Do you know what a physician extender is? Or maybe you have heard the term mid-level provider? It is the umbrella term for physician assistants and nurse practitioners. You may have seen a physician assistant or a nurse practitioner for healthcare services. We are newer professions to the healthcare team. We diagnose and treat patients. We aren’t doctors and we aren’t nurses. Are we less than doctors? Are we well educated? Are we capable? Can we do what a doctor does? We are a group of healthcare providers who haven’t been around as long as doctors have been practicing and when something is somewhat new we all have questions. This blog hopefully will answer those questions.
Since I am a nurse practitioner I can explain that profession best. Nurse practitioners are registered nurses who go on to get a masters degree to become Advanced Registered Nurse Practitioners(APRN). APRN’s have experience in the medical field as an RN before being accepted into graduate school. All APRN’s have a bachelors degree and a masters degree in Nursing. In the state of Arkansas all APRN’s have passed “boards” which is a certifying exam. APRN’s can go through different tracks in school to chose a focus. Some of the different focuses include family, adult, gerontology, pediatric, women’s health and psychiatric practice. They can also get different certifications post graduation in almost any specialty. After graduation and after requirements are met, an APRN can practice independently in his/her scope of practice diagnosing and treating patients. He/she can only write prescriptions if he/she has a collaborating agreement with an MD. Collaborating agreements vary but you can see examples at www.arsbn.org. Nurse Practitioner licenses are regulated by the Arkansas State Board of Nursing.
Physician Assistants have a little different educational pathway. I hope I understand and explain it correctly. They go to undergraduate school and can have varying undergraduate degrees. They then apply for a physician assistant graduate school. Their schooling takes them through all the specialties. Looking at the UAMS website, for admitance they are also required 500 hours of clinical experience, this requirement varies from school to school. PA’s are also required to take national “boards” to get licensed. PA’s can also get post graduate certificates in almost any specialty. When they graduate they cannot practice independently. They have a supervising physician and their scope of practice is what their supervising physician and the Arkansas State Medical Board decide. They are governed by the State Medical Board.
In my opinion, PA’s and APRN’s travel two different roads to get to the same end point. I have worked beside PA’s and APRN’s in past and present jobs and we basically do the same thing. Of course, I have worked with lots of physicians too and sometimes we do the same duties. Here is what you should know about midlevels.
1. Just because we are called midlevels doesn’t mean the care we give is midlevel. I give my patients the kind of care that I want my family and loved ones to receive. If I think you have a problem out of my scope of practice then I will refer you to my collaborating physician. Just like a dermatologist physician refers someone with heart problems to a cardiologist. Not because the dermatologist is a bad doctor but because cardiac arrest is out of their scope of practice.
2. We aren’t training to be doctors. I constantly get asked if I’m going to “go on” to become a medical doctor. The answer is no. I would have to start from square one. It’s a different profession. I know it seems like a PA, APRN and MD are all the same profession but we are actually three different professions that might happen to do the same daily tasks in the eyes of the general public.
3. We don’t want to replace doctors. We need physicians to be able to practice at our highest level. Each practice uses physician extenders in different capacities. For example, in our clinic Dr. Sandy may be the provider that you are scheduled with and see that day but Honey or I may do your biopsy. Or you may just see Honey for your entire visit for psoriasis (she is our psoriasis expert). Or you may just see Dr. Brad for your entire visit (he is our MOHS surgeon).
4. We don’t like stereotypes. There are good doctors and bad doctors. There are good APRN’s and bad APRN’s. There are good PA’s and bad PA’s. Judge us after you meet us and see if you like the care we give. Don’t assume we are better or worse just because of the letters behind our name.
5. We improve healthcare. We can often shorten the time a patient waits for an appointment and give you more time during your visit. For example, in our practice Dr. Sandy manages the difficult medical issues and Honey and I are more expert with common dermatology issues such as acne or warts. By having us join the practice Dr. Sandy can spend more time with each individual that has complicated problems because we are seeing the wart and acne patients she would otherwise be seeing. Plus, we now have three appointments available at 11:00 instead of the one before Honey and I joined the practice. This results in people getting appointments quicker.
6. We are educated and licensed. We are prepared. When you have an appointment with a physician extender instead of a physician you aren’t getting “left overs” or “second choice” or less care than you would receive from a physician. Not at Johnson Dermatology anyways. I graduated top of my graduate class with a 4.0 GPA, could someone “sub-par” do that?
7. We are just part of a team. Midlevels NEED nurses, front office staff, physicians, lab technicians, radiology technicians, pharmacists, pharmacy technicians and even pharmaceutical sales reps to give you the best care. To get the best healthcare you deserve it literally takes a whole team. Realize that when you go to a healthcare appointment. Your healthcare provider is just a piece of the puzzle. You need the whole A-team to make it work the way you want.
8.We satisfy our patients. According to the AANP there are 916 million visits made to NPs each year and patients “report an extremely high level of satisfaction”. Maybe you should give us a try too?
9. We are experienced. When I was a travel nurse I would work in teaching hospitals and teach med students how to start IVs or how to read arterial blood gases and manage ventilators (patients on life support). At that time I had more experience in doing those tasks (I was an ICU nurse for 7 years). My point is that sometimes experience and repetition at tasks are as important as the letters behind your name.
10. Everyone has their strengths and roles. Dr. Brad is our MOHS surgeon. If you need a skin cancer removed then he is your guy, not Honey. But Honey is our psoriasis expert. If you need your severe psoriasis managed, she is your gal. Not because Dr. Brad couldn’t do it but she does it all the time and knows which insurances pay for which medications. Plus it’s what interests her. So on the weekend she is going to be the one more likely to read that new study that just came out on psoriasis while Dr. Brad is reading (maybe even dreaming) about surgery.
I’m guessing this post is longer than you cared to read. I hope I didn’t lose you because it was just too darn long! There is no simple answer to the role of midlevel providers but we are here to stay. Chances are you’re going to run into one of us. There are too many baby boomers and not enough doctors. There are too many health problems and not enough doctors. Heck, there are not enough midlevels. Lots of offices are booked three to six months out! I just hope whoever the midlevel is that treats you gives you a good experience that represents our profession well. I know that I promise to give you the best care at Johnson Dermatology. If I can’t answer something for you I will do everything in my power to find you an answer. Honey is as smart as the dermatology book we read front to back together. She can take care of my skin any day. She is literally one of the smartest women I know and I am honored to work beside her as the midlevels of Johnson Dermatology. Of course we are only as good as our team, which is the best.
Thank you to the physicians and nurses that made me the provider I am today,