• I Referred My Patients to Subspecialists; So Why Did They See NPs?

    I knew when I chose to work in rural West Virginia that referral to subspecialty care would be challenging. Rural patients have higher rates of chronic disease, morbidity and mortality, and they die younger.

    I knew that then, and I see it happening in my community now. Rural patient populations have challenges with transportation, social isolation, lower overall education and other socioeconomic markers. That combination of characteristics has the potential to create not just barriers, but perceived impossibilities, to accessing subspecialty care or diagnostic workup if those services require traveling.

    Travel, to me, involves flying or having to spend the night out of town, but to many of my patients it just means crossing county lines. It is not uncommon for people here to feel uncomfortable driving on highways, or as we call them in West Virginia, the interstate.

    For anyone who has not driven (or spent time with me driving) on West Virginia back roads, it is interesting to know that we have high speed limits up to 55 mph on most county and state routes, so the reluctance to take the highways -- which are less curvy, less steep and have only a modest increase in speed (65-70 mph) -- has always confused me. But something as simple as road choice is a real barrier to accessing care for my patients.

    Some subspecialty care requires referral to a center three or more hours away from the town in which I work. It might take multiple visits with me to convince a patient to get to the office or hospital where the care they need is located -- or to find a way for them to get there. In some cases there is simply a shortage of subspecialists or equipment, and there may only be one individual physician in the entire state able to address the patient's needs. Often, there are frustrating insurance limits that prohibit patients from utilizing a geographically appropriate site.

    There are endocrinologists and ophthalmologists an hour from my office (via the interstate), but they do not participate in one of our Medicaid plans. Patients on those plans are left with the option of driving more than two hours to a part of the state many of them have never been to or forgoing care. The majority choose not to see those subspecialists, despite my encouragement. Not everyone has the luxury of taking a day off work to go to a doctor's appointment. Not everyone has a means of transportation, or even a friend or family member with a means of transportation.

    None of those challenges surprised me as a new physician. However, recently I started to notice a pattern that I hadn't anticipated. Some of my patients don't have financial or transportation challenges, but they still face barriers to appropriate subspecialty care. For example, I care for one family that I advised to drive to a specific hospital eight hours away, and they did. Regardless of resources, I often send people long distances for higher levels of care, and when they get there they expect to see a doctor, not a nurse practitioner or physician assistant. But increasingly, I either get a call from a disappointed patient or parent, or a consult note signed by an independently practicing nurse practitioner, or both.

    As primary care physicians we have been engaged in scope of practice battles across the country for more than three decades. We, as physicians, know we are more appropriately trained and educated to care for patients than those providers who did not go to medical school. But in many states there are independently practicing nurse practitioners who attempt to do the work of a physician with no physician collaboration. That could be the subject of a series of blogs and discussion all on its own. What that has led to, in my experience, is not only rural primary care sites being staffed only by nurse practitioners, but a new trend in referrals to subspecialty care being addressed by nonphysicians.

    Many fellowship-trained subspecialists have nurse practitioners working side by side with them. This model of a physician-led team is effective, it lessens wait times for visits, it increases the number of patients one physician can serve, and it has a financial benefit for the group, as well. However, this is not the model I am seeing utilized. I am getting back notes on consults where patients have been seen by a nurse practitioner independently for their initial visit, with no engagement by the physician.

    What upsets me most is that often I have worked hard to convince and/or coordinate my patients to travel to a subspecialist that they may see only one time, especially if they have a less-than-productive or less-than-ideal experience.

    And I find it insulting when the patient is not evaluated by a fellowship-trained physician when I have placed a referral for that level of training. I have more training than a mid-level provider, and therefore I don't feel the evaluation -- and more importantly, the differential diagnosis -- considered by anyone other than a subspecialty-trained physician does my patients justice.

    Kimberly Becher, M.D., practices at a rural federally qualified health center in Clay County, W.Va. You can follow her on Twitter @BecherKimberly.    


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