Written by Brandon Betancourt
Even if you are not a football fan, I’m sure you’ve heard about the NFL and referee fiasco.
If you haven’t heard, here is the scoop. The NFL owners have been unable to reach an agreement with the referees. As a result, the referees were locked out and the NFL owners replaced them with cheaper less experienced referees.
The result?
Although qualified to referee a game, these less than professional referees don’t have the experience, the full requirements and the practice of a professional NFL referee. Consequently they’ve made some really, really bad calls.
Some calls have been so bad, that they have cost teams games.
In healthcare, there is a lot of talk about filling the primary care physician shortages that we expect in the near future, with mid-level providers such as nurse practitioners and physicians assistance.
Mid-level providers are competent healthcare providers. But they don’t train as long as a physicians do. As a result, they have less experience. On the flip side, they’re cheaper to train, and they earn less than a physician does.
Naturally, if you are trying to reduce healthcare cost, and you are planning on having a labor force shortage, mid-level providers seem like a good solution.
Don’t you think?
I think this is a bad idea. The NFL debacle is great example of what happens when one chooses to settle for next best.
For the record, I’m not putting down mid-level providers. I think they are valued team members. If I didn’t believe that, we would have not hired a mid-level provider in our practice.
I believe mid-levels have a place in our healthcare landscape and they will play an integral role in the future of primary care. But what I’m saying is, they are less experienced. They don’t go to school as long as a doctor does and don’t bare nearly the same responsibility as a doctors do.
Here is the thing, primary care doctors are tremendously valuable. Although they may appear to be expensive to visit, when you compare it to the value they return, the cost is minimal.
Think about it this way. How much would you pay to be assured that your child is healthy? What is the value of having a person that has dedicated 100% of their professional career to learn about children so that each child can reach their full potential?
Don’t make the same mistake the NFL owners did by choosing a less expensive, quick fix solution.
I can almost guarantee you won’t regret it.
Brandon Betancourt is a practice administrator. He blogs regularly at PediatricInc
Survivor: Pediatrics 
Spot on!
Comparing NPs or PAs to the crappy replacement refs is condescending and rude. And it’s not accurate. Because mid-level providers in many surveys are preferred over physicians. Patients think we spend more time and have better listening skills and compassion than mds. If I was the mid-level provider in your practice and read this post I would think twice about workin with you.
I’m truly disappointed this was posted on this blog. I constantly refer to the posts and find it really valuable. Now this post has sent a tone that is bothersome.
I am sorry you interpreted the post in the way that you did, because that was clearly not its message. Physician extenders have a valuable place in the primary care medicine and clearly are often preferred by patients and often do have skills not possessed by many primary care physicians.
However, I strongly object to trade organizations representing physician extenders taking the position that their members are an adequate and equivalent replacement for physicians and do not require true physician oversight. This is particularly true in the care of children.
Physician extenders are just that: Extenders. They do not have similar training and are not competent to preside over the medical home. They do not have the depth of training or experience to deal with unusual or complex problems which is the focus of the medical home. They are not a replacement for physicians.
This may be a “solution” that is forced on us by the current health care reform efforts and regional accessibility issues, but it is not an optimal one. I stand by the these statements as the true take home message of the post.
Are there bad physicians who are worse than their extenders? There is no doubt that this is true. Are there extenders who overstep their expertise? True as well.
We need to find a good working relationship within the reality of our training. We need to use extenders in areas where they can improve care. Extenders need to realize that they are NOT physicians.
Jamie,
Since the NP mentions offended you, let me use General Pediatrics as an example then… fair?
Pediatric NPs are not pediatricians in the same way general pediatricians are not pediatric gastrointestinologist (or any other subspecialty of pediatrics).
There are limitations to what a general pediatrician can do when faced with a complicated GI issue (just like there are limitations with what an NP can do).
Is this an offensive statement to a general peds? Is the peds GI condescending when he says a general peds can’t or shouldn’t treat GI patients? Is the gen peds incompetent because she referred her GI patient to Peds GI? Of course not. Each play an integral part in the healthcare of the child.
Let me see if I can make the same point without mentioning NPs…if we allow general pediatricians to fill the gap of pediatric gastrointestinologist, because of a shortage of Peds GI and/or it takes less time to train a pediatrician than it does to train a Peds GI, and/or general peds earns less than a Peds GI, then I say we are heading in the same direction the NFL referee debacle went.
But the plan is not to fill peds GI positons with Gen Peds…
Thank you for taking the time to share your feelings and thoughts and I hope you will continue to consider us as a source of information.
In all honesty Brandon I think you have right to discuss the use of mid-level providers on a forum such as this, but I still find the fact that you needed to compare us to the replacement refs, well, it really grinds my gears. Actually saying …”Consequently they’ve made some really, really bad calls” and “The NFL debacle is great example of what happens when one chooses to settle for next best”- I mean, just ouch. You can have a frank discussion about mid-level providers place in practice without making such statements.
I’m actually one of those “lesser thans” and Yes! I’m a newbie. Happy to be working in pediatrics, thrilled to have two fully supportive physicians and experienced NPs to go to with any questions or concerns. I’m beyond lucky. I came upon this site when I started up in peds and was thrilled at some of the posts on here. I refer to many of them in my practice- like the recent post on solid foods- YES! What a refreshing piece that I shared everyone in our practice. So yes, when I saw this post, I took it personally, discussed it with colleagues and friends, etc. And wondered, what exactly, is your motivation for this piece?
Brandon, I get what you are trying to say in your reply comparing specialists and general physicians. And of course that’s not how I feel at all, I just found your post ignorant and insulting. This is really the icing here-
“For the record, I’m not putting down mid-level providers. I think they are valued team members. If I didn’t believe that, we would have not hired a mid-level provider in our practice”- imagine if you replaced mid-level provider with women! See what I’m saying? It’s the tone that really stinks here…wrought with kind of an old school mentality.
A “quick-fix solution”
Jaime
Jaime,
I can certainly understand why you would not like being compared to the replacement referees (or, at least, how the replacement referees have been portrayed), but I don’t think it was Brandon’s intent to demean your profession. He was using a current situation (replace experienced but expensive NFL refs with less expensive replacement refs) as an analogy for a proposed solution to high healthcare costs (replace primary care physicians with less-expensive mid-level providers).
As Brandon and several others have commented, mid-level providers play a valuable role on the healthcare team, but they should not be considered equivalent to primary care physicians. If mid-levels are put in a role for which they are not appropriately trained, bad things can happen. If I, as a pediatrician, were to decide to perform orthopedic surgery, or heart caths, or dialysis, bad things could happen because I am not trained to fully perform those tasks. The same could be said of other professions in healthcare (replacing orthopedists with physical therapists, replacing PTs with PTAs, replacing RNs with CNAs) and of professions in other industries (replacing attorneys with paralegals, replacing your 747 pilot with a helicopter pilot, etc.).
I hope that you, as a nurse practitioner, can accept that your role is not the same as the role of the physicians with whom you work. If you do accept that, then I think you agree with the intent of the post, even if you don’t like how the idea was presented. If you don’t accept that your role is different than the role of a physician…well, that is part of why this discussion is needed.
Good luck to you in your career,
David
I definitely do not want the same role as a pediatrician, I understand the intent but it was a poor analogy and execution. That’s all I’m going to say on this topic anymore. I don’t understand the motivation of a practice manager in pediatrics undermining mid-levels as second rate. We’re just different and do a world of good in the field.
Perhaps we are conflating training and experience.
I don’t think there’s any question that physicians have the most comprehensive and lengthy training, for both primary and specialty care. I spent 7 years after college training to be a pediatrician, and most of those years were significantly longer than 40 hours. Were a midlevel to assert that his training in pediatrics is equal in scope or depth to mine, I would feel insulted. The implication is that two or three years is the “standard” training but I was somehow on the “remedial” seven-year track!
Experience is a different animal. It takes practice, and getting feedback, and wanting to continually hone one’s skills, regardless of training. I am in debt, time and time again, to experienced nurses who are sharp enough to recognize when something is wrong with a child. These dedicated professionals may not even have the advanced training of an APRN, but their years of constant practice make them experts in, for example, sussing out a sick newborn among the healthy babies in the nursery. Often it is the sharp-eyed nursery RN who first spots the problem and starts the first intervention promptly. That’s just as important, if not more so, as anything I might do later.
Experience must be relevant. I’m an experienced pediatrician, but if you have a heart attack, I’ll give you an aspirin and call 911. The EMTs in my community have a lot more relevant experience than I do, even if I’m older and went to school longer.
Experience comes with time, but it doesn’t accrue passively like a pension. It requires being able to function in a team setting, and the honest humility to accept feedback and correction from other people on the team. Humility is hard for anyone, and physicians seem to have particular difficulty with it, sometimes.
Midlevels who assert that they need not be part of a team, that they are prepared adequately to deal independently with the range of problems in primary care, concern me, for both the training and experience reasons. Anyone who feels that 2 years of training is adequate — and doesn’t want to be part of a team, with the ongoing feedback/supervision/mentoring/collaboration that entails — severely underestimates how challenging primary care can be, or really, does not understand what primary care encompasses.
Agree wholeheartedly.
Jaime, thanks for speaking up. This is a super important conversation. You asked what are Brandon’s motivations for writing such a post. I will share with you why I was glad he did. If you look at healthcare reform you will note that politicians are turning their law making pens towards cost. Replacing primary care MDs with NPs/PAs is a very attractive short term cost saving solution. It seems you agree that MDs and NPs have roles but they are different. A lot of NPs including your national leadership believes NPs do “primary care just as good if not better than doctors” and in fact should pratice independently without supervision. I view these developments as dangerous to our health as a nation. Of course, I’m biased as a pediatrician but I do think most people want doctors in charge of their health (especially when they are really sick). My personal concern is that there will be no internal medicine physicians left in my old age and no pediatricians left for my grandchildren. Sounds crazy? look at the British system. Our citizens need to have their eyes wide open as our country has this great debate. Brandon’s post nicely demonstrates to the average citizen there are differences between NPs and MDs – better start paying attention people. So replacement refs aside, how do you see your role in the healthcare system now and in the future? Jaime, thanks again for chiming in.
BTW, I also agree 100% with Dr.Berman and love the NPs in my practice. Going to work each day is a pleasure with such a great staff!