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?