Which Health Care Provider Do You Need?
Case #1 – Episode 9 – Matching the Right Patient with the Right Provider
THE PATIENT JOURNEY
After being treated for her urinary symptoms for the 5th time in less than a year, the 24-year-old called her doctor’s office after the holiday weekend to get an appointment as instructed by the Emergency Room nurse. Again, because her regular doctor had no appointments available for two months, she was given an appointment with another provider, a physician’s assistant.
Healthcare Providers are Different
I worked with nurse practitioners in my office as part of our health care team. For decades we employed advanced practice nurses to augment care of patients.
Over the years, physicians have increasingly relied on physician assistants (PA) and advance practice nurses (NP) to enhance patient care. When doctors are occupied with more critical cases, these licensed providers effectively manage some of the doctor’s patients. Midlevel practitioners often handle patients who urgently call the medical office when the doctor’s schedule is full, improving accessibility for patients. Without these providers, when a sick patient calls, the receptionist consults the doctor’s nurse, who then triages the patient. Sometimes the nurse must interrupt the doctor. Typically, patients requiring most, but not all, acute care have common non-life-threatening conditions that a PA or NP could handle. Healthcare providers’ training and experience vary significantly: licensed physicians accumulate at least 12,000-20,000 clinical hours,1 while NPs have around 1,000 hours,2 and PAs have at least 2,000 hours of supervised clinical practice.3 It is important that patients are treated by the appropriate healthcare provider determined by their clinical presentation, not the arbitrary schedule of the system.
Health systems often schedule physicians weeks in advance to ensure their time, which is a significant expense, is fully utilized. Insurers typically reimburse based on the number of diagnoses and procedure codes, meaning a patient with multiple diagnoses can generate more revenue than one with a single diagnosis. While this might seem logical, it can lead to less-than-optimal care. For instance, a chronically ill patient with stable conditions who only needs medication refills would be better managed by an advanced practice nurse and see their physician once a year. Usually, these are the patients who fill the doctor’s schedule unnecessarily. In contrast, an acutely ill patient experiencing symptoms like weakness, fatigue, and dizziness should be seen immediately by an experienced physician. Without proper clinical triage, however, most health systems will have mid-level providers see acutely ill patients regardless of their medical needs. Mid-level providers not properly trained for clinical settings or unsupervised by physicians can endanger patients.4
THE PATIENT JOURNEY
The patient in our case is an example of why her regular physician should have seen her much earlier in her protracted course.
Opinion:
Medical diagnosis is difficult. All patients without a known diagnosis should have a licensed physician responsible for their care regardless of whether that care was rendered by a NP or PA either directly (physically present) or indirectly (virtually). Before any patient was referred out of our office by an NP, the patient was always presented to a licensed physician before the patient left the premises.
Health Conditions are Different
There are three basic types of medical illnesses, each requiring a different approach. This concept is based on the work of Clayton Christensen in “The Innovator’s Prescription: A Disruptive Prescription for Health Care.” 5 He divided health care into three business models and suggested cost and quality improvements could occur as a result of creating different workflows for each type of condition.
• Value healthcare – Some conditions have known signs and symptoms, a known diagnosis, a known treatment, a known outcome and a known cost of care. Examples would be sinusitis, female cystitis (urinary tract infection), influenza, seasonal allergies, and erectile dysfunction. These illnesses can be treated by an algorithm, that is, if certain criteria are met without other criteria, then a treatment can be rendered with minimal professional effort.
• Network healthcare - Chronic health problems have already been diagnosed and a long-term treatment plan instituted. Examples would be high blood pressure, diabetes, asthma, arthritis, and chronic lung disease. The clinical findings change very slowly. Once documented, the physical findings need only re-evaluation at an annual examination by a physician. Treatment and outcomes are most successful through patient education, change in habits and lifestyle, ancillary services, and support from staff or others with the illness.
• Solution healthcare – Some conditions are difficult to diagnose and treat. Examples are fatigue, bleeding, high fever, syncope (fainting), chest pain, abdominal pain, or unexplained weight loss. These conditions have changing signs and symptoms, may be a condition assumed to be straightforward and recurred, or be a combination of chronic conditions with a superimposed acute complaint. The definitive diagnosis can take time and require testing and evaluation. Outcomes can vary widely to include reassurance that the patient will get better to likely morbidity or mortality. The treatment may not be known for some time and requires frequent adjustment. The cost of care is uncertain. You need a doctor.
In a clinical setting where patients are seen with undefined illnesses, the skill set of the practitioner is important. Supervised clinical practice is appropriate for commonly occurring conditions, but academic training is needed to recognize complex conditions that the healthcare provider with less training has no basic knowledge of, never encountered before, or that has no experience managing.
As discussed in Episode 2 (Benefits of Doing Nothing When You Are Ill) we know most illnesses resolve without any medical intervention. In a small number of illnesses medical intervention will prevent significant morbidity and mortality. In these instances, training will make a difference.
Anecdote:
Recently, my neighbor experienced a new onset of recurrent chest discomfort on exertion and using his arms. He called his doctor’s office and was seen by the physician’s assistant. He appropriately received an immediate referral to the cardiologist. When my neighbor told me about the appointment, I knew he needed a cardiac catheterization, but I did not want to render any medical advice. When he mentioned the continued symptoms, I asked if he had been given a prescription for nitroglycerin. Surprised he had not been, I felt compelled to say something. I told his wife that it was important he call the doctor’s office back, ask for a prescription of nitroglycerin, and take it immediately when he had any of the symptoms until his cardiac evaluation was complete.
Healthcare providers don’t know what they don’t know. The less experienced healthcare provider knew the patient had a condition that was outside their scope of practice, and correctly referred the patient to a specialist, but they did not know that immediate treatment was needed. Naturally, there is no reason to expect them to know the treatment for a condition, angina, they never manage.
The only patient died soon after an office visit was like my neighbor. I treated the patient, but he cancelled the appointment with the Cardiologist doing the heart catheterization. He died suddenly a few days later. I still ruminate over why I did not do a better job educating him about the important of the medical process. I will discuss the issue of compliance and outcomes in Case #3.
When Is Treatment Needed?
Time to treatment initiation (TTI) is an important concept to understand about healthcare. TTI is the interval of time between onset of symptoms, or suspicion of disease and initiation of therapy; being a combination of wait times for consultative, diagnostic, and treatment services. TTI is important in patients presenting with new onset angina because they have a >1% risk of sudden death awaiting definitive diagnosis by catheterization and treatment by coronary bypass grafting.6 Nitroglycerin is the mainstay of angina treatment to delay serious complications of heart attack and stroke. It should be given for even a suspicion of the diagnosis of angina. Unstable angina is one of a small number of medical conditions for which time to treatment initiation can be critical. Lengthy time to treatment initiation (TTI) has previously been associated with an absolute increased risk of mortality, from 1.2% to 3.2% per week of delayed treatment in cancers.7 A 30% increase in mortality for two months delay in care is very significant.
How Emergency Rooms Match the Right Patient to the Right Provider at the Right Time
Regrettably, most of our healthcare system fails to differentiate between various health conditions as defined by Clayton Christensen when determining which provider should treat a patient. There is one exception: the Emergency Department, also known as the E.R. In the E.R., patients are initially seen and triaged by experienced clinical personnel to assess their level of acuity or how urgently they need care before a critical event occurs. Bad things sometimes happen quickly in an ER so time to treatment initiation (TTI) is critical. This triage process essentially involves making repeated assessments about the severity of the patient’s illness and plan actions for the patient based on the assessment.
Patients are seen in order of severity. The ER doctor evaluates the patient to determine whether they can manage the case in the Department or if a referral is necessary. This triage system helps sort patients for appropriate and timely care, from a cast application to stabilization with intravenous (IV) fluids until the patient can be transferred to the operating room for surgical management.
Opinion:
Only emergency care is individualized to the patient. Other healthcare environments take a one-size-fits-all approach as if each clinical presentation is a unique episode of illness to be managed without regard to the patient’s history, social environment or context and a fee charged for each part of the process. Instead of a healthcare system, we have a sick care system.
PATIENT ACTION:
PHYSICIAN ACTION:
Please answer the following questions.
Preview
The next Episode will describe a patient-centric care. Subsequent Episodes will discuss how healthcare is can be individualized.