Are We Training Our Mid-Level Provider Replacements?

I’ve been in private practice for 12 years, and during that time, health care has changed faster than I could have ever imagined. Private practice numbers have decreased annually, hospitals have been purchased and merged, and corporate medicine now rules the land. Doctors have lost their independence and now midlevel providers (MLPs) are slowly replacing physicians, driven by the desire to maximize profit margin in corporate medicine. Accordingly, the quality of health care has deteriorated and the patient-physician relationship has changed for the worse.

MLPs have been around for years. Physician Assistants (PAs) began to practice in the mid-20th century and have worked alongside surgeons for years. Nurse Practitioners (NPs) started in the 1960s and their role expanded in 2010 with an Institute of Medicine recommendation. Realizing they could not staff operating rooms with only attendings and recognizing that their profits may increase, anesthesiology practices began to staff surgeries with Certified Registered Nurse Anesthetists (CRNAs). Now, many patients who have surgery in hospitals or surgery centers never even see an attending physician anesthesiologist. Due to physician shortages, hospitals have hired increasing numbers of NPs and PAs to help physicians see patients in both the inpatient and outpatient settings. Hospitals even encourage physicians to allow the NPs to see the inpatients for them so that they can focus on outpatients/new patients.

In my opinion, a major turning point—for the worse—in the patient-physician relationship occurred when family doctors stopped seeing patients in the hospital, and hospitalists and MLPs took over the inpatient care of their sick patients. Physicians were essentially telling patients, “I only take care of you when you are healthy.” In the outpatient family care setting, MLPs see a significant number of outpatients without physician supervision. The physician message to patients is, “This MLP can do just as good a job as I can.”

Given our reliance on MLPs and the message we have been sending to our patients that “MLPs can take just as good of care of you,” it should come as no surprise that patients have accepted the loss of physicians in their medical care and turned to MLPs for care.

I foresee a future of health care where MLPs provide the vast majority of inpatient and outpatient services with minimal physician supervision, much like the anesthesia model. This could easily be accomplished in emergency departments, hospital floors, ICUs and clinics, where MLPs could see all the patients, order diagnostics, call consults, and discuss complex care with one or two attending physicians, much like a residency.

The reality is that physicians are training their eventual (MLP) replacements! The first three years of work for a NP is essentially their own “residency.” However, compared to physician residencies, they are being compensated handsomely (>$100,000), working less than 80 hours/week and starting without the same medical school debt! Some employed physicians have stepped forward and refused to work with MLPs, and the result has been termination by these corporate hospitals. We are being forced to train our replacements!

Eventually, MLPs will take over surgical practice; they are already performing procedures in emergency departments, outpatient settings, and even in interventional radiology to name a few. They can be trained to do surgery just like any resident.

As long as corporate medicine drives health care, profit margin will be the priority. With the Medicare lump-sum payment model pending, hospitals know they can pay an MLP less than a physician to do the same work and pocket the profit. And, they won’t have to deal with “difficult physicians.”

What can be done now? Sadly, I can’t see any situation where this ends well for physicians. Most states are passing legislation that increases NPs’ independent practice. The Accreditation Council for Graduate Medical Education has increased residency positions, but that is too little and too late. Even if we adopted universal Medicare, undoubtedly the government will see value to utilizing MLPs over more expensive physicians.

Unfortunately, the MLP train has already left the station!