The Nurse Practitioner … Er, We Mean Doctor Is In

flying cadeuciiA rash could be leukemia or idiopathic thrombocytopenic purpura. A sore throat could be glossopharyngeal neuralgia or a retropharyngeal abscess. A blocked ear could be Ramsay-Hunt syndrome, a self-limited serous otitis or sudden sensorineural hearing loss with an abysmal prognosis if not treated immediately with high doses of steroids. A headache or sinus pain could be cancer, and a cough could be a pulmonary embolus or heart failure.

Treating the Well:

In my early career in Sweden, well child visits were done in nurse-led clinics, some of them only open on certain days, with a local doctor in attendance. Parents carried the children’s records with them, containing growth charts, immunization records and so on.

These nurses had great expertise in differentiating normal from abnormal appearance of children, and would direct the attending physician’s attention to children with abnormal metrics, appearance or behavior.

With this arrangement, the physician time requirement was reduced, and limited to evaluating children attending the clinics who needed special attention. Physicians also performed specific examinations at certain ages, such as checking for hip clicks. These clinics freed up the local pediatricians to evaluate more sick children.

Well-baby visits are now the bread and butter of American pediatricians and family practitioners, and with the ever expanding mandates of politically determined items that must be covered in order for doctors to get paid for their services, we sometimes have trouble accommodating illness care demands.

The same thing happens in primary care for adults; between checkups and chronic disease management, Meaningful Use and other documentation requirements, many primary care doctors are unable to see all the sick patients, who call for an appointment.

A simple calculation illustrates this phenomenon. If the ideal caseload for a primary care physician is 1,500 patients but commonly exceeds 2,000, only providing a 30 minute physical or “wellness visit” (not the same thing) visit once a year for every patient chews up 750-1,000 hours. Total “contact” hours for each doctor according to recruitment ads these days number 32 per week times 46 weeks, or 1,472 hours. That doesn’t leave very much time for treating the sick – less than 500 to at most 750 hours, to be exact. That’s a maximum of 16 hours per work week, most of which is spent on managing chronic conditions like diabetes and cardiovascular disease. Most of the time, this amounts to tracking and treating numbers in fairly asymptomatic people – blood sugars, glycohemoglobins, microalbumins, blood pressures, lipid levels and so on.

Treating Chronic Diseases Leaves Little Room for Diagnosing and Treating Acute Illnesses:

With primary care physicians’ time increasingly spent on the routinized housekeeping details of modern chronic disease management, their diagnostic and therapeutic skills are less often used on the front lines of sick-care. Their new role of managing populations is not making full use of physicians’ traditional diagnostic and therapeutic skills. Instead we are performing more nurse-like duties such as carrying out standing orders (read “following guidelines” and “practicing Evidence Based Medicine”), and keeping track of our patients’ scheduled specialist visits as well as their sick visits, not just at the local emergency room, but also at competing walk-in-clinics. Ironically, the doctor who was too busy to see that child with an earache must now sign off on the chart notes from the local Walmart. We also end up, unreimbursed, keeping track of and even rubber-stamping orders for immunizations given at pharmacies like RiteAid.

The elimination of the truly quick and easy visits from doctors’ schedules (the rashes that the experienced clinician quickly determines are not leukemia or ITTP) makes the daily load of chronic care management greater, and often decreases total revenue in a fee-for-service system. The truth is that a skilled and experienced physician can often handle “simple” medical complaints faster and with greater accuracy than providers with less training and experience. Equally true, Nurse Practitioners can be just as good at following clinical guidelines and counseling patients about blood sugar, exercise, smoking cessation and the benefits of aspirin as physicians are. The broader and deeper training of physicians comes to its best use in diagnosing and managing atypical or rarely seen symptoms and conditions, many of which present acutely with nonspecific symptoms.

Yet, because of the so-called “doctor shortage”, this is what sometimes happens:

In many states, Nurse Practitioners, even newly graduated ones, are asked to fill the role of primary care provider or urgent care clinician, while seasoned physicians with mature practices are increasingly spending their time on the routinized treatment of asymptomatic conditions that arise from the modern lifestyles of the western world.


I have worked with many NPs who shoulder the responsibilities of frontline, independent, clinical practice very well because of their postgraduate experience and their personal qualities. But, “out of the box”, a new NP is not as well prepared for that role as today’s residency trained physician. The days of practicing general medicine straight out of school ended for American physicians in the 1950’s.

My point is that in today’s healthcare system, we are often asking the providers with the least training to see the unsorted clientele in “sick-call” while doctors with decades of experience may be limiting their practice to following insurance-mandated guidelines and care plans in treating non-urgent chronic medical problems and providing equally scripted wellness visits that may actually be better suited for nurses-turned Nurse Practitioners. I think the wisdom of this needs to be discussed openly. I think the perceived “doctor shortage” may just be an allocation issue.

Or, in one sentence:

If provider care teams are the way of the future, perhaps doctors should be handling more of the “sick-call”, and Nurse Practitioners more of the “maintenance“ of modern healthcare.

Let’s really talk openly about who should do what in primary care today!

7 replies »

  1. Aside from specialists rigging the table, absurd bills for routine services and access based on when the docs prefer to work, rather than when people are able to see them, “destroyed” the MD-patient relationship – which doesn’t matter as much as you believe it does anyway, Paps.

  2. The pharmacist is the most overlooked professional in this whole mix. Instead of counting out pills and managing people’s PBM issues, they should be heavily involved in medication management for chronically ill patients. Nurse Practitioners and PA’s don’t have nearly enough training in this area. Perhaps giving pharmacists a chance to be a part of the team in the clinic would be tremendously helpful.

  3. I agree that NP’s can handle many chronically ill patients and even some of the simpler diagnostics. As for new NP’s though, they are right out of school – correct. BUT, they are not afforded the privilege of having a salary while a resident (trainee). Medicare pays only for doctors to learn, not nurses.

  4. ‘And in many, if not most, offices the least experienced providers see the “acutes”.’

    This is bad.

    It is also bad to tell patients that “you are not allowed to see your doctor because you are not sick enough.”

    Both approaches are based on destroying the doctor-patient relationship, presented under the rubric of being more “patient-centered.”

    We should oppose both.

  5. Someone is telling patients just that in many clinics. And in many, if not most, offices the least experienced providers see the “acutes”.

  6. Or: why should patients be tossed like a hot potato from MD to NP to PA based on what the scheduler thinks is appropriate?

    Are we really willing to tell patients quite bluntly that they do not have the right to see their provider of choice?