Hierarchy In Medicine – NP/PA’s and MD/DO’s

The urgent care, like many other outpatient medical specialties, has a mix of MD/DO’s usually referred to as doctors and NP/PA’s usually referred to as mid-levels or affiliate clinicians (AC’s). For the most part the docs and NP/PA’s work well together, often doing the same exact work in the urgent care setting.

The common complaint from the docs is that the mid-levels are a bit slower, less confident and perform too many tests. The mid-levels complain that they aren’t viewed as equals to the doctors which makes them feel inferior. They find that doctors throw antibiotics out left and right and aren’t as closely scrutinized.

Over the years I have worked at various urgent cares, both privately owned as well as hospital affiliated urgent cares.

The AC’s tend to be part of unions in larger organizations. In the urgent care they are sometimes given the role of seeing lower acuity patients at a faster pace. I have seen several hard-working, highly competent AC’s and many lazy, incompetent ones.

What about their doctor colleagues?

In the urgent care I must say that few of the MD/DO’s are incompetent and few to none are lazy. I also have witnessed very little animosity towards AC’s from the doctors. Doctors tend to have an emotional disconnectedness from their colleagues.

They will talk shit and be rough around the edges without meaning to be personally insulting or being personally insulted. We can point out shit to each other and sure, it hurts our ego when we make mistakes but we don’t think ourselves inferior to another clinician because of it.

Doctors aren’t unionized. Sure, there are some residency unions and some quasi-unions with MD/DO’s which are so tiny and weak that we are gonna assume the large majority of docs are not unionized.

The AC’s tend to be in unions in larger organizations. In my organization we have a high number of AC’s and they are given the same responsibilities as the docs. They are expected to see the same level of acuity and the same age groups as the docs. For this they are paid quite well in our group.

As a medical director of 2 clinics I sometimes have to deal with docs that are performing below the standards of our organization. They may have too many sick calls, too many bad patient outcomes or they might be over-utilizing certain resources. I can usually meet with them at a moment’s notice, find out what the problem is, offer some help, measure their improvement and make adjustments on the fly as needed.

When I identify an AC that’s weak, slow, incompetent or who orders way too many tests I need to first bring it to their supervisor’s attention. Then I need to document everything with “proof”.

And, as if we are in a fucking court-room, I have to meet with their union-rep and discuss this person’s inadequacy. Right away, I am told that certain expectations are against union contracts so those have to get tossed out, can’t even be brought up. The changes which I can “demand” I need to write out in an “action plan” that we can implement over a 3-month period. After that time we reassess and see what needs to be done next.

I then will need another meeting with that provider and their union rep and multiple ones after that if I need to impress my point upon them. In order to get someone fired for incompetence it takes even more effort.

The inefficiency of the above system has led my organization to hire and keep many ineffective AC’s. It’s simply too costly and time-consuming to get the AC’s to change.

Repeatedly I have to hear “it’s not in the union contract” when I try to implement changes on the fly. Then I have to hear complaints from my doctor colleagues that the AC’s they work with are lacking some basic efficiency which increases their work-load. I have to also deal with patient complaints usually directed at the AC’s for various reasons.

Remember, we’re talking about the problem AC’s here, the great ones are off the radar, too busy doing superb work for the patient and their medical group.

There are AC’s who are incredible at what they do, strong workers, and with their priorities directed at patient care. These individuals are not common and even though I am generalizing it happens to hold true no matter where I go.

Would the solution be that the AC’s should no longer be in unions? Should we stop hiring AC’s?  Or should we hire stronger supervisors who are willing to ride these AC’s as hard as necessary to get them to perform on-par with their doctor colleagues?

I never used to have any issues with AC’s. I did notice that they tended to be a little weaker than the docs but for the most part I was glad they were there to help. But now that I am in a management role and see so many AC’s hiding behind their title and union-status when convenient I am actually starting to have a more negative impression of AC’s.

In the entire organization, the urgent care is the only clinical setting where AC’s and Doc’s are completely on par. Same hour, same responsibilities, same patient acuity, same work-load. The pay is different but we have closed the gap by a lot compared to other organizations.

My belief is that medicine is inundated with patients. We need to start redefining roles. Nurses could be doing a lot of the work of clinicians.

Pharmacists could be managing a lot of medications and taking on more clinical roles.

AC’s could and should embrace their role, forget about trying to be on “equal” grounds with doctors and focus on what they are good at. The gap between docs and AC’s won’t close because some higher power will make that decision. It will come from AC’s working their tail off to show they are just as good and even better than MD/DO’s.

Hierarchy is here to stay and though I find the reverence of doctors to be absurd and unfounded it isn’t going to change anytime soon. Anyone wanting a piece of that pie is gonna have to work their ass off twice as hard as those holding the throne.

Many doctors are nagging and wining about their jobs being too hard, bullshit, of course it’s not too hard. They (myself included) are working too much, they are chasing the cheese and trying to live the ‘doctor lifestyle’ minus the old-school doctor income.