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Upper Level Mid-Levels

By Eric Van De Graaff, MD July 06, 2009 Posted in: Heart Health

Mid-Level providers give great high level care

“When I go to the hospital I don’t want to see a nurse practitioner.  I want to see a doctor!”

I heard this a few weeks ago from one of my neighbors.  He was complaining about a recent visit to the ER at an area hospital.  As far as I can tell he survived the encounter with all but his civility intact.

My group employs 7 physician assistants (PA) and nurse practitioners (NP).  To reward them for being faithful readers of my blog (or maybe to punish them for being frequent critics) I’ve decided to devote this segment to them.

Collectively, these health-care professionals are known by the terms “mid-level providers” (MLP) or physician extenders.  The concept of an MLP really began to blossom in the 1960s when the demand for rural health care outstripped the supply of medical doctors.  These days this profession is seen as a good one—well paid, highly respected, in huge demand—so good, in fact, that in 2006 Money magazine ranked physician assistants as having the 5th best job in the country (my guess is they would rank at least a notch or two higher with the economic collapse of this last year, since the number 3 and 4 spots were occupied by financial analysts and human resource directors).

What PAs and NPs are allowed to do really depends on the state laws that govern the independent activity of these health-care providers.  Nebraska is a primarily rural and often underserved environment and the state provides wide latitude in the types of settings where MLPs can operate.  Many MLPs in the primary care arena see patients independently with only loose oversight from a medical doctor.  A number of the primary care groups we interact with have such an arrangement, where the PA or NP is really the only face the patient ever sees and provides all the routine care.

In my practice the MLPs serve a somewhat different role.  Their main purpose with us is to make us more thorough and efficient.  In both the hospital and clinic the MLP collects information, examines and interacts with the patient, creates an opinion of the patient’s medical condition, and devises and implements a treatment approach.  Since our MLPs are all very experienced and competent, each of them is perfectly capable of executing every step of this process without the input of the doctor, but they rarely do.  In nearly all cases my physician colleagues and I have a direct hand in the process of patient care, even if it is to simply confirm what the MLP has already deduced.

So, do you get inferior care when you are seen by an MLP alone?  I used to think about this type of question when I was in training.  I spent part of my residency at a private hospital where many of the more affluent members of the community sought care.  It wasn’t uncommon for some of them to begin their hospitalization with the demand that only attending physicians have access to their cases.  I remember thinking how wrong their perceptions of quality care were.  Sure, you may have to put up with some additional poking and prodding if you allow yourself to be admitted to the “teaching service” but look what you get in return.  Throughout the course of a single day you and your chart will be examined by a medical student (or two), an intern, a resident, perhaps a fellow, and then finally by the attending physician.  With that type of scrutiny I can guarantee there will be no lab anomaly unaccounted for and no possible diagnosis unimagined.  If you limit yourself to your solitary attending physician you’ll be lucky to see him for 2 minutes a day.

Care can be measured in a lot of ways, length of time given my MLPs might actually be better

Now I’m years out of training and I still stand by the belief that a patient should never turn down the opportunity to be seen by trainees.  I feel the same way about MLPs, too.  Several studies have clearly shown that care by MLPs is not only as good as care by physicians, but that MLPs spend more time with patients, dispense more information, provide more preventive care and receive higher patient satisfaction scores—all this while saving health care dollars.  In my group our MLPs also serve as an automatic second opinion—a second set of eyes on your case.  For better or worse, our MLPs don’t seem to have any compunction about calling into question any decision I make about which they have concerns.  Our debates and disagreements result in more reasoned decisions on behalf of our patients.

So, feel lucky if you get to see a nurse practitioner or physician assistant.  They provide great care and, according to Money magazine, they love their jobs.  And if they don’t, I heard there are some openings in financial consulting and human resources.

Eric Van De Graaff, MD
Eric Van De Graaff, MD

Eric Van De Graaff, MD is a Heart & Vascular Specialist at CHI Health Clinic.

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