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Physicians, Nurses Continue Primary Care Debate

Cheryl Clark, for HealthLeaders Media, December 23, 2010

Two Perspective articles in the New England Journal of Medicine fan the flames of discord about whether scope-of practice should be expanded for nurse practitioners in the face of a primary care physician shortage, especially in rural areas.

Predictably, nursing groups are for the expansion. But some organized physician groups, such as the American Medical Association, have been opposed.

"Although nurses are critical to the healthcare team, there is no substitute for a physician's education and training," American Medical Association President Cecil B. Wilson, MD wrote in a letter. In states that allow nurses to practice without physician supervision, "physicians and nurses continue to work in the same urban areas, so increasing the independent practice of nurses has not helped to resolve the problem of shortages in rural areas," he wrote.

The first Perspective article is co-authored by University of Miami president Donna Shalala and others at the University of Pennsylvania School of Nursing and the Robert Wood Johnson Foundation Initiative on the Future of Nursing. 

It points to the wide state-by-state disparity in what nurse practitioners and advanced practice nurses are allowed to do, with or without physician supervision.

"This variance appears not to be correlated with performance on any measure of quality or safety," the authors write. "There are no data to suggest that nurse practitioners in states that impose greater restrictions on their practice provide safer and better care than those in less restrictive states or that the role of physicians in less restrictive states has changed or deteriorated."

The authors wrote, "If we are to bridge the gap in primary care and establish new approaches to care delivery, all healthcare providers must be permitted to practice to the fullest extent of their knowledge and competence," they wrote. "This will require establishing a standardized and broadened scope of practice for advanced-practice registered nurses – in particular nurse practitioners – for all states."

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6 comments on "Physicians, Nurses Continue Primary Care Debate"


Sudheer D (8/21/2012 at 3:19 PM)
Does nursing school have a tough admissions process making students work to their potential starting in undergraduate? Do nursing school admissions have the most difficult standardized exam as a prerequisite for admission? An exam that tests on material that nursing students don't even know once they're certified? Chemistry and Physics are not even required courses for a majority of nursing schools. Seriously so many topics are neglected. Biochemistry, Buffers, Eye Disorders and how they are fixed, how scans work,just to name a few are topics medical schools right in their undergraduate education.Medical school last for years and is known for its rigor while I've seen nursing graduates go to school, raise a kid, work a job, and have time for their own hobbies comfortably. In nursing school, a strong emphasis is placed on procedural education such as [INVALID]ion of intravenous and urinary catheters, sterile dressing changes, proper administration of medications, physical examinations, caring bedside manner, and other vital skills. You know why? Because it's nursing! It is not practicing medicine. Then additionally nursing students can earn their doctorate in a maximum of 5 years where they see patients. At this time, future physicians have already been thrown into managing their own patients for 2 years of medical school and are in their first year of residency. The primary care physicians still have two more years of residency. Let's not forget the rigorous USLME test that spans throughout medical school and the beginning of residency.

Natalie González (1/19/2011 at 11:40 AM)
Dr. Bowman, thank-you for your thoughtful response to a divisive issue. Your concern is how to assure adequacy of primary care in rural areas or to underserved populations. what you presented were numbers to show over time where "we" can expect that help to come from. Your data show what I too have found over the past 10 years of recruiting for rural and underserved populations in WA State: an increasing number of Physician Assistants and Nurse Practitioners who want to stay in urban areas and work in specialties. As many others have said until we can change the reiumbursement system to reward primary care and health not specialty and illness it will be difficult.

Robert C. Bowman, M.D. (1/18/2011 at 7:29 PM)
Rural workforce and underserved workforce are both specific to family practice workforce - MD, DO, NP, and PA. No other specialty choice contributes to significantly higher levels of workforce where needed, including 30,000 zip codes in 96% of the land area where 65% of Americans reside. Starting in family practice or training in FP is not the answer. Staying in family practice is essential as departure from family practice means departure from primary care, rural, and underserved - simultaneously. Family physicians stay 95% in family practice. Non-physician clinicians were over 50% in family practice but have declined to 25% contributions for a career in the past 25 - 30 years. The rate of decline is about 1 percentage point per year. New PA entry into family medicine is 20% indicating downward trajectory. PA primary care entry numbers increased minimally 30% despite a doubling of annual PA graduates 1998 to 2008 while non-primary care increased 200%. Nurse practitioners have increased recently from 31% to 38% in cities of over 250,000.(AAPA and AANP data). Teaching hospitals have been a primary means of recruiting NP and PA away from primary care and family practice (work hours restrictions gap in resident workforce). NP contributions are lower in Community Health Centers despite 50% more graduates than family physicians (Rosenblatt, JAMA). Decreasing percentages of primary care graduates staying in primary care have negated NP, PA, IM, and PD primary care contributions even with expansions and IM is decreasing as the result of lowest primary care retention. FM contributions are the same due to no increase in annual graduates (still 3000 for 30 years). Rural primary care demands are going up with population growth and elderly population growth, but primary care workforce is declining, as are the general specialty types of career choices in surgery, orthopedics, and obstetrics-gynecology. Each top source of current rural workforce is in decline and there is no new creation of rural workforce and deterioration in all current sources. Japan has responded by 1000 annual physicians obligated for 6 years after training, up from 110 in recent years (US equivalent of 2400 annual grads). The US has no response. By the way, with family medicine choice cut in half in the medical schools in the 25 most rural states, the major source of instate rural workforce is declining. The US can choose mandatory long term instate rural workforce, or permanent primary care training and practice support designs. Primary care, rural, and underserved workforce as a side effect of the current designs - are all failures by design. Robert C. Bowman, M.D. Professor of Family Medicine A T Still University School of Osteopathic Medicine Arizona www.basichealthaccess.org