The role of nurse practitioners in primary care

Posted by • May 16th, 2013

Sara is a 31-year-old healthy female professional living in Boston who gets her medical care at a large, multi-provider primary care clinic. When Sara goes to the clinic for a routine visit, she sees a nurse practitioner (NP) about 75% of the time.  Sara says that she chooses to see the NP rather than an MD for a number of reasons:  “For primary care I usually find that it is easier to get an appointment with an NP. I also feel like the NP spends a little more time with me and does not seem to be in as much of a hurry to get through the visit. I’ve been very satisfied by the care I’ve received from the NPs that I have seen.” However, when asked about whether she would prefer to see a NP for all of her clinic visits, she hesitates: “If I had a more serious illness or a complex medical problem, I would feel more confident being evaluated by an MD who has received more years of training and has broader overall medical knowledge.”

Sara’s experience is not unique. In the United States an estimated 60,000 nurse practitioners are currently working in the primary care setting, yet there is no clear consensus as to what role NPs should play in delivering care. A 2010 report from the Institute of Medicine recommended that NPs “should be able to practice to the full extent of their education and training.” But, how do we determine what activities fulfill this mandate? Should NPs be given free range to prescribe all medications including controlled substances? Should NPs have their own panel of primary care patients, or should they only see patients as part of a care team led by an MD?

This week’s issue of NEJM features a Special Article by Donelan et. al describing the findings from the 2012 National Survey of Primary Care Nurse Practitioners (PCNPs) and Physicians. The authors surveyed nearly 1000 primary care nurse practitioners and physicians to learn what attitudes they had on the scope of practice of NPs as well as to learn what services NPs are currently performing in the primary care setting. While the majority of MDs and PCNPs surveyed agree that NPs should practice to the full extent of their education and training, the responses to most other questions were widely divergent.

The survey showed that on average, PCNPs work fewer hours, see fewer patients, and are paid less than their MD colleagues.  While 83% of PCNPs felt that they should be able to lead primary care medical homes, only 17% of MDs agreed. Similarly, 64% of PCNPs felt that they should be paid equally to MDs for the provision of the same services, but only 4% of MDs agreed. When asked about the effect of increasing the supply of PCNPs in the US, more than three-fourths of PCNPs felt that such an expansion of the workforce would improve patient safety, primary care effectiveness, and lower health costs. However, only about one-quarter of MDs surveyed felt that a larger supply of PCNPs would result in better safety, effectiveness or improvement in costs. Finally, there exists a disconnect in perceived quality of care provided – as two-thirds of MDs felt that they provide a higher quality examination and consultation, while fewer than 10% of PCNPs agreed.

Despite these differences of opinion and attitude, the fact remains that primary care in the US is currently under enormous strain. Other surveys have shown that primary care physicians today feel overworked, underpaid, and have lower job satisfaction than those in other specialties. In many cities, waits for new appointments with primary care providers can reach six months or more. And with roll out of the Accountable Care Act, as many as 35 million uninsured Americans may finally gain health insurance – yet who will take care of them? Many health policy experts have suggested expanding the role of non-MDs in the primary care space, yet this report raises significant concerns about how such a move would be received by those MDs currently practicing primary care. Recent attempts to expand the scope-of-practice of NPs to allow them to practice more independently have met with opposition from physician groups, including the AMA, AAFP, and American Academy of Pediatrics. The Robert Wood Johnson Foundation has recently taken the lead in working to bring the nursing and physician communities together to create consensus on this issue. As we move towards new models of care delivery in which physicians and nurses provide team-based primary care, one can only hope that such interprofessional collaboration will eventually result in agreement on how best to define the role of advanced nurse practitioners in the primary care clinic.

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