Viewpoints: Talk Back

Letters address midlevel usage and consumer options.

Use midlevels but know limitations

I am the office manager for an internist. We had a nurse practitioner for a couple of years who left us, and we now have a physician assistant. We are definitely advocates of midlevel practitioners, as long as everyone understands the limitations of their training and knowledge.

In our practice, we try to have our PA perform the annual physical exams and the simple follow-up visits or acute sick visits. For straightforward visits, the PA frees up the physician's time, which is definitely cost-effective. However, when a patient presents with a more serious issue or multiple comorbid problems, the physician also examines the patient with her, taking him away from his schedule.

After having employed two midlevel practitioners, we are keenly aware of their strengths and weaknesses and would not support their ability to practice without physician oversight.

Thomaston, Connecticut

Consumers will opt for the cheapest option

First, let's set up the premise that medicine is no longer fundamentally about the patient, but rather largely about money. Second, let me tell you that I have worked with many PAs and ARNPs with incredible backgrounds and training who have truly represented their professions well (I was in solo practice for two years at my own indigent-patient care clinic, where I worked with the best ARNP ever!).

But, that said, did you know that many ARNPs are now getting a large portion of their training online? I hired a part-time ARNP who had received a large portion of her training online, and she could not describe the causative organisms for a simple urinary tract infection.

When these graduates are pressed on basic pathophysiology, they fail miserably. I used to oversee and assist with chart audits for a retail clinic chain in Kentucky. They would do a rapid strep test on a patient, with a negative result, then proceed to dispense an antibiotic anyway. Simple cystitis was treated for 10 days with antibiotics, and a simple gastroenteritis case was treated with metronidazole.

ARNPs and PAs will continue to fill the gaps that the consumer desires. It will be some time (likely decades) before consumers realize that they are frequently consuming the equivalent of poorly made goods from discount big box stores (which now often have retail clinics staffed by-you guessed it-midlevels). As long as monetary gain dictates the majority of medical care, many will opt for the cheapest option. Hence the rise of the midlevel.

Primary care doctors need to return to the small practice (as many are), great care, and no-insurance models of yesteryear. Economics aside, these docs have placed themselves squarely against the rise of substandard care and have placed the patients first. Cheers to all of you who do it.

Lexington, Kentucky

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