Does it matter to patients whether they’re seen by a physician vs. a mid-level health care professional? Should it even make a difference, as long as the care is competent and appropriate?
It might not seem like a big deal. After all, patients are increasingly likely these days to receive their care from a nurse practitioner or physician assistant. A newly published survey suggests, however, that patients do indeed have preferences – and often their preference is for a doctor, not a mid-level.
The survey appears in the American Journal of Bioethics as part of a collection of articles examining the ethics of implied consent in these situations. The findings are intriguing. First, there’s often a lack of transparency about the title and qualifications of those who are providing care. Second, it’s often assumed – without asking – that patients are OK with seeing a mid-level instead of a physician. And third, patients themselves can be confused or uninformed about the role and educational background of mid-level professionals.
I’ve blogged here before about the challenges patients sometimes face in trying to figure out who’s that person in scrubs providing their care. Some of the considerations are practical: hard-to-read name tags, for instance, or busy professionals who don’t always take the time to introduce themselves with their title.
The ethical issues go deeper than this, however, and I’m not sure how adequately they’ve ever been explored.
Take the question of patient preference. Hospitals and clinics often presume that it’s fine with patients if their care is delivered by a mid-level, and indeed might not even give them the choice of seeing a doctor instead. But when a survey was conducted among 500 emergency-room patients at three teaching hospitals in Philadelphia and Dallas, nearly 80 percent of the respondents expected to see a doctor. The authors of the study reported in the bioethics journal that even in the case of a hypothetical and relatively minor ankle injury, the majority of patients said they would rather wait two hours to see a doctor than be seen sooner by a physician assistant or nurse practitioner. Nor did they mind that the doctor’s services were more expensive.
Dr. Gregory Larkin, the study’s lead author, told American Medical News that patients “deserve greater disclosure about who is providing care and what the level of training is.”
“If we are going to advertise ourselves as a high-quality health care system, we should be trying to think of patients as health care customers more than we have,” Dr. Larkin said. “We have been handing down these alternative providers to patients without any level of informed consent whatsoever. … We inadvertently mask the fact that they aren’t really physicians, adorning them with long white coats, small name tags and high-end Littman stethoscopes. It’s very hard for the unsophisticated patient to tell who’s caring for them.”
It would be hard to draw any broad conclusions from a single survey. Perhaps patient preference for being evaluated and treated by a doctor is stronger in the emergency room setting, where the stakes might be higher.
It raises important questions, though, about the assumptions that often get made in patient care. Do patients have the right to have some say in who provides their care? If they really, really want to see a doctor rather than a mid-level, should they be accommodated? To what extent should issues such as cost, physician resources and clinic or hospital efficiency outweigh patient preferences? If a patient makes a doctor’s appointment and arrives at the clinic in full expectation of seeing the doctor, is it acceptable to do a bait-and-switch and assign the patient to a nurse practitioner or physician assistant instead?
A discussion on Dr. Dominic Carone’s blog makes clear that patients do have preferences for whom they want to see. Dr. Carone, a neuropsychologist, writes about going to a family appointment with a neurologist and – surprise! – being ushered in to see a nurse practitioner instead. It’s not that he doesn’t respect the expertise of nurse practitioners, he explains:
It was about insisting that we be seen by who we were told we would be seen by. I would not have a problem if Dr. Smith told patients that they will be scheduled with a nurse practitioner ahead of time, giving people the option to refuse if they want to. What I don’t appreciate is sandbagging patients at the last minute like this and then putting patients in the uncomfortable position of confronting the medical staff.
Judging from the online comments that follow, he has plenty of company. “Physician extenders become more mainstream every day and it is a shock to patients… there should be some ground rules that everyone follows,” one person wrote. A physician assistant who works in a dermatology practice said he left a previous dermatology group because he didn’t like how patients were being switched to a PA without their consent:
As a practitioner, I certainly don’t want to see a patient that is unhappy seeing me before I have even said hello. I am sure you would feel the same as a physician. No matter how correct my evaluation or treatment plan was, the patient may still feel that their care would have been better if it was from the MD or DO, regardless of how correct or incorrect their assumption.
This seems to be an emerging issue in health care for which there isn’t much data. How do patients truly feel about receiving their care from a physician assistant or nurse practitioner? Although many might be OK with it, others might genuinely resent it, especially if they feel they haven’t been given a choice. Do patient demographics make a difference? Maybe someone with a complicated health history is more comfortable seeing a physician, while someone who’s very healthy might welcome a mid-level instead. Do patient expectations make a difference? Patients don’t seem to mind being seen by a nurse practitioner at a retail clinic – but then again, they know up front what they’re getting at a Minute Clinic and presumably have made a purposeful decision to go there.
There’s nothing inherently wrong with seeing a mid-level practitioner instead of a doctor, and it behooves patients to be reasonable, flexible and open-minded about it. Likewise, patients would be doing themselves a favor to become more aware of the role of mid-levels in health care delivery and to ask questions if they aren’t sure of someone’s credentials.
The greater burden, though, lies on the health care system itself to be more transparent about who’s providing the care. Above all, providers shouldn’t automatically assume that patients won’t object to being seen by someone other than the doctor – because they might just be wrong.