Most observers of the American healthcare system conclude there is a primary care shortage, though opinion varies on what to do about it. Nurse practitioners and other mid-levels such as physician assistants have been suggested to fill the gap. Could they become the primary care providers of the future? I think the most accurate answer is: It depends.
First, let’s acknowledge there is good evidence that nurse practitioners and other nurses with advanced training provide excellent care for single chronic diseases such as diabetes, asthma, and high blood pressure, and focused procedures such as anesthesia in low-risk patients. The quality of their care is essentially identical to physicians, and some studies conclude that patients are just as satisfied with NP visits.
The problem with all this evidence is that it doesn’t represent the real world of primary care, where patients have multiple chronic diseases, new symptoms, family difficulties, and financial struggles. Nurses in general are comfortable following treatment algorithms for straightforward situations. In many types of patients, especially those middle-aged and older, and those with several chronic diseases, issues raised in the office don’t fit into neat boxes with clear definitions and boundaries.
U.S. organizations have already tried giving nurse practitioners completely independent practices. Roger Merrill, M.D., the chief medical officer at Perdue Farms Inc., spoke at the AAFP Annual Scientific Assembly in 2009 of their experience with this experiment. After the NPs were given independent practice, referrals to ologists climbed, hospitalizations increased, and overall costs increased. (I can’t find written confirmation of this, but several people who heard the speech told me the same thing.) Perdue Farms abandoned this approach.
My institution had a similar experience 15 years ago. A NP clinic was set up and even had a full time internist available for consultation. Compared to our family medicine resident clinic patients, the NP patients were less sick, had three times as many referrals, twice the hospitalizations, and the NPs saw half the patients per day as our 2nd-year family medicine residents. That experiment was also abandoned after many years of it being propped up by sympathetic high-level nurse administrators.
Let’s also acknowledge that there are family physicians in practice, and probably internists, who don’t embody the full potential of primary care. They practice scared and refer patients they shouldn’t. One example is a family physician who refers skin tags to dermatologists for removal. These physicians commonly practice band-aid primary care: prescribing medicines for symptoms without spending the time and energy, nor taking the responsibility, to diagnose the underlying cause. I’m not suggesting they should order more tests, but I am saying these physicians should use their brains more and take full responsibility for their patients without pawning them off to a parade of ologists.
Could NPs replace family physicians? If your view of family medicine is that they are merely medical traffic cops – “You have a nose problem, I’ll refer you to a nose doctor. You’ve had diarrhea for a few days, I’ll send you to an intestine doctor,” then yes, nurse practitioners can do that as well as any physician. If your view of family medicine is that they only deal with colds and well person care, then yes, nurse practitioners can do that as well as any physician.
On the other hand, nurse practitioners and other mid-levels could be part of the answer to the primary care shortage if they work in teams with physicians who can closely supervise them. Many general practices in Britain have hired nurses to do the chronic disease checklist care to meet pay-for-performance targets, freeing the general practitioners to focus on acute care. An example of an unacceptable approach is when a colleague of mine agreed to supervise a NP in a rural health clinic 20 miles from his office, but was unsuccessful in getting her to stop giving antibiotic shots (ceftriaxone, or Rocephin) to every patient with a runny nose.
However, if you’re idea of a family physician is someone who cares for 100% of the patients and 90+% of the issues that walk through the clinic door, there is no way a nurse practitioner, physician’s assistant, or even a “nurse doctor” can do an adequate job. The breadth of knowledge is too great. The expectation of the final accountability for the total patient is beyond most NP’s comfort levels.
If we’re going to launch into a major reform of physician/nurse roles, instead of expecting NPs to handle the complexity and uncertainty of primary care, it makes much more sense to teach them how to do heart caths.