Introducing New Nonphysician Providers

Here's a dilemma: How do you tell patients that their regular doctor is too busy to see them as often as she used to, and, so, for many of their visits they'll see someone else - a so-called "nonphysican provider" who has less medical training and perhaps fewer years in practice?

Carefully, that's how.

The use of nurse practitioners, physician assistants, and other nonphysician providers (sometimes called midlevels) is on the rise around the country, as practices seek to handle an ever-increasing workload. Midlevels can take the heat off of physicians, especially with ordinary checkups and minor sick visits. And practices report that most patients are fine with it. Still, top-performing practices are proactive in introducing midlevels to current and potential patients, who may prefer to see the doctor.

New nonphysician providers at Bronson Medical Group, a multilocation practice in southwest Michigan, for example, are introduced to patients via mailers sent to patients' homes from their primary-care physicians. The fliers include a photo of the new providers, their credentials and educational background, and other special clinical interests.

"It presents the midlevel provider in a way that shows all the providers in our practice are welcoming that person to the team," says Laurel Wilson, Bronson's administrator. "They are endorsing this new person in the practice and telling the patient we trust this person completely."

So how can you avoid patient confusion or even anger when they are greeted with a nonphysician provider and not a physician at a future visit? Follow these steps:

Make the introduction

Anthony L. Javorka, senior manager of the healthcare team for consulting firm Somerset CPAs in Indianapolis, applauds the move by Bronson Medical Group to send fliers to patients and encourages other practices to do the same, just as they would with a new physician. If you don't want to do a mailing, make pamphlets with detailed information about your new staff members and place them in the office. Make use of e-mail and your practice Web site, too.

Susan Keane Baker, a healthcare speaker and author of "Managing Patient Expectations," advocates using on-hold messages to announce new NPs or PAs. Patients love having "inside information" about the office, knowing all about new hires well in advance of their next visit, Baker says. She advises incorporating a little personal information to your announcements about new hires, such as hometown, hobbies, favorite sports teams, or even charities they support, along with information about their professional credentials.

"This can be really powerful for the patient to say 'this is a real person,' 'this person has twins,' or 'this person came here to practice because his wife is from here,'" she says. "Whatever the story, this gives patients something to talk about with them."

Promote the value

At Bronson Medical Group, in addition to fliers sent to existing patients and press releases to local media to reach potential patients, the practice also ensures its staff works to promote the value of nonphysician providers.

Wilson, a registered nurse, says scripting is available to scheduling staff so if a patient calls in to see their physician and can't find an immediate opening, she is informed that a nurse practitioner has joined the practice and is also available.

"Sometimes it is the case where the doctor can see them tomorrow at 4 p.m. or the [nurse practitioner] can see them today at 3 p.m. and we give them the choice," says Wilson. "And we explain that a nurse practitioner is very capable in evaluating a patient, making a diagnosis and treatment plan, as well as implementing that treatment plan under the oversight of the physician."

Javorka says another key element to introducing nonphysician providers and increasing patient comfort is the personal endorsement of the physician.

"If the physician knows the next appointment is with a nurse practitioner, for example, that is a good time for an endorsement," he says. "Just having the doctor say, 'I see you are going to see our nurse practitioner for follow-up. She is a part of my team and I fully support her' is being proactive and helps set the stage for the next visit for that patient."

And if your practice has a patient that can't stop raving about their visit with an NP or a PA, Baker says patient testimonials are a great patient education tool.

"Let your patients tell the story in a letter in the waiting room or on your Web site about how maybe they did not know what a [midlevel provider] was, but after seeing her, they loved the experience," she says.

Baker also advocates other steps, including nominating staff for awards and copublishing academic research with physicians to both boost morale as well as increase patient acceptance of midlevel providers.

Dealing with upset patients

But as you well know, not every patient visit is a positive one - especially for patients who were expecting to see a doctor.

Let's say you've skipped the fliers, the on-hold introductions, and other proactive approaches to introducing nonphysician providers, and now you have an upset patient. No worries, say our experts, but you have some work to do.

Cindy Adams has been an NP since 1994 and currently serves as chief nurse executive and vice president of nursing for Community Heart & Vascular, representing more than 30 cardiovascular physicians in Indiana. When a patient is surprised to see her instead of a physician, she says, "I talk about my education and how I went back to school … and that has enabled me to have more skills like the doctor in terms of diagnosing and prescribing. It is about communicating that you aren't there to replace their doctor, but to work side-by-side regarding their care."

But if a patient outright refuses to see anyone but a physician, Wilson says, Bronson Medical Group accedes to that request. The patient might have to wait a bit, but a physician will come in to the exam room and in addition to conducting the visit, take the time to discuss the value of midlevel providers as a part of their care team.

"Sometimes, a patient just needs to hear from the physician that it is OK to see someone else when they need to come in," Wilson says.

Patrick Killeen has been a PA for 25 years and is currently the president of the American Academy of Physician Assistants. During his career, Killeen has seen a number of upset parents in the emergency room demanding to see a physician.

"I usually am able to discuss my role with them and I say, 'Let's make an agreement that I'll do my part of the physical exam and history to get all the information. I'll prepare that and make a decision with the attending physician,'" says Killeen, who works in pediatrics at a Connecticut hospital. "I can say 99 percent of the time, patients are fine with that."

And like Adams and Javorka, Killeen says a little endorsement from the physician goes a long way.

"I can tell you through my experience that the next time that patient comes in, I'm going to have a much better visit and a much stronger relationship with them because I have full physician confidence in my care," he says. "That is part of a team-based care approach."

Keith L. Martin is associate editor at Physicians Practice. He can be reached at keith.martin@ubm.com.

This article originally appeared in the February 2011 issue of Physicians Practice.