Correspondence

Nurse Practitioners in Primary Care

N Engl J Med 1994; 330:1537-1540May 26, 1994

Article

To the Editor:

In response to your editorial on the role of nurse practitioners in primary care (Jan. 20 issue),1 the scope of practice for nurse practitioners and nurse-midwives is defined by a program's competency standards and by state requirements for licensure. If we encounter a problem that is outside our expertise, we consult others or make a referral. In this way, a nurse practitioner or nurse-midwife always works in collaboration with a physician, so that the transition to acute care can be made quickly and easily. Our education and experience make it unlikely that we would dismiss a serious medical problem or an abnormal symptom. Our protocols serve as guidelines for safe practice.

Nurse practitioners and nurse-midwives seek the independence to complete the delivery of therapeutics that we have been trained to give. In four states, including Ohio, we cannot deliver that care to the full extent that our education and knowledge allow, because we lack the authority to prescribe medications. In addition, justice and common sense require that we receive nondiscriminatory reimbursement for our services.

Supervision by physicians of work that is within our scope of practice not only erodes our sense of professionalism but insults both physicians and nurses. Laws that require such supervision place physicians in a difficult situation, one in which they can obey the law and waste time duplicating the work that the nurse practitioner or nurse-midwife has already done or, as often happens, ignore the law2. Patients are also more likely to question the authority and competence of a nurse practitioner or nurse-midwife who is supervised in this way2.

The effectiveness of nurse practitioners and nurse-midwives has been the focus of hundreds of studies for more than 20 years, but the cost effectiveness and quality of the care provided by physicians and the accessibility of physicians have been studied only recently2. We need more data on the cost and efficiency of physicians' services in order to compare them with those of nurse practitioners. The lack of uniformity of the legal statutes governing the practice of nurse practitioners and nurse-midwives and the difficulty of distinguishing the tasks of medicine from those of nursing are obstacles to the comparison2. Nurse practitioners and nurse-midwives have long provided care that has improved the health of communities and lowered morbidity and mortality3,4.

Jeanne A. Knudtsen, C.N.M.
Case Western Reserve University School of Nursing, Cleveland, OH 44106

4 References

1
Kassirer JP. What role for nurse practitioners in primary care? N Engl J Med 1994;330:204-205
Full Text | Web of Science | Medline

2
Saffreit BJ. Health care dollars and regulatory sense: the role of advanced practice nursing. Yale J Regul 1992;9:419-485

3
Haire D. Improving the outcome of pregnancy through increased utilization of midwives. J Nurse Midwifery 1981;26:5-8
CrossRef | Medline

4
Slome C, Wetherbee H, Daly M, Christensen K, Meglen M, Thiede H. Effectiveness of certified nurse-midwives: a prospective evaluation study. Am J Obstet Gynecol 1976;124:177-182
Web of Science | Medline

To the Editor:

In response to your editorial “What Role for Nurse Practitioners in Primary Care?” how can the issue be anything else but turf?

Here is what women know. Women know that 39 million people do not have health insurance and therefore do not have health care. Women know that a national cesarean-section rate of 24 percent is entirely unnecessary. Women know that 15 percent of our gross national product is spent on health care, and yet we are no better than 17th among industrialized nations in infant mortality. Women already know that they are getting inadequate and unsafe care.

Whether “nurse practitioners provide primary care equal in quality to that provided by physicians” is an issue that will be resolved by women. They will vote with their feet and will ultimately resolve the issue. What advanced-practice nurses across the country are demanding is that women be given a legal choice and that they not be restricted by artificial barriers designed to maintain a medical monopoly in the delivery of health care.

Jean R. Rasch, C.N.M.
Sand Hill Women's Medical Group, Menlo Park, CA 94025

To the Editor:

You ask what special strategies nurse practitioners use that allow them to provide primary care that is better than or equivalent to the care provided by physicians. The philosophy of nursing stresses a holistic approach that includes all aspects of the patient's condition -- physiologic, psychological, social, and spiritual. Nurse practitioners in family practice have a heightened awareness of these influences on the patient's physical condition. The holistic approach has only recently become a matter of interest to physicians. It is largely not incorporated into medical training, which is often disjointed in its presentation of the patient in terms of pathophysiologic features. A purely medical focus often gives too narrow a view of the patient's needs in primary care, as many physicians learn through experience.

Yes, billions of dollars would be saved each year if more nurse practitioners delivered primary care, because of their unique approach. In most cases, the nurse practitioner tries to solve a patient's problems by first looking at the whole picture of the patient's symptoms and only then referring the patient to a specialist. Nurses study patients in terms of their environment, social situation, habits, family interactions, occupational hazards, and psychological problems, as well as their medical conditions. In primary care, lack of knowledge and specific types of behavior are often found to be the culprits behind the patient's medical condition, and in such cases counseling or teaching is the appropriate method of treatment. I am convinced that nurse practitioners are well suited to provide primary care because of their academic background in critical thinking, astute assessment skills, and unique holistic focus.

Theresa Capriotti, R.N., D.O.
Villanova University College of Nursing, Villanova, PA 19085

To the Editor:

There is more to working with nurse practitioners than was presented in either the thought-provoking article by Mundinger1 or your cautious editorial2. From the perspective of managed care, a new role combining those of clinician and care manager is emerging3,4. In the future, when managed-care organizations care for chronically ill populations, such as nursing home residents, management of care by nurse practitioners may be essential to cost effectiveness. This will not occur because they are less expensive to use than physicians, but because they bring the right combination of nursing and medical perspectives.

With complex long-term care in particular, the nurse practitioner is in a unique position to manage the use of resources directly rather than depend on traditional approaches that lack the advantages of having a nurse practitioner at the bedside. Complex care is managed most effectively and efficiently at the bedside, from the outset and for the duration. Nurse practitioners are especially well suited to this role.

Patrick W. Irvine, M.D.
EverCare, Minneapolis, MN 55401-2146

4 References

1
Mundinger MO. Advanced-practice nursing -- good medicine for physicians? N Engl J Med 1994;330:211-214
Full Text | Web of Science | Medline

2
Kassirer JP. What role for nurse practitioners in primary care? N Engl J Med 1994;330:204-205
Full Text | Web of Science | Medline

3
Malone JK, Chase D, Bayard JL. Caring for nursing home residents. J Health Care Benefits. January/February 1993:51-4.

4
Fama T, Fox PD. Going an extra mile for the frail elderly. HMO Magazine 1993;34:22-30

To the Editor:

Your editorial on the role of nurse practitioners in primary care did not exhibit your usual incisive and analytic clarity. Without a better definition of the terms and issues, questions similar to yours could be asked about the current primary care practices of physicians. For example, what definitions of quality or value ought to be applied to medical practice, and where are the data to analyze this subject? In primary care, as opposed to specialty and academic practices, what data are available on how reasoning from first principles, causal reasoning, or probabilistic reasoning is used in support of diagnostic and therapeutic decision making? Do data support the optimal use of invasive (or noninvasive) diagnostic tests in current primary care practice? How often are patients deprived of needed tests or, conversely, tested needlessly? How is the cost of medical care to be assessed, and from whose perspective is its value (quality times cost) to be judged? Finally, which aspects of current primary care practice have been proved “efficacious and safe,” and how often are they now implemented? If we question the independent delivery of primary care by nurse practitioners, as we must, on the basis of the issues raised in your editorial, we should subject the current practices of physicians to similar scrutiny.

Robert Matz, M.D.
Mount Sinai Medical Center, New York, NY 10029

To the Editor:

You make a series of important points in your discussion of nurse practitioners as providers of primary care, including the point about the escalating complexity of modern primary care practice. However, you stop short of acknowledging that in many contexts, primary care has become so complex that it has actually outstripped the primary care provider, who has devolved into primarily a coordinator of consultation services.

This extraordinary phenomenon occurs among insecure house staff and litigation-conscious attending staff alike. It turns good primary care into an endeavor that actually requires very little independent thinking, diagnostic acumen, or reasoning from first principles -- that often, in fact, becomes a euphemism for efficient secretarial work, prompt referral to other services, and conscientious monitoring of others' therapeutic plans.

In this incarnation of primary care, nurse practitioners, despite their lack of training in pathogenetic mechanisms and differential diagnosis, have a great deal to contribute. Their training is probably more suitable than that of physicians for bonding with and educating patients, following treatment plans, monitoring signs and symptoms, and making consulting physicians aware of untoward events. In fact, these duties are not unlike those of nurses without advanced-practice qualifications.

The questionable figures in the scenario, of course, become not so much the nurses as the physicians themselves. Are they still viable agents? Can individual practitioners really still navigate solo voyages through modern diagnostics and therapeutics with medical confidence and legal impunity? Or are all primary caretakers, physicians and nurses alike, destined to evolve into case managers, consultation planners, health care monitors, and participants in a two-class medical system reminiscent of the Russian one, in which primary care is delivered by practitioners (largely female) who are rewarded with neither salary nor prestige, whereas the actual practice of medicine, as we still understand it, falls to a smaller cadre of well-paid, well-respected consultants?

Abigail Zuger, M.D.
Albert Einstein College of Medicine, Bronx, NY 10467

To the Editor:

Not every sniffle is “just a virus,” and not every earache a simple middle-ear infection. My own family experience has repeatedly shown that nurse practitioners, so very useful, competent, and caring in many collaborative settings, do not currently have the training to see beyond the immediate, simple-appearing illness to the deeper, possibly serious root cause. That is so because training for physicians and nurse practitioners is separate and unequal. If one wants to practice front-line primary care, there are some 16,000 seats in medical school that open up each year. If this is not feasible for the nurse or nurse practitioner and he or she has years of experience in patient care, maybe such professionals should go on to residency training if our national need is so great.

The upper-middle-class, well-insured people who advocate allowing today's nurse practitioners to operate independently in underserved areas make me wonder whether they would be willing to accept the same level of care for themselves and their families.

David E. Rubin, M.D.
53 Captain Courtois Dr., Attleboro, MA 02703

To the Editor:

Are there no boundaries to sex and career warfare? After reading your editorial on advanced-practice nursing and the article by Dr. Mundinger, I suppose the answer is no. The shortage of primary care providers should mean that there is enough pie for physicians and nurse practitioners to share (while the question of comparative competence continues to be studied). More important, in the words of Rodney King, “Can't we get along”?

Jeffrey M. Bloom, M.D.
100 Casa St., San Luis Obispo, CA 93405

Author/Editor Response

Dr. Kassirer replies:

The diverse opinions on the role of nurse practitioners in primary care are aptly represented in these letters. Dr. Mundinger argued for collaborative practice between physicians and nurse practitioners,1 and Drs. Irvine and Zuger agree with her, but Ms. Knudtsen argues persuasively for considerably more independence. Dr. Mundinger thinks primary care is simpler now; Dr. Zuger implies that medical care has become so complex that it should be left to specialists. Dr. Matz and Ms. Knudtsen both make the point that there is no gold standard for physicians' performance against which other practitioners can be judged. In an editorial published just after their letters were submitted, I made the same point -- namely, that our methods of assessing physicians' performance need considerable refinement2.

Physicians, I believe, have taken a bad rap for not considering the patient in a holistic or comprehensive fashion. Although nurse practitioners often claim to have cornered this market, there are no data to show that primary care physicians -- general internists, pediatricians, and family physicians -- perform any less ably in considering the patient as a whole.

Ms. Rasch rails against substandard outcomes and implies that they may have resulted from care dominated by male physicians. I believe she undervalues the judgment of women. They will, I think, opt for high-quality care whether or not it is delivered by practitioners of their own sex.

I agree with Dr. Mundinger that quality and competence are among the critical factors that will determine which practitioners survive on the health care team of the future. But I have disputed her undocumented assertion (made in her letter on page 1537) that a body of research “demonstrates the quick and accurate recognition of serious illness and referral of the patient by these nurses.” I also believe that she and others have compared the costs of the services of nurse practitioners and physicians inappropriately. If nonexempt nurse practitioners worked the same number of hours as residents, for example, the difference in their incomes would be eliminated.

Finally, Dr. Rubin's comments illustrate the heat given off by the turf battles underlying this issue. In fact, there are overlapping competencies between nurse practitioners and primary care physicians, between the various kinds of primary care physicians, between primary care physicians and specialists, and even between specialists and nurse practitioners. Unless we define these crossover areas of expertise more precisely and concede that more than one type of professional can and should handle them, Dr. Bloom's call for a peace treaty will have the same effect as similar entreaties in the world's ethnic trouble spots.

Jerome P. Kassirer, M.D.

2 References