Of Two Minds

I was surprised at my own ambivalence upon reading this article in today's Los Angeles Times. It has to do with the increasing use of nurse practitioners in the County's system of health clinics. County officials want to add to the responsibilities of nurse practitioners because of the shortage of primary care physicians, primarily because of the cost factor, but also because patients need to be able to see one person on a regular basis, someone who is familiar with them and with their ailments, and there aren't enough doctors to do that.

California is among 23 states that allow nurse practitioners to act as primary care providers without a doctor's supervision, a move aimed at stemming a shortage of physicians and reducing costs.

Now the nurses are poised to take on an even greater role as Los Angeles County and other health systems develop "medical home" models of care that expand the number of primary care providers, including nurses, to meet the requirements of national healthcare legislation, reduce unnecessary hospital visits and cut costs. ...

Nurse practitioners are registered nurses with advanced degrees who can interpret lab results, prescribe medications and do many of the things doctors do — with the added bonus that they cost less to train and hire than doctors, and are easier to find. As of last month, there were about 16,000 nurse practitioners statewide, a 16% increase from five years ago, according to figures from the state nursing board.

At Los Angeles County hospitals and clinics, nurse practitioners are paid $88,000 to $128,000; primary care doctors earn $106,000 to $186,000.

Sure, the cost savings is obvious, but should that be reason enough to place the primary care focus upon nurse practitioners who by all accounts have far less training than doctors? The California Medical Association certainly doesn't think so.

An Institute of Medicine report last fall urged state officials to expand what nurse practitioners can treat. The report found health systems that increased nurses' responsibilities delivered "safe, high-quality primary care," including Kaiser Permanente, the Veterans Health Administration and Geisinger Health System in Danville, Pa.

But Dr. James Hay, president-elect of the California Medical Assn. said some health systems have found such nurses more expensive than doctors because they lack doctors' training and as a result, refer more patients to specialists and order unnecessary tests.

That last quote from Dr. Hay did raise my eyebrow a bit. I'm not so certain that those health care professionals with the magical "M.D." after their names haven't engaged in some of the same behavior on a fairly regular basis. And, as the article makes clear, most of the programs using nurse practitioners usually provide for a medical doctor so that in particularly complicated cases the doctor can be brought in.

Additionally, at the clinic level, the nurse practitioner is generally not treating brain tumors or fractured limbs. Most of the cases the nurse sees are for the flu, diabetes management, and conditions that are fairly routine. The nurses have been trained to read lab reports and to recognize symptom clusters. A primary care physician is available if the nurse needs guidance.

I guess on balance I would go with the proposed system, especially since medical schools are simply not turning out enough primary care physicians to serve the needs of the country, especially the needs of the poor and uninsured. Besides, I tend to like and trust nurses more than I do doctors.