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When the “Doctor” Is Not a Doctor

Teaming with nonphysician clinicians

The New Physician July-August 2007
They are called by many names—nonphysician clinicians, allied health professionals, physician extenders—and they have many different titles, specializations and competencies. But when it comes to patient care, they are no less than central to the clinical team. Working effectively with these professionals is essential to keeping the system afloat.

Health care today is dizzy with changes. One of the most striking is that when a patient sees “the doctor,” that person may not be a licensed physician at all. Nurse practitioners (NPs), physician assistants (PAs), physical therapists, certified nurse anesthetists and midwives, medical technologists and a host of other professionals are shouldering more of the day-to-day duties of patient care. Their roles are constantly evolving, and getting all those masked heroes working together in the most efficient, patient-friendly manner can sometimes be a challenge. It’s a challenge that must be met, however, because these folks are here to stay.

According to a 2005 report by the Robert Wood Johnson Foundation (RWJF), the number of nonphysician clinicians (NPCs) in the United States increased by two-thirds in the preceding decade, and shows no sign of slowing.

This is due at least in part to a projected shortage of physicians. Although their numbers are increasing slightly, the growth will not keep up with projected demand. An aging population, and with it, an alarming increase in high-maintenance chronic diseases like diabetes, will add additional strain to an already stressed system in the coming years. On top of that, U.S. physicians themselves are aging: More than 20 percent are over age 55. At the same time, newly minted practitioners are demanding less grueling, more family-friendly lifestyles than their mentors had, which means cutting back on the time available for patient care. And under financial pressure from large payers like private insurers and Medicare, a physician is fortunate to spend more than a few minutes with each patient.

It’s one of the defining characteristics of medicine in today’s world, says Dr. Andrew W. Seefeld, a third-year resident in emergency medicine at UCLA Medical Center: “Too many patients, not enough staff.” One solution to this dilemma, he believes, is NPCs. “I think they are invaluable. They are helping to increase the quality of care patients are getting. I wish we had more.”

So what do NPCs bring to the exam table and bedside? The most immediate resource is time. “Physicians are typically with a patient for 15 minutes. Allied health professionals may spend hours with a patient,” says Deborah Larsen, associate dean of Ohio State University College of Medicine and director of the School of Allied Medical Professions. But just as importantly, NPCs often develop a body of knowledge that M.D.s don’t have. For example, a physician can diagnose and treat Type 2 diabetes and stress the importance of a careful diet in the management of the disease. But when it comes to designing a particular diet for a patient and ensuring compliance, a registered dietician (RD) is better for the job. No medical school curriculum has room to include in-depth training in nutrition, and it doesn’t need to—that’s what RDs train to do.

But where NPCs are most immediately valuable is right there in the clinic or the ER: NPs and PAs are trained and qualified to take histories, order diagnostic tests and, in many cases, treat and manage illnesses independently, saving the physician precious time that can now be spent more productively with the patient, or with others who require more intensive treatment. “NPCs…can make clinical decisions based on their knowledge and experience, and come to us if they have problems, or the patient needs care that they cannot provide,” explains Seefeld.

Family Squabbles

Still, the rapidly changing roles of NPCs can make it difficult to get a feel for exactly what they do, particularly as the degree of responsibility and autonomy awarded them varies enormously from specialty to specialty and state to state. And regulations are changing even as The New Physician goes to press. Several states have pending legislation concerning the scope of practice for various nonphysician disciplines.

Nonetheless, one thing is clear: NPCs working alongside physicians in a team effort is becoming an accepted norm. A 2003 study from the New England Journal of Medicine showed that demand for NPC care often comes from the patients themselves, and that insured, middle- to high-income patients with some college education are those most likely to avail themselves of nonphysician care.

The study also put to rest fears that a proliferation of nonphysician providers might constitute unwanted competition for physicians. The study found that physicians are likely to refer patients to NPCs, and the two typically work side by side in the same clinic or hospital. All the same, the authors of the study did raise a concern that the use of several providers might result in fragmented care. But in a commentary that accompanied the study, Linda Aiken, a registered nurse and director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania, noted, “Many studies of nurse practitioners and nurse midwives, for example, provide solid evidence that the excellent outcomes of care they provide are due in part to their central roles as case managers and coordinators of care.” It turns out that having an allied health professional coordinate patient care might be more beneficial than having a slew of physician specialists.

Of course, some tension has always existed between physicians and, well, everyone else in the room. The paradigm of the physician as God and everyone else, no matter how skilled or well-trained, as landing somewhere much lower down the hierarchy is a stereotype with years of medical culture to support it.

While NPCs have been complaining for years that they don’t get enough respect from physicians, hard evidence of mistreatment—beyond gossip and anecdotes—isn’t readily available. Nevertheless, off-the-record reports of surgeons demeaning their intelligence or ignoring their recommendations—even when the NPCs are in a better position to make the call—are legion. Careful reading of studies and reports prepared by doctors often gives clues to what is going on beneath the surface. For example, one passage in the RWJF report reads: “Although the principle that [NPCs] can deliver high-quality care is unequivocally true, more research is needed to test this principle under conditions of greater clinical complexity and autonomy.”

In other words, the “unequivocal truth” that NPCs deliver high-quality care is, in the opinion of some physician policy-makers, not enough to grant them the authority to do just that. The problem, it seems, is not so much a lack of evidence demonstrating their competency as a lack of respect for their skills.

When asked what message she would like to send from allied health professionals to physicians, Larsen replies, “We’d like you to have respect for the body of knowledge and experience that we bring to [health care]. It is OK to ask questions of us.”

Jeff Pepin, now a third-year at St. George’s University School of Medicine, was a paramedic before starting medical school. “Walking through the doors of the ER as a paramedic and attempting to communicate with physicians was often a nerve-racking experience,” he says. “I believe that [many] physicians have a lack of understanding as to how allied health professionals are trained and how they can be more effectively utilized…. In my experience, more often than not, multidisciplinary health-care teams have not worked as well as their administrators would have liked.”

But the culture of medicine is always changing, and Pepin’s experience may not be the norm for long. “The concept of a medical team is much broader than it used to be,” says Larsen. “[Medical school] graduates in the ’50s, ’60s and ’70s had less training in the ‘team concept.’ Today it is often not a physician, but another health professional, who runs team meetings.”

Catherine Jones, an M.D./M.P.H. candidate at Tulane University School of Medicine, has found this to be true. “After Katrina, I took eight months off and worked at Common Ground Health Clinic in New Orleans,” she says. “The clinic was run by a nurse practitioner. Doctors were not dictating the care on a daily basis.”

And this kind of experience is helping to influence a change in the larger culture of medicine. “My experience [at Common Ground] will definitely have an impact on how I practice medicine,” Jones adds. “The idea of being disrespectful of an allied health professional is alien to me.”

Twenty-first Century Teaming

If you say it enough times, the word “teamwork” begins to sound like business jargon. But in fact, it is the key to making the contribution of nonclinical professionals a valuable part of medicine. In fact, teamwork is one of the fundamentals taught to NPCs.

Alison Williams, a student in the surgical assistant program at Virginia College in Birmingham, Alabama, says that in her experience, “a surgeon couldn’t do his or her job without the rest of the team doing theirs.” And according to Williams, most of the surgeons she has worked with (and in the Virginia College program, students take part in two or three surgeries a week) understand this. “They can occasionally be rude or even mean,” she says, “but when they are, they usually apologize after. They know that they couldn’t do it without their teams.”

Today’s health-care environment is making this a lesson worth learning. Larsen believes that the diversity of health-care professionals will work better together in the real world if they also train together.

“We are looking into co-teaching [medical students and allied health students] so that it will be easier for them to work together when they are out of school,” she notes. And Pepin suggests, “As part of problem-based learning in the clinical skills block of the basic-sciences course, medical students should learn how to delegate to allied health practitioners.”

Training together is not the only approach. At many schools, NPCs themselves take part in teaching. And why not? They are extensively trained in their particular areas of specialty and can take the time to share this knowledge with medical students. “When I was on OB rotation,” recalls Jones, “one of my instructors was a surgical PA. He was an amazing teacher—very knowledgeable.” Jones was also taught by a nurse anesthetist on the same rotation.

Focusing on this kind of teamwork early in the study of medicine might keep medical students from making common “rookie” mistakes—everything from assuming that all nurses are female to believing that all NPCs are low-level assistants with token training. While such mistakes mostly occur in matters of courtesy and respect, at least some will have a negative impact on patient care. According to Larsen, the most common error medical students make when dealing with allied health professionals is “failing to ask for information from other members of the team—they don’t want to look like they don’t know something, so they don’t ask. Often medical students are unfamiliar with the educational preparation and knowledge of allied health professionals and, therefore, fail to recognize [them] as a source of information, or in some instances the need to relinquish control of the situation to the other professional.” When the other professionals are their teachers, this mistake is far less likely to happen.

If “teamwork” sounds like business-speak, Williams has another word for it: “It’s really like a family,” she says. “Everyone has a role to play and a job to do.” With a little practice, health-care teams might become that rare breed: a functional family.
Avery Hurt is a freelance writer in Birmingham, Alabama.