Doctoring Health Care Reform

Extending…and perhaps improving

My colleague, Dr Wes penned a provocative piece this weekend about the role of physician-extenders in the future of health care reform.

It was a great piece about a timely topic–a definite glimpse into the future.

My introduction to physician-extenders started more than a decade ago when my second child had an ear infection.

He looked tired, old, and rushed.  This wasn’t how he looked in the Best Doctors article.  There, in the glossy photo, he looked patient, caring and distinguished.  Maybe it was just a bad day, but he clearly wasn’t in the mood for squirming or crying during an infant ear exam.

In response to our son’s protests, the “Best” doctor retorted, “welcome to reality, buddy.”

After that day, we saw the nurse practitioner.  She was great.

There are many ways to see the debate over physician-extenders.  One is to view it as yet another example of new versus old.  Scrub tops versus ties, tennis shoes versus wing-tips, social media versus fear, ablation versus pills, and last but not least, spending time on other pursuits (including family) versus doctoring day and night.

The traditional-minded argue that when patients come to “the doctor’s office” or to the hospital they expect to see an MD.  They also add that physician training is more extensive, more rigorous and certainly more vetted—at least for now.   Though some in this category would like to deny it, there undoubtedly is a component of back-in-the-day kind of thinking. You know the notion:  I did years of training and endless nights of call, thus you should you too . And…back in the day, we walked in the rain and snow to school.  (Wait a minute, I did do that.)

My struggle with applying such traditional (we’ve always done it that way) thinking to physician-extenders is the reality of today.   Let me share my pragmatic side with you.

Reality number one: Supply and demand.  At this moment, and surely in the future, there simply aren’t enough doctors to meet the demands of an increasingly insured and aged population.   We will need help delivering (and documenting) all this care.

Reality number two: Medical training is unnecessarily long. Much of what we spend years learning bears little on our doctoring skills.  One of the commentors, to Wes’ blog (Jay—an electrophysiologist) pointed out that organic chemistry knowledge doesn’t aid clinical decision-making–neither does ornithology, or my 1990’s rotation on the Bone Marrow Transplant Unit.  I’d even take this logic one step further and concur with those who tout liberal arts as better physician preparation.  For doctoring purposes a BA isn’t BS.

Reality number three: Much of what doctors do is transferable.   My ability to cannulate a leg vein, torque an ablation catheter or suture skin has nothing to do with letters after my name.  These manual dexterity skills share similarities to any other hand-eye skill; some observers have likened ablating AF to a complicated video game. Could we offer the benefits of AF-ablation to more patients if skilled, well trained assistants were allowed?  Professors have fellows, why shouldn’t private practitioners have specialized helpers?  Would this kind of help extend the career of those with specialized skills?

Reality number four: Personal experience tells me that the physician-extender model can work.  In cardiology today, most ARNPs (or PAs) pick an area of specialization.  They hone in on one topic.  Electrophysiology is one example; lipid management is another.  Other areas of medical and surgical practice have their selected examples.

The reality is that an experienced and well-mentored EP-nurse practitioner might know more about AF management than the average doctor.  Sorry.  There, I said it.  Don’t misunderstand though, this isn’t a knock on doctors.  It’s impossible to know more than someone who deals with a single problem every day–regardless of one’s degree.  I ask the opinion of specialized physician-extenders regularly, without remorse.

Take this example:  Let’s say a patient presents with cough, fever and shortness of breath.  A fairly common scenario.  But let’s add in the history that this patient had a lengthy AF-ablation two months ago.  The regular doctor would still think respiratory infection 99 times out of a hundred.  The EP-nurse on the other hand, would worry (a lot) about the possibility of pulmonary vein stenosis, an important diagnosis to consider in this case.

So in summary, I offer a sport’s analogy.

The goal is to build a dream team. One way is to take the most accomplished individual performers.  Another way is to mesh together a group of diverse–perhaps statistically less accomplished–players who each reveled in their specific and complimentary roles.

Obviously, more often than not, the latter team wins handily.

Why can’t this be the model of physician-extenders?


4 replies on “Extending…and perhaps improving”

About once a day I see a consult (rheumatology) from a PA or ARNP for an issue that turns out to be due to a disease of their, not my, speciality (typically hepatology or primary care). The patients protest when I instruct them to go back to their PCProvider for further management because “they already missed it.” I’ve even gotten calls from the PA or ARNP asking if I could manage it because they aren’t trained for it. To both reactions I’ve politely but bluntly suggest they see the supervising doctor. The patients squirm at the idea of having to find someone else (for ARNP only clinics) or being “difficult” by demanding to see the doctor only, and the physician extenders act like I’ve just questioned their right to live. It is shameful we’ve created an environment like that.

PA/ARNPs were initially billed as being able to handle “85%” of the typical day to day stuff with the physicians being able to be called for the remainder, but in practice, this is not what I witness.

Also, the general education that physicians get is invaluable. Being a good doctor is not just about your speciality. Telling a patient and their consulting provider, “well, I don’t know what you have but I know it’s not my problem” makes no one happy. Being able to recognize diseases in general and not just limited to their limited area of training is one thing that separates a physician from a lay-provider.

Finally, when I consult a physician, I expect the physician to see the patient. When I get back a note from the extender, that’s the last time I consult them. I respect their choice to run their practice as they see fit, but I reserve the right to consult who I see fit.


I agree strongly with the notion that good doctoring entails knowing more than just your just specialty. It also means communicating well with patients and colleagues. Your example of unhelpfulness was at the hands of a physician-extender, but all of us could provide ample examples of less than useful doctors.
An unknowing outside observer might suggest an obvious solution: stop referring patients to the unhelpful group. The trouble is that’s not how our system works anymore. (But that topic is a month’s worth of posts.)

I did not mean to suggest that physician-extenders can replace good doctoring. Obviously, I believe in good doctoring. It’s what motivates me most.

Clearly my experience with extenders has been different than yours. One isn’t wrong or right, rather they are just observations.

Thanks for taking the time to write.

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