Some characterize the latest showdown between nurse practitioners and physicians in Pennsylvania, Michigan, Massachusetts, New Jersey, California, and Texas as a turf war — a medical fight like the farmers versus ranchers.
Legislatures in those states are considering bills that would allow nurse practitioners, or NPs, to treat patients without direct physician supervision. NPs are nurses with advanced training beyond that of RNs – most have a Master’s degree and a one-year internship.
So are some doctors resisting because of ego, coupled with just a plain old stubborn resistance to change? Or is it a genuine concern for their patients?
A survey conducted by Doctor Patient Medical Association shows that patients are top of mind – 64 percent of doctors polled said that quality would worsen by expanding nurses’ responsibilities.
And many doctors fear that the use of NPs and other “physician extenders” — a term they resent for its implication that doctors’ unique skills can be magically transferred to mid-level practitioners – is the first step down the slippery slope to “replace” doctors with cheaper, less-skilled professionals in the relentless pursuit of lower costs.
There are also practical reasons for their anxiety. Physicians Practice columnist James Doulgeris points out that most doctors don’t have the time or tools to effectively manage mid-level clinicians. And they rightly worry about assuming the liability for NPs who practice under their supervision – a potential cash cow for litigation-happy lawyers.
But smart doctors are figuring out that allowing NPs to practice what they are trained to do can be good for patients. “Docs have to wake up to the reality that the role of primary care must change, and get the tools to become team leaders,” says Nicholas Bonvincino, M.D., and VP of MDClick, an innovator in doctor-run, patient-centered medical homes.
Does that mean the “dumbing down” of medicine for patients? Not at all. Instead it allows NPs to practice at the top of their skills, and frees up the doctors to handle the more complex and difficult cases that play to their strengths.
For example, employing NPs in nursing homes would minimize those patients’ trips to the ER, often for slight changes in condition. This would save billions and keep ER resources free for those needing emergent care.
There aren’t enough doctors. As DC reports, only one-fourth of California counties meet federal guidelines for the number of primary care docs. And demand is about to explode with Obamacare. Insurance isn’t much good if you can’t get actual care.
Given the choice of no doctor or a NP when you have a sick child — a common dilemma for the underserved and Medicaid patients — most parents will choose the NP.
But there is an even more convincing argument to be made for changing the paradigm of primary care:
Americans love convenience.
Retail clinics, which are mainly staffed by nurse practitioners, have exploded as a place for parents to take their kid with a runny nose without an appointment or for a millennial with no medical home yet as they bounce between jobs or college.
As changes in delivery strive to make health care a more abundant resource, patients and professional, rather than the strong hand of government or organized medicine are best to sort out these new delivery solutions.
But the current legislative battle is about “oversight,” and whether NPs are capable of practicing without any. Experts like Doulgeris say bills that allow NPs to practice without doctor supervision are not in the best interests of patients.
Instead, the conversation should be about figuring out how to get doctors and NPs to collaborate in new and better ways instead of just trying to plug people into slots already held by physicians. Dr. Bonvincino says NPs should not look to replace doctors in their current roles, but rather to forge a new frontier. And that’s not something that can be achieved through government interventions like laws and regulations.
The best the legislatures could do is to eliminate the liability issue and expand the number of NPs allowed to practice under the tutelage of a single physician. California’s Marcy Zwelling, MD says that would immediately increase access.
But then the legislatures should get out of the way and let the professionals work it out. And the professionals need to start talking instead of fighting over old turf that’s already begun to disappear.
Kathryn Serkes is CEO of the Doctor Patient Medical Association (DPMA) & co-author of “The Patients’ Handbook.” Derek Dye is Executive Director of DPMA and an aspiring medical student.