Want to know a medical trade secret? If you call a physician’s office or a clinic for a new patient appointment these days, your first visit is likely to be with a physician extender. Answer one of those ads promising same day doctor appointments, and your odds of face time with an actual physician are like winning a $100 payout on a single play from a nickle slot machine.
What is a physician extender? Medical assistants, mostly high school graduates, have been the extra hands in most physician practices for eons. They answer the phone, check in patients, take vital signs, help the physician with simple procedures and maybe draw blood.
Physician assistants began as a carve out for returning military medics almost 50 years ago. The Veterans Administration embraced the concept, and training programs for “more than a nurse, less than a doctor” proliferated. The nursing profession took umbrage and hatched nurse practitioner programs. Since Hurricane Katrina, the employment of physician extenders in medical practices, clinics and hospitals has soared.
Today, newly minted physician extenders do much that was once the sole prevue of physicians. Nurse practitioners and physician assistants were once known as mid-level providers, a now despised term. For nurses, the buzz word is advanced practice clinician. Physician assistants are becoming physician associates.
“New patients typically see the nurse practitioner for their first visit, and I see them on their second visit. Once patients become established, they usually see the nurse practitioner, but I try to see all patients at least once yearly,” said a prominent primary care physician in the New Orleans area who asked to remain anonymous.
“We have a large managed care practice with several physicians. We hired our first nurse practitioner over 10 years ago. They are a tremendous help as true physician extenders. They take care of the non-critical stuff and do a good job. If the nurse encounters something complicated or out of the ordinary, they ask me to say hello and take a look. By working eight-hour days, our nurse practitioners probably see twice as many patients a week as our physicians who all like to have days off.”
Hospitals, especially those lacking intern and resident helping hands, first hired physician extenders to work in their emergency rooms. Happy number crunchers and patient acceptances led to expanded use all over the hospital. Only one emergency room in Orleans and Jefferson parishes does not utilize physician extenders as primary treaters.
“At East Jefferson General Hospital emergency room, you will be cared for by a board-certified ER physician. When your life is on the line, our patients deserve and receive the highest quality of care. Whether it’s a heart attack or a little heart burn, we believe that board certified ER physicians provide the highest quality emergency room care,” said Dr. Charles Ochello, an LSU-educated physician who did an emergency medicine residency at Duke before returning to Louisiana.
Nurse practitioners and physician assistants now work as hospitalists, in addition to performing speciality consultations especially in the Ochsner system. They interact directly with patients performing duties once limited to credentialed physicians such as ordering blood tests, imaging studies, drugs, and other treatments. They make daily rounds seeing patients without accompanying physicians. They write discharge orders, issue new prescriptions, and suggest follow-up appointments. All of this is in collaboration with staff physicians who may or may not actually lay hands on the person in the bed.
“There are some very good physician extenders. However, I have also seen floor nurses who took online courses and poorly supervised ‘clinical rotations’ suddenly turn in to graduate nurse practitioners. And bingo. Suddenly they are making some frankly scary medical decisions. Over the past few years I am seeing more and more patients that have been misdiagnosed or mistreated by physician extenders. A straightforward “sore throat” is not always so straightforward in the presence of a peritonsillar abscess,” said a local otolaryngologist who asked me not to use his name.
Patients and their families should remember that non-physician providers should always honor requests for direct physician involvement, according to a veteran physician I interviewed.
Licensing of physician assistants and nurse practitioners in Louisiana
The Louisiana Board of Nursing currently licenses over 3,000 nurse practitioners, a threefold increase since Hurricane Katrina. Requirements include a nursing degree plus additional coursework and training. In Louisiana, nurse practitioners can diagnose and prescribe for patients, but they must be in a defined working relationship with a collaborating physician.
This collaborative agreement must include clinical practice guidelines specific to the practice setting. The physician must be available in person or by telephone for any needed advice or assistance. Nurse practitioners have pushed state law changes, so far unsuccessfully, that would allow them to practice independently from physicians and on their own.
Unlike nurse practitioners, physician assistants are licensed by the same state board as physicians. They must first pass a national certifying examination after completing two plus years of curriculum study in an accredited program followed by clinical rotations providing hands on patient experience. Our state board website is difficult to navigate; but according to a national database Louisiana has 769 licensed physician assistants as of April 2017.
“The number of persons with chronic conditions such as hypertension, diabetes, and lung diseases has increased. Nurse practitioners and physician assistants can help treat these patients. However, we need to assure quality and evidence based care,” said Keith Ferdinand, a noted cardiologist at Tulane who recently served as the interim head of the Louisiana State Board of Medical Examiners.
Dr. Vincent Culotta is a well-known gynecologist with strong ties to the Louisiana State Medical Society who took over from Dr. Ferdinand as executive director: “My goal is to make sure we have the best possible medical providers with whatever supervision is needed to protect the citizens of Louisiana.”