A national crisis, a controversial solution, and a heated battle over patient safety, provider control, and the financial cost of physical health – it’s all just another day in the field of medicine. As the shortage of primary care physicians becomes increasingly influential and even dangerous, Nurse Practitioners are now stepping up to fill the void – or they would be, if state laws allowed them to.
When it comes to any medical issue, the patient’s wellbeing must be of the utmost importance. Doctors argue, quite rightly, that a Nurse Practitioner’s education and training differs from that of an M.D. Whether or not that difference impacts the quality of care that patients receive is up for debate. But can we really argue that it’s better for patient care to be delayed indefinitely in the wait for a doctor’s attention, when the alternative is immediate care from a nurse with advanced education and training? In my personal opinion, the sooner a medical concern gets the appropriate treatment, the better.
Your medical care provider wears a doctor’s uniform and provides independent care – does that mean he or she is a doctor? Not always. Photo Credit: Flickr (Creative Commons license).
At the heart of the Nurse Practitioner autonomy debate is an alarming shortage of primary care physicians that experts say is only getting worse. “Let’s do the math: We have nearly 30 million uninsured people about to get medical coverage under the health care law come January,” wrote AARP. “And we have a projected shortage of 45,000 primary care physicians by 2020.” No increase in the number of doctors will accompany the resulting upsurge in the use of medical services. This means an even greater strain on an already limited workforce.
Why is there a doctor shortage? You’d think a job with prestige and a hefty paycheck wouldn’t have difficulty attracting new workers. Unfortunately, the prospect of lengthy education programs and training, high costs, and intense competition to even begin pursuing the career deters a number of would-be doctors.
Consider just the cost of applying to medical schools alone, without even factoring in the expense of first pursuing a Bachelor’s degree, prepping for and taking the infamously difficult MCAT examinations, and of course the astronomical costs of textbooks. Aspiring doctors submit applications to 14.3 medical schools on average, U.S. News reported – and with application fees as high as $100 a pop, that’s a small fortune to the broke college kid living off Ramen noodles. Unless we want the medical field to be a career path open strictly to those students who hail from the wealthiest of backgrounds, our nation needs to take a look at the outrageous financial cost – and, if they don’t make it into medical school immediately, the financial risk – that would-be doctors face long before any paycheck comes into play.
For anyone who has fallen prey to believing the myth that medical malpractice claims and liability insurance are what’s driving doctors out of business, The New York Times debunked the misconception back in 2009. Photo Credit: adapted from Flickr (Creative Commons license).
If the staff at your family doctor’s office told you the earliest appointment they could give you is still weeks away, you’re not alone (and the wait is only going to get worse as the shortage becomes more pronounced). Primary care physicians are especially hard to come by in the wake of the shortage – and again, financial factors are at work here. “Over a lifetime, a primary care doctor can expect to make $1.5 million less than a medical school classmate who goes into specialty care – and $2.8 million less than a doctor in the best-paid specialty, neurological surgery,” wrote The Washington Post. When these doctors have already shelled out such a large sum for education, wanting to earn more in return seems like a smart career decision.
Medical schools look impressive – and with the average price tag as high as $207,868 for public universities or $278,455 for private schools, MSN Money reported. Photo Credit: Flickr (Creative Commons license).
Of course, medical care shouldn’t be measured in purely financial terms. There are, and should be, doctors out there who enter the field because they genuinely care about helping people, and who work hard to meet the needs of those patients even when they could be earning more money for doing less work. As the dwindling number of doctors and specifically primary care physicians shows us, though, financial concerns do play a role – and that means thousands or millions of patients simply cannot get the basic medical care they need when they need it.
At times, a crisis calls for innovation. State legislatures across the nation currently are considering solutions that range from permitting doctors to practice in states other than those in which they are licensed to allowing nurses, rather than doctors, to prescribe physical therapy, according to national politics and policy magazine GOVERNING.
Many proposals to cope with the shortage include expanding the scope of responsibilities for nurses. In Florida, giving nurses the ability to prescribe physical therapy as a treatment is up for consideration. In many states, nurse practitioners and their supporters are pushing for autonomy, for the opportunity to work without doctor supervision and even to set up their own private practices. The Columbus Dispatch refers to a Nurse Practitioner as “a kind of super-nurse, who’s gone through four years of nursing school plus at least two more years of training in diagnosing and treating disease.”
For those of us not in the healthcare field, the differences between nursing and medicine aren’t always immediately apparent. When it comes to tossing around the term Advanced Practice Nurse, the discussion may become even more convoluted. “A nurse practitioner is actually a registered nurse who has had advanced education and advanced clinical training. And the purpose of using those practitioners is so they can do acute and chronic care,” reported National Public Radio (NPR). This solution could work, supporters argue, because nurses collectively are “turning out 3.5 times as many family nurse practitioners as the physicians are turning out family practice docs,” NPR added.
That’s not the only purported benefit of expanding the scopes of nurse practitioners. Healthcare Finance News suggested that assigning emergency room patients with less acute or complex conditions to Nurse Practitioners and saving physicians’ time and energy for those with more severe conditions would be cost-saving.
In emergency rooms, nurse practitioners “can free up doctors by performing more time-consuming services like sewing a laceration,” Healthcare Finance News reported. Photo Credit: Flickr (Creative Commons license).
Already, Nurse Practitioners operate with more freedom than they did 20 years ago, especially in primary care. “State legislatures have amended Nurse Practice Acts to reflect a nurse practitioner’s expanded role in primary care, authorizing nurse practitioners to write prescriptions for primary care–related diagnoses in every state,” reported a study published in The Temple Law Review. Still restrictions exist, and they vary from state to state. So far, in only 16 states (and Washington, D.C.), are Nurse Practitioners legally allowed to diagnose, treat, refer patients, and prescribe those medications without physician supervision, wrote Wharton School of the University of Pennsylvania. The vast majority of states still limit even these highly-trained and highly-educated nurses from using all of their training independently – and that restricts the medical care would be available to patients if only the supervisor was around to sign off on it.
In New Jersey, as in 31 other states, a Nurse Practitioner can only prescribe medications under the guidance of a doctor. Pennsylvania regulations are even stricter. PA is one of 24 states across the country in which physician involvement is necessary for Nurse Practitioners to diagnose and treat health conditions – so basically, if the doctor’s not in, do not count on any help from the Nurse Practitioner.
So what do Nurse Practitioners do? The short answer is, whatever they’re allowed to do.
In 2010, proponents of more independent roles for Nurse Practitioners found support in what may seem like an unlikely place, according to The Student Doctor Network: The Institute of Medicine. The organization released a report that recommended greater autonomy for nurses. Yet many doctors are still critical of the idea, and their reluctance may have little to do with either preserving egos or protecting job security.
“Doctors say it’s a miscalculation to think that patient safety won’t be compromised by not having a doctor overseeing things,” wrote the AARP. “Family physicians have more than four times as much education and training” as Nurse Practitioners who perform primary healthcare services.
Patient safety must be the top priority, regardless of whether it’s a physician or a nurse practitioner providing the care. That may mean increased training exercises for every aspiring medical care provider. Photo Credit: Duke University Human Simulation and Patient Safety Center, Wikimedia Commons (Creative Commons license).
California lawmakers are “working on proposals that would allow physician assistants to treat more patients and nurse practitioners to set up independent practices,” the Los Angeles Times reported. “Pharmacists and optometrists could act as primary care providers, diagnosing and managing some chronic illnesses, such as diabetes and high-blood pressure.” Many find this concept frightening. Should we trust optometrists to make important treatment decisions that have nothing to do with eyes? Should we depend on the same people who are supposed to be specialists in medications to also diagnose conditions? I understand the significance of efficiency – but this may be taking it a step too far.
A law passed this year in California allows Registered Nurses with only a bachelor’s or associate’s degree or diploma to prescribe birth control pills for patients without a full physical examination, The Huffington Post reported. The California Nurses Association opposed the bill due to RN’s limited experience and its disregard for clinical exams. Photo Credit: ParentingPatch. Wikimedia Commons (Creative Commons license).
Sure, it may seem like a simple, if not perfect, solution – but expanding the scope of Nurse Practitioners’ duties opens a metaphorical Pandora’s box of questions. Should Nurse Practitioners hold the title “doctor,” if they are performing a physician’s work? Should they be paid the same as their M.D. counterparts? (What are we paying for, after all – the provider, or the service?) And if so, doesn’t that partially defeat the point of the time-saving and cost-saving aspect of Nurse Practitioners?
Coming from a background in personal injury, I completely understand the fears of those who worry about patient safety. I have tremendous respect for the good doctors out there – the careful, thorough, precise, and concerned physicians who heal the sick and the wounded and help accident victims get back on their feet, often literally. The last thing I want is for the “solution” to our national crisis to set reckless practitioners loose in the field of healthcare.
Yet I can’t justify stopping a patient from getting prompt medical attention because the job title isn’t correct, because the doctor is too busy or out of the office, when healthcare assistance is available immediately from an educated and experienced provider. Do I think Nurse Practitioners should be all-powerful, answering to no one? No. Do I think they can, will, or even should replace physicians? Definitely not. But I do think that opportunities for compromise exist, and there will be no better time to talk about them than right now.
In one context or another, nurse practitioners have become a major part of the healthcare system, and they’re here to stay. The crux of the debate is how exactly to best use their skills in order to improve efficiency of medical attention and still maintain patient safety. Photo Credit: Bill Branson, Wikimedia Commons (public domain).
More than interdisciplinary communication or even collaboration, I think what’s most important when discussing whether or not to give Nurse Practitioners more autonomy is how that provider is prepared to deliver medical care. Education is key. Already, Nurse Practitioners need to complete a Master’s-level program in order to earn their title and job role – and soon, this requirement may escalate. Nurses can now actually earn a Doctor of Nursing Practice degree (DNP), the Atlanta Journal-Constitution reported. While it’s not comparable to a medical degree, it represents the highest level of academic study in the field, and it expands the knowledge of nurses who already have clinical experience. Another trend is the establishment of new board certification requirements that similar to those established for doctors, reported Physician News Digest.
These new certification requirements can make a big difference in both the perception of Nurse Practitioners and the reality of their ability to provide patients with the best, most accurate care possible. And really, isn’t that what nurses, doctors, hospital administrators, and every patient who walks into a medical facility wants – for each professional, regardless of title, “to practice at the top of their licenses,” as A Nurse Practitioner’s View puts it? Healthcare shouldn’t be about power plays, territory squabbles, or turf wars. It should be about every doctor, nurse, assistant, and technician working to the full extent of their education, training, and abilities for the all-important purpose of taking the best possible care of their patients. Anything less than that is simply less than we as a nation, and as individual patients, deserve.