The problem with specialists is that they only look at what they specialize in. Sometimes things are hard to figure out and everything in the human body is connected and interrelated. I hear so many stories of people going to several wrong specialists before they get their issue figured out. You hope a good PCP gatekeeper sends you in the right direction to the correct specialist. This is especially true when the symptom could be tied to many different causes - what is the reason for your headache - which specialist should you go to.
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That is why it would be desirable if the top medical students in terms of understanding the widest range of medical problems went into primary care specialties (or emergency medicine). However, the cost of medical school and the lower pay of primary care specialties creates the opposite incentive.
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Several specialities have internal medicine residencies including cardiology, oncology, pulmonology, rheumatology and gastroenterology.
Surgery wonât have as much experience in internal medicine but for instance neurology would have their first year in internal medicine, with the additional years specializing in neurology. Surgery residency first year will be general surgery with additional training in their specialty or continuing in general surgery
For instance cardiology has 4 years of internal medicine followed by 3 years of cardiology fellowship. Could also add more time as a super fellow for heart failure for instance.
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In general Iâm not on the bandwagon for AI replacing human judgement. But⊠perhaps this could be a good kind of tool for doctor education. And perhaps there could be something like it to reference during diagnosis.
At a glance:
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Researchers have developed an AI system called Dr. CaBot that spells out its reasoning as it works through challenging medical cases and reaches a diagnosis.
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For the first time, the New England Journal of Medicine has published an AI-generated diagnosis â produced by Dr. CaBot â alongside one from a human clinician in its medical case study series.
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The tool holds potential for use in medical education and research.
I have never ever referred to a PA or NP as a PCP. Even in legal depositions. (Legal witness/expert in some cases ) . The PCP is âAlwaysâ the treating Doctor. No one else.
Maybe thingâs are regional?
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My PCP is a NP. My husbandâs PCP is a PA.
No, cardiology requires an internal medicine residency which is 3 years, followed by a cardiology fellowship that is another 3 years/
PAs are always required to have a supervising physician. They are not licensed to practice independently. NPs may or may not be required to have a supervising physician, depending on individual state licensing requirements.
So strictly speaking, in a legal sense, the supervising physician is the primary care provider. The PA or NP is the mid-level practitioner working under the physicianâs direction and oversight.
The exact scope of practice for a mid-level provider is governed by individual state regulations and thus will vary from state to state. Some states require tighter oversight of mid-levels than others. Some require the supervising physician be at the same site as the mid-level provider; others donât. Most states require the supervising physician to co-sign any medical record patient notes made by the mid-levelâwhich puts the physician on the hook malpractice-wise for the patientâs treatment outcomes. The ultimate responsibility lies with the supervising physician.
Californiaâs Supreme Court just upheld a state law that prohibits NPs with a DNP or PhD from using the title âDoctorâ in any type of healthcare setting, in advertising or on social media because it can confuse patients/potential patients.
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I havenât had a physician in my file as a PCP for many, many years. My NP is the only practitioner listed as PCP in all my documentation.
it all depends on what your stateâs licensing regulations require. Some states allow NPs to practice independently without any physician oversight. Perhaps you live in one of those 27 states.
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Yes, Iâm in CA.
My healthcare group now actively advertises the use of NPs and PAs for all primary care: https://www.sutterhealth.org/-/media/Project/SutterHealth/SutterHealth/Files/PatientResources/your-visit/advanced-practice-clinicians-guide.pdf
At least from the patient perspective, they also donât make any distinction between NP and PA in terms of whether they can serve as a PCP (this is a screenshot from the pdf above):
My husbandâs PA is listed in his file as his PCP as well. There is no MD name in the file.
Not arguing this is a good or bad thing, just noting that this is what we have here now. There are still a couple of MDs at the practice where we get primary care, but they are no longer accepting new patients.
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Since you mention using Sutter Health, does their provider search find MD/DO providers in internal or family medicine accepting new patients? For example, Find Provider Search Results but change the location to where you are.
Iâll also note that there are many situations where this seems to get blurry. My NP would never refer to herself as âDoctorâ but when I go to check in at her practice, itâs not uncommon for the front desk staff to refer to her as âDoctor NPName.â And when I go to a specialty appointment at another clinic they invariably say something like, âWould you like us to send your test results to your PCPâŠâ (glancing at file) ââŠDoctor NPName?â
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LOL - Now I know why I have been confused over NP and PA roles. Lots of variations.
The first page of that search comes up with a list including 2 PAs, 4 NPs, 1 DO, and 3 MDs. But I happen to know that 2 of the MDs listed are not routinely accepting new patients because they are at our clinic. If you call the clinic youâll be directed to sign up with a PA or NP.
Yes. And in my experience, itâs even more pronounced if you are at an urgent care clinic, where the receptionist, medical scribes, nurses aidesâ all refer to âDr. Xâ whether or not âDr. Xâ is actually a doctor.
I get it- weâd all like to think that the person figuring out if your ankle is just a sprain or youâve actually broken a bone in your foot is an actual MD or DO. But wearing a white coat and throwing a stethoscope around your neck doesnât make you a doctor. And as much as the old school, sexist practice of calling all men by their titles and all women by their first names was and is obnoxiousâŠ.now that a sizeable number of the women in these clinics are likely physicians, and a large number of the men are actually NOT physicians- accurate nomenclature would be nice.
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This is EXACTLY what the recent CA federal court case was about and this is now prohibited behavior.
Judge Jesus G. Bernal wrote in the opinion that using the title âDrâ by nonphysicians in clinical contexts is *âinherently misleadingâ*and amounts to regulated commercial speech. Because of that, it does not fall under free speech protections.
The court sided with the state, which argued that allowing nonphysicians to use âDrâ could confuse patients about who is providing their care. Bernal cited an American Medical Association (AMA) survey showing:
Judge Jesus G. Bernal wrote in the opinion that using the title âDrâ by nonphysicians in clinical contexts is *âinherently misleadingâ*and amounts to regulated commercial speech. Because of that, it does not fall under free speech protections.
The court sided with the state, which argued that allowing nonphysicians to use âDrâ could confuse patients about who is providing their care. Bernal cited an American Medical Association (AMA) survey showing:
- 39% of patients mistakenly believed that DNPs are physicians.
He concluded that even when nurses disclose their credentials, the risk of confusion remains high in healthcare settings.
It appears that your healthcare provider organization needs to do some retraining for their personnel.
And perhaps set up a better system for distinguishing between physicians and mid level providers in patient records.
FWIW, CA is a state the partially restricts mid-level provider (NP and PA) practice rights. Mid level providers cannot provide all the same primary care services as physicians. The restriction is in flux, however, and CA is in the midst of phasing in FPR for NPs over the next few years.
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What would the proper one word title in a health care context be for an NP or PA? Or is it just an uphill battle to get people to say âNurse Practitioner [Name]â or âPhysician Assistant [Name]â?
Yes, the orthopedic urgent card in our city is staffed by nps/PAs and supervised (we are told) by an md. Also an MD looks over imaging. The people you see and interact with are the NP/APRN. After the initial visit, you can request an appointment with an orthopedic MD/APRN/PA for follow up.
Going through that urgent care is the best way to get in to see the top orthopedic mds in our city.
Quite possibly⊠but Iâm not sure how easy it is to actually notice this distinction when they are looking at the file. Although my PCP is with Sutter, most of my specialty care is through Stanford, and every time a staff person associated with Stanford refers to my PCP, they say âDoctor NPName.â So Iâm guessing the file just shows something like PCP: NPName without having her title right next to it.
When people at our clinic refer to my NP and do not use the word Doctor, they use her full name (both first and last) without any title⊠or they just use her first name! They wouldnât do that if she was an MD/DO. It always bugged me a little that they referred to her so informally compared to other practitioners, but it also bugs me if they incorrectly say âDoctor.â