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Tuesday May 30, 2017

I Referred My Patients to Subspecialists; So Why Did They See NPs?

I knew when I chose to work in rural West Virginia that referral to subspecialty care would be challenging. Rural patients have higher rates of chronic disease, morbidity and mortality, and they die younger.

I knew that then, and I see it happening in my community now. Rural patient populations have challenges with transportation, social isolation, lower overall education and other socioeconomic markers. That combination of characteristics has the potential to create not just barriers, but perceived impossibilities, to accessing subspecialty care or diagnostic workup if those services require traveling.

Travel, to me, involves flying or having to spend the night out of town, but to many of my patients it just means crossing county lines. It is not uncommon for people here to feel uncomfortable driving on highways, or as we call them in West Virginia, the interstate.

For anyone who has not driven (or spent time with me driving) on West Virginia back roads, it is interesting to know that we have high speed limits up to 55 mph on most county and state routes, so the reluctance to take the highways -- which are less curvy, less steep and have only a modest increase in speed (65-70 mph) -- has always confused me. But something as simple as road choice is a real barrier to accessing care for my patients.

Some subspecialty care requires referral to a center three or more hours away from the town in which I work. It might take multiple visits with me to convince a patient to get to the office or hospital where the care they need is located -- or to find a way for them to get there. In some cases there is simply a shortage of subspecialists or equipment, and there may only be one individual physician in the entire state able to address the patient's needs. Often, there are frustrating insurance limits that prohibit patients from utilizing a geographically appropriate site.

There are endocrinologists and ophthalmologists an hour from my office (via the interstate), but they do not participate in one of our Medicaid plans. Patients on those plans are left with the option of driving more than two hours to a part of the state many of them have never been to or forgoing care. The majority choose not to see those subspecialists, despite my encouragement. Not everyone has the luxury of taking a day off work to go to a doctor's appointment. Not everyone has a means of transportation, or even a friend or family member with a means of transportation.

None of those challenges surprised me as a new physician. However, recently I started to notice a pattern that I hadn't anticipated. Some of my patients don't have financial or transportation challenges, but they still face barriers to appropriate subspecialty care. For example, I care for one family that I advised to drive to a specific hospital eight hours away, and they did. Regardless of resources, I often send people long distances for higher levels of care, and when they get there they expect to see a doctor, not a nurse practitioner or physician assistant. But increasingly, I either get a call from a disappointed patient or parent, or a consult note signed by an independently practicing nurse practitioner, or both.

As primary care physicians we have been engaged in scope of practice battles across the country for more than three decades. We, as physicians, know we are more appropriately trained and educated to care for patients than those providers who did not go to medical school. But in many states there are independently practicing nurse practitioners who attempt to do the work of a physician with no physician collaboration. That could be the subject of a series of blogs and discussion all on its own. What that has led to, in my experience, is not only rural primary care sites being staffed only by nurse practitioners, but a new trend in referrals to subspecialty care being addressed by nonphysicians.

Many fellowship-trained subspecialists have nurse practitioners working side by side with them. This model of a physician-led team is effective, it lessens wait times for visits, it increases the number of patients one physician can serve, and it has a financial benefit for the group, as well. However, this is not the model I am seeing utilized. I am getting back notes on consults where patients have been seen by a nurse practitioner independently for their initial visit, with no engagement by the physician.

What upsets me most is that often I have worked hard to convince and/or coordinate my patients to travel to a subspecialist that they may see only one time, especially if they have a less-than-productive or less-than-ideal experience.

And I find it insulting when the patient is not evaluated by a fellowship-trained physician when I have placed a referral for that level of training. I have more training than a mid-level provider, and therefore I don't feel the evaluation -- and more importantly, the differential diagnosis -- considered by anyone other than a subspecialty-trained physician does my patients justice.

Kimberly Becher, M.D., practices at a rural federally qualified health center in Clay County, W.Va. You can follow her on Twitter @BecherKimberly.    


YES. This x 1000. We work so hard to get our patients to someone who knows more than we know as primary care physicians, and it useless when we and our patients make this effort only to see a non-physician.

Posted by Joy on May 30, 2017 at 08:40 PM CDT #

Holy cow!!! It's as if you read my mind!! This has become a real issue to me as well. It results in my patients realizing (quite rightly I might add) that I was doing more for them than the highly touted "specialist" and refusing to go back.

Posted by KSMITHMD on May 30, 2017 at 10:26 PM CDT #

This is an embarrassment to the profession. All referrals should initially be seen by the MD. If appropriate, follow up visits can be conducted by the PA/NP.

This has been going on for over 10 years and is far and away the norm. Good luck finding a specialist that doesn't practice this way.

We as PCPs are largely to blame though through our greed by promoting the NP/PA as providing care as good as an MD.

Posted by KEITH DINKLAGe on May 31, 2017 at 07:24 AM CDT #

I think it is appropriate to see an MD/DO for initial consult and NP/PA for follow up care. But I think that this is the future of medicine where there will be more NPs and PAs seeing our patients....

Posted by Joyce on May 31, 2017 at 10:30 AM CDT #

I agree and prefer to be called doctor not health care provider....

Posted by John on May 31, 2017 at 10:27 PM CDT #

I agree totally. I'd like to think I know as much as a mid level and if I am stumped about a dx, I want an MD to weigh in. To that end, my hospital did not permit primary care family med MDs (or DOs ) to become hospitalists after years of work both on and off the wards when the hospitalist practice was introduced, but now after some years of having hospitalist practice, NPs now have the privilege of being hired as hospitalists (although their training does not include ward rounding). Its very insulting.

Posted by Paula Mahon MD on June 01, 2017 at 04:09 PM CDT #

If we buy into the talking point that patients receive medical care not from a physician but from a team, this is the inevitable and completely predictable result.

Once again, thanks, AAFP

Posted by R Stuart on June 01, 2017 at 04:28 PM CDT #

Nothing new about this here in Santa Fe. I employed a PA for many years and she decided to leave in 2003-2004 and take a job down the street with the local GI group who could pay her more than I could afford to pay myself. She was great with primary care and I certainly couldn't fault her for wanting to get paid more and learn new skills. But it galled me (pun unintended) to send my complex patients to her for consultation (while the GI docs were doing procedures and raking in the really big bucks). Until she got the years of experience in that specialty, it always felt that I was referring my patients to a lower level of care; knowing that she would have been asking me to supervise her on such patients in our practice. The mistaken assumption that training more mid-levels was going to alleviate primary care provider shortages didn't take into account that the mid-levels were going to be used in a role with specialists and get better pay for those roles than they could in the primary care sector.

Posted by Alan Rogers on June 01, 2017 at 06:56 PM CDT #

Here in Albuquerque there's a nurse practitioner in private practice who touts herself as an endocrinologist! She did work under a reputable endo doc here for years, but she primarily did his diabetes care (which I do in my clinic) I do not refer to her. I send to endo for possible pituitary or parathyroid or adrenal issues I always try to get an MD but patient and frequently front office staff helping with referral process do not realize she is NOT and endocrinologist. mind numbing the insanity that is allowed:(

Posted by CBlacksten on June 05, 2017 at 02:01 PM CDT #

This is insulting to us and our patients .The specialist will not even see the patient but the office visit is still very high priced.

Posted by Harry Haus MD JD on June 05, 2017 at 04:59 PM CDT #

These folks are using lower cost labor to serve the lower paying insurance contracts. Fair enough - we can ask them to be transparent or refer elsewhere. If they hold a monopoly (nobody else to refer to), we should be able to bypass them with telemedicine consults. Is there any specialty telemedicine that accepts insurance?
Maybe those specialists can also do without your commercial patients. As much as we try to be professional, some doctors pretend to be professional but act like businessmen. They bank on the local physicians not talking to each other about their "businesslike" practices. I bet you that this happens more in those areas where HMOs/ACOs/Medicare Advantage is favored. Why? Because we are so busy hurrying from visit to visit that we cannot sit down with our colleagues and come up with solutions.

Posted by Nirav Patel MD on June 05, 2017 at 08:24 PM CDT #

We have no one to blame but ourselves as physicians. We have allowed this "new" medicine to evolve. We are so many and in numbers we can change things; the large number of nurses have been able to do it with help from the nursing boards. I to find it insulting to refer to the specialist to then be seen by a midlevel, a step backward for the patient. There is so much talk about how healthcare spending has spiraled out of control; this is a perfect example of an added cost to the patient and a money making "scheme" for the institution or facility that employs the mid-level. Granted, specialists are busier today but it is no excuse to be seen by the mid-level who will agree with the reason the patient was being referred for in the first place only to then be seen by the specialist at a later date. If our medical associations would stand up as the nursing associations have, we could potentially fix this problem. And yes, it is a problem.

Posted by C Trevino MD on June 06, 2017 at 11:17 AM CDT #

This is the case here in our rural Midwest practice as well. My office schedules with the M.D. at my request. The specialists' offices, GI and rheumatology especially, will call the patient and offer these desperate patients a much sooner appt with the mid level. The patient reschedules, only to then schedule a follow up with the M. D. AFTER the appt where the mid level repeats many of my recent blood tests and imaging. The specialists then interprets those duplicate tests at the second visit, and my patient is seen by the M.D. Even later than initially scheduled. Due to our very limited insurance networks, I can't punish this practice by referring elsewhere.

Posted by Diane Krall on June 07, 2017 at 08:52 AM CDT #

Let's not forget to involve and empower our patients in this affront to their medical care. I remind my patients to specifically ask who they will be seeing and to insist that they see the specialist before they leave.

Posted by Steve Vogelsang on June 09, 2017 at 10:34 PM CDT #

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