MD versus NP as a primary care provider

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    A nurse I work with forwarded on the following article to me that is definitely worth the read: http://www.healthaffairs.org/healthp...hp?brief_id=79

    It is interesting how the article refers to “overqualified” primary care physicians and that much of primary care can be done by an APP (NP or PA) provided that they know when to refer an issue to a physician. Aspiring to be a nurse practitioner and work in primary care myself, I was wondering what other people thought about APPs moving into the role traditionally held by MDs. Particularly in light of the massive insurance changes going on in the next couple of years...
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    I like NPPs in primary care, particularly nurse practitioners. I realize many here will not agree with me, and that's fine, but let's not fight about it!

    There have been studies that show NP care is equal to (in some cases superior to) physician care, particularly with management of chronic illnesses. NPPs are likely to have more time for chronic disease management and that's the role they would fill in the PCMH model. Frankly, no one needs a physician to diagnose or manage diabetes, hypertension, obesity, etc., since these diseases are diagnosed by numerical value guidelines and managed (in the majority of cases) by published disease-specific guidelines. NPPs work so well in this area since what chronic disease requires is TIME to talk with patients, listen to their concerns/barriers to self-care, help them set goals, assist them in managing all that comes with living with a chronic disease, etc. My personal opinion is that NPs are great here because the focus on communication that comes with nursing education, as well as education in theory which includes helping patients make important changes in their lives.

    In addition, NPPs are more than qualified and very skilled with providing preventive care (also guidelines-driven) which will soon be covered under Obamacare for millions more than currently have access to these services.

    Now, if I'm having a mysterious constellation of new symptoms that signify a new and possibly serious disease process, I may prefer to have a physician who has spent years honing diagnostic skills and looks for zebras. But for routine care and maintenance of the human, I prefer an NP.
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    From what I have read and experienced I tend to agree that physicians are overqualified for primary care. We definitely need good physicians in internal medicine and all the other specialty areas of medicine but I think NPs can serve the need of 80% - 90% of the population. On the other hand it does put more pressure on NPs and PAs to know when to refer and when a seemingly mild symptom is actually something much more serious, I think they are up to it though.
  6. 0
    Quote from mammac5
    I like NPPs in primary care, particularly nurse practitioners. I realize many here will not agree with me, and that's fine, but let's not fight about it!

    There have been studies that show NP care is equal to (in some cases superior to) physician care, particularly with management of chronic illnesses. NPPs are likely to have more time for chronic disease management and that's the role they would fill in the PCMH model.

    NPPs work so well in this area since what chronic disease requires is TIME to talk with patients, listen to their concerns/barriers to self-care, help them set goals, assist them in managing all that comes with living with a chronic disease, etc.
    Just a few comments on the notion that APCs have more time. I think it's a myth in many cases. The only reason why an APC would have more time, is if they're seeing fewer patients. And if one isn't working for themselves, the employer will try to get the provider to see as many patients as possible, as quickly as possible. If an APC is seeing the same amount of patients as a physician in a practice, that math just doesn't pencil out. TIME is determined by how many patients/day one sees, not their degree. Time is required for patient education. Not sure why this myth is so perpetuated that APCs "get to spend more time with patients".

    One area where I do agree with you strongly, is that nursing education is much more consistent with education of patients. Medical educations places ZERO emphasis on that, which as we all know is absurd.
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    Agree with teejay. I see just as many patients as my MD colleagues, and I don't spend any more time with patients than they do. I can't. I have the same responsibilities and the same number of hours in a day as they, there is no way I can spend the mythical "extra time" addressing the "holistic care" every one thinks NPs do so much better.

    My guess is non-physician providers will come to dominate primary care, women's health, and healthy peds, while physicians with their specific skill sets will be isolated in the specialties or see only the very sickest and most complex patients in internal medicine.
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    Time...definitely a challenge. I've been working with some educational material for practices going to the PCMH model and NPPs should have more time under that model. Chronic conditions will be followed by the NPPs (freeing the MDs to see new patients and more complicated cases who require trickier diagnostic skills) and those chronic care appts should be scheduled at 30 minutes, minimum.

    We all know that a patient with a chronic condition (and, really, how many of them only have ONE chronic condition?!) needs to learn how to self-manage...and that's where NPPs can shine in primary care. Diabetes, for instance, is about 10% care from a medical professional and 90% patient self-management. The only way to manage chronic conditions correctly is to work with the patients on their lifestyle, the pathyphys behind their condition, how (and why) to follow instructions like checking home blood sugar, daily weights, danger signals for those with breathing difficulties, etc. And how about time to coach and encourage those patients in caring for themselves? What about some motivational interviewing to help patients see for themselves that their goals are not congruent with their behaviors?

    I know many NPPs are paid bonuses for "production" when they see large numbers of patients. I think we need to take it upon ourselves as a profession, to change the mindset from seeing more numbers of patients to seeing our patients more completely so they make progress in caring for themselves. An ounce of prevention...
  9. 0
    Quote from icelind
    A nurse I work with forwarded on the following article to me that is definitely worth the read: Health Policy Briefs

    It is interesting how the article refers to “overqualified” primary care physicians and that much of primary care can be done by an APP (NP or PA) provided that they know when to refer an issue to a physician. Aspiring to be a nurse practitioner and work in primary care myself, I was wondering what other people thought about APPs moving into the role traditionally held by MDs. Particularly in light of the massive insurance changes going on in the next couple of years...
    I'm a primary care NP in a community clinic. I see the same 25 patients/day as my MD colleagues. We occasionally trade patients amongst ourselves according to favorite sub-specialties but otherwise see the same patient population, with the same (lack of) clinic time. Most of our patients don't seem to have strong preferences about what type of provider they see - they care more about seeing the same person each time.

    Someone has already mentioned patient-centered medical homes. I have worked in one of those, and my current clinic is transitioning to this model. The first medical home was located in a place where most patients had basic insurance, and 30 minute appointments with decent reimbursement were achievable. My current location? I can't imagine us ever being able to book 30 minute appointments and still serve our current patient population or make enough money to keep the lights on.

    I think the time issue is going to be a much bigger problem than what type of provider you spend it with, frankly.
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    That medical home 30-40 minute visit, at least here for our BCBS patients, whom are at present the patients covered for the plan, in a once annually visit. Follow ups are, you guessed it, 15 minutes. And the paperwork for the MH visit is such a nightmare, none of want to do them. It is a coding nightmare as well. I'd rather see three 15 minute visits in the same time. In the long run those three will pay better, are more pleasant, and infinitely less hassle. I too was excited about the medical home model when I first heard about it, but like everything else the execution has been a disaster. I'm going to decline to see them until they fix it. I won't do Welcome to Medicare visits either. Have you seen that nightmare? Oh no thank you. Medicare can take their $225 someplace else. No one in my office is willing to do them. What a mess.
  11. 0
    One more comment about the title NPP vs APC. Non-physician providers defines us what we aren't. Advanced Practice Clinician defines us by what we are. I dunno. To me, it seems the latter is the better term.

    treejay
    PA Student
  12. 0
    I worked as a PCP for 3 years before going into a specialty practice. I think a PA or NP is certainly well equipped to serve in this role for the vast majority of patients. I have to agree with Blue Devil that we did not have to see fewer patients than our physician colleagues, nor did we have more time to spend with the patients. 15 minutes per appt., be it for a new or established patient, a sore throat or a complete physical with GYN. We were paid less than 50% what physicians were paid for the same job. I didn't expect to be paid the same as an MD, but 50% was not acceptable. Needless to say, these reasons prompted my move to specialty practice.

    We tried the medical home model at my previous job and it failed. Too many patients, too many issues, no support from admin. I understand why many MDs don't want to go into primary care. It was a great learning experience for me and I don't regret it, but I'll never go back to primary care.


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