The PA NP Debate is Complicated

Care is now boilerplate with pre-printed protocols.  Thought is removed.  Google search the movie “Idiocracy” and “Hospital scene” for a series of videos that perfectly encapsulate the current world of protocol-driven healthcare.

At our small private practice, we do not employ physician extenders.  This is based on choice.  We fear the liability of supervising Nurse Practitioners and Physician Assistants (NP’s and PAs).  In prior decades, as employed physicians, we were tasked with adding our signatures to the notes of physician extenders.  We realized several things: Good extenders, who knew their limits, barely needed supervision.  They were an asset to the practice.  Bad extenders, however, delivered bad care and intensive supervision did not change this.  The bad seemed to exceed the good.

Over the decades, we watched the growth of PAs and NPs with alarm.  It is now possible for a hospitalized patient to never see a physician except as a very brief formality, often little more than a wave from the doorway, so the physician can sign the note and attest to seeing and examining the patient.

If you go to a Gastroenterologist, you will see a PA or NP, except while you are asleep and the physician does the endoscopies.  This made sense from a business side.  The practice physicians believe little is gained from the initial introductory visit.  The money is made in the actual procedure. Same with Cardiology.  Listening to people ramble on about chest pain and heart failure is not good for revenue.  Lots of cardiac caths, echos, and other procedures are where you get the money. Orthopedics learned this long ago.  Only a small number of visits result in surgery.  Let the PAs screen these and decide who needs an expensive operation.

Neurosurgery?  Rarely do you ever see the doctor in our town.

Night call?  Give it to the extenders so the doctors can sleep.

Long ago, many primary care doctors learned they could make more money by hiring extenders and skimming off some of their revenue. The idea was to send the easy patients to the extenders and leave the hard patients to the actual doctors.  Unfortunately, this proved difficult to execute and now it is simply “luck of the draw.”

About fifteen years ago, I became acquainted with the concept of care protocols, etched in stone, via the EMR.  Chest pain has a protocol.  Shortness of breath has a protocol.  Pneumonia has a protocol.  Abdomen pain has a protocol.  You get the picture.

It seemed to make sense at the time.  In prior years, care was dictated by a protocol we had in our heads.  That made care inconsistent.  It also allowed for errors.  If we standardized care, we could reduce errors.

That was the theory, at least. When so many of us left the hospital to the Hospitalists, we delegated control of hospital care to someone who had never seen the patient before.  Protocols seemed to make even more sense.

Then, hospitals learned they could make more money using extenders and eliminating the doctors.  EMR “Protocols” made it easy:  You just click the right heading and the entire care protocol is laid out for you.  It seems so much safer… right?


We’ve dumbed down hospital care so much, protocols have become the safeguard.  Unfortunately, it all depends on someone at the front pushing the right button for the correct Protocol.  After that, all thought is removed.

As Primary Care doctors, we can complain but do little else.  Unfortunately, we walked away from the hospital and gave away our authority.

The bad part was the “dumbing down” of medical care.  Coinciding with this, the patient’s doctor was being replaced by an overworked hospitalist physician.  Soon, the hospitalist physician was replaced by a hospitalist physician extender. The specialists followed the trend.  Now, you get admitted from the ER by a PA.  A Hospitalist NP does your admission H&P.  The GI consult comes from a PA. The Cardiology evaluation is done by an NP.  Neurology is also now an NP.  The danger becomes one of “What if you picked the wrong protocol?”  Limited training makes it harder to suddenly change direction.  Less experience makes it harder to critically assess your plan.  We often pick a plan, only to realize we have missed something or made a mistake or false assumption.  If we recognize it and amend the plan, the damage is avoided.  The problem is, those with less experience (doctors included) have trouble seeing the danger of their errors.

The fallback for the busy Hospitalist was the safety net of the specialists.  Yet, the specialists are now physician extenders with far less training than a generalist physician.

What about obscure diagnostic challenges?  Those with limited training will never figure it out.

So who did this?  Was it the sleazy training programs?  Is it money-hungry insurance?  Is it hospitals?

Yes to all of those.  But the other problem is the doctors.  We welcomed this disaster!  Doctor-run practices ushered in physician extenders such that they now often outnumber the true physicians in such practices.

There is also the dirty little secret we doctors hate to admit. Many patients prefer the greater discussion and patient education they receive with many PAs and NPs.  They feel less rushed than the often brief doctor visits and minimal exams.  Again, doctors did this to themselves.

The problem is care often goes “off the rails” and patients want someone with a bit of knowledge to get things back on track.  As referring doctors, we are frustrated when the “specialist” is someone with only a small fraction of our own training. I’ve seen a lot of ranting on this site about physician extenders. But doctors accelerated this and they have a strong financial incentive to maintain the model.  None of these groups are interested in stopping this fundamental change in healthcare. I don’t like what is happening, but doctors need to own what they helped to create.

Orthopedic doctors just want to operate.  Cardiologists just want to do caths or procedures.  Gastroenterologists just want to do scopes.  Cognitive skills simply don’t pay enough.

Now, we are seeing the results! Complicated patients with inflammatory bowel disease?  Good luck!  No one wants you.  Rheumatoid patients? Crazy Neurologic symptoms? Same.  Go away.  You’re too complicated.  Maybe someone in one of those big centers will see you….

440155cookie-checkThe PA NP Debate is Complicated