The Rise of the Non-Physician Expert

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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  5. 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.

  6. 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.

  7. 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.

  8. 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.

  9. 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.

  10. 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!


  11. 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

  12. 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.

  13. I feel like it the patients and doctors responsiblity to be aware of the whats going on.
    The patients need to use the tools that is available on the web,magazine , or books. That why the patients can have a better understanding of there illness whether it’s life threaten or not. And doctor should be more understanding with the patient by explaining or addressing any of the patients questions.
    With that being said patients need to listen to the doctor also.
    Patients and Doctors both need each other

  14. Fantastic points!
    Nicole J the Smartheart device is an excellent form of technology that increases patient safety and maximizes health function. I have a family member that has an extensive cardiac history and inquired about having the AngelMed Guardian System implanted. The device monitors your heart rate and oxygen levels every ninety seconds. It advises the patient to immediately go to the emergency room or it will inform them to follow up with a doctor soon if an abnormality is detected. The unique quality about this device is that it detects abnormalities before cardiac arrest and symptoms occur. The physician treating my family member initially did not have knowledge of this device nor its capabilities. The physician was asked if he thought this device would offer plausible benefits and contribute to her well-being. He researched and read literature about the device and determined that would be beneficial in her treatment regimen and cost effective. This device has detected major abnormalities twice since being implanted. Each time she was asymptomatic. The accessibility of medical information to a lay person and willingness of the physician to engage the patient in the coordination of her care resulted in life saving measures. It is nearly impossible for medical professionals and physician experts to have knowledge of each new form of medical technology and medical treatments that are available. However, medical professionals should remain open to exploring and considering different treatment alternatives as well as engaging the patient in the coordination of their health care.

  15. Patients should do their homework and be armed with information about notable forms of treatment. It is imperative to stay abreast of the latest medical treatment. It can make the difference between life and death. Medical professionals should find value in patients that are well informed. These type of patients are usually more compliant with prescribed medical regimens and have a healthier lifestyle.

  16. Hello,

    Thanks for the amazing information you are discussing. I come from a family that has had heart issues for generations and generations. This has given me enough motivation to work with patients who suffer from the same problems.

    As part of my work, I have to look for new technology to help reduce the time it takes a patient to get diagnosed and start treatment for any heart disease. A
    As I was browsing online, I found a very interesting company called SHL, who’s products are some of the most modern I found in the market. They have a device called Smartheart that allows patients to take EKGs at home and send the results to their doctor immediately. Please take a look, as I think it is something very unique.

    Hope it helps.
    Kind regards

  17. The patient-physician relationship is enhanced when patients have adequate knowledge of their health conditions and of the appropriate measures that should be taken to treat the condition. Patients are now interested in taking an active role in their health care. Medical information should be available to all lay people. It helps individuals to make informed judgments about healthcare decisions that may have life altering effects.

    As stated in a previous post, the length of consultations and follow ups with physicians are often time restrained. It is beneficial to have a broadened knowledge base so that appropriate and relevant questions can be asked by patients and physicians can provide necessary insight. Patients and their families are no longer willing to be uninformed consumers that receive subpar medical services. The standard of care and expeditions has risen exponentially. I do agree that credentialed health care professionals such as physicians are not replaceable by non-credentialed health care professionals. Credentialed health care professionals have been armed with immeasurable knowledge to provide competent care in unpredictable medical circumstances.

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  19. I’ve been a lay patient advocate, author of health books, and patient educator for almost two decades, and in recent years, have also been involved in one-on-one patient education coaching, primarily in the area of thyroid disease and hormonal health and balance. Dr. Sidorov raises some interesting issues in his article regarding patients who become astonishingly knowledgeable in their own disease areas. I’ve seen many in my own field. Unfortunately, this development is to a large extent borne of necessity, as visits with doctors often last mere minutes, and HMOs and insurance companies dictate the very limited and often old/out-of-date guidelines and policies regarding the diagnosis and treatment of hormone imbalances and deficiencies. So I welcome the rise of the non-physician experts to help patients navigate the system. But in the end, though — as with everything, it’s an issue of moderation. Some patients clearly take it too far, and doctor shop until they find a rubber-stamp doctor who allows the patient to direct every aspect of their own care, or even go so far as to self-treat, change dosages and medicines on their own, or buy medications offshore without prescriptions — all of which pose significant risks. At the same time, there are many doctors who clearly don’t realize that patients are no longer going to sit passively and without question, blindly accepting advice from on high as if it receiving the Ten Commandments themselves. Both extremes are counter-productive. The ultra-militant patients and the patronizing, ivory tower physicians both need to figure out that in the end, they need each other, and must meet somewhere in the middle in order to achieve the best possible outcomes.

  20. “deliver babies, administer anesthesia, prescribe drugs and perform surgery.”

    All true until there’s a complication. My L&D nurse wife was better at picking up delivery problems than the docs, and her inciteful and attentive care resulted in better outcomes for many babies.

    I’ve had bad experiences with docs who “think” they know everything, but who really knew nothing about my body and my condition and were pretty much guessing, usually wrong.

    However I’d much rather have an educated doc (when I need one) that has stood the test of time and who has a good mind for understanding the whole picture and how the body interconnects. Unfortunately many treat with tunnel vision.

  21. Their expertise is brilliant until death ensues. Charlatans have pervaded society for centuries.

  22. I have several chronic conditions: skin, heart, brain, digestive system, voluntary muscles. Each are mild and I function quite normally. I appear robust and healthy. Doctors, the so-called experts, have been useless. Each knows something about his or her area of expertise and know nothing of the others.

    3 months back , as my heart surgeon and I were walking to the operating room — He commented, “There is nothing you need to work-on.All your numbers are indicative of good health — Odd.”

    Getting several specialists into a room, where the necessary dynamic would occur, in today’s world would cost $5-10 K per hour. If they each did one week of research and came together in a room. They might be able to arrive at a solution. The time and money required for this undertaking is well beyond reasonable costs.

    My extensive research has led me to believe, I have mitochondrial disease. I have been unable to find a suitable physician in Chicago. My primary care physician has never even heard of it.

    A primary care physician, who orchestrates lesser paid specialist nurses for these cross functional issues would have a better dynamic, more expertise and lower costs. Our medical industry has low availability, poor processes, too many bad outcomes and insufficient expertise. It is time for a change.

  23. This makes perfect sense to me. I am not a clinical professional, but a medical writer specializing in diabetes and health economics. I have seen first-hand the benefits that patients with chronic disease receive when they do their own research and implement what they find. And since I am a layperson who is hired by MDs and other professionals to research just these questions, I tend to feel confident that, with some training and awareness of things to avoid, patients are capable of this.

    With T2DM, of course, the primary lesson that patients need to truly take on board is the importance of improving their nutritional intake and increasing physical activity. In these efforts, they are typically provided with only minimal societal (or medical) guidance or support. Trying out a new diet (even one with an evidence base) that’s not one your MD is familiar with is likely to result in a shrug of the shudders, or worse discouragement. As a result, IMHO, too many patients are either not fully honest with their care practitioners or (more likely) do not even bother trying to stay on top of their own condition (it’s the experts job). In an era where more than 20% of seniors have a chronic illness, it seems to me that greater patient proactivity and participation is one of the few things that could actually change the chronic disease curve.

  24. Just brilliant, Dr. Sidorov and thank you. With the shared decision perspective, the general public will over time master the art of preparation for the physician/patient (subscriber) encounter. With continued encouragement that patients access the information in the public domain one of the barriers – patient literacy will improve. We have already seen the devaluing of the MBA because there is so much real world perspectives missing from those programs, so its possible the medical profession will emerge as the practice of very highly specialized mini disciplnes.

  25. Excellent overview of the forces coming into play here:

    “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…”

    Why indeed?

  26. Interesting perspective here – thanks for this. As Dr. Mike Evans ( of the video-gone-viral “23 and 1/2 Hours” fame) told a European TEDx audience in describing a moving story of patients telling other patients how to tell your kids you have cancer:

    “Patients are much smarter than you or I are about this subject, even it that’s our field, and what they come up with is more useful and more real.”

    And as one of my blog readers, a heart patient who told her doctor that she’d gone online seeking more information about her condition, astutely explained:

    “He gave that small, insulting half-laugh that doctors reserve for this response, and said that he wasn’t sure he approved of patients doing research.

    “I told him I had no inclination to apologize for it. I said that I knew he was interested in my health, but not nearly as interested as I am.

    “It’s his job, but it’s my life.”