Of ethics, identity and patient choice

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.

7 thoughts on “Of ethics, identity and patient choice

  1. This was an okay study, but inherently flawed from the start with a probably selection bias. As a disclaimer, I practice as a PA in a large, academic emergency department. I also work as a health policy wonk/analyst, and a health services researcher.

    By selecting only large, academic centers, 3 in the study, IIRC, you have introduced a possible selection bias. Patients who obtain their care in these centers are often seeing world class specialists, and there is a higher expectation of care from these centers. This could at least partially explain some of the findings. It would be likely, a good idea to replicate this study in a smaller rural ED setting, where there are likely only family medicine physicians, and PA/NP’s working without residents present. This would serve as a good validation tool, and might show a different response, although who knows without actually doing the study.

  2. Having been a PA for forty years this discussion intrigues me as I have seen these situations, particularly relating to discovery of the credentials of the health care provider. Perhaps, this is the reason why PAs have been explaining the definition of a PA for so many decades, because there is the assumption by new visitors to a health care system, that they are being seen by a physician. I can argue that we wear a name tag that clearly demonstrates our credentials, the tag is exactly similar to that of the other members of the staff and in addition, usually have a white lab coat that also says, PA or NP and then has the definition on the second line. We wear these credentials proudly as we do not take it for granted that we supply many of the same services as our physician colleagues.
    The idea has been surfacing that the facility should have the names of the providers in a conspicuous place in the ED or facility to clearly demonstrate that there are a number of providers involved with their care. If a patient chooses to see a physician only, it should be made clear at sign in, that the waiting time will be lengthier. I also believe that a description of the training of the provider should be available on sheets, cards or booklets which will advertise their credentials and create a better understanding as to qualifications. The problem lies in the fact that we care for multiple socioeconomic groups with language skills and understanding that may reflect an inability to discern the fine points of education and training. For my entire career I have mentioned to colleagues who appreciated my skills that I feel the difference in our abilities is tied to a residency however this obstacle is usually overcome in a seven year period of specialization in a sub-specialty.
    Utilization of advanced practice clinicians differs from state to state and institution to institution. In many cases the APC (Advanced Practice Clinician or mid level provider) may serve in the Fast Track or a portion of the main ER leaving the Cardiology, Pulmonary and Neurology patients to the physicians whereas in other departments the CT PA or NP is the most educated and clinically skilled provider in the department, particularly on the 11-7 shift. I have seen this countless times in all three of the specialties that I have just mentioned. I have been the lead provider on many trauma teams when the night physician was a moon lighting psychiatrist or pediatrician. the difference was that the physician was always in charge and nodded assent to therapeutic interventions as they knew the skills of the non physician provider.
    We have all seen orthopedic technicians who were called cast men that were more skilled than any other provider in splinting and casting. Likewise we have all been on codes where we were grateful that the lead airway specialist was a respiratory technologist. The trauma team leader may have had the overall responsibility but it was the RT that had the skills and the assignment to provide the airway.I have seen more than fifty occasions where the head nurse on a code team “suggested” that the differential may be a drug overdose or pnumothorax or cardiac tamponade and this comment redirected the physician, PA or NP. I think that we need to see ourselves as a highly skilled team where every specialist compliments the overall result and acknowledge the physician as team leader. We need to put our differences aside and be grateful that the tasks are shared by a multidisciplinary team.
    bob blumm

  3. I wonder if some of the authors of this blog have strayed off the track of what this study is all about. I read this as exploratory research about a construct that has not been previously examined. The issue is whether the theory of willingness, a sociological issue, has been obtained by patients who might be expecting to see a doctor when they come to the Emergency Department. The tool the researchers used is a classical economic one of time trade-off. This issue includes EM residents and “moonlinghters.” That the majority had expectations of being seen by a doctor does not identify this as a selection bias (as Halasay states). All studies start somewhere and build on this experience. Exploratory research is intended to identify a phenomenon or issue under somc circumstance. I suggest this one did just that. The next step is for some refinement to find out if this is a single site phenomenon, if time since the study was done has changed expectations, or if this has something to do with culture in Pittsburg or Dallas. I am not familiar with the term IIRC unless “If I Remember Correctly” was the jargon meant.

    Blumm is right that this is an intriguing situation since the use of NPs and PAs is over three decades old and the use of nurse anesthetists 50 years and the use of nurse midwives 80 years. The history of skilled assistants and trainees is as old as gilds and the development of formalized medicine. All people want the best care possible but that is not to say the the doctor attending to you knows much more than a PA or NP that has done the spinal tap 300 times.

    Polta and I did not read this study the same way “How do patients truly feel about receiving their care from a physician assistant or nurse practitioner?” To her she may not see this as a patient friendly study. I see it as the next reserarch question to pose to the NPs and PAs since I don’t know what the patient satisfaction is of the patient having been seen by a NP or PA. A recent study identified that CRNAs have no different outcomes of care than board certified anesthetists. The British nurse midwives showed that when normal pregancy is managed by a midwife the outcome of care is slightly better than obstetricians (and in Britian there is a preference for CNMs). Blumm and I seem to share that this is an “intriguing” study and opens up a lot of interest in understanding me. The Larkin study discussion section is very interesting as it tries to get a handle on this subject – to me that is the meat of this study. If NPs and PAs are not going away soon perhaps we need to learn more about them and how they fit into the landscape of medical care.

  4. I don’t see the study itself as non-friendly to patients. I think we would both agree that it identifies an issue that is worth exploring further, and that the data are too limited yet to make any sweeping conclusions.

    If health care providers in actual clinical practice are making assumptions about patients’ preferences, and if they’re assigning patients to mid-level practitioners without asking them first or giving them another option, then yes, I would see this behavior as not particularly patient-centered, especially if patients are led to believe their appointment is with a physician. Obviously there are many times when patients can be equally as well cared for by a PA or NP as by a physician. I thought Dr. Larkin’s study was interesting, though, for posing this issue as a question of ethics/presumed consent rather than efficiency or economics.

    The vast majority of studies I’ve seen on the question of patient satisfaction with mid-levels have indicated that once they’ve had experience with a PA or NP, most patients are very satisfied with the care. But I see this as a separate question from that of choice and consent.

    • I am a ED Rn, currently studying for my NP. I am thinking about ENP as my focus. In the ED where I am employed, we have more PACs, but the issue would be considered the same being they are mid-levels. I do not witness patients inquiring about the PAC’s credentials very often. When they enter the room, they introduce themselves as the PAC working with DR (who ever is supervising the care). With acuity levels higher than 4, the doctor always sees the patient at some point of the care. I am in agreement that a patient should be able to choose, but maybe the letting the patient know the doctor is overseeing their care and is available makes a difference too.
      DL.

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