Time, Money and Midlevels

A Primary Care resident wrote in one of the journals recently about making the limited time she has with each patient matter the most.

How refreshing, I thought when she concluded that time ultimately is an absolute and finite resource. We often feel as if we are battling time as much as we are battling disease, and we sometimes have trouble admitting when we are losing either one of those battles. Some of us find it more difficult than others to say “no” to unrealistic demands for clinical output per unit of time.

But the writer had another agenda: By teaming up with Nurse Practitioners or Physician Assistants, she envisioned having more time to spend with each patient.

This type of New Math doesn’t really work in Primary Care. A physician who performs expensive procedures can maximize his or her time in the operating room by sharing office visits with a less trained and lower-paid “midlevel” practitioner, who could never replace the physician in the operating room.

In Primary Care, however, physicians, Nurse Practitioners and Physician Assistants tend to do the same type of work, and if anything, physicians tend to have shorter appointments than “midlevel practitioners”, reflecting their higher level of training and justifying their higher salaries. Every patient deserves the best care we can give them, and there is no reason to believe that patients who see a physician are so much more complicated that they always deserve more time than patients who see a “midlevel”.

If the young writer expects to have “midlevel providers” somehow subsidize her requirements of time and money, she is not likely to find this in today’s medical environment. She may instead find herself in direct competition with them. In states where Nurse Practitioners can practice without physician supervision, she might actually be at a competitive disadvantage, should her productivity drop below that of providers making half her salary.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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