Wednesday Sep 19, 2012

Nurse Practitioners No Substitute for Physician-led Team

By the year 2020, our nation is expected to face a shortage of 45,000 primary care physicians. To address this shortfall, as well as rising health care costs, the nation is seeing a movement to grant independent practice to nurse practitioners.

But, this flawed, stop-gap approach overlooks some obvious obstacles to replacing physicians with non-physicians. For example:

  • The nursing field faces its own deficit with a shortage of 260,000 nurses projected for 2025. You can't fill a gap with something else you lack.
  • Though some have supported the idea of independent nurse practitioners because of the lower costs involved with training and employing nurses, the approach fails to consider that those savings may be offset by decreased productivity and less efficient use of staff resources.
  • Granting independent practice to nurse practitioners would create two classes of care: one run by a physician-led team and one run by less-qualified health care professionals. Physicians are required to complete roughly 16,000 more hours of training than nurse practitioners.

The Academy addressed all these issues yesterday when it released a report -- with support from the American Academy of Pediatrics, the AMA and the American Osteopathic Association -- that explains in detail the differences in training and clinical expertise between physicians and nurses, why a team-based approach is preferable, and why substituting non-physicians for physicians just won't work.

Our report is intended, in part, to educate the public about those differences in training. Consumers are not discerning purchasers of health care when they don't know the facts. Many patients, however, already express a preference for physicians. According to a recent AMA patient survey, 86 percent of respondents said that they benefit when a physician leads a primary care team, and 75 percent said they prefer to be treated by a physician -- even if it takes longer to get an appointment. 

At a time when the AAFP is advocating a team-based approach to health care to improve outcomes and lower costs, some nurse practitioners are eager to go it alone. Our report makes a strong statement that the patient-centered medical home model is designed to be run with a physician leading a team of health care professionals. A recent report by the Patient-Centered Primary Care Collaborative offers more than 30 examples of public and private payers finding that better care, better outcomes and lower costs are possible in the PCMH model. Specifically, team-based care has been proven to reduce emergency room visits, hospital admissions and total inpatient stays.

The PCMH gives patients access to physicians, nurse practitioners, physician assistants and other health care professionals. Together, these health care professionals can complement each other with their experience and expertise.

Finally, the report stresses that national workforce policies are needed to ensure adequate supplies of family physicians and other health care professionals to improve access to quality care and avert the anticipated shortages of primary care physicians and nurses. Wholesale substitution of non-physicians for physicians is not, and should not be, an option.

Please share your thoughts below.

Roland Goertz, M.D., M.B.A.is the board chair of the AAFP.

Comments:

THANK YOU!! Well-said! Bravo!

Posted by Dr. A. on September 20, 2012 at 07:05 AM CDT #

Unfotunately, we already have a 2-tiered system that I see as a full-time Emergency Physician. MLPs are trying to care for elderly patients with complex chronic medical problems, and Urgent Care, Critical Care Access Hospital ED patients without supervision. The MLPs call and say, "I'm sending them to you, because I don't know what is going on with them", and become angry when I ask if they have discussed the patient with their supervising physician. They were never intended to be independent practitioners that substitute for physicians.

Posted by Charles Olson, Jr., MD on September 20, 2012 at 09:48 AM CDT #

As a primary care physician (MD) in private (rural) practice, I seem to have two choices: 1) work an excessive number of hours seeing as many patients as I can possibly work into my schedule and completing an unbelievable amount of paperwork to make a reasonable physician salary or 2) see patients at a comfortable pace where my workload is manageable but I make less than $75,000 per year. If I hadn't spent so much time in training and I didn't have so much student debt (i.e. if I were a mid-level provider), I might be happy with the second option. This is the primary reason that I think mid-level providers will take over the bulk of primary care in the future.

Posted by Dr. S. on September 20, 2012 at 10:36 AM CDT #

We have created this problem out of greed. We tell our patients that it is perfectly fine for them to be evaluated and treated by a nurse practitioner and now that the nurse practitioners want to practice independently, we act surprised. It is pure hypocrisy to tell patients that they are suddenly receiving substandard care from the nurse practitioner just because the same evaluation and treatment is being performed in a separate building. We have opened a Pandora's box and are vainly trying to close it now.

Posted by Keith Dinklage M.D. on September 20, 2012 at 02:49 PM CDT #

We should structure the NP's and PA's so that they have a MD backup. All the NP's I have worked with know their limitations as do I. When I need help, I ask for it. Sometime it is the ED. Sometime it is a sub specialist. Sometime it is another Family Physician. We should build a referral service for them to use rather than leave them and our patients to their own devices. Build a bridge not a wall.

Posted by Harold DuCloux on September 20, 2012 at 07:53 PM CDT #

Thanks for saying what others might find not "PC" to put into print. While I agree with some of the other comments about working together/building bridges, and talking out of both sides of our mouths about the NPs, I also know from first hand experience that even seasoned FNPs are not the same as well-trained family physicians. I work with two very competent NPs, they do in and outpatient work; but they do not have the same knowledge base or ability to hone in on appropriate diagnostic studies that an experienced physician does. I believe that they function best in a system where physicians are still the captain of the ship.

Posted by Diane Zavotsky on September 20, 2012 at 09:30 PM CDT #

While I appreciate the AAFP taking a stronger stance concerning the NP issue, it is still not strong enough. What many don't realize is that NP movement is not looking to be a part of a physician-led team; they have pushed and received independent practice in 22 states and will continue to push for more. The majority of them want to replace us. I don't know how exactly to stop this plague of mediocrity, but perhaps pushing this campaign further to instill fear in the public concerning their reduced training (and our anecdotal evidence that they make more mistakes and increase costs via those mistakes) and point out their hubris in assuming they could do the same job with less training just by lobbying the government. Blitz the media with these thoughts. Ask our friends the trial lawyers how their case loads may be picking up and even use their data.

Posted by Dr. SS on September 21, 2012 at 01:51 AM CDT #

First let me say that I have worked with some very competent NPs and PAs. I feel they do have a place in medical care, especially given the current path of healthcare in this country. I also believe for these physician extenders to practice appropriately, there should be a supervising physician involved. The biggest hurdle besides manpower shortages will be financial, because the whole point of having these types of practitioners is to save on costs while increasing access to care. What I see is that physician's reimbursement will be driven down to the point where there will be little or no incentive for an individual to go through the hassles of obtaining a medical degreee.

Posted by Perry Williams on September 21, 2012 at 12:35 PM CDT #

Finally, you did something right. You took a damn stance. Hiring LELTs (less educated, less trained) is thought to be the answer to our healthcare dilemma. Look at Massachusetts and how they doing the same thing with PAs. NPs and PAs are not bad people. They are helpers in the healthcare arena. But they are NOT doctors. They used a trojan horse (to help the poor and needy in the rural areas) to gain traction and now they want to compete with us. It should have been game on at that time. They have killed our negotiating leverage with hospitals and the government. Finally, the AAFP has grown some metaphorical balls and stood up to this. You were warned. Us members begged you but you had to be the nice guys and appease all. Well, unfortunately it is too late and we have lost. Your only shot is to spend our dues on media ads explaining your stance listed above! Hammer them! Be mean! And then walk away from the RUC and let those idiots come to us. Man up!!!!! We have no time to sit back!

Posted by Douglas Farrago MD on September 21, 2012 at 01:27 PM CDT #

Forgive my cynicism as I once again prepare to ding my credit card for more CME--part of that supposed quality that physicians bring over less-trained NPs. Where's the data that all that extra training makes a difference in patient outcomes? Better get ready to market that to the general public who will choose someone with good rapport and plenty of time over somebody with lots of credentials.

Posted by kevin hepler on September 21, 2012 at 03:08 PM CDT #

It seems to me that the question is not whether NP's are equivalent to physicians. Of course they are not. They have different training and focus. They are better trained in some areas than physicians, and less trained in some areas than physicians. The relevant questions are whether or not they have adequate training to provide good quality health care, achieve good clinical outcomes at a relatively low cost, and earn high patient satisfaction. Solid research, including a meta-analysis and a Jama published RCT comparing physicians and NP's indicates the answer is yes. So maybe we need to rise above the "us vs. them" concern and look at the big healthcare picture. Maybe we need to ask the right questions before we answer them.

Posted by Paul Hartlaub on September 22, 2012 at 06:50 AM CDT #

Fascinating comments here and on the other thread dealing with this topic. All I can say is that is is truly PATHETIC that our specialty has allowed itself to be reduced to fighting with NPs for the privilege of being woefully underpaid for our work. Why isn't this effort being directed against the large insurers and CMS, those who are actively working to destroy family medicine? Look around on the web: this agonal gasp from our specialty is a source of great merriment among other physicians, laughing all the way to the next RUC meeting.

Posted by Robert Watkins on September 22, 2012 at 02:42 PM CDT #

As an urgent care physician, i have had to supervise PA's and NP's from time to time and honestly, i am shocked that some states are letting them practice independantly. From over prescribing medicines and antibiotics to over ordering tests to having difficulty interpretting labs to half the time not realizing their limitations, were just some of the issues i had with them. The best ones were the ones who realized their limitations. I know that there are bad doctors too but mid-levels were never meant to be doctors or they should go back to school and get an M.D. degree and be made to learn actual medicine vs bits and pieces and be considered qualified.

Posted by Dr A. on September 22, 2012 at 09:18 PM CDT #

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