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Wednesday, June 29, 2011

Physician extenders

I think the use of physician extenders is a great and necessary idea and will enhance patient care if deployed correctly. However, it is not being uniformly deployed in such a way. Extenders should do tasks which do not require skills which can only be acquired via more extensive training. Extenders should not be used to deal with problems beyond their training and skills.

What are extenders used for in the real world. I see circumstances where extenders are used very appropriately. However, more often I see extenders used for simple financial reasons. Low margin endeavors induce physicians and health systems to use lower cost extenders, no matter how complex and difficult the task.

The worst offenses involve the use of extenders to manage patients before or after procedures. Expensive proceduralists, who in order to cover their salaries must spend their time doing high margin activities, cannot be burdened with the responsibility of preparing their patients for or caring for their patients after they are the recipient of procedures.

I do hospital consults on a regular basis and I see some of the sickest patients you can imagine. They have undergone solid organ transplants, bone marrow transplants, or have decompensated after long bouts of chronic disease and toxic therapies. Some of these patients are cared for primarily by hospitalists. Others are the responsibility of extenders under the supervision of physicians whose primary expertise lies in the operating suite. While some of the extenders I work with are remarkable clinicians who have developed remarkable expertise, others have simply been put in situations which has not allowed for the development of requisite professional competence, yet requires them to manage remarkable complexity. We end up with very odd lines of authority where extenders on a given hospital floor ostensibly answer to an absentee attending physician while the defacto attending is the consultant dejour who may be called in to put out some particular fire that day.  

The same thing happens in the ambulatory setting although perhaps the stakes are much lower. A substantial portion of the most complicated outpatient referrals I receive show little or no evidence of any MD involvement in the records forwarded. When I ask the patients who they saw, it is rarely if ever the physician in the practice. In these cases I virtually never receive a call from the physician involved. Communicating with your colleagues is also a low margin activity.

The reason is clear. The services delivered complicated patients which require synthesis of information, weighing of options, and nuanced thinking are low margin services. These services will be delegated to lower paid professionals no matter how complex they might be.  A payment system which assigns low value to these activities virtually guarantees they will be increasingly performed by lesser trained personnel, no matter how difficult or important the task may be.

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