Doctors and nurse practitioners: We’re failing the reality test

Yul Ejnes practices internal medicine in Cranston, Rhode Island, and is the Immediate Past Chair, Board of Regents, American College of Physicians. Dr. Ejnes just published what looks to me to be a very honest perspective on the controversial subject of medical care by NPP, or “non-physician providers”.

I don’t make my living as a physician, so it’s easy for me to see much-expanded use of NPPs as way to better and less costly medical care. See what you think.

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My practice uses NPPs to increase our patients’ access to care. Our patients can see NPPs for urgent visits, follow up of chronic conditions such as diabetes and hypertension, and preventive services. Our NPPs do not have their own patient panels because we prefer that every patient in the practice have a primary physician. Our preference is based more on logistics than our judgment of the NPPs’ ability to manage a panel of selected patients. However, some of our patients take matters into their own hands and find a way to see the NPP for all of their problems. I don’t view that as a threat but see it as an affirmation that we have a team of providers that patients feel comfortable seeing. Some patients, on the other hand, refuse to see anyone but a physician. That is their choice. When they request an appointment, we make clear who they can see and what their credentials are.

Our NPPs see patients independently. When they have a question, they ask one of the physicians. In a typical day, that might happen once or twice, usually because the patient is complicated or has an unclear presentation. Often, the NPP will recommend that such patients follow up with one of the physicians. That isn’t surprising given the differences in training and expertise. On the other hand, sometimes one physician will ask another for help with an exam finding or a management question. One of my NPPs worked in a dermatology office for many years, and sometimes I will ask her to look at a rash that I can’t figure out. When we are not sure of something, we ask for help, regardless of our title.

Physicians review and cosign every office note from an NPP visit. There are a few reasons for that, including billing requirements, but it also helps us to keep up to speed with what is happening with our patients. That stated, there are very few occasions that I read an NPP’s note and disagree with the care provided, and most of those disagreements are more over style than substance. I suspect that if I reviewed my physician colleagues’ notes I would have similar disagreements from time to time.

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One thought on “Doctors and nurse practitioners: We’re failing the reality test

  1. I’ve worked with both NPs and PAs and they vary. Some are good. Some seem to be in love with their prescriptive authority. Most patients don’t really realize that they are not seeing a physician. On the phone they will refer to the NP/PA as “Dr. X.” The way the system is headed most people will be lucky to be able to see the less expensively-trained NPs. There won’t be enough physicians.

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