The Rise of the Non-Physician Expert

The Rise of the Non-Physician Expert

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I remember when one of my patients with coronary artery disease suggested that he be given a course of an antibiotic to lower his future risk of a heart attack. The patient had done his homework, quoting literature that pointed to a possible infectious link to atherosclerosis. He also was aware of the theory that aspirin’s benefit had less to do with blood thinning than reducing underlying inflammation.

Fast forward to the Feb 2-8 Economist that has an editorial pointing out that U.S. legal expertise may not require the completion of three years of law school. Why not, it asks, cut the requirement back to two years or, even better, skip the school requirement entirely and license anyone who can pass the bar exam?

And then there’s the Feb. 11 Wall Street Journal, where “Notable and Quotable” refers to the “BA Bubble.” Charles Murray argues that a looming oversupply of college graduates may portend a decline in the employment value of a liberal education. Work careers may consist of serving as “apprentices” and “journeymen” before becoming “craftsmen.”

All of which makes me wonder if the vaunted Doctor of Medicine degree may be vulnerable.

Why should physician education be immune from a perfect storm of over-priced graduate education, “alternative” web-enabled learning with on-the-job-training? The declining value of the formal credential may be less about the university degree and more about competency, turbocharged by flexible licensing and a discerning consumer.

Non-physician health care professionals are arguing that their expertise is enough to enable them to deliver babies, administer anesthesia, prescribe drugs and perform surgery. My traditionalist colleagues argue that patient safety is at stake and that lay persons may not be able to discern all of the possible risks, benefits and alternatives. When things go occasionally wrong in the delivery suit, operating room or with a drug, they say a credentialed and experienced doc can make the difference between life and death.

I also remain impressed by the ready availability of medical information in the public domain that is enabling some laypersons to become astonishingly expert.  In addition to the patient above, think about the self-taught parent of a child with a rare condition or the plucky cancer patient who guides the oncologist toward choosing the right life-saving therapy.  Imagine what happens when IBM’s Watson is fully commercialized and available to anyone at anytime.

I understand all the perspectives above, but given the decline of the BA and the law degree, I worry that the medical traditionalists may ultimately end up being on the wrong side of history.

While regulators and the markets sort all this out, this may open another business proposition for care management. As patients with chronic conditions continue to seek ways to better share in their self care, they’ll also be seeking providers that best suit their needs and expectations.  In other words, the population health vendors can not only help with shared decision making, but provider selection making.

Jaan Sidorov, MD, is a primary care internist and former Medical Director at Geisinger Health Plan with over 20 years experience in primary care, disease management and population-based care coordination. He shares his knowledge and insights at Disease Management Care Blog, where this post first appeared.

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31 Comments on "The Rise of the Non-Physician Expert"


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Guest
Apr 17, 2013

I am a physician assistant with 20 years experience as a primary care and emergency room provider. I have never tried to replace or supersede my supervising physicians. I have practiced in satellite clinics I have taken call in rural hospitals, this however was well into my career and after extensive hands on experience. I agree that the expertise of a Physician is required to be involved in the management of patient care.

Guest
Apr 16, 2013

Several points here. I am in favor of patients being engaged in their care, but the web is a tricky place. Not all of the information there is accurate or unbiased. Doctors do roll their eyes sometimes, but often because they have to take the time to explain why a certain therapy is “NOT right for you”. I also warn against using education alone as a criteria for who can make decisions in treatment. I have yet to meet a newly graduated med student who has any idea how to actually treat a patient. That comes from experience. I’d rather see and NP who’s seen my disease 1000 times than a doctor who’s seen it twice.

Guest
Mar 28, 2013

A great post. We may be headed for an era during which physicians will serve largely as technicians and gatekeepers for only the services that absolutely require their skills. As a clinician myself, I know that when I or my family interact with one of our care providers, I am frequently more well-versed in the evidence and issues at the time of the visit than the physician is. Then, the dialogue is about what I want done, with the physician serving as a reality check. The conversation is always respectful and good-natured, but it’s clear — to them and me — that I am in charge of what happens. They are just a conduit.

Guest
Mar 25, 2013

As health care systems are asked to become more efficient (i.e. save money) in their delivery of service, the use of nurses and PAs are obviously going to be the preferred method by administration. Nurses, in particular, are being required to obtain higher degrees now so the “educational gap” is shrinking.

Guest
Feb 28, 2013

It has alsoto be noted that, among the great and correct medical information available at the public’s finger tips via the internet today, there also is that big sea of unproven alternative therapies and outright hoaxes that lead people down the wrong path.

While applauding the informed consumer (or patient, if you will), we also have to think about teaching people to correctly evaluate information.

Guest
Feb 27, 2013

Thanks for an interesting article!

Many physicians went into medicine thinking they would become a walking encyclopedia of medical physiology. It turns out that there are MANY non- physician experts, as you said.

So, what unique product do physicians have to offer? Is there anything they offer at a level superior to all other providers and experts?

K. Montgomery suggests that, compared to other providers, physicians offer clinical judgement. Sure, other providers develop clinical judgement, but never to the degree developed by physicians. Her book “How Doctors Think: Clinical Judgment and the Practice of Medicine” is worth the effort.

Thanks again for a great article!

Shawn

Guest
Tiffany Foreman
Feb 26, 2013

I do agree that patients should act as informed consumers to receive optimal health care services. The relationship between the health care provider (including physicians) and the patient face new challenges as patients become more informed. The inaccuracy of the information may create dilemmas and informed patients forces health care providers to offer more explanations, provide more education, determine the validity of the obtained information, and consider alternative methods of medical care. These measures will boost the quality of health care and help to ensure patient satisfaction. I do not believe that nurse practitioners and physician assistants will replace the role of the physician. Professionals in both of disciplines have a broad knowledge base and excellent clinical expertise. There are also patients that feel as if NP’s and PA’s spend more time with patients and therefore make more informed medical decisions. Some studies also indicate that patients feel more comfortable with receiving care from physicians if they perceive their symptoms to be of a serious nature. The studies also revealed that patients felt that NP’s and PA’s were just as knowledgeable as physicians however; their perceptions were shaped by familiar medical structure and traditional hierarchy. I feel that NP’s, PA’s, and physicians work as part of a team and each discipline compliments each other. Emphasis should be placed on working as a medical team, improving the quality of patient care and improving the health of general population in our country. A great peer reviewed article is The Patient’s Accounts of the Differences in Nurses’ and General Practitioners’ Role in Primary Care.

Redsell, S., Stokes, T., Jackson, C., Hastings, A., & Baker, R. (2007). Patients’ accounts of the differences in nurses’ and general practitioners’ roles in primary care. Journal of Advanced Nursing, 57(2), 172-180. doi:http://dx.doi.org.ezproxy.memphis.edu/10.1111/j.1365-2648.2006.04085.x

Guest
Shelonda
Feb 25, 2013

Subject: Nurses & PA’s replacing physician’s

In my opinion, it is possible for nurses or PA’s to replace physicians due to the fact that they have more hands on experience with the patients. With my experience in the hospital, basically the nurses & PA’s have to report to the physician and the physician make the call. I don’t see it being a problem with nurses of PA’s making the call as long as they have a second opinion or have the credentials or trainings.