I’ve had the same primary care practice for a couple of years now, at least two, maybe three. I say “practice” because the physician under whose name the practice operates retired last fall and was replaced with another physician.
During those two or three years, I have never seen either doctor. I don’t mean, “been examined by,” I mean “laid eyes on.” All of my care has been rendered by a nurse, an LPN or something to that effect. I have not complained because I believe the nurse has done pretty good work for me. She has taken and ordered tests for me, has advised me to see specialists for this and that, and caught some stuff that could have been cancerous and sent me to a specialist that nipped that in the bud, so to speak. (It wasn’t cancerous, but headed in that direction.)
Here’s the problem: virtually all they do for me in terms of treatment is refer me to specialists. Which is fine for some stuff. But when I complained about back pain on a visit, I was told to go to a pain management clinic, you know, the folks who deal with chronic pain … which I don’t have, it was just a temporary thing that aspirin and ibuprofen weren’t handling. And when I had a red, itchy rash on my leg, she referred me to a dermatologist.
I used to have a doctor I saw in person, and he prescribed meds for things like that. Treated them.
So I am wondering, is this a deliberate approach by the clinic: give all the work of seeing and evaluating patients to an LPN, who never diagnoses or treats anything on her own but send patients to a specialist when anything pops up? With the doctor just a figurehead for the clinic? Maybe reviewing stuff on occasion? Am I getting a lower quality of health care in the interest of the practice making money?
I go to a primary care provider within General Internal Medicine at the hospital, and I’ve never seen a doctor either. There is one who is the head of the unit, but my “doctor” is an ARNP and I always see him. He can prescribe, do all the routine testing and procedures, and refer me to specialists if needed.
When I used to get my psych meds at the counseling place, it was from a non-psychiatrist, but I forget her exact title.
First of all, let me get your terms straight.
What you are seeing is likely not an LPN, but an NP. BIG difference!
LPN=licensed practical nurse-has likely an associates degree
RN=registered nurse-has a nursing degree, usually at least a bachelor’s and can give medications to patients (but not prescribe)
NP=nurse practitioner-RN with additional training that allows them to function as an advanced practice nurse, in this case as a primary care provider. Depending on the state, they may have full prescribing abilities and may not need any MD supervision.
Now for my mini rant:
The nursing lobby would like nurse practioners to be considered primary care practitioners who are essentially equivalent to primary care physicians, with the same rights and privileges. To that end, they have even created a new degree, a doctorate of nursing, that will then allow nurses with the degree to legally call themselves “Doctor” in the office. Also, let me say that I have know many nurse practitioners who are better than the majority of doctors and who I would not hesitate to send my family to at any time. That said, in the aggregate:
NP-usually 4 years of college/nursing degree, with 1 1/2-2 years of additional training (6 years total)
Primary care doctor (MD or DO)-4 years of college, 4 years of medical school and at least 3 years of additional residency training (11 years total)
That is why the MD was able to handle some things that an NP cannot. In the end, it comes down to a couple of things:
Are you somebody who mostly has very uncomplicated problems (colds, allergies) that this NP feels comfortable handling
Are you the type of person who wants to see a specialist for every problem( and if you do develop a complex multisystem problem are you willing to go to three or 4 separate specialisst to get a diagnosis and treatment or are you looking for somebody to be a “big picture” person and oversee the care and treatment as a whole)
If the above are true, then this practice is right for you. If not, then you should look for one where you can see a physician for your primary care.
And to answer your question-not every practice operates like this but many do. Most likely the physician also has a full slate of patients but the practice uses nurse practitioners to improve volume since you can’t make a living as a primary care MD seeing all the patients yourself-(trust me, I’m trying).
NPs, especially specialty NPs, don’t have any need for all those years in what they’re not specializing in. So much of medical school and residency is teaching MDs to be so many different things. They’ve got their Ortho and their Gero and their Oncology and their GI and their OB/GYN all in rotations. If you’re “just” going to be an NP in OB/GYN, why on earth waste your time learning Ortho?
This may be less of a yesbut for PCPs, who do need to know at least enough of everything to know when to refer to a specialist, granted.
Agreed.
Now for *my *rant:
I *adore *individual NPs. I would rather see an NP as my PCP, because I’m solidly in level 1, and I find that NPs spend more time with me and ask me questions that make sense to me, as well as being less terrified/scornful of herbal medicine and letting me have some input into my care plan. (Broad brush is broad, but it’s been my consistent experience.)
I hate the push for NPs. “It’s a cost saver!” Um…sure. It’s a cost saver because you’re paying NPs less than MDs for the same work. :dubious: It really seems to me, when you factor in the gender disparities in Nursing and Medicine, that we’ve found a new way to pay (mostly) women less for the same work as (mostly) men. Chaps my hide. Also, it pulls the best and brightest RNs away from bedside nursing to be NPs, leaving us with a bunch of subpar nurses doing actual nursing.
But as for the OP: yes, that’s pretty common these days, at least in any area urban enough to have a lot of specialists around. And it’s common whether your PCP is an MD or an NP. Referrals to specialists are the thing now.
The OP demonstrates exactly why much of the above post is not entirely true.
First of all, the reason that the NP in the OP refers to specialists for things like rashes and back pain is precisely because she doesn’t have the same training as an MD. All those years of doing rotations in orthopedics and Ob/Gyn and dermatology mean that if a patient comes to me with a problem they are going to be treated or at minimum diagnosed and not just pawned off on a specialist.
Second, referrals to specialists are not necessarily “the thing” now. And the quickest way to make sure there are no more primary care physicians is to continue to insist that the same care can be provided by an NP with half the training and to continue to not pay them comparably to other specialists. As a primary care MD, if a patient comes to me with diabetes, I am capable of diagnosing and treating them. However, if the argument is that I do no more than the NP who refers them to a specialist and therefore I should not be paid more then why bother? What benefit is there to taking the time and energy to diagnose and treat a rash when your reimbursement is only marginally better than the NP who literally takes 20 seconds to write out a dermatology referral. We are losing the primary care doctors as the OP makes clear, and it is only going to get worse. If you have to wait 3 months to see a specialist now, image what will happen when there are no more primary doctors and only NPs and therefore there is nobody around who can treat the patient without referring them to every specialist on the block.
I think we need to get to a system where we use NPs for simple diagnoses and treatments (like in the urgent care clinics) as well as for specialized services such as in Ob/Gyn but continue to have broadly trained primary care doctors who have the breadth of training to treat the whole patient.
The primary care NPs in my area handle diabetes, as well.
Neither the primary care NPs nor MDs handle rashes - those get sent to dermatology. Anything cardiac requiring more than one med gets send to cardiology. Anyone with protein in the urine gets sent to a nephrologist. Funky toenails? Off to podiatry.
Part of my job is helping to coordinate my patients’ doctor’s appointments, and calling the PCP whenever a specialist changes the treatment plan. I don’t have a single patient who has only one doctor, and most of them aren’t even all that sick.
Being sent to a different specialist for every body part sucks. It gets old repeating your story and history over and over and it seems none of them talk to each other or share your chart. There is hardly any experience more stressful for me than dealing with the medical professionals. They always seem to have an entirely different set of concerns from mine. They worry about things that may happen someday or conditions I might have. I worry about things that hurt and impact my quality of life. I really like my primary care doctor. She listens and genuinely tries to help. The specialists she sent me to did absolutely nothing but suck up money. I didn’t like them at all. Sorry about the rant. I’m not happy about them right now. I guess I need to work on getting some diseases there is actually some treatment for.
I love my PCP, he’ll always take the first stab at my problem and often a second try before sending me off to a specialist as long as it’s something he’s comfortable dealing with. On top of that, a lot of times he’ll say 'try this, if it doesn’t work, he’s a script for radiology (or whatever) or you need to see a specialist, no point in wasting the cost of another appointment just so I can tell you that". Also, I also see him, but I don’t think he has any LPNs and I know he doesn’t have any PAs in his office.
At my neuro’s office, I only see the PA, but I make an appoint specifically to see him, so that’s okay.
What it comes down to is ‘are you comfortable with the level of care you’re receiving?’ and it sounds like you aren’t. If you feel like you’re just being referred without any attempt to fix you first (and that’s what you want), you might want to look into a different PCP. You might also want to check his/her ratings on the internet to see if you’re alone about feeling this way.
Two people said rashes should be treated by derms, but IME, when I’ve gone in with a rash of some sort, it was ‘try this cream, let me know if it doesn’t clear up in a week or two’. I’d be kind of annoyed (personally) if they said 'Thanks for seeing me for $150, go see this $200 doctor for some creme to put on it, even though it’ll probably clear up on it’s own in the 6 months before you can get into a dermatologist"). C’mon doc, just tell me to put some cortisone on it and when I say I’ve tried that, maybe write me a script for something stronger. But, maybe I’m wrong about that.
Luckily, my insurance company doesn’t require referrals, so I can just go see anyone I want if I know my needs are above and beyond what my PCP can do for me.
My problem is not so much with titles but with the NP not being willing to treat even minor stuff like skin rashes and back pain. I thought the unwillingness to prescribe a pain killer for the back pain might be because of all the publicity over people getting addicted to prescription narcotics (but as I said, I don’t HAVE a long-lasting pain, just a brief one). But the skin rash thing kinda bothered me. It’s the sort of thing you’d expect a doc in the box place to treat, y’know? And your primary care outfit oughtta be able to handle that, I think.
Yeah, it sounds strange to me. I mean, I have zero issue with seeing a nurse practitioner for routine stuff, or nonroutine stuff like, say, an asthma flare. But to never see a doctor, and to have the NP not treat anything?? Then why are you even going to that practice, since they aren’t doing anything?
I’m a firm believer in having the primary care doc do most routine maintenance stuff - I go there first for any oddball symptoms; I’ll go there for followup after an evaluation by a specialist if the condition isn’t something the specialist NEEDS to be hands-on for, and so on. For example when my asthma was misbehaving a few years back, I visited a specialist a couple of times, ruled out some stuff, and went back to the primary care doc for the ongoing management.
The one practice where I do NOT see the doctor - ever - actually annoys me a bit. It’s a specialty sleep clinic (I have an assortment of sleep / wake issues, and they really ARE a bit outside the purview of a general practitioner - I personally found that I knew more about the topic than my primary care doc). I saw the doctor there once. Since then I’ve seen one of their on-staff physicians’ assistants. I’d think they’d have me see the doc every couple of years just to check in but oh well.
To the OP, you probably can request to see only the MD. But that will likely increase your wait time for the appointment. Instead of a week or less, you might wait a month for an appointment.
Just for clarification . . .the only reason I see my doctor is for a sinus infection once every 18 months to two years. Ecen for something like that, they’d refer you? Because if I got refered for a sinus infection, I’d be livid.
I’ve discussed this issue with my PCP. He handles my hypertension meds and that is it. If I come in with a rash, he sets up a derm referral. Joint pain? Ortho referral. Gastrointestinal issues? Internal med specialist. All of this without any real exam, other then asking about symptoms so he can route me correctly.
According to him, it’s the way his group practice wants him to do things. Ten minute appointments; volume, volume, volume.
I had left a previous PCP office because I only saw a NP, but to be fair, most of issues were with her.
I found her dismissive of some of my concerns (“we can test that, but there’s no way to treat it” was said. Look, I know PCOS exists, and I know there are treatments. There aren’t cures, but treating some of the symptoms can do a lot to mitigate some of the risks, if those treatments are right for me).
she looked at her computer screen constantly
I was very bothered by the way she asked some things. There was a “are you in a relationship” question, to which the answer was no, but there was no follow up with “are you sexually active/are you intimate with anyone”. There doesn’t have to be a relationship to be intimate with anyone. Now, in my case, I was not having sex with anyone at that point in time, but it’s important to remember that not in a relationship does not mean not having sex.
Then I switched offices to a clinic associated with a Major University Hospital here in town. And it was hell for me: I’d walk in the door and feel my heart start pounding. Anytime I brought up a concern it led to a referral to another of their services. Need help figuring out weight issues? Go to Major University Bariatric! (yes, I’m fat. I’m working on it. What I needed was a nutritionist, not a freaking bariatric clinic. That referral meant I did some serious Eating My Feelings - and I knew I was doing it, I admit) My BP always tested VERY high when I was in there - but they’d also take it right after I got into the building after driving there in stupid Atlanta traffic. And I’ve since learned that they were using a cuff that was too small. That doctor looked at her computer the whole time I was there, and there was never an explanation as to why things were being done in some way.
So, I was almost out of BP meds - I had ~30 days left - and I could not bring myself to go back to Major University Clinic. So I called the original office and made an appointment with the doctor who’s joined the practice since I was first there. I figured if I didn’t like her, I could find someone else, but the thought of going back to Major University had me freaked out. So I went, and found that I like her. And I’m even willing to see NP when I need to when something comes up (like, say, an ear infection or the like), now that I know it’s personality, not the practice as a whole.
It seems to me, then, that you shouldn’t even need an appointment. You should be able to call and say “I have a rash/joint pain/GI Issues, I need a doc in that field” and they should be able to handle it from there. Why even go into the office?
That reminds me of one of the reasons I left my last doctor, every.single.appointment, was turned into two appointments. I’d go in with crippling pain and he say ‘take some advil and use an ice pack, call me if it doesn’t get better in 2 weeks’. Sound advice, but after a few years of hearing that, I thought I’d get a step ahead of him, so one day I went into him with neck pain so bad I couldn’t turn my head. He gave me the same advice, Advil, ice, call me in two weeks and I said “This has actually been bothering me for about a month now, I’ve been taking Advil three times a day, icing it regularly for the last two weeks and it’s still bugging me”. His advice…“Try Advil and ice for two weeks, then call me if it still hurts”. IMO, he was just hitting me up for a second appointment.
I was so happy the first time I saw my new doc with a pain related issue. After we decided on a course of action for it (some muscle relaxants), I asked him how long I should wait before I call him. He said 'that would be a waste of time, I’m writing you a script for some radiology, if hasn’t cleared up in a few weeks, go get an x-ray/MRI (don’t remember which) and I’ll call you, we’ll go from there.
My HMO provides an e-mail system for patients to communicate with doctors for non-emergency situations. My own PCP, in particular, very much encourages this and is very good about responding to e-mail questions. I’ve also had occasional rather extensive consultations by telephone.
Here’s something interesting though: I don’t get charged anything at all for e-mail or telephone consultations. Not even a co-pay. They’re totally free (to me). Somewhere in the Plan (it’s a Medicare contract plan), I noticed that telephone consultations are not a covered benefit.
And yet, I’ve noticed (in the EOB documents they send me), that they did charge Medicare for those phone consults I had, even though there was no co-pay for me.
I don’t know if my doctor gets paid anything at all for the time he spends dealing with patient e-mails.
In my practice as a Family Medicine specialist, I do rashes, up through biopsying them and even treating psoriasis with methotrexate; I do CV stuff, ordering stress tests, managing heart failure and stable angina (with referrals for procedures when necessary), don’t send my renal patients to nephrology until they’re stage III renal failure (if the etiology of their disease is understood), rip out the toenails of my own patients with ease, manage moderately severe asthma and COPD on my own, handle chronic liver failure, and combinations of all those diseases. I can do 90% of my patient’s healthcare needs. And I hate that so many generalists like me and my fellow internists are reduced to ‘triage’ for systems and patients that demand a specialist for everything.
That’s what I love about my job; I get to practice to the level of my skills. And my skills are pretty high, frankly. And breaking the referral habits of my new minions by saying ‘we can do that here’ is fun.
So come sign up as my patient, Evil Captor! You’ll get the majority of your healthcare right from one spot, from myself or my associates, generalists all of us!
