The latest chapter in the nurse practitioner scope of practice debate played out in the pages of the Wall Street Journal earlier this week. Angela Golden, president of the American Association of Nurse Practitioners (AANP), and Reid Blackwelder, MD, president elect of the American Academy of Family Physicians (AAFP), answered the question “Should nurse practitioners be able to treat patients without physician oversight?”
As expected, Golden took the affirmative side of the debate, while Blackwelder took the stance that nurse practitioners should continue to work in a team environment with physicians. The two sides disagreed over points such as cost effectiveness, education and training, outcomes and patient satisfaction, as well as whether nurse practitioners can ease the primary care shortage.
Blackwelder cited a recent study in the journal Effective Clinical Practice that showed patients treated by nurse practitioners use more medical services that those treated by physicians. Patients assigned to nurse practitioners had 13 more hospitalizations annually for each 100 patients, and 108 more specialist visits than those who were treated by physicians. Golden said any research that suggests nurse practitioners are not cost-effective providers is statistically insignificant considering there is four decades worth of research that shows otherwise. She also states nurse practitioners typically treat patients with chronic conditions, which could explain their high use of medical services. Golden also says requiring physician supervision causes redundancies that contribute to high costs and waste in the system.
Education and Training
Golden contends that although nurse practitioners’ training is less extensive, it is focused. Nurse practitioners focus solely on one specialty throughout their graduate education and clinical training. On the other hand, physicians participate in several rotations that are “peripheral to the care they ultimately deliver.” She also states nurse practitioners are more likely to pursue primary care than physicians. Blackwelder said primary care physicians’ extensive education and training allows them the ability to consider many possibilities, make a diagnosis, and create a comprehensive treatment plan for patients with undifferentiated complaints.
Outcome and patient satisfaction
Golden cites independent research that says nurse practitioners receive higher patient satisfaction scores than physicians and produce clinical outcomes that are similar.
“For example, a study published in 2000 by the Journal of the American Medical Association compared the care and the resource utilization of nurse practitioners and physicians for randomly assigned patients over a two-year period. The study found no differences in health status physiologic measures, satisfaction, or use of specialist emergency room or inpatient visits.”
Blackwelder claims that the many of the outcomes referenced in the studies are from models where nurse practitioners are collaborating with physicians, and that the work of many nurse practitioners begins after a physician has already made a diagnosis. He says monitoring patients with stable chronic conditions is the appropriate role for nurse practitioners.
Easing the physician shortage
Golden contends that independent nurse practitioners will become critical when the Affordable Care Act takes full affect, and millions of Americans seek primary care services. Allowing nurse practitioners to practice independently will expand access to primary care at no cost to the taxpayer and no risk to the patients. Blackwelder says independent nurse practitioners will not solve the primary care shortage. He says states that have allowed nurse practitioners to practice independently still have primary care access problems. He also noted that nurse practitioners are beginning to favor specialties over primary care, which will exacerbate the primary care shortage.
Readers weigh in
My favorite part of the piece is the reader poll that asked readers, “What do you think about being treated by a nurse practitioner?”
- 65% Have used them and have confidence in them
- 21% Have used them and don’t have confidence in them
- 8% Haven’t used them and wouldn’t have confidence in them
- 6% Haven’t used them and would have confidence in them
It is interesting that of the readers who have used nurse practitioners are mostly confident in them, while those who have not are less confident.