With a shortage of primary care providers looming, the idea of using nurses and physician assistants to fill the gap often appears to be gaining traction. But according to a report released Tuesday by the American Academy of Family Physicians, having more nurse practitioner-led medical practices is not a viable solution.
“Perceived shortages don’t justify less than qualified care for our family,” said Dr. LaDona Schmidt during a conference call about the report. She was a nurse practitioner before receiving her medical degree in family medicine.
Instead, the organization urges the adoption of physician-led, patient-centered medical homes, a model of care that promotes integrative care to help lower health care costs. The model is supposed to decrease referrals to specialists and help doctors diagnose and treat patients with the collaboration of their staff and administration.
The tension between some nurse practitioners and physicians has become more palpable in recent years as these nurses with advanced degrees have received more authority in some states to diagnose, treat and prescribe medicine. In 16 states, they can practice independently of a physician. Physician assistants receive different training and work under the direction of doctors, but some have also advocated for them to have more independence from physicians.
In physician-led, patient-centered medical homes, nurse practitioners work under the supervision of doctors, often managing pain and long-term treatment. AAFP members said this model cuts down on readmission rates and increases patient satisfaction.
Citing a difference in education, the report’s authors said nurse practitioners receive 5,350 hours of training and study on average, compared to the 21,700 hours that physicians accumulate through medical school and residency. Nurses can practice at the end of their studies, which include clinical training, while doctors go on to their internship and residency, a difference that the report said is crucial to treating a patient.
Describing her experience in both roles, Schmidt said medical school provided a depth to her understanding of the human body that wasn’t clear as a nurse. The report said that while nurse practitioners are vital to performing procedures and long-term care treatment, the complexities of the human body are better handled by a physician.
Research on the health care outcomes of nurse practitioners suggests two sides to the pro-physician argument. A study published in the Journal of the American Medical Associated (JAMA), for example, found that there were no significant differences in patients’ health status when they were treated by nurse practitioners instead of physicians for primary, ongoing or urgent care.
But THE AAFP board chair, Dr. Roland Goertz, said that recognizing the strength of both health care providers and integrating them into patient-centered medical homes was the only way to address a shortage that hits rural areas especially hard.
“I think we’re beyond testing it,” said Goertz about the medical home model. “I think the evidence is there supporting it in a very large way.”
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Even my primary care physician (PCP) agrees with having more nurses in primary care. He is always saying that about 85 percent of his normal day can be handled by a registered nurse. He has told me that he’s been approached by an venture capital group that is in the planning stages of building a network of Urgent Care Centers in cities on the east coast. Urgent Care Centers treat the most common injuries and illnesses – including colds, ear infections, cuts and back pain – in addition to taking X-rays and performing simple blood, urine and drug tests. This is the kind of work that normally does not require a doctor to be on site. My PCP says he would serve as an on-call doctor in the unusual case that needs his oversight. Initially, he would be required to consult by phone and possibly visit his assigned group of centers. He would become a salaried employee of the company with regularly scheduled hours, regularly scheduled holidays and vacations, a healthcare and dental plan for himself and his family, a pension plan, a 401k plan, a profit sharing plan, an expense account and a company car. The Marcus Welby types will continue to fight Nurse Lead Practices because they refuse to accept any new ideas and continue to insist on 1950′s style solo doc practices. This Neanderthal thinking will gradually end because more and more doctors, just like my PCP, are realizing the need for change. We simply can’t afford to pay an expensive doctor to remove warts and administer flu shots. Those days are coming to a close. All this talk about the sanctity of the doctor/patient relationship will be reserved for those who can afford that kind of care. Most of us are seeing our doctor way less often and are rationing our meds because we simply can’t afford participating in Marcus Welby style medicine at the level of Mitt Romney and his family.
Direct Primary Care (DPC) practices are on the rise. Physician-run and as affordable as $59 per month, all care is provided by doctors at an affordable level. MedLion, the fastest growing DPC company, for instance, is gearing for a national rollout that will also directly address physician shortage.
$59 per month? That’s pretty good! Obviously that price only applies to healthy people. What does a really sick person pay? Huh? Does a diabetic paraplegic with stage 4 prostate cancer pay $59 per month? Huh? Inquiring minds would like to know. Really!
Samir Qamar pimps MedLion Direct Primary Care as an end all solution for $59 a month.. Which is then followed up by an astute remark from Larry Canes that asks – the $59 a month is also going to cover a very sick patient, with co-morbidity problems, like a diabetic paraplegic with stage 4 prostate cancer – Right? This just illustrates the complex nature of healtcare and that there is no one-size fits all, answer. People peddling a short mini-health plan, similar to the MedLion approach are called, Pre-paid Suscription Health Plans. They are not full health plans. They offer services that can be provided at their facility level and do not offer specialty care or hospitalization. You have to buy a supplemental plan (if available). If healthcare were a $59 a month solution, Medicare would not be having any troubles at all. As for a National roll out of something like MedLion, it has a place – but it will have to be honnest in its marketing that it is a limited services plan. Many people would buy a limited plan – that don’t feel they use a doctor that much, or they are young and impervious to ever really being sick beyond a simple medical maladie like pink-eye, flu shots, small stitch and sew incidents, and common colds. In the healtcare business – this is just a small step up from the nurse run clinics at CVS, Walgrens, or Walmart that will refer you to a doctor when the incident calls for it. Healthcare like any other business is mostly – YOU GET WHAT YOU PAY FOR. The problem is a lot of us would like it free. But even free healthcare has to be paid by somebody – or for those looking for it free, by somebody other than themselves. You can see how quicly this can become polarized without a real solution. However, we are at a time in place in our society that calls for better thinking and needs to be more constructive in finding a solution other then my political party is right and your politcal party just wants unhealthy people to die. At that point it has regressed into idiot thinking and serves no one. Will we actually be able to ever get beyond a one-party solution fits all? I truly hope so, although it doesn’t seem much of a possibility yet.
No other industrialized nation in the world pays 18 percent of GDP on a completely dysfunctional healthcare system that ranks just behind Costa Rica and just ahead of Slovenia. No other industrialized nation in the world allows fully one fourth of their entire population to be either uninsured or underinsured. Why? It’s all in the power of a universal risk pool. Any person that works in the insurance industry knows how risk pools work and that they could never function without the largest risk pool they can muster. The bigger the risk pool, the better. It’s sad that moron politicians don’t understand this elementary concept.
This is nothing but a turf battle.
It’s a false equivalency to say that there are “two sides to the pro-physician argument”. In fact, there is multitude of studies that show that care delivered by NPs is safe, more cost effective AND that patient satisfaction is higher, the most prominent of which was produced by the US Institute of Medicine – The Future of Nursing. (To compare the “two sides” is like saying there’s two sides to the global warming debate, when in fact the preponderance of evidence supports one side over the other).
What this is REALLY about is that NPs are cheaper than family care docs, a specialty that gets little respect in the rest of the medical world and is also paid way less. If you have more cheap NPs in the practice pool, it’ll drive down reimbursement for those docs.
Don’t buy this stuff about “we only want patients to be safe.” What they’re really saying is “we want to protect our already-poor salaries.”
I am not sure why the 18% of GDP argument fits here. The fact that there now exists a huge physician shortage is at very least the reason why Nurse Practitioners and Physician Assistants should pick up the slack. We all know that. The problem is political. Physicians in general and many who are AMA members cannot accept the fact that PA’s and NP’s are incredibly smart and competent professionals. Most MD’s who embrace us have a much more rich and full practice and those who trust to do the right thing and practice competently, do much better than practices and systems that don’t. It is just that simple, people. This is all based on egotistical physicians and managers who are more concerned about losing their political clout as opposed to looking at the real picture. This is so childish and foolish and won’t last very long. When MD’s realize they simply cannot survive independently without us, I will chuckle loudly when they begin to beg to have us in their practices!!!
To end the turf war the system should be revamped , medical education should start with the PA/NP model and all graduates should be required to perform 2 years of Primary Care and be designated physicians . At the end of that period if further training is desired a residency / fellowship etc. could be obtained leading to the designation of Physician and Surgeon . This approach solves both the primary care shortage and ends these ongoing battles over “competency ” , all of which are bogus .
We keep mentioning Nurse Practitioners both in remarks and in this article. How about the Physician Assistant. In most casse, you do not see a doctor when you go to his office. You usually see a PA, most people don’t even realize this fact. PA’s get similar formal education as a Physician, they just do it faster. It is also a fact that getting into PA school is harder than getting into medical school. This is primarily because there are far less programs and a lot more applicants. While most websites state that you must have an overall GPA of 3.0, try getting into PA school with that GPA. It will never happen, truth is most have a 3.5 or higher. Now, look at medical school applicants, they are required to have a GPA of 2.5 and most have around a 3.0. The only real difference is the amount of time that a doctor spends in “training”. This time is spent as a resident which is when they practice medicine while being overseen by a group of attending physicians and are constantly being taught how to be experts in a chosen field. PA’s work under this same model, only they are required to do it for there entire careers. More and more however, PAs are starting to attend residency to further their education and there ability to provide quality medical care. It is time that we start looking at the PA to fill our shortage of physicians as a whole. It isn’t just primary care that is lacking, it is physicians across the board. I have news for you as well, if we do not use PAs and NPs to fill the gap then there is no other model that works. You can restructure all you want, it still does not cover a shortage. You NEED more people. Not a different system. You cannot eliminate specialists, they are specialists for a reason. Any family physician that thinks they can fill that role because they had a class on it in medical school is dangerous and should not be practicing medicine.
Maybe if we had more NP’s and more PA’s doing wart removals and dispensing flu shots instead of paying expensive doctors to do such mundane work, maybe we could take a huge bite out of spending 18 percent of GDP on the most expensive broken healthcare system the world has ever known, huh? However, I guess it takes getting hit by a meteor for some folks to understand such logic, huh?
It’s understandable that patients want the assessment and care that a medical doctor provides. As physician assistants (PAs), we also understand that the gap between the need for primary care and doctors who can provide it is serious and growing. PAs can help fill that gap while working under the direction of a physician. It’s why our profession exists and it’s what we do. We can provide top-quality primary care and expand a physician’s ability to treat all the patients who need her. Next to physicians, PA’s have the greatest number of clinical hours and are trained in the same medical model as physicians. Our challenge, and one that faces nurses, PAs and physicians alike, is that in order for the PA education system to continue to provide highly trained PAs to help fill the primary care shortage, we need more clinical training sites, and preceptors that are willing and able to teach. Until we solve this critical pipeline issue, none of the members of the patient-centered medical team will be able to realize their full potential role in the solution to primary care.
The research shows that care by NPs and other advanced practice nurses results in patient outcomes that are as good, if not better, than physicians; patients are more satisfied because nurses are better communicators; and care is more accessible and affordable from advanced practice nurses. Physicians put a smoke-screen of patient safety concerns; their true concerns deal with money. It’s a turf war, not a patient safety matter.
1) PAs and NPs work with physicians. They should NOT be working independently.
Midwives delivering babies without OB doctors available is very dangerous.
2) Why do people think primary care is easy done well by PAs and NPs? I would
say that a good primary care doctor is more essential then most specialists because
they can prevent and treat the disease.
3) The comparision of training is ridiculous; a doctors education is far different
then nurses, NP, or PAs. If you dont believe me ; attend some lectures at any medical
school.
4) State medical boards should be ASHAMED if they allow unsupervised PAs and NPs.
They are supposed to protect the public from harm.
As a PA of 3 decades’ experience, who has worked with many physicians, NPs and PAs… and is currently in a clinic with only PAs and NPS doing ALL patient care, of incredibly complicated patients… with a “medical supervisor” who reviews some charts off-site and never sees any patients, I can assure you that this is NOT the best “model” at all. WE ARE NOT DOCTORS, we do not have the depth and breadth of training and experience, and yet we are being used as such. It’s terrifying. (And I hate to tell you folks, but NPs, by and large, are not as competent as PAs. I have had numerous nurses tell me that, adamantly. they would rather see a PA than an NP themselves). So if that is what anyone thinks is going to be the perfect model for our future in health care, you are wrong. It is dangerous for all concerned. The reason we “get away with it,” is that most patients don’t know what they don’t know, ie they have no idea their care is being run by providers who do not know what they should, oft-times the most fundamental medical knowledge is missing. I know. I am IN IT every day! I see gross negligence and errors every day. The model we need? If you have a competent doctor in the setting at least several days a week, with the non-MD providers? Hey, THAT might be ok. The team leader has to be a doctor, has to be onsite regularly, has to actually SEE patients. This independence talk is too scary for words, in a regular practice setting. Miniclinics? Fine; that’s all minor stuff. We can do it. But regular offices and such, with chronic care, complex health issues? Nope, nope, and nope. I am proud to be a PA. But I am a PA, not a doctor! Here’s a question for you…. we PAs can reportedly do 80% of what the family doc can do (I think thats way too high anyway). Ok, assuming even that, what happens with the other 20% ?! Ohhhh. There MUST be a doctor in the practice, actually leading this medical home team. Period.
Hey “Dr” Karen Kelly, I am a REAL Doctor, a physician…not someone who earns a non-medical doctorate who thinks he should practice medicine because a nursing association finds bogus research that makes me believe that I am capable of producing quality care at or above the level of a family medicine specialist. The ego of the vocal APRNs causes nurses to lose sight of the goal of what is in the best interest of patient care. And by the way, for all of you who claim we physicians are political or protecting our turf, take a look at how much money the nursing lobby pours into politicans cofers.
Doctors are concerned about ‘protecting their turf’. It is a career that costs a lot of money to get into, and they want to be reimbursed at a rate that will allow them to repay that. Physicians have been in the field for a long time and they have a MUCH stronger lobby than NPs. All physicians join the AMA, there isn’t one central nursing advocacy lobby. NPs tend to be in their specialty associations.
NPs do not want to get rid of doctors entirely, but think there is a place for both models of care. The MDs freak out if NPs integrate more of the medical model into their care, and yet they are constantly attempting to integrate the nursing model into theirs, because it provides better care and makes patients happier. I think there is an ingrained society bias against nurses and that line because of their history of being a woman’s job and being the handmaiden to the doctor. Many doctors do not want to lose their handmaiden and don’t want to realize that that woman working with them could quite possibly have important knowledge to share.
There are good NPs/PAs, and there are bad ones. There are also good MDs and bad ones. You cannot throw in anecdotal evidence of good or bad NPs/PAs/MDs and base your argument on that. Evidence-based practice demands we actually examine how we do things and look at the results, not just what our ‘gut’ says. Over and over, NPs have been shown in primary AND critical care to provide equivilant if not better care than MDs.
While MDs have greater years of book knowledge and are forced to memorize amazing amounts of information for every possible specialty, NPs typically have years of bedside nursing and life experience to give them additional information to pull from for their practice. Additionally, all of the NPs training is specialized and focused on their chosen patient population. I did not have to learn how to give a pap smear to an adult woman or check a male’s prostate. But I did have years of learning just embryology and neonatalogy, assessment of the neonate and related topics. If you ask me to provide care for an adult, I won’t be much help, but I will be able to care for the 24 week infant delivered through an abruption. I may not have memorized as much, but being able to recognize the abnormal, research, call for specialists/help is arguably as important if not more important than memorizing every single inborn error of metabolism. Knowing a baby might be showing signs of it, knowing what tests to order, how to treat it in the meanwhile, and who to call if those tests are concerning are just as important. I know what my resources are and how to use them.
Medical internships and residencies are largely focused on surviving the process and they are forced to go through many specialties, including ones they have no interest or skill in. Now that wide training allows them to be an MD and theoretically provide care to any patient population, but we have never studied if this is the most effective and safe manner of even educating doctors, it’s just how we’ve done it before.
I respect the physicians I work with greatly, they are great members of the care team. When we round together, it takes the MDs, NPs, RNs, parents (and other disciplines) to provide optimal care. The MD could provide care alone possibly, but it wouldn’t be optimal, same with the NPs and even RNs. Each brings something different to the practice of health care, and all aspects give us better patient care.
I did like the suggestion of Rob to some extent, except the part about starting in Primary Care. I’ve never worked in Primary Care in my life, have no interest in providing Primary Care and I doubt I would be nearly as successful as a Primary Care Provider. I think we need to take a look at the whole process and revamp it.