By Paul V. DeMarco
Guest Columnist
In 1993, as a new physician fresh from residency, I joined an internal medicine practice composed of three doctors and one physician assistant in Marion. The next year, one of the doctors left the practice and our call schedule went from every fourth to every third night. I was the father of two young children, and this sudden increase in my workload threatened to overwhelm me. I would have left the practice and probably the Pee Dee if we hadn’t hired another PA. She enabled me to remain living and practicing in Marion.
I tell you this to underscore how important physician assistants (PAs) and nurse practitioners (NPs), collectively known as advanced practice providers (APPs), are to the practice of medicine. In my 30-plus years of practice I have worked closely with six APPs in two different internal medicine practices. Practicing with them as colleagues has been a privilege and of great benefit to me and my patients.
However, despite my love and respect for APPs, I oppose the current bills in the SC Legislature that would allow them to practice independently (S 45 and H 3580). The bills would allow APPs to see patients independently after only a year (2,000 hours) of working with a physician.
I have a host of reasons for my opposition. I will offer two here. First, training matters. Medical school is more rigorous and almost twice as long (4 years vs. 2 to 2.5 years) than APP training. But the most important difference is clinical experience. NPs need only complete 500 hours of clinical training to satisfy their national governing body. The PA national minimum standard is higher, at 2,000 hours, which are divided into multiple rotations in different medical specialties. At best, a PA doing an internal medicine rotation might get 8 weeks (about 300 hours) of IM training. An NP would likely get even fewer hours.
In contrast, physicians come from a tradition in which training was so grueling that it had to be scaled back. I finished my residency in the early 1990s before the Accreditation Council for Graduate Medical Education put a work hours requirement in place. In those days, every other night call was allowed, which meant residents could work more than a hundred hours a week. In 2003, an 80 hours-a-week maximum was instituted. Even if we use a more conservative estimate of 60 hours a week for an IM resident, over a three-year residency internists begin practice with approximately 9,000 hours of clinical experience, 30 times as much as the best case for an APP. It is a deficit that is very difficult for an APP to make up.
It’s not only the hours, but the intensity of the training. Physician residency training is remarkable for its depth and breadth. In the first (intern) year, physicians are intimately involved in their patients’ care. We perform histories and physicals, order labs and imaging, and create differential diagnoses and treatment plans. As second- and third-year residents, we remain closely involved, but also supervise the interns. Experienced attending physicians make rounds mornings and sometimes evenings, do bedside teaching, and are available for advice, but the residents are entrusted with significant responsibility and are the patients’ primary doctors.
By the end of our residencies, we have managed a vast array of clinical problems in the office and the hospital, from the trivial to the life-threatening. An exhaustive residency is the best way to prevent knowledge gaps, which are a common source of medical errors. If a provider’s training is too short or too narrow, they may not be able to recognize a condition they have never seen.
Second, the primary argument for independent practice is that it will increase access for underserved patients. But these bills will not remedy that problem. In about half the states, APPs have independent practice authority, so there is a record to examine. But different lenses produce different conclusions. Nursing researchers have produced papers claiming that independent practice does increase patient access; unsurprisingly, data from American Medical Association refutes this, concluding that APPs tend to practice in the same areas as physicians.
Current state law allows APPs to work alone if the supervising physician is “readily available,” although that term is not defined. Specific requirements for supervising physicians’ distance (45 miles) and travel time (60 minutes) to APPs’ practice locations were eliminated in 2018. Many of these solo APPs are only lightly supervised. Eliminating supervision entirely is a step in the wrong direction. We need more collaboration with our APP colleagues, not less.
Given the demands of modern medical care, the likelihood that a private solo APP or even a small group APP practice could offer affordable care, generate acceptable revenue, and sustain bearable working conditions is low. Rural practice can be grueling and lonely, and the burnout rate is high.
The best option for APPs to offer this type of care is through a community health center like HopeHealth, where I have worked for the past 14 years. CHCs receive enhanced Medicaid reimbursement and can offer a sliding scale for uninsured patients. If they are like HopeHealth, they offer competitive salaries and benefits, strong leadership, and educational and social opportunities for all providers, physicians and APPs alike.
I urge the legislature to focus on incentivizing doctors and APPs to collaborate. APPs have rightly argued that not enough physicians are willing to work in rural areas. But there are still some of us who will. In SC, physicians can supervise up to six APPs, so a single willing physician could catalyze a large rural clinic, or several smaller ones. This model, in which the physician and APPs work together, sharing the burdens and rewards of caring for rural patients, is the best way forward.
A version of this column appeared in the August 20th edition of the Post and Courier-Pee Dee. Dr. DeMarco’s opinions are his own and do not necessarily represent those of HopeHealth.
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Note that since I posted this yesterday, I’ve added links to the text so you can go read the bills to which Paul is referriing. Sorry I didn’t have those in there originally. I asked Paul for that info, and he provided it by text right after I posted, but I’m just getting back to it now,
He also mentioned that the SCMA backs a bill (S 669), which proposes requiring continued supervision of APPs.
And Paul tells me he supports the SCMA-backed bill, also known as the “Team Based Health Care Act.” I figured he did, but checked with him anyway.
As for MY views as a layman with LOTS of experience with MDs, PAs, NPs, RNs and at one point a chiropractor…
I’ve had good experiences with all — and some less-than-excellent experiences as well. With one of my specialists, I’ve made a point in recent years of making my appointments deliberately with the PA, because he’s really good. I’ve generally had good experiences with most APPs. With others — meh.
More than 30 years ago, I was in the hospital for surgery, and when my primary care doc dropped by I took advantage of the opportunity to complain about a side effect of something he was prescribing for me. He said there was no way the drug was doing that. After he left, the nurse who had been in the room at the time confided to me that she had seen a number of patients having the same trouble I was having with the same med. I thanked her, and later asked my MD to change drugs, and he did, and I suppose the problem went away, because I remember being convinced that the nurse was right. Nothing against the doctor. We all have gaps in our knowledge.
Wisdom can come from anywhere. That said, one of many, many things that separates me from Donald Trump and his minions is that I value expertise (and experience, such as that nurse’s) very highly.
And Paul makes a strong case as to why APPs need to have a physician standing by and supervising.
So as much I like APPs, I’m with Paul on this…
Of course, when I say, “I’m with Paul on this,” I’m not saying “If I were, say, a state senator, I promise I would vote against S 45 and for S 669.”
This is connected to the reason why I despise campaign promises. They are almost always ill-advised. Not that — as so many alienated voters out there believe — the politicians are lying, but because if they really BELIEVE they can deliver such promises, they don’t understand the process and constraints built into our system, and therefore shouldn’t be running to begin with.
While I agree with Paul’s reasoning, there are circumstances in which I would be open to voting for 45 or against 669. They could each be amended before I get a chance to vote. The bill one supports or opposes at this moment may not be the same bill at all when it gets to the floor.
Also… since I’m now reading about these bills for the first time, I can’t say I’d vote as Paul would recommend. The information I have is insufficient. I haven’t even read the bills, or spoken with the members who sponsored them to understand what caused them to have their current content. And I haven’t spoken to other authoritative sources besides Paul. As much as I trust his experience and judgment, that’s not enough.
I’m just reacting to what I’ve read here, and as far as that goes, he’s got me convinced. That could change as we went forward, if I were a member of the Legislature.
It is NOT the duty of legislators to do the will of a majority of constituents on Election Day, once they’re in office. Unfortunately, it may be a political necessity, if the lawmaker wants to get re-lected. But it’s not his duty. In fact, it could be indirect opposition to his duty.
A conscientious lawmaker doesn’t stride forth to Columbia or Washington with an obligation to do what his constituents, and he himself, thought was a good idea on Election Day. His duty is to go forth and become smarter about the issues.
It’s a matter of the delegation necessary in a complex, post-agricultural society. Hunter-gatherers were all experts at every aspect of life — making stone tools, catching rabbits, skinning rabbits, cooking rabbits — and every other creature they ate. They all had the rough equivalent of a doctorate in botany, because they knew all the placts in their vicinity, knew which ones were edible and which were poison, and which had branches that were good to use with those stone blades to make tools.
Once agriculture started, we started living in towns and cities. We had to specialize, because various skills became more and more complicated, some requiring years of education, all requiring that you plug away at them all day (especially after money economies developed), so that you had no time to become expert in other things.
In this system, everybody pays the doctor to help them with medical matters, and he is therefore free to dedicate himself fully to medicine, and become better at his craft.
Legislators have a similar obligation. Once they’re done with the all-consuming task of getting elected, they have time — they are given time, by the system — that constituents don’t have. Time to study, and understand issues — and specific proposals to deal with them — far better than they did when they started. And certainly far better than most of their constituents.
If they simply vote as their constituents wish — constituents who have their own full lives and responsibilities with what they do day-to-day — that might get them re-elected. Which is why so many politicians follow that path. But they shouldn’t. It makes them pretty much worthless. Our representative democracy doesn’t work right when they do that. That’s one of a number of reasons why we are where we are today…
Of course, any politician to whom I say that will likely seize the opportunity to deliver an indignant sermon on how wonderful and wise their constituents are, and how dare I question their judgment.
Lawmakers SHOULD respect their constituents, and should listen to their concerns. And factor that in with many other sources of information, many of them far better informed about and issue than most constituents. And then make the best decision they can…
So many voters firmly, ferociously believe that the process of going to the capital, listening to fellow members and various experts, and listening to their staffs and lobbyist for interest groups, is nothing but CORRUPTION writ large.
Of course, those things COULD lead to corruption, if the lawmaker is so inclined. That’s why the duty of the smart voter is to elect someone of good character.
I say it all the time. Character matters in a candidate. Promises do not. Elect intelligent people who have, in their past pursuits or in the way they speak to you, indicated their good characters and judgment. Vote for them, and let them take it from there. If you don’t like the result, you can replace them at the next election. But make sure you make an effort to understand why the representative does something that at first glance you don’t like, within the limited time you have to devote to becoming a smart voter.
I don’t vote at all. I’m proud of that more than ever.
I don’t trust any of them. None of them deserve to be trusted. To be elected today takes a ton of compromises, a lot of lying and 99% of politicians know how they will vote before they listen to any so called “experts.” That’s because their party tells them how to vote.
had one upstate Republican who is personally moderate (not that you can tell it from his votes) tell me earlier this year “most things aren’t worth going against the party over because you won’t win the argument or the vote and they really hold a grudge and let you know”
That’s almost a word for word cut and paste from something he emailed me- I changed a few words as his wording was pretty crude.
And of course, as I’ve said before, I couldn’t disagree with you more about not voting.
We don’t have many duties as citizen, but one that we cannot shirk is the duty to vote. This is particularly true of the thoughtful citizen. The UNthoughtful people are destroying the country by getting out to vote on the basis of their ill-considered, uninformed impulses. That greatly amplifies the duty of thoughtful people to get out, individually and en masse, to counter that, and get our country back on a proper, wise course, and KEEP it there…
I know- just one of the things we will not agree on.
Now THAT’s an attitude with which I can agree.
And too few people understand that such an attitude is necessary in this world.
There’s not one person on this planet with whom I agree about everything. And that’s fine. In fact, it’s essential to understand it, and accept it.
And yet now we’ve got all these millions of people today, on the left and right, who believe they owe it to their “team” to bitterly despise anyone who disagrees with them…
The state is getting ready to hand over voting data, addresses, social security numbers and other voting data to the Trump administration.
No way in hell me or my wife will be voting again. My adult children (2) can make up their own minds, but don’t seem interested in voting. My almost 18 year old daughter (in a 2 months) hates politics and I can’t imagine will even register at all.
Experience matters.
The Centers for Disease Control and Prevention have been in free-fall. I watched the Senate Finance Committee meeting with Robert F Kennedy Jr this past week. RFKJr didn’t get roasted; he got burned. Even Trumpian senator, a physician, that confirmed him blasted Kennedy. Of #47’s cabinet, RFKJr has got to be the most unqualified. An anti-vaxxer full of conspiracies is leading HHS.
A president wouldn’t nominate a plumber to be the attorney general, choosing a lawyer instead.
The secretary of HHS should have a degree in public health or medicine.
In fairness,
Makary (Johns Hopkins surgeon) and Bhattacharya (Stanford medical economist) are medical doctors, and they seem to agree with everything Kennedy says or even guesses at.
I would not be surprised at all if in 2 months, Kennedy says drinking water causes leg fractures and Marty Makary and Jay Bhattacharya run to the nearest tv monitor to get on Fox News to say how they always knew water was dangerous for fractures and that “Mr. Kennedy and Mr. Trump simply have the guts to admit it”
We have a medical doctor in Florida, the Surgeon General, who says he’s against making school kids take any vaccine. Dr. Oz, another member of the administration, a cardiac surgeon and in control of Medicare, etc.- agrees with the Florida Surgeon General about vaccines don’t need to be mandated for anyone.
Doctors disagree with each other all the time on every issue under the sun.
You can find a medical doctor or public health expert to tell you anything you want to hear- plenty of them.
The days of trusting a doctor are way over.
My sister is an RN in South Carolina- with over 30 years of experience in a hospital.
The stories she has told me of correcting a physician’s mistakes and confusing statements is too long to mention. (I just wrote out two examples but decided to delete them).
I’d have no issue with PAs or APPs having more responsibility and authority. My wife greatly prefers to see the NP at her doctor’s office anyway. She’s more responsive, more receptive, friendlier and has never led her astray and my wife tells me – that she knows of- never has needed to ask the doctor anything related to my wife.