Monday, January 16, 2012
Filling the void (... the young docs, vol. 2)
The CDC released a recent report ("data brief") on the subject of physician assistants (PAs) and advanced practice nurses (APNs).
Physician assistants are a growing cadre of professionals who practice medicine under the supervision of doctors. Advanced practice nurses are registered nurses with advanced training, who work independently (but in collaboration) with doctors.
PAs and APNs are often referred to in health care-speak as "physician extenders," a term I loathe. To me it implies that these professionals are somehow not fully formed human beings, but rather mere appendages of almighty doctors.
There was a lot of initial resentment toward PAs and APNs by doctors. I can still hear some of the claims:
--They will take our patients, thus stealing our business.
--They don't have enough education.
--Will patients really want to see them, with their "lesser" education and experience?
--They can't be trusted to prescribe mediation independently.
--They're not doctors.
Those cries have greatly diminished as their numbers have grown. Doctors in the private world relish working with "extenders," because they help improve volume (i.e. patients seen) which brings in additional revenue. And because they earn less (presumably because they have less in the way of education [two years vs. four for medical school] and experience [one year internship vs. three years-and-beyond residency training periods], they are in fact quite economical for private physicians who hire them, or the larger groups (especially hospitals) that employ doctors.
In a prior brief, the CDC demonstrated that nearly 50% of office-based physicians work with PAs and APNs. The larger the practice, the more likely this is to be true.
The most recent brief, highlighted courtesy of V.S. Elliott in American Medical News, looked at "allied health workers" (PAs and APNs) working specifically in hospital-affiliated medical practices. The data shows a 50% increase in visits to these office sites in which a patient saw only a PA or APN over the most recent eight years.
I find this important for a couple of reasons. As we inch closer to health care reform, with several million uninsured people expected to enter the insured pool, allied health workers will be more frequently counted on to pick up the load, as the number of primary care doctors isn't growing enough to meet demand.
In addition, under health care reform it's expected that one of the formats for improving delivery of health care will be the Accountable Care Organization (ACO). In this model, doctors will supervise teams consisting of nurses, PAs and APNs, who will see most of the patients. It is argued that this will be the most efficient, cost effective, and highest quality deployment of health care personnel.
Some beg to differ on those assumptions. My own feeling is that doctors don't go to medical school to learn to manage teams of other professionals. Some of us may actually like it or have talent for it, but current medical education models don't have any bearing on these skills.
It's a tumultuous time to be in health care. Stay tuned.
This post by John H. Schumann, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.
Labels: accountable care organizations, GlassHospital, guest post, health care reform, John H. Schumann, nursing, physician assistant, Workplace issues
posted by John Schumann, MD at
11:00 AM
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Members of the American College of Physicians contribute posts from their own sites to ACP Internist and ACP Hospitalist. Contributors include:
Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.
David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.
DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.
Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
I'm dok
ACP Member Mike Aref, MD, PhD, ACP Member, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.
Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.
KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.
MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Medical Lessons
Elaine Schattner, MD, ACP Member, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.
More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).
Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.
Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.
Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.
White Coat Underground
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.
Other blogs of note:
American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.
PLoS Blog
The Public Library of Science's open access materials include a blog.
White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.
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