Can a medical office just substitute a NP for the expected doctor at an appointment?

Maybe it’s obvious, but in the end, if the consumer is dissatisfied, seeking care elsewhere is something to consider.

To be clear, this varies pretty widely from state to state in the US: (PDF)

Many states require there to be a doctor involved, or at least a written protocol in place. My wife has to review all prescriptions made by the NPs that work with her, I believe.

In my doctor’s practice (certainly dozens of doctors, possibly hundreds in three large buildings) the NPs see patients on their own, but there has to be a supervising MD (or DO) on the premises.

There was one time when the NP who was seeing me wanted a doctor to look at my complaint. It took almost an hour, but she basically didn’t feel comfortable closing out the visit without it.

On the report of my visit (which I get electronically) there is always a doctor’s name listed in addition to the NP/PA’s

Here’s the deal on mid-levels’ Scope of Practice laws for each state:

Our family provider is a PA and she very likely saved my husband from permanent paralysis. He was trying to get an appointment with his neurologist, but nothing was available for several weeks. So we got an immediate appointment with the PA who did a couple of tests, then asked for the neurologist’s phone number. When she came back to the exam room, she said we were to go immediately to the ER at the hospital where the neurologist was that day. The next day, my husband had his 10th spinal surgery. The surgeon said if he’d waited even one more day, he may well have lost the use of his legs.

Needless to say, we’re big fans of our PA.

My most favorite doctor ever had a staff of NP’s and PA’s that would handle the things like rashes and fevers while she managed the chronic conditions. When you made an appointment with her office, you always knew who you’d see when you got there……and if there was an emergency and you had to see another practitioner it would be explained to you

I feel that’s a good system. But I’d be a little less copacetic with having a PA or NP handling the annual wellcare visit, because that involves a lot more than just a bunch of tests. My doctor handled at least the interview portion of the annual visit herself and she took a whole patient approach. She’d discuss diet and exercise, assess for mental health issues and compliance with medication. She was the rarity, a doctor that really knew how to listen.
I once needed a procedure that is widely considered to be a simple and painless office procedure, but I had it before and found it to be traumatic - not really painful, just traumatic. I told her so and she didn’t push back at all, she just worked to find a clinic that would perform the procedure under anesthesia, and that wasn’t easy.

But she thought it was important for a doctor to sit down with every patient, even the healthy ones, once a year. I got really good care from her, that approach made a difference.

My PCP doesn’t diagnose those things either - he might order some tests but he’s definitely sending me to a specialist if he thinks it might be something serious. But sometimes I end up seeing the NP. It’s typically under the same circumstances I would see another MD back when my PCP practiced with another MD - when I’m sick and don’t want to wait an extra few days for an appointment with my PCP, or when he was expected to be available when I made the appointment but isn’t when the appointment date comes - like if he’s ill himself or his car breaks down or something.

I saw a PA at an Urgent Care clinic who was superb. I asked about his background. He’d previously worked in an ER for 3 1/2 years.

I’ve been peeving for years about why Primary Physicians refer patients to specialists (which they do for almost everything it seems) and when you go to the specialist you meet with a PA instead of the actual specialist. If a PA can address the problem, surely your primary doctor can handle it, so why the referral? I don’t mind seeing NPs or even PAs, if they’re good in the specialty, it’s the extra trip & higher charge I object to. (In the couple of cases where I can compare, the charge for an NP/PA is slightly less than that for the specialist, but much higher than the Primary doctor charge).

In my experience, seeing a PA or NP means your medical issue or treatment is not so serious as to require the specialist’s personal attention, and that’s a good thing. But PAs (I’m not sure about NPs) are NOT specialists, so it’s very individual as to how well they know the specialty in which they are working. Which raises the question of whether they can recognize circumstances that require the doctor’s attention. And, again, if it doesn’t require the specialist, why can’t the Primary Physician handle it.

I suspect the answer is a combination of reasons, including equipment (my primary doesn’t have ear-cleaning equipment, for example), and malpractice insurance. And the use of PAs and NPs means you can get in to see someone sooner, which is good. And many PAs are clearly well-versed in the specialty. (but many aren’t so you need to pay attention). But it still peeves me as an unnecessary extra in many cases.

I think you sort of get to this later, but …

Would you rather your Saab automobile with a complicated issue be worked on by a

  • Master Technician with 30 years experience, but who has only ever worked on Chevrolets, or
  • A mechanic who lacks the Master Technician certification but who has worked at a top-rated Saab shop, and worked only on Saab automobiles for 20 years


I’ll take the less well-trained, less experienced person who tends to work with issues exactly like mine all day, every day.

Mid-levels who specialize tend to know a lot about that specialty. Primary care, internal medicine, and family practice physicians may rarely, or never, see patients with a condition covered by the specialty to which they referred.

Besides … there are no end of stories of NPs and PAs who made serious diagnoses after one or more MDs missed those diagnoses.

If they’re good, they’re good. If they aren’t, they aren’t. I think that matters more than the letters following the name.

[married to an NP]

Forget the midlevels even - if I were in the sitcom situation of delivering a baby in an elevator, I’d much rather have an L&D nurse who was at a delivery yesterday there with me than have my PCP who probably hasn’t delivered a baby in over 30 years.

But , really, when you think about it, what makes a doctor a specialist other than experience? Sure, he or she might be board certified or board-eligible *- but what makes them eligible to take those tests is the experience gained during their residency.

* or maybe not - a doctor certainly can’t call himself board certified if she isn’t but from what I understand board certification isn’t actually necessary for a physician to specialize.

I agree. But I would be happier if PAs/NPs working in specialties were required to have some degree of expertise in that specialty. Because “well-trained” is the key. My opinion is based on experiences with a single PA who did NOT have the specialized knowledge she should have had to be seeing a cirrhosis patient, and I’m aware this is not a good basis for blanket judgements. So I’ll also note that we see several NPs/PAs who are very, very qualified in their specialty and often more accessible than the specialist.

I’ve been seeing a NP for my dermatology appointments for years and I trust her completely. According to the scheduling staff that I’ve talked to, she’s a favorite of many patients at the clinic.

I’ve had NPs as my PCPs for decades. I choose them based on the opinions of my MD friends. The ones I’ve seen approach health care from a perspective that includes wellness and systemic thinking. They’re collaborative, smart, and skillful. My current PCP has an interest in diabetes, and provides me with a wealth of relevant research-based information. I also see an NP for dermatology and, until she moved her practice out of county, for gynecology. All are proactive about consulting and will recommend a specialist if I need one. My oncologist trusts my NP and is happy to follow her lead in general terms.

When my mother changed countries, she had to re-sit medical exams to get her medical licence. She was a very good primary care physician, judged against other PCP’s I’ve used since. She failed the obstetrics exam first time around, which did not please her. She hadn’t done any obstetrics since completing training, was not doing any obstetrics, did not plan to do any obstetrics, would not have been hired for obstetrics, and as it turned out, actually did not do any obstetrics in the rest of her life.

She studied, while holding down a full time job and caring for a family, and passed the obstetrics section at the next examination. I’m a bit in awe of the ability to study that medical members of my family exhibit.

It used to be that a typical residency trained, boarded Family Medicine specialist could take care of 90% or so of their patient’s issues without need for referral. However, lots of insurance companies were willing to reimburse specialists at a higher rate than primary care doctors. A lot of multi-specialty medical clinics adjusted their practices so that those specialists got the opportunity to treat these patients as a result, hence making more money for the system and specialist.

Sadly, a lot of primary care physicians skills atrophied as a result, and too many were relegated to care for the ‘worried well’. I now encounter cases where both internists and family medicine docs alike refer everything to their clinic specialist in that area. Apparently only urologists are able to check prostates for hypertrophy or prostatitis, only endocrinologists can figure out how to dose insulin or thyroid hormone for their diabetic or hypothyroid patients, etc. It drives up costs, it delays care, and and it does not help the patient.

I shifted over to public practice myself in 2002 after 16 years in the private sector, because I found myself being marginalized in that regard: Told to refer stuff that I could handle.

And bless the well trained NP and PA who know their specialty and also know what they don’t know. I’ve worked with and trained dozens of NP students and NPs in my career, and been the collaborating physician for many of them also. I’ve trained and supervised a fair number of PAs also. There are some great ones out there whom I would recommend over physicians for their knowledge and manner.

But I also see too many whose training in their specialty was pretty inadequate. One NP who was part of a cardiology team and called herself “an expert in heart failure” repeatedly told a colleague of mine (a psychiatrist) that she had no heart failure at all. My colleague did have quite severe heart failure (an atypical but not rare type), nearly died of it due to months of lack of proper treatment.

There are brilliant, dedicated, hardworking practitioners in the US healthcare system. But our system is so badly broken as well as designed to reap financial reward rather than make patient care the first priority that it makes me angry.

TLDR: 1) Some NPs are really really great. 2) A medical office shouldn’t let you think you’re seeing a doctor when you’re not. 3) I’m old and need to rant about other stuff in the twilight of my career.

[golf clap]

NPs have stand alone licenses. They do not need a physician cosigner. Physician Assistants work under the physician’s license. Back when I worked in Urgent Care, on Sundays if the doctors weren’t in the building and a PA was on duty, we couldn’t open til the doc was there. If we had an NP, we could open.

The caveat to that is that medicare does not allow NP or PA to sign nursing home orders without a physician cosigner.

I hear what you are saying, and I agree that things often get referred out too often, but in other cases, they don’t get referred out quickly enough. In my experience, Ob/Gyns are the worst for this. A lot of them will treat infertility for a long time, even though they haven’t had much training, or their training is out of date. Reproductive Endocrinology covers a ton of stuff that your average Ob just hasn’t been trained in, and women struggling to conceive should be sent out sooner rather than later. Six months or a year can be critical, and you just have to redo all the tests, anyway. Likewise, I’ve know Ob/Gyns to really step into a more of a PCP for women they have a relationship with. I’ve personally known more than one woman whose Ob treated her (incorrectly) for persistent UTIs or other non-gynecological problems.