19 December 2008


Ezra Klein suggests that Nurse Practitioners could just "take over" primary care and girlvet over at Emergency Room Nurse makes the same argument, extending it to the ER as well.

There's some validity to this argument -- limited validity, I must emphasize. There's certainly a role for mid-level providers (MLPs) in both primary care and in the ER. We utilize PAs (which are comparable to NPs) to great effect in our fast track, where they work within a defined scope of practice and with a subset of patients who are unlikely to have a complex or dangerous condition. Properly trained, they are cost-effective and valuable members of our group. What they are not is this: physicians. No disrespect, but they are mid-level providers; this implies that there exists a level of sophistication and quality of care somewhere between that provided by a doctor and a nurse. That's consistent with my experience. Their academic background is not as strong as that which physicians go through, and the selection process is less rigorous. The duration and intensity of their training is less, and due to their practice environments, the breadth and depth of their experience is lesser.

Again, no disrespect -- I employ a number of fantastic PAs that I would allow to care for my children. But they are not doctors. Girlvet pointed out that 90% of EM could be carried out by NPs. Perhaps. I'd put the fraction a bit lower, but whatever. If you are one of the 10% who needed something more, and all you get is an NP, you're screwed. (Note: that 10% would still be 10,000 patients annually in my ER.) And it's not easy to figure out in advance who the one in ten is who will need the doc.

While some primary care can be performed by a MLP, There was one comment at Ezra's piece that "primary care providers rarely treat anyone that has anything (really) wrong with them. by that i mean anything that wouldn't go away on its own given enough time." Oy. I suppose that things like diabetes and hypertension will go away on their own (just like "All bleeding stops... eventually."), but the management of chronic diseases is fantastically complex and not something that a simpleton with an algorithm can successfully pull off. I think people really do have no clue what it is that PCP's do. It's maybe not as immediately gratifying as Emergency Medicine, but it ain't easy. Some of it -- wellness care and some acute care -- certainly can be performed by MLPs, so long as they have access to a doc for the unexpected and complex issues that invariably do arise.

As for the general assumption that adequate NPs and PAs exist and could be convinced to provide primary care, I agree with Kevin that this is unlikely. There aren't 40,000 unemployed NPs hanging out waiting for primary care jobs, and even if there were, there are better opportunities to be found elsewhere for them. I know what we pay, and I know what some local surgeons pay their MLPs. Suffice it to say that these guys make more than most pediatricians or family practitioners. Shameful, but that's the market. Why on earth would they volunteer to take a (substantial) pay cut to do the job of primary care?

Finally, Ezra argues, that "I'm not aware of any consensus showing worse outcomes when patients see nurse practitioners." Sure. That'd be one hell of a study to do, particularly difficult in light of the fact that most patients change PCPs every year or two and that the relevant "outcomes" differences are undefined and probably undefinable (see the debate over how to define quality). Seriously, you're implying that we should assume that docs and MLPs are equivalent, absent evidence to the contrary? That's a stretch which absolutely defies common sense as well as my experience. If that were the case, indeed, it would not make sense to increase the pay of PCP's, but to cut it, as the job is too easy for a doctor.

No, Ezra is on the right track in the first part of his piece, in which he argues that the compensation system should be rejiggered to incentivize graduating doctors to enter primary care, and possibly to mitigate the cost of medical eduation for those entering primary care. I am sure that PAs and NPs will continue to play a role, possibly a growing role, in the provision of primary care. It is, however, highly unrealistic to expect that physicians can or should be displaced as the chief providers of primary care in the future.


  1. I suppose that things like diabetes and hypertension will go away on their own

    Hypertension and type II diabetes CAN go away on their own, depending on if lifestyle and things like obesity are major contributors. For example, when I was an aide at the NH, a lot of Type II LOLs were cured of their diabetes just because of the NH diabetic diet for instance (or, more accurately, they were a "diet-controlled" diabetic instead of on pills/insulin). All it took for that was a nutritionist and adherence to their recommendations. My brother stopped smoking and drinking and was normotensive soon thereafter.

  2. Not saying anything in particular about primary care, just pointing out a really "duhr" statement, sorry. Would be nice if PMDs/NPs had the time to talk about lifestyle adjustments. Next on my agenda is convincing asthmatics that their asthma could possibly STOP!! if they stopped smoking 1 PPD.

  3. It is actually not difficult to argue both sides of the debate. The hospital for which I work employs both MD/DO's and PA's in the ED. From 10am until 6pm there is an overlap in which we have two providers, however the rest of the time there is only one provider working in the ED that may be a physician or a PA. After 6pm the ED provider is often times the only provider in the entire hospital unless a hospitalist has been called in.

    But in this instance one needs to take into consideration several other factors. The nearest hospital is 40 miles away, our catchment area is about 3200 square miles, two of our ambulance bases are 60 miles north of the nearest hospital and there are times when we respond 45 to 60 minutes farther north of our ambulance bases. Our PAs absolutely have to be on top of their game in order to work in our ED.

    I do realize of course that there is a vast difference between urban and rural medicine and that in a much larger facility it would be outright foolish to staff our ED strictly with MLPs.

    The whole debate centers around the capability of the MLP. Around here we have some great ones, in other places I have worked with paramedics who also happen to be MLPs who "aren't comfortable" calling a cardiac arrest in the field despite the fact that the patient is 90+ and has been pulseless, apneic and asystolic for for 20 minutes with 10 minutes of down time prior to EMS arrival despite the fact that the rest of us routinely do so.

    I would be quite interested to see some solid data on the subject.

  4. Dirty Little Secret is no way NPs or PAs will work for that shitty PCP pay....

  5. Nurse K,
    Asthmatics are smoking TB Skin Tests!!!??? No wonder they can't breathe.....

  6. I worked as a primary care provider for several years in a tertiary care academic setting. I felt rather uncomfortable and ignorant as a new NP and was fortunate to have several excellent attendings as my collaborating MDs. With mentoring and experience, by the time I left I felt comfortable with chronic disease management of HTN, DM, CAD, COPD. But I always felt that there was way too much to know as a PCP; and I was doing adult medicine, with family pracitice I think it would be worse. I left and went back to what I felt more comfortable with - cardiology (I had been an ICU, then cath lab and EP lab RN). I still don't know nearly as much as the docs, but I feel more comfortable since being in a subspecialty area. If I have questions or issues with management I don't hesitate to call my docs. Perhaps having always worked in a teaching institution makes this easier as there is always an attending available. In private practice it may be different.

  7. The clinic I go to has a full time MD, a full time PA, and a part time NP (she comes in two days a week I think). Depending on what I go in for I see either the MD or the PA (I usually don't find out until one enters the room). Both of them are competent, but because the PA has only been out of school for three years he is very much aware that he does not know everyhing yet. The MD knows a ton and he is always willing to clarify something. I gave my PA and my MD giant, plush microorganisms for the holiday (when a card is tacky and everyone gives food what else can you give?). My PA wanted to know why my MD got a giant rhinno virus and he got a giant Clap organism. Watching your medical provider turn bright red really makes it worth it ;)

  8. SickInSeattle12/22/2008 10:16 PM

    I have complex health issues and I find that my primary care physician doesn't have the time to evaluate the situation and often uses the algorithms to stuff me into the box.

    Also when things get tough and I need urgent care, my PCP has no time for me and I usually see the NP in the office anyway. It seems to me I would get better care if I saw the NP all the time-at least s/he would be familiar with my health issues.

  9. Here is another interesting take on the situation:

    I have a degree in education; a mother down the street has no college degree. I teach in high school biology, and she homeschools. My students are going all to public schools. Her kid just got a full-ride to Harvard. My training and knowledge is more in depth than hers, however she got the better end result.


Note: Only a member of this blog may post a comment.