Last week in some discussions I heard someone use the phrase levels of primary care. The context involved comparing Nurse Practitioner primary care with Internal Medicine primary care. I was dumbfounded.
Readers know that I have argued that most internists provide complex comprehensive care. We have called that primary care, but others have interpreted the term differently. So I heard someone discuss levels of primary care.
We are in the midst of a political campaign to improve patient care through funding primary care more appropriately and through training more primary care physicians. Politically we must continue to use this moniker, even though many staffers, congressman and senators do not understand the implied meaning.
We need more family physicians and more comprehensive internists, so if we must allow this confusion, perhaps we should start to define the levels of primary care. Or perhaps we can all remain like the title of the Led Zeppelin song – "Dazed and Confused."
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Would it be possible to demonstrate, from a thorough analysis of chart documentation – especially of Decision Making – that internists show, from the gitgo of their professional relationships, “complex comprehensive care” while PA’s and RNP’s show simpler Decision-Making? Are there index cases where this complexity saved lives while reducing the cost of care? Would a blinded group of quality medical judges (doctors, insurers, policy wonks, patient advocates, etc.) be able to pick out from a large enough group of charts those patients who had received only doctor-care vs those who had received only RNP care vs those who had received a mixture? And then could you map the cost of care for basic pathology in each group (e.g., CV, pulmonary, ortho, etc.) against each cohort and follow changes in morbidity and mortality as well?
Is this too ridiculous to do? I’m guessing that this is the kind of data that Pete Stark at the House Ways & Means Subcommittee on Health would like to see.
As a family doctor, I would feel better if the scope of practice of NPs and PAs were better defined. For instance, if they can take care of a patient with X number of chronic conditions (maybe 1 or 2), while those with more conditions get their care primarily from physicians. I love seeing young, healthy patients because they offer lots of opportunities for education and counseling, but they don’t really need the level of care I provide. The way things are now, though, non-medical people seem to think that NPs and PAs can take care of patients with multiple comorbidities in the same way that I can, and that’s just not true. Ideally, more simple patients would go to mid-level practitioners (and I think that’s what we should call them, mid-level providers, not primary care providers) and others would go to those with higher levels of training.
I don’t think we’ll ever see a good study on the care provided by NPs versus MDs, it’s just a really hard thing to do. I suppose you could look at number of referrals made and imaging tests done, but it’s so hard to adjust for confounders.
I don’t at all disagree with you, Sharon. But this may just end up being a tug of war and the decisive factor may be cost of care – unless we can show “medical necessity” for the presence of the physician. It seems to me that here is a chance for medical academe to demonstrate more than moral support.
DB-couldn’t agree more about the confusion surrounding the use of PA’s and NP and other “physician extenders.” I think patients view them the same as physicians, and don’t know the differences required in training and experience. I doubt that Congress and the American public will agree to pay primary care physicians more–not when can be easily replaced by an “extender.” Seeing a “mid-level” is like going to Jiffy Lube–it’s all okay if all you need is your oil changed, but what if there is a serious problem that requires more knowledge?
An interesting topic and comments that follow. It is obvious that even many “medical people” do not understang the role of the nurse practitioner since their comments are minimalizing and denigrating – Jiffy Lube? Fine – keep on thinking that NPs are “simple” and can’t handle “complex” patients. We want to work together with you so that we can care for the many patients that don’t have providers. It’s ok for NPs to care for the un or underinsured but don’t let them care for the patients with real insurance. There is no evidence that NPs order any more tests or referrals than any other provider.
We as NPs will continue going into primary care when many physicians completely avoid it and are leaving in droves. We want to partner with you – not so that you can supervise us – but so that we can collaborate and bring best practices to our patients. Is it not possible that NPs have areas of specialty where we are better equipped to handle a certain situation or patient? Perhaps you all have worked with what you consider substandard NPs – has that not happened with your physician colleagues?
The argument becomes so tired. Our healthcare system is literally falling apart and costing trillions while many people go without care althogether. I challenge us all to find a way to work together and form a model of care where the best clinician is taking care for that patient at the right time and place.
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