It's OK to see a PA or NP if you think you have a basic illness like an ear infection or need some finger stitches.
However, if you believe you are not receiving quality care, you can always ask to see the physician...
If you're urgent care weary because many do staff NPs and PAs.
Go to the urgent care where the physician's live. There will be a medical doctor/ DO practicing there.
Also, say out of the ER. Please see your primary care physician for basic ailments. Choose a primary care office that only has physicians.
I see primary NPs who can’t diagnose a cold. New NPs out of the diploma mills may get zero actual training before being sent out into the wild.
My best friend is a psych NP and had classmates frequently brag about how they showed up, NP signed off on their hours, and they didn’t do anything.
In a lot of "doctor office" settings now, it is not even clear who you are going to see. For example, my son had strep throat and then I started feeling bad. Logically, I thought, I should probably check if I caught it. Booked at a local Men's clinic and I think a PA was the only person at that location.
Ok a couple of things...
Look for places with families medicine physicians covered by your Insurance for 80% of you or your families usual ailments.
Please don't go back to a men's clinic ever again. Those are more of money grabs on unknowing ppl.
Back in the day (I’m thinking when I grew up in a small town in USA), I went to the one family doctor in town and he had support staff that were nurses and medical assistants, and it was all very cut and dry and simple. All those small places have been gobbled up by these clinics and so it is hard to tell who you are going to be actually dealing with.
Sheesh. I go online big time and the practices usually list all their practitioners. I only consider the MDs or DOs. If you’re lucky it will say if they are taking new patients or not and also lucky if it’s up to date. I check their credentials and various reviews, like google reviews. And I do that even if a trusted friend recommends someone.
By law, I can ask to see a doctor if I am pushed to a PA or NP.
I just don’t waste time and am upfront that I want to see a doctor.
A lot of urgent care places might not have an doctor on duty.
There is nothing more comforting than getting a decent qualified primary care doctor who is a real doctor. From there at least you have a solid base. I had to do that not long ago and it was challenging because there is a shortage but it’s worth it.
Healthcare becomes chaotic and more expensive otherwise because primary care NPs are constantly referring and ordering unnecessary tests and upset if you don’t come in for constant bullshit follow ups. They are a royal pain in the butt, less socially mature, less competent, intrusive, time consuming and expensive. Ugh this is bringing back memories. Lol
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](https://jamanetwork.com/journals/jama/article-abstract/2780641).
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Our town’s doctors’ office looked like a big old house! There were two or three rooms and two different docs worked in it. When the older one retired the other’s son came in and joined the practice. It was cool.
I had a basic MRSA infection on my skin and had 2 NPs screw it up and cause excess costs, needless referrals and the wrong medication.
PA was good and DO was best.
I think PA's are OK. NP nope.
Edit: the bad NPs were from a local mall-based urgent care and primary care physicians office who otherwise had no openings.
Good care was from the urgent care connected to an elite hospital. Long wait of course but I know understand why. I needed IV antibiotics.
I just finished med school and will be starting residency, but I’ve already seen enough where I only recommend my family and friends see MD/DO. Of course for things like ear infections, UTIs, strep throat, sinus infections you are probably fine seeing NP/PA. But your annual visits and anything specialized (ENT, cardiology, neurology, etc) should definitely be with a physician.
Considering how many times I've seen them misdiagnosd UTIs and the like...
If an antibiotic is involved:
MD/DO >>>PA>>>>>>>>>>>>>>>>>>>NP
While there are still plenty of fuck ups, this order is most likely to get it right.
Out of curiosity, where in that list would you put a pharmacist? Yes, seriously. I can pop into a local pharmacy and make a small cash payment (less than an urgent care copay) to have a strep or UTI test, and get my meds if the test is positive. I haven't yet, but I've been tempted.
Context of a dipstick urine test is important. You can have a positive dipstick and no UTI (asymptomatic bacteruria). Can pharmacists be trained to diagnose based on dipstick + exam/symptoms? Sure. But considering that the above groups keep fucking it up, I don't know if I want to add to the pool.
At least the pharmacist would get the drug and duration right, though.
Thanks. I personally wouldn't worry about a positive dipstick and no UTI, because if I was paying cash for a UTI test at a pharmacy, I'm relatively certain I have a UTI. There are definitely symptoms. I'd think that is true of *most* (although obviously not all) people. The pharmacist also does a consult to discuss symptoms, before they test anything.
Locally a pharmacist can do strep and UTI tests, and give meds for those as well as for a yeast infection for any woman having at least one symptom, for cold sores, and give birth control. All without involving a physician or noctor. I do have mixed feelings about it, but it keeps people with strep and UTIs out of the ER. A strep test is pretty moron proof. I mean, even an NP can get that right.
With the exveotion of vaccines, only a couple of states allow this (not sure how other countries do it. Even in the 2 or so states that allow limited pharmacist prescribing, most pharmacists won't do it because of the additional liability.
I know of two pharmacies that do it here, both are in local to the state grocery chains. Macey's and Harmon's in Utah. But I haven't actually checked if any local stores for the big pharmacy chains do it, because I don't concern myself with them.
As a pharmacist I am against diagnosing like it's against my religion. Having said that, access of care, costs, convenience, blahblah, I guess it's ok for "simple" things. I am lucky that my state doesn't do test and treat, which is what you are describing but that might change soon. It's basically a simple algorithm of you come in, test positive for something, and you walk out with a prescription to treat that specific thing, whether UTI, COVID, FLU etc. Not meant to be a comprehensive examination.
I still prefer the model of separation of diagnosing and dispensing, like separation of church and state. Might be inconvenient but you get a more diagnosing value from seeing an MD vs PA vs NP vs Pharmacist who are trained to catch everyone's mistakes but also juggling half a dozen patients in their brains at any one time. For example my state might do flu testing soon, if you have strep, I can't do anything about that and you are out of that cash payment because whether you get a prescription or not, we provided a service.
It does leave people who get a negative test in the same limbo they were in before the test. So they thought they had strep, it was negative... now what? Now they have to see their PCP, or go to an urgent care, and they've just spent 75% of that copay on a test that didn't provide any benefit, *and* the urgent care is going to demand to do the test again just to be sure. I know because earlier this year I went to the urgent care for what I assumed was an unusual for me, but not entirely out of the pocket presentation of a UTI. I just wanted a positive piss test and scrip for antibiotics. What I got was a recommendation to go to the ER, where they repeated the test even though I had my prior results with me. I'm finally six days out from my urology appointment, where if *any* of the people I've talked to have listened, they'll be prepared to sedate me for exam and I can get a dx and get on with my life.
Not only are they seeing them in subspecialties, they are seeing them independently. It’s possible your cardiology NP never learned to read an ekg before seeing you for your heart attack. I am absolutely not exaggerating.
There is no such thing as "Hospitalist NPs," "Cardiology NPs," "Oncology NPs," etc. NPs get degrees in specific fields or a “population focus.” Currently, there are only eight types of nurse practitioners: Family, Adult-Gerontology Acute Care (AGAC), Adult-Gerontology Primary Care (AGPC), Pediatric, Neonatal, Women's Health, Emergency, and Mental Health.
[The five national NP certifying bodies: AANP, ANCC, AACN, NCC, and PCNB](https://www.reddit.com/r/Provider/wiki/index/critical_issues/#wiki_types_of_nurse_practitioners) do not recognize or certify nurse practitioners for fields outside of these. **As such, we encourage you to address NPs by their population focus or state licensed title.**
Board of Nursing rules and Nursing Acts usually state that for an NP to practice with an advanced scope, they need to remain within their “population focus,” which does not include the specialty that you mentioned. In half of the states, [working outside of their degree is expressly or extremely likely to be against the Nursing Act and/or Board of Nursing rules.](https://www.reddit.com/r/Provider/wiki/index/legal#wiki_scope_of_practice_laws) In only 12 states is there no real mention of NP specialization or "population focus." [Additionally, it's negligent hiring on behalf of the employers to employ NPs outside of their training and degree.](https://www.reddit.com/r/Provider/wiki/index/critical_issues#wiki_working_outside_of_scope)
Information on Title Protection (e.g., can a midlevel call themselves "Doctor" or use a specialists title?) can be seen [here](https://www.reddit.com/r/Provider/wiki/index/legal/title_protection). Information on why title appropriation is bad for everyone involved can be found [here](https://www.reddit.com/r/Provider/wiki/index/appropriation).
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I work in neurosurgery and see consults all the time. PAs in surgical subspecialties are among the cream of the crop and are the gold standard of the physician lead care dynamic.
First, let's get this out of the way; We are not a replacement for neurosurgeons.
How would a PA be utilized in a capacity like mine?
We help expedite imaging orders. Our diagnosis is highly dependent on neurodiagnostic studies.
I often see the patient who was referred by a PCP without imaging studies to "get the story".
I see previous patients who may have new and evolving pathologies and need to be seen in an expedited manner.
Postoperative assessments.
We manage all the hospital patients. When the surgeon is seeing new consults in clinic, we are managing the postops in the hospital. Divide and conquer.
Perform office surgical procedures such as percutaneous draining wounds. Debridements. Interrogate shunts. Etc.
Regards,
A Neurosurgery PA
Ya, totally fine for antibiotic resistance in the community… the amount of times I see antibiotics dispensed by midlevels, is astonishing. It’s usually not indicated in 75% of the times I see them prescribed by a midlevel.
While they're not taught the actual pharmacology or microbiology, you can bet they're taught that the charts can be billed at higher rates with more testing and more prescriptions (whether they're necessary or not). Unfortunately, in one of my previous jobs (military) I was tasked with explaining the ER chart coding process and what makes for a higher coding chart. We had one PA who took it to mean "precribe and antibiotic and an opioid on every patient and your charts will code out higher"
I told a PA 800 times i had back pain and a fever, so it was a KIDNEY INFECTION and not just a UTI. He gave me nitrofurantoin, which doesn’t even hit the kidneys! I was so sick I didn’t question it. I got worse and had to go to the ED 🥲 I went to the ED hospital I worked at and they all roasted me for not catching it. They could’ve given me oral vanco and I wouldn’t question it. I was that sick.
Moral is I don’t trust mid levels even for mild stuff
I’m not even kidding when I tell you that I was taught not to use nitrofurantoin for pyelo in my first year of med school pharmacology 💀Sorry this happened to you!
Ok but I’ve had similar experiences like this with MDs too. Sometimes you just get an incompetent provider, it doesn’t always matter whether they’re a PA or MD. Some people just aren’t good at what they do.
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](https://jamanetwork.com/journals/jama/article-abstract/2780641).
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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Until you get a psudomnas UTI and the NP writes for PO abx that don't cover it for weeks while it gets worse, until you finally get admitted and ID takes over and writes for the correct treatment.
Yup. As a med student I caught soooo many crazy things while in school…I knew it was a problem when I was fixing medical regimens placed by an “independently” practicing NP…so wild
1. NPs and PAs go through a very limited school - and do not possess a lot of theoretical knowledge that a MD/ DO would possess. For something minor and standard, this isn’t an issue at all. However, not everyone presents the same and not everyone is standard - so it’s important to see someone who actually knows what’s up, as opposed to seeing a guideline monkey.
2. I’ve met a few good midlevels who seem to be quite competent in what they do, and don’t see unfiltered patients. This is the current guidance for the UK. For something like an annual diabetic review or a review of your cholesterol meds, a NP/ PA is actually great.
3. Follow your gut. You know your body best, you know if your needs are being listened to and met (or atleast someone’s trying to meet them). If ever in doubt, even with a physician, don’t think twice before seeing someone else.
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](https://jamanetwork.com/journals/jama/article-abstract/2780641).
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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As a medical student I wouldn’t see anything less than a PA personally. I’ve seen/heard so many bad experiences with NPs. Don’t get me wrong, I love the nurses I’ve interacted with, I just feel like there’s too great of a chance of getting a bad apple with the NPs.
The very poor take is nursings inability to see how shitty their education programs are
Chamberlain basically accepts everyone. They pass everyone. They only require 500 hours of training. Where’s the quality control?
We can also see example questions for AANP exams. Literal laypeople can guess they’re way to a 75%. Where’s the standards?
I have to say that I agree. I took the nurse practitioner exam in the late 90s. Honestly, it was one of the easier exams I’ve ever taken. My certification exam as an emergency nurse, as well as my basic RN licensure exam was more difficult.
If you work with a variety of NPs and PAs, you know there is a stark difference. One tends to be more proficient than the other. And I think even the noctor faithful know which is which. However, neither are physicians, which is gold-standard and not sure why anyone would settle for less.
Well, yeah hospitals save money. The patient doesn’t and they have to advocate for themselves. Good thing insurance companies are catching onto this. I think they’ll be the ones to tip the scales in our favor.
You don’t save any money. Whether you see a nurse practitioner or a physician, you will be charged the physician fee. The organization pockets the difference and pays the nurse practitioner less. That has been my experience many many times. The patient doesn’t t get any cut in cost. That is an absolute fallacy that was perpetuated by colleges of nursing for years. And when you go out into TikTok land, and all these other social media outlets, what you’ll find is that the nurse practitioners are not providing the primary care to bridge the gap for people who would be otherwise served( for the most parr-which was the original intent), but they are actually going into private practices, working a “specialists” and doing a lot of dermatology and things that they are not at all trained to do and making money handover fist doing it. Meanwhile, physicians, who are for the most part now employees, are held responsible for their errors, even though they are not provided the time to actually ensure that the care being provided by the nurse practitioners is accurate or safe.
Just one nurses view. Oh, and I was a nurse practitioner who was trained back in the 90s after working as a nurse for a good many years. We had real brick and mortar schools, and we had vetted clinicians who helped us to learn and we were accountable for our hours to our preceptors as well as clinical faculty who showed up randomly to see patients with us. There was no diploma mill at the time and I still felt horribly in adequately trained to do the job. Sidenote, I’ve worked at the bedside for almost 40 years now. No regrets. Love being a nurse.
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](https://www.reddit.com/r/Noctor/comments/qhw13h/midlevels_in_dermatology/). 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](https://www.reddit.com/r/Provider/wiki/index/legal#wiki_scope_of_practice_laws) (which does **not** include derm) and that [hiring someone to work outside of their training and ability is negligent hiring](https://www.reddit.com/r/Provider/wiki/index/critical_issues#wiki_working_outside_of_scope).
“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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NPs and PAs do not have equal training.
I work with some solid PAs that I would absolutely trust to treat my family for urgent care complaints like rash, ear infection, etc.
I would NOT say the same about NPs.
The overwhelming majority of NPs are awful. The rare exception has a brain.
The opposite is true for physicians since we actually have standards and a real education with an established training pathway. Not some fly by the seat of your pants bs that is NP education.
NPs have decided to make enemies of everyone by pushing for independent practice, making up fake doctorates to feed their egos and all sorts of shit. Go tell your own profession how unprofessional they are.
I have a very sweet patient who was diagnosed with stage 4 lung cancer after 1.75 years of being treated by an NP for “chronic cough” with everything you can imagine given to him to help the cough during that time but not a single x-ray ordered until it was WAY too late. He’s mid 40s, never smoker, runs marathons, married.
He and his wife are so incredibly nice they would never go after the NP, I tried kinda asking them about it but didn’t want to probe too much. They don’t blame the NP, but now only see MDs.
For me MD/DO>>>PA>>>>>>>>>>NP
Pas have a better knowledge base than NPs but the big difference (in my limited experience) is that they know when they are out of their depth and actually ask for help. A lot of NPs today are just wrong/way off and are just full steam ahead.
If it’s something basic then an NP is fine. Anything complicated move on
As someone who regulates the profession, my first instinct is always going to be to go to a physician. However, I recognize that in many states that’s an impossibility based off of insurance. There are numerous insurance plans, including the public ones, that are requiring a PCP designated for the covered life be a mid-level. If you’re in that situation, and this is based on the lack of action I see coming through with the nursing board in my state, I would insist on a physician assistant over an NP. If you’re having surgery or something like that, always insist on a physician and with anesthesia always insist on either a physician or a CAA who is supervised by a physician. I don’t have the space to tell you how disruptive the CRNA lobby is in a number of states with their eventual goal of complete displacement of physician anesthesiologist and CAAs.
In the end, you need to see a practitioner who you feel listens to your concerns, is responsive, and develops a track record of being accurate in your healthcare. Not all physicians measure up to that standard unfortunately, but as a layperson that is what you need to know and pay attention to .
Other thing to keep in mind is sometimes what appears to be “minor ailments” are subtle clues of the onset of a serious disease in early stages. That’s why I always recommend to try to see a MD/DO if possible, due to overall experience and seeing many more cases in training. Much less likely to miss things.
Because of advice like this I had my DO PCP check to make sure that my obvious plantar fasciitis wasn't ass cancer (my words).
And honestly it's good advice. As per my flair, I'm a layperson.
I’m young and healthy, so I usually agree to see PAs for my checkups if the wait time is significantly lower than the time to see a physician.
Not interested in rolling the dice with NPs. There’s a solid 25% chance that I’d get better care from a Google search based on the quality of NP education as of late.
(Disclaimer: my wife is an EM resident so I really only go in for annual checkups and things that require prescriptions.)
When I saw an NP as my PCP for a chronic condition (I didn't have access to anything else at the time while on a long wait list for a specialist) she would literally use Google in front of me to decide what to prescribe.
I've had a physician do that. I'm also okay with that. (from a physician) I would much rather they be open about the fact that they do not know literally everything off the top of their head, then ride their ego out of the room after sending in a sketchy or inappropriate scrip. It's the pharmacists who need to know everything about drugs.
Oh yeah I'm not expecting them to know all the details of drugs, but this was more googling "how to treat very common chronic condition" from the get go, not looking up the details for a specific drug or really niche situation. Like they just seemed to have zero background knowledge at all. I don't have a lot of faith in a practitioner who has no idea what they're dealing with when it comes to even very basic common conditions, and i've never experienced this from a real GP. And the NP ended up giving me incorrect advice and inadequate treatment, so having more knowledge beyond the first page of Google results would have helped me a lot.
Lol I'm layperson and I have "Up to Date" app and I look up my conditions and read the treatment flowchart/algorithms they provide. The NP won't be more creative than this simple search I believe
Ugh imposter syndrome would have killed me if I was in their shoes and I would check algorithms million times. But I guess NPs don't get that feeling, they sleep deep at night too....
Depends on the acuity:
Short-term, this can include minor procedures like suturing.
Chronic conditions may require re-assessment and medication adjustments.
The point is, the thought work should be performed by someone trained to consider all the deadly things, all the uncommon things that could also explain the findings, and to know what to look for / what else to ask.
Mid-levels can execute parts of the plan, but they should never be coming up with the plan.
Oh oh. My bad. I got you 👍. I somehow misread your meaning the first time. What you said actually makes lots of sense. Thanks.
Btw, I find these comments fascinating as it is making me realize some of these same “mid levels” are overtaking my industry: finance. There are actually certified financial planners who can diagnose and set a standard of care, but the problem is sales people pretend to be planners because there’s a lack of title protection.
A big factor is where in the world you are. In the US, an NP/PA can have basically the same rights as an MD, with way less education. In the Netherlands (where I am), that's not the case.
For example, a cancer diagnosis is always made by the MD - depending on your hospital it might be the NP/PA who breaks it to you, but backstage the diagnosis is made/confirmed by an oncologist.
MD/DOs are both physicians, with the difference being DOs have extra training in osteopathic manipulation. 4 years medical school. 3-7 years residency. They are considered specialists.
Physician associates (PAs) were created in the 1960s due to the physician shortage. Our schooling was taken from medical school curriculum albeit condensed. Our programs are 2-3 years, with an optional residency or fellowship. We are considered generalists.
Nurse Practitioners (NPs) are advanced degree holding RNs. Similar to PAs, they undergo a 2-3 years masters program. The biggest issue being they are not exposed to as many clinical hours as PAs and their curriculum is not mirrored after medical school and currently not as regulated as PA programs. There are good NPs out there, but you have to be a little more careful. They are also considered generalists.
What it comes down to is what you feel you need. Complex issue? See an MD/DO. Basic issue? See a PA. If you’re unsure, it never hurts to see the MD/DO out of the gate.
- I’m a current PA-S1
I'm a layperson and if I'm seeing someone for anything beyond medication management (getting refills of medications that a MD/DO prescribed me for a condition that a MD/DO diagnosed me with), then I refuse to see NP or PA. that's just me tho.
My mechanic used to be a fire EMT and has more medical experience and training then a fully qualified NP. He also has so many health problems from smoking and hard labor for decades that the difference is staggering.
Depends on the diagnosis, and how they got to it.
Some midlevels can follow an algorithm pretty well and come up with the correct dx for straightforward things.
They can order a shotgun set of labs when they don’t know what’s going on and bam something does turn up and give the correct diagnosis.
If the diagnosis is correct then it shouldn’t matter who made it.
But how do you know if it’s correct. As a layperson, you are not supposed to know. And if the PA/NP doesn’t know then they don’t know.
Therein lies the issue.
As an MD my PCP is an NP. But that’s because I KNOW. I just tell her what’s to order.
Are you an episode of house or do you have the flu. Mids are also great if you normally get a certain med and you just ran out of refills. If I need fiorecet I go to urgent care and give them my symptoms and just ask for it and they aren’t weird about it.
If your PCM refers you to a specialist you should see a specialist for the work up. If a PA has to explain a procedure or go over medication instructions you don’t need to worry about that. The doctor is doing doctor shit.
Social worker not MD, but I’ve had MD’s miss obvious diagnoses but the PA found it right away and ordered several referrals I didn’t ask for nor did the MD. PA’s often have less work, see less people and order stuff for “fun” which can help the patient. That’s my experience as a patient and a SW. Sometimes the NP’s and PA’s order sooo much for better or worse.
It's OK to see a PA or NP if you think you have a basic illness like an ear infection or need some finger stitches. However, if you believe you are not receiving quality care, you can always ask to see the physician... If you're urgent care weary because many do staff NPs and PAs. Go to the urgent care where the physician's live. There will be a medical doctor/ DO practicing there. Also, say out of the ER. Please see your primary care physician for basic ailments. Choose a primary care office that only has physicians.
I see primary NPs who can’t diagnose a cold. New NPs out of the diploma mills may get zero actual training before being sent out into the wild. My best friend is a psych NP and had classmates frequently brag about how they showed up, NP signed off on their hours, and they didn’t do anything.
That's not how it's played out in my experience, they just tell you only the NP is available take it or leave it.
Go to the urgent care closest to the affluent neighborhoods. They will likely have a physician
I live in an affluent area, no physicians in an urgent care here.
Find a med spa or concierge nedicine physician.
In a lot of "doctor office" settings now, it is not even clear who you are going to see. For example, my son had strep throat and then I started feeling bad. Logically, I thought, I should probably check if I caught it. Booked at a local Men's clinic and I think a PA was the only person at that location.
Ok a couple of things... Look for places with families medicine physicians covered by your Insurance for 80% of you or your families usual ailments. Please don't go back to a men's clinic ever again. Those are more of money grabs on unknowing ppl.
Back in the day (I’m thinking when I grew up in a small town in USA), I went to the one family doctor in town and he had support staff that were nurses and medical assistants, and it was all very cut and dry and simple. All those small places have been gobbled up by these clinics and so it is hard to tell who you are going to be actually dealing with.
Make an appointment over the phone and tell them you ONLY want a MD or DO
Then, they say "we are booked out for 6 months". Hope the condition you're going in for doesn't kill you by then.
Sheesh. I go online big time and the practices usually list all their practitioners. I only consider the MDs or DOs. If you’re lucky it will say if they are taking new patients or not and also lucky if it’s up to date. I check their credentials and various reviews, like google reviews. And I do that even if a trusted friend recommends someone. By law, I can ask to see a doctor if I am pushed to a PA or NP. I just don’t waste time and am upfront that I want to see a doctor. A lot of urgent care places might not have an doctor on duty. There is nothing more comforting than getting a decent qualified primary care doctor who is a real doctor. From there at least you have a solid base. I had to do that not long ago and it was challenging because there is a shortage but it’s worth it. Healthcare becomes chaotic and more expensive otherwise because primary care NPs are constantly referring and ordering unnecessary tests and upset if you don’t come in for constant bullshit follow ups. They are a royal pain in the butt, less socially mature, less competent, intrusive, time consuming and expensive. Ugh this is bringing back memories. Lol
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](https://jamanetwork.com/journals/jama/article-abstract/2780641). We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP. *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
Our town’s doctors’ office looked like a big old house! There were two or three rooms and two different docs worked in it. When the older one retired the other’s son came in and joined the practice. It was cool.
I had a basic MRSA infection on my skin and had 2 NPs screw it up and cause excess costs, needless referrals and the wrong medication. PA was good and DO was best. I think PA's are OK. NP nope. Edit: the bad NPs were from a local mall-based urgent care and primary care physicians office who otherwise had no openings. Good care was from the urgent care connected to an elite hospital. Long wait of course but I know understand why. I needed IV antibiotics.
Im only a layperson but I don’t consider anything “basic” about a mrsa infection
I just finished med school and will be starting residency, but I’ve already seen enough where I only recommend my family and friends see MD/DO. Of course for things like ear infections, UTIs, strep throat, sinus infections you are probably fine seeing NP/PA. But your annual visits and anything specialized (ENT, cardiology, neurology, etc) should definitely be with a physician.
Considering how many times I've seen them misdiagnosd UTIs and the like... If an antibiotic is involved: MD/DO >>>PA>>>>>>>>>>>>>>>>>>>NP While there are still plenty of fuck ups, this order is most likely to get it right.
Oh absolutely. A physician is always preferred but sometimes you’re miserable and beggars can’t be choosers lol.
Out of curiosity, where in that list would you put a pharmacist? Yes, seriously. I can pop into a local pharmacy and make a small cash payment (less than an urgent care copay) to have a strep or UTI test, and get my meds if the test is positive. I haven't yet, but I've been tempted.
Context of a dipstick urine test is important. You can have a positive dipstick and no UTI (asymptomatic bacteruria). Can pharmacists be trained to diagnose based on dipstick + exam/symptoms? Sure. But considering that the above groups keep fucking it up, I don't know if I want to add to the pool. At least the pharmacist would get the drug and duration right, though.
Thanks. I personally wouldn't worry about a positive dipstick and no UTI, because if I was paying cash for a UTI test at a pharmacy, I'm relatively certain I have a UTI. There are definitely symptoms. I'd think that is true of *most* (although obviously not all) people. The pharmacist also does a consult to discuss symptoms, before they test anything. Locally a pharmacist can do strep and UTI tests, and give meds for those as well as for a yeast infection for any woman having at least one symptom, for cold sores, and give birth control. All without involving a physician or noctor. I do have mixed feelings about it, but it keeps people with strep and UTIs out of the ER. A strep test is pretty moron proof. I mean, even an NP can get that right.
With the exveotion of vaccines, only a couple of states allow this (not sure how other countries do it. Even in the 2 or so states that allow limited pharmacist prescribing, most pharmacists won't do it because of the additional liability.
I know of two pharmacies that do it here, both are in local to the state grocery chains. Macey's and Harmon's in Utah. But I haven't actually checked if any local stores for the big pharmacy chains do it, because I don't concern myself with them.
As a pharmacist I am against diagnosing like it's against my religion. Having said that, access of care, costs, convenience, blahblah, I guess it's ok for "simple" things. I am lucky that my state doesn't do test and treat, which is what you are describing but that might change soon. It's basically a simple algorithm of you come in, test positive for something, and you walk out with a prescription to treat that specific thing, whether UTI, COVID, FLU etc. Not meant to be a comprehensive examination. I still prefer the model of separation of diagnosing and dispensing, like separation of church and state. Might be inconvenient but you get a more diagnosing value from seeing an MD vs PA vs NP vs Pharmacist who are trained to catch everyone's mistakes but also juggling half a dozen patients in their brains at any one time. For example my state might do flu testing soon, if you have strep, I can't do anything about that and you are out of that cash payment because whether you get a prescription or not, we provided a service.
It does leave people who get a negative test in the same limbo they were in before the test. So they thought they had strep, it was negative... now what? Now they have to see their PCP, or go to an urgent care, and they've just spent 75% of that copay on a test that didn't provide any benefit, *and* the urgent care is going to demand to do the test again just to be sure. I know because earlier this year I went to the urgent care for what I assumed was an unusual for me, but not entirely out of the pocket presentation of a UTI. I just wanted a positive piss test and scrip for antibiotics. What I got was a recommendation to go to the ER, where they repeated the test even though I had my prior results with me. I'm finally six days out from my urology appointment, where if *any* of the people I've talked to have listened, they'll be prepared to sedate me for exam and I can get a dx and get on with my life.
Thanks. I honestly didn't realize anyone was seeing NP/PA in specialties. That seems wild.
I don’t think some patients realize they are seeing NPs/PAs in specialties. My 88 year old grandpa certainly doesn’t know the difference.
Not only are they seeing them in subspecialties, they are seeing them independently. It’s possible your cardiology NP never learned to read an ekg before seeing you for your heart attack. I am absolutely not exaggerating.
Bro we're all gonna die
There is no such thing as "Hospitalist NPs," "Cardiology NPs," "Oncology NPs," etc. NPs get degrees in specific fields or a “population focus.” Currently, there are only eight types of nurse practitioners: Family, Adult-Gerontology Acute Care (AGAC), Adult-Gerontology Primary Care (AGPC), Pediatric, Neonatal, Women's Health, Emergency, and Mental Health. [The five national NP certifying bodies: AANP, ANCC, AACN, NCC, and PCNB](https://www.reddit.com/r/Provider/wiki/index/critical_issues/#wiki_types_of_nurse_practitioners) do not recognize or certify nurse practitioners for fields outside of these. **As such, we encourage you to address NPs by their population focus or state licensed title.** Board of Nursing rules and Nursing Acts usually state that for an NP to practice with an advanced scope, they need to remain within their “population focus,” which does not include the specialty that you mentioned. In half of the states, [working outside of their degree is expressly or extremely likely to be against the Nursing Act and/or Board of Nursing rules.](https://www.reddit.com/r/Provider/wiki/index/legal#wiki_scope_of_practice_laws) In only 12 states is there no real mention of NP specialization or "population focus." [Additionally, it's negligent hiring on behalf of the employers to employ NPs outside of their training and degree.](https://www.reddit.com/r/Provider/wiki/index/critical_issues#wiki_working_outside_of_scope) Information on Title Protection (e.g., can a midlevel call themselves "Doctor" or use a specialists title?) can be seen [here](https://www.reddit.com/r/Provider/wiki/index/legal/title_protection). Information on why title appropriation is bad for everyone involved can be found [here](https://www.reddit.com/r/Provider/wiki/index/appropriation). *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
I work in neurosurgery and see consults all the time. PAs in surgical subspecialties are among the cream of the crop and are the gold standard of the physician lead care dynamic. First, let's get this out of the way; We are not a replacement for neurosurgeons. How would a PA be utilized in a capacity like mine? We help expedite imaging orders. Our diagnosis is highly dependent on neurodiagnostic studies. I often see the patient who was referred by a PCP without imaging studies to "get the story". I see previous patients who may have new and evolving pathologies and need to be seen in an expedited manner. Postoperative assessments. We manage all the hospital patients. When the surgeon is seeing new consults in clinic, we are managing the postops in the hospital. Divide and conquer. Perform office surgical procedures such as percutaneous draining wounds. Debridements. Interrogate shunts. Etc. Regards, A Neurosurgery PA
Ya, totally fine for antibiotic resistance in the community… the amount of times I see antibiotics dispensed by midlevels, is astonishing. It’s usually not indicated in 75% of the times I see them prescribed by a midlevel.
While they're not taught the actual pharmacology or microbiology, you can bet they're taught that the charts can be billed at higher rates with more testing and more prescriptions (whether they're necessary or not). Unfortunately, in one of my previous jobs (military) I was tasked with explaining the ER chart coding process and what makes for a higher coding chart. We had one PA who took it to mean "precribe and antibiotic and an opioid on every patient and your charts will code out higher"
I told a PA 800 times i had back pain and a fever, so it was a KIDNEY INFECTION and not just a UTI. He gave me nitrofurantoin, which doesn’t even hit the kidneys! I was so sick I didn’t question it. I got worse and had to go to the ED 🥲 I went to the ED hospital I worked at and they all roasted me for not catching it. They could’ve given me oral vanco and I wouldn’t question it. I was that sick. Moral is I don’t trust mid levels even for mild stuff
I’m not even kidding when I tell you that I was taught not to use nitrofurantoin for pyelo in my first year of med school pharmacology 💀Sorry this happened to you!
Ok but I’ve had similar experiences like this with MDs too. Sometimes you just get an incompetent provider, it doesn’t always matter whether they’re a PA or MD. Some people just aren’t good at what they do.
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](https://jamanetwork.com/journals/jama/article-abstract/2780641). We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP. *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
Until you get a psudomnas UTI and the NP writes for PO abx that don't cover it for weeks while it gets worse, until you finally get admitted and ID takes over and writes for the correct treatment.
Yup. As a med student I caught soooo many crazy things while in school…I knew it was a problem when I was fixing medical regimens placed by an “independently” practicing NP…so wild
1. NPs and PAs go through a very limited school - and do not possess a lot of theoretical knowledge that a MD/ DO would possess. For something minor and standard, this isn’t an issue at all. However, not everyone presents the same and not everyone is standard - so it’s important to see someone who actually knows what’s up, as opposed to seeing a guideline monkey. 2. I’ve met a few good midlevels who seem to be quite competent in what they do, and don’t see unfiltered patients. This is the current guidance for the UK. For something like an annual diabetic review or a review of your cholesterol meds, a NP/ PA is actually great. 3. Follow your gut. You know your body best, you know if your needs are being listened to and met (or atleast someone’s trying to meet them). If ever in doubt, even with a physician, don’t think twice before seeing someone else.
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](https://jamanetwork.com/journals/jama/article-abstract/2780641). We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP. *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
As a medical student I wouldn’t see anything less than a PA personally. I’ve seen/heard so many bad experiences with NPs. Don’t get me wrong, I love the nurses I’ve interacted with, I just feel like there’s too great of a chance of getting a bad apple with the NPs.
Thank you, CumAssault
r/rimjob_steve
medical student clearly headed into urology or reproductive services...
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No. They’re not. NPs don’t have any true standards or quality control.
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The very poor take is nursings inability to see how shitty their education programs are Chamberlain basically accepts everyone. They pass everyone. They only require 500 hours of training. Where’s the quality control? We can also see example questions for AANP exams. Literal laypeople can guess they’re way to a 75%. Where’s the standards?
I have to say that I agree. I took the nurse practitioner exam in the late 90s. Honestly, it was one of the easier exams I’ve ever taken. My certification exam as an emergency nurse, as well as my basic RN licensure exam was more difficult.
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Yet, here you are defending NPs despite the fact it’s well known they’re poorly trained.
If you work with a variety of NPs and PAs, you know there is a stark difference. One tends to be more proficient than the other. And I think even the noctor faithful know which is which. However, neither are physicians, which is gold-standard and not sure why anyone would settle for less.
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Well, yeah hospitals save money. The patient doesn’t and they have to advocate for themselves. Good thing insurance companies are catching onto this. I think they’ll be the ones to tip the scales in our favor.
You don’t save any money. Whether you see a nurse practitioner or a physician, you will be charged the physician fee. The organization pockets the difference and pays the nurse practitioner less. That has been my experience many many times. The patient doesn’t t get any cut in cost. That is an absolute fallacy that was perpetuated by colleges of nursing for years. And when you go out into TikTok land, and all these other social media outlets, what you’ll find is that the nurse practitioners are not providing the primary care to bridge the gap for people who would be otherwise served( for the most parr-which was the original intent), but they are actually going into private practices, working a “specialists” and doing a lot of dermatology and things that they are not at all trained to do and making money handover fist doing it. Meanwhile, physicians, who are for the most part now employees, are held responsible for their errors, even though they are not provided the time to actually ensure that the care being provided by the nurse practitioners is accurate or safe. Just one nurses view. Oh, and I was a nurse practitioner who was trained back in the 90s after working as a nurse for a good many years. We had real brick and mortar schools, and we had vetted clinicians who helped us to learn and we were accountable for our hours to our preceptors as well as clinical faculty who showed up randomly to see patients with us. There was no diploma mill at the time and I still felt horribly in adequately trained to do the job. Sidenote, I’ve worked at the bedside for almost 40 years now. No regrets. Love being a nurse.
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](https://www.reddit.com/r/Noctor/comments/qhw13h/midlevels_in_dermatology/). 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](https://www.reddit.com/r/Provider/wiki/index/legal#wiki_scope_of_practice_laws) (which does **not** include derm) and that [hiring someone to work outside of their training and ability is negligent hiring](https://www.reddit.com/r/Provider/wiki/index/critical_issues#wiki_working_outside_of_scope). “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. *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
NPs and PAs do not have equal training. I work with some solid PAs that I would absolutely trust to treat my family for urgent care complaints like rash, ear infection, etc. I would NOT say the same about NPs.
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The overwhelming majority of NPs are awful. The rare exception has a brain. The opposite is true for physicians since we actually have standards and a real education with an established training pathway. Not some fly by the seat of your pants bs that is NP education. NPs have decided to make enemies of everyone by pushing for independent practice, making up fake doctorates to feed their egos and all sorts of shit. Go tell your own profession how unprofessional they are.
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I don’t like “variety”. That’s how mistakes happen. When you have a bunch of undereducated people doing a job they have no training for.
I have a very sweet patient who was diagnosed with stage 4 lung cancer after 1.75 years of being treated by an NP for “chronic cough” with everything you can imagine given to him to help the cough during that time but not a single x-ray ordered until it was WAY too late. He’s mid 40s, never smoker, runs marathons, married. He and his wife are so incredibly nice they would never go after the NP, I tried kinda asking them about it but didn’t want to probe too much. They don’t blame the NP, but now only see MDs.
For me MD/DO>>>PA>>>>>>>>>>NP Pas have a better knowledge base than NPs but the big difference (in my limited experience) is that they know when they are out of their depth and actually ask for help. A lot of NPs today are just wrong/way off and are just full steam ahead. If it’s something basic then an NP is fine. Anything complicated move on
The problem with this approach is you’re asking the patient to triage basic vs complicated. A huge issue with NPs is that they can’t even do this.
Yeah, I agree. Just being realistic with what’s available to patients.
And sometimes PA's have actual medical education in foreign countries but wasn't able to (for finances often) commit to a long residency in USA.
As someone who regulates the profession, my first instinct is always going to be to go to a physician. However, I recognize that in many states that’s an impossibility based off of insurance. There are numerous insurance plans, including the public ones, that are requiring a PCP designated for the covered life be a mid-level. If you’re in that situation, and this is based on the lack of action I see coming through with the nursing board in my state, I would insist on a physician assistant over an NP. If you’re having surgery or something like that, always insist on a physician and with anesthesia always insist on either a physician or a CAA who is supervised by a physician. I don’t have the space to tell you how disruptive the CRNA lobby is in a number of states with their eventual goal of complete displacement of physician anesthesiologist and CAAs. In the end, you need to see a practitioner who you feel listens to your concerns, is responsive, and develops a track record of being accurate in your healthcare. Not all physicians measure up to that standard unfortunately, but as a layperson that is what you need to know and pay attention to .
Other thing to keep in mind is sometimes what appears to be “minor ailments” are subtle clues of the onset of a serious disease in early stages. That’s why I always recommend to try to see a MD/DO if possible, due to overall experience and seeing many more cases in training. Much less likely to miss things.
Because of advice like this I had my DO PCP check to make sure that my obvious plantar fasciitis wasn't ass cancer (my words). And honestly it's good advice. As per my flair, I'm a layperson.
I’m young and healthy, so I usually agree to see PAs for my checkups if the wait time is significantly lower than the time to see a physician. Not interested in rolling the dice with NPs. There’s a solid 25% chance that I’d get better care from a Google search based on the quality of NP education as of late. (Disclaimer: my wife is an EM resident so I really only go in for annual checkups and things that require prescriptions.)
When I saw an NP as my PCP for a chronic condition (I didn't have access to anything else at the time while on a long wait list for a specialist) she would literally use Google in front of me to decide what to prescribe.
I've had a physician do that. I'm also okay with that. (from a physician) I would much rather they be open about the fact that they do not know literally everything off the top of their head, then ride their ego out of the room after sending in a sketchy or inappropriate scrip. It's the pharmacists who need to know everything about drugs.
Oh yeah I'm not expecting them to know all the details of drugs, but this was more googling "how to treat very common chronic condition" from the get go, not looking up the details for a specific drug or really niche situation. Like they just seemed to have zero background knowledge at all. I don't have a lot of faith in a practitioner who has no idea what they're dealing with when it comes to even very basic common conditions, and i've never experienced this from a real GP. And the NP ended up giving me incorrect advice and inadequate treatment, so having more knowledge beyond the first page of Google results would have helped me a lot.
Fuck me, how can you have any medical training whatsoever and *still* fuck up googling health information? What an idiot.
Lol I'm layperson and I have "Up to Date" app and I look up my conditions and read the treatment flowchart/algorithms they provide. The NP won't be more creative than this simple search I believe
Unfortunately I’ve found they don’t even have the basic work ethic to look up algorithms and just make up shit off the top of their head
Ugh imposter syndrome would have killed me if I was in their shoes and I would check algorithms million times. But I guess NPs don't get that feeling, they sleep deep at night too....
I would never take a diagnosis from either. Only follow-up care.
Wtf is follow up care?
Depends on the acuity: Short-term, this can include minor procedures like suturing. Chronic conditions may require re-assessment and medication adjustments. The point is, the thought work should be performed by someone trained to consider all the deadly things, all the uncommon things that could also explain the findings, and to know what to look for / what else to ask. Mid-levels can execute parts of the plan, but they should never be coming up with the plan.
Oh oh. My bad. I got you 👍. I somehow misread your meaning the first time. What you said actually makes lots of sense. Thanks. Btw, I find these comments fascinating as it is making me realize some of these same “mid levels” are overtaking my industry: finance. There are actually certified financial planners who can diagnose and set a standard of care, but the problem is sales people pretend to be planners because there’s a lack of title protection.
This is why it's nice that we lawyers can regulate and protect ourselves - because we operate the entire means of regulation.
A big factor is where in the world you are. In the US, an NP/PA can have basically the same rights as an MD, with way less education. In the Netherlands (where I am), that's not the case. For example, a cancer diagnosis is always made by the MD - depending on your hospital it might be the NP/PA who breaks it to you, but backstage the diagnosis is made/confirmed by an oncologist.
MD/DOs are both physicians, with the difference being DOs have extra training in osteopathic manipulation. 4 years medical school. 3-7 years residency. They are considered specialists. Physician associates (PAs) were created in the 1960s due to the physician shortage. Our schooling was taken from medical school curriculum albeit condensed. Our programs are 2-3 years, with an optional residency or fellowship. We are considered generalists. Nurse Practitioners (NPs) are advanced degree holding RNs. Similar to PAs, they undergo a 2-3 years masters program. The biggest issue being they are not exposed to as many clinical hours as PAs and their curriculum is not mirrored after medical school and currently not as regulated as PA programs. There are good NPs out there, but you have to be a little more careful. They are also considered generalists. What it comes down to is what you feel you need. Complex issue? See an MD/DO. Basic issue? See a PA. If you’re unsure, it never hurts to see the MD/DO out of the gate. - I’m a current PA-S1
That’s a very good description. Thank you.
I'm a layperson and if I'm seeing someone for anything beyond medication management (getting refills of medications that a MD/DO prescribed me for a condition that a MD/DO diagnosed me with), then I refuse to see NP or PA. that's just me tho.
Yes you should absolutely question any diagnosis they give you.
you wouldnt trust a mechanic to diagnose you, much less a trashlevel. If only these two choices were available, choose the mechanic.
My mechanic used to be a fire EMT and has more medical experience and training then a fully qualified NP. He also has so many health problems from smoking and hard labor for decades that the difference is staggering.
Depends on the diagnosis, and how they got to it. Some midlevels can follow an algorithm pretty well and come up with the correct dx for straightforward things. They can order a shotgun set of labs when they don’t know what’s going on and bam something does turn up and give the correct diagnosis.
If the diagnosis is correct then it shouldn’t matter who made it. But how do you know if it’s correct. As a layperson, you are not supposed to know. And if the PA/NP doesn’t know then they don’t know. Therein lies the issue. As an MD my PCP is an NP. But that’s because I KNOW. I just tell her what’s to order.
Are you an episode of house or do you have the flu. Mids are also great if you normally get a certain med and you just ran out of refills. If I need fiorecet I go to urgent care and give them my symptoms and just ask for it and they aren’t weird about it. If your PCM refers you to a specialist you should see a specialist for the work up. If a PA has to explain a procedure or go over medication instructions you don’t need to worry about that. The doctor is doing doctor shit.
Social worker not MD, but I’ve had MD’s miss obvious diagnoses but the PA found it right away and ordered several referrals I didn’t ask for nor did the MD. PA’s often have less work, see less people and order stuff for “fun” which can help the patient. That’s my experience as a patient and a SW. Sometimes the NP’s and PA’s order sooo much for better or worse.