While many physicians perceive the growing population of mid-level providers to be a threat, the reality is that physician numbers are and will continue to be inadequate to meet the health care demands of our nation.
Mid-levels are trained to provide much of the care that our patients need including evaluation and treatment of common straightforward problems, screening services, patient education, and follow-up care. Depending on the degree of post matriculation training, other levels of service may be appropriate.
My opinion is that mid-levels are best utilized as part of a health care team and not in isolated practices where they are sometimes employed by hospitals and clinics to function as less expensive doctors. They have the skill set to be an asset to a medical practice when integrated into a system with clearly defined roles and ready access to physician input. Rather than being viewed as an enemy camp, my practice has been able to employ mid-level providers, particularly family nurse practitioners, to benefit our patients, our physicians and the health of our practice.
Addressing the Physician Shortage
Years ago my physician partner and I realized that recruiting a physician to our rural clinic in an economically depressed area was nearly impossible. We certainly could not meet the salary demands that unproven recent residency graduates were requesting. The appeal of practice ownership was no longer an enticement, but rather had become an obstacle to recruitment. Our practice was busy, and had the potential to grow but we needed more manpower. We both had had the good fortune to train in programs that had utilized mid-levels and were comfortable working with them. With relatively little effort, we were able to successfully recruit and employ the help we needed. Starting salaries were covered in short order, and we soon began to see excess revenue being generated to help the overall bottom line. It has not been perfect. As was true with some physician hires, not all mid-levels turned out to be a good fit. Over the years we have identified several factors that help make this integration work for us.
Finding the right health care practitioners
First of those is a mutual understanding of the mid-level role in our practice. That has evolved over time as we have developed greater confidence in their individual competencies, but the most fundamental issue is that the mid-level desires physician input and support. These are people who are very bright, have an excellent clinical skill set, and good decision making skills. However, they also recognize that we have years more training, respect our input and are willing to seek it out. Initially, visit types are limited and closely supervised with opportunities for discussion. Over time, there is opportunity for more independence as we learn that they are able to recognize when the need for our input exists.
We always have at least one physician on site. That physician needs to understand that if one of the nurse practitioners needs his help, he gives it and does not treat that request as an annoyance. Sometimes it is just a matter of reviewing an EKG, or giving advice about ordering a test. Sometimes we need to examine the patient along with them. Sometimes we just need to back them up to the patient.
Introducing our mid-levels to commonly referred to physicians has been a useful practice. When the doctor has a face with a name, they are much more receptive to phone calls and requests for consultation knowing how our office is set up. If a new physician joins our community, we invite them to meet both our doctors and out mid-level providers. They universally have recognized the value of our set up where physicians and nurse practitioners work together to meet the patients’ needs, as opposed to independent mid-level practices where the only physician is off-sight.
Another asset that occurred by accident, is having a shared work-space. When we remodeled our building several years ago, we elected to eliminate private offices. They were little used and took up a lot of square footage. Instead we built a conference room with perimeter desks . A smaller room is available if there is need for a private phone conversation, and most of our dictations are done at our work carrels. The conference room provides a space where we are able to work together, discuss cases informally, and learn from each other on a daily basis.
Equally important is the fact we all share a common work ethic. Pay is based on a base salary with opportunity to bonus based on productivity minimums being met. However the base salary is competitive so there is no push to meet productivity minimums.
Midlevels are not physicians. However, with a proactive approach , they can be a tremendous asset to a primary care practice helping meet patient needs and significantly improving the financial bottom line.
Our author today is Guy Winker M.D. from the Spindale Family Practice in Spindale, NC. Dr. Winker graduated from Davidson College and attended Bowman Gray School of Medicine, completed his family practice residency and fellowship at Baptist Hospital in Winston-Salem. Dr. Winker has been in private practice in Spindale since 1989.
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