Dr. J.’s Work Wife II has something to say about your lisinopril.

Dr. J.’s Work Wife II forwarded this NYT editorial to him last week and this was the first opportunity he has had to comment on it.

When one gets past the douchebaggery that is the title “When the Doctor Is Not Needed,” and the token, ‘I hate extenders’ quote from a backwards thinking physician, the article makes some interesting points that Dr. J. has spoken about in the past. These are the salient points. The increased demand for services due to an aging population, Obamacare and a medical profession not growing with those demands, demands will be met with delayed access to care. There are a finite number of doctors, but there are also physician extenders. Specifically, nurse practitioners, physician assistants and clinical pharmacists.

An extender’s scope of practice and how they can bill for services varies from state to state. Their training is much more limited than a doctor’s, with PA’s having Masters level education, NP’s having Masters, and, in some cases doctorate level education. Clinical pharmacists having doctoral level education and a 1 or 2 year pharmacy residency.

PA’s typically have technical skills. They can supervise stress tests, assist in procedures (e.g. harvesting the vein for bypass surgery, placing chest tubes, etc…), and see patients. NP’s are usually more clinic based. They can see, examine and diagnose patients in the inpatient and outpatient setting. They sometimes have additional skill sets such as interrogating and adjusting pacemakers/defibrillators.

The key to a successful use of extenders is as follows:

1) The extender must be cost effective. Through a combination of being able to bill for the services he is providing, and maximizing the ability of the physician to be clinically and economically productive the extender must be able to provide value to the system.

2) The extender must capable of performing tasks within his scope of practice within an appropriate degree of autonomy.

For example clinical pharmacists know drugs and can manage medications very well. A practice can have a protocol for titrating blood pressure and cholesterol medications, and a clinical pharmacist can follow up patients checking BP, blood chemistries, and lipids, and other objective biomarkers and make adjustments. They can also initiate medicines within the protocol if that is within their scope of practice. For example LDL cholesterol is not at goal on 80 mg of Simvastatin, it can be switched to 80 of atorvastatin or 40 of rosuvastatin per protocol. Alternatively, niacin can be added per protocol, with the physician prescribing. Clinical pharmacists adjust warfarin (Coumadin) per protocol. Now once the patent maxes out the protocol, the clinical pharmacist can have the physician manage the situation. This would be in 1 out of, say, 10 patients.

Nurse Practitioners similarly can see established patients for routine follow up care, not only for drug titration, but for routine f/u of pacemakers, patients with congestive heart failure, and stable CAD. NPs and PAs can do wound checks and some amount of surgical follow up as well. In some states, their scope of practice will permit new patient and urgent care visits as well. The advantage they have over clinical pharmacists is that they have better physical diagnostic skills. Dr. J. believes, however these are complimentary degrees (NP and PharmD.) and each contributes something different to the team.

The physician can then spend his time seeing new consultations, sick or complex follow up patients, or be reading imaging studies. He can also be providing useful oversight to his extenders, being a resource for complex issues. Each person in the team can use their degree to its fullest potential and to maximize revenue for the practice, allowing it to thrive and thus remain open. The fact is we are still, as a profession, trying to figure out how best to partner with our extenders, but this opinion piece at least introduces the topic. Dr. J. has seen it work well, and with talented extenders a group can deliver outstanding care efficiently.

Dr. J.