Midlevel Providers: The Future of Hospital Medicine, or “Here Today, Gone Tomorrow”?

Summary and Comment |
April 16, 2010

Midlevel Providers: The Future of Hospital Medicine, or “Here Today, Gone Tomorrow”?

  1. Neil H. Winawer, MD, SFHM

Arguments for and against employing midlevel providers to alleviate physician shortages

  1. Neil H. Winawer, MD, SFHM

In the February 2010 issue of the Journal of Hospital Medicine, four physicians discuss using midlevel providers (MLPs), namely physician assistants and nurse practitioners, as a solution to current and future physician shortages. One pair maintains that MLPs can provide improvement in hospital continuity and can offer a multidisciplinary approach. The other two physicians agree that MLPs have a well-established role on protocol-driven inpatient services, but they believe that the diagnostic and therapeutic complexity of a general medicine service requires additional training.

Two physicians from Pennsylvania cite studies showing that integrated MLPs improve quality of care and lower costs. They discuss models of care in which MLPs can serve as the bridge between patients and rotating physician teams and in which MLPs can drive quality initiatives. Two physicians from Michigan and Massachusetts disagree with this view: They argue that the existing literature on use of MLPs in inpatient settings is not robust and that the studies suffer from substantial limitations. They discuss recent experiences of three major medical centers that employ MLPs: In all cases, the programs were challenged by high costs and difficulties of training MLPs to attain high levels of autonomy and efficiency (2 of the 3 medical centers eliminated their MLP programs, and the other supplemented with additional hospitalist staff).

What do you think? Should MLPs play a larger role in the evolution of hospital medicine? Can they be trained sufficiently to meet the complicated needs of medical inpatients? We would like to know your opinion. Please give us your thoughts by using the Reader Remarks feature, located directly below this summary on our website.

Citation(s):

Reader Comments (8)

Cindy R Walden

May the attending use midlevels employed by the hospital for inpatient split/shared services? The midlevel provider does not have individual billing privileges. Does that matter with split/shred? I have only find guidelines that refer to midlevel NPI of their own, which is not the case. I need official resourse/guidlines please. Thanks a lot

Competing interests: None declared

Lorraine Britting, NP

Shared billing can be done only if the attending and the midlevel are employed by the same institution, i.e the hospital. More information is available on the Society of Hospital Medicine web site at hospitalmedicine.org

Competing interests: None declared

Alexandra L. Scott

This is regarding the Feb. 2010 article which discusses the lack of success with PAs on the hospitalist service at the University of Michigan (UM) Hospital. As a PA who worked on the UM hospitalist service for four years I feel compelled to comment. While the article appears to place the blame mainly on PA lack of training, there were many other contributing factors. For one, the UM hospital is known as a tertiary care center that accepts the most complex patients in the state. PAs on that service were expected to take care of these extremely difficult patients regularly. Another factor is that each of the PAs was required to work with over 20 different physicians on a rotating basis. This was not conducive to a good PA-physician relationship, as it allowed little opportunity to learn the working style of each other. This was compounded by the fact that every July a (mostly) new group of hospitalists joined the service. In addition, many of the physicians appeared to be unaware that PAs could actually work more independently. Given all of these factors, it is no wonder that we did not have high levels of autonomy. Of note, I worked quite successfully and largely independently for two years on a hospitalist service at another hospital prior to coming to the UM.

Competing interests: None declared

Janet L. Groth

The acuity of our medical and surgical patients is rising to a level not ever seen before. No one discipline is going to save the day in dealing with what is going down on our medical floors. As with interns and residents, NPs and PAs can be incredibly useful and effective in the hospital and post acute arena. They generally have excellent communication skills, high energy and a good understanding of the arena they are working in. However it is essential that they, just like every other member of the care team, have the support of clinicians from all disciplines readily available to them. Also essential are ongoing training seminars and team rounding. Only when it is expected that every person on a team is to bring their best efforts to the table, as well as a sense of sharing and tolerance for the hard work involved, will we see the excellence we are looking for.

Competing interests: None declared

Dr Story

Midlevels are best used in outpatient primary care, where they can clearly handle preventive health and chronic disease using protocols. However, the acuity of hospitalized patients demands more extensive training only found in physician training, and which no level of practical experience can replace.

Competing interests: None declared

ellie n Tehranchi, M.D.

I seen too many mistakes in the hospitalized pt's with MLPS.two year masters degree does not replace 7 yers of medical school and residency. this is why they miss important problems in pts.

Competing interests: None declared

thomas d schmitz

i have worked with many mlpS and prrobably the best place would in 1,2or three level disease portals ie htn,diabetes and asthmma like the durham nc model for ex diabetics tom s

Competing interests: None declared

Ronald Roth, M.D.

In primary care today, patients admitted to hospitals are attended by their primary care providers who bring in appropriate consultants to manage complex medical problems. The use of NPs and PAs to help coordinate this care is useful and approriate when supervised by their physician colleagues.

Competing interests: None declared

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