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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.

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.

About the author

Dan Gorenstein is the senior reporter for Marketplace’s Health Desk. You can follow him on Twitter @dmgorenstein.
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Catherine, PA's do not have a spotlight on them at this particular time, but, I can assure you, that if NPs are allowed to practice at the height of their license, PA's will follow suit. PA's are paramount in the reshaping of American healthcare! Yes, we are different on some level, but not much.

More access to nurse practitioners (NPs) might be especially helpful if they are not affiliated with doctors groups. After all, one of the big expenses in health care is all those people who go to the emergency room not because they have emergency needs, but simply because there are no clinics available at odd hours. But a groups of NPs might find their niche by offering extended hours, or weekend hours, or services in more out-of-the-way places.

It is also possible that an NP clinic might specialize a bit. In modern medicine we are seeing more and more use of algorithms, in order to decide on the appropriate drug or therapy or diagnosis. And so, in certain fields, the nurses might actually provide very good specialized care, before having to send the patient on to a doctor specialist.

Of course this doesn't work out so well when the nurses cost more than pediatricians or veterinarians, as they do in my part of the woods!

I want to point something so telling about how the world perceives nurses, let alone, nurse practitioners (NPs); the picture for this story is a practice assistant- not a NP! Nothing against practice assistants (I'm not even sure what that is), but I'm a grad student getting my MSN to become a Family Nurse Practitioner and this is something nurses and NPs face daily, the daily perception of who we are and what it is we do. Marketplace, I listen to you a lot and respect your program, but this picture pretty much defines a NP as someone who walks you to the bathroom. You couldn't find ONE picture of a NP in practice? Seriously? Did you try the AANP or even google nurse practitioner? Here's one from a quick google image search of nurse practitioner: https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rj...

Not to seem petty, but perception is everything and if you're going to maintain the standards of what journalism should be, then you should make it a point to know what a NP looks like. Please change the picture to something that is more accurate.

Well said! As a manager of a psychiatric practice in Florida, I along with my staff have to fight this perception every day. Our doctor is scheduled out 3-4 months - but I can usually get them in with an ARNP in a few weeks....after we spend five minutes trying to persuade them that they will receive the same of level of care. More education is definitely needed!

In my 33 years as a family physician I have taught nurse practitioners (NP’s) and have worked alongside of NP’s almost the entire time. It is irresponsible to suggest NP’s should replace family physicians. NP’s have a skill set that complements the family physician. Without the deeper understanding of pathophysiology, NP’s tend to order more tests and consults that could be avoided if they work in close collaboration with a family physician. This way of practicing medicine is much more expensive.

NP’s are no more capable of replacing a family physician than a family physician is of replacing a cardiologist. To suggest otherwise is to continue to have the 20th century mindset of medical practice. The future is a team based approach in which the primary care physician, NP, RN, LPN, RPh, MSW, mental health professional and specialists all collaborate rather than practice in individual silos. Each member has an essential function but neither is a substitute for the other.

jmessmer, I am neither an NP or an MD, I am a consumer. My 10 yr old daughter presented to her pediatrician (MD) with rapid weight loss, sweet breath, stomach ache for over 3 wks. His deep knowledge did not lead him to a correct diagnosis of Type 1 diabetes; I think all would agree hers was an obvious textbook presentation. It wouldn't have changed the diagnosis if he had picked up earlier, but it would have kept her out of a PICU w/ a bg of 981. Conversely, my son had a few random, seemingly unrelated symptoms and our NP (fired the pediatrician) ordered the proper texts to detect Lyme dz. Don't disparage what NPs can bring to the health care provider scene.

In my 16 years as a nurse practitioner, I have taught medical students, NP students, and have worked alongside physicians and NPs. I have found that the quality of care of a nurse practitioner in primary care is equal to that of a physician - even in complicated cases. This perception has been backed up by 30 years of national research in quality of care, outcomes, and patient satisfaction.
It is time to put aside the bickering over turf. It is time to put the patient first, and the health care of the nation ahead of provider groups. It is time to recognize the reality of the market place. Family practice physicians are declining in numbers as they increase in age. Family practice, most unfortunately, does not attract the young physicians - it is a money issue. Nurse practitioners are well trained and highly skilled, and are doing the primary care job now, independently in over 19 States and DC. It is time to look at practice models that are working well with NPs at the helm. We refer to specialists, we collaborate all day, with our colleagues, with pharmacists, mental health providers, physical therapists, and others - that model works, and saves money, and provides efficient health care

As a specialist who takes consults from FP and NP I can honestly say there is no comparison. NP are overconsulting specialists due to there lack of knowledge and ordering tests which are unneeded. This is because they are overwhelmed by their lack of knowledge secondary to lack of appropriate training. NP cost more for medical care by far even with the small disparity in salary. Just because NPs are practicing independently doesn't mean they are doing a good job. It is not uncommon for NPs to have no clue what I am talking about when I report findings as they simply haven't been exposed to so much in medicine. There are certainly exceptions to the rule (decades of experience can compensate) but overall this is the reality.

Excuse me, but a seasoned RN, NP or PA is worth his or her weight in gold!! Over the past 30 yrs, on the front lines of primary care, I have witnessed those practitioners add a great value to our broken heath-care system. I would want to see the data, before I can conclude otherwise.

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