Nurse practitioners are staffing retail health clinics, diagnosing and treating ills from strep throat to conjunctivitis. They’re giving flu shots and prescribing drugs. And the influential Institute of Medicine says they should not only work side by side with physicians, but replace them in some cases.
But a survey published on Wednesday shows a huge gap between what nurse practitioners think they can and should do, and what doctors think. And that’s bad news for patients, Karen Donelan of the Mongan Institute for Health Policy at Massachusetts General Hospital says.
“We were surprised by the level of disagreement reported between these two groups of professionals," says Donelan, who led the survey published in the New England Journal of Medicine.
Her team’s survey of 467 nurse practitioners and 505 physicians found both groups agree that nurse practitioners should practice “to the full extent of their education and training.” Where the disconnect comes is just what this training should allow them to do, and how much they should get paid for it.
Only 17 percent pf physicians agreed that nurse practitioners should coordinate a patient’s care as a leader of a “medical home”, versus more than 82 percent of the nurse practioners, the survey found. And only 3.8 percent of doctors felt that a nurse practitioner should be paid the same for providing the same service as a physician, compared to 64 percent of the nurse-practitioners.
“At the core of the controversy is whether nurse practitioners have the education and experience to provide high-quality services and lead clinical practices without supervision by a physician,” Donelan’s team wrote.
The Institute of Medicine tried to settle that question in a 2010 report, saying that nurses can handle much of the strain on the health care system and should be given both the education and the authority to take on more medical duties.
But the American Medical Association, which represents about 120,000 practicing physicians and students, rejected the idea immediately.
"Nurses are critical to the health care team, but there is no substitute for education and training," the AMA said at the time.
The Association of American Medical Colleges estimates that by 2015, the United States will be short about 62,100 physicians. Many experts are looking to the 180,000 nurse practitioners now in the field to help cover the gaps.
When the Robert Wood Johnson Foundation set up a series of meetings among doctors’ and nurses’ guilds to try to smooth out the disagreements in 2011, things looked up until the organizers issued a report urging less hierarchy, says John Iglehart of the journal Health Affairs in a separate commentary in the New England Journal. “The `captain of the ship' notion … needs to be eliminated, focusing on the patient as the driver of care,” the report read. “A physician, nurse, social worker or other provider may take the lead in a given situation.’
The American Academy of Family Physicians, American Osteopathic Association and the American Academy of Pediatrics pulled out and the whole attempt collapsed, Iglehart says.
Dr. David Blumenthal and Melinda Abrams of the Commonwealth Fund said the survey confirmed that doctors and nurse practitioners often “inhabit different universes”. And clearly they have different training and skills. Nurse practitioners, often referred to as advanced practice registered nurses, usually have a four-year bachelor's degree with at least a master's degree and sometimes a doctorate beyond that, depending on the requirements of their state.
But nurse practitioners can fill the growing gap in the supply of health care prviders for the U.S., they argued. “The existing literature shows that nurse practitioners provide care similar to that of physicians with respect to health outcomes, resource utilization, and cost, and the same studies show that nurse practitioners get higher grades than physicians with respect to communication with patients seeking urgent care,” they wrote.
Jan Towers, policy director for the American Association of Nurse Practitioners, saw it coming. “There is nothing surprising there,” she said in a telephone interview. “The disconnect has been there a long time.”
She thinks relationships will improve as doctors and nurse practitioners work together more. A bigger issue, Towers says, is the way the U.S. healthcare system pays for care. “How do we institute value-based purchasing so that we look at outcomes rather than who is performing the task?” she asked.
Once the medical system evolves toward taking care of a patient’s health, instead of the current system of paying for each individual test, treatment or consultation, the differences should even out, she predicts.
Donelan isn’t so hopeful. “Our findings suggest that a substantial number of primary care physicians are unlikely to embrace policy recommendations aimed at further expansion of the roles and supply of nurse practitioners,” her team wrote.
“In particular, physicians' concerns about the likely effect of an expanded workforce of nurse practitioners on several aspects of health care quality need to be addressed in discussions of strategy for the development of the U.S. health care workforce.”
Peter Buerhaus, director of the Center for Interdisciplinary Health Workforce Studies at Vanderbilt University and a registered nurse with a Ph.D who worked on the survey team, agreed.
"It is unsettling that primary care physicians and nurse practitioners, who have been practicing together for several decades, seem so far apart in their perceptions of each other's contributions. I am concerned that these large gaps in perceptions will inhibit efforts to redesign care delivery and to improve the productivity and configuration of the primary care workforce,” Buerhaus said in a statement.