Tuesday, June 23, 2009

Primary Health Care Defined

Once again, a debate is reignited about physicians versus nurse practitioners over at A Happy Hospitalist's blog. I'm not getting into a contest of who is smarter than who. I have always acknowledged that a physician's education is longer than that of a nurse practitioner's. My education and training has prepared me for a career in primary health care - a field that I am passionate about, am constantly trying to increase access to and one that I'm good at. Primary care is part of that vision of primary health care. There are many definitions of what "primary health care" is and the one that I use is not made up by me in my fairy tale world - it is the one that the World Health Organization defines as:

    • reducing exclusion and social disparities in health (universal coverage reforms)
    • organizing health services around people's needs and expectations (service delivery reforms)
    • integrating health into all sectors (public policy reforms)
    • pursuing collaborative models of policy dialogue (leadership reforms); and
    • increasing stakeholder participation

I believe in treating people equally and fairly. I don't treat them as disease, illness, number or an inconvenience in my day. I provide culturally competent and evidence-based practice. I recognize that an individuals culture may have an impact on a prescribed treatment or intervention.

I don't pass myself off as a physician. New York State says that I have showed competency as a nurse practitioner in Family Health, have thus received certification with prescriptive privileges and ultimately national board certification. I'm not making it up as I go along. I don't know it all and am honest and open about that. But I'd be damned if I send a patient back out there without a plan or without collaborating with other members of the health care team. Maybe the word "independent" is the issue. I say, anyone who thinks they practice anything independently will not get very far. The health care system is just that - a system. A system that relies on one another, of different disciplines in the common interest of patients. No one discipline "owns" health care. Would that word "autonomous" be less threatening? I'd be happy to use that describing my practice if we can ultimately work together and make a damn difference in the work that we do.

My education, that is on-going and what I consider life-long, hasn't prepared me to be a physician. As an NP, my education and practice is blended of both nursing and medicine. If/when I am sick, I seek care from a team of providers that is best prepared to assess and treat me in a partnership at that particular time and place.

Maybe I am still too idealistic after 10 years of NP practice. But you know what, that's the stance that I'd rather take than complaining about patients, the staff that I work with and our payment structure (not that some of those issues aren't worth complaining about).

So for now, I choose to focus my energies on trying to improve this health care system and finding ways to ensure health for all.


Anonymous said...

In no way is my comment intended to get into an argument about the capabilities of physicians versus nurse practitioners, since I agree with you that each are valuable parts of a health care team and continuum.

I would point out, though, that the WHO definition of primary care could actually be met by an MBA with no medical training at all. The WHO definition's yard stick of health care need is much lower than experienced in most developed countries.


Jane Know said...

I'm not sure I understand how the WHO definition of primary care could be met by an MBA with no medical training. Could you explain that a little more? Do you mean on a theoretical level or a practical level (with an MBA actually providing health care that would help eliminate health disparities)?

Whitny said...

Hi, I guess I'm a little late to this debate--I just found your blog, y'see. I'm an NP student... I always intended to go to med school after becoming a nurse and I finished my prereqs for med school and took my MCATs and everything but decided to go with an FNP program because I love nursing, I love nurses, I love the place where nursing meets medicine, and I wanted an education that honored my nursing background. Anyhow, reading this debate made me a little nervous...HH spewed some vitriol about the NPs lack of "training" (he seems to use training and education interchangably here, though). I began to wonder if I've made the wrong decision, if I'm going to woefully underprepared for primary care. I don't want to function as a 2nd year resident (as one MD commenter described his impression of the "good" NPs he's worked with), nor do I want to subject my patients to my early-career learning curve. Newly-minted doctors get the benefit of a residency... now new RNs have the opportunity to complete a nurse residency program at many hospitals as well. What about NPs? I guess my questions are: 1) Did you ever or do you feel underprepared for you job? Now, I know feeling underprepared is normal for everybody at some point in their career (even MDs), but I mean, have you ever been in a dangerous situation because of your education, or is HH just bitter, misinformed, self-righteous, threatened and biased? My father is a doctor (a surgeon) and he gave me the impression that the NPs he works with are absolutely outstanding. 2) Have you heard any substantial chatter about residency programs for new NPs?

Thanks, and I am loving your blog so far.

Stephen Ferrara, NP said...

Hi Whitny,

As you states, it's normal to have the feelings you are experiencing at this point as a student.

Any uncomfortable situation I've encountered, I had the luxury of having a supportive team to collaborate with. I think it is imperative for a newly minted NP to have a very clear understanding of the support structure at their first job. Don't jump at the 1st offer you get - this is vital to your professional growth and development.

I haven't heard anything substantive about NP residencies yet. I am sure there will be hybrids of a residency-type program. If primary care is your thing, I feel that spending time in the hospital is not where you should be spending the bulk of our time. Yes, its important to know complex diseases and comorbidities but our goal is to ensure that they dont get to that point.

Thanks for reading and your comments. Good luck and feel free to ask any questions you may have,