Correspondence
Advanced-Practice Nursing -- Good Medicine for Physicians?
N Engl J Med 1994; 330:1536-1537May 26, 1994
- Article
To the Editor:
I am writing in response to the Sounding Board article by Mundinger on advanced-practice nursing (Jan. 20 issue)1. As a family practitioner and the director of a family-practice residency program, I am very much aware of the skills that a good family physician needs. I was truly insulted by the negative tone of the article. I was particularly offended by the statement that primary care holds relatively little allure for physicians because specialists have more manageable and intellectually more interesting practices. These words could have been written only by someone who has never truly provided primary care.
I firmly believe that if we are to deliver primary care to all citizens in this country, a strong and effective collaboration between physicians and mid-level providers is essential. Nevertheless, because of their education, skills, and experience, it is essential that physicians lead these teams. Currently there are wonderful opportunities to develop collaborative, effective partnerships that would include primary care and advanced-practice nurses. Articles like Mundinger's will only prevent or delay this progress.
1 ReferencesJames R. Buechler, M.D.
Union Hospital, Terre Haute, IN 478071
Mundinger MO . Advanced-practice nursing -- good medicine for physicians? N Engl J Med 1994;330:211-214
Full Text | Web of Science | Medline
To the Editor:
Mundinger makes several unreferenced assertions, which should not go unchallenged.
She states, “Primary care no longer requires the level of training that it once did.” When I trained in general internal medicine 10 years ago, the knowledge and skills required were formidable. Since then, the numbers of identified diseases, drugs and other treatments, research studies, and guidelines have all increased dramatically. To have a working knowledge of these, the generalist is required to achieve an increasingly higher, not lower, level of training.
Mundinger states that “the gap in competence between the specialist and the primary care physician has increased.” Here it seems that she may be confusing competence with technical expertise. I am unaware of any data suggesting that generalists are less “competent” at what they do than specialists are at what they do.
Mundinger's points would be well taken if generalists did nothing more than treat colds. However, this is not now the case. Furthermore, as the emphasis on primary care increases, generalists will be expected to care for patients with more complicated conditions and problems that are currently referred to specialists. Pressures from health maintenance organizations to skimp on health care can best be resisted by physicians with a sound knowledge of disease processes and therapies. Guidelines may standardize treatment, but will require ever greater vigilance on the part of astute clinicians to determine when deviations from guidelines are necessary for good care. I am concerned that Mundinger has greatly underestimated the knowledge and skill required of generalist physicians to provide excellent care to their patients.
James C. Blankenship, M.D.
Geisinger Medical Center, Danville, PA 17822To the Editor:
Mundinger's statement, “Primary care no longer requires the level of training that it once did,” reflects a fundamental and rather shocking lack of understanding of what is involved in primary care. Very much to the contrary -- the necessary body of knowledge is expanding rapidly, so that several hours a week of reading and study are required for a physician to stay current. The primary care physician not only must treat common ailments, but must also be able to recognize a broad range of disease states that present in both typical and atypical fashion, and must stay up to date with major advances in therapeutics and developments in all the specialties of medicine. Currently, medical educators in internal medicine are contemplating the need for an additional year of training for generalists to prepare them better for the wide-ranging demands of primary care.
Mundinger goes on to denigrate the value of primary care relative to the specialties, by suggesting that the gap in financial compensation reflects the limited value of primary care services. What she fails to appreciate is that although primary care services are widely believed to be undercompensated, the primary care physician is the patient's very lifeline through the complexities of the medical environment.
Mundinger makes a callow attempt to raise the putative expertise of the nurse practitioner by demeaning that of the primary care physician. Her argument fails to convince me, since it contradicts my 20 years of experience in this challenging endeavor.
Nolan L. Weinberg, M.D.
6801 Miami Ave., Cincinnati, OH 45243To the Editor:
Mundinger makes a statement that does not correspond to my own experiences as a house officer. She writes, “Such substitution [of clinical nurse specialists for first-year residents] can also increase quality. Every July, novice residents go through several weeks of orientation and training to reach the level of competence that experienced clinical nurse specialists presumably have already achieved.” Although many in academic centers have casually posited that house staff deliver care of lower quality at the beginning of the academic year, I am not aware of any data that support this contention, and none are cited by Mundinger. Indeed, it is my experience that excellent care is delivered early in the academic year because of the high levels of supervision. Furthermore, I do not think it is fair to “presume” that clinical nurse specialists have greater competence than interns in July; the latter, after all, are not novices but rather physicians who have completed four years of extensive scientific and clinical training during medical school.
Seasoned clinical nurse specialists might be more competent, but perhaps the more scientifically oriented background of physicians in training would lead to greater competence, particularly in the care of hospitalized patients with complex problems. My bias favors the latter, but without data, I think any presumptions are premature.
I am not interested in protecting my “turf”; nor am I opposed to expanded roles for advanced-practice nurses. Rather, I wish to point out that in exchange for training, resident physicians work exceedingly long hours, take care of extraordinarily sick patients, make enormous personal sacrifices, and receive pay that, if they were awarded an hourly wage plus time-and-a-half for overtime, would often equal the minimum wage. To suggest, without supporting data, that nonphysicians could perform these complex and demanding duties better and more cheaply than my colleagues strikes me as wholly unrealistic and weakens Mundinger's discussion.
Edward R. Arrowsmith, M.D.
Vanderbilt University Medical Center, Nashville, TN 37232To the Editor:
The article by Mundinger on the case for expanding the role of advanced-practice nurses in primary care suggests that primary care is not something that physicians should want to do, and that the nation would be better served by “continuing to train the majority of medical graduates in the specialties.” This view is seriously flawed in two respects: it demeans generalist practice, and it fails to consider the effect of a continuing glut of specialists.
The practice of generalist medicine is both a viable and an attractive option for many physicians, many of whom enjoy developing long-term relationships with patients. The intellectual task of treating undifferentiated patients is exceptionally demanding and challenging. The assertion that a 1:1 ratio of primary care providers to specialists could be obtained before the end of the decade if primary care-nurse graduates and primary care-physician graduates were combined is mathematically incorrect. It underestimates the effects of the long pipeline of physician specialists in training and makes many unstated assumptions regarding the numbers of physicians and nurse practitioners entering primary care. For example, even if 100 percent of medical school graduates chose fields in primary care, beginning in 1993, it would still take until 2004 to achieve a 1:1 ratio1. Furthermore, Mundinger does not take into account the effect of the oversupply of specialists on both health care and costs2.
A lot more thought needs to be given to the nature of collaborative practice. The scope of practice, as well as definitions of competence for each type of generalist provider, needs to be more clearly defined. Differences as well as areas of overlap deserve careful consideration. A fundamental first step is for all the primary care disciplines to engage in a meaningful conversation about these topics. Considerably more collaborative planning and research -- and less rhetoric -- are needed to address these issues.
Ideally, the composition of the nation's health care work force should depend on the nation's health care needs and not the needs of the nation's health care providers. It is critical that we do not lose sight of this fact. As we move into a new era of health care reform, it is essential that the changes made improve the outcome of health care for all Americans.
2 ReferencesSteven A. Wartman, M.D., Ph.D.
Mount Sinai Medical Center, Miami Beach, FL 331401
Kindig DA ,Cultice JM ,Mullan F . The elusive generalist physician: can we reach a 50% goal? JAMA 1993;270:1069-1073
CrossRef | Web of Science | Medline2
Lundberg GD ,Lamm RD . Solving our primary care crisis by retraining specialists to gain specific primary care competencies. JAMA 1993;270:380-381
CrossRef | Web of Science | Medline
Author/Editor Response
Dr. Mundinger replies:
To the Editor: The comments of Drs. Buechler, Blankenship, Weinberg, and Arrowsmith reflect a surprising level of disbelief that advanced-practice nurses can, within their scope of practice, deliver care equivalent to that provided by physicians. Twenty-five years of research in advanced-practice nursing demonstrates the quick and accurate recognition of serious illness and referral of the patient by these nurses.
Clinical nurse specialists with four years of nursing education and two years of clinical training, even without experience, have trained longer than a first-year resident. Thus, it should not be surprising to Dr. Arrowsmith that clinical nurse specialists are high-quality substitutes for first-year residents. Much of the cost of care delivered by residents is incurred in the post-residency years, when the resulting specialists generate millions of dollars in fees while substitute clinical nurse specialists are still providing low-cost care. Even if one looks at the cost of training a resident, the amount is higher; the average annual cost is $70,000 per resident, as compared with the average salary of $43,000 per clinical nurse specialist1,2.
It is gratifying to read Dr. Weinberg's and Dr. Wartman's testimony to the attractions of primary care. It is, however, inarguable that the medical profession has devalued this area of practice. Nursing and medicine working together can ameliorate this situation. In my view, the health and medical team that offers the most (in quality, competence, and scope of services) at the best price will be the team that prevails in the emerging health care system. This may also be one way to raise the status and satisfaction of primary care medicine.
Medical students are increasingly choosing specialties and are fleeing careers in primary care. If it is not the lack of financial rewards or the unappealing content of practice, what then makes primary care unattractive to physicians? I understand the anger that satisfied primary care physicians feel when their practices are undervalued, but it is the medical community and not nursing that has formed these judgments.
2 ReferencesMary O. Mundinger, Dr.P.H.
Columbia University School of Nursing, New York, NY 100321
Mundinger MO . Advanced-practice nursing -- good medicine for physicians? N Engl J Med 1994;330:211-214
Full Text | Web of Science | Medline2
AACN Fact Sheet. Increasing health care system primary care capabilities by using graduate medical education funds for nursing education, 1993. Washington, D.C.: American Association of Colleges of Nursing, 1993.
