Monday, August 3, 2009

Nurse Practitioners NOT the Answer for the Primary Care Crisis

Time recent article titled, "If a Health-Care Bill Passes, Nurse Practitioners Could Be Key" bothered me not because I see nurse practitioners as competitors. It disturbed me because the article had elements of truth to it and yet reached the wrong conclusion.

"[Nurse practitioners - NPs] can often treat and diagnose patients, as well as prescribe medication. And they can do these things at a lower cost than doctors — Medicare, for example, reimburses nurse practitioners 80% of what is paid to doctors for the same services."

This is true. Problem? The issue isn't about how much the primary care provider makes but rather how many tests, imaging studies, and medications are ordered that drives overall healthcare costs (as noted recently in Atul Gawande's New Yorker piece).

While there is no question that NPs generally are far better than doctors with bedside manner, good bedside manner and focus on prevention isn't going to stop healthcare costs from rising.

In my experience, these primary care providers, which Congress includes NPs and physician assistants (PAs), are very skilled when part of a team of specialty care, like orthopedics, hospice, oncology, neurosurgery, etc. Their depth of knowledge is typically far more than a primary care doctor has, which makes sense.

However, I've noticed that when it comes to the field of primary care these alternative primary care providers don't do particularly well unless the diagnosis is very straight forward.


The challenge in primary care (and often why many colleagues of mine wonder why I find primary care so interesting) is the level of uncertainty that exists with every patient encounter. When someone walks in the door, you haven't the foggiest idea what you are dealing with. What Clay Christensen calls "intuitive medicine" relies heavily on the doctor's cognitive and deductive reasoning skills. As medical students know, 90 percent of getting the right diagnosis is from the patient history and the physical exam. At this point, a doctor has a list of working hypotheses or what is known as a differential diagnosis of the possible causes of a patient's symptoms. If lab work and imaging studies are needed, then they are done to help clarify the diagnosis in situations where there are at least two plausible causes and the treatments vary drastically enough that knowing precisely what is wrong matters.

As the TIME article notes, "Nurse practitioners may have less medical education than full-fledged doctors, but they have far more training in less measurable skills like bedside manner and counseling."

When it comes to primary care, less medical education, in my experience for NPs and PAs while many be less expensive per provider in terms of salary are usually more expensive in testing, lab work, and medication. I don't fault them any more than I fault my colleagues going into specialty medicine. Primary care is a really tough field.

Perhaps that is the real issue. Primary care is often seen as easier and hence replaceable by other less expensive providers when it should be looked at as a very cognitive specialty that deserves the same level of respect as others. No one talks about cardiology NPs or oncology NPs being the primary care providers in those specialties.

The crisis in primary care is real. If healthcare reform was serious about increasing the number of primary care doctors now, there are many doctors in training in the pipeline now in medical schools and interns. Immediately wipe out their medical student loans, give them a stipend, and a short commitment in underserved areas so they all have incentive to commit to primary care rather than think about fellowship training in a specialty field. (Because of the shortage of primary care doctors in Massachusetts after universal coverage, I suppose working in that state should count). Add bonus payments to the second and third year internal medicine residents so that they seriously think about dropping their fellowships.

There is no question that doctors must improve our bedside manner and our focus on prevention. NPs and PAs do have a role. It isn't in "intuitive medicine" but rather "precision medicine" where clear rules and treatments apply. Strep throat and bladder infections (known in medicine at UTI - urinary tract infections) can be done by these providers as well as allowing them to counsel and focus on wellness and prevention. No doubt this is why they were chosen to run the walk-in retail clinics found at Target and Wal-mart.

But, don't equate their skills to be comparable to a well-trained primary care doctor when it comes to figuring out what is wrong with you. In my experience they tend to order more tests, more medications, and more imaging, which then begets more tests, more medications, and more imaging. The cost per provider may be cheaper, but the cost to the entire healthcare system is more expensive.


Michael said...

There are some valid points you have brought out but as the article you mentioned, with some inconsistency. Practitioners in many states are restricted in the way they practice, including what they can order, bill and even how they prescribe medicines. Often times they fall under the auspices of the medical profession and they dictate what they can order.
Mid levels can be unsure of themselves simply because they have been caught up in the politics between the AMA and politicians. All we want to do is take care of people, not compete for the almighty dollar!


Anonymous said...

I would think that NP's are capable of "intuitive medicine" as well, if they are at a certain level of expertise in their chosen specialty or field. It really comes down to individual clinical experience. As a nurse, I've known some absolutely brilliant NP's. I can tell you that I believe that the current educational process for NP's should be lengthened, there should be more experience required (I don't think you should be allowed to go to NP school w/o atleast 5 years experience, and I think you should have work experience in the ICU setting). The most brilliant, intuitive NP's I have ever worked with had years of nursing experience, most in ER and ICU. This is beneficial to them when they step into their new role. Overall, I value primary care doctors very much and agree that they should be supported so as to grow the profession.
I have to say that I think NPs are actually superior to physicians in acute care settings in caring for patients post-operatively, I have worked with them in surgical units, and they work beautifully with the nursing staff to ensure terrific care....I believe pt. issues like pain, constipation, infection control, etc are much better cared for with a NP (not PA in my exp.!) working along side. And safety issues/sentinel events are decreased.

rene' said...

Your "evidence" is subjective and anecdotal. See the Literature( research ) in this area lots if it out there. NPs have better Dc and Tx rates w/ less dollars based on their holistic approach. Fewer unneccessary tests better satisfaction than phys based care

Anonymous said...

Ah, seriously? NPs may not have as much medical training, but hey, theyre great at bedside manner. Im not a doctor. But when I want primary care, or any other care, I dont need bedside manner, I need a properly trained, board certified physician. I dont want some half trained Kook with a kindly bedside manner ruining my body.

I cant believe anyone is even thinking of this seriously.

What is a Nurse Practitioner? A physicians Assistant? WHy create all these fancy names for people WHO ARE NOT DOCTORS? I dont want to be doctored over by Sally Mae playing doctor in a Lab suit.

Anonymous said...

MDs seem to really be afraid of NPs. I think because they NPs can do just as a good a job if not better for a whole lot less money. And the MDs, who like their big paychecks, are getting worried that they might not be necessary since NPs can do the same job they can do at 1/10th the cost to patients and society. Greedy greedy greedy MDs

Davis Liu, MD said...

Nurse practitioners certainly can be excellent, however, in my experience that isn't the case in the broad clinical aspect of primary care. As for the comment about greedy MDs, I have never seen salaries of NPs to be only 10% (that is 1/10 as anonymous posted) of doctor's. They are often very similar and in some cases more.

Given a choice, I advise no one in my family to see a NP in primary care. As a primary care doctor, I don't believe that they can have the depth of clinical expertise in this specialty which can be the most challenging.


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