William T. Sheahan, MD

Many physicians want "extenders"but often   don't want to be bothered by the oversight. Here's how groups can create productive   teams. 

 Over the last seven years in primary care, I've worked with about   20 physician assistants and nurse practitioners. I've learned that successful   collaboration among doctors, NPs, and PAs depends on how your group deals with   issues that are part and parcel of the doctor-midlevel relationship. 

For example, how do doctors react to the limitations of their assistants' clinical experience? Sometimes we're fortunate to find employees who have had extensive experience in related medical fields, such as the PA who was a corpsman in the military for eight years, or the NP who worked as an ICU nurse before getting her master's degree. A PA I work with now was previously employed by a dermatologist. He performs procedures in our office usually done by plastic surgeons.

But more often PAs and NPs have had only 18 to 24 months of training, and in primary care their on-the-job learning curve is particularly steep because of the variety of clinical diagnoses they encounter. Remember what it was like to be a third-year medical student? Most of us were glad we had more-senior students, residents, fellows, and an attending physician to turn to when we strayed beyond our skill and confidence level.

 It's a different story in a busy primary care practice. We physicians want   our NPs and PAs to be independent and productive; there's little time to counsel   them or answer questions. Yet, at the same time we insist that they practice   only within their clinical expertise and comfort. Most NPs and PAs sense this   dichotomous force field that physicians emitand some doctors can be downright   rude to midlevels who they feel are bothering them. 

So assistants search out the most approachable physicians to ask their questions. Those doctors may be willing to teach, but most ultimately find the burden of managing their own patient panel 

 overseeing the PA's or NP's patients too stressful. As their unencumbered partners are making phone calls, dictating charts, eating lunch, and leaving on time, the physicians who consult with NPs and PAs fall further behind in their own work.

Far less disruptive of a practice's operation, but exasperating to many physicians, is the tendency of patients to address an NP or PA as "doctor." Although our midlevels routinely correct them, I still frequently hear patients schedule a follow-up visit with a PA or NP by asking for an appointment with "my doctor."

This bothered me a great deal until my mother told me about her visit with a "nurse physician." When I reminded her that she saw a nurse 

, she observed that the NP was like her doctor of many years ago. Mom was so happy that someone actually spent time with her and didn't appear distracted or in a rush to get out the door. Similarly, an elderly man told me he knew the assistant wasn't a "real doctor," but she was the best "doctor" he'd had had for a long time because she "listens and cares." Making patients feel they have been listened to and cared for is no small talent, and it should be prized wherever it is found.

 I have been very impressed with the midlevel providers I have worked with,   so I realize why the issue of compensation can be a problem for them. NPs and   PAs in primary care often feel they are undercompensated for what they do. They   have colleagues who make significantly more money in specialty practices. Complicating   matters, PAs generally earn more than NPs, which causes tension in a group where   both are employed. Both sides will argue that their particular training is more   extensive, but I haven't seen any difference in their responsibilities or competence. 

Finding solutions to the many challenges raised when doctors and other professionals work together is essential for good patient care, says the author of the accompanying article. After years of working with PAs and NPs, he offers the following suggestions to help create a harmonious and productive team:

1. Pay NPs and PAs on the same salary scale.

2. Have one or two physicians in the group serve as the "attending" for a particular NP or PA. This way, the midlevel provider will be spared the frustration of having to deal with the wide range of personalities and practice styles among the other physicians in the group.

 3. Give the attending physicians compensation or perks for the additional   workload and responsibility of overseeing an NP or PA. In my former practice,   a physician who did a detailed consultation or an evaluation of an assistant's   patient received a 1/2-patient credit. When bonuses are based on production,   doctors suddenly become much more cooperative in working with NPs and PAs. 

4. Always allow a midlevel provider to transfer to the attending physician a patient he or she isn't comfortable treating. It's very helpful to have a scheduling coordinator telephone new patients so that patients with complicated medical conditions can be given an appointment with a doctor rather than a PA or NP.

5. Institute a policy that assistants always consult with a physician for certain clinical diagnoses or situations, such as a diabetic with complications or a patient with unstable congestive heart failure. In my practice we also have a rule that the PA or NP must consult a physician whenever a patient comes back for a third time with the same complaintif not before. This removes much of the guesswork by the assistant on when to get the attending physician involved. 

 6. Have a formal policy regarding chart reviews. A lawyer will tell you to   review the charts of all patients seen by a PA or NP you employ, but that isn't   realistic in a busy practice. One approach is to automatically review those   charts with diagnosis codes that indicate a certain complexity of medical condition,   and review other charts at random. Make sure you document that you've notified   the midlevel provider when your review uncovers an error in treatment. 

7. Formally recognize the PAs and NPs in your group on business cards, letterheads, and signs.

8. Encourage your PAs and NPs to further their education with time off for conferences and allowances for CME materials.

9. Productivity or year-end bonuses foster a sense of "ownership" in the practice among midlevel providers.

 10. Treat NPs and PAs with the respect they deserve. 

 

William Sheahan. How to harmonize with  PAs and NPs. 

Articles

Many physicians want "extenders"&#151;but often don't want to be bothered by the oversight. Here's how groups can create productive teams.

How to harmonize with  PAs and NPs

You can't be the right doctor for your family

Why wouldn't the surgeon operate on his own daughter? Theauthor couldn't understanduntil he became a physician himself.

By William T. Sheahan, MD 
Family Physician / Winter Park , FL

The author (below) woudln't treat 5-year-old Tommy for a serious illness. But a fast boat ride is a treat for both father and son.

I love you," my mother says, as we're concluding a phone call. I'mready to reply, "I love you, too." But she interrupts: "Oh,by the way. My right leg has been painful, red, and swollen. Should I beworried?"

Several days later, my older brother asks for a favor. He has a physicalexam form that he needs completed. Would I mind doing it?

My other brother calls because his cat just scratched him, leaving anasty laceration. Should he be concerned? What treatment would I recommend?

You, too, have no doubt been called upon many times to offer informaladvice to friends and family. And perhaps you've found, as I have, thatfriends usually understand a mutually respected boundary, and seldom crossit except in certain situations.

With family members, though, the dynamic becomes much more complex. Notonly are you dealing with the emotional upset of a loved one's being ill,but there is a stronger desire to diagnose and treat, as well. Boundariesaren't as clear for those involved.

I learned first-hand about this issue many years ago. My mother's fatherwas a general surgeon. For years, he was a chief of surgery, in additionto serving a term as president of the Medical Society of New Jersey. I remembermy grandfather working long hours and being admired by patients and colleagues.

In the spring of 1979, when I was in college, my mother was diagnosedwith breast cancer. During her surgery, I was confused to see my grandfathersitting in the postoperative waiting room along with the rest of us-notperforming the operation himself, or even assisting. I thought he had letmy mother down. Here he was, a surgeon who'd treated hundreds of women withbreast cancer, sitting in the waiting room when his own daughter neededcare. Surely, if my grandfather had operated, my mother's lymph nodes wouldn'thave been positive and she wouldn't have needed chemotherapy.

I was even more disappointed when my mother subsequently developed adeep venous thrombosis in her right leg. How could my grandfather have alsoallowed this to happen? It made no sense to me then.

It does now. I realize the terrible sense of helplessness he must havefelt. Although he possessed the professional skills to treat my mother,he understood the even greater importance of being, first and foremost,her father. He knew instinctively that it was best to leave her care tothose who could proceed more objectively, and probably more effectively.He was her father, not her physician.

I am now in a similar situation. Roughly three decades ago, when he wasin his mid-40s, my dad was diagnosed with Parkinson's disease. Today, hehas little use of his arms, has swallow dysfunction, and is incontinent.His speech is nearly unintelligible. He is delusional and has some dementia.

I have tried to be helpful to my parents over the years. However, mymother has always insisted on doing the bulk of the caregiving, and forthat, although I am almost ashamed, I've been very thankful. I've oftentalked with my father's physicians and tried to help explain to my familythe issues related to his care. Because I'm boarded in both family practiceand geriatrics, I have the professional knowledge and skill to care forhim myself. However, when we are together, I am his son, not his physician.

The time will come when I will have to help my family decide about initiatingenteral nutritional supplementation and make other difficult end-of-lifechoices. When I'm counseling my patients and their families in such matters,I present all the options. I let them know that by withholding artificialnutrition, they are not actively causing the demise of their loved one.I assure them that the inability to eat sufficient calories to sustain lifein the end stage of an illness is a natural way to die.

I don't want my father to die. But I also don't want him to suffer. Therefore,as his son, I'll need to address the many difficult choices my family inevitablywill face. I'll do my best to enable us to feel comfortable with our decisions.

The question, then: What boundaries are important for a physician whendealing with health-related concerns of a family member? You wouldn't treatoutside your expertise, of course, but beyond that the lines begin to blurand the desire to diagnose and treat remains strong. Still, there seem tobe several situations in which a family member's care is better left toanother doctor. Among the boundaries I try not to cross are these:

When the situation is too personal. Luckily for me, my brother declined  to have me complete his physical exam form when I told him I would need  to do a history and physical, including a sexual history and genital-rectal  exam. If he hadn't withdrawn his request, I would have told him I wasn't  comfortable performing the exam. Similarly, if my mother had a gynecologic  problem, I certainly wouldn't feel comfortable as her examining physician.  

When it's too emotional. You also wouldn't want to be a family member's  physician if you thought that your emotional involvement might render you  less effective. Emotions might cause you to overreact and make less-than-optimal  decisions. There's also the risk that you might not take the situation  seriously enough.  

When you know too much to be objective. Background knowledge is helpful  in treating patients, but it can hinder managing the care of a family member.  For instance, if I'm treating a nursing home patient, I'll carefully consider  the staff's insights and input. After all, they see the patient a great  deal more than I do.

But if I'm treating a family member, background knowledge might renderme less objective. For example, I can appreciate how it might make me lessresponsive in treating my own children, simply because I know they havea certain pain threshold or emotional makeup.

It's important for a physician to recognize the emotions involved whentreating family members. It's also important to be comfortable with developingboundaries appropriate for your family. There's no definitive word on when-andto what degree-to provide care for family members. As with so many otherfacets of medicine, we're forced simply to use our best judgment. Most ofthe time we know instinctively when our loved ones will be best served bydeferring to a colleague.

William Sheahan. You can't be the right doctor for your family. 

Why wouldn't the surgeon operate on his own daughter? The author couldn't understand--until he became a physician himself.

Author | William T. Sheahan, MD

Articles

How to harmonize with PAs and NPs

You can't be the right doctor for your family