Letters

Editor's note: The following letters are responses to "Nurse Practitioners: Growing Competition for Family Physicians?" in our October 1998 issue.

Family practice is still family practice

To the Editor:

I am concerned about the aggressive way in which independent nurse practitioners are marketing themselves. I shared my concerns with the nurse practitioner who shares my office, and she agreed that it is time physicians made some kind of challenge, before it is too late.

We can have a good relationship with nurse practitioners as long as we realize that our training is not the same. Physicians need to make abundantly clear the difference between a medically schooled and residency-trained physician and a nurse with a two-year master's degree.

Family practice is still family practice, but it needs to be controlled by physicians, not nurse practitioners.

Russell Lee-Wood, MD
Freeport, Ohio

Collaboration, not supervision

To the Editor:

I am concerned that this article makes readers think that most nurse practitioners want independent practices. I don't believe this is true.

I think most nurse practitioners want a collaborative relationship with physicians instead of supervision. This team approach allows us to offer high-quality care while retaining responsibility for our decisions. If all our work or our prescription writing has to be directly supervised by a physician, or if a physician is responsible for the care we provide, a nurse practitioner is a hindrance instead of a help.

Don't assume that nurse practitioners are seeking statutory prescriptive authority and collaborative (as opposed to supervised) agreements in order to practice independently. Changes to states' nurse practice acts are sought to allow nurse practitioners to provide patient care more effectively and efficiently.

Susan Murawski, MSN
Westfield, N.Y.

There's room for everyone

To the Editor:

There's plenty of work and plenty of room for professional growth for everyone -- nurse practitioners, physicians and physician assistants. Focusing on turf battles is missing the point: People need decent health care!

Nurse practitioners have been part of the primary care landscape since the late 1970s, not the '90s. We have a good track record. Let's take care of our patients and get on with it!

Eileen O'Connor, MSN
Yonkers, N.Y.

NPs are here to stay

To the Editor:

Nurse practitioners are here to stay, and we family physicians need to do the honorable thing by helping them in every way possible.

Family physicians will do better by realizing there is enough business for all of us to make a comfortable living and still give our patients plenty of choices. Patients will do fine deciding for themselves what type of provider they want to see.

Bill Manahan, MD
Mankato, Minn.

Turf battles for the insecure

To the Editor:

I have been a certified pediatric nurse practitioner in independent private practice for 27 years, and I was pleased to read the correct description of the history of my profession, the education of a nurse practitioner and the philosophical similarities of nurse practitioner practice and family physician practice.

Nurse practitioners and family physicians have much in common and have historically been collaborative colleagues. In my office and in countless other offices across the state of New York, nurse practitioners and family physicians are impacting health care together, and individuals and communities are living longer, healthier lives as a result of their joint efforts.

Turf battles are best left to the insecure, and I don't believe that family physicians generally fall into this category. You know what you do, and you do it well. Many family physicians also know what nurse practitioners do, and we want to work collaboratively with you. It works. I know it. My patients know it. Family physicians know it.

Harriet L. Hellman, MSN
Water Mill, N.Y.

Priced out of a job

To the Editor:

All primary care physicians should be concerned about independent practice for nurses. We need to lobby for supervised practice arrangements and against prescribing privileges. If we don't, we may soon find ourselves priced out of a job.

Jon F. Bode, MD
Panama City, Fla.

The good old days

To the Editor:

Until the early 1960s, medicine was relatively simple and was practiced mostly by general practitioners, such as the one portrayed by television's Marcus Welby, MD. With the passing of time and the increased availability of diagnostic tools, medicine has become big business, and there is less time for individual compassion. Patients have become "consumers" and physicians "providers," having no time or desire to be part of the patient's life. Computer scheduling takes the place of "Come down if you don't feel well," and our credibility and standing in society has disappeared. We have become money-oriented businessmen in the eyes of the public.

With CAPNA [the nurse practitioner practice mentioned in the article], something from the old days is back. They take the time to listen to patients, which used to be the secret of our success.

Indeed medicine has become very complicated and expensive, and there is probably no place for Dr. Welby anymore. But having done it successfully for more than 40 years, I am a firm believer that there is a place and a need for the compassion and personal relationships we used to have with our patients.

While it isn't easy to recreate some aspects of the "good old days," not trying to at all will certainly eliminate the need for the family practice of today.

Gabor Somjen, MD
Dover, N.J.

The NP's role

To the Editor:

The presence of a nurse practitioner in our practice has improved our ability to provide care to all our patients, especially those most in need, in a cost-effective manner.

However, I think it would be unfortunate if any population, especially our most needy, had to have their care primarily supervised by nurses. The scope of training between nurse practitioners and family physicians is widely disparate. While experienced nurse practitioners may be better able to approach the clinical and diagnostic expertise of physicians, even they should not be ultimately responsible for the care provided to patients.

We must oppose independent clinical practice and prescribing for nurse practitioners. Physicians must remain united behind the idea that if someone wants to undertake the practice of medicine independently, he or she must be expected to graduate from medical school.

Joseph A. Anistranski, MD
Wilkes-Barre, Pa.

Academy action

To the Editor:

I am concerned about the AAFP's lack of action on the problem of independent nurse practitioners. With the ongoing destruction of the doctor-patient relationship by third-party payers and hospital-run IPAs, the push for nurse practitioners may well be a knock-out punch!

A nurse practitioner receives two extra years' training after college as opposed to our seven. If we are to believe that nurse practitioners have the same abilities as family physicians, we are allowing our profession to be mocked. Nurse practitioners can handle the minor routine problems of family practice, but I fear that, without a physician's supervision, they will not uncover the more subtle diagnoses.

What actions are being taken by the AAFP to protect the relationship between family physicians and their patients?

Marybeth Yuskavage, MD
Clovis, Calif.

Response:

You are rightfully concerned about the burgeoning scope-of-practice issues facing family physicians all over the country and in various practice settings.

Over 80 percent of the AAFP's members are working with physician assistants, nurse practitioners or both. The AAFP supports the training of family physicians and nurse practitioners as teams. The end result of this extensive training and teamwork is truly comprehensive health care where patients are the winners.

However, the AAFP does not support independent practice for nurse practitioners. We have opposed broad expansion of scope of practice for these professionals on both the state and federal levels, precisely for reasons you have cited -- nurse practitioner training does not prepare them for the diagnostic challenges of the "undifferentiated" patient.

It has been the AAFP's contention that using nurse practitioners as the first point of contact with previously undiagnosed patients is actually more expensive due to their extensive use of subspecialty referrals. Making the appropriate diagnosis at the first point of contact means better patient care, causes less hassle for the patient and makes better fiscal sense.

In addition to working legislatively on the state and federal levels to influence scope-of-practice issues, we have been very vocal in our opposition to independent practice by nurse practitioners through a number of national news programs and articles, including 60 Minutes, Newsweek and People. And we will continue to make sure our voices are heard.

Lanny R. Copeland, MD
AAFP President
Albany, Ga.

We want to hear from you. Letters is an open forum for our readers. Write to Letters Editor, Family Practice Management, 8880 Ward Parkway, Kansas City, MO 64114-2797. If you prefer, fax your letter to 816-333-0303. You may also contact FPM by e-mail at fpmlet@aafp.org. Include your address, daytime phone number and fax number, if any. Letters may be edited for length and style. All letters sent to the editors of FPM are presumed to be intended for publication unless otherwise specified in the text of the letter.

Copyright © 1999 by the American Academy of Family Physicians.
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