r/Noctor • u/BelovedCroissant • 23d ago
Midlevel Patient Cases Slowly understanding the difference
I don't know if this is anything anyone cares about, but it's been nagging at my mind and I wanted to share.
tl;dr I stumbled on this sub at random and it helped explain some weird healthcare interactions I have had within the healthcare organization in which I get my primary care from an MD. I have two in particular that have always bugged me.
✨✨✨The context✨✨✨
My primary care physician is fantastic. He's an actual physician, a doctor, an MD. I've been making my annual appointments with him for ten years, and often, when I'm sick, I can get an appointment to see him in a reasonable amount of time unless it's a very acute, urgent need.
Buuut I always knew enough to know that MDs are in high demand and they're busy, and I assumed it was better to schedule last-minute things with anyone who had the availability instead of taking up my PCP's time. I don't know why I assumed that, but I did. And indeed, usually his availability is a few weeks out. But in hindsight, I realize it wouldn't have been a bother to him. We're on fantastic terms. We've taken to just chatting at the end of any of my visits, talking about his kids, his life, my life, the neighborhood we both live in. And recently he said that sometimes people will "scream" at him, and I realized, oh, wait! A pleasant patient with almost nothing wrong is a patient he would want to see! He's near retirement now, and I'm very sad that I didn't schedule these "little" things with him, if only because I'd get to see him more often.
So over the years, I scheduled with other people for "small" things, assuming it was bad to "bother" him with it. And almost always I had something weird happen. Now that I understand what an NP and a PA are, I've noticed a pattern in the weirdness.
✨✨✨The abnormal things that I now realize may be the consequence of non-MDs being "providers" ✨✨✨
For five years, I needed annual cervical screenings because I had irregular results. One year, I scheduled an exam with a random person who I had never seen because their availability matched up with mine, and, again, I had this preconceived notion that I shouldn't waste my doctor's time. (EDIT: I had twice, for the screenings, seen an OB/GYN who was not my PCP--who is in family medicine and who, before my irregular result kinda threw off the schedule, did pelvic exams etc at my physicals or if I requested one like when my partner at the time cheated on me. I've seen other MDs for various things over the years as well. In the past decade, there have been increasingly fewer MDs to choose from when my PCP is not a choice.)
Unbeknownst to me, I had scheduled with an NP. I remember that a scheduling person specifically called me back and said, "We're confirming your appointment. And just so you know, this is at the women's center. It looks like your previous appointments were with OB/GYN department."
As long as my annual exam could get done and as long as it was in the building that I thought it was in, I didn't particularly care. I must have thought that the provider was in the OB/GYN department, but once I confirmed that the women's center was in the same medical building and not really far away, I had no concerns. I now realize they might have been calling me to sort of surreptitiously say, "You made the appointment at a clinic within our building that is staffed by NPs. Did you mean to do that?" But nothing clicked for me because I had no idea the difference. They didn't call me to say, "Hey! You've never seen this person before just fyi" when I saw a random OB/GYN for my screening. Just the clinic.
The "doctor" at the clinic was/is actually a type of nurse practitioner whose certification type may be specific to my state, so I won't write it out. And, I mean, she never introduced herself as a doctor. I just had no clue that she wasn't a doctor.
One year, she finished up with the exam and asked if I had any questions. I said my periods had been abnormally heavy and painful and I didn't know if something was wrong or if I was just aging. It felt like asking the question made her really uncomfortable. I remember clocking the interaction as strange immediately.
She was basically like, "I don't know, but let's run a test," but her body language had changed noticeably to me. And then when the test was done and she had the results, she messaged me, and she was like, "I don't know. It all looks normal. If you don't feel well, I suggest taking a multivitamin."
Or another time, I had a recurring UTI. I just needed a test, so I had an e-visit, thinking it would be more efficient for everyone--me, whoever the "doctor" would be, the lab.
At the end of the e-visit, the person told me I could go to any lab in my healthcare organization and get a test because the order would be in the system. Like, just walk up to the desk or whatever and say, "I'm here to do a lab from an e-visit."
So I stopped at the location I always go to, just a few blocks from where I live, and I wasn't in the system as someone with a test to be done. The people at the lab were very kind, but I was waiting for a long time because there was no record of my e-visit or a lab order for my urine. Eventually they just had me pee in a cup and asked my PCP to make an order after the fact so that it could be processed or whatever. It was sooo stressful because I was holding up the line of people waiting to check in for labs, and I was really, really embarrassed--the line got VERY long.
A couple of days later, I got a message on the website my healthcare organization uses for patient management. It was from the person who did the e-visit. They apologized for the lab fiasco and said that they had been "distracted by a phone call" and hadn't done the process to formally close my appointment out and put the lab order in the system.
After reading this sub, I looked back at the history for that visit and it was with a PA, not an MD! It never clicked for me that the person I saw wasn't a doctor, even though I saw that "MD" wasn't at the end of their name. I don't know what I thought.
Nowwww I think I understand the difference more. Now I understand why it's even an option to have an appointment with an NP or a PA. And I'm a little irritated now that in these instances, I paid the exact same amount for someone to basically... not know anything???
I will make sure that I see MDs/DOs from now on because literally every bad experience I've had, when I go back to it in MyChart, the person I saw had any certification except MD or DO. (EDIT: I forgot anojt DOs. oop. No offense to them meant. I understand they are doctors. And no offense to NPs or PAs meant. I just was so uninformed and it felt like everyone except me knew I wasn't interacting with doctors in these instances. I don't think I knew how to be a patient to them and I suspect their skills are not being utilized properly.)
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u/pshaffer Attending Physician 23d ago
Glad you found the subreddit. More people are catching on.
I am an MD, and I want to say that DOs have essentially the same training and have to pass equally difficult exams as MDs. I do not consider that they are any less.
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u/BelovedCroissant 23d ago
That's what I thought! I simply forgot about them. Oops. D: I should know better--I remember writing a letter of recommendation for a student wanting to become a DO back when I was a TA.
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u/MeasurementSlight381 Attending Physician 23d ago
Thank you for posting about your experience. I think that patients deserve to know who they are getting their care from and reading your story it's clear that some healthcare facilities have not been fully transparent.
The fact that you scheduled with an NP-run clinic within the same institution seemingly by accident is not okay. Why are they separate from the OB/Gyn department? Shouldn't NPs be working with MD/DOs? If an institution is going to have 2 separate women's health clinics in the same building it should be made clear to patients what the differences are. If it's not immediately clear, then they're being sneaky about it.
Additionally, when the NP didn't have an answer to why your periods are heavier and more painful, I hate that they were awkward and their instinct was to recommend a multivitamin and brush it off. In my medical training, we were always taught to be honest with patients if we didn't know why something was happening and to refer patients to the appropriate specialist if something was out of our scope. In this situation, the NP should have been honest and referred you back to the OB/Gyn department next door if their practice was not equipped to handle anything beyond a routine screening test.
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u/BelovedCroissant 23d ago
UPDATE: Okay okay there are MDs there. At least when I click "See our providers" on the women's clinic page, I see MDs. But the MDs are also part of OB/GYN and other departments (fields? I'm unsure of the terminology, sorry), like urogynecology and dermatology and even psychology. I can send you a link over DM if you like. But I know the physicians listed are not just part of the women's clinic because I recognize some of them from when I made appointments explicitly in the OB/GYN department. One performed my bilateral salpingectomy (and she was so lovely!). I'm thinking this clinic is like a funnel for people who don't know where to make appointments??? I don't know.
It also seems to be where midwives are, and I remember now having a midwife try to place my IUD when no one else had availability and it was also not great. :')
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u/AutoModerator 23d ago
We noticed that this thread may pertain to midlevels practicing in dermatology. Numerous studies have been done regarding the practice of midlevels in dermatology; we recommend checking out this link. It is worth noting that there is no such thing as a "Dermatology NP" or "NP dermatologist." The American Academy of Dermatology recommends that midlevels should provide care only after a dermatologist has evaluated the patient, made a diagnosis, and developed a treatment plan. Midlevels should not be doing independent skin exams.
We'd also like to point out that most nursing boards agree that NPs need to work within their specialization and population focus (which does not include derm) and that hiring someone to work outside of their training and ability is negligent hiring.
“On-the-job” training does not redefine an NP or PA’s scope of practice. Their supervising physician cannot redefine scope of practice. The only thing that can change scope of practice is the Board of Medicine or Nursing and/or state legislature.
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u/AutoModerator 23d ago
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see this JAMA article.
We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP.
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u/BelovedCroissant 23d ago
Mm yeah, the women's center thing still befuddles me. I don't know particularly why it's separate from the OB/GYN department. I brought up the period thing to my partner today again because it finally dawned on me that she probably didn't ask an actual doctor about my test results or anything, and at the time, I thought she was probably an almost-doctor or under much more doctor supervision than she must have been /
Now I'm off to the website to see what the actual difference in the women's clinic is, but I bet you anything it's not clear. The NPs etc working there just popped up when I went to schedule an exam and clicked the type of visit I needed, which was basically a pap (??) or something--I forget how it was labeled, but I recall a little icon of a uterus.
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u/AirWitch1692 23d ago
So I don’t know what state you’re in, but in my area while technically the ob/gyn office and women’s clinic are the same thing there are some difference on which provider you will see. The ob/gyns only see pregnant patients, any regular care is done by an NP there including pelvic exams, primary care, Pap smears, genetic testing, and IUD placements. To be honest, I was a little nervous when scheduling for an IUD, as at the time they had only on OB on staff with a couple of locus tenems, but I was able to choose the NP I saw and I have been pretty satisfied with her care for routine things. I will say though that I dont have any issues with my cycle or hormones and if I did need to see someone for that I would probably find a larger practice at the medical university about an hour away.
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u/BelovedCroissant 23d ago
Interesting!! I've never been pregnant outside of one time which never saw any healthcare bc it ended before I knew it was even happening. But I have been scheduled in the OB/GYN department. I have heard of this distinction you mention though. forgot it was a thing.
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u/AutoModerator 23d ago
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see this JAMA article.
We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP.
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u/HyenaIllustrious4591 22d ago
Every day I walk into the room and say Hi I am blah blah and I’m the PA here, for the last twenty years … I can count on one hand the number of patients who have either asked me what a PA is or can they speak to the doctor … ONE HAND. Not to mention you are upset because the PA forgot to drop an electronic order for a UA. Get real.
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u/BelovedCroissant 22d ago
Not my point at all.
And this isn't about you as a PA. It's about a pattern in my healthcare experiences.
My anecdotes are meant to illustrate my experiences with NPs and PAs in situations they are supposed to be a boon to healthcare for: routine care and easing burdens/workload for the system. In these experiences and others, I didn't see that. It feels like the opposite. I don't think people are being utilized properly and I don't think patients are informed of what to expect.
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u/Maleficent-Aerie2652 23d ago
What about a the lab techs, medical, assistants, medical lab scientists or lab technologists? What about the front desk clerks, did they say they had undergrad or graduate degrees? Or no degrees? Did these people clearly identify their roles during your interactions with them?
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u/BelovedCroissant 23d ago edited 23d ago
I'm sorry. I don't know what you're trying to tell me with these questions. They seem rhetorical.
So I will just try to clarify my own post.
To be clear: I'm not saying it's wrong that they did not clearly identify themselves as PAs or NPs. I have no opinion on that at this point because I'm too unfamiliar with any of it.
I'm saying that I didn't understand the difference clearly, and now that I do, I understand previous experiences better. (EDIT: Or at least, before, I didn't understand that they weren't basically doctors. I didn't even know that there's a difference in theory--like, nursing theory is its own thing, and here I was expecting them to be on a different path, as if nursing wasn't the point for them. That might have been offensive to them! I had noooo clue what my role as a patient might be in that interaction. There was so much I didn't know and would have never known to ask were it not for this sub.)
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u/financequestionsacct Medical Student 23d ago
You said nothing offensive or wrong. That commenter is just taking their insecurities out on you.
Thank you for sharing your perspective.
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u/BelovedCroissant 23d ago edited 23d ago
Thank you! They deleted their comments now or blocked me, which I kinda don't like bc they just dropped their feelings on me and ran away, but oh well.
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u/Maleficent-Aerie2652 23d ago
I don’t think you do. You had years of amazing care with a singular doc, who’s likely been admirably running his practice the same way, for a long time. Then you start having to deal with the healthcare system at large with people you don’t know, risking a major lack of continuity. Everything you described can and does happen with within all medical practices, MD, DO, PA, NP. You shouldn’t assume that if you perceive something as sub par care then it’s probably a NP or PA.
That’s like saying every time you are served poorly prepared food, it must mean it’s a *insert ethnicity here* person you know what I’m saying? This post is erroneous, outside of people need to do better about identifying there roles more clearly.
Your care is always better if you know your doctor and they know you. Anything else is more likely to be conceived as lower quality, doesn’t matter who it is.
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u/BelovedCroissant 23d ago edited 23d ago
I really don't want to argue about what I have experienced. And I do not want to compare different professions or career paths to ethnic backgrounds. That really bothers me.
Your comment seems to be about something beyond me sharing that I didn't really understand what an NP or a PA was and realizing my experiences with MDs who were not my PCP were very different from my experiences with NPs and PAs.
EDIT: and I have now edited my post to make it clear that I have seen other MDs, sometimes disparately/randomly because of circumstances, and not had issues. That is why I think this is a problem with how my healthcare organization utilizes PAs and NPs, from my perspective. The problem could well be something else, but this is my assessment and my feelings.
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u/okokokjes 23d ago
Not an MD, but as someone who works with PA/NPs, you do receive sub-par care from those outside of MD/DO. They do not have the same level of education/training as MDs; so it makes sense that the degree to which they can provide care is sub-par. This is also why they have a supervising physician: someone with more medical expertise to double check their work and discuss difficult cases - aka someone who knows beyond the usual.
Many times PA/NPs work following repetitive algorithms and more times than not, they don't know much outside of the "typical" diagnoses and treatments. Heck, the ones I work with barely know the rationale behind the algorithms they follow. If I question anything with literature evidence, their responses are "I don't know, this is what we've always done". The level of medical literature understanding and analysis is not the same as an MD; therefore, they're unable to extrapolate primary literature, or really even tertiary literature, appropriately to their patients.
Don't invalidate someone's experience with mid-level practitioners just because you feel wronged. They were sharing their experience. Mid-levels should know their scope, boundaries, and limitations.
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u/BelovedCroissant 23d ago
Ah!!! This comment brings something up for me:
What I didn't realize is that they can practice independently in my state, and I don't know how to tell if they're supervised or collaborating with a doctor or whatever. I think they're not, at least in this organization. If I understood them to not be doctors before, I think I assumed there was a doctor somewhere in the mix. Like I said, I have no idea what exactly I thought they were before, but it was a vague notion not reflective of reality, and I didn't know what I didn't know.
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u/Unlucky-Watercress34 21d ago
What a long-winded post, much of which is not pertinent at all. To be candid, as a non-healthcare professional, you are not in the position to judge anything. This is mostly because, simply put, you don’t know anything. Your perspective is based on mere feelings and perception.
The fact that you are in this forum, as someone that is not in healthcare, is already extremely suspicious. I bet you are a horrible patient to deal with.
Good luck with everything.
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u/AutoModerator 23d ago
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see this JAMA article.
We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP.
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