We have stretched our healthcare system to its limits, and continue to stretch it every day. The ACA was touted as the key to unloading our overburdened emergency rooms. It did not, with a CDC report noting “[f]ew changes in ER use were noted between 2013 and 2014.” There are some people who just prefer the ER, whether for convenience or lack of access to a primary care physician or some other reason.
One problem noted by many is the lack of primary care physicians. We have known of the looming physician shortage issue for years. A 1989 study published in JAMA noted that despite an overall doubling of the number of physicians in the US since 1963, the proportion of primary care physicians decreased. The Association of American Medical Colleges (AAMC) reports the supply of primary care physicians will remain inadequate well into the next decade. One important point noted by the AAMC is that it takes about a decade to train a physician. We cannot solve it impetuously.
One solution touted by many is the use of “physician extenders.” On the surface this seems a rational, practical solution. For less complex illnesses, many of us once sought treatment from Dr Mom. In the gap between Dr Mom (or ourselves) and physicians, is there room for some mid-level provider?
Our health care system has long been taking a very critical look at this potential solution. Lobbying groups for nurses assure us that increased utilization of Nurse Practitioners are the solution. They claim a Nurse Practitioner can perform many primary care tasks efficiently and in a cost-effective manner. An examination published in the Annals of Internal Medicine suggests that Nurse Practitioners (NPs) utilize resources and provide care much the same as primary care physicians when dealing with low complexity out-patient maladies. Other studies are yielded different results. One study demonstrated that nurses ordered more imaging studies. Another study compared NPs to experienced physicians, resident physicians (physicians in training), revealing that nurses utilized health resources at a higher rate.
I am going to go out on a limb here, and make a prediction: studies by physicians are likely to show physicians are more efficient and cost less, while studies by nurses will almost certainly argue the opposite.
The answer is somewhere between the two extremes, and it is not some rigid demarcation. I have worked with NPs (and Physician Assistants, called PAs) who have been outstanding. What made them outstanding? Hard work, a pleasant nature, kindness to their patients, a devotion to their practice, a hunger for professional knowledge, and self-awareness come to mind right away. In other words, traits to which we should all aspire.
What is apparent, however, is that policy makers don’t always appreciate this laundry list. For many who thrive on checklists, hiring a provider – any provider – means “task completed.” A wise policy would be to use the providers appropriately. I can sense eyes rolling as I write this – “of course we use providers correctly.” Right. And you are from the government, and are surely here to help.
Not so fast. Let us examine a recent study comparing not NPs to MDs, but nursing assistants to nurses.
At this very moment, some poor policy wonk is salivating: if nurses can replace doctors, and nursing assistants can replace nurses, our healthcare problems are all solved!
This study provides a cautionary insight we should all heed. Replacing nurses with assistants resulted in an increase in mortality. The reasons should be apparent. We should be using the right tool for the job.
There are some elements of care that no doubt may be rendered by nursing assistants. Some is better provided by a nurse. At another level, a nurse practitioner or physician’s assistant. Beyond that a physician. Further still, a specialist. Perhaps a certain condition requires the attention of the world’s expert. The right tool for the job.
Our job is to make sure we have all the tools in our toolbox. We must use them properly and in concert as we look to the future. Just as we would never call a screwdriver a hammer, we should not confuse the roles of our providers. Family physicians and pediatricians devote years to learning their craft. Internists, the same. All physicians are not neurosurgeons, or cardiologists, or pulmonologists. Just as a pediatrician would not perform a liver transplant, or a liver transplant surgeon perform a joint replacement, a nurse should not contemplate treating a complex medical problem without an appropriate collaborative relationship. Together we may do great things. Working at odds only weakens us.
To use the immortal words of Harry Callahan, “a man’s got to know his limitations.”
It should be apparent that expanding the role of NPs and PAs in delivery of care is worthy of consideration. A sticking point is that of autonomy. I believe in the team model, and my reasoning is simple. It is the difference in the level of training. A nursing curriculum is not the same as a medical curriculum. An advanced nursing or physician’s assistant program is not the same as a medical or surgical residency. A NP or PA degree should not be seen as a cheaper (yes, the training programs are expensive) and easier (yes, I know it is hard to become a NP or PA) means to becoming a “doctor”. Indeed, some nursing programs have taken to awarding their graduates doctoral degrees, making them doctor-nurses.
That is confusing to patients, but the real issue is care. Physicians, NPs and PAs all contribute to good care. The primary focus is delivery of care to a patient population outstripping provider population? While a patient should know with confidence who is his or her physician, physician’s assistant, nurse practitioner, nurse, nursing assistant, and so on, it is more important that the patient be provided excellent care. If a role is appropriate for a nurse practitioner, why use a physician for the task? Even more costly, and dangerous, is to consider using a NP for a role that needs a physician’s skill set.
In an overburdened health care system, we must shepherd our resources. We must not sell ourselves short, or take the easy route to checking that box on the checklist. We must strive not just for adequacy; we must achieve excellence. Blurring roles for the sake of ego has never been a means to that end.
Maybe we should all just get to know our limitations...
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