By Dr. David Scales
Let's say you hurt your knee doing your best Tom Brady impression playing flag football.
It hurts like the dickens and you’re not sure if you tore something or just have a really bad case of tendonitis. You go to your local urgent care clinic, or doctor's office, and you’re seen by a physician assistant (PA), who examines you, says everything is structurally intact, and you should use ice, elevate your leg and take some ibuprofen for the pain.
What the PA said makes sense, but shouldn’t you see -- you know -- the doctor?
Well, maybe not. While it seems to make sense to always ask for an expert, there can be some downsides. It can take months to get an appointment with a doctor, or cost more to see them versus a PA or nurse practitioner (NP). Also, with the holidays approaching, it's prime season for senior physicians to be away, with the rest of the health care team pitching in. So when is it fine to see someone besides the doctor for your medical care? And when should you avoid it?
Well, who else might you see at a medical clinic? In addition to a doctor, you could see a PA or NP. If you haven’t seen one yet, you will. Medicine is increasingly becoming a team sport, requiring well-synchronized "pit crews" rather than isolated physicians. In Massachusetts, for instance, there are already close to 8,000 NPs and over 2,000 PAs and those numbers are rising to fill a growing shortage in primary care. A 2013 study estimates that Massachusetts will need 725 more primary care providers by 2030.
I asked a few NPs and PAs — each with at least five years of clinical experience, and some with more than 30 — what they think patients should know about all this. They agreed that it's best to focus on experience rather than the degree behind the name. An NP with three decades of experience may be more knowledgeable than an MD who just finished their residency -- and I say that as someone who is just about to finish residency.
One of those NPs with over 30 years experience is Lynne Crawford, a primary care NP at Cambridge Health Alliance. She phrased it this way: “If you see someone and you’re uncomfortable with the encounter, it might be your rapport with them rather than the degree behind their name.”
That’s likely because a good medical provider possesses more than book knowledge. Another primary care NP at Cambridge Health Alliance and Boston Health Care for the Homeless Program, Deidre Allesio, recommended looking for “the intangibles.” Things like how well they communicate, how well and how fully they answer questions, who they turn to for further guidance and whether they focus on a particular health issue or the population as a whole.
Joanna Gross, an ear, nose and throat PA at Cambridge Health Alliance, added: “You have to trust your gut and feel like you have a good rapport with that person to trust them with your care,”
Clearly, no one knows everything about every specialty. It takes experience for the provider to learn the line of when they’re over their head and need to refer a patient to a specialist. “My doctors trust me -- I’m not going to do something that’s out of my league and they feel confident that I know when I’m in over my head,” Gross said. “You have to have that level of humility and ability to say what is the extent of my knowledge and my practice and when do I need to call for help.”
The key is collaboration, according to Marcos Pienasola, an emergency room PA at MetroWest Health Center in Framingham. “If a patient is pretty sick, I’ll start the initial workup,” he described. “I’ll get a couple lines, some IV fluids, then I’ll run the case by an attending [physician].”
But not everyone agrees the expanding practice of NPs and PAs is a good thing. Some physician organizations would like to restrict the scope of practice for NPs and PAs until research proves their care is high quality. The American Medical Association accepts them practicing as part of a team as long as a physician is always at the helm.
These organizations complain that, unlike doctors, NPs and PAs do not do a residency program after they graduate, so they start with on-the-job training. That might mean a newly minted graduate may have only a few weeks experience in any particular clinical area under their belt, as The New York Times noted in an article on PAs last year.
These different roles and responsibilities reflect the fact that PAs and NPs don’t go through as much formal training as MDs. Most physicians do an undergraduate degree, medical school, then complete a residency of at least three years where they practice as a doctor under the supervision of more senior physicians. PAs and NPs can enter practice under the supervision of a doctor immediately after graduating from their respective training programs, both of which are shorter than the four years physicians spend in medical school.
You might think that this proves that you should always ask to see the doctor, but that’s not borne out by the evidence. In fact, most studies suggest that the care you get from NPs or PAs is indistinguishable from physician care in the outpatient setting, in the hospital and possibly in the intensive care unit and emergency room, though there is less data in the latter two settings.
In certain circumstances, you might be better off seeing an NP or PA. In one study, the patients who saw NPs in an outpatient clinic said they were more satisfied compared to those seeing physicians, perhaps in part because their visits with NPs were usually longer.
NPs also tend to have more of a focus on education. They can receive extra certification to be a nurse educator for conditions like diabetes or asthma. That educational component is also what drives some people to the profession. “My identity is a nurse -- I’m an advanced practice nurse -- but I will always be a nurse,” Crawford said.
Seeing the PA or NP can also streamline your care. For example, a CAT scan, X-rays or even some small procedures can be scheduled after a visit with a mid-level provider, helping you save months waiting to see a physician specialist.
This won’t be the case in every state, unfortunately, because every state has different regulations for NPs and PAs that require different levels of physician supervision. In Massachusetts, both have a “physician supervisor” that oversees aspects of their work. Yet, while there are very few things that a PA or NP strictly cannot do, how much autonomy they have varies based on the physician supervising them and even from hospital to hospital.
For PAs in Massachusetts, the scope of their practice is determined by their supervising physician, who does not need to be physically present, only “available for consultation,” during clinical encounters. Those competencies are reviewed every couple of years as the PA gets re-credentialed.
NPs with prescribing authority in this state need an official physician to supervise them but have an independent license to practice. In fact, according to the American Association of Nurse Practitioners, Massachusetts is the only state in the region to place such restrictions on NPs.
So regardless of which provider you see, the question may not be: “should I see the doctor?” but “when should I get a second opinion?” And that second opinion could be with a doctor, or a more experienced NP or PA.
With any practitioner, you should consider a second opinion whenever you feel one is necessary. “Certainly it’s a patient’s right to see an MD,” Pienasola, the emergency room PA told me. “In the emergency department there is no real barrier to that.”
Any time you have a very serious or life-threatening disease:
• where the treatment is very risky or toxic;
• where the diagnosis is not clear, the treatment is experimental, or there is no established consensus or Food and Drug Administration-approved treatment;
• if you're considering participating in a trial for a new drug;
• if you're considering some new experimental approach or a procedure that involves using experimental instruments or devices.
Seeking a second opinion can feel awkward because you might worry you’re questioning the authority of the doctor, PA or NP. Don’t worry, second opinions are common and every provider knows to expect patients will ask for them. The Center for Advancing Health has some suggestions for what you can say to politely broach the topic with your provider:
• “Before we start treatment, I’d like to get a second opinion. Will you help me with that?”
• “I think that I’d like to talk with another provider to be sure that I have all my bases covered.”
• “You know, this is a big decision for me, and I would like to talk with another expert or two so that I feel completely confident in our treatment plan.”
• “My family insists that I get the opinions of a number of specialists before moving forward.”
Hopefully by now your knee feels better after the ice and rest. Next time you’re at the doctor’s office, it might just save you time, money and energy to see the PA or NP rather than wait months to see the doctor.