Hi everyone,

Interesting topic. Over the past 25 years, I have been in a supervisory relationship with six mid levels. Over the first 18 years, I was at a Community Health Center, with a maximum of three mid-levels at any given time. For the last seven years I've been in private practice, with one physician's assistant.

I am a family physician, so my comments apply only to this specialty. Specialists may have very different perspectives.

All of the comments so far in this thread are very well taken. Patients, generally speaking, view the mid-level as a doctor, I have had very few patients who have objected to seeing the mid-level. Those that did, usually didn't like me either.

I agree that there is not much difference, practically, between a physician's assistant and a nurse practitioner. In my experience, a physician's assistant probably has somewhat better fund of basic knowledge, compared to NPs. The NPs, especially if they have worked as nurses for a while, usually have more clinical experience.

The most important quality for a mid-level is to know what they don't know. I'm not sure exactly how you determine this in an interview, but once they start you will find out pretty quickly. I emphasize to them that I would much rather be bothered too much, than too little, especially for the first six months or year of their practice.

A mid-level should be time and energy consuming, especially in the first six months. During residency, it took me quite a while to develop a basic approach to patients and their problems, and I don't think I really perfected this until several years in practice. A mid-level right out of training will benefit greatly from guidance, a mid-level who has worked elsewhere will take time to learn your approach and preferences. This is an investment. My physician's assistant was actually the first mid-level I worked with, we have worked together for over 25 years, she knows how I think and I know how she thinks.

However, as also mentioned earlier, you don't know how long you'll be working with any given mid-level. To put time and effort into them, and (usually when they've just gotten good) to see them move on is frustrating.



There is also an interesting development in Maryland. I'm not sure if this is the case in many other states. Maryland nurse practitioners no longer require a supervising physician. It is required that they have a collaborating physician. Once this physician indicates that he or she will serve in this capacity, the nurse practitioner is required to have no contact with him/her. No cosigning, no chart review, they may never see each other again.

I believe that one of the reasons for this is to try to remove any legal liability from the physician.

I doubt very much that that would be effective. I'm guessing that if a nurse practitioner were sued, the collaborating physician would be brought in to the legal proceedings, alleging that the collaborating physician provided inadequate oversight. Anyone with any thoughts or experience in this area?

Gene

Gene Nallin MD solo family practice with one PA Cumberland, Md