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Thought it was a a pretty decent article until...

"Limitations: P.A.s usually aren’t trained to handle multiple complicated diagnoses or complex procedures on their own. And they can work only under a supervising physician.

CR’s advice: It’s fine to rely on a P.A. for routine matters, such as a urinary tract infection or sprain, Lipman says. You can also go to them for follow-up visits for such conditions as high blood pressure. But avoid relying on them for complicated procedures."

But, at least it says a somewhat similar statement regarding NPs, essentially that the patient should see a doctor for complicated problems.  Unfortunately the article relies only on a few MDs and doesn't describe PA education as accurately as it could if they had actually talked with a PA.

It's especially funny since the IM doc that I work with regularly sends patients to me for ortho problems, as well as for diabetes and hypertension.  He is a great doc, and great to work with, but he just doesn't want to make the time to spend significant time talking about diet/exercise/etc. for these issues.  More often than not, the patient's stay with me after that first visit.

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Dear Editor:

As a practicing Physician Assistant (PA), I was quite pleased overall with Hallie Levine's "Will You See an Actual Doctor the Next Time You Go to the Doctor?" (February 1, 2018), but noted that the terseness of her otherwise excellent healthcare provider overview skipped over a key aspect of the Physician-PA relationship: the specialist PA.

Many PAs practice primary care medicine, but others work in specialty areas such as orthopedic surgery, psychiatry, interventional radiology, or headache medicine.  PAs receive generalized training and our initial board exams focus on general medical knowledge, but many specialty physicians and surgeons employ PAs, and there are both on-the-job and formal residency training programs to develop PAs into specialty practitioners.  When I had my own hip replaced, I saw my surgeon twice--at the visit where we decided on the surgery, and immediately prior to the surgery.  All my in-hospital and outpatient follow-up was done by a PA, leaving the surgeon free to do more surgeries. As I practice sleep medicine, I see patients referred by primary care providers--many of them physicians--I order and interpret sleep testing, and diagnose and treat sleep disorders.  As a part of a team practice, I work with a subspecialty board certified MD as my medical director.

Thus, when patients are sent to see a specialist and are seen by a PA, your readers should know that PA has the education and training to handle their case, and a collaborative relationship with a specialist physician who has even more training than the specialist PA.

Jonathan Clemens, PA-C
Olympia, WA

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I found this online https://www.consumerreports.org/doctors/will-you-see-an-actual-doctor-when-you-go-to-the-doctor/:


Will You See an Actual Doctor the Next Time You Go to the Doctor?

It’s getting harder to see a doctor, but you can still get quality care from a host of other professionals if you know who’s who

By Hallie Levine
February 01, 2018

It used to be so simple: You made an appointment with a doctor and would almost certainly see an M.D., someone who spent four years in medical school and then had at least three years of additional training, usually in a hospital.

But today you’re likely to encounter a veritable alphabet soup of healthcare degrees: D.O., P.A., N.P., R.N., and N.D., to name a few. Who are all these people? What training do they have? Which one is best for you? And where’s your good old M.D., anyway? (See our guide to healthcare providers, below.)

The truth is, you may not always need a traditional physician—and may have a difficult time finding one. The U.S. is short on doctors, especially those practicing primary care, who typically earn less than specialists. We now have fewer primary care physicians per person than many other developed nations. Canada, for example, has 1.2 per 1,000 people; the U.S., just 0.3.

Because there are fewer primary care doctors, it’s more difficult to get an appointment. The average wait time for a new patient in a big city to see a family-medicine physician, for example, is now 29 days, compared with 19.5 days in 2014, according to physician recruiting firm Merritt Hawkins.

At the same time, doctors today are feeling pressure to work faster. Because of competitive forces in the marketplace, including many hospitals buying up physician practices, doctors are now more likely to work for large networks than for themselves. And those employers often set daily patient quotas—16 to 25 per day is typical—that can limit your time with a doctor.

That time crunch, combined with growing demands to document all their encounters in often cumbersome electronic health records, is taking a toll on doctors.

More than half of primary care doctors report feeling burned out, according to a 2017 Medscape survey. And that could undermine the care they provide, make them less willing to work collaboratively with patients, and drive even more out of the profession.

The Growth of Different Medical Professions,


Source: Bureau of Labor Statistics (N.P.s, P.A.s, D.C.s, and R.N.s) and the Federation of State Medical Boards (M.D.s and D.O.s).

*Data available only for 2012-2016.

A Team of Providers

Enter “advanced practice providers.” These are the N.P.s (nurse practitioners) and P.A.s (physician assistants) you may run into at a doctor’s office.

They don’t have as much training as M.D.s but are licensed to do many of the same things. And their ranks are growing fast. The share of physicians with these clinicians on their team has risen from 25 percent in 1999 to more than 60 percent now.

But is seeing one of them as good as seeing a medical doctor? In most cases, yes, says Ateev Mehrotra, M.D., an associate professor of healthcare policy at Harvard Medical School.

His January 2017 study in the journal Medical Care found that practices with more N.P.s and P.A.s had fewer specialist referrals, hospitalizations, and ER visits. And other research has found that when it comes to high blood pressure, diabetes, respiratory infections, and other common problems, there’s little difference in treatment from M.D.s and advanced practice providers.

The team approach is also efficient, allowing each clinician to focus on what he or she does best. And it can mean shorter wait times and better patient education, according to a 2016 analysis by the Agency for Healthcare Research and Quality.

In addition to N.P.s and P.A.s, you may also be more likely to encounter other healthcare professionals now.

They include reputable ones, such as doctors of osteopathic medicine (D.O.). Their education is similar to an M.D.’s, with special training in muscle and skeletal issues, and their numbers have been growing.

But you may also encounter some more controversial providers, such as naturopathic doctors, or N.D.s.

This guide explains who’s who, gives advice on how to get the most of your precious time with each of them, and identifies those you should consider steering clear of.

A Guide to Today's Healthcare Professionals

For a routine office visit these days, you might not ever see an M.D. A case of the flu, for example, might be handled by a physician assistant (P.A.), and a regular checkup might be done mainly by a nurse practitioner (N.P.). And that can be just fine: Practices with advanced practice providers have outcomes at least as good as those that rely mainly on M.D.s. But it can be reassuring to know exactly who it is you’re seeing. Here’s a guide to some of the providers and what sets them apart from one another:


Training: Earning this degree requires four years of medical school—typically with two years studying biomedical science and basic clinical skill and two more rotating through a broad variety of specialties. Then there’s an additional three to seven years under the supervision of experienced faculty physicians

Strengths: M.D.s (and D.O.s; see below) have the most training of the providers you’ll see. So if you have several conditions or symptoms that don’t easily add up, an M.D. can connect the dots more easily, says David Blumenthal, M.D., president of the Commonwealth Fund, a nonprofit foundation that focuses on health policy.

Limitations: Primary care docs are in short supply, so it might be difficult to find one accepting new patients, and he or she might not be able to spend as much time with you as you like.

CR’s Advice: If you have a complex health condition or one that isn’t responding to treatment, you’re better off seeing an M.D., says Marvin M. Lipman, M.D., CR’s chief medical adviser. But if you’re in good health or your condition is well-controlled, it can be fine to get the bulk of your care from an advanced practice provider.


Training: The four years of medical education for D.O.s largely matches M.D. programs but also includes 200 hours in osteopathic manipulative medicine, hands-on techniques designed mainly to treat pain. These doctors participate in many of the same residency programs as M.D.s and can specialize in anything from pediatrics to psychiatry to surgery. One of four U.S. medical students now attends an osteopathic medical school. But don’t confuse D.O.s with osteopathic practitioners who are trained abroad; they’re neither M.D.s nor D.O.s., only perform manipulative treatment, and can’t prescribe medicine.

Strengths: “D.O.s are virtually interchangeable from M.D.s,” says Susan Hingle, M.D., chair of the Board of Regents of the American College of Physicians. They provide a full range of medical care for all types of diseases and health problems, but they may be especially good at treating musculoskeletal conditions such as lower back pain and less likely to prescribe drugs for that problem, according to a 2015 study in the Journal of the American Osteopathic Association.

Limitations: Like M.D.s, they don’t have much time to spend with patients. The average osteopathic visit is actually a couple of minutes shorter than the average visit with an M.D., according to that same 2015 study.

CR’s Advice: A D.O. can serve as your doctor in any case where you might seek an M.D. More than half of them practice family medicine or pediatrics. And by seeing a D.O., you get the benefit of his or her extra training in the musculoskeletal system.


Training: Before someone can become an N.P., he or she must be a registered nurse (R.N.), which requires an undergraduate degree in nursing. N.P.s go on to advanced education and clinical training, earning either a master’s or doctorate degree, specializing in an area such as family practice, pediatrics, or women’s health, says Diane Padden, N.P., Ph.D., vice president of professional practice and partnerships at the American Association of Nurse Practitioners.

Strengths: N.P. education and training emphasize patient-centered care, which means that in addition to diagnosing and treating conditions, N.P.s focus on health education and counseling. One study found that patients tend to be more satisfied after a visit with an N.P. and that those visits tend to be longer. In some states, N.P.s can practice independently.

Limitations: Those with diagnostic dilemmas, such as an unexplained fever that has lasted a few weeks, should usually be referred to an M.D. or a D.O.

CR’s advice: It’s fine to choose a nurse practitioner as your main healthcare provider and to have one provide routine care during an office visit. But you should expect to be referred to a physician for complicated problems.


Training: Becoming licensed as a P.A. typically involves a three-year master’s program with coursework in anatomy, physiology, pharmacology, diagnosis, and ethics, as well as training in areas such as family medicine, internal medicine, emergency medicine, and pediatrics. Many P.A. programs also require some sort of patient-care experience, such as working as an EMT, a phlebotomist, or a registered nurse.

Strengths: They can do many of the same things as M.D.s and D.O.s, such as taking medical histories, doing physical exams, ordering X-rays and other tests, and prescribing medication.

Limitations: P.A.s usually aren’t trained to handle multiple complicated diagnoses or complex procedures on their own. And they can work only under a supervising physician.

CR’s advice: It’s fine to rely on a P.A. for routine matters, such as a urinary tract infection or sprain, Lipman says. You can also go to them for follow-up visits for such conditions as high blood pressure. But avoid relying on them for complicated procedures.


Training: Laws vary by state, but R.N.s generally have a Bachelor of Science degree in nursing, an associate’s degree in nursing, or a diploma from an approved nursing program.

Strengths: R.N.s are vital members of a medical team, taking medical histories, assessing symptoms, and supporting patients. They tend to focus more on patient education, “for example, counseling someone with high blood pressure on how to take their blood pressure at home,” Hingle says. That’s because their training “tends to be a lot more relationship-focused than what doctors get in medical school.”

Limitations: R.N.s can’t practice independently or write prescriptions, and they must work under the supervision of an M.D. or a D.O.

CR’s advice: You shouldn’t rely on one as a primary care provider. But R.N.s are a great resource at your doctor’s office if you need diet or lifestyle counseling, or instructions on day-to-day treatment of a disease (such as monitoring blood sugar levels).

This article brought to you by the letters A, M, and A.

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