Monday, December 1, 2008

Medical Doctors and Advanced Practice Nurses: Can't We All Just Get Along?

This fall, I attended ACP chapter meetings in Michigan, Nebraska, California, Texas, and Delaware. A hot topic of concern among ACP members is the role of nurses - specifically advanced practice nurses - in primary care.

In Dallas, an anxious general internist said he was worried that nurses were trying to replace general internists. He reasoned that with fewer physicians going into primary care, the government would turn to nurses as a solution. I heard similar comments from other internists.

The heightened attention to the role of nurses in primary care stems from several developments.

One is nurse-doctorate degree programs, creating concern among physicians that the public would be "confused" or "mislead" into thinking nurses have the same training and skills of allopathic and osteopathic doctors. The Nurse Practitioner Roundtable says "recognition of the title, 'Doctor', for doctorally prepared nurse practitioners facilitates parity within the health care system."

Another is efforts by advanced practice nurses to lead patient centered medical homes. In December 2007, the American Academy of Nurse Practitioners released a position paper that argues that practices led by advanced practice nurses meet all of the principles of a patient-centered medical home as defined by ACP, the American Academy of Family Physicians, American Academy of Pediatrics and the American Osteopathic Association.

And then there is the decision by the National Board of Medical Examiners to provide assessment services to the Council for the Advancement of Comprehensive Care (CACC), a leadership group in the Doctor of Nursing Practice (DNP) community.

One can understand, then, why many general internists might conclude that nurses could replace physicians as the principal source of primary care in the United States.

But is this really so? Renee Zerehi, ACP's manager of health policy, says that "two recent workforce studies suggest that greater use of nurse practitioners and physicians assistants will not have enough of an impact on the primary care physician shortage":

"Colwill et al found that 42 percent of patient visits to NP/PAs in office-based practices are in offices of specialists - not generalists. In addition NP graduation rates fell from 8,199 to 5,920 between 1998 and 2005. They may decline further as master's-level NP programs are replaced by clinical doctoral programs by 2015. The Association of American Medical Colleges predicts a shortage of 124,000 physicians by 2025, and estimates that primary care will account for 37% of the total projected physician shortage - nearly 46,000 FTE primary care physicians. The baseline demand scenario assumes a continuation of current supply, use and demand patterns. It also assumes that PA and NP supply would grow by at least 26%, with PAs and NPs maintaining their proportion of services provided. The study found that although it is more likely that NPs and PAs will continue to serve an important role in the provision of care, their numbers will not be sufficient to eliminate the emerging physician shortage."

In other words, the demand for primary care may grow so fast that there will be a need for more advanced practice nurses and physicians to meet the need.

Today's questions: Do you think advanced practice nursing can, should or will replace primary care physicians? Do you think it is possible for both professions to find common ground on their respective roles in primary care - and if so, how?


The Happy Hospitalist said...

If a nurse could do what a doctor does and gets paid the same to do it, then we should all be going to nursing school. Putting doctor behind a nurse degree does not make you a doctor of medicine. It makes you a doctor of nursing. If we as a nation want nurses taking care of complex medical problems independently of physician oversite, then we should say so and stop beating around the bush.

My experience, as a whole, with extenders? I wouldn't want them managing complex anything. They don't have the training to do comprehensive internal medicine. Go do a 12,000 hour residency and then maybe we can talk.

furrydoc said...

the legacy of physicians trying to control practitioners of limited scope but less training has never gone particularly well. for many decades the md's have waged turf war with the do's, the chiropractors, the optometrists and the podiatrists. we can now add the nurse practioners to the roster. peace was always achieved, sometimes with deserved parity, as in the case of the osteopaths, and sometimes via court decisions as those favoring the chiropractors. for the most part, the american culture favors a free economic market with some protection for the public. the protection is not supplied by the physicians but by licensing boards and professional certification agencies that set standards for education and complement of skills that the practioners need to acquire.

there may very well be tasks for which physicians are no more or less capable than other practitioners. i think a lot of the dissatisfaction of primary care physicians derives from having to do large volumes of work that does not challenge the intellect or advance professional skill. it may be better for our profession to delegate activities that really do not require the extensive training of the physician to colleagues of more limited education but better defined professional focus.

rich the furrydoc

DrJHO7 said...

Internists will not be replaced by nurses (even Dr. nurses), at least, not in the forseeable future. My conversations with knowledgable persons in the educational hierarchy of nursing, indicate that the primary function of Doctors of Nursing Practice will be in the areas of research, education/faculty, administration, and probably a small pool of clinicians who see patients in a variety of specialties, usually in collaboration with physicians, rarely independently, depending on the needs of the community and the physician work force conditions there. Since almost no physicians are going into primary care specialties, there will be a significant need for nurse practitioners in general (and PA's), and some of these may have DNP level educations. I agree with Bob and Renee that the numbers of NP's that we predict we'll need for the primary care work force will far outstretch the supply. Doctorate level education is longer, more expensive, and more difficult to attain. Even BSN and MSN are not sought by many nurses for those reasons. As pointed out, the clinical training track that is proposed for these folks is simply not comparable to a medical education and a residency program in a specialty. Our system still needs the knowledge and skill set of the physician, but the supply is dwindling. If State medical licensing boards and medical societies are smart, they'll keep tabs, and an element of supervision and control on the practice of Medicine by nurses. Meanwhile, it's a no-brainer that NP's and PA's are going to play an important role in the primary care work force of the forseeable future in this country, along with IMG's, DO's, Boy Scouts and anyone else who feels compelled to answer the calling of the needs of our health system. I'm afraid that, when the salary of cardiology PA's exceeds that of the general internist/family physician or pediatrician, the only place a patient may get to see one of these doc's is in an exhibit in the Smithsonian, the local wax museum, or a documentary on the History Channel entitled: Physicians Driven to Extinction.

PCP said...

This issue is really at the crux of why younger physicians are deserting Primary care.

The system treats IMs and other primary care doctors at parity with NPs and other midlevel parity, just look at the CMS fee schedule for an E&M 99213 visit of a NP or a MD IM boarded internist generalist.
Yet we all, our patients, our physician colleagues, know the difference.Everyone it would seem except those that ought to.
How is this fair, and how are younger doctors to take this?
As for the advanced medical home, unless it is explicitly stated as to be headed by Internists/FPs/Pediatrician/Other board certified physician, then here too we will encounter the same issues.

Extending from this issue are the other issues, lower professional respect, lower pay, frustration etc. This is an issue that it is time we address directly as a country. Politicians would rather put their heads in the sand than deal with it.
Younger doctors have looked at this situation and feel they do not want to do it unless it is addressed. Once this is dealt with it will clear the path for Doctors, Advanced practice nurses, and others. Autonomy with an unlimited scope of practice is frankly unacceptable.

Fairy said...

Thanks for the great post, I started my career in nursing after finishing a associate degree in nursing from associate degree nursing schools

MD no NP said...

No Way

Jasmine G. said...

Interesting Post! I am actually in school to become an NP and my reasoning is because I saw a need for the community. Working in the ICU, there are many patients with preventable diseases being admitted. Nurses are not Doctors and recognize the differences in the scope of practice. The goal is to cater to our communities need while teaming up with a great physician to do so. We are not trying to replace you guys. I don't understand why Physicians are so threatened by NP's. It is literally two different things. I concur that it can confuse the public, but it is up to us to educate them on the role of an NP.

Great post.....Now it is 2019 and NP's are very present and are valuable to the team.