Baylor University Takes Down Misleading NP Page
Dr. Duprey explained how their conclusions were flawed here. And now the page is gone. It was supposed to here but all we get now is:
Why do you think they took it down? We hope because they also realized it was flawed and someone complained (like us).
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When I was in practice I dealt with this nonsense by not using that specialist again.
A good use of specialist extenders would be fulfilling the billing requirements of a new visit, but there’s no reason the specialist can’t then do what they were referred for. What a joke. And what an insult. Maybe if referred by a noctor that visit without the doctor could be considered medically necessary, otherwise it’s not and it’s billing fraud.
Congratulations on at least one small Victory! I have copied several a couple of your essays on NP’s-PA’s into my electronic medical record and send them to specialists’ offices as my reply to their requests for referral authorizations for my patients to see their Physician Extenders: DENIED! My patients get the Doctor or I’ll handle it myself. You might be interested in reading the following commentary by Joseph Friedman, MD on the topic published in the Rhode Island Medical Journal last September, 2019 which I also send to offending specialists. Copied and pasted below for your ease of reading. Dr Friedman is the local movement disorder specialist in Neurology who is well known in the whole country and world for his expertise in Neurology and Parkinson’s Disease.
“Rhode Island Medical Journal, September 2019
http://www.rimed.org/rimedicaljournal-2019-09.asp
Physician overextenders
JOSEPH H. FRIEDMAN, MD
I recently learned from
a scheduling secretary
that my new patients frequently
ask, Am I going
to see Dr. Friedman?
She told me that patients
often find themselves
referred to specialists by
their primary care physician
(PCP), only to see
physician extenders and
not the physician. Many
patients also tell me they have never even
seen their Primary Care Physician, only the physician
assistant (PA) or the registered nurse
practitioner (RNP).
I am a strong believer in physician
extenders, the cadre of RNPs and PAs
who have been increasing the amount
and quality of care in the U.S. I have
had the pleasure to work with some on
a day-to-day basis and can attest to the
benefits they provide. However, there
is a limit to their capabilities and their
increasing use as subspecialists without
oversight has unnerved me.
A recent patient, transferring care
from another state, thanked me after her
examination. Thats the most complete
exam Ive had since I saw the PA in my
previous neurologists office. The doctor
never examined me. What should one
think of a neurologist who doesnt examine
a patient? The neurological exam is
the heart of the discipline.
I have referred patients with gait abnormalities
to orthopedists to determine if
a particular joint problem
or set of joint problems
might explain a peculiar
gait. I consider myself a
clinical gait specialist. I
have given medical grand
rounds at other universities
on assessing gait disorders.
I give a talk every
year to geriatric internal
medicine fellows, and
occasional gait lectures
to other groups. Gait disorders may be
complex and I am often stumped, and
therefore request opinions of others,
who I believe will have more knowledge
or experience in some aspect of the
problem, since walking problems are
often due to more than one contributing
problem, like a brain disease plus bursitis.
Most physicians, including neurologists
and orthopedists, are uneasy
assessing gait disorders. So, imagine
my surprise to see my referral addressed
by a PA. Ive seen patients referred by
a neurologist to a neurosurgeon, who
saw only the neurosurgeons PA who
then sent the patients to me. The first
neurologist would have sent the patient
to me directly if he wanted my opinion.
He wanted the neurosurgeons, which
he never got.
I sent a patient to a spine specialist
because I wanted to be sure that her
scoliosis was due only to Parkinsons
disease and not to an intrinsic spine
problem. The patient told me that the
PA told her that she had degenerative
joint disease and scoliosis due to
Parkinsons disease, which is what I
had thought, but I wasnt sure if this
assessment was correct, which is why I
sent to patient to the orthopedist in the
first place, and without an orthopedists
opinion, still dont know if it is correct.
I wouldnt have thought twice about it
if I knew this was the spine specialists
opinion. I sent a letter to the spine orthopedist
to ask if I needed in the future to
specify that he needed to see the patient!
Not only that, but the same day I asked
a patient why he limped after his hip
replacement. He didnt know. Didnt
the orthopedist who operated on you say
something? I never saw the orthopedist.
Never? He came to the emergency
department before the operation,
but I never saw him again. In seven
months! Luckily, this has not been the
experience of most of my patients who
have had hip or knee replacements, but
the fact that this was deemed acceptable
behavior was a surprise to me.
I understand the need for physician
extenders and have worked with them.
When I worked with RNPs, I used them
only to see patients who I had first evaluated,
and I considered relatively stable.
If the patient was found to have not been
stable, the RNP would get me so that
I could review the case, at that time. I
cant imagine why a fellow physician
would refer a patient for a non-physician
evaluation. Ive had patients tell me
they were referred by a rheumatologist
to an orthopedist and saw the health
extender. Imagine, a doctor, possibly a
specialist in a related discipline, sends a
patient to another specialist in a closely
related discipline and sees someone,
perhaps a PA with 2 years of training,
for an opinion. Aside from betraying a
profound lack of respect for the referring
physician, it displays one of the many
weaknesses in our health care system.
We train too few doctors, burden them
with time intensive requirements that
are not reimbursed and then use less
well-trained health professionals to help
compensate. This allows more patients
to be seen in a timely manner, but for
consultations, it may actually delay
being seen, since the patient may have
to wait again, several weeks, or months,
to see the doctor.
It upsets me to think that my surgical
colleagues think more of their PAs than
they do of their medical colleagues or
me. I am generally not keen to refer my
patients to newly graduated surgeons,
since they lack much experience. Why
would a PA or an RNP be an appropriate
substitute?
I now have my patients check to make
sure they will see the doctor, and call
me for an alternative referral if not. I
may lose doctors Ive dealt with over the
years but why tolerate a drop in quality?
I am further asking you, the reader,
to do the same. Physician extenders
have a major role to play in health care.
They can provide special services, like
follow-ups after an operation, learning
to identify danger signs so that they can
call the doctor on call, to change dressings,
reassure the patient and further
supplement the routine care that used
to be provided by registered nurses. They
can likely sew up some lacerations,
apply casts, assist in the interventional
radiology suite, insert canulae and catheters,
and follow patients in the office
who have well-defined problems. If they
can substitute for the doctor completely,
why not get rid of the doctor and save a
lot of money?
Author
Joseph H. Friedman, MD, is Editor-in-chief
Emeritus of the Rhode Island Medical Journal,
Professor and the Chief of the Division
of Movement Disorders, Department
of Neurology at the Alpert Medical School
of Brown University, chief of Butler Hospitals
Movement Disorders Program and first
recipient of the Stanley Aronson Chair in
Neurodegenerative Disorders.