Free the Nurse Practitioners to Do Primary Care on Their Own

What women really think about news, politics, and culture.
April 18 2013 8:14 AM

Free the Nurses

One answer to our health care crisis: Let nurse practitioners do primary care on their own.

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But making a head-to-head comparison is tricky. Unlike the broader and basic science-heavy education of medical students, nurse practitioner students (many already having a few years of nursing experience) get practical right away and select a specialty— such as pediatrics, geriatrics, anesthesia, family, or midwifery—immediately upon beginning their training. During the corresponding years, medical students are studying subjects like embryology and biochemistry and learning the basics of how to talk to patients. Once nurse practitioners graduate, some opt for a year of additional training in a nurse practitioner residency program. (Newly minted doctors at that point will have chosen a residency specialty and will embark on at least three more years of training.) A few more years in training and nurse practitioners can earn a doctorate in clinical nursing—a DNP, which the Institute of Medicine report recommends for all advanced-practice nurses as of 2015.

Meanwhile, medical training is getting a makeover, so the difference between nurse practitioners and doctors—at least in terms of years of training—is lessening. The 100-year-old paradigm is on the chopping block in many medical schools, and some schools and hospitals are already cutting the length of med school and residency training. (Let’s not even get into the outdated prerequisites for med school. Suffice it to say that I learned more about caring for patients by reading Chekhov than studying organic chemistry.) According to Ezekiel Emanuel, doctors' training could be shortened by about 30 percent. Medical-school graduates of six-year training programs (which collapse the usual eight years of college and medical school into six) don’t do any worse on board exams; some schools already offer a three-year track. For internal medicine residency, Emanuel argues that three years is unnecessary; many programs have long offered two-year “short-track” options for residents eager to jump into a specialty, so why should training for primary care be any different? In my primary care residency, I spent many months on inpatient and intensive care unit rotations. This made more sense in the mid-1990s, when most primary care doctors still rounded on their own hospitalized patients. Nowadays, with hospitalists running many of the inpatient wards, many primary care physicians are becoming almost exclusively outpatient. 

The Institute of Medicine report highlights a number of studies that show that nurse practitioners provide as good care with as good outcomes as primary care physicians, along with high rates of patient satisfaction. In one of the most-cited studies, 1,316 mostly Hispanic patients were randomly assigned to see either doctors or nurse practitioners, and the outcomes of patients with diabetes and asthma were about the same. But the trial only lasted six months, which is a pretty short period of time in primary care for drawing conclusions about disease management and the patient-provider relationship. Whether you can extrapolate these findings to patients of different ages and backgrounds and to all of the chronic conditions that surface in primary care (and Walgreens) remains unclear.

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Primary care is not an easy field to master; the breadth and depth of knowledge is vast, unlike the narrower world of the shoulder specialist, who only sees patients with shoulder problems. Sure, every now and then there’s the glamour of cracking a diagnostic mystery case, the chance to dredge up some obscure and critical fact buried in our overloaded brains, but most of the time it’s like this: We talk. We listen. (Hopefully, we listen more than we talk.) We treat common illnesses and try to prevent chronic ones. We learn about where our patients live, what they eat, who they talk to, how they get around. We listen to the patient whose marriage is on the rocks and relate this to her elevated blood pressure. We coordinate care and help devise a plan when multiple specialists are giving different and sometimes contradictory recommendations. We make a lot of phone calls and answer a gazillion emails. When we’re not sure about something, we look it up, or knock on a colleague’s door, or call across town or across the country. And because primary care is all of these things, an ever-evolving conglomeration of medical knowledge and systems and empathy and integrity and creativity in problem-solving, this is precisely why it’s good to mix it up and reap the benefits of some nurse practitioner-doctor hybrid vigor.

This is why I think nurse practitioners should be released from their arbitrary bondage and do what they are trained to do, what they’re board-certified to do, and what many do so well: take care of patients and collaborate with physicians because they want to, not because they have to. Nurse practitioners and doctors should welcome each other’s perspectives, experiences, and abilities. As physician assistant and researcher Roderick Hooker told me in an email, “America is a nation of innovators and the advancement of medicine and nursing are no exceptions. Nurse practitioners and physician assistants are part of the social experiment to deliver healthcare in beneficial and effective ways. The independence of [nurse practitioners] is merely another step in this social experiment."

It’s time to unlock the gates to the primary care club. There will be plenty of patients for everyone.

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