I Took the Bait

I have tried to refrain from taking the bait from some recent negative opinions regarding nurse practitioner delivered care. Quite frankly, the arguments are old and tired. My goal as a clinician is to deliver the highest quality, evidence-based, and culturally competent care that I am capable of. I refuse to pit NPs versus other professions. We all have our own slightly varied philosophies and approaches to delivering care. Some may prefer the approach of a DO while some choose to see a NP or PA or MD. I believe patients have that right. However, I cannot believe the nonsense and out of context rubbish posted on the AMA's "Virtual Mentor" in a column entitled, "The Primary Care Shortage, Nurse Practitioners, and the Patient-Centered Medical Home." Oh, where to begin!

The opinion piece begins with the patronizing idea that NPs are part of the solution but not THE solution to the primary care crisis in this country. Funny, but I couldn't find a single reference that states NPs want to solely take over primary care. It goes on to give a functional definition of primary care and states:

Primary care serves four important functions in the delivery of health care: (1) first contact access for each new medical need, (2) long-term, person-focused (not disease-focused) care, (3) comprehensive care for the majority of a person’s health related needs, and (4) coordination of care when it must be sought elsewhere.

Wow, that sounds an awful like what NP philosophy is grounded in:

NPs diagnose and treat a wide range of health problems. They have a unique approach and stress both care and cure. Besides clinical care, NPs focus on health promotion, disease prevention, health education and counseling. They help patients make wise health and lifestyle choices. They are truly your Partners in Health. In addition to being top-notch healthcare providers, NPs deliver a unique blend of nursing and medical care. They provide comprehensive, personalized health education and counseling. NPs assist patients in making better lifestyle and health decisions.

The next statement in the piece is truly baffling:

Primary care physicians are the only medical professionals who provide patient-centered, integrated, accessible health care that addresses the large majority of patients’ needs in the context of a sustained partnership with the patient and the community [2].

Huh?!? Is that your opinion or is that paraphrased? That reference comes from Donaldson MS, Yordy KD, Lohr KN, Vanselow NA, eds. Primary Care: America’s Health in a New Era. Washington, DC: National Academy Press; 1996.

I could not find any mention of that within the reference. Unfortunately, there is no page number to cite it from. In fact, reading through this very reference, I found:

...[the] definition of primary care...is presented in terms of the function of primary care, not solely in terms of who provides it" (p. 2).

These authors go on to say that critical elements of primary care include: "services provided by primary care clinicians - generally considered to be physicians, nurse practitioners, physician assistants - but involving a broader array of individuals in a primary care team..." (p.2).

The next few paragraphs suggest that primary care by primary care physicians is *better* than care delivered by anyone else. Of course, these studies aren't even looking at physician-directed care - they just underscore the need for primary care.

Here is another great quote:

Policy discussions about ways to increase the primary care physician workforce have considered utilizing nurse practitioners to address the shortage of primary care physicians. Nurse practitioners are part of the answer, but they are not the solution. Although nurse practitioners provide some types of care that primary care physicians do, their training is very different. There are limits to a nurse practitioner’s ability to deliver the full-service, comprehensive care delivered by primary care physicians.

The limits to a NPs ability to deliver this care has nothing to do with education but oftentimes is restricted by antiquated statutory regulations. Requiring a collaborative agreement costs practices time and money requiring physicians to co-sign charts, which is not a good use of anyone's time, is retrospective, and has no evidence to support enhanced quality in any way.

Next the author mentions the 2004 Cochrane systematic review, "Substitution of doctors by nurses in primary care." A systematic review attempts to use a non-biased systematic approach to review the available evidence from previously completed studies. I am certain that this author did not even read the full review since their criteria was looking for data from the period of 1966-2002 (he sites the lack of "recent" data) and in total only 16 studies were used for inclusion methods (he makes it seem as if the evidence was robust). Incidentally, the review didn't just examine NP care - it also looked at registered nurses trained in primary care and clinical nurse specialists). Incidentally, the reference list in this study has the authors names misspelled. I am also perplexed by this statement:

By comparison, the studies cited above on outcomes in primary care have demonstrated improved patient outcomes with an increased primary care physician workforce [4, 6].

Now maybe its my little NP incapable brain that cannot comprehend all of this data but the aforementioned studies DID NOT EVEN MAKE THIS COMPARISON as he purports! Again, I checked those references and could find no such information.

Next, the author refers to some fuzzy calculations that NPs going into primary care is declining. While this may be true, it is because the NP profession has had explosive growth over the last 10 years and there is no way that it could be sustained. It has also been traditionally difficult to gather accurate data on NPs in the workforce. So, yes, the numbers are declining but not because we are choosing not to go into primary care. In fact, one estimation states there are collectively more NPs and PAs providing primary care than they are family physicians (Green LA, Dodoo MS, Ruddy G, Fryer GE, Phillips RL, McCann JL, et al. The physician workforce of the United States: a family medicine perspective. Washington, D.C.: Robert Graham Center, 2004.)

Finally, the author uses the current buzz-term, the patient-centered medical home, to suggest a physician-centric approach utilizing NPs as "vital team members" will somehow meet the demands of the primary care crisis. This statement is patronizing, is simply misaligned with the definition of primary care and is anything but "patient-centered." If it's truly patient centered, I say let the patient have a say in the provision of care.

To sum, I am woefully disappointed that such a crudely researched article with out of context facts is allowed to be published on a professional organization's website. The Virtual Mentor (VM) "explores the ethical issues and challenges that students, residents, and other physicians are likely to confront in their training and daily practice." This type of rhetoric only begets further silos among disciplines and misrepresents the nurse practitioner profession where ultimately coordination of care and communication is compromised. Shame on them.

I just had to get that off my chest.