THREE PROVIDERS IN MAINE
Mary Hunt is a busy family physician with a full caseload. A twenty-five year veteran with an Ivy League medical degree and a residency training at an eastern seaboard tertiary care center, she has seen a lot, but she never jumps to conclusions or takes shortcuts. This makes her run late sometimes, but her patients don’t mind; they know she provides top-notch medical care.
Mary’s schedule is filled weeks in advance, and she seldom sees patients for acute illnesses. The bulk of her work is chronic disease management. Her EMR inbox is filled with prescription requests, results of standing lab orders, consultant reports, records from the emergency room, inpatient hospitalist service and the local walk-in clinic. Her office visits the past several years have become more and more scripted with checklists for the different quality measures from her Medicare Accountable Care Organization, NCQA and all the other agencies that measure her performance.
Almost every night after supper, Mary logs on to her EMR from home to finish office notes, go through results and answer “medical calls” from her medical assistant and her office case managers.
Megan Brown has been a nurse practitioner for two and a half years. She considers herself lucky to have Mary Hunt as her supervising physician. For the first two years after her graduation from her Masters program at the local branch of her state university, Dr. Hunt co-signed her chart notes and had weekly tutoring sessions, but now she is only available if Megan feels she needs help.
Megan has a small panel of patients of her own, but mostly she sees “acutes” down the hall from Dr. Hunt. She hates to interrupt the doctor because she sees how busy she is, but never feels put down for needing help managing a case. She often sees presentations that are unlike anything she has encountered in the four and a half years since she started nurse practitioner school. Before then, as a nurse, she was never exposed to the diagnostic process; she was more focused on assessing patients for comfort versus discomfort and for carrying out existing treatment plans.
Rhonda Smart has been a nurse practitioner for a decade. Before that, she was an emergency room nurse, which helped prepare her for a career as an independent frontline clinician. She has worked at a shopping mall urgent care center for three years now. She sees a fairly interesting variety of patients, but is starting to feel a little stale, because she rarely gets to hear how her patients make out. She sends her reports to the local primary care physician offices, but they never give her any feedback or updates. She does her shift and goes home and rarely spends much time with the other nurse practitioners who work at her clinic. She has no mentors and no peer group to share difficult cases or career conundrums with.
THREE QUESTIONS:
Is Mary Hunt doing what we want doctors to be doing in a way that is sustainable for her and her patients?
Is Megan Brown our best choice for first responder for undifferentiated medical symptoms and conditions?
Is Rhonda Smart growing in her profession or will her medical acumen shrink as she continues to work in the isolation of her storefront clinic?
A Country Doctor Writes: 
1. No
2. No
3. No, she is not growing, so … yes, her medical skills will narrow.
100% correct answers in my humble opinion, Peter!
This has been my fear. I fit very well with the patients that Dr. Hunt would see on a regular basis. But if my complaint is a week of severe headache that isn’t made worse or better by anything I’ve tried, is Megan going to think to explore brain mets from the breast cancer I had 10 years ago? Most likely she will deem it a migraine and send me home with meds. She most likely is right, but what if she’s not? It has been my experience that many of my illnesses first present with non-descript symptoms, even breast cancer.
No, no, and no. I’ve been a PA for over 30 years and have experienced both 2 and 3. What was best was working in an academic setting with students and residents, which I got to experience in three or four pretty long jobs. You could mentor the residents and students, go to the attendings for advice or back-up with difficult problems, and have the advantage of constant education. Plus, you get to become very specialized at some facet of your job and people actually refer patients to you for it and respect you for your value. You could follow the course of all of the patients by seeing them or speaking with the clinician taking care of them now, in patient and out. Follow-up is 90% of the educational value of “practice”. All three clinicians would benefit from collaboration rather than silo practice.
No, no and no. Flip #1 and #2. Urgent care exists because of #1. Fix #1 and #3 goes out of business.
No, no, and no. #1 and #2 describe our office almost to a tee. I am pediatrician and may day is almost always spent with well visits and ADHD consults or follow-ups. My nurse practitioner of 2 1/2 years experience sees most of the acute walks ins. She constantly feels overwhelmed and worries about missing something. Of course, she knows she can consult me or my colleagues for help but it is still stressful for her. Meanwhile, I feel that my diagnostic acumen is starting to atrophy and I am afraid it will get worse if I continue doing what I am doing. I just don’t know how to turn the tide.