One of the criticisms physicians hear from non-physician provider organizations is that doctors are engaged in a “turf war,” or that nurse practitioners (NPs) are working in places where physicians “won’t go.”
But in talking with my colleagues, I have found that physicians want to work in rural or underserved areas, but are being replaced by lesser trained (and less expensive) non-physician providers. Unfortunately, this substitution may harm our most vulnerable patients—those who are most likely to need the skill and care of a highly trained physician.
Take the example of Martin Young, MD, a pediatrician who attended medical school and fellowship in the United Kingdom and then completed a second fellowship at Boston Children’s Hospital. Young told me he lost his position as a primary care pediatrician in rural practice to a family nurse practitioner.
Young, a 30-year veteran physician who previously served as an assistant professor at the Tulane University School of Medicine, was recruited by a rural hospital to start a primary care pediatric practice in 2012. “I picked up and moved across the state to live in a small town as was stipulated in my contract,” Young told me.
The practice was a success. After three years, Young needed help, and the hospital hired a pediatric nurse practitioner to join him. “Everything went well for two years, but then the hospital began to have financial difficulties,” he said.
One day, Young was introduced to a family nurse practitioner, who the administration told him would be joining the practice. Within a few months, Young said he was called into the administration office and given his 90-day notice of termination.
“From a financial point of view, I completely understand the hospital’s action. From a patient point of view, it’s like Russian Roulette,” said Young. “The clinic that I started is being run by two NPs with no physician pediatric cover. My departure has also meant that there is no physician to provide inpatient care for kids at this hospital—the NPs will do the admissions.”
“Do it or quit. This is how it is.”
Jacqueline Hanna, MD, is another pediatrician who was also replaced by non-physician providers. Hanna told me she took a job at a pediatric urgent care in Texas right out of residency in 2011. “I didn’t know anything about supervising NPs at the time, and I didn’t really need to, since when I started there were 13 physicians and only one nurse practitioner,” she said.
But gradually that ratio began to change. Hanna noted that every time a physician would leave the group, he or she would be replaced with a NP or physician assistant (PA) rather than another physician. “I found this very frustrating, but even worse, we were told by our administration that supervision was not an option. Do it or quit. This is how it is,” she said.
Hanna told me physicians were not given any compensation at all, and no administrative time to review charts, much less to do actual supervision. “I was in a state of high anxiety,” she recalled. “I couldn’t physically see every patient that I was supposedly supervising, and I worried about patients being harmed.”
Hanna felt patients were harmed. “I noticed that patients were bouncing back to the urgent care more often. The administration didn’t see this as a problem – in fact, it was a financial incentive,” she said.
Ultimately Hanna left the organization because of the supervision conflict, but she has found that most jobs in her field in Texas require her to supervise NPs and PAs. “I really don’t have any option. Every job offer I have had requires supervision. I just make sure that I can interview the midlevel first, and then I am very hands-on about supervision. I also make sure that I get compensated for my work.”
Leaving patients no alternative
A deeply concerning example of vulnerable patients being affected by physician replacement is in the field of child psychiatry. Alison DeLuca, MD, a child and adolescent psychiatrist with a telemedicine practice had been providing care in a health provider shortage area in New Mexico for five years when she was replaced.
“I job shared with another psychiatrist. I worked two days per week, and she worked one day per week. There was also a NP who provided services on the other days,” said DeLuca. While she told me she was never told of any problem with her job performance, “the company said that they had decided to consolidate services and that they only wanted one provider,” Deluca said.
DeLuca and her psychiatrist colleague were given 90 days’ notice and told to transfer their patients to the nurse practitioner. “My patients were very upset, and I was upset for them. While I can always find another job, these patients have no alternative. This population is underserved, underprivileged, and patients are very ill with chronic disease. They can’t drive three hours away to see a psychiatrist. They have no choice.”
Instead of continuing care with DeLuca—who completed five years of psychiatry training after medical school (three in general psychiatry and two in child psychiatry)—the clinic’s patients will receive care from a Psychiatric Mental Health Nurse Practitioner (PMHNP), a certification which requires just 500 supervised clinical hours of training.
“I contacted the New Mexico Board of Medicine,” DeLuca told me. “I wanted them to know that the psychiatrist shortage in the state has nothing to do with physicians not wanting to work. It’s because we are being let go.” DeLuca said that she has not yet had any response from the board.
I spoke with another child and adolescent psychiatrist with a similar experience: Ann Marie, MD. She is using an alias because her current company director has a Director of Nursing Practice degree and she fears retaliation. Marie told me that she was also replaced by a mental health nurse practitioner. “The NP who replaced me received her degree from an online program through Liberty University. Before I was let go, she would sometimes ‘sit-in’ on my telepsychiatry sessions. But I never had any real dialogue with her, or any teaching moments.”
Marie told me that she chose to work for a Federally Qualified Health Center (FQCH) because she wanted to serve needy patients on Medicaid. In 2012, she and a colleague developed a telepsychiatry program to provide access to care to some of the most underserved patients in Maryland.
“The program flourished,” Marie told me. “Between the two of us, we were able to provide for 700 patients, and perform 1,000 visits per year.” But in May 2017, Medicaid regulations changed, and FQHCs were no longer able to provide telepsychiatry services. “We worked really hard, tried to get politicians involved, but ultimately the CEO, a nurse, decided to hire an onsite NP instead,” Marie told me.
While Marie expressed empathy for the financial situation of the FQHCs, she worries about patient care. “I spent three years doing a general psychiatry residency, and another two in pediatric and adolescent psychiatry. On top of that, I spent a year in a longitudinal autism spectrum clinic, even working with preschool children. This is not the type of experience that can be gained from an online program or just ‘shadowing’ a psychiatrist.”
Obligation vs. integrity
Other vulnerable patient populations are being affected by physician replacement. Shannon Mitchel, MD, a wound care specialist, describes losing her job providing care to patients at skilled nursing facilities (SNF) because she refused to sign off on midlevel charts without adequate supervision. “My contract required me to supervise a physician assistant (PA) and two NPs,” she explained. “These were all new graduates who were given a two-day course on wound care and then sent off to work independently at different SNFs. But I was given no time to supervise or train them.”
When Mitchel followed up on one patient that one of her NPs had seen and realized that the care had not been medically appropriate, she was deeply concerned. “These patients in SNFs often have dementia or other conditions that don’t allow them to speak for themselves, and I couldn’t allow this kind of care to happen to them on my watch,” she said.
Ultimately, Mitchel found herself at an impasse. “I was obligated by the nature of my employment to sign-off on NP charts, but my integrity would not allow me to do it unless I was truly allowed to supervise in a meaningful way and not just ‘signing-off’.” She left the wound care company but is still struggling to find a job that doesn’t come with similar strings. “Every physician contract I see has a supervision clause built into it,” Mitchel noted.
Physicians, patients, and politicians need to know what is happening. Physicians are willing and able to care for the underserved, the needy, and the vulnerable. But we are being replaced by lesser trained providers to save a few dollars – which is likely to be a short-term cost savings at best. How much will it cost our society when patients, especially our children, grow up without adequate treatment of medical conditions, particularly when they are facing mental health crises? This may prove to be a true national catastrophe.
Editor’s Note: The author spoke with all physicians involved in this blog. All four physicians reviewed the text and approved the details.