I avoid controversy. Like the plague. Don’t get me wrong, I have very clear and very strong opinions, I just do not feel the need to share them with everyone or try to convince you that mine are right. You do you. It might be wrong…but it does not impact me. However, today, I feel compelled to tell you to immediately start asking about the credentials of healthcare providers.
I am not an activist, but I am eternally grateful for the women’s rights movement which has made incredible progress over the years.
Women are not second-class citizens, and it is a fight that continues to be fought in terms of power, prestige, pay and job opportunities.
I would not be able to blog or discuss healthcare as a successful surgeon if the civil rights movement did not occur.
Thankfully, ordinary people stood up and sounded the alarm. Again, there is still much work to be done and a batch of new leaders are taking the helm.
What does this have to do with healthcare? Well, I have been sitting on the sidelines watching an ugly trend increase.
I have watched valiant physicians sounding the alarm that something is happening that will impact us all. I have been sitting quietly applauding those that shouted.
But now, I feel an undeniable pull that has urged me to add my voice. My 25 years of experience in healthcare in different roles as a military physician, as a private practice physician and as an employed physician has given me several perspectives.
Healthcare is dependent on money
Healthcare is expensive. And sadly, most people associate these costs with physicians. If you are one of those people, YOU ARE WRONG.
Today, there are more layers of healthcare management than ever before. Although these jobs are important, they do not directly add to actual healthcare, and these costs are eating up healthcare dollars.
And don’t forget the top healthcare CEO’s who also benefitted from increasing salaries. This money needs to come from somewhere. So, these administrative salaries also make costs rise, but profits still need to be obtained somehow. Guess where the additional profits come from?
As hospital systems began to seek ways to increase their profits, some of them looked at physicians. Yes, these are well-trained, dedicated providers, but administrators had to find some way to provide care cheaper. And then they found a way.
In order to see more patients and make additional revenue, more healthcare providers were needed. However, paying for an increasing number of physicians became an issue.
The brainchild to answer the need for increased profits was to create more mid-level provider positions. Meaning, that instead of solely hiring fully trained physicians, an increasing number of nurse practitioners (NP) and physician assistants (PA) have been hired.
Increasing use of midlevel providers has been helpful
Initially, many of these roles were designed to fill areas of physician shortages in rural areas. Later these roles were expanded to supplement care in physician practices where the midlevels would see patients and be directly supervised by physicians.
Physicians who would read and sign their charts to make sure nothing was missed and also review prescriptions to make sure appropriate medications and dosages were correct. It was indeed a collaborative partnership.
But some healthcare systems just saw dollars. More patients could be seen, and the NP or PA was less expensive than hiring another physician. Consequently, the ratios started changing.
First, it was several physicians to one midlevel, then it changed to a 1:1 ratio, now, sometimes, the midlevels outnumber the physicians.
However, the physicians are often still “supervising” the midlevels even though they are not able to check the notes or prescriptions. Nurse Practitioners then decided to expand their roles and lobbied state governments to give them the ability to practice medicine without any physician supervision.
Midlevel providers began to work as physician equivalents
Think about that. In 23 states plus Washington, DC, nurse practitioner healthcare providers have complete practices where they see, diagnose, and treat patients with no oversight from a physician. Umm, do you think the years of medical training, internship, and residency are just for fun and games?
The extensive training required by all physicians provides a more in-depth educational experience compared to nurse practitioners. Nurse practitioner education and training is not standardized and varies based on the program. Some programs are 100% online.
I have witnessed this shift of midlevel providers working without a supervisor by following my sister’s career. She is an Emergency Room (ER) physician who has worked across the entire country, has managed a trauma center and was the supervisor an ambulance system. She knows her stuff!
Her work experiences include a variety of practices included those that only hired physicians, those that required her to supervise midlevel providers and has sadly worked in those where she might be the only physician on a shift.
Do you know this when you bring your child to the ER for stomach pain? How about when your father is seen for chest pain? Do you know that there are some ERs in the country that ONLY staff with midlevel providers?
Physicians have been punished for discussing this situation
As I have witnessed this transition of increasing usage of lesser trained healthcare providers, I have been moved to get out of my safe corner. It is not directly impacting me in my personal practice, but it is impacting physicians every day around the country.
Some physicians have been fired for not training midlevels. Some of have been fired for speaking out about the system. One physician was fired shortly after writing an informative post like this.
There are cases where a patient in the ER did not like the care she was receiving and asked to see the physician. She was told that the PA or NP is the same as a physician. Nope.
When people request to see a physician in some offices, they are told there are no appointments for months or at all. This forces people to use the less expensive, less trained providers. They feel that they have no choice.
You have a choice in healthcare…but you must ASK
But you do have a choice. Starting today, when you receive healthcare, you must ask about the credentials of your provider. There is an absolute need for midlevels, but it is not to replace physicians! They should be supplementing our care.
Many midlevel providers work hard to inform patients who they are and what their credentials are. But some do not. You should feel free to ask a provider about their training, how long they have been in that job or how long in that field.
We pay good money for healthcare. When we are seen by midlevels, do we pay less for the visit? No. How are we benefitting from using increasing numbers of the midlevels?
Well, we are all getting increasing access to healthcare, so midlevel providers are incredible for allowing this to happen. However, their level of expertise should continue to allow them to function in their trained capacity and not as a fully trained medical physician.
I believe everyone should have the option to see a physician.
Why did I finally decide to speak out?
So why now? What motivated me to leave the comfort and safety of my little quiet corner?
Could it be my concern for my young adult daughters who have their own insurance and will navigate the healthcare system independently? Do I worry that they will be given medical advice that is not from the highest authority? Maybe.
Could it be that my husband and I are reaching an age bracket where we will be seeing healthcare providers more frequently? Am I worried that this trend will continue and gaining access to actual physicians might be difficult in the future? Maybe.
Actually, the true reason caught me off guard.
I performed surgery on an infant a few years ago. The family moved out-of-state and recently returned to Georgia; however, she returned to a different part of the city.
When new health issues occurred, my patient was referred to a local ENT office. The child was evaluated and recommended to have surgery. The mom told the new ENT about her previous experiences with me.
Mom was happy to hear good things about me! (Whew, so was I!) She was also told that the new ENT had worked with me for years in the past.
Ultimately, my patient’s family decided to drive across town to see me for a second opinion. After my evaluation, I started asking more about her other ENT…you know… so I can thank someone for showing me some professional love!
The other provider was a female pediatric ENT!
Woohoo! There are only a few of us in Atlanta. So, I described each woman. Nope.
I was confused and really needed to solve this mystery. Finally, Mom checked her phone and found the name.
I was stunned. Not only was her provider NOT a pediatric ENT, but the provider was not a physician! So, obviously, she was also not a surgeon!
I then shared with Mom that I had enjoyed working with this provider but informed her that the woman was a nurse practitioner. Now Mom was stunned
Then she became angry and began showering me with questions. Why didn’t she tell me? Why didn’t she let me see the actual physician? Was I only going to find out on the day of surgery?
These were all good questions. But sadly, the reason she didn’t know these answers is that she didn’t ask!
It seems that healthcare delivery can sometimes use a “Don’t Ask Don’t Tell” protocol. People make assumptions that are not true.
The range of emotions that I witnessed from Mom pushed me over the edge. She simply didn’t know that she had to ask. How many other people are in this situation? At least this patient would have eventually seen a true ENT surgeon because, at this time, midlevels do not perform these surgeries. Yet.
Listen to my voice: Ask about the credentials of healthcare providers
I have a unique position where my voice could save unsuspecting future patients from having anguish because they were uninformed. And so despite my desire to have others share this information, I know it is my turn.
I am now standing up and saying my piece. You can do with it what you will.
Nurse practitioners and physician assistants serve an invaluable role in our healthcare system. They absolutely provide excellent care. They are just not physicians, so you need to know the source and experience level of your providers!
You MUST ask for the credentials of healthcare providers. You need to be able to decide if you want a higher level of care for a complicated, persistent or progressive problem.
Midlevel healthcare providers were initially hired to practice in primary care but have been expanded to become medical and surgical specialists. Some are working in Dermatology clinics, independently treating cancerous skin lesions. Yikes.
So there. I said it. I have stood up and made my voice heard.
This is an unfamiliar place for me, and I am bracing for some serious backlash. Thank goodness I have cloaked myself in an invisible force shield, like in Star Wars. The negativity will come, and I plan to watch it bounce back on them. Pray for me that my force shield holds!
Or I may become a turtle and stick my head back in my shell and go back to my corner.
Regardless of the outcome of this post, the problem still exists. Research it. Understand who your providers are and their level of training and experience.
You have the right to be seen by physicians!
Eventually, I will share more insight into the training differences between nurse providers, physician assistants, and physicians. They are not the same. What do you deserve?
As always, much love for supporting my work. I will be adding many more posts to highlight parenting and healthcare tips, so be sure to consider subscribing to my podcast or to my blog to avoid missing a post!
68 comments
Excellent!!!! -OB/GYN
Thanks so much for reading. I am hopeful that more people will begin to better understand that all healthcare providers do not have the same level of training and expertise and they should be able to choose the level that they need.
I agree that you will probably get backlash for this, but in my opinion it’s a very respectful and important post. You acknowledge that midlevel providers can provide excellent care, which is true. But they need to identify themselves with a proper degree/position. They can be taught to do certain assessments and treatments well, but their training is very limited in scope compared to what physician training covers, both in years spent studying and in clinical exposures. I rely on nurse practitioners in my office to see and treat patients. They are supervised by the physicians and we (the physicians) are happy to see or discuss a patient with them as needed. This helps more patients to be seen in a timely fashion, and as long as the presenting problem is something the NP feels comfortable with, she can handle it. If not, she can ask for help. This is what collaboration looks like and can really help in many settings due to existing physician shortages. But no one should think that any person knows everything. Even as a physician with many, many years of education and practice, I know my limits. I ask for help when needed. If my partners can provide that, I use their knowledge. If I need a specialist, I use their knowledge. One common thread I hear though is that many people who have limited training don’t recognize their limitations. That is scary. It can be hard to know what you don’t know (think of kids who have limited life experiences but think they know it all, only to find out in their adult years they were so naive), and since NPs get about 3% of the education and training as a physician, they can easily miss things that they don’t know. That’s why supervision is key. No one should claim to be what they aren’t, so I don’t think anyone should claim to be an expert in any field unless they’ve had extra training in that field and are certified in that way. There are many NPs who are opening up their own clinics and calling themselves specialists in that field. Many states allow NPs to change their field without any additional training. I did a 3 year pediatric residency, so I can say I’m a pediatrician. As an example, if I do a lot of dermatology, I can tell people I like dermatology, but I can’t claim to be a dermatologist unless I complete a residency in dermatology. That is not true for NPs. They can work with an ENT one week and be an “ENT” and change to dermatology to be a “dermatologist” the next week without any additional training. To me that’s very scary – especially if they jump in unsupervised!
You have brought up so many excellent points! I have worked with many NPs in my practice and when reviewing a chart, I would find things the NP did not think was a problem. We were then able to call the patient back or make a note to followup on it the next visit with me. The main key is that NPs working alone, with no one reviewing their charts or sharing their additional 10 years of knowledge can lead inexperience errors. New doctors (interns and residents) require years of supervision before they are free to make all decisions alone. Nurse practitioners are immediately free to work in stand-alone clinics as soon as they graduate. Patients need to know that they may need to request a follow up with a physician as well.
Very well said! Just as someone needs to know whether they are seeing a dentist vs a dental hygienist, or an attorney vs a paralegal, a patient should know whether they are seeing a physician or a midlevel provider. There is a significant difference in the education/training involved. I saw one statistic in which a dog groomer required 800 hours of training, but a NP only 500 hours of clinical experience (I am sure some programs require more than others). Thank you for speaking out!
Yes! This is absolutely my point. I have had my teeth cleaned for years by my dental hygienist and after she is done, the dentist comes in and checks. Sometimes they both agree things are fine. Sometimes she was concerned about something and he was not, or vice versa.The point being is that the hygienist is an extremely valuable asset to dental care and allows more people to be seen each day, HOWEVER, dentists are still responsible for managing patients and check us and make recommendations. Midlevels need this same oversight by physicians. The training and expertise are not the same.
You are starting only 500 hours of clinical but you fail to recognize that NO may have been a practicing RN for over 30 years. At which, that RN now NP has spent more hours at the bedside than any other clinical professional, including an MD. All providers offer a unique, qualified and licensed skill set! I prefer to see my NP for annual care and routine needs. I prefer to see a surgeon if I need surgery. It appears to me that the issue is that historical medical billing abuse, financial threat and increased demand put many MD providers on edge when “mid level” as your refer professionals serve patients well.
One of the reasons I employed an NP in my private practice for 15 years was because they had valuable RN experience before getting their NP. Sadly, I now see brand new RN go directly to online NP and then get hired as a fully trained healthcare provider, with no experience. There is no requirement for NP to work any specific amount of time before they are placed independently in an urgent care center. All healthcare providers are indeed valuable but the newer NPs are being placed in positions that they are not experienced enough to perform. Unfortunately, they do not know what they do not know! Because urgent care centers are frequently staffed with brand new inexperienced NP, many patients do not realize that they are not physicians. So I am just making sure that they ask and not just assume.
I also find things physician’s have missed. We should work as a team. No one is perfect in their practice though we strive. I’m an NP. We are not midlevel anything. The AANP requests you call us NPs. After 18 years of pracrice I can practice independently but let’s be real. No one practices in a vacuum. I refer when a pt needs surgery, a colonoscopy and an endocrinologist as do you. The IOM state we provide at least equal care and sometimes better in primary care. I’m an NP and glad in my practice I can serve my 350 pts in the rural area I practice. I am dual board certified and am Associate of the American College of Cardiology. I can provide primary care safely. I have devoted my life to caring for those in my rural community and am on call 24 7 for them. We provide different care I’m a nurse practitioner your a physician but my 18 years under a ohysicusn count. I’m tired of being discredited for my 9 years of college and years if practice in both critical care and now primary care.
I think one of the reasons this issue has escalated is due to finger pointing! I wanted to start a discussion about differences in healthcare providers because patients assume things that are not true. I want them to ask so they know who they are seeing and understand the specific training of that specific provider. There can be a huge difference in experience between independent NPs. Someone can have 10 years of experience and work well with less supervision but brand new online NPs are being placed independently in urgent care centers. This is unacceptable. The field of medicine is not an exact science and diseases may look different in different patients. So perfection is never achievable and no one says that physicians are perfect! But the risk of missing critical things is higher with less experience. I used the term midlevel because it is my way of saying non-physician providers, which included NP and PA practitioners.
Shannon, I agree – call us what we are. “Midlevel” is insulting and a made up term. No accrediting body refers to us this way. It is truly a slight. Also, it is widely published for anyone to read how different the education/training, as well as experience, for NPs and PAs is. To group us together is to further potentiate the problem of misinformation for patients. CALL US WHAT WE ARE.
I am sorry you find midlevel offensive.But there are still plenty of people who use the term. This particular discussion is about healthcare providers who are physicians vs non-physicians. I understand that education training varies between PA and NP, but they vastly vary between NPs as well. In the old days, it was required that RNs work for 2 years to gain clinical experience before getting NP. Now inexperienced RNs can do only NP work and then immediately secure a job as an independent practitioner! My goal is to inform patients that they should not assume anything about their providers since there is a wide gap between education and experience. Having an NP who has worked for 10 years vs 1 year may make a patient feel better. Knowing your child is recommended to have surgery by an NP vs a surgeon is important. The goal of my post is to simply tell patients to ask. It should only take a few minutes for each provider to state that they are a physician, PA or NP.
Well said. NPs (and RN) are important to the healthcare team. A physician led healthcare team. Very well written.
Every career field has team leads and other invaluable team members. No matter how long a paralegal has practiced, it will never be equal to a lawyer. Due to a physician shortage, we have accepted midlevel care to bridge the gap but we must remember that the fully trained physicians should remain the team leaders.
Honestly, you would want to know that if you were accused of murdering someone, that your lawyer wasn’t a tax attorney! Why wouldn’t you want to know what the credentials of your healthcare provider are?
Excellent point! We just need to remind everyone that they have choices and the right to ask who their provider is!
I am a NP myself and have been in practice for 18yrs. I have seen a lot of changes over that time and as you pointed out some are very scary. I agree with you 100% that our training in most cases is very good but not up to that of a Physician. Any NP or PA who chooses to misreprent themselves to their patients should be ashamed. If they truly feel they are well trained and capable to treat patients then stating their true role should not be an issue for them! Thanks for the acknowledgment that our roles do help patients when in fact it’s done honestly and professional in collaboration with a physician.
Thanks so much for posting. I worked with NPs in my office for over 15 years. They were incredibly valuable but there was never any confusion about our roles. I think things became confused when states granted autonomy. Then it became a slippery slope that whatever they felt comfortable doing was fine. The healthcare community has greatly benefitted from both NPs and PAs and we should continue to strive to work as a collaborative team!
I’m with you! I’m a PMHNP. Everyone (even my MD) called me ‘Doctor’ to start with. I go by my first name now, because I am not and likely never will be MD or DO, but I provide excellent care, collaborate with my colleagues (both ways), and I am very VERY proud to be a Psychiatric NP. If my patients don’t respond the way they are expected to, I call in MD, PharmD, other NPs… I’m looking for answers, not initials, at that point.
Thanks so much for your post. We should all be proud of our professions and work to provide the best care possible. Your doctorate is a great honor but I am so glad that you understand how confusing this can be for patients. Providing great care is all of our goals.
This is a great resource to describe the training differences…
Thanks for the great post!!!
https://www.tafp.org/Media/Default/Downloads/advocacy/scope-education.pdf
I truly was hoping to bring awareness that we all see a variety healthcare providers. We just need to be aware of the training differences and not assume each provider is the same. Thanks for reading AND sharing that great resource for more thorough comparisons.
I’ve always been a supporter of the health care team. Like any team, each member performs a specific role that is vital for the team to function smoothly. And as with any team, there can only be one captain. The best health care team is the physician-led team. For the team to remain successful, all members of the team must be respected, from the physician to the medical or nursing assistant/tech. Once each begins misrepresenting who they are, ceases to respect the role of each member and ignores their contribution, the team falls apart and we lose the game. And when we lose the game, the patient suffers. We have allowed the business of medicine to not only disrupt the team, but to re-structure it, all in the interest of increasing profits. The patients never even entered into the equation. Now there is a ground swell of physicians taking back the lead and re-forming the original team with one unified goal: to win the game. And our patients should expect no less than the best in this great country of ours.
I could not say this better! Such a perfect explanation. Thanks for sharing that.
Thank you. My 18 yo Daughter with T1D was in DKA and she was seen by a PA in the ED. Mind you she and I have been managing her T1D for 14 years and her last ED visit was 12 years ago (I am an RN as well as a Mother). She was just in DKA due to dehydration related to the Flu., not severe hyperglycemia. The PA wrote admission orders for SS Regular Insulin every 4 hours, and told her to turn her pump off! Well I disagreed with the PA, explaining that everyone needs a basal Insulin…she continued to disagree…. (the pump was never turned off)
Example of why these providers (PA’s) with limited education should not be caring for complex conditions
I am so sorry you had to go through that. Simply having a physician to consult with would have allowed the PA to consider other options instead of simply working on “standard” DKA protocol. We must individualize care. Thanks for sharing your story.
Im so glad someone is speaking out about this madness.
When we have mid levels work up up pts by following algorithms that they barely understand and managing diseases they have not been trained to treat ! It’s not madness but dangerous!!!
I agree that patients cannot be managed by following protocols. Those are meant as s starting point but then we individualize it. It is harder for midlevels to deviate from protocols without input from physicians. This is what the team is about!
Thank you Doctor Momma! The patients deserve to know who is making decisions about their healthcare! Misrepresentation rarely occurs with the highly skilled and competent mid levels because they know they can be proud of the care they are providing. It takes years to get to that level of competency and it is downright dangerous to have someone with 3 months of shadowing able to practice independently!! I am a doctor mom OB/Gyn with three daughters so look forward to reading more of your blogs as I am certain I will be able to relate!
Yes, the range of experience and training in NP is variable. But there are some who go directly from an online training to an independent walk in clinic. There are no rules for how long an NP needs to be in practice before they can function without a physician present. It is just important for patients to be aware of the training level of their provider!
As an NP student, and BSN RN with 6 years of RN experience and 15 years of healthcare experience, two bachelor’s degrees, and am working on my 2nd master’s degree, I have never heard of an NP program that allows you to graduate and practice (let alone a state Board of Nursing and/or Medicine–many states require both to license an NP) with 3 months of shadowing. You can pick apart bad NPs all you want, but at least use accurate information. Further, the entire thrust of this post is “new RNs go straight to a 100% online program, graduate and are independent nurse practitioners” could not be further from the truth. ALL nurse practitioner program require 500 or more hours of clinical rotations, in which you see patients, diagnose and treat their symptoms through all the normal means (lab work, imaging, referrals, etc.). Every program that I have encountered also requires several on campus experiences, including the diagnosis and treatment of “standardized patients” (oh, the same standardized patients that are used in the medical school and PA program–in fact, the testing occurs in the same lab). These *minimum* number of hours of clinical rotation (in person, in flesh and blood) are REQUIRED by law by states’ boards of nursing and/or medicine. There is no getting around these requirements. Seems like in your post, you are making a faulty argument–one the one hand, you discuss the very negligible brand new RNs who somehow tricked the system and got into NP school, completed didactic and clinical rotations, graduated, took and passed boards, and are now ALSO living in a full practice state. On the other, you compare this unicorn to the esteemed and long-tenured practicing surgeon. Maybe compare that unicorn, no-experience NP (that basically doesn’t exist) with oh, I don’t know, a doctor who fast tracked their degree by doing a sketchy program in the Caribbean, then passed their USMLEs and end up working as an MD, by themselves in a small town, doling out meds for $. Compare apples to apples and oranges to oranges. The anecdotes that you give in your piece are just that, anecdotes. Your patient quite possibly misremembered or didn’t understand that the provider at the ENT office was an NP. That does not mean the NP misrepresented himself or herself. She/he may have stated everything clearly and your patient misheard/misunderstood/misremembered. With all due respect, your post is quite inflammatory and needs to be fact-checked. Perhaps doing some more research on this topic would behoove you and your readers. Cheers.
Thank you for your response. I will just have to disagree with you since I have spoken directly to an NP who did her degree immediately after her BSN and did not use her RN clinically. She did her NP online, then she “shadowed” a physician who did not allow her to see or treat. He signed her paper. She accepted it but felt untrained. Anyway, the gist of my post is to inform patients that all healthcare providers do not have the same training. They should simply ask for the credentials and you can say all that you did above. That should make your patient feel better. If you had to say that you graduated in December and are working alone in an urgent care center, the patient may not be as happy.
As an FNP student, and RN for 11 years, I feel as though I need the support and back up of a lead physician. The licensing exam we take only ensures that we are minimally competent. The rest comes with on the job training. I would never choose to work with full autonomy. One thing we are constantly told is that we are standing in a gap made by fewer medical doctors choosing to enter family practice as there is less money there than in specialty care.
I love your comment because it speaks about you as a healthcare provider seeking to do what is best for patients. After training, many new NP are offered jobs where they function independently. Regardless of what others tell them, they know they do not have the experience or expertise to do that. But sadly, it is a decision that each NP gets to make, even if they are not prepared. It is not acceptable to learn on patients when they could easily have a physician for back up. Thanks for your comment.
Well said.
Ain’t gonna happen.
I have enjoyed a 20+ year career in primary care as an NP.
Physians do not have time to supervise NP’s.
The MD’s I’ve have served with are slammed and are just trying to keep their nostrils above water. Review and advise patient’ charts after a crazy-busy day seeing 30 patients, dealing with fractured EMR systems, med refills, reviewing labs, dealing with phone calls to patients, specialists, reviewing records?
One of the issues you do not address is a major driver on heath-care costs, and that is the crazy salaries
Commanded by specialists?
Your article is sweetly but glaringly one sided,
Are you willing to take a 25% salary dive to supervise the NP’s in your office?
I employed NPs in my private practice for 15 years. One of the reasons I stopped was because the training changed and level of experience was glaringly absent. It used to be RN needed at least 2 years of work experience before getting their NP. But now online NPs are being hired to do independent clinical work. Salary discussions are another topic but should not make up for inappropriate care. An NP with no experience working solo in an urgent care center is inappropriate! The discussion about specialists is also a completely different discussion. An NP specialist will at least have more experience than the brand new NP doing primary care. This is indeed complex and it is not a good thing to mix all the issues. I am starting the conversation and letting patients know that they need to ask for credentials and experience and not just assume that a provider working an urgent care center alone is a physician. That is assumed many times.
I think you missed her point. Whether or not physicians have the time to supervise is irrelevant when non-physicians must be supervised. Corporations have slipped by this hurdle by placing pressure on physicians to indirectly supervise. That is, sign charts on patients they have not seen or after the patient has been dispositioned. On paper, it is assumed to be direct supervision. In reality, it is fraud. Physicians who refuse may lose their jobs. Less physicians being hired because the corporations don’t want to pay cost it takes to hire a physician anymore. Not because they cannot afford it, but to increase the profit margin. Like the author of the article, Those being supervised inappropriately have a responsibility to speak up on their own behalf. As a resident, if I had not received adequate supervision, I would have complained to my program director. It is not only my education, it is my license. I supervised and trained multiple NP’s for nearly 18 years(I’m EM). The ratio of physician to MLP was doable. Then I was required to supervise 2-3 while simultaneously seeing the most critical patients. I was no longer supervising the more seasoned, experienced nurses, I was getting unprepared, inexperienced nurses with minimal to no clinical knowledge base. And I had all the liability, the company had none. So I stopped. Makes it difficult to find a job because I refuse to supervise anyone for whom I had no input into hiring. Not worth my license or livelihood. For the record, I have not been paid once cent to supervise or teach a NP in my entire career. No where else is someone who is expected to teach is expected to do so free of charge–except in medicine. In addition, the article is not about salaries, it is about Truth in Advertising. And it is wrong for a NP to misrepresent themselves as a physician. Period. It is also wrong for an inexperienced NP to open a practice simply because they have the license to do so. The nursing establishment should demand standardization of the entire nursing educational process before fighting for the unsupervised practice of all. It is simply not right or fair to the patients. They need to do the right thing and police their own.
As a practicing NP, and what I feel to be one of the “good ones,” I completely agree with you. I strongly support NP residencies and am appalled by the online NP school. I have been lucky enough to work with a cardiologist who treated me as if I was in a residency program which vastly helped to expand my way of thinking and my knowledge base. This was invaluable. I am now in family practice and was expected by the physician owner to basically be “seen and not heard.” He wants me to see as many patients as possible and bother him very little. Hes a nice guy, but just sees the $ I suspect. When I was hired I voiced my desire to have a weekly lunch meeting for education/ case study, but he simply asked “why?” And despite my pushing it never occurred.
I feel that your fear of backlash comes from the frequently voiced opinion by MDs that NPs are terrible and dangerous providers. I appreciate your statements that we are valuable. Thank you.
Yes, this issue has many parts to it and everyone is to blame. The system is flawed in many areas. All sides are tired! I am not sure why the requirement for 2 years of RN experience before going for NP was dropped. This helped with their care. And physicians have been placed in direct competition with new NP at urgent care center so many are not hiring NP and letting them function the same way. That is wrong too! They have taken the route of “if you can’t beat them you need to join them”, but having an NP working in your office without you spending time to train and teach them is counterproductive When I employed NPs, I reviewed all notes and sent feedback and would explain my reasoning so that over time, they learned. Just on the job training alone does not create good skills. NPs and PAs do provide great and valuable care, but we need to acknowledge training and experience and let patients know.
I have practiced as a PA for over 40 years and agree completely with what has been said here. However in my opinion the problems being seen with mid-level provider are not entirely due to healthcare organizations worrying about the bottom line. Physicians are partially responsible. Where were the physicians when 23 states and DC gave NPs independent practice? Why aren’t the physicians banding together and telling healthcare administrators enough is enough. They owe it to the patients. I firmly believe that healthcare should be provided by PHYSICIAN LEAD TEAMS but the physician leaders need to exert their leadership.
You are absolutely correct. The pendulum has been swinging for a long time and physicians assumed it would stop. And that NPs would avoid taking jobs beyond their comfort level but this has not happened. Many new NPs voice concerns about being in over their head but they do the work anyway. It started as a bottom line solution and now it has morphed into a huge healthcare issue. Physicians are now starting to band together but our governing bodies are not nearly as aggressive as nursing governing bodies who are aggressively approaching state officials. We as a group are behind but starting to make progress. In the meantime, we do need patients to know that because they are could be seeing providers with limited experience, patients must ask for the provider’s credentials and level of experience. Then if they are not satisfied, seek a more experienced practitioner. PAs and NPs are invaluable members of the healthcare team but physicians should remain the team leader!
One Old PA,
You have hit the nail on the head. Physicians are passive and compliant by nature, that is how we lost control of medicine in the first place. Our opinions are not respected nor are we valued by the Corporate Medical Groups, hospitals or even each other. The CMG’s infiltrated medicine and made it a business while we stood by and allowed it to happen. Until I became a member of an organization fighting the expansion of unsupervised practice of non-physicians, I had no idea the problem that existed on such a large scale. I work in a supervised state(California). I was stuck in that cocoon and never knew other states had unsupervised practice. My organization, along with other patient advocacy organizations, are now fighting this progression. As with most change, the effects of the lack of supervision has now become apparent over a period of years. It has led to mismanagement of patients. Many of us began noticing this trend and became concerned. It is when we began doing our research and became aware of the online degree mills proliferating all over the net without any regulation. Then it all made sense. If anything will mobilize physicians, it is when patients begin to suffer the consequences of bad decisions made by the medical/nursing establishment. Yes, we are behind the eight ball, but we are doing our best to catch up. We owe it to our patients. We let them down in the past. No more.
I have been a PA for almost 30 years. I think your thoughts on the matter are pretty fair and, overall, balanced. Among other things over the years I have been on the board of a hospital district and seen and heard many discussions and arguments not just about PAs but among physicians about each other. Should the well trained general surgeon perform EGDs and colonoscopies? NO shouted the GI physicians. Should podiatrists be allowed to operate on ankles? NO shouted the orthopedists.
All of these arguments were settled with a couple of basic questions. Do they have adequate quality training and has their competency been tested and proven.
We all have our lane of traffic and need to stay in them. PAs, much like physicians, come from varied training (I’m an Army trained PA BTW), and have different skill sets and experience levels. There is too great a propensity to paint the entire profession with a broad brush. Are their PAs acting outside their scope. No doubt. That needs to be addressed as it happens much as bad actor physicians are. These one-off anecdotal stories don’t pass the sniff test as proof of anything. Anyone follow the story of the Dallas TX neurosurgeon who killed and paralyzed several patients before anything was done? I don’t think he was representative of the profession and would not use that as an example of anything global.
As to identifying ourselves and our credentials…absolutely. Anyone who doesn’t simply isn’t being forthright. I have a PhD but NEVER use the title doctor at work. I rarely use it at all. I think my colleagues that do are being disingenuous. One man’s somewhat unpopular opinion. On the flip side I have to wonder how many of my physician colleagues would welcome a grilling about their education and experience several times a day every day. good for the goose…..
Thanks so much for this discussion. These are all valid points which is why I am suggesting to start with the basics! Ask who your provider is, their training and experience. When I was a young doctor, I was constantly quizzed about my credentials because I was felt to look too young! I have printed bios that are passed out to my patients so they know my training but I still answer questions that are asked. It is fair and should take just a few seconds to answer! It is always assumed that “Dr” in the clinical setting means physician which is why doctorate nurses and PAs who use their earned title add to the confusion. I understand that the degree is earned but patients are making assumptions. When patients begin to ask about training, they can then learn it is a doctorate in nursing or PhD. Years of experience are invaluable. And yes…turf wars are another whole discussion! Overlapping specialties are normal but I am addressing non-physicians who are working in clinics with no supervising physician. No one to check notes and medication choice. Many of these providers are directly out of an online program. That is not acceptable. There should be some way to be sure that experience with supervision is done first.
Well stated. And excellent points.
AGREE that patients should know the training and experience level of the person treating them. A point not mentioned in your post is that sometimes the non-physician provider is the more experienced provider. I am an emergency medicine PA with 30 years of experience in the field. I work solo in a rural emergency department with physician backup as needed. The facility I work in also hires FP physicians who just graduated from residency. As a patient, would you prefer to be seen by a PA who has done nothing but emergency medicine for 30 years, has intubated forever, has run codes forever, reduced fractures/dislocations, treated overdoses, heart attacks, and strokes, etc or a 29 year old FP physician who may have spent as little as 3-6 months in an ER over their entire medical career to date and may NEVER have seen the condition you are presenting to the ER with? I am proud to be a PA, introduce myself as a PA, and have PA all over my ID, scripts, business cards, etc so there is no confusing me with a physician. I am well aware that a residency trained and boarded EM physician has more experience than I do, but the truth of the matter is that physicians do not always work within their training, sometimes to the detriment of patients.
Experience is always important! A physician with 10 years is better than a physician with 2 years. But at a baseline, a physician has had a minimum number of years of supervised training whereas the some of the new NPs received online degrees and have never seen patients. Yet they are placed in urgent cares with no supervision. New providers in all disciplines are the least experienced but coming right out of training, it should be required that you have some level of physician supervision. There is no doubt that NP/PA providers with years of experience are invaluable.
But since there is a wide range of experience levels, I believe patients should know who is providing there care. For the most part, they make assumptions.
Agree that new grad PAs/NPs should work as part of a team with physicians until they have a firm grasp of their specialty and should always consult(just like physicians), regardless of their years of experience, if they come up against a situation they are unfamiliar with. FWIW my experience prior to working solo as a PA was 5 years as a paramedic in busy 911 systems followed by a PA program concentrated on emergency medicine with rotations in EM, Peds EM, trauma surgery, ICU, etc then 15 years working in fast tracks, community ERs,and level 1 and 2 trauma centers. I also have an academic doctorate, but never introduce myself as “Dr” in a clinical environment. I agree that physicians have a baseline level of training during medical school and residency, but that it is specific to a given field. A urologist or dermatologist should not be allowed to moonlight in an ER as a solo provider(I have seen both). How many trauma codes does a dermatologist run during the course of their training? how many chest tubes, etc.? It is all about training and experience. I wouldn’t try to do a MOHS procedure on someone’s facial basal cell carcinoma. A dermatologist should not staff an ER…..Thank you for posting this important discussion. This type of thing often become heated and you have treated the topic well in your blog.
Thank you so much for this comment. The bottom line: experience is king. Even recent residency physicians, they need to consult with their new partners until they are better experienced. You had a ton of experience before going to PA school so your growth curve was quick. Because there is no requirement for supervision, it is completely up to each provider to decide what they want to do. A nurse who has worked for 5 years before going to NP school is very different than the new RN doing online NP program, yet they are offered same jobs! We cannot stop anyone from taking a job without supervision, but if patients simply ask about training and graduation and prior experience, they may opt to followup with a more experienced provider. I love hearing so many PAs say that they would never introduce themselves as Dr in the clinical setting, but doctorate nurses do. It simply adds to the confusion. But if patients ask, they will learn it is a doctor of nursing rather that medical doctorate.
Some of these “midlevel providers” have more bedside clinical experience then most physicians who’ve just had their heads in their books. PS, they are doing away with that term- it was declared inaccurate and demeaning. Look at your recent research, studies show just as good, if not better outcomes from “mid level providers”. So I’ve been studying medicine since 2008, have practiced as an ICU nurse for 5+ years and have been in school for the past 3 years going for my Acute Care NP license… Simple math demonstrates that I’ve either been studying medicine or practicing in a clinical setting for 10 years. 10 YEARS. How long is medical school again? Residency? Fellowship if someone decides to specialize? Training is different, I won’t argue that. But everything else you declare is nothing short of a terrible and misinformed opinion.
I am not sure why you are saying I have misinformed opinions! I simply said I think patients should ask about the credentials of their providers. Some NP/PA do have more experience than new physicians. However, there will never be a new medical school graduate who works unsupervised in an urgent care center. All physicians have a minimum level of education AND residency/internship, which is not head in the books. It is actual clinical care. There are new RNs who pursue online NP degrees without any clinical experience and they are staffing urgent care centers with no supervision. You have been in the field for a long time, that is awesome. But I am saying that all NPs do not have RN experience or NP experience before they are practicing. Because there is such a wide range, I suggested patients ask. If they are seeing you and you say you are an NP who has practiced for 10 years and worked in ICU for 5 years, your patients may feel more comfortable than you saying you received your degree in December. Answering questions about credentials should take a few minutes. I had to do it for years even after I completed my fellowship because patients thought I looked too young and inexperienced. I simply laid out how experienced I was!
Here we go. The point of her post is that people should not have to guess if they are seeing a physician, an NP or a PA. She was simply asking people to inquire about credentials. That is totally fair. If you feel that your credentials as an ICU nurse and education/experience as an NP are equal or superior to the education of an MD or DO, then you should not be at all threatened by her opinion. Also, the research you refer to was largely conducted when non-physician providers were treating previously diagnosed patients as part of direct supervision under a physician-led team. The VA conducted a meta analysis on these studies and stated that they were limited by methodological deficiencies and poor quality data. In other words, they did not meet the standards or rigors of quality, peer-reviewed, evidence-based research. You mentioned that you have been studying “medicine”, so I assume that you would be aware of this. More recent studies are demonstrating a different trend. But I digress…the point of this is to encourage patients to ask for the credentials of their provider so they don’t feel they have been lied to when they realize they have not been seeing a physician, which seems to be happening quite a bit.
Thanks so much for clearing up the research question!
As dismissive as you are about books, it is where we begin our education. The human body is a complex system that requires extensive knowledge. The information necessary to acquire that material is nothing to denigrate. Medicine is not static, it is continuous and everchanging. Therefore, one’s knowledge must continue for the duration of one’s career. I’ve been practicing EM 22 years and I still have my “head in the books”. For you to say you have been “studying medicine” is misleading and dishonest. In this country, the study of medicine includes medical school and residency. Simply reading books used in that course of study does not constitute studying medicine unless there is an appropriate didactic and clinical structure in which one is also taught by those who practice medicine. You are spinning. And those years of ICU experience, although admirable, do not constitute the practice of medicine. You were practicing nursing. No where in any book, criteria, guideline, protocol, etc. does nursing experience equate with the practice of medicine, any more than my years of practicing medicine make me a nurse. More spinning.
The studies you quote that prove clinical outcomes are “as good or better” than Family Medicine physicians(not all physicians as your statement implies) are based on accumulated data of supervised NP’s. Cannot utilize studies for unsupervised NP’s using data for supervised NP’s, it is inaccurate and useless. A meta-analysis of those studies performed by the Veteran’s Administration, referred to as the “Evidence-Based Synthesis Program”, was published in September of 2014. The conclusion drawn? One can draw NO CONCLUSIONS based on the studies because there was insufficient information and the studies were poorly done.
Bottom line is that the author is encouraging Truth in Advertising. The patient should know who is treating them. It is the right and honest thing to do. Anyone who says otherwise has an agenda that is not in the best interest of the patient.
Thanks so much for this post. Yes, studying medicine requires extensive book studying which is why we spend 4 years after undergraduate degrees. But then EVERY doctor must have clinical training in the form of internships and residencies before they are allowed to independently practice. New NPs are allowed to see patients with no clinical experience after an online degree. This is something that patients need to be aware of. Asking can save them any confusion.
I cannot believe the amount of misinformation in this post. The education and experience of Nurse Practitioners is sorely misrepresented and the use of the term “midlevel” is insulting. I am not a midlevel anything I am an Advanced Practice Nurse with 20 years of experience who has witnessed MDs make plenty of mistakes including an IVY League graduate MD and a Psychiatrist misdiagnose a woman with hypothyroid for years putting her on anti-depressives instead of testing her thyroid. Radiologists missing fractures on x-rays, Surgeons causing fatalities and these are just a few of the mishaps I have witnessed myself. NPs don’t pretend to have gone to medical school or to be physicians. We have our own profession thank you and I will keep practicing because my patients prefer to be treated for by an NP and in the end it is the patient who benefits from our care.
I am glad your patients are happy. You have alot of experience and can provide care based on that. I guess my concern is that no one has addressed the trend that I have seen where RNs are no longer required to work for 2 years before getting NP degree. And NP degrees can be obtained online. This is a fact, and I am not saying every NP has done that but there are some who work independently at urgent centers with that degree of experience. Since it is a fact, I am not sure what is misrepresented. I have simply said that patients should ask about their healthcare provider’s credentials. Then they can decide if they appreciate the experience or not. The less training and experience someone has the more likely the mistakes will be, in any profession. I would hate for physicians to change their training so they can open private practices without going through a residency to get the needed experience.
I anxiously await for a single shred of evidence for anything you said in this post. There is a plethora of evidence showing equivlence in care provided. All these years APRNs have been working independently and the outcomes are the SAME.
This practice would have long since ceased if there was an increase in complication or risk. Yet it hasn’t because there isn’t.
I understand your desire to promote a physician monopoly but just say it. Your statements here are intellectually dishonest and promote fear mongering.
As uptown Sinclair famously stated:
“It’s hard to convince a man of something where their salary depends on them NOt being convinced of it”
I am confused about your statements. My biggest concern is that the new NPs do not have the same level of rigor in training that the old ones do. Previous NPs had clinical RN experience, then NP training and then working with physician supervision. Now it is possible for a new RN to get online NP degree and then be hired to work independently with no physician supervision. This was not the case. This is something people do not know is possible. I did not say NPs give poor care. Experienced NP and PA can provide great care, but just as new physicians need supervision (residency) before they can practice, it might be good in NPs are required to have some supervision before going solo. Or…they should have no problem saying they just graduated when patients ask. I am not fear mongering. I am saying patients should ask about credential so they are not confused.
“Absence of evidence is not evidence of absence.” No one has bothered to do any good research, just lousy studies by the nursing organizations. None of those studies include “independent” NP’s–none. They are all based on supervised NP’s which makes the studies useless. It is so easy to do a review analysis of the very studies you quote, so why don’t you? Accusing someone of spouting misleading information when you haven’t done your homework doesn’t make you any more honest. There is evidence of increased claims and payouts since the increase of unsupervised practice. Contact the Nursing Services Organization(NSO) and get the statistics. These are data collected by a nursing liability company. Factual data with no physician involved in the collection of the data. Therefore, no one can claim it was biased because a physician had input. Or contact your local nursing association and ask for the data for your state. You may find what I found in CA(which is a supervised state). Since 2009, claims and payouts have increased. Largest claims are in missed diagnoses, misdiagnoses and over-prescription of medications(ie: antibiotics, narcotics, etc.). Your own data. It’s there, all you have to do is ask for it from your organizations. And the NP’s still keep practicing. No one has put a stop to anything because the nursing boards are notoriously lax. And it has become very popular for some NP’s to accuse physicians of being greedy for money because we resist unsupervised practice. It couldn’t possibly be because we care about our patients, just like you do. Most of us have never been paid to supervise or teach MLP’s, myself included. In 22 years I’ve not seen one red cent. And not one NP ever offered to compensate me, despite my time. But I sure as heck have accepted the liability. We have a right to make a living, just like you do. We took a Hippocratic Oath, not an Oath of Poverty. That would be Mother Theresa.
This is a great post filled with useful information. I agree that old studies were based on the old way NPs practiced, supervised. Now it is very different. And the unsupervised practicing NPs with less experience has been a recent trend. The data is being collected though. I will just reiterate: Ask your providers for their credentials and ask how long they have been practicing. This is a simple thing that all healthcare providers can easily answer and allows patients to be seen with transparency.
A couple of points about your post and my opinion on the matter. I am an NP and in Ontario where the training required to license is regulated and the education is very standardized. In fact Ontario’s top universities deliver our curriculum via a partnership through a consortium. Secondly you can’t compare PA’s and NP’s, the difference in education, training and licensing is not the same just like NP versus physician is not the same but that is a separate issue entirely. NP’s are trained to work independently within their scope of practice and they should know their scope!
I have worked for 14 years as a registered nurse and now 4 years as a nurse practitioner and trust me you are not the only one that has found many situations where there were obvious mistakes, mishaps and just plain ignorance regarding the care of patients at times. Sometimes these mistakes or mishaps seem to be part of a system problem where the patient has fallen through the cracks, or a situation where a physician or other healthcare provider has misdiagnosed or completely ignored the patient’s concerns or the patient themselves didn’t bother to follow through with things to ensure proper diagnosis and treatment. Trust me I have seen many situations that have kept me up at night. I practice within my scope and I am never worried or frightened to tell a patient that I don’t know something and I am never shy to consult or refer to a physician or specialist or any other healthcare provider as needed. You mentioned that collaborative practice is important between and NP’s and physicians and I agree with you there, however for many NP’s this isn’t an easy reality. Mid level providers as you call them are fighting a battle with both administration and the physicians group. We have administrators pressuring us to see more and more (quantity versus quality healthcare system) and we have physicians being passive aggressive or just plain aggressive when we need their support in dealing with a problem that is truly outside our scope of practice. I have had specialists refuse my referral all because they would be paid less then if a physician did the referral! Luckily this issue seems to be resolved now, at least in Ontario. On top of this we are constantly fighting a battle to help patients understand what our role is within the healthcare system and we are constantly working to gain trust of both our patients and our coworkers and physician colleagues. Trust me when I say post like the one you’ve written do not help the matter. In my opinion you would’ve been better to write a letter to the nurse practitioner that misrepresented herself ensuring that they change their practice and make sure that they know that it is unacceptable to allow patient to believe that they are being seen by a physician when they clearly are not. Your post instead is suggesting that every patient should just instead request a physician because nurse practitioners aren’t capable of handling people’s health care needs and you were painting the profession all with one brush! I could do similar and write multiple posts of many detailed situations that I have witnessed handled badly by other healthcare providers including physicians. Anyone who would read these posts would surely question and may begin to feel insecure about the care they receive by these providers. In my opinion you should be focussing on changing the system not bashing the mid-level providers that help support your practice ensuring that patients are seen in a timely manner in the most efficient way possible and in many cases cleaning up messes sometimes before they even happen. In my career I have been especially lucky to work alongside a dedicated group of healthcare providers including physicians that I have learned from learned with and can consult without fear or intimidation. I would encourage all physicians to work with and encourage your NP colleagues and directly and politely ensure you continue to educate in situations when needed. I would also suggest that everyone start holding each other accountable for excellent care for all no matter what title that person holds. If you have a question about my management of a patient please pick up a phone talk to me write me a letter I will always respond I guarantee you that most nurse practitioners will. Please don’t bash everyone of us or paid us all with one brush but please reach out and help guide and inform and educate when needed this is what will grow the profession and the collaboration between healthcare providers work on system solutions stop pointing fingers and for goodness sake‘s stop telling patients that we are not educated enough to manage most of their healthcare needs. ( dictated via my iPhone I apologize for any grammatical errors )
I am sorry you feel that my post is personally attacking you. In fact I went out of my way to be generalized. Medical schools are standardized in the US, NP programs are not. It is awesome that yours is. I also did not compare NP to PA, I simply put both in the midlevel/nonphysician category. You have spent alot of time listing details that are not related to my post. I was not attempting to discuss the many different options for training for NPs or PAs. There are lots of degrees and different criteria, including an online version. The gist of my post is simply to allow patients to know that they should ask about all healthcare provider training. Experience is important for all providers. I was asked for years as a young physician, I am simply saying to avoid confusion ask. I don’t understand how you can feel my post bashed anyone. I said NP/PA are not physicians and patients should not assume they are. Asking is the solution.
I temporarily closed this post to new comments because it became a collection of stories not related to my topic. I felt the need to reply to all comments but it went off subject. In no way did I intend to discuss the criteria and merits of each training program or what each person has personally done. I purposely tried to discuss just one small topic because trying to discuss all aspects of the healthcare team rapidly spiraled into stories of providers who gave poor care. That is not the topic.
I think we can agree that some RNs work for years getting clinical experience, while others do not at all. Some NPs are in great training schools while others are online. Some NPs work with physicians for supervision to improve their skills before going to work independently, some do not. Some NP/PAs who have earned doctorates understand that using the title “Dr” in a clinical setting is misleading to patients while others insist on the title. Some NP/PAs clearly state their training and others do not. For these reasons, I believe the public should know that their assumptions may not be correct. Every patient does not need to be seen by a physician but every patient should have the right if they choose. When patients ask healthcare providers about their credentials, they have the right to know your degree and the length of time that you have practiced in the field. Then they can continue their carefully informed.
Thanks for taking the time to read my post!
Woah! I’ve never even thought to ask these questions. Thank you for this information.
This is great to hear as it was really the main intent of the post. To allow people to never make assumptions and empower them to ask the questions they need to better understand their medical treatment plan.
Dear Dr. Mommasays,
I love your input and personal/professional comments. I was working on my CRNA when God had other plans for me due to health issues and crosses that I bear quietly and proudly.
Your input helped my question… Is my FNP qualified good enough for my PCP? I say yes, but I know that she errs on the side of caution which is why I’m referred to a specialist for every possible problem that could be outside the scope of her safety margin or competence level.
I know she’s smart and relates well to me as I am a 4.00GPA medical professional… a few years away from my CRNA which I bowed out from… (Due to the fact that my precious father was improperly medicated… (i.e., DX = Myasthenia Gravis and given Fentynal push which is strictly contraindicated in the PDR. He also received Pancuronium Bromide (Pavulon) and Versed while hospitalized… which are also contraindicated, He was in good health, strong cardio and yet at 5.5 weeks in a teaching hospital they euthanized him as he was 76 yrs young. He did NOT HAVE a DNR (flag in his med file).
It’s no wonder why medical costs are incredible as I’ve been referred to Pain Mgmt., re: Spine etc., Ortho (Bi-lateral avascular necrosis of both hips…(L) hip is J&J metal on metal DePuy hip that is already replaced but needs revision , Neurology (Spinal problems T2-L5), Endocrinology for Low T, ENT for malignant throat cancer, etc. My former Board certified PCP took care of everything. However, now I’m on Medicaid and I get the runaround. I’m a boomer also and happened upon your site.
God Bless you, happy safe holidays.
Paul (Phx, AZ)
I am so sorry about your journey through our complex healthcare system. There are many reasons our system is broken, including an emphasis on cost savings which actually end up costing more! Extra specialist referrals do cost more than having fully trained primary care physicians to become involved in care early. I am a strong advocate for nurse practitioners and physician assistants working to provide healthcare as long as a supervising physician reviews the care. There are many details that are learned in medical school and residency that simply cannot be learned in shorter training programs.