Nurse Practitioners: We Need More of Them, But Not in Place of Physicians

Last Updated May 25, 2010 12:00 PM EDT

For many years, nurse practitioners have been arguing that they can do almost anything that a primary-care physician can, and that they should be allowed to practice independent of a doctor's supervision. Twenty-eight states are now considering providing that authority, and more are likely to as the primary-care shortage worsens. But it's nonsense to say that NPs are as capable as physicians or that they should be addressed as "doctor," as some advocates contend.

Healthcare pundit and author Maggie Mahar doesn't go quite that far in a recent post on The Health Care Blog, but otherwise she trumpets the NP line. Her basic contention is that physicians oppose the pending state bills because they're trying to protect their turf. I don't disagree, but that's not the only reason many doctors feel it would be a mistake to give NPs equal status. The plain fact is that while these professionals have additional training beyond that of regular nurses, they have not gone through three years of medical school and four years of residency. If their skills were equal to those of a general internist, a pediatrician, or a family physician, we'd have to conclude that the bulk of medical education is wasted.

Mahar counters that argument by quoting a post on the Yale Journal for Humanities in Medicine blog, which suggests that primary care physicians are overqualified for their work:

Clearly, while they have taken on the role of health care 'coordinators' they have become more dependent on specialists to take care of the sickest patients. Their 'scientific' medical role has decreased while their 'coordinating" role has increased. For many primary care physicians their medical training is of less importance in their new roles.

Mahar concedes that in some parts of the country, where there are fewer specialists, primary care doctors "do more of the work of diagnosis and treatment themselves.... But it is true that the internist working solo or in a small private practice in many cities often finds himself/herself mediating care rather than providing care."

There is a grain of truth in this: Especially in the Northeast, primary care physicians are prone to refer patients to specialists if they have complex problems. They do this because that's what many patients expect, and because that's all they may have time for. But this doesn't mean that they're incapable of diagnosing or treating complex problems. They do that all the time, and NPs can't compete with them in this area.

NPs are good at providing routine care, especially to chronic disease patients, and we need more of them as part of care teams in medical practices. But if I have symptoms that indicate I might have a serious problem, I want to see a physician. That's not to say that a doctor might not miss my abdominal aortic aneurysm or my incipient cancer. But I'd have a better chance of being correctly diagnosed if an experienced physician responded to my symptoms.

Mahar does give some space to observers who criticize the idea of nurse practitioners practicing independently. But she's uncritical of studies that purport to show that the care of NPs is equal to that of primary-care doctors. For instance, she holds up a 2004 study by Mundinger, Kane and colleagues as a paragon of objectivity. Mary Mundinger, dean of the school of nursing at Columbia University, is a leader of the movement to give NPs equal status. Moreover, that study followed only 1,100 patients who'd seen an NP or primary care doctor following an emergency or urgent care visit. To really compare how many serious diagnoses NPs and physicians missed, or how many bad outcomes their patients had, a much larger cohort would be required.

I'm all in favor of using NPs to increase the capacity of our overstretched primary-care system. In fact, I hope that many more NPs are trained in coming years to help cope with the impending influx of newly insured patients when healthcare reform hits the fan in 2014. But let's just remember that we still need physicians to separate the routine cases from those needing immediate medical attention.

Image supplied courtesy of Flickr.nurse.
  • Ken Terry

    Ken Terry, a former senior editor at Medical Economics Magazine, is the author of the book Rx For Health Care Reform.

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