Print Page"Nursing" Primary Care Back to Health
Ed Volpintesta, M.D.
evolpintesta@snet.net
For some time nurses have been pushing for advanced training and the right to practice independently. Programs now exist that actually confer a doctorate of nursing practice degree (DNP). By passing a test, nurses can become certified. Some physician leaders worry that patients will be confused over deciding whether to see a doctor of medicine (MD) or a doctor of nursing (DNP) for their primary care.
Primary care is evolving and medicine has not kept up with the changes. Medical educators need to focus on what are its required skills and knowledge. Primary care is defined more by the needs of a community and the number and types of specialists in it than by the narrow academic standards imposed upon it. In rural communities where specialists are few, primary care doctors have broader practices, some doing minor surgery, attending to patients in the ICU, CCU, hospital wards, emergency rooms, and nursing homes; while those in urban and suburban area where specialists are more numerous have limited practices.
Unfortunately, medical educators seem unable to grasp how primary care has changed over the past few decades. Depending on the locale, some primary care doctors no longer follow patients in hospitals and nursing homes, delegating that aspect of care to other physicians. Primary care doctors spend more time coordinating and monitoring patients’ care because they live longer and have more chronic diseases as well as social and emotional problems. Many require home health care services.
As a result, the actual medical knowledge required in many instances is less while the social and administrative skills are more. The coordinating functions which consume a large potion of time and energy are best learned on the job. Others like connecting with patients and attending to their emotional and social needs are more an intrinsic part of a doctor’s character and personality than formally learned skills.
Clearly, a new paradigm of primary care is evolving. One that requires ever greater amounts of interpersonal, coordinating, and communication skills. The old one that required intense exposure to basic science has been ineffective. The advanced practice nurses’ training may not be identical to physicians in primary care but that is not a reason to assume that doctors of nursing could not practice competently if they tailored their practices appropriately.
Be this as it may, organized medicine and medical educators have known about the need for more primary care doctors for over fifty years. The Millis Commission Report made this issue public in 1966. In recent years, the Institute of Medicine (IOM), the American College of Physicians (ACP), and the American Academy of Family Physicians (AAFP) have voiced similar concerns. Yet, the primary care shortage remains a top public concern and has gotten steadily worse. Experts predict a shortage of about 85,000 by 2020. The present administration’s push for universal coverage will make the shortage even greater.
Quite simply, there are not enough primary care doctors around to do the job. As a result many are over worked and routinely battle burnout and, to borrow Thoreau’s words, lead lives of quiet desperation. Some would not choose primary care again and advise young doctors the same. The primary care provider of the future may be a hybrid that combines the best of medical and nursing training.
Although medical educators sympathize with the plight of primary care, the past fifty years’ experience has shown that they are unable to help. With twenty-four medical boards and one hundred and twenty-one subspecialties each of which watches out for its own turf boundaries and financial security. Out-numbered and out-voiced, it is no wonder that primary care has withered on the tree of medicine.
The furor and confusion over primary care and the role of nurse practitioners represent hope and opportunity. It is natural evolutionary step. It could lead to a national association of primary care providers composed of doctors and nurses and may be the only way to provide the clout needed to ensure primary care’s survival.
Published: June 17, 2009