How to harmonize with PAs and NPs

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

By William T. Sheahan, MD
Family Physician/Orlando

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 plus 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 practitioner, 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.

How to make the best use of PAs and NPs

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. Medical Economics 2000;16:69.