Who’s Who at your doctor’s office

Who’s Who at your doctor’s office – How to make the most of your time and get things done by knowing who you need to talk to.

There was a time when everyone in town knew everyone else, and everyone knew who to call for a problem. Today you’re lucky if you know someone who knows someone who has s guy for that! Our world includes a lot more people than it used to, which makes things complicated and often frustrating to get done. This is especially true in medicine. It used to be that there was the doctor, the patient, and perhaps a nurse who probably doubled as a receptionist. But today there are many people in an office with a lot of letters behind their name that indicate what they do. Years ago you simply called your doctor directly, or possibly left a message with his office assistant who relayed it to them. However, today leaving a message specifically for the doctor may not be your best use of time and energy and may actually slow your progress. I’d like to share with you the roles at your doctors office to help you get things done efficiently.

Let’s start with the phone call-in. At this point you may be talking to one of two people. You may be talking to an office associate. These are the gatekeepers to the entire practice, so treat them with respect and give them the information they ask for as succinctly as possible. I promise you they are NOT trying to waste your time with unnecessary questions! They are trying to get you to the right person. These people are not clinicians, so giving them the full history of your illness since the time of first symptom onset and every goory detail will not help. Just give them the info they ask for. They will ask about your needs, timeframes, severity and possible symptoms that could serve as a red flag that you may need immediate medical attention (At which point they will direct you to the local urgent care or emergency department, not because they’re too busy for you, but because clinical assessment can not be made at that moment and they want you to be safe) These people take care of scheduling and relaying messages, but they likely don’t take care of billing. Billing is almost always taken care of by a billing specialist. They may take care of faxing and receiving orders, medical records, etc, or that may be taken care of by centralized department or other personnel depending on the size of the practice. Any physician worth their salt will tell you that a good office staff is worth a thousand good doctors. Because they are hard to find, hard to train, hard to keep and you can train anyone to practice medicine, but training someone to keep a smile on their face while being berated by strangers after cleaning up someone’s vomit from the hall and wearing a mask for a 12-hour shift surrounded by sick people and juggling 5 busy phone lines and responding to emails, takes a special kind of heart that you just can’t teach! This person may have office specific training or may have taken a short certification course.

The next person you likely encounter is the Medical Assistant (MA). The MA is the oil that keeps every office running smoothly. They take vitals, medical histories (This is the person that you can give the bulk of your information to, but even they don’t need EVERY detail because they can’t diagnose or treat your ailment but they do chart it and pass along info to those who follow which saves some time) They can also assist with simple medical procedures, collect samples, even draw blood , administer shots, or provide wound care as directed. This person is a people person specialist. They help calm and relax patients who are anxious and give a listening ear. Remember, they’re not going to tell you what’s wrong with you, or what you should do about it. They are also not therapists so try not to pour out your entire life. This person’s job is to assist with duties so that other staff can move about more swiftly. Tying up the MA with a lot of questions they can’t answer or asking them for things they can’t give (like something to eat, or something for the pain etc) will only slow the works of the whole office down. Don’t be offended if they breeze in, connect with you like you’re old highschool friends, then breeze out with a jolly “The doctor will be right in” that’s their job! MA’s can process doctor’s orders for labs or prescriptions but cannot write or refill them. In some offices the MA may also be doing clerical duties such as medical records, or scheduling.  The MA has taken a certification course and exam to be certified, they are overseen by the American Medical Assistant Association

Some offices have MA’s and RN’s The RN is a registered nurse. This is a licensed position overseen by state and national boards of nursing. Nurses must complete a minimum of 2 years of clinical practice in a minimum 3 year program and pass a national exam for licensure. Nurses provide patient education and care under the orders of an MD, NP or PA. Nurses cannot diagnose a disease, but they can complete assessments and educate patients on options for possible issues, treatments, and therapies. Nurses can make referrals to other medical specialists or services. The biggest difference between a Nurse and an MA is in scope of judgement. Essentially an MA can only do what they are directly told, and they can only take information but are not responsible for doing anything with it. An RN applies “nursing judgement” to assess the information collected and form a plan of care which the prescriber then approves or alters. For this reason, the nurse is a great person to give every detail of what you’re dealing with since they can sift through for what to act on and what may be a red flag, and what may not be relevant or part of a different problem.  Physician offices may or my not have RNs in practice. In advanced care offices RNs may serve many of the same roles as the MA in terms of patient intake and collecting patient history etc. Nurses also work in all areas of patient education. From diabetes education to how to take medications, to chronic diseases management. Nurses will administer medications, perform procedures, are responsible for nearly all patient education, and complete treatment care plans for patients with complex or chronic conditions. Very often if you have a question and are looking for how to handle it, a recommendation or referral the nurse can easily take care of this for you. Demanding to hear back from your prescriber may mean delaying hearing back for hours, days, or never hearing back at all!  You will typically get much quicker help from a Nurse. Nurses can also transcribe a doctor’s orders making refills and quick prescription needs faster to communicate to the nurse than the MD directly.

Now it’s time to meet your prescribers PA, NP and MD.

Physicians Assistants (PA)   and Nurse Practitioners (NP) are very similar in nature as they are both licensed medical professionals with advanced degrees (Typically at least a master’s degree with thousands of hours of clinical professional practice). They have the ability to diagnose and treat diseases including writing prescriptions. One difference may be in autonomy. In some states Nurse practitioners can prescriber independent of physician oversite, in other states they can prescribe but must notify a physician, in some states they can only prescribe certain things independently. It can be helpful to know what NPs can do in your state. PA’s (as the name indicates) always work under the supervision of a physician (MD) Another difference is the training model that they came through. A PA will have come through a “medical” training model with no specific specialty. This means they are very focused on diagnosis and prescribing; they are looking for the labs, the data and the assessment and are trained in general medicine. NPs on the other hand come from a nursing model. They must specialize (for example primary care, pediatrics, women’s health, geriatrics, endocrine, or psychiatric specialty) and are certified by their specific accrediting bod and their state in that area. Nursing roots also mean that these practitioners are more focused on holistic patient-centered care and patient education to support prescribing.

Either of these clinicians are fantastic providers. They often have more “real world” experience than prescribers which can lend them a better “bed side manner” they are also more accessible allowing you to get seen much faster than n MD in post practices. Both can prescribe labs, diagnostics, medications, therapies as well as make referrals. They can each perform minor procedures as well as assisting in surgeries. How their services are paid for my insurance/medicare varies on the service. An NP may be able to directly bill and so can be in independent practice, where a PA may have to bill through a physician or practice.

PAs and NPs can be hard to tell apart or identify as they often have a long string of letters behind their name. Feel free to ask anyone in your clinical visit what their licensure or certifications mean!

This brings us to our physician or MD. This is a board-licensed physician with full scope of practice, they can prescribe, perform surgeries and procedures, diagnose, treat, advise, and refer patients. Why would one see an MD instead of a PA or NP? The first would be for specialty. MDs practice for years in their specialty area so their knowledge base can be highly specific and very deep. MDs are also the only level of licensure able to perform/lead surgeries. MDs are also often the central body under which care is billed. Because of this billing checkpoint your insurance may require that you be seen by the MD for certain things or with a certain regularity in place of or in addition to an NP or PA visit. MDs are also often engaged in research or academic teaching or pursuits in addition to their clinical hours. This means that the time constraints on MDs are typically higher than those on PAs and NPs which can lead to less time to spend with patients, less time to reply to messages, and less scheduling availability. Many patients see the MD as the top dog and the status reducing as you work your way to the front door. But a well-run office will be just the opposite. The MD is the oversight, but the patient care increases as one goes down the ladder with the strength of the practice build on the support staff Pas and NPs.

This is a very brief explanation of the highly complex overlapping and ever-evolving dynamic of clinicians in medical practice, and practices vary greatly (we haven’t even touched on lab techs, various therapists, social workers, directors, and scores of administrators that make a practice run!). But hopefully, this brief outline of these health professions and how they can best serve you as the patient can help you navigate your clinical world with more savvy and less wasted time and effort.