Are Physician Extenders Up to the Task?

May 29, 2012
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The Affordable Care Act is predicted to result in a tremendous, rapid increase in the demand for primary care services.  Who will meet this demand?  The job may fall to physician extenders.  There’s considerable controversy as to whether they are up to the task.

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The Affordable Care Act is predicted to result in a tremendous, rapid increase in the demand for primary care services.  Who will meet this demand?  The job may fall to physician extenders.  There’s considerable controversy as to whether they are up to the task.

Writing here on the HealthWorks Collected (http://healthworkscollective.com/rdowney14/33378/nurse-practitioners-can-take-some-pressure-doctor-shortage), Roger Downey writes about his and his family’s wonderful experiences being cared for by a nurse practitioner.  He also notes that, “Doctors are often hard to convince that NPs can and should play a more significant role in primary care.”

Some doctors feel very strongly that patients with illnesses should see a doctor, not a physician extender.   Are these doctors only concerned about their own turf and pocketbooks?  No, doctors who feel strongly that patients should see a doctor do so not because they are concerned about their livelihoods (though it is easy to think that’s the reason they feel this way) but because they are concerned about patient welfare.  These doctors don’t think patients should have to see a lesser-quality health care provider.

Physician extenders, often under the supervision of a physician, give patients great medical care.  So why do physicians who have never worked with a physician extender think that physician extenders offer lesser quality care?  It may be because doctors who haven’t worked with a physician assistant or nurse practitioner will have seen only their failures, never their successes.

Imagine a town with two doctors, Doctor X who works alone and Doctor Y who works with a nurse practitioner.  Probably 98% of Doctor Y’s patients and Doctor Y’s nurse practitioner’s patients are happy and well cared for.  Perhaps 1 or 2% aren’t happy or have a bad outcome.  Of the hundreds or thousands of patients that Doctor Y and the nurse practitioner care for, how many go to see Doctor X?  Not any of the 98% who are happy and have good treatment outcomes.  Only the tiny fraction who were unhappy or who didn’t have a good result would.  Based on Doctor X’s experience, though, it might seem like all of the nurse practitioner’s patients where unhappy or had bad outcomes.

I like to think of the world in terms of compartments.  When people are divided into different groups, different compartments, misunderstanding and conflict easily develop.  Often there are things about people in other compartments about which we just don’t know, perhaps how they are trained or how they think in general.  As illustrated above, we often see a biased sample of things from another compartment.  This happens to me, a dermatologist, all the time.  Out of the thousands of patients I’ve seen with rashes referred to me by a family physician, I think I can count on one hand the number of times the family physician got the diagnosis right, prescribed the right medicine and cleared the patient’s rash.  Some dermatologists might think family doctors don’t know what they are doing with regard to the treatment of skin disease.  I’ve come to realize that every time a family physician gets the diagnosis right, prescribes the right medicine and clears the patient’s rash, they don’t send the patient to a dermatologist.  I try not to draw judgments about family doctors based on the patients of theirs that I have seen, just as I hope surgeons would be circumspect about drawing judgments about dermatologists based on their experiences of the patients on whom we dermatologists have done surgery.

Our compartmentalized medical system makes it easy to misjudge other people.  Needless conflicts develop between specialties because it is so easy to see that we care, but so hard sometimes to see that other people care, too.  Physicians, drug companies, insurers and other health care stakeholders all tend to blame the other groups for the limitations of our health care system, yet people in all these groups and organizations probably sleep well at night knowing that they are trying to help ill people get well.

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Feldman is author of Compartments: How the Brightest, Best Trained, and Most Caring People Can Make Judgments That are Completely and Utterly Wrong (www.compartmentsbook.com and available at Amazon.com and BN.com).

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