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The nurse practitioner will see you now
Program assistant Mayra Dittman (R) helps Juanita Gilbert walk to the restroom at the Lifelong Medical Marin Adult Day Health Care Center on February 10, 2011 in Novato, Calif.
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It can be tough to see a primary care physician today. Just wait till next year when another 30 million patients or so get insurance under Obamacare.
“We need all hands on deck. We need more family physicians. We need more primary care nurse practitioners, we need more physicians assistants…we need pharmacists. Everyone with a focus on the patient,” says Dr. Wanda Filer, a physician in York, Penn., and board member of the American Academy of Family Physicians.
The nation is facing a shortage of primary care physicians. Estimates range from several thousand today to 52,000 by 2050. Annual spending on primary care is approximately $200 billion.
Not surprisingly, nurse practitioners, physician assistants, pharmacists and others are raising their hands to help fill the growing gap in coverage.
Nurse practitioners like Andrea Vettori who runs the Mary Howard Health Center in Center City, Philadelphia. Vettori says if she sees a patient outside her scope of practice, she will refer the patient directly to a specialist. There’s no need for a primary care physician in the equation.
“People talk about the future of health care and NP filling the role of the primary care provider, physicians becoming specialists. I don’t see any reason why that couldn’t be,” she says.
Rand Corporation health economist David Auerbach says there’s good reason for primary care doctors to be looking over their shoulders. Nurse practitioners can treat 85 percent of what a primary care doctor can treat.
“The number of primary physicians is growing very slowly. And the number of NPs is probably going to double in the next 15-20 years,” he says.
All this isn’t lost on powerful medical organizations like the Family Physicians and the American Medical Association. Those groups say providers should work together -- as a team -- so long as physicians run the ship.
Bring on the turf war.
“Currently there are 12 states with active legislation looking at utilizing nurse practitioners at the top of their education to meet patient care needs,” says Tay Kopanos with the American Association of Nurse Practitioners.
She says nurses want to end laws that require some level of physician oversight, like for prescriptions or diagnosis.
Doctors say they aren’t opposed because they’re afraid other medical providers will steal their jobs. They say they’re concerned about patient safety. What if there is a complex case and the nurse practitioner misses something?
“I see it as physicians being true to their oath. And being true to their training and education. And I think most physicians feel that way. They are not threatened by this. At the end of the day what they want to do is deliver the best healthcare possible,” says Dr. Adris Hoven, president-elect of the American Medical Association.
Dr. John Rowe at the Columbia School of Public Health dismisses those concerns. He says nurse practitioners are already working without primary care doctors.
“The fact is this is going on in 16-17 other states and there is no evidence that it’s not good for the patients,” he says.
As a doctor himself, Rowe gets why doctors are concerned.
“The physicians feel they have something special to offer. And being told there are individuals who are less well trained can do it as well as they could is a very difficult lesson for them,” he says.
But Rowe says if doctors and nurses can’t come together to solve the primary care shortage, that could be a painful and expensive lesson for all of us.
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As an RN I see both sides. I have a lot of respect for M.D.'s and the incredible training they go through, at the same time I see patients who simply do not have a PCP and many FP M.D.'s who can't take on new pt's or are soon to retire. Something has to give, I see NP's as a logical way to provide care as a shortage looms. At the same time the push to make NP a Doctorate degree (not masters as it is now) only make sense if the extra time and money is used to make them more competent and knowledgeable in their practice, not simply a money grab by universities to add "leadership" courses that don't translate to better pt care. As others stated, this needs to be about the pt and if no provider is available and we end up seeing them when their condition is well advanced, then outcomes are sure to be poor. Final note, thanks to all you FP Doc's and NP's, it is a tough job with less compensation then specializing, and we need more of you!
As a geriatric NP I would never put an 85 yr old on an NSAID. Especially one with Renal impairment. I would comfortably and safely work up each of those diagnosis in the office and would likely not need to refer. I would not hesitate to refer if needed.
Please help Advanced Practice Registered Nurses remove barriers to their practice by signing the White House petition below.
https://petitions.whitehouse.gov/petition/remove-barriers-prevent-advanc...
I am an NP who specializes in orthopedics. My track in grad school was family practice. I was an orthopedic RN prior to grad school, so I gravitated towards orthopedics as an NP as well. I had an excellent ortho surgeon as my mentor and he trained me how to apply casts and give joint injections, as well as read xrays and mri's. I have numerous family practice physicians who refer their patients to me because they don't know what else to do. I get calls from pediatricians asking me to look at their patients' xrays to see what they should do. The orthopedic surgeons I work with trust me, and that trust has been earned, believe me.
In addition to being board certified in family practice, I am also board-certified in orthopedics as an NP. These are national board exams that follow national standards.
Going back to primary care, sorry docs- patients don't need a physician to treat strep throat or a UTI. If something comes along that is beyond the NP's scope, he/she would consult with doc.
I would like to direct everyone's attention to this C-Span video from earlier today. I think it can answer many of our questions.
http://www.c-spanvideo.org/program/311803-5
As a NP, I can tell you that unfortunately, even though the profession of nursing has evolved tremendously, we have not done enough to help the public (including MDs) to see this. The example of the journalist of this article showing you some kind of healthcare worker walking a patient says it all. Organized medicine would like nothing more than to keep this false perception going. Who can blame them? I urge all of the physicians here to watch this. I can tell you that I feel completely misunderstood by MDs about my professional training all the time. They simply do not understand my level of education and what was involved in getting to this point, yet, paradoxically,they understand that I am excellent at what I do! I amreferring to a collaborating physician I worked with who asked me, "What's on your board certification test...research?" He has no clue. Neither does the public. But, you will be pleasantly surprised.
To add a comment/agreement to throckmorton's note:
This is the big issue with NPs in primary care. Lacking the in depth training and knowledge of pathophysiology, the NP tends to consult and test when experience and knowledge would suffice for a family physician. If you think you can afford a system where NP’s do all the primary care, let me tell you there is not enough money in our entire GDP to do that.
Also, when I do have to consult a specialist, who do you think sees the patient first? A nurse practitioner. So if NP’s are the answer, why not eliminate cardiologists, orthopedists, anesthesiologists, endocrinologists, otolaryngologists – all specialties who have NP’s doing the consulting work.
If an 85-year-old patient comes to me with well controlled hypertension, diabetes and stable coronary artery disease but complains of knee pain, a new rash, abdominal pain and has stage 3 chronic renal failure, it is likely an NP will consult a dermatologist and an orthopedist after getting an MRI of the knee and put the patient on an NSAID until seen. If I see the patient (or the NP asks for my input) I will likely take care of all the problems today, by myself, and do it as effectively and for less money than the two specialists and NP will. THAT is the difference between a physician and an NP.
I've been in medicine for 30 years and the example you give is complex for any provider. Now if the patient has been yours for half a decade ? maybe easy. If this person walked in for the first time ? the 85 y/o would take up a lot of office time sifting through the medications, history, phone calls to prior docs, old records, talking to family members etc. They should already have a team of specialist following them and even then all the specialist would not agree on a diagnosis, let alone a plan of care. That is a complex case!
Dr. R - agreed. A 90-year-old buddy of mine sees I don't know how many doctors. Between the VA and his 'regular' doc, it is a never ending stream of changing meds. The docs will not talk to each other, and I am always faxing stuff to one doctor or another. What a waste of time. Geez louise, I can't believe they haven't killed him yet.
As a board certified Family Physician I am not surprised that a lot of people would like to practice medicine without going through the 11 or so years of education required. It is a grueling experience, but it is necessary to learn to care for a wide variety of medical issues in a wide variety of people. Physicians are required to pass four national board exams before we can even apply for a license. Almost everyone training today takes a board specialty exam as well. Then we must continue to study and complete further training each year to maintain a license and board certification.
A Nurse Practitioner studies for two or three years after getting a BSN (4 years) and then "specializes" by getting a job with the type of clinic or physician practice he or she wishes. There is no formal specialty residency track. In fact, there is no formal national standard NP licensing exam as there is for Physicians. Licensing requirements and scope of practice vary widely from state to state.
There is a common misconception that primary care is "easy" when, in fact, it is the hardest job in medicine. Where do most Specialist's patients come from? My patients often have little idea what is really wrong with them. All they know is that they feel bad and they came to the Doctor for help. They don't usually come in with obvious broken bones or gaping wounds. They have more subtle symptoms. This is where time and training come into play.
I know there are studies which supposedly show there is no difference in the quality of care given by Physicians and NP's, but I have worked beside NP's and taught NP students and I would much prefer to have a Family Doctor as my primary care provider.
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