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Primary Care for the 21st Century: Meeting the Country’s Need for Primary Care Physicians
There has been a significant amount of discussion among the health care and
policy communities about expanding the roles of nurse practitioners to practice independently and direct medical homes without a physician on staff. The rationale
is to cover health care needs resulting from the primary care physician shortage. The movement for nurses to treat patients without a physician comes at the same time as the medical practice itself is changing to a team-based approach. These two approaches take this country in opposite and conflicting directions. Granting independent practice to nurse practitioners would be creating two classes of care: one run by a physician-led team and one run by less-qualified health professionals. Americans should not be forced into this two-tier scenario. Everyone deserves to be under the care of a doctor.
Substituting nurses—even advanced practice nurses—for licensed physicians cannot be the answer in a system built around medical homes.
Nurse practitioners are a vital part of the health care team, but they cannot fulfill the need for a fully trained physician. A physician brings a broader and deeper expertise to the diagnosis and treatment of all health problems, ranging from strep throat to chronic obstructive pulmonary disease, from unsightly moles to cancer, from stress headaches to refractory multiple sclerosis. The family physician is trained to provide a complex differential diagnosis, develop a treatment plan that addresses multiple organ systems, and order and interpret tests within the context of the patient’s overall health condition.28
Today, 22 states and the District of Columbia allow nurse practitioners autonomy in diagnosis and treatment. About half of those, however, require involvement of a physician for prescribing all or certain drugs.29 Some have called for removing scope-of-practice barriers for advanced practice registered nurses, or APRNs, in all states. The reality, however, is that the education and training of physicians and APRNs are substantially different, and physicians and nurses are not interchangeable. Dr. Bruce Bagley described this scenario well, saying that “with four years of medical school and three years of residency training, the physician’s depth of understanding of complex medical problems cannot be equaled by lesser-trained professionals. It’s in the patient’s best interest for family physicians and nurse practitioners to work together.”30
Research shows that the best care is achieved when the ratio of nurse practitioners to physicians is about 4-to-1.31 At this ratio, we can provide everyone a physician-led team, and fill the primary care shortage.
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