Yusuf (JP) Saleeby, MD
To start off with let me define Advanced Provider. In years past a healthcare provider such as a nurse practitioner (NP) or a physician’s assistant (PA) were referred to as mid-level providers. This I have always felt was a pejorative term, somewhat demeaning. Mid-Level in what regard? To the level of care you receive? Well with my experience working with many in the Emergency Departments of my previous career in medicine I found some NPs and PAs to be exceptional healthcare practitioners. Some I would trust my own health issues to. In fact, there are practitioners out there that do a much better job than some MDs and DOs that I have observed. So, to call some of these practitioners ‘’mid’’ is insulting.
To be fair there are good and bad practitioners at any level… from your medical assistants to the double board-certified medical doctors who are chairmen of a department in a large teaching hospital. If you have read “Uncaring” by Dr. Robert Pearl (former CEO of Kaiser-Permanente) then you will understand the culture of medicine. An aspect of this culture is that ‘’we are better than they are’’ and this goes for the mentality of doctors between specialties like Family Medicine and Neurosurgery. One specialty can put down another. In recent years there has been a movement to refer to Physician Assistants as Physician Associates. Through the prism I view the world I am okay with this, but the AMA and others within the profession gave it much pushback. At a dinner one physician asked me: ‘’well if you call them advanced providers what should we be called?” My response was “Super Advanced Providers.” But of course, not all of us should be referred to as such unless we earned it by showing how we practice medicine.
Another part of the culture is the horrible experiences in residency training. When I went through my post-graduate training, we were essentially poorly paid slave labor. I routinely worked 90-hours a week taking call (24-hrs in the hospital) every 3rd day. Sleep deprived and terminally exhausted was the norm. When we did the math, we actually made less than those in the janitorial service at the same hospital. Much has changed since the early 1990s when I was in that environment. It was certainly not conducive to a good learning environment. We would often say jokingly about the specialties in training that: “Family Medicine residency programs would breast feed their young; Internal Medicine programs would beat their young; Surgical residency programs would eat their young” and that was pretty close to the truth. Again, a very bad culture that required young impressionable doctors coming up through the ranks to have ingrained this ‘’right of passage’’ and ultimately retaliate on the next group coming up. Reform in medical school and post-graduate training is something I have been screaming for years.
An example of how terrible current medical education is are two blatant examples. Nutrition and vaccinations. When in my first four didactic (classroom) years in medical school we have one-hour of nutritional education. We had almost nil regarding vaccination education when I did my pediatric rotations. We were essentially handed the CDC guidelines for pediatric and adult vaccination schedule and told to memorize them and that they were ‘’safe and effective’’ and one of the biggest advances in medicine in the past 100-years. That was it. I now must self-educate on vaccines by reading books like “Dissolving Illusions” co-authored by Dr. Suzanne Humphries to get a better picture of that rather important aspect in medical practice.
When a registered nurse decides to advance his/her education to become a licensed nurse practitioner that candidate takes on extra coursework in addition to the knowledge acquired for their BS or MS degree in nursing and then rotates in clinical settings to gain more experience. Finally, there are medical conferences and webinars that can further enhance their medical acumen. The type of nurse practitioner that I seek for my offices are those with a knowledge and passion for integrative and functional medicine (FxMed). But it does not stop there for me. I insist on a curriculum of constant education and research. I impress upon any provider that works for me at Carolina Holistic Medicine (CHM) to continue their educational aspirations. I enroll them as a ‘’perk’’ of employment in our non-profit Priority Health Academy. The academy was set up in 2018 formally as an educational NGO to advance the training and knowledge base of advanced providers. Advanced provider is the preferred term for what was once called mid-level provider. And in the case of those working at CHM that is certainly the case. Our providers can out-shine the majority of doctors out there. I have no reservations in making these braggadocious claims because in the lens I see the world it is in fact true in many cases.
Not only are the PAs and NPs that work at our centers educated by self-study and the annual functional medicine symposiums we sponsor, but they are under my constant tutelage and my model of FxMed. So, when I claim that our Advanced Providers are exceptionally trained and top-notch it comes backed up with a program put into place a half-decade ago.
Our patients benefit from my direct input as I review and sign off on 100% of charts when the norm is only 10% in general. Given this fact no patient should ever worry about any substandard care.
As my role changes at our CHM centers to that of a more supervisory position as our centers become busier and increase in volume, I personally will have to take a step back from day-to-day clinical encounters with patients. I will also be transitioning to almost 100% Telemedicine in the near future. As I increase the amount of research for writing/authoring projects, increase my contributions to the educational endeavors I am involved in and overseeing my current team of NPs and PAs, I will entrust them to carry on the delivery of our exceptional model of healthcare services.