is an abundance of evidence over the past decade documenting the inability of most primary care MDs to: (a) detect, evaluate, and/or accurately diagnose common mood disorders like dysthymia and even clearly-evident major depressive disorders, and (b) adequately and effectively treat these mental health issues when treatment is indicated.
Amusing. Last week I interviewed with an internist - a nice guy who is looking for an PA/NP as a partner in his primary care practice. Reflecting on his 30+ years of standard medical training and clinical experience, he stated: “You know, Bill, just last night I was whining to my wife that I can’t believe that I spent all those years in medical school and training just to be doing THIS! When I think about the cost of all that education just to end up doing primary care, I think: WHAT A WASTE!”
And while he might need a couple of sessions of supportive mid-life career counseling, his (painfully) honest reflections and assessment of the skills and training required to provide safe, high-quality, person-centered primary health care seems far more reality-based, and far less defensively grandiose, than the litany of years presented by Janice Boughton, MD.
Just my thoughts.
Bill
REALLY!
Wow! How sad to see that this MD describes PAs as “Physician’s Assistants” rather than Physician Assistants. I did not realize I was “owned” by a physician. I will be sure to ask my supervising physician when I go up for sale to not sell me to this doctor.
I also was glad I was able to use my cognitive skills to pick up on this very basic issue with grammar. Phew, being I am merely a PA that my tap me out for thinking for the year. 
Silly me. Being a PA I had some trouble with my last sentence. I really must be tapped out for thinking.
Was this written by Nancy Snyderman? She has about as much insight to PA’s and NP’s as this joker does. Sadly, it could have also been written by one of my former attendings-someone so condescending I am grateful on a daily basis not to be working with him any longer.
Dude.
It becomes a foolish exercise to debate with the unknowledgeable physicians about utilization and SOP. We don’t have much less education than a physicians, look at the summers PAs utilize and it quickly dispels that theory. Years ago we discovered a PA with 6 or 7 years of experience in a specialty area is equivalent to a graduate resident in the same field. As far as permitting us to do a list of technical procedures, it feels nice to the ego but as a forty year veteran of surgery as a first assistant in every specialty, an assistant at surgery is not the same as being the surgeon. I’d gladly disuccc this with any room full of surgeons or residents. I know how we function, our skills, our expertise but guess what? We are not trying to be mini-surgeons but rather the best advanced practice clinicians in the world that have the ability to work in all areas and stretch into other areas but have the integrity and common sense to know our limitations. A general surgeon does not do crainiotomies and neither does a FA.
Bob
I agree with Dr. Boughton. Something as routine as cataract removal should not require a 14 year medical degree and should not command $1500/hr in reimbursement. It makes more sense to train an NP or PA to perform such procedures, which would lower costs and allow health care dollars to be shifted to primary care (health promotion, disease prevention and management).
there are models overseas that have pa’s and np’s doing no scalpel vasectomies and other procedures. some countries(kenya and malawi that I know of) license pa’s through reciprocity as independent “clinical officers” who do significant procedures like c-sections but I see a big fight with the docs to try to get it done here. some hmo’s(notably kaiser) use pa’s to do routine colonoscopies and there is a program at duke to teach pa’s to do routine diagnostic(not interventional) cardiac caths but these are all small programs and have been in existence for 10+ yrs without any indication that they will expand outside of these centers.
Cataract removal is probably routine for the ophthalmologist who does it day in and day out, and gets bored with it. Why would an NP or PA who “gets trained” to remove cataracts not be paid at the same level as the ophthalmologist? I would not be willing to get paid less to perform a procedure, and have the liability on my hands if I accidentally blinded a patient. (Speaking from ignorance, here as I don’t know what the risks are of blinding a pt. in cataract removal surgery).......
I am not a monkey to be trained! If the issue is the reimbursement rate for cataract removal, just lower the rate and let ophthalmologist continue to do what they do.
in my mind the reason to have a pa/np do any procedure normally done by a physician specialist would be to improve access not to lower cost. before adding pa’s to the gi service at kaiser who do nothing but colonoscopies all day long the wait for a routine scope was something like 8-12 weeks. now it’s 7-10 days. they are improving access, detecting disease earlier, saving lives, and requiring less invasive procedures to tx cancer, etc therefore saving money.
We’ve discussed clinical officers on other posts, and I really like the model. I know a PA in a GI specialty who does all of the liver biopsies and teaches the GI residents to do them.
Ultimately, we are discussing changes to our current medical education/reimbursement/insurance systems, etc. I just believe if I had skills to do certain surgical procedures, I deserve to be paid for it at the going rate.
I think part of the concept of having pa’s/np’s do these is that you would make a good salary to do these procedures and not work on production while a specialist would make 500k for doing them as part of their practice. doing 1 procedure (say colonoscopy) doesn’t make you a gi doc(obviously) as you can’t do ercp, etc so I think it is appropriate for you to make a good salary but not a physician level salary for doing 10% of their scope of practice. the gi pa’s I know who do nothing but colonoscopies are salaried at around 160k/yr with a full benefits package. not too shabby. but they earn their money....
To Eric: you have a good point about learning a specific procedure that may be only 10% of a specialists practice, and then being paid a good salary. I wasn’t thinking about that aspect.
paha: to answer your question as to where this post is on KevinMD.com the post is from June 21st, almost 6 months ago. Comments on it are closed. There was one very good posting in the comments area to this blog post from Carrie, who is almost done with her NP degree. She defended the PAs/NPs and what we do very nicely.
Dave: why did you post this blog entry from June, 2011? Isn’t it rather late to post it at this time?
Maybe due to the postings on KevinMD about MD negative feelings/leanings re: PAs/NPs is why Kevin Pho, MD asked me in August to be a regular contributor to his blog, I’ve posted 8 so far and had very positive responses to my postings.
I’ve also submitted an essay to NEJM for their ‘perspectives’ area and I’ll see whether they decide to publish it or not.
And just for the record, I agree Dr. Boughton is totally off the mark re: PAs/NPs, she knows not what she speaks of.
To respond to the cataract comment, I have seen an Ophthalmologist do a cataract that end ed up being an e nucleation. Folks, there is no such thing as easy surgery. The landscape can change and with it, the procedure. Tonsillectomies are the most underrated operations in the world when you consider the anatomy. If people can’t buy into this idea than maybe they should become physicians.
bob
Responding to why I posted I saw it on an email from Kevin MD i am sure.
In any case, it seems to have make us all think a bit more.
Dave
Responding to why I posted I saw it on an email from Kevin MD i am sure.
In any case, it seems to have make us all think a bit more.
Dave
Janice Boughton, MD. - I can hardly believe what I have read! I am a PA who probably falls in the lower third of my profession in regards to education, experience, and knowledge. However, for the sake of discussion, please consider this:
I entered medicine as a military surgical tech and corpsman with service in S. Viet Nam. (That by the way was not a “police action” but a REAL war!) Those of us that served there saw more trauma in the field than 90% of the practicing traumatologists see in a lifetime, and I was only there seven months. We saw tropical diseases that most practicing physicians have only read about and will most likely never see first hand. That was in 1970. I continued as a surgical tech and as a Certified Surgical First Assistant until I attended the UW MEDEX NW program in 1997. The least experienced class mate had 8 years as an ICU nurse. Less Training?!! Maybe in the classroom, but what prospective PAs and NPs learn in the real world is far more valuable that what the classroom often offers. I sat next to other med students that were on the path to becoming MDs. We studied the same courses and learned the same basic skills. I had to remember that the excitement of these student MDs over learning CPR was due to THEIR inexperience and the age difference.
Like many of my colleagues, I have had the privilege to act as a preceptor to not only PA/NP students, but also medstudents training to be MDs/DOs. Interesting that we know enough to share knowledge with those that are so much better than us! I have served, and will serve, in a remote community in Alaska where MDs fear to tread, by myself, seeing patients that have a varied health profile with issues ranging from runny noses to Heart Failure! I treat and manage patients with complications that some of the MDs, (Primary Care trained), that I currently work with are afraid to see due to their lack of experience! Amazingly these patients have a life with their conditions well maintained. By the way, I have never had a patient to want to see my academic record before being treated.
I am not saying that I am a poster child for the midlevel professions, far from it! There are many that I am proud to stand with, however, that have better skills and a deeper knowledge of medicine than I do. But like them, I would dare say that I don’t care what you call me - PA, NP, MD, DO, etc, just as long as you call me a medical provider! What I read in your blog is an emphasis on joining the “MD/DO club” with a membership fee of a quarter of a million dollars plus! Money seems to be the emphasis of becoming a physician. If that is true than I am truly saddened! I have stayed in medicine for over 40 years to provide care for those that need it, not worry over my stock portfolio.
Please forgive if I come across angry, for I am not! I am just disappointed that you obviously didn’t do your homework before you published your article. Sadly, you are not alone with this view, and the real loser in all this is the patient.
well stated, cjbrown.
Cjbrown would love to train with you. I can learn a great deal
Thanks for you, we exist.