Last week I interviewed a doctor who told me that his primary care doc is a “physician assistant” who has been trained to deliver primary care. He said it casually, dropping the fact into a long conversation.
Dr. David Kauff is an internist at Seattle’s Group Health Cooperative (GHC), an organization that has a fabulous reputation–both among patients and among physicians—for its primary care program. One reason is that at Group Health, doctors, physicians assistants and nurse practitioners work together in teams. “The success of our model is based on the fact that everyone in this together; we are corralled by a common purpose,” says Kauff, who also serves as GHC’s Medical Director for Practice and Leadership.
I’ll be writing more about Group Health Cooperative in a few days.
In this post, I would like to focus on the growing role of Nurse Practitioners (NPs) and Physician Assistants (PAs) as clinicians. NPs are registered nurses who have gone on to earn a master’s or a doctorate. Some specialize in areas such as anesthesiology, pediatrics (pediatric nurses) or Ob-Gyn (certified nurse-midwives). NP’s can run clinics; some run their own practices.
By contrast, physician assistants (PAs) don’t usually work alone. While physicians may not be on-site, typically doctors oversee their work.
PAs are formally trained to provide diagnostic, therapeutic, and preventive health care services. They take medical histories, examine and treat patients, order and interpret laboratory tests and X- rays, and make diagnoses. In many cases, they did not begin their careers as nurses. They may have been paramedics, respiratory therapists, or emergency care technicians (EMTs) before becoming PAs.
Currently, 17 states, plus the District of Columbia, let nurse practitioners operate independently. In 33 states regulations vary. As this map reveals, in some places NPs are not allowed to prescribe medication. In others, they may have to consult with a physician when treating patients.
It’s worth noting that NPs enjoy greater freedom in the Northwest, the Upper Middle West, and Northern New England (areas that some healthcare reformers refer to as “Canada South” because these states are in the vanguard of reform) as well as in the Southwest, where many NP’s started working in group practices, and they went out and established their own clinics. Nationwide, about 6,000 nurses operate independent primary-care practices.
Why Physicians Object
Today, 14 states are debating whether NPs should be allowed to practice on their own. Many emphasize the difference in education and years of training. Though in truth, the length of training is not so different. Becoming a primary care doctor requires four years of medical school plus three years of residency. A nurse practitioner attends nursing school for four years, then spends two to three years in graduate school, depending on whether he or she is getting an M.A. or a Ph.D. (In 2015, all nurse practitioners will be required to earn a Ph.D.)
Most NPs also have nursing experience. At the University of Michigan, for instance, the average candidate admitted to the NP program has 7 years of hands-on experience as a nurse. But while the number of years spent training are not so different, as I explain below, traditionally ,the nature of that training has been very different.
Doctors say that they are worried about patient safety. “I see it as physicians being true to their oath ” Dr. Adris Hoven, president-elect of the American Medical Association recently told Marketplace Health Care’s Dan Gorenstein. Hoven insists that doctors are “not threatened” by NPs. “At the end of the day what they want to do is deliver the best healthcare possible.”
Dr. John Rowe, a professor of Health Policy and Management at Columbia’s School of Public Health, doesn’t buy the argument. As he points out, nurse practitioners are already working without primary care doctors: “The fact is this is going on in 16-17 states,” he told Gorenstein, “and there is no evidence that it’s not good for the patient.” A recent Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation backs him up: “studies comparing the quality of care provided by physicians and nurse practitioners have found that clinical outcomes are similar.”
At the same time, Rowe understands why doctors are uncomfortable. “The physicians feel they have something special to offer,” he explains. “And being told there are individuals who are less well trained can do it as well as they could is a very difficult lesson for them.”
When I last wrote about nurse practitioners, back in 2010, one physician/reader (“Sharon M.D.”) was exceptionally candid on this point:
“I think there’s enough work for all of us in primary care,” she wrote,” and I think NPs and PAs are vital to meeting the demand.” But, she added: “I do find myself pushing back against the idea that an NP is as qualified as I am to care for patients, but that mostly comes from me wondering why I went through 4 years of medical school and 3 grueling years of residency if I’m no better at my job than someone with far fewer training hours. But it doesn’t come from any reasoned perspective: it’s mostly jealousy for all those years lost. . . . and all that debt yet to be repaid!
Without question, she is right when she says that there is plenty of work for everyone. With millions of Americans joining our health care system in 2014 no one needs to worry about NPs pushing primary care physicians (PCPS) or family docs out of their jobs.
(Nor are nurses likely to bringing down reimbursements for primary care. To the contrary, the Affordable Care Act requires that insurers pay nurses working in their own clinics the same rates they pay doctors for the same services, starting next year. Medicare will continue to reimburse nurses at 85 percent of the doctors’ rate, though the legislation boosts the Medicare reimbursement rate for certified nurse midwives to bring their pay to the same level as a doctor’s
Meanwhile, across the reform movement, there is a wide understanding that in the future, we must pay more for primary care — while reimbursing less for certain aggressive interventions that provide little or no benefit for certain patients.
More importantly, Sharon M.D. echoes a theme that I have heard repeated when physicians respond to the idea of NPs doing their work –and gaining the respect that they feel belongs to them: “She didn’t go through what I went through: the ‘grueling’ years of training and residency.”
I can sympathize with doctors who say this. Imagine what it feels like then to be told that someone who went to nursing school, and then got a Ph.D. can do the same work you do—even though he or she doesn’t bear the scars of medical training that I describe in the post above. This is a sticky issue, made all the more difficult by the fact that medical school education and residency is so punitive. (For a first person description of how medical students are abused, see Dr. Val Jones’ essay.)
Various studies have documented the bullying. One found that mistreated students frequently display symptoms of PTSD. Another study, published in the Annals of Internal Medicine, showed “a high prevalence of suicidal ideation among US medical students and suggest that the increased risk for suicide among physicians may begin in medical school.”
(Let me be clear: I am not suggesting that nurses don’t bully each other; sometimes they bully young residents. But the problem seems to be greater in med school where it is part of the macho tradition of what was once a male profession.)
Here, let me suggest that perhaps no one should be exposed to the psychological brutality and abuse that so many experience during medical training: the hazing that turns medical education into an endurance test, the bullying, the lack of supportive mentoring, the intentional public humiliations. Meanwhile, the “See One, Do One, Teach One” philosophy can leave a student alone on the front lines of medicine, as a third-year medical student describes in the post above.
This tradition goes back to a time when “men were men” (and all med students were male). Today few young men—and even fewer women—believe that this prepares them to be better physicians. The lashing only hardens them.
As I suggest in “The Psychological Impact of Medical Training on Physicians” above, a good doctor needs fortitude, courage and compassion. Scar tissue is not required.
Going forward, if we want U.S. healthcare to become a collaborative enterprise made up of caregivers who are not afraid to ask questions, admit mistakes, learn from each other—and even learn from their patients—we must change how we train physicians.
Communication and Collaboration
Reading the comments on the Marketplace HealthCare post, where Drs. Hoven and Rowe disagree, I was impressed by one nurse-practitioner-in-training’s vision of a “better future” for healthcare :
“I am at an Ivy League institution and competed against hundreds of other outstanding candidates to come here, and my cohort is full of high caliber, intellectually strong individuals with a stunningly diverse array of life experiences to bring to their studies. I would put any of us up against any of the med students at this school in a battle of intellect and understanding. Our guest lecturers often come from the medical school, our anatomy class was taught by somebody from the med. school, and I would say that we are getting a superior education for what we are going to be doing.
“It is not a question of smart versus dumb, but a question of which philosophy of care you subscribe to. Nursing emphasizes treating the whole person, or whole family, and it emphasizes wellness, preventive care, and empowering individuals to take charge of their own health. My perception of doctors is that they are trained in recognizing and treating pathologies. My goal as an NP is to provide care for people such that they never develop the pathologies in the first place. If 1 in 7 healthcare dollars in this country is spent on treating chronic disease, then we need to address these issues BEFORE people get the Type II diabetes or CAD diagnosis. NPs can do that (come on, you know this next part is true), boring, less well-remunerated work that I do not see medical students signing up for in droves. Not many med students want to be Marcus Welby anymore.
“NP residencies are becoming increasingly common and available,” she adds. “I am all for an extra time after school to work under supervision, especially if it is paid the way that residencies for doctors are paid.
“I would highly encourage … any doctors who are skeptical about the value of NPs to talk to us, find out what we can actually do, instead of just assuming that NPs are not adequately trained. Collaboration and dialogue will advance the healthcare of the citizens of the US much faster than engaging in turf wars and belittling.”
I would add that these days, more family doctors are, in fact, being trained to engage the whole person –or the whole family—and to help patients learn to manage their own chronic diseases. But she is right, many internists have been taught to focus on diagnosing pathologies.
And I absolutely agree with her last statement: The future of patient-centered healthcare in America is all about collaboration and dialogue, both between doctors and nurses, and between caregivers and patients. We don’t have time for turf wars. There is too much to be done.
Being Part of a Team: Active Collaboration vs. Passive Cooperation
Both nurses and physicians have what Dr. Rowe calls “something special to offer.” Their experience and training is not comparable, but precisely because it is different, a NP or PA can complement an M.D.’s skills. Many doctors understand this, and believe that physicians, NPs and PAs should work together, in teams—as long as doctors call the shots.
For the American Medical Association, that last phrase is key. Although the AMA acknowledges that nurse practitioners can provide essential patient care, they believe that such care is most appropriately provided “as part of a physician-led team.”
The problem with the AMA’s position is that being part of a medical “team” is all about equality. Hierarchies dissolve. Everyone feels free to speak up, to say, “Excuse me, but I think we slid over the third point on the check list.”
A recent report from the Robert Wood Johnson Foundation (RWJF) quotes a NP talking about “the ‘moral distress’ a nurse may feel …seeing a surgeon rushing through, and skipping parts of, a safety checklist—and the ‘moral courage’ it can take to speak up. ‘A nurse who intervenes can make that surgeon very angry.’” She needs support from the very top of the hospital’s administration, and all too often, that is not forthcoming—particularly if the surgeon is a rain-maker..
The RWJF paper cities the Institute of Medicine’s 2010 report, The Future of Nursing: Leading Change, Advancing Health. It recommends an expanded role for nurses in improving patient safety: “nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States.” The report quotes Mary Jean Schumann, D.N.P, executive director of the Nursing Alliance for Quality Care (NAQC): “it comes down to the culture. Everyone needs to be heard. Too often,” she notes, “nurses are not in the room when solutions are devised and are brought in only when it’s time to talk about implementation.”
A study published in the American Journal of Critical Care suggests that some physicians just don’t understand that “collaboration” is all about “an interaction between doctor and nurse that ‘enable[s] the knowledge and skills of both professionals to synergistically influence the patient care being provided.’”
The paper describes a two-year project in an acute inpatient medical unit that divided patients into two wings. In one group a nurse practitioner was added to each inpatient medical team. The nurse practitioners accompanied the house staff in the morning on “work rounds” and attending physicians on teaching rounds
In the other wing, which served as the control group, there were staff nurses, but no NPs. Over the two year-period, physicians, staff nurses and NPs all answered surveys designed to determine the degree of communication and collaboration in the two groups.
The surveys asked caregivers to answer questions on a scale of 1-100 with “1” meaning “never” and 100 meaning “always”
–Did nurses and doctors plan together before making decisions?
— Did nurses and doctors share in decision making?
— Did nurses and doctors cooperate in decisions?
— Was there open communication between doctors and nurses in making decisions?
— Did nurses and physicians receive complete, accurate and timely information from each other?
— Did they enjoy working together?
–Did staff nurses find it easy to ask the nurse practitioners and attending physicians questions?
Their answers were very different, depending on whether a physician, a nurse practitioner, or a staff nurse was answering the questions.
Physicians in the group that included NPs reported greater collaboration with nurses than did physicians in the control group where there were no NPs. By contrast, nurses and NPs in both groups reported similar levels of communication with physicians. In other words, the nurses saw little or no improvement.
But staff nurses did report better communication with NPs than with physicians when NPs were added to the mix. Interestingly, physicians also reported improved communication and collaboration with other doctors in the groups where NPs worked with them.
In their summary the researchers (who were themselves physicians) observed: “the difference between physicians and nurses in their reports of a collaborative effort is striking.” The authors of the study tried to explain the difference, saying, “Physicians may define or view ‘collaboration’ in a different light than do nurses:
— “Perhaps the physicians thought that collaboration implied cooperation and follow-through with respect to following orders rather than mutual participation in decision making.”
— “Possibly, communication styles differ . . . so that physicians perceive collaboration whereas nurses feel they (ie, the nurses) are being ordered to do something.
— “Or, possibly the input the nurses gave was not valued or acted upon, and thus the interaction was not perceived by nurses as ‘collaboration.’”
Nevertheless, there was good news for patients: “In the group where NPs worked with physicians both length of stay and cost for patients fell, without an increase in readmission rate and without reductions in health-related quality of life and satisfaction.”
Nurses Practitioners and Physician Assistants Are Here to Stay
Despite the controversy, in the next few years, NPs and PAs will play a growing role in primary care. The simple fact is that we need them, and they are responding to the demand for their help. NPs are now the fastest-growing group of primary care providers, with NP students who plan to enter primary care graduating at three times the rate of their medical student counterparts.
Could we entice more med students to go into primary care by raising reimbursements? I don’t think the shortage of family docs is all about the money.
Median income for primary care physicians is now approaching $200,000. Half earn more; half earn less–sometimes much less. Many of those in the bottom half are underpaid; this is particularly true of young doctors who are struggling to pay off loans.
But in the top half, those earning more than $200,000, (and sometimes significantly more), are well-compensated, especially if they work for a large institution that covers their overhead and malpractice insurance.
A first-person post on Kevin M.D. titled “Why this medical student found primary care awesome, and boring” suggests that, even if we lifted median income for primary care doctors to, say, $250,000, most still wouldn’t choose family medicine.
Make no mistake: I am not suggesting that primary care is “boring.” Done well, it engages the finest minds (not to mention the stoutest hearts). The family doctor is a generalist who must know a great deal about everything.
But the post on Kevin M.D., reflects the reality of how many of today’s medical students view family medicine. (This is in part, because, in most of our medical schools, primary care is granted far less respect than the sub-specialties.)
By contrast, nurses are eager to go into primary care, and in October of 2010, the National Academy of Sciences’ Institute of Medicine (IOM) issued a report endorsing their role. The IOM found no evidence that the way NPs practice endangers patients and concluded that “now is the time” to allow nurses to practice to the full extent of their education and training without limitations by doctors.
The IOM recommended that state legislatures revise laws and regulations to let nurses expand their roles, and urged the Centers for Medicare and Medicaid Services to clarify that hospitals participating in the Medicare program must allow nurse practitioners to have clinical and admitting privileges and to be eligible to be on the medical staft. At the federal level, the IOM suggested that the Federal Trade Commission should identify state regulations related to advanced-practice nursing that have an anticompetitive effect without contributing to the health and safety of the public..
Meanwhile, the revolution already has begun on the ground. In a paper that focuses on “Implementing the IOM Future of Nursing Report,” RWJF observes that at Health Partners in Minnesota, (a health plan that garners high ratings from patients) nurses “once defined their roles as supporting particular physicians. Today their roles have been re-defined . . . HealthPartners hires NPs, physicians, and physician assistants to work as primary care providers.
Health Partners “also hires NPs to diagnose and treat common conditions via the Internet . . . . For primary care, this meant replacing a reactive, visit-focused approach with what HealthPartners calls the Care Model Process” . . . a highly respected model, which emphasizes the delivery of evidence based care to an informed and activated patient by a team of prepared and proactive practitioners.”
But will patients accept nurse practitioners? Health Affairs’ policy brief reports that “patients seeing nurse practitioners were found to have higher levels of satisfaction with their care.” If many patients are happy with NP’s, they will choose them, and acceptance will continue to grow. Patients, I think, will settle the matter.
If patients are wrong (and, let me stress that “patient satisfaction” is just one measure of healthcare quality), then critics will need to come forward with medical evidence showing that NPs are undermining patient safety.l.
At this point, few doctors argue that NPs cannot enhance care when working alongside physicians. Nevertheless the question remains: should NPS work alone?
In my next post on Nurse Practitioners, I will tackle that question. My initial response is “No caregiver should work alone.” But that is a simple response to a complicated problem.