A rash could be leukemia or idiopathic thrombocytopenic purpura. A sore throat could be glossopharyngeal neuralgia or a retropharyngeal abscess. A blocked ear could be Ramsay-Hunt syndrome, a self-limited serous otitis or sudden sensorineural hearing loss with an abysmal prognosis if not treated immediately with high doses of steroids. A headache or sinus pain could be cancer, and a cough could be a pulmonary embolus or heart failure.
Treating the Well:
In my early career in Sweden, well child visits were done in nurse-led clinics, some of them only open on certain days, with a local doctor in attendance. Parents carried the children’s records with them, containing growth charts, immunization records and so on.
These nurses had great expertise in differentiating normal from abnormal appearance of children, and would direct the attending physician’s attention to children with abnormal metrics, appearance or behavior.
With this arrangement, the physician time requirement was reduced, and limited to evaluating children attending the clinics who needed special attention. Physicians also performed specific examinations at certain ages, such as checking for hip clicks. These clinics freed up the local pediatricians to evaluate more sick children.
Well-baby visits are now the bread and butter of American pediatricians and family practitioners, and with the ever expanding mandates of politically determined items that must be covered in order for doctors to get paid for their services, we sometimes have trouble accommodating illness care demands.
The same thing happens in primary care for adults; between checkups and chronic disease management, Meaningful Use and other documentation requirements, many primary care doctors are unable to see all the sick patients, who call for an appointment.
A simple calculation illustrates this phenomenon. If the ideal caseload for a primary care physician is 1,500 patients but commonly exceeds 2,000, only providing a 30 minute physical or “wellness visit” (not the same thing) visit once a year for every patient chews up 750-1,000 hours. Total “contact” hours for each doctor according to recruitment ads these days number 32 per week times 46 weeks, or 1,472 hours. That doesn’t leave very much time for treating the sick – less than 500 to at most 750 hours, to be exact. That’s a maximum of 16 hours per work week, most of which is spent on managing chronic conditions like diabetes and cardiovascular disease. Most of the time, this amounts to tracking and treating numbers in fairly asymptomatic people – blood sugars, glycohemoglobins, microalbumins, blood pressures, lipid levels and so on.
Treating Chronic Diseases Leaves Little Room for Diagnosing and Treating Acute Illnesses:
With primary care physicians’ time increasingly spent on the routinized housekeeping details of modern chronic disease management, their diagnostic and therapeutic skills are less often used on the front lines of sick-care. Their new role of managing populations is not making full use of physicians’ traditional diagnostic and therapeutic skills. Instead we are performing more nurse-like duties such as carrying out standing orders (read “following guidelines” and “practicing Evidence Based Medicine”), and keeping track of our patients’ scheduled specialist visits as well as their sick visits, not just at the local emergency room, but also at competing walk-in-clinics. Ironically, the doctor who was too busy to see that child with an earache must now sign off on the chart notes from the local Walmart. We also end up, unreimbursed, keeping track of and even rubber-stamping orders for immunizations given at pharmacies like RiteAid.
The elimination of the truly quick and easy visits from doctors’ schedules (the rashes that the experienced clinician quickly determines are not leukemia or ITTP) makes the daily load of chronic care management greater, and often decreases total revenue in a fee-for-service system. The truth is that a skilled and experienced physician can often handle “simple” medical complaints faster and with greater accuracy than providers with less training and experience. Equally true, Nurse Practitioners can be just as good at following clinical guidelines and counseling patients about blood sugar, exercise, smoking cessation and the benefits of aspirin as physicians are. The broader and deeper training of physicians comes to its best use in diagnosing and managing atypical or rarely seen symptoms and conditions, many of which present acutely with nonspecific symptoms.
Yet, because of the so-called “doctor shortage”, this is what sometimes happens:
In many states, Nurse Practitioners, even newly graduated ones, are asked to fill the role of primary care provider or urgent care clinician, while seasoned physicians with mature practices are increasingly spending their time on the routinized treatment of asymptomatic conditions that arise from the modern lifestyles of the western world.
SO, WHO SHOULD DO WHAT IN PRIMARY CARE?
I have worked with many NPs who shoulder the responsibilities of frontline, independent, clinical practice very well because of their postgraduate experience and their personal qualities. But, “out of the box”, a new NP is not as well prepared for that role as today’s residency trained physician. The days of practicing general medicine straight out of school ended for American physicians in the 1950’s.
My point is that in today’s healthcare system, we are often asking the providers with the least training to see the unsorted clientele in “sick-call” while doctors with decades of experience may be limiting their practice to following insurance-mandated guidelines and care plans in treating non-urgent chronic medical problems and providing equally scripted wellness visits that may actually be better suited for nurses-turned Nurse Practitioners. I think the wisdom of this needs to be discussed openly. I think the perceived “doctor shortage” may just be an allocation issue.
Or, in one sentence:
If provider care teams are the way of the future, perhaps doctors should be handling more of the “sick-call”, and Nurse Practitioners more of the “maintenance“ of modern healthcare.
Let’s really talk openly about who should do what in primary care today!
A Country Doctor Writes: 
Everything you say makes sense. However, I wonder if NPs and PAs, those who seem to be dealing with the brunt of the acute outpatient issues, are less likely to be up to date on chronic management if for no other reason than they are not doing chronic management. I say this because I had a patient who was sent to the IM clinic I am working at the other day because their primary provider, who happened to be a PA (unknown age or experience), couldn’t control his blood pressure or blood sugar. He was an African American man on 3 BP meds, but the calcium channel blocker was the most recent one added. Current guidelines state that a Ca blocker should have been his first med. He is a recent (< 1 year) onset type 2 diabetic with max metformin and sigaliptine and an A1C of 9.2. He wants to do whatever it takes to avoid insulin so we had a very frank talk about diet and exercise and then we’ll see what his results are in 4 months. I told him that his performance and discipline will determine if he goes on insulin or not – it was all up to him. I find it very interesting that these two relatively simple chronic things couldn’t be handled by the PA, but could be handled by a 3rd year med student. Did I know that Ca channel blockers are first line for African Americans? Not the day before, but I did that morning before he arrived because I read up on it.
It’s hard to generalize, clinicians are individuals. An experienced PA or NP can usually handle the demands of urgent care pretty well. I have met residency trained new FPs that flounder. PAs (and I know that this is controversial) get more exposure to both the diagnostic medical model and diagnosing sick patients of various types during their 2000 hours of clinical rotations, while NPs get more nurse led training in patient management. But both catch up with each other in these areas after five or so years of practice. Both practice in specialized areas and can get a tremendous fund of knowledge in that area, way past the expertise of generalist physicians (cardiothoracic surgery PAs, oncology NPs, etc.).
But, you are correct, the initial design of the non physician clinician, back in the 1970s when the original programs were 12-14 months long, was to be able to differentiate normal from abnormal. That would include the “normal” course of controlled chronic disease and other basic problems fitting certain criteria in most specialties. Perhaps that should still be the baseline expectation for new NPs and PAs (giving them some additional privileges for longer programs and more education) and further credentialing, testing, experience, or residency training would be necessary and perhaps documented for each additional level of responsibility, up to the management of moderately sick and very sick patients (like those PAs and NPs in critical care and EDs, for example).
I think the time is coming where some residency training will be necessary, at least for those PAs and NPs that take care of the sick, undifferentiated patients upon initial presentation….hospitalist and ED settings, for example. The program of Certificate of added qualifications (CAQs) for PAs exemplifies this, as does the proliferation of 1-2 year residencies and fellowships for PAs. MDs/DOs meet that level with initial post residency practice, although studies have demonstrated that they are at the peak of their competencies after about eight years of independent practice. Perhaps instead of practicing at the “top of your license” people should practice at the “top of their competence” until increasing competencies can be documented. Good research studies of the outcomes of patients of different kinds of clinicians would be extremely helpful as well.
Just wanted to let you know I enjoy your posts. I’m currently a resident in pediatrics (incidentally, with a laptop, a house call bag, and a fountain pen), getting ready to enter practice.
I think you make a great point here–sometimes it’s a very minor deviation from normal that would prompt a physician’s concern about a child’s development, a possible malignancy, or another slow-brewing manifestation of disease. While nurse practitioners or physician assistants can certainly learn to recognize these abnormalities, it’s absurd to think that a newly-minted NP just beginning to practice in a particular field would be familiar enough with that field’s “normal” to key in on these initial clues.
Oftentimes in pediatrics, the NPs/PAs handle a large percentage of well-child care, simply because the physicians don’t find them interesting. Maybe that’s worth re-thinking.