Doctors vs. Nurses: A primary healthcare debate

Examining the growing independence of nurses under a microscope. With doctors gravitating towards high-paying specialties and the continued shortage of medical personnel, will nurse practitioners (NPs) or physicians assistants (PAs) replace the primary care physician in the future? In some states, nurse practitioners can already open independent clinics where they diagnose and treat patients, and write prescriptions. Like it or not, this controversial practice could cure many of our burgeoning healthcare issues.

Are nurses pushing the envelope?

Nurses have always had to fight for respect. Patients and doctors alike may perceive them as inferior, less educated and sometimes less intelligent as a result, but the truth lies in the individual. As in every profession, some nurses, like some doctors, are supremely competent, while others in both professions are less so.

Like doctors, nurses endure years of education and arguably more hands-on training and patient interaction. Nursing organizations across the nation are often accused of trying to push the boundaries of their profession, presumably eating into doctor profits. The American Nursing Association (ANA) denies this, insisting that nurses just want to perform the jobs they are trained and qualified for. Some of the issues on the table include nurses leading home practice and clinic operations free of doctor supervision like those in Alaska, Arizona, Colorado, Connecticut, District of Columbia, Hawaii, Idaho, Iowa, Maine, Maryland, Minnesota, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Dakota, Oregon, Rhode Island, Vermont, Washington and Wyoming, where nurse practitioners can legally write prescriptions. In practice, hundreds of thousands of patients in every state make doctor appointments and never see the doctor for minor complaints. Instead, they see a nurse practitioner in the doctor’s office. The number of primary care physicians is shrinking rapidly as medical students are lured by the big paychecks attached to specialty care, leaving people suffering from common ailments like pink eye or a virus with nowhere to turn.

Beginning in 2030, baby boomers will be older than 65 which will expand the size of the older population to the extent that one in every five Americans is projected to be of retirement age..3 Americans are becoming increasingly concerned over a growing medical crisis as aging baby boomers retire from the medical profession and require additional medical care, while at the same time the Affordable Care Act (ACA) is giving more people the opportunity to seek medical care for common ailments. More patients and fewer medical personnel could result in very big problems very soon. Clinics ran and staffed by nurses, NPs and PAs could provide an answer to the primary care physician shortage, leaving doctors free to specialize while lowering overall medical costs for patients with ordinary complaints.

Ethics and trust play a large part in the working equation. NPs and PAs are bound by law to refer patients outside their area of expertise to a physician, so the vehicle is already in place to ensure quality healthcare.

Physicians argue yes.

Some doctors and doctor associations have spoken out publicly against nurses acting as doctors, making a point that 11+ years of schooling trumps a nursing education and affords more comprehensive diagnostic skill, which is a valid concern. Dr. Ted Epperly, President of the American Academy of Family Physicians who runs a multi-clinic general practice in Boise, Idaho said, “The nurse practitioner replacing the family doctor is not good for America. To say a nurse practitioner can fill the shoes of a family physician, in terms of comprehensiveness, is just not true.” 4

Registered nurses are required to have about 1/3 the years of schooling required for doctors, a bachelor’s degree plus residency. A nurse practitioner is a registered nurse with more advanced education—at minimum a master’s degree—plus residency and training in the diagnosis and management of a wide range of common medical conditions and chronic illnesses; but still has a good deal less education and training than any doctor.5 The common fear is that less education could translate to a significant deficiency in diagnostic skills, resulting in misdiagnosis and inferior patient care. The controversy may be due in part to state regulations concerning the duties of PAs and NPs. Without established federal guidelines, in some states, PAs and NPs have far more latitude than in others. PA and NP duties already parallel those performed by a general practitioner in several areas of the country.

These duties may include:

• Wellness checkups and care for children and adults
• Primary care for children and adults for common illnesses and injury
• Performing diagnostic tests and ordering lab work
• Counseling and educating patients and advising treatment options
• Administering immunizations for children and adults
• Requesting and evaluating medical histories
• Conducting physical exams
• Diagnosing, treating, and managing chronic or acute illness and disease, such as diabetes and high blood pressure
• Prescribing and administering medications
• Providing prenatal care and family planning services
• Performing minor surgeries like suturing and casting
• Providing referrals to physicians, specialists or physical therapists

The question is whether allowing physician assistants and nurse practitioners to act independently would be a good thing for the medical profession and for the public. Earning the Ph.D. required to become a physician involves an intimidating 11-14 years of schooling and residency 6 and comes with a staggering price tag. For some, it’s a calling, something they feel they were destined for. For others, the price and long years of schooling are not a problem due to family wealth or ideological views, and for a few truly gifted individuals, much of the associated costs are covered by scholarships or grants. For the majority, however, the burden of cost and time alone mitigates the decision to become a physician. Pair that with limited entry opportunity into higher medical education, and you have a convincing argument for choosing either nursing or physician specialization, since specialists generally make more money to offset student loans and the ridiculous cost of malpractice insurance.

So what do the patients think? From the patient perspective, there is growing frustration at the medical personnel shortage. It has become increasingly difficult to find a doctor for primary care, and requesting to see a specialist can take up to six months. In addition, people often need ongoing care for a number of different ailments. Seeing half a dozen specialists to treat a combination of ongoing issues like hypothyroidism, allergies, back pain management and gastric distress, can add up to outrageous co-payments even with the best possible insurance. Specialists are certainly the answer for diagnostic issues and critical care, but a medical professional—either a nurse or a general physician—able to address a number of ailments in a single visit is more likely to fit the time schedule and budget of the average person. This may explain why low-cost, quick-service clinics able to see patients the same day are becoming increasingly popular.

Weighing the implications.

What would federal guidelines releasing nurse practitioners from doctor supervision mean to the nursing profession? It could help encourage students to enter the profession and result in more people willing to stake their futures on a nursing degree, which could relieve the growing medical personnel crisis.

Would physician practices suffer? Perhaps in terms of billing, as more people take common illnesses to nurse practitioners for faster, lower cost treatment. But there will always be a need for specialists and surgeons, and there will always be a trust factor that drives people with serious health concerns to choose doctor care. Removing common ailments and injuries from emergency rooms and doctors’ offices can save doctors from crippling overwork and allow them time to build deeper relationships with their patients and therefore allow for better patient care for those who really need their skills, talent and experience.

Would patient care suffer? Unlikely, as Americans are savvy and educated partners in their own healthcare. If they are unsatisfied with the level of care they receive, they will take their business elsewhere and speak out. A good facility will quickly remove poor quality caregivers before things get out of hand.

What’s the right answer?

For now, there is none. Physicians are clearly more educated, and therefore better able to serve as diagnosticians and specialists. They have earned the title of doctor and the professional respect that goes with it. However, NPs and PAs have competently practiced under doctor supervision for more than 20 years and already serve independently in many states. No answer will satisfy every stakeholder in this race, but the increasing need for more personnel in every facet of medical care is crystal clear.

Sources

1. National Resident Matching Program, “National Resident Matching Program, Results and Data: 2017 Main Residency Match,” 2017.: http://www.nrmp.org/wp-content/uploads/2017/06/Main-Match-Results-and-Data-2017.pdf
2. US Census Bureau, “Older People Projected to Outnumber Children,” 2018,: https://www.census.gov/newsroom/press-releases/2018/cb18-41-population-projections.html
3. Naples News, “Patients turn to nurse practitioners, physician assistants (third in a series), 2018,: http://archive.naplesnews.com/news/local/patients-turn-to-nurse-practitioners-physician-assistants-third-in-a-series-ep-399048823-344075232.html/
4. Nurse Journal, “Requirements to Become A Nurse Practitioner,” 2018,: https://nursejournal.org/nurse-practitioner/what-to-know-tobecome-a-nurse-practitioner/
5. Study.com, Requirements to Become a Doctor in the U.S. , 2018,: https://study.com/requirements_to_become_a_doctor.html