My Practice's Next Hire: Nurse Practitioner or Physician?
My Practice's Next Hire: Nurse Practitioner or Physician?
I am beside myself. Just about a year ago, I hired a nurse practitioner (NP) to work in our office on a part-time basis. It was great for me financially. I didn’t have to worry about paying her benefits and, as she was being paid hourly, I didn’t have to worry about filling her schedule too quickly. I was hoping that over time, as she got busier, that she would transition to full time. Well, she will — just not here. She was offered a better opportunity elsewhere, and while she will still be working here one day a week (instead of two), I am going to have to look for someone to work full time.
The dilemma is: Hire another NP or another physician?
Here was my vision for the NP's role. She or he would see some of our follow-up patients. She would help with lab results, phone calls, and patient education. The patients would still “belong” to their respective doctors. I hope the NPs reading do not take this the wrong way, because I really do value their role in our patient’s care, but when a patient is referred to a specialist, I think it is important that the physician still be the principal healthcare provider. I have had patients who were concerned that I was “giving them up” or even leaving altogether when I told them that their next appointment was with the nurse practitioner. It reassured them when I told them that we would alternate visits between the NP and me. Having the NP see follow-up patients leaves me some room to see some new patients.
Having said that, we get calls for new patient appointments every day, and patients are upset that there is a wait. And again, when patients are referred to us by their primary-care physician, I feel obliged to have a physician see the patient and not an NP. It’s hard enough to get them to see my associate who has been here for over two years! And it’s not that they don’t like her (they haven’t even met her yet), they want the senior person, i.e., me.
This brings me to option number two: a new associate. A new associate could see a lot of new patients, but only if patients are willing to see him or her. And some patients want to get their foot in the door by seeing “the other doctor” and then want to follow up with me, but I barely have time to see my follow-up patients, how can I squeeze in somebody else’s? And I’m not sure how I feel about having the new doc see my follow-ups for me. We have had an office policy of not sharing or swapping patients, primarily to avoid the situation I just described, and I am having a hard time justifying to myself doing the reciprocal.
So I need help, but have yet to decide what direction to go in. And I haven’t taken into account yet the financial side of the issue.
Doc,
I guarantee you your patients will be happier with a PNP. Spot-on care in a caring individual able to give your parents and children the time they need. You won't regret it. You just need to find the right personality to fit you and your practice.
M. Cain, OB/GYN/FNP
You should start by letting your patients know that NPs are highly trained and competent healthcare providers who have the training to diagnose and treat diseases and educate for health promotion. Allowing them to only see "follow-up" patients is a poor utilization of an NP. who would be invaluable for any practice. That being said, what you described as your utilization for your NP is nothing more than a typical stereotype that demonstrates to your patients, as well as others employed by your office that you have no confidence in his or her abilities and are perpetuating a myth that nurses in general are nothing more than a physicians "servant" with no ability to think critically or diagnose and prescribe properly.
Not sure how an NP seeing follow-up visits necessarily means that the physician has no confidence in the NP and it's really stretching to say that this mode of practice necessarily affirms any perceived myth that NP's are servants of physicians. The physician is ultimately responsible legally for everything that happens in their practice. It may be informing to you that many MDs are also "used" as "servants" by senior MDs in a practice as well, except MDs have to buy their own malpractice. NPs come under the MDs malpractice insurance. I also know many MDs who have their NPs seeing new and follow-up patients. If the responsible physician chooses to hire an employee and utilize that employee to perform specific tasks in the practice, that is their prerogative given their level of responsibility. Your thoughts indicate some prior issues with physicians in the past. Most physicians today have very open ideas toward NPs, especially since many NPs are obtaining higher level degrees. My problem in hiring NPs in the past has only been in finding one who was willing to work hard ("I don't get out of bed for less than $50/hour" - types) while shouldering the full capacity of the responsibilities of the practice ("I will only see 15-20 patients per day"-types). I am still hopeful that I will find this person.
Your patients only react to your behavior and concepts about your staff. Please hire a nurse or a MA to your bidding and not a NP/PA. We need them seeing patients helping in a appreciated role. Not sure where you get your information from but NPs can and do have there own malpractice insurance and are responsible for their own actions.
Good luck with that
Actually, NP's are legally responsible for their own care and typically carry their own malpractice insurance. It's PA's that fall under the coattails of a physician's coverage and legal practice. Having any provider only see "follow-up" visits I think disrupts the patient's trust and quality of care. I want to follow my own cases to the end unless they need referral to a specialist. In that case, I still will follow them after the consultation is obtained. I believe that patients appreciate a provider, be it MD, DO, NP or other, that takes time to show that they genuinely care about them.
How is seeing follow up patients a poor utilization of an NP? Diabetes patients are very complicated and require and lot of time and effort and expertise. Quite honestly, I value her skills so much, that I give her the more challenging patients. The hypothyroid people who only need to be seen once a year, I don't bother her with those.
I'm almost finished with NP school with a dual degree in Family and Gerontology. Since living in San Diego I have seen a NP as my Primary Care Provider. I am assigned to one of the MDs, but if he walked into the room now I wouldn't recognize him. My NP takes care of all my needs and referrals and follows up. All the specialists I need to see I let know that the NP is my PCP, not the MD. NPs must follow "protocols" set up in collaboration with the physician and other office personnel. As long as "protocols " are specific or vague (There are very little guidelines by the way, just that you should have them) and you trust your colleague that's all that matters. I am working in an Urgent care that is run essentially by a n NP and physicians are part time, due the physician owner who is retired. She set up the protocols in the beginning and they were "signed off on" by the owner and staff. (Staff, who writes these laws?!). Her pay is negotiated, by the ways, where she is paid a full physician rate, not the 85% mandated by medicare. It's going to be a trust, growth, learning curve, but it's here. Being here, do we treat a "bad" NP like a "bad" physician? And conversely, do we seek to hire the best and brightest whether a physician, PA or NP? You can hire an NP and train them in what your "protocols" are. Remember, we started off as RNs who follow physician orders well. Just remember also, we have our learning base and judgement which are both well founded in evidenced based medicine. Give us a chance. Thank you Doctor for at least questioning and considering. Robert Johnson RN (soon to be FNP/ANP).
I agree with Kenneth's comment. We have 5 MD's and 4 PA's in our practice. Our PA's see new patients, established patients and do biopsies as well as excisions. Our PA's are capable of seeing all but the most difficult diagnoses. We did, however, make the decision about 5 years ago to have our PA's see most of the acne, rosacea, psoriasis, eczema patients, leaving our docs to see many of the skin cancers and all of the more difficult diagnoses. This has work extremely well for us and our PA's feel very valued. We do always ensure that a physician is in the office when a PA is practicing so the MD can be brought in to help with a difficult case. We give our PA's the same benefits as our other employees, with the addition of an extra week vacation and week to attend CME conferences, and reimbursement for licensing fees. Hope this helps.
I am a Family Np of 17 years. I worked in a private practice with 3 doc's and a Pediatric NP. The doctor's just plain supported me. The receptionist just straight forward said we can schedule you with-------, or it wil be ? long until we can get you in with a doctor. My practise was very full, I worked 4 days a week and saw a lot of the clinic patients as the doc's had time off. I have now opened my own clinic and for 2 and 1/2 years I have grown this practice and I need another provider. I am looking for a doctor becasue It will increase my reimbursements. Just tell your patients the options, they will comply and if you give good care and are competent it takes care of itself. Theresa Russell
Good for you Theresa. It's sad that the Physician is needed for reimbursement. But that's how it is at present. Sounds very similar to where I'm working now. The NP runs the show. The Physician's have other jobs and come in part time and doing nothing different than we do! We all "collaborate" as it is in California. What state are you in?
Good for you Theresa. Sounds like the Urgent Care I'm working in. What State do you work in? Every State is different as far as collaboration, or supervision or independence regarding working with a Physician. I do understand the reimbursement issue. Hopefully one day that will change as well. Where I work there are part time physicians, but everyone seen is according to who is available, whether it's NP or Physician. Also, our NP has a Doctorate and refers to herself as "Dr......NP" "how can I help you?" Phamacists and Physical Therapist now will have a Doctorate and soon all NPs will.
Dear Dr. Young,
Another option to consider may be employing (part or full time) an experienced Physician Assistant. Introducing the PA into your practice is not a difficult or time-consuming process. If addressed properly, adding a PA or NP can enhance the patient's confidence and comfort level with your practice. For example, often patients have easier and sooner access to care. PAs may provide coverage when you are briefly out of the office- at another clinic, attending a CME, etc. Physician assistants may also step in to provide care for your scheduled patients when you are detained by an emergency or a more difficult case. Informed patients know that they are still YOUR patients and always have access to the physician directly or indirectly via your PA. Your PA will practice with your protocols as opposed to a partner physician's protocols. Working with the same chart (electronic medical record) ensures continuity of care from physician to PA.
I hope my suggestion will give you another option to consider.
Sincerely,
Marc T. Dicker, PHD, PAC
NPs and PAs may provide assistance to physicians. However, in many offices, NPs and PAs are given the same responsibility as a physician. They do not have the same training! By continuing to hire NPs and PAs and allowing them to act as a physician, physicians are demeaning themselves and in the long run will push themselves out of jobs.
I am only responding because this is such a common and sad belief. Mid-level providers (NPs and PAs) have been around since the 1960s and have made it possible for physicians to expand their practices, thus providing better access to healthcare. We represent two different, yet rigorous, education tracks that build on our previous medical service histories. We know our roles and scopes of practice and, most importantly, our clinical limitations. I am a PA and am licensed by my states Board of Medicine. I have a DEA #, an NPI #, and am required to complete 100 CME every two years. If the state Medical Boards, AMA, DEA, and Medicare trust us not to "demean" the medical profession why can't you?
Your vision for the NP ensures you will only attract those who "won't get out of bed for less than $50.00" or those who "won't see more than 15 -20 patients/day." If you want someone who is willing to shoulder the "full capacity of the responsibilities of the practice" you will have to design a practice setting different from what you currently have. You want someone with a brain big enough to handle the labs, phone calls, followups, and patient education, but also dumb enough work hourly without benefits and doing only the easy work. You have to pay better and increase your utilization to get a decent NP. It's kind of like hiring someone to care for your child .... you want someone really kind, smart, compassionate, and with a good moral compass. You want someone like you! .... But then you want to put on restrictions, lower the salary, whatever, to a point where you would never apply for the job.
In terms of malpractice, lawyers follow the money train, the not responsibility train. If they thought for a minute they could get more out of the NP than the MD, they'd ignore you.
Take this conversation and think about broadening the job description for your NP, or stick with an MD. Either way, be aware that most new hires, MD or NP or PA, will come to the table with more of a "what's in it for me" attitude and less of a work ethic than those of us in middle age. This emphasis on life style is most likely a positive cultural shift, but the days of giving your 20's to learning your profession, or sacrificing personal life on the alter of work life seem to be waning. Good luck.
You seem to be a decent and caring doctor dedicated to your patients, but I can tell you, if I was a NP, I would happily have dinner with you, but never work for you.
Well from a Medical Malpractice - there are similar coverages at lower $$ - so not an issue - unless these are gross negligences and ignored by the Overseeing Physician. . So yes a point - but not a big one.
However - everything else you say Josie - I AGREE :-) . .
Feroz ( Medical Consultant - also has successful and failed practices in background.)
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I read Chrystal's response - if you are closer to retirement (12 - 14) years away - then hire a Physician - with a transition of over 10 years (8 minimum). . More later . . if you need to know why?
Nurse Practitioners are good - but they also need directive to make sure they have a certain number of patients etc . . other wise they will be more expensive than a Doc on the practice. We had a NP at our practice - who saw 6 - 7 patients/ day. . when 15 - 20 / day was break even . . need I say more . .
Well I closed the practice - as we were earning in other professions to pay the employees - if you do not set guidelines - you may have to take a second job at Walmart or McDonald's to pay your employees - Be careful. . Sometimes - not growing is a good thing. Not all growth is good - especially in the current Healthcare storm . . THINK?!!
I think you answered your own question. You need another MD to see new patients and evaluate them. Swapping patients should not be a problem if your front office staff make it clear than unless unforseen emergency occurs, the patient will see their MD or PNP each time but that you do not "swap" from one MD in practice to another. Also you will still need NP to see followup patients for new MD and the 2 existing MD's. Try writing a script for your front office staff to promote the new MD and clearly let patients know you trust the new associate and that you want them seen promptly. Second, spend some time in the hosp cafeteria or at the hospital or at private offices having your new MD do the "meet and greet" to meet and introduce him/herself and leave their "brochure/resume" and business card so your referring colleagues know you trust the new MD and your referring colleagues can put a face with the new MD's name and will feel more comfortable referring to the new MD.
Dear Dr. Young,
Have you thought about precepting an NP or PA in his or her last semester of their program? During this period you get to assess, teach and evaluate their progress all without paying a dime. At first, I took your comment negatively, but then I thought to myself you are worried about your "brand" or good reputation being lowered. If you choose and train this individual to your standards and have confidence in him or her your patients will gladly see him or her. Why would you choose someone who would lower your brand. I am an NP of 2 years, but have 13 years of nursing. I have excelled as an RN and now I am excelling as an NP. I met my employer who owns and runs an internal med and pediatrics practice in my last rotation. I worked extremely hard as a student and was given the possibility to shine. He saw that we both had something to offer his patients. I was not expected to just see colds and such. He started me off seeing acute patients and in less than 6 months I was seeing the same level of patients he saw. I have found illnesses and cancers that other providers missed because they did not listen to what the patient was telling them. I have managed some of the most difficult diabetic patients that he had trouble managing. I have proved to be a valuable asset to his practice and where it took 2 weeks to get a new patient appt with the doc it now takes 2 weeks for a new patient to get an appt with me. I see 15-16 patients in a 7hr day. I feel that seeing much more than this will in fact lower my brand and his. However, as far as pay goes whether it be an NP, PA or MD you will have to pay for quality stock. I believe you pay for what you get.
I have precepted NP students doing their clinicals, and I would much rather hire someone with experience. And I am willing to pay for that experience, and provide benefits and a retirement plan and all that good stuff...to the right person. I know of one NP I would hire in a heartbeat if I could pry her away from where she is. I have also met NPs from other practices, and have serious concerns (about their docs, too).
Tracy, I totally agree with you. I did my training with my family physician. After training during my first semester of clinicals, he ask me to come work with him when I graduated. I jumped at the chance, you see I think he is the best physician I have every know and I have worked with some excellent physicians. He took me in and began teaching me as his preceptor at John Hopkins taught him. He spent my next 2 semesters training me and I spent my every free minute learning whatever I could not only from him but from books/articles/cases he recommended. I then worked with him for almost 2 years before moving back home -an hour and a half away (I bought a home where he was so I could work and learn from him). To continue, after my first 6 months, I was on my own - I too found illnesss, abnormailties and cancers that other physicians missed, at the same time questioning something that I couldn't quite put my finger on -glad for my physicians support. He looked at his patient's reports and I looked at mine. At the end of the day and even when I left - he treated me as an equal. Don't get me wrong, at no time did I think I was a physician, nor did I act like one. I went to school to be a Nurse not a Dr. (I spent 20 years as an Engineer for a large utility company before retiring) - I am finishing my doctorate in the next couple of months and love being a NP. The finale to the story - his wife was a NP and taught at a major university for their SON and taught MSN-FNP students - not the school I was attending when I did my clinicals with him - he would not take NP students usually but made an exception in my case. I will forever be grateful to him for the training I received and for allowing me to work with him until I gained some great experience.
Dr.Young - as practice managament consultants we have frequently been asked this same question. If you are a solo physycian and:
you are too busy to see your current patients on a timely basis, and
have a backlog of new patients who should be seen earlier
Wr recommend brining on an NP or PA, ratgher thana physycoian.
First, consider the finanvials
Dr. Young,
I work for a Multi-Specialty practice, where we utilize both PA's and NP's. I fully understand your concern regarding patient care and appointments. We have grown to over 20 providers in three years and are still expanding our practice. We employ a few well established physicians who were in your same situations. Basically, your concerns can be addressed by hiring or partnering with a young physician who's medical / clinical management of patients is excellent, demonstrates good judgment, compassion, commitment, professionalism and integrity. We have utilized a Recruiter and kissed many frogs to find physicians with this criteria! Hiring a physician can be a long, expensive and arduous process. You may consider offering a potential partnership buy in based on patient encounters & reimbursement.
Offer New Patients the option to wait on your next available appointment or schedule much sooner with your new Associate. It is all in the manner in which you present this new provider. In your case, I would closely script my office staff on how to properly address any concerns a patient may have. Again, if you are confident of your hire, it's your staff's job to communicate that to the patients. I am not sure how you currently communicate your policy with your patients, but that may be a statement disclosed when the appointment is set or within your initial packet. Best of Luck to you!
In psychiatry, being a practice that takes insurance, no MD's will even look at us. So, we hired a cnp to replace a physician that left for higher pay. What a wonderful decision we made. Patients need to just be educated to their role, education and that there is a collaborative agreement. We have had little issue filling her up. Dawn
I am a NP(just finishing my DNP) that works in a ENT clinic and have for 5 years. I have a 6 week waiting time the provider I work with has a wait time of 3 months. The patients see us as a team. The biggest help you can do for your practice is to not set your NP up for failure. If a patient has an hesitation don't schedule that appointment. I see many new patients with specific diagnosis and do the full work up with the follow-up visit with the MD that allows all the labs, testing and information to be available to the provider. If it is a urgent problem (surgery) I consult the provider that day. We average 50 people a day, with 15-20 surgeries a week (which I assist with) between the two of us. Phone call, refills are taken care of by the NP as is some grant funding for specialized programs. I also know the MD's patients (most of them) so if they are out I can easily care for them and have built a relationship. Much comes down to how you add the NP into the practice if they are treated as important part of the team who diagnoses, treats, and educates patients and is brought in with the right attitude then all goes very well and can be extremely productive. When I first started my first week or two I was brought around with the provider and introduced to patients as a colleague and provider that would be working with the MD to provider care as a team. I have many patients that call and ask to see me because they have confidence in the provider and the relationship I have with my MD I work for. I have previously worked GI and generally surgery with similar situations and never had trouble with being accepted or patients having any troubles it really comes down to the practices handling of NP's.
Jenn
It would be nice to see "physician assistant" mentioned in this article with equal billing, or better yet, the combo-term of "mid-level provider".
I was the first PA in a practice of 3 MD'S and now we have 6 PA's including myself.
Katherine, No one likes the term "mid-level provider" because we don't feel as if we give "mid-level healthcare. I can't speak for PA's because I have only seen one in practice and what I remember was her using an ophthalmoscope and standing 3 feet back from the patients and telling him that his eyes looked good.
Unfortunately the unintended consequence of the "coming" outcomes-based medicine may have the effect of making this situation null and void. It won't matter if you are an NP, PA or MD. You will be mandated to follow the established protocals without deviating or face penalties. In may not matter your intelligence level, education level or success as a diagnostician, you will neither be incentved or encouraged to think. This is the real concern when it comes to providing healthcare to patients.
Melissa,
Your curve has followed mine for several years now. So I hope you take my advice seriously (this time).
I had employed and worked collaboratively with a senior NP for 8 years. She was a CDE too, which was great. I used her for whatever she was competent with - new patients & follow up. If you decide to hire an NP, you need to have enough confidence that the person is competent so you can assure your patients. Unfortunately, my NP retired last summer after a series of skeletal ailments. From 2011-12 I also had hired a PT Endocrinologist, who we helped build a practice. But she did not have the patience or perseverance to succeed...sad!
Now, I am back to being solo, and I actually love it! Nobody to supervise or worry about. I get my work done and I am home on time. My staff is happy and patients too. of course my schedule is filled for 3 months, but being solo, I don't hesitate to extend my day by an hour if a pregnant diabetic needs to see me.
However, it is vital for all of us in small practice to decide if we really want to rely on "volume". What I decided was to sign off all poor paying insurances, and keep better paying contracts. I have slowly built an increasing direct-pay base - all those folks who want to pay me cash because I don't want to play ball with their poor-paying insurers. My feeling is I don't miss those patients who want to see me only because I am in their insurance network...so I have decided I will work only for my patients, not for 3rd parties...which should be our goal any way. So try this method and let me know if you are happy.
Truly you jest!Do you realize that NP's have the same education (and more) that the GP's who have just retired had? Only thing you could fault most of us is no operating room experience. NP's are the wave of family care providers of the future. We have more uniformity in our education that ever before. Our bedside manner is truly liked by our patients especially the elderly, kids, and the mothers. I have just recently moved my practice to another state and the previous patients are still calling just to consult. I personally find your remarks offensive.Also, you don't seem to understand the economic value of NP's in practice. I suggest you do better economic research before you put your opinions forward in mass media.
I'm sorry, to whom are you responding? I don't see how anything I said was offensive or derogatory towards NPs. If I had no faith in them, I wouldn'y considering hiring another one.
I do not think I would hire an NP again. You are correct. The community expects you to at least see the patient and reiterate what is going on. You need to make an addendum note on your NP's chart that states you agree with this before you send anything back to any doctor. THEY WANT TO KNOW YOU ARE INVOLVED-and you should be. As great as NP's are, they are NOT doctors that know everything you do. Since when did this forum become mostly NP's??? With another MD, you do not have to worry about overseeing that person. yes, in the beginning you have to make sure they are taking care of "your" patients;ie, the ones that are really being referred to you but, once you are feeling comfortable with that person, they can fly solo!
MG, MD
I am an endocrinology PA, and appointments are left up to the patient. When a patient makes a new appointment (consultation), they are asked if they want to see myself or the doctor. A lot of patients will choose me, either because they want a woman (I work with a male doc) or because my wait time is slightly shorter (3 weeks v 6 weeks). When I do the consult, I tell the patient up front that they will first see me, then the physician. I tell them that they can choose up schedule follow-up visits with either one of us. You might be surprised, but patients (especially my diabetics) rarely schedule follow-up visits with the physician. I present the "case" to the dr I work with at the end of the visit, which takes less than a minute. Then he comes in and usually re-summarizes what I have already said. It is a good team approach, and I think the patients benefit from having the input of two providers. The patients only see me for follow-up visits. In other words, a good NP/PA can really handle a lot of new or complicated cases - provided the patients are on board. If you have a good PA or NP, your patients will be so happy with their initial visit, they will choose to follow-up with them for subsequent visits. Good luck!
I am a nurse practitioner employed by a specialist (electrophysiologist). I see new patients, take a thorough history and order appropriate diagnostic studies prior to the physician meeting the patient. This saves time for the physician and allows me to establish a relationship with the patient. Patients feel comfortable speaking with me and appreciate the time I spent with them. They sometimes see me in follow up with no objections. This way 2 people know all of the patients which pays off when the physician is off or not available.
That is why this nurse practitioner is intending on relocating to Arizona where I can open my own practice, so that I CAN practice to my full abilty. Hopefully the Locum position I am in will not treat me as such, as my understanding is they are trying to build me a patient base that see exclusively me unless I am unavailable or I feel the need to defer their care up the ladder.
The question would be, What is your personal goal? Are you interested in increasing your overhead at a fraction of the cost? Are you interested in having a stand alone partner, eventually? NPs can get the job done, and in the end have positive patient satisfaction. Their liability, salary, compensation bonuses are usually much less than a physician. If leaving, they usually do not set up practices and take half of your patients. Research states that healthcare goals and overall pt. satisfactions is that of a physician, not to mention the proper management of disease if that and often better according to some studies. If your are not wanting a collaborative role, want someone to build their own practice instead of be team, don't want to be bothered with a protocol agreement, signing off of on charts, don't mind a less bottom dollar, the MD is for you. Pt. care and satisfaction will eventually even out, according to research. To be a successful midlevel provider practice, you have to operate as a team. In the end it will be finding the right personality fit whether MD or NP and deciding if you want the larger bottom dollar.
As a former RN who is now an MD, I look at what you had your NP do and think an RN would very capable of what is described. Consider that option and then see if your number of patients would later support another clinician. I would think another physician might be a better for for your future plans to transition the practice to him/her.
In the same dilemma here at my office. My part time MD gave notice and now I have to decide if I get another MD or a PNP (pediatric nurse practitioner). I have a small office (3 exam rooms) and parents want to see me the more senior person since I am there most of the time. But as I think about cutting back I worry that the patients will leave if they have to see the new younger MD. But I need help -
I am leaning towards an MD as a way to eventual transition the practice to them.
Good luck with your situation too.
Chrystal de Freitas, MD