Mid-Level Health Providers

[7ontheline]

I want to get a sense of people's attitudes toward non-physician health providers. These days, there is an increasing role for so called "mid-level" health providers. These may include such professions as nurse practitioners, nurse anesthetists, physician's assistants, and nurse midwifes, or optometrists. (I realize the optometrist comparison is not as exact, but it is close enough for this discussion.)

All these professions require less training than physicians. They are also easier to gain admission to. For instance, physicians are required to have 4 years of medical school after college, and then at least 3 years more of internship/residency. Many specialties require more than 3 years. A physician's assistant has 3 years of school after college. They may or may not spend another year becoming more familiar with a specific area of medicine.

With the current state of health care, the role of these mid-level providers has increased because they are cheaper to hire and possibly more willing to practice in less desireable (rural, or sparsely populated) areas. Optometrists, for example, are also much more numerous than ophthalmologists. Nurse practitioners and physician's assistants are increasingly found in places like urgent care clinics and emergency rooms (handling the less serious medical problems in general). In some cases, these providers are fighting for the right to provide higher levels of care. Optometrists have introduced bills in a number of states asking for more drug prescription rights as well as the right to perform surgery. CRNAs (nurse anesthetists) have been asking for the right to have more independence from supervising physicians.

So what do you all think about this trend? Do you even notice? Many people do not even know the difference between optometrists and ophthalmologists. (Both work with the eye, ophthalmologists are the M.D.s - only M.D.s have full prescribing capabilities and can do surgery). Do you care whether you see a physician vs. someone else? I would also be interested in hearing any stories anyone has about their experiences with these providers. Some people prefer to see these mid-level types because they feel they get more personal attention.

I understand that the average age of this forum is going to make some of this discussion difficult. Most of us are younger and do not have health problems that require frequent medical attention. Also, in the interest of full disclosure, I am an ophthalmologist and certainly have my own opinions about all these professions. However, I will keep them to myself initially because I want to see what people think. If nothing else, maybe we can get into a flame war between M.D.s and slimy, incompetent, smelly non-M.D.s. [img]/images/graemlins/laugh.gif[/img]

[Unoriginalname]

I feel like the trend towards mid-level providers gaining more and more power and autonomy is inevitable and at least partially keeping health care costs from getting even more ridiculous. More mid-level providers means less salary hospitals and physician groups have to pay, which means they can afford to accept lower fee schedule rates from insurance companies and medicare without going busto. When insurance companies can pay lower rates, they can keep premiums lower (although it also means they can write bigger checks for their officers).

I could definitely see how this could potentially hurt quality of care if someone with say 2-3 years of schooling is expected to diagnose and prescribe with the same level of accuracy as someone with 7-10 years of training. (Does anyone know of any studies done to see if there's been any changes in quality of care with the mid-level provider trend?) Although in some situations it's really just not necessary to see a full fledged MD or DO.

I know for me personally there are certain situations where I don't care if I see an NP, PA, or MD, for instance if you know the only reason you have to go to the Doctor is so you can get someone to write you a script or a referral.

But I also think there's always going to be plenty of people that refuse to see anyone else but an MD or DO, especially for something like surgery. There's no way I would get my eye surgically operated on by an optometrist, no matter what kind of certifications he has. I'm going to an ophthalmologist for something that serious.

[hobbes9324]

Sorry to disappoint you, but for the most part I think NP's
and PA's do a pretty good job, with uncomplicated health issues in uncomplicated patients. Also, for the following, anywhere I say "MD", understand that a DO would be fine.

I have seen some GROSSLY mismanaged patients, but I pretty much hold the supervising MD (in Nevada, both NP's and PA's practice under an MD/DO) responsible. If the supervising MD utilizes the capabilities and understands the limitations of the mid-level provider, things seem to go pretty well. If the mid-level provider is being used solely to increase the supervising MD's income, not so well.

I'm a bit jaundiced on midwifes - I had to pronouce a kid who was essentailly killed by one, who couldn't recognize that the baby was dying and delayed bringing mother and future corpse to the ED until it was too late. Several of our nurses have used midwives for birthing and liked it, so this might be a case of me being too results oriented.

Optomitrist's aren't really a good choice for this - they pretty much should do exams and write for glasses/contacts -if they stay in their scope of practice, they should be OK for most things. Having said that, I got a lot better result from an optho MD with my last eye exam/perscription.

I can't comment on N.A.'s - I don't work with them. I wouldn't let one put me under for surgery, but I'd just feel more comfortable having an MD do it....

If you want me to say something rotten about someone, bring up lawyers...I can go on all night....

MM MD

[7ontheline]

Hobbes,

In general I agree with you. NPs and PAs I am generally OK with. The problem often lies in the way they are utilized by the supervising M.D. When properly placed they can be great in taking care of little, everyday stuff. However, some M.D.s use them solely to make more money without doing more work. This inevitably puts the mid-level person in situations where they shouldn't be.

I am also a bit prejudiced against midwives. In many cases they will do fine - however, it's the birth of your damn child. Get your butt to a hospital where they can save your baby if something goes wrong. CRNAs are similar in my mind. Why take a chance?

Optometrists are obviously my main area of concern personally. I agree that they are fine with general exams and glasses/contacts. However, when they try to expand the scope of their practice I feel that there are problems. I have seen extremely mismanaged glaucoma from a number of optometrists (and to be fair, some MD/DOs also). The push to achieve surgical rights through legislation is particularly repugnant to me. Although it is a vocal minority that is pursuing this agenda, it reflects poorly on the profession IMO. It has led to a lot of bad blood between the ODs and the MD/DOs. It's too bad, because I feel that each profession has their place.

If any CRNAs, optoms, NPs, or PAs want to chime in with their side of the story that would be great.

[anduril]

I am an Athletic Trainer, my wife is an RN (maternity). I used to work very closely with a orthopedist and specifically his PA. I can tell you that I am qualified to see the majority of patients in the clinic, nevermind having the just the PA see them. This makes me a little concerned, since an office visit costs $250. Patients just don't know that because they only see that they have to give $15 for a copay.

edit: as a small tangent, I hate our healthcare system more and more every day, and I'm part of it.

[2461Badugi]

I'm just a chronically ill patient, but in my experience it's a lot easier to find a good nurse than a competent doctor. So I'm all in favor of letting the nurses do more.

I'm okay with opthamologist > optometrist though. I seem to have gotten a competent neuroop the first time around, unlike any of my other neurologists.

[skylos]

The healthcare system in this country is so screwed. Just look at obstetrics, there's no scientific reason for women to lie on their backs to give birth. The upright posture is so much better for so many reasons. But hey guess whats more convienient for the doctor?

I don't have a problem with midlevel providers who aren't exactly qualified wanting a bigger share of the pie as doctors have been doing it for a long time already. I know in Florida at least you don't have to be board certified in Plastic Surgery to actaully do plastic surgery. Lots of family practice docs/ophthalmoligists buying a couple lasers and taking a couple classes and then hanging a shingle offereing "plastic surgery". It's buyer beware just like in anything else.

[The Bride]

[ QUOTE ]
The healthcare system in this country is so screwed. Just look at obstetrics, there's no scientific reason for women to lie on their backs to give birth. The upright posture is so much better for so many reasons. But hey guess whats more convienient for the doctor?

[/ QUOTE ]

Umm, its kinda easier to lie down when you've had an epidural.

[Roan]

[ QUOTE ]
[ QUOTE ]
The healthcare system in this country is so screwed. Just look at obstetrics, there's no scientific reason for women to lie on their backs to give birth. The upright posture is so much better for so many reasons. But hey guess whats more convienient for the doctor?

[/ QUOTE ]

Umm, its kinda easier to lie down when you've had an epidural.

[/ QUOTE ]

And pretty difficult to stand still if you haven't.

[skylos]

Yeah I know the cavemen and other ancient cultures went thousands of years squatting and it was such a problem that the earths popultion dwindled to a measly 6.5 billion. I'm not gonna link anything but if you google you can find out on your own.