Yesterday my sister went in for her annual checkup. The normal routine at the office is that a nurse(?) or some such takes care of showing her to a room, handing over one of those embarrassing gowns, weighs her, takes her blood pressure and such, and then tells her to wait. After a bit, the doctor comes and proceeds to question her about her health, checks her heart and lungs and eyes and ears and all that. After that it varies, according to what might be going on, like a prescription or referral for further blood work or a visit to a specialist, whatever.
This time after the nurse (maybe, could be she’s some type of med tech or whatever) did her thing, instead of the doctor it was a Nurse Practitioner who came in and did the rest. When my sister asked, the NP said the doctor was too overloaded with patients and therefore they had NPs to do the ‘ordinary’ wellness type checkups, and only set up another visit later if anything out of the ordinary was found. In this case, nothing was.
But my sister (and I) find it very strange that a patient can be fobbed off to a lesser professional without her being informed first and asked if this was okay. And, will she be charged the same amount for the physical as if she’d seen her doctor? No offense to the NP, who my sister said was polite and seemed to know what she was doing, but it sort of feels like she got a ‘bait and switch’ pulled on her. She’d ordered a steak, and the waiter delivered a hamburger.
I mean, we pay what we do for doctor’s visits for the doctor’s skill and medical experience and all those years of extra schooling – and sister didn’t get the benefit of that.
It just seems shady.
Note: I understand that GPs can be facing heavier work loads now, what with the pandemic, but this wasn’t even a case of my sister wanting/needing an appointment. The doctor’s office called my sister to tell her she was due for a checkup, and set up the appointment for the visit WITH HER DOCTOR, and then deliberately didn’t provide the service expected. Can this possibly how medical practices are supposed to operate?
It more than likely depends on WHAT the mid-level provider (NPs and PAs) is being asked to do. In my doctor’s practice (3 doctors and a PA), they let the PA do a lot of the everyday sick person visits- the allergies, the boils, the sinus infections, etc… You can try to schedule your doctor, but if you can’t, you can probably get a sooner appointment with the PA, because they only handle the acute stuff, not the chronic stuff, or the weird diagnostic stuff. And mid-levels practice under the supervision of an actual MD who in theory, reviews and approves their work.
Based on what I know, the in-office part of your average physical could easily be handled by a mid-level provider, as it’s just poking, prodding, listening, etc… that’s well within their capabilities and training. I’ve personally been to mid-levels for acute stuff, and they’re just as good at diagnosing and treating that stuff as a regular doctor is.
I wouldn’t call it “shady,” but it doesn’t strike me as a good way to run a medical practice. Many people are hung up on having “their” doctor and wouldn’t be pleased at all with this scenario.
I’m in my 60s and had a bunch of different doctors, and I’ve never seen a medical office run this way. I’ve been told “Dr. Whoozit is not available today—would you be okay with seeing the NP (or PE) instead?” but it’s always something I’m told on the phone prior to the appointment, and it’s presented as my choice. I’ve never had that switcheroo done as a surprise once I’m there.
That would be the critical point around here. Medical Insurance – private or state – would not pay a ‘doctor visit’ if you weren’t seen by a doctor. And although I personally wouldn’t mind seeing a qualified NP for triage and treatment, and would expect to pay as much for a NP who was qualified to do that (for the same level of training, you pay the same amount, regardless of path or title), I agree with the insurance companies: if you contract for a doctor visit, you get a doctor.
All my doctors are part of university medical service. Going to a routine check-up or post-surgery follow-up at a specialist’s office often means seeing a NP. If there are any real issues, they’ll pass you along to the specialist doctor. One time they did have to call the surgeon, and that meant I had to wait around he was available. Otherwise, they’re perfectly capable of basic medical procedures, write prescriptions, and get you in and out on time.
In the hospital, in fact, they’re the ones who came around every day to check me out in the morning. The surgeon appeared when he could, but NPs do all the grunt work these days.
Is this the best possible system? Maybe not. Or maybe the old system was wasting doctors’ time on routine matters when they should have been seeing people with pressing issues. Probably some of both, some times, somewhere.
I think there are two issues. One is having a person with “lower” qualifications. The other is having an unexpected person.
For example, my son’s pediatrician is part of a large practice, but we have a relationship with her. She’s seen him since he was in the hospital. I would be pissed if someone else showed up unannounced at his well-child visit: if they told me at scheduling that she wasn’t available, I’d chose a different time. If they called at the last minute and said she had an emergency, I wouldn’t be pissed, but I would probably reschedule.
On the other hand, if he’s sick and she’s not available, that’s fine. She’s not required to be there whenever we need a doctor. We can see whomever the practice has available.
In terms of qualifications, for routine stuff I don’t really care if it’s an MD/PA/NP.
I personally have no problem with having a nurse practitioner or similar health professional do a routine exam; in fact I think it makes a lot of sense in terms of the allocation of resources. Maybe that would be one part of a strategy to bring down America’s insane health care costs.
However, if your sister was led to believe she’d be seen by an MD, and/or the charge to her and/or her insurance reflects a higher rate than it should, I think she should call the practice and complain. No need to be rude, but it’s appropriate to politely state that she expects to be informed prior to her appointment what type of professional she’ll be seeing.
This assumes that she was actively misled, of course. If she was just notified that it was time for a wellness check with a particular clinic, and the fees charged are commensurate, I don’t think she has cause to complain.
(Sorry, kind of an IMHO answer to a GQ question, but unless someone with knowledge of the laws in a particular state can comment, I’m not sure there is a GQ answer.)
To answer your specific OP: Yes I think they can and it has happened to me often enough in the last 15 or so years that it no longer bothers me. Nowadays if I want to see a real MD I tell the office scheduler I want to see Dr. X and I’m willing to wait for an opening. Have not yet had a switcheroo.
My office visits are most often medication dosage assessments. I have blood work done and go it to talk to a Physicians Assistant. In all cases I was satisfied with the PA.
I also feel that an office visit with a PA or NP should be less than the true MD. But the office I go to charges $135 no matter (A) who sees you or (B) how long it takes. I’ll admit, I like the (B) part but not the (A) part.
Though, of course, the medical insurers might conceivably take the position that they are not going to pay for a consultation with a doctor if the business of the visit can be competently attended to by a nurse practitioner. So the decision of the medical practice about who will attend to which patient may well be coloured by the payments the practice will get for that attendance, which is not something the patient may control.
The OP didn’t make explicit by repetition who would ultimately pay, but if the insurance company is dictating what kind of visit you get, individual payers perhaps deserve the same power.
sometimes it’s in the contract of the HMO that in non-emergency visits nurse practitioners will be seeing you, but in CA it seems most ERS and urgent care places, there’s like 4 nurse practitioners and 1 or two doctors there for something serious and checking their work… and signing off on prescriptions
Well usually everything turns out to be routine but sometimes it turns out to be cancer or something else very serious. And I just don’t think nurse practioners or physicians assistants are adequate to diagnose these rare, dangerous medical problems.
A huge amount likely depends on where this occurred. The rules on billing vary from extraordinarily between say the UK , Australia, and the USA. Countries with national health systems (basically every Western country other than the USA) have codes that are quite clear on who and why things are charged. The UK is a trifle odd with its capitation system.
However the idea that a lesser standard of care comes with a NP is generally just not the case. Indeed for a lot of medicine you will prefer the NP. They are trained not as a lesser GP but as a specialist front line professional. A GP is a generalist. If you are being managed for a chronic illness or you are otherwise healthy and need a checkover, the NP is likely to provide better care. That is what they are for. The idea that a GP is more likely to pick up some subtle sign of a serious illness early versus a NP is IMHO probably backwards. I would trust a NP to be more sensitive. They will escalate things as needed.
Generally however I agree that if I book a consultation I expect to see the doctor I booked with. An ongoing relationship with ones GP is an important part of life, especially as one gets older. If however the booking was clearly for a general update on health with no issues, a NP might be regarded as the more appropriate person to perform the consultation.
In my experience, a NP is often more knowledgeable than the actual doctor. My endocrinologist is one of the best around, yet everyone tries to get an appointment with his NP, who is more patient-friendly.
A few years ago I went to the emergency room with a painful rash. I was seen by a NP. She took one look at my skin and said I had shingles, and gave me a prescription. If I waited for an MD it would have taken a lot longer.
They don’t “diagnose” rare, dangerous medical problems. They are trained to screen, so that when something appears abnormal they direct the patient to additional, more advanced care and tests.
I (in the UK) am very used to not necessarily being seen by a doctor (let alone my “named” GP), for the kind of things I’m there for. The practice has a number of GPs (partners, salaried assistants/trainees and occasional locums) and nurses. For just an annual/medication review, the various test results can easily be read as to whether or not something needs following up, whether vaccinations are up to date, whether I need advice on diet and exercise, whether I’m going gaga, or whatever, and I trust their nurses to know when to refer things on to the doctor. But my needs are not too complicated or unusual.
On the other hand, it is still the case that some proportion of people do expect to see “their” doctor, and I’d guess that’s responsible for a lot of moans about getting appointments. I’m perfectly OK with online communication and phone appointments, too, which some people loathe. We are increasingly getting concerned about shortages of GPs in the face of increasing demand, Covid burn-out and so on, but here’s my recent anecdotal evidence:
I got a request for an updated blood pressure reading, so called in at a local pharmacy, which came out a bit high, so they called me in to see the nurse at the practice, who took a normal reading, but referred the fluctuation on to my named doctor, who phoned to run over all the results. While he was on, I asked about what looked like an infected toe, sent a photo online and he asked me to call in that afternoon (perhaps because he had a medical student on observation that day, who knows), took a swab and prescribed antibiotics. All dealt with within a week or so.
As observed above, the “what I’m paying for” question doesn’t really arise here. The practice gets its block payments, and the rest is down to the clinicians’ judgement in applying whatever standard protocols That’s what I’m paying for in my taxes, and most of us are brought up to trust it.
To be clear, when I see my endocrinologist’s NP, it’s because I have an appointment with her. When my appointment’s with the doctor, I do see him. They recommend that we alternate our appointments between the two. If it were up to me, I’d always see the NP.