As of early April, you can walk into Walgreens in 18 states (plus D.C.), and along with a gallon of skim milk, a pair of photo mugs, a six-pack of toilet paper, and a flu shot, you can meet your new primary care provider, get your cholesterol checked, pick up your statin, and schedule a return visit. That primary care provider will not be a physician but a nurse practitioner (or a physician assistant, but that’s for another article). Those states, and now Walgreens, have recognized that nurse practitioners can handle a lot more than antibiotics for urinary tract infections: They can practice primary care just fine without physician oversight. And it’s a pretty smart move.
Lagging behind are the other 32 states (this map lays it out), in which nurse practitioners are supervised to varying degrees by physicians, the scope of their practice restricted by laws that vary from state to state. In some states, nurse practitioners can’t enroll a patient in hospice, order a wheelchair, or prescribe certain medicines without a doctor’s signature. This is true even when it’s impractical geographically and financially, not to mention belittling. Nurse practitioners in a number of states, including Connecticut, Nevada, and West Virginia, are currently pushing for legislation for the right to practice independently and improve access to care.
The time is ripe: Despite new medical schools designed to attract students interested in primary care, the long dwindle of interest in the field has left a gaping hole, and it’s growing. When an additional 32 million or so Americans are covered through the Affordable Care Act next year, the primary care physician shortage could be catastrophic; it’s estimated to climb as high as 45,000 too few primary care physicians by 2020. Anyone who’s looked for a new physician recently has probably heard some variant of this: “The doctor isn’t taking new patients, but you can see the nurse practitioner or the physician assistant.”
When I called Linda Pellico, associate professor at the Yale School of Nursing and director of the Graduate Entry Prespecialty in Nursing program, she didn’t mince words. “Lifting the barriers on the scope of practice will solve the health care dilemma,” she said, pointing me to the nearly 700-page 2010 report by the Institute of Medicine called “The Future of Nursing.” The document, co-authored by Donna Shalala, recommends that nurse practitioners practice independently, without restrictions, to the “full extent of their education and training.”
The nurse practitioners I’ve worked with as colleagues (I’m a primary care doctor, and I’ve practiced in clinics in Baltimore, New York, and Connecticut), and those who have taken care of me have been pretty awesome. When I was pregnant, I saw a middle-aged lanky nurse midwife who had a wry and down-to-earth sense of humor. He didn’t exude that sense of impatience that you get with so many doctors, that feeling that you’re holding him up from something more important. When I have questions about my very old patients, many of whom have dementia complicated by agitation or insomnia and who are not responsive to my usual bag of tricks, my go-to person is not a psychiatrist—she’s a gerontological nurse practitioner.
For some doctors, a larger number of independent nurse practitioners would be great news: John Schumann, a general internist who runs the University of Oklahoma–Tulsa internal medicine residency program, told me that he welcomes all hands on deck: “We should be happy when people from other career lines want to work in primary care. Primary care is hard and undervalued, and doctors should not have a monopoly on it.”
So I was surprised when some of the most open-minded doctors I know hesitated before offering their take on the issue. Most echoed some of the concerns of the major physicians' organizations: If collaboration with a physician becomes optional, will nurse practitioners know when to ask for help? And if primary care doctors need to attend four years of medical school and three of residency, can just three years of nurse practitioner postgraduate training create competent clinicians?
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Happy Constitution Day!
Too bad it’s almost certainly unconstitutional.