Consumer Reports

[TWR]

Consumer Reports: When Your A Nurse (Or PA) Is As Good As A Doctor

 

When a nurse is as good as a doctor

Nurse practitioners and physician assistants can offer first-rate care

Published: July 14, 2015 08:00 AM

Across the country, nondoctor health care professionals—usually nurse practitioners (NPs) and physician assistants (PAs)—are turning up in a range of medical settings. We see those so-called advanced practice providers most often in primary care and family medicine practices, but they also work as specialists in hospitals and retail clinics, and more. In rural areas, they may be the only health care providers who are regularly available.

Their ranks are growing fast. In the past 10 years, the number of licensed NPs in the U.S. has almost doubled to 205,000. Between 2003 and today, the number of certified PAs grew from about 43,500 to more than 102,000.

One major reason: Demand for doctors, especially family physicians and internists, is outstripping supply. The Association of American Medical Colleges expects a shortage of up to 31,100 primary care doctors and up to 63,700 other physicians by 2025.

Advanced practice practitioners can make up the shortfall. But can they give you the care you need? And how does the care compare with what you’d get from a doctor? 

What they do, what they don’t

PAs and NPs are handling many tasks that were once the exclusive domain of doctors: They can write prescriptions in every state. In 21 states and the District of Columbia, NPs can practice autonomously. Some NPs and PAs substitute for residents at academic medical centers.

But there are differences between them and doctors. One distinction: What advanced practice practitioners are permitted by law to do can vary from state to state and even from hospital to hospital. For example, NPs can’t prescribe controlled substances in Florida. In some states, a supervising physician needs to be on site when a PA treats you; in other states, it’s not necessary. Nationwide, an NP’s or PA’s authority to admit you to a hospital is up to the hospital.

Training differs, too. Doctors and PAs train under the so-called medical model (though primary care doctors have about 23,000 hours of education and training, PAs have around 3,000). That teaches physicians to “work through a diagnostic process that directs the questions you ask, the physical you perform, the diagnostic studies and treatments,” says Reid Blackwelder, M.D., chair of the American Academy of Family Physicians’ board of directors. Nurse practitioners are educated under the nursing model, which stresses health promotion and education.

Ultimately, what an NP or PA does in your doctor’s office will depend on his or her experience, the setting, and the speciality, notes Marc J. Moote, PA-C, chief physician assistant at the University of Michigan Health System in Ann Arbor. “Often, each physician/PA/NP team will decide the best use of everyone’s skills on the health care team, and this can vary from practice to practice,” he adds.

6 big benefits

NPs and PAs are indispensable in handling everyday problems such as sore throats or urinary tract infections, freeing primary care doctors to handle more complex conditions, says John Santa, M.D., medical adviser to Consumer Reports. They can also prescreen patients, make hospital rounds, do follow-up care, monitor treatment, manage chronic conditions, and have a place in specialty care as well. “They can be very good at the history taking, reviewing a patient’s records, and coordinating everything the specialist needs,” Santa adds. What’s more, many PAs work as surgical assistants. Though seeing an advanced practice practitioner is unlikely to lower your co-pay, it can help reduce overall health costs. Other benefits may include:

Shorter waits for appointments. Merritt Hawkins, a health care search and consulting firm, found that in 15 metropolitan areas, new patients wait, on average, 18.5 days to see a cardiologist, dermatologist, family physician, obstetrician/gynecologist, or orthopedic surgeon. But with more providers in the office, the PA or NP can see a patient if the doctor can’t.

A team approach. Having an NP or PA on staff makes some aspects of team-based health care more feasible. He or she can check a cough, cut, or sprain, and ensure vaccinations and blood pressure and cholesterol checks are done. A 2013 review in the Journal for Nurse Practitioners reported comparable blood glucose and blood pressure levels in people cared for by NPs as in people seen by doctors.

Convenient care. NPs and PAs staff some walk-in clinics at drugstores. So if you develop a urinary tract infection, for example, you can get the care you need ASAP.

Faster emergency-room treatment. Canadian researchers have found that in ERs with NPs and PAs on duty, people without life-threatening symptoms were twice as likely to be treated within 15 to 60 minutes.

Help with chronic conditions. Once you and your physician decide on a treatment, a PA or NP can make sure it’s going smoothly, for example, that your blood glucose levels are well-controlled.

APPs are especially helpful for seniors with chronic illnesses. A study in the Journal of the American Geriatrics Society noted that older patients managed by both an NP and a physician had higher quality care for dementia, falls, and urinary incontinence than those treated only by a physician. Co-management “is most appropriate for conditions that require a lot of close monitoring, patient engagement, and education,” says study co-author David B. Reuben, M.D., chief of the division of geriatrics at the David Geffen School of Medicine at UCLA.

Lower risk of hospital readmission. Leukemia patients in the hospital for chemotherapy cut their stays by about 6 days and were less likely to be readmitted within 14 days when cared for by PAs instead of doctors in training, according to a small study in the Journal of Oncology Practice. A 2013 study in the Journal of Thoracic and Cardiovascular Surgery found that when PAs make home visits to heart surgery patients as part of a PA home care program, it lowered 30-day readmissions by 25 percent.

See our Guide to Doctor Ratings and get advice on how to choose a doctor.

 

When to stick with a doctor

More research is needed to definitively assess when seeing a doctor might be preferable to seeing an NP or PA. Advanced practice practitioners have the know-how to play a primary role in diagnosing and treating common ills and an auxiliary role managing complex ailments, says Marvin M. Lipman, M.D., chief medical adviser to Consumer Reports. “Doctors are good for those 5 to 10 percent of patients whose symptoms don’t add up and need more detailed investigation,” he notes.

NPs and PAs say they can handle more than routine tasks. “It’s a misconception to assume they can’t diagnose or manage complex care,” Moote says.

That said, some research suggests physicians may be more skilled in some areas. For example, one 2013 study found that family physicians who referred patients to a medical center better understood what the symptoms might suggest and were more likely to order the right tests than NPs and PAs. The doctors’ referrals showed “a much more logical approach,” says William Mundell, M.D., assistant professor of medicine at the Mayo Clinic in Rochester, Minn. “They were getting closer to the diagnosis.”

Another key question: How many tests are different types of providers ordering? Recent research in JAMA Internal Medicine found that NPs and PAs tend to order slightly (less than 1 percent) more imaging tests than primary care physicians for similar Medicare patients.

The takeaway: All of those providers have an important place in health care. Make sure that you see the right one for you at the right time.

Editor’s Note:  

This article also appeared in the August 2015 issue of Consumer Reports on Health. 

http://www.consumerreports.org/cro/news/2015/07/when-a-nurse-is-as-good-as-a-doctor/index.htm

 

[RuralER/Ortho]

Couldn't finish that one.... Got too nauseated.....

[Guest Paula]

NPs and PAs say they can handle more than routine tasks. “It’s a misconception to assume they can’t diagnose or manage complex care,” Moote says.

That said, some research suggests physicians may be more skilled in some areas. For example, one 2013 study found that family physicians who referred patients to a medical center better understood what the symptoms might suggest and were more likely to order the right tests than NPs and PAs. The doctors’ referrals showed “a much more logical approach,” says William Mundell, M.D., assistant professor of medicine at the Mayo Clinic in Rochester, Minn. “They were getting closer to the diagnosis.”

Another key question: How many tests are different types of providers ordering? Recent research in JAMA Internal Medicine found that NPs and PAs tend to order slightly (less than 1 percent) more imaging tests than primary care physicians for similar Medicare patients.

 

The article saved the best for last. At least that one sentence rings true.

 

Where do you think the 23,000 hours of medical education and training comes from?  Does it include undergrad, med school and residency? It seems a bit inflated to me.  

 

 

[EMEDPA]

"PAs are indispensable in handling everyday problems such as sore throats or urinary tract infections, freeing primary care doctors to handle more complex conditions"

 

HATE this kind of thing. So the fracture reduction, the code, the cardioversion, the intubation, the STEMI, the CVA, etc I do/see working SOLO with no physician in house are "everyday problems"?

[LT_Oneal_PAC]

"PAs are indispensable in handling everyday problems such as sore throats or urinary tract infections, freeing primary care doctors to handle more complex conditions"

 

HATE this kind of thing. So the fracture reduction, the code, the cardioversion, the intubation, the STEMI, the CVA, etc I do/see working SOLO with no physician in house are "everyday problems"?

This past week and this week, in my family med clinic, I've handled toxic megacolon, orbital blowout fracture, myelodyspastic syndrome, failure to thrive, sexual assault, prolactinoma, and bilateral pyelonephritis. I'm sure there was a few sore throats as well. I let the nurses handle UTI with their protocol, so I guess I'm falling down on the job.

[rev ronin]

Eh, it could be worse.  Still not where it should be, but it's praising by faint damnation--the only thing they can come up with is that we order 1% more imaging? Really?

 

However, I'm staggered by the 23k vs 3k numbers.  What, exactly, are they counting?  I spend 3k hours just in clinical rotations.  So if they're counting, say 4k for med school, and 9k for residency (we'll say they can do 3k a year x3 years), where are the other 10,000 hours of training come from?  Or is this even an apples-to-apples comparison?

[EMEDPA]

Eh, it could be worse.  Still not where it should be, but it's praising by faint damnation--the only thing they can come up with is that we order 1% more imaging? Really?

 

However, I'm staggered by the 23k vs 3k numbers.  What, exactly, are they counting?  I spend 3k hours just in clinical rotations.  So if they're counting, say 4k for med school, and 9k for residency (we'll say they can do 3k a year x3 years), where are the other 10,000 hours of training come from?  Or is this even an apples-to-apples comparison?

apparently college x 4 yrs counts for them but not for us. it's like the other stat they use : 11 yrs to become a physician, 2 yrs to become a pa. really? my math has me at ten years for this pa.

[BruceBanner]

^Agree. Not necessarily flattering, but could be worse.

 

The biggest load of BS was the "23k vs 3k" thing. Who is the as$hat that wrote that article? Did they just make that up??

 

1 year of full-time work is 2,000 hours. So most of us spent 2,000 hour in academics and at least 2,000 hours in clinical rotations, if not closer to 3,000. That's between 4,000-5,000 hours.

 

I have no idea where 23k comes from. That would be almost 6 years of 80 hour weeks.

 

 

My other problem with the article is it kind of makes us seem like "drive-thru" providers who only treat routine illness. Unfortunately this is what you can expect when non-medical folk are writing our job descriptions.

[rev ronin]

Can PAFT please respond to Consumer Reports, at the very least correcting the 3k vs 23k numbers?

[jmj11]

apparently college x 4 yrs counts for them but not for us. it's like the other stat they use : 11 yrs to become a physician, 2 yrs to become a pa. really? my math has me at ten years for this pa.

I think this is a bit of misinformation that the AAPA or PAFT should address officially. So, as a patient, would I want to see someone who has 12% of the training of a physician?

[jmj11]

I think this is a bit of misinformation that the AAPA or PAFT should address officially. So, as a patient, would I want to see someone who has 12% of the training of a physician?

I wish that we had the gall and right attorney to sue people when they publish mis-information that hurts us. It fulfills the criteria for slander.

[EMEDPA]

Can PAFT please respond to Consumer Reports, at the very least correcting the 3k vs 23k numbers?

note sent to board.

[winterallsummer]

Wow I am SO happy that I can handle cuts, sore throats and coughs to free up time for my attending!  Now let me go manage my STEMI, complicated facial lac, perf'd viscus, crashing peds patient with head trauma, watch my PA collegue enter a room to intubate a crashing COPD'er, and enter in admission orders for my DKA patient.  There, I am SO glad I freed up time for the doctors here to handle the real problems.

 

Sigh.  That being said, I have seen worse articles, but still these people feel the need to interview an MD who thinks our profession's sole purpose in life is to free up time for them.  Give me a freaking break.

[GetMeOuttaThisMess]

"Would you like sprinkles on your Mchydrocodone? Please pull up to the front desk."

 

 

Sent from my iPad using Tapatalk

[Febrifuge]

I wish that we had the gall and right attorney to sue people when they publish mis-information that hurts us. It fulfills the criteria for slander.

No, it doesn't, unless the writer knows it to be untrue, and publishes it maliciously. It's stated as a fact rather than an opinion, so it might look like we have something on first blush, but simply repeating incorrect information in good faith doesn't usually meet the standard for slander. And I think you mean libel anyway, since it's printed. The burden of proof would be on anyone bringing a suit, to prove it was a lie intentionally published by Consumer Reports, with the intent of damaging (or with a reasonable expectation that it would damage) the reputation of PAs. There are stacks of previous published articles that the respondents could offer up with similarly bullshit, poorly-researched, incorrect factoids, so nothing really stands out about this one. A good lawyer would tell us to forget about it.

[jmj11]

No, it doesn't, unless the writer knows it to be untrue, and publishes it maliciously. It's stated as a fact rather than an opinion, so it might look like we have something on first blush, but simply repeating incorrect information in good faith doesn't usually meet the standard for slander. And I think you mean libel anyway, since it's printed. The burden of proof would be on anyone bringing a suit, to prove it was a lie intentionally published by Consumer Reports, with the intent of damaging (or with a reasonable expectation that it would damage) the reputation of PAs. There are stacks of previous published articles that the respondents could offer up with similarly bullshit, poorly-researched, incorrect factoids, so nothing really stands out about this one. A good lawyer would tell us to forget about it.

Okay, you are probably right. Maybe I was speaking from emotion.  It seems we have no clout to fight back when mis-information after mis-information is published about us.  I know we live in a very different world, but I read when TV-doctor shows were on in the 1960s, like Dr. Kildare and others, that the AMA actually had a doctor onsite to review scrips and rehersals to make sure that doctors were not put in a negative light.  That's not what we are asking for but when someone publishes 23,000 hour of training compared to 3,000 there is something going on here. I want to know who gave them the 23,000 hour number. 

 

A number of years ago The Men's Journal published a piece that was very negative about PAs. It warned it readers to make sure their provider was not a PA, that PAs often disguise themselves as real doctors but make a lot of mistakes and etc. (both were of course untrue and it was hurtful to our profession)  I actually met with an attorney over that one.  He, maybe as your are say, said that maybe I could have a case but it would take a lot more than a small town lawyer like him to take it on.

[Febrifuge]

I'm glad we have PAFT to put a little pressure on media entities to be accurate. And for what it's worth, the people who make "Royal Pains" do a good job with the PA character on that show.

[Guest Paula]

The doctors’ referrals showed “a much more logical approach,” says William Mundell, M.D., assistant professor of medicine at the Mayo Clinic in Rochester, Minn. “They were getting closer to the diagnosis.”

 

Then they send it to the PA for follow up and the PA nails the diagnosis.   LOL!  (Actually is true in a number of cases). 

 

The problem with the whole article is that the voices of the physicians who were interviewed out shout the one PA who was interviewed, who at least defended PAs by saying it's a misconception saying we can't diagnose or manage complex cases.. 

[delco714]

So the M.D. Pcp sends the pt to the specialist who is too busy to see the referral, so I see the pt and take care of them (and go to one of my docs prn).

[acozadd]

I see equally "well thought out" referrals from MDs, PAs, and NPs. "Well though out" is a general term meaning sometimes they get the body part right...