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Dr. Mary Jennings' Editorial: My midlevel nightmare in the real world

I just got kicked out of an MD’s office evidently for not following the orders of an MD I have never met. Does that sentence even make sense? It does if you have turned your practice into the game of Post Office and you are getting second-hand information from your front desk, your records department, and your midlevel provider.

 I was recently hospitalized for complex diverticulitis. Ouch! I had an awful time trying to schedule a follow-up with a real MD, so I settled for a PA. I thought the PA was nice, but out of his league. I followed his orders to see a surgeon. Turns out I didn’t need surgery. YAY! 

I scheduled with the MD to see if we could manage my still-present pain with better antibiotics. That is when all hell broke loose. 

Something slipped in the diagnosis and communication between my PA and the MD. Combine that with hubris, stupidity, and lack of good manners, and I ended up with my new MD greeting me with, “I don’t know why you are here. You are supposed to have surgery. I can do nothing for you.” Huh? I finally just left. 

The upshot is that they are not running a well-oiled machine, and they are certainly not communicating well. A quick inventory tells me that the front desk did not communicate my chief complaint, and whoever manages surgical reports failed to get it to the MD before my visit. 

I want to focus on what seems to be a failure between the MD and his PA. That is my midlevel nightmare come to life. I was an acute patient when this visit was scheduled. In the dental midlevel model, acute patients are supposed to be seen by dentists. How did the medical model dumb down acute care to PAs? I don’t have to be a dentist to know my PA was in over his head, and I felt sorry for him. I saw him ask for help, but he was sent back to me, embarrassed. 

To me, that is the scariest flaw in the midlevel model. What happens when the midlevel’s skills are not up to snuff? What happens when the doctor doesn’t support his midlevel? What happens when the doctor does not have the insight to know his midlevel is not competent or works in a system that does not allow him to do something about it? What happens when the doctor is too busy with other legitimate concerns and misses…me?
I was an acutely ill patient with inherent communication issues of my own. In this lousy condition, I had to manage chaos to get my needs met or cut bait and run the risk of getting worse while waiting for an appointment with another group. I should not have been put in this position. 

I think the non-clinical people who make up medical models like midlevel providers always think in ideal terms, not in real-life scenarios. My father always said that all men must be treated equally under the law, but make no mistake, we are not created equally. We all have skills and weaknesses. Building a flawless team is the stuff of all doctors’ dreams. 
I have every confidence that should we ever get dental midlevel providers, it will not be too long before they see acute or complex patients, too. We live in a world where we want the biggest bang for our buck and we want it right now. Especially when we do not feel well. 

I got lucky, caught a break, and got the care I needed. But what if I hadn’t? What happens to those people? Besides writing a Yelp complaint and crawling like lemmings to the emergency room, what do they do? That is what policy makers really need to think about. 
Let’s look at the money. It ripples. I am not working. My community clinic loses revenue. My two disability insurances hold me in good stead, but I lose. My disability insurers lose their bet for my sustained health. My health insurance still has to pay for the two worthless appointments because no one actually broke a law, plus another one appointment to get me back on track. How is that cost effective?

Healthcare these days is all about the money. It has to be. Legislators are taken with the assumed financial benefits of the midlevel model, and they further assume quality of care will follow. They forget that this model is designed for most people, and it leaves acutely ill people like me vulnerable for catastrophe. That’s just not right.

I am never going to forget the incompetent care I got when I was critically ill. I am also never going to let this happen in my practice. Please help me keep dentistry safe for everyone and join WSDA in Olympia this year. I need you.
 

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