When You Go To The Doctor, What Are The Chances You Will Actually See An MD?

Apr 29, 2016

Wait times at doctors' offices could be longer if more practices weren't using nurse practitioners and physicians assistants to increase the number of appointments.
Credit Mark Nootbaar / 90.5 WESA

The days of an individual doctor hanging out a shingle and offering a general family practice are all but gone. The new norm is that your primary care physician is part of a multi-doctor practice. It’s also more likely than not that those doctors have either already hired a nurse practitioner or a physician assistant, commonly referred to as physician extenders, or they are considering making such a move.

“I find that the PA (physician assistant) generally gives you a lot of time,” said Jeff Phillips of McCandless.  Phillips said until recently he never saw a PA, but now almost exclusively sees a PA when he visits his doctor’s office. “So far so good.”

Phillips' experience is becoming the norm.

“Being a physician extender, a PA or a nurse practitioner, is a very very hot profession these days,” said Dr. David Detrick. “Most of these kids that are graduating (from PA or NP programs) don’t have to look very hard for a job, people come recruiting.”

Deitrick uses nurse practitioners to help deliver babies at Allegheny Health Network’s Jefferson Hospital. 

The trend is not limited to AHN doctors. UPMC has become the second largest employer of physician assistants and nurse practitioners in the U.S., according to Ben Reynolds who directs UPMC’s Office of Advance Practice Providers. 

The Bureau of Labor Statistics predicts the number of jobs in the US to grow by 7 percent in the next 10 years, but for nurse practitioners and physician assistants that growth is expected to top 30 percent. 

Reynolds, who is also a practicing PA said we are in, “a perfect storm” for physician extenders.

“If it were just a physician work force that we had to rely on, well then the waits for care would be months.  The time that you would be able to spend with your physician would be short,” Reynolds said.

There are several factors creating the “perfect storm.” Reynolds said the first factor driving the need for more physician extenders is the increased pressure baby boomers are putting on the health care system. He said that pressure for more office and hospital visits will not let up until 2035. 

Also in the mix is the advent of the Affordable Care Act and Medicaid expansion, which have put insurance into the hands of hundreds of thousands of individuals who had never been insured in the past.

Then, according to Dr. Francis Solano, there’s the increasing expectation among 18 to 35-year-olds that doctors' offices should be ready to take patients without an appointment.

“We’re a traditional internal medicine practice," Solano said. "We do believe in spending time with patients. So having a walk-in clinic is very disruptive to your schedule."

So why not just add another doctor? First, there is a nationwide shortage of primary care doctors. And second, nurse practitioners and physician assistants get paid about one-half to one-third of what doctors get paid. 

So Solano added two nurse practitioners to his eight-doctor team.

“It seems to be a win for everyone right now,” Solano said. “Our patients love it.”

Because they spend less time doing tasks only physicians can do, NPs and PAs can often spend more time in the exam room.
Credit wonderlane / Flickr

But he admits there was some resistance among the doctors who were worried about the business model and maybe a little worried about defending their turf.  

“But we have all learned that this is really a value-added service and this is really what’s happening around the country,” said Solano of the seven other physicians in his practice.

Deb Byrns is one of the nurse practitioners in Solano’s office. She said at times there has also been resistance from the patients.

“It’s more because people are afraid and they don’t know what a nurse practitioner is," she said. "And so once I explain what my role is and what I am able to do, then usually people are very open to having me see them."

By law, nurse practitioners and physician assistants must have collaborative agreements with a physician and they must identify themselves a PA or NP when seeing a patient to make sure there is no confusion. 

Which begs the question, is the quality of care provided by a PA or NP adequate? 

“We are trained to look at, treat and diagnose a patient kind of the same way that medical school is set up,” said Judy Truscott, Associate Program Director of the PA program at Chatham University. “We have clinical rotations where we spend a lot of hours.  And then we also … are able to discuss patients with the physician if we need to.”

A NP or PA can make a diagnoses, recommend a course of treatment, order and interpret most tests and usually can write prescriptions, but they are unable to perform anything beyond the most basic of surgical procedures and often cannot order home care or durable goods, such as walkers. Because they are usually not making hospital rounds or spending time in the operating room, PAs and NPs spend more time in the clinical setting, which translates to being able to spend more time in the exam room.

Several recent studies have found that having PAs as part of a larger care team has either a positive impact or no impact on patient outcomes. 

The same holds true for nurse practitioners who move up the ladder from a basic nursing program or bachelor's degree, through a master’s degree and then to a nurse practitioner’s program. It is usually a process that plays out over several years while the individual is working full time as a nurse.

“Nurse Practitioners, when they are practicing as RNs, think to themselves, ‘I can do more and I want to do more and I can develop the knowledge base that I need to do more,’” said Shelia Gealey, retired nurse practitioner who helps give care at the Community Health Clinic of Butler County.

In 21 states, nurse practitioners are not required to have collaborative agreements with physicians, meaning they can run clinics on their own. A bill pending in Harrisburg would lift that requirement in Pennsylvania.  The bill has been the subject of intense debate in the medical community and it’s unclear if it will come up for a vote.

Gealey said the measure could make it possible for nurse practitioners to open clinics in rural areas where the general practitioner shortage is even more acute than it is in urban centers. 

In the meantime, schools continue to open new nurse practitioner and physician assistants programs to fill the growing need.

Healthcare coverage on 90.5 WESA is made possible in part by a grant from the Jewish Healthcare Foundation.