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Are Nurse Practitioners the Solution to Shortage of Primary-Care Doctors?

May 26, 2011 at 12:00 AM EST
As more Americans become covered by health insurance, the need for primary care is on the rise, but there is a shortage of primary-care physicians. Health correspondent Betty Ann Bowser reports from Philadelphia on the growing role of nurse practitioners as primary caregivers.
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JEFFREY BROWN: Next, what to do about the growing need for primary care providers.

NewsHour health correspondent Betty Ann Bowser reports from Philadelphia on one potential solution to the shortage.

NELLIE LAZAR, Rising Sun Health Center: Hi, Ms. Etienne.

WOMAN: Hi, Ms. Nellie. How you doing today?

NELLIE LAZAR: Good.

WOMAN: How was your day?

NELLIE LAZAR: It’s good. It’s good to see you.

WOMAN: Yes, me too.

BETTY ANN BOWSER: Every day, Nellie Lazar sees more than a dozen patients. She sometimes works day and night.

NELLIE LAZAR: I’m able to take a call in the middle of the night and help them talk through what’s going on with them, help keep little babies out of the emergency room who just have a fever or ear infections.

BETTY ANN BOWSER: But Lazar is not a doctor. The Rising Sun Health clinic, where she works, is run by herself and one other nurse practitioner.

NELLIE LAZAR: We diagnose. We treat. We manage chronic health conditions, but also there is a strong emphasis on health promotion, as well as disease prevention.

BETTY ANN BOWSER: Lazar is part of a nationwide trend. In the last four decades, the number of nurse practitioners has risen to more than 140,000.

And more and more are working on their own, especially in poor inner-city neighborhoods and rural areas, where there are few doctors in private practice.

The scope of what nurses can do medically has also been growing for the past decade, at a time when the pool of primary care, or family doctors, has been shrinking. And now the need for professionals to do basic family medicine has never been greater.

In 2014, when key provisions of the federal health care reform law kick in, it’s estimated 32 million Americans who currently have no health insurance will be able to buy coverage. And the experts tell us that’s going to make the shortage of primary care physicians worse.

Tine Hansen-Turton is director of a trade association that represents nurse-managed health clinics.

TINE HANSEN-TURTON, National Nursing Centers Consortium: The challenge in this country is that, right now, we have an estimated shortage, according to the American Medical Association, of about 91,000, you know, physicians. Half of them would be primary care physicians. So we see the nurse practitioners playing a stronger role in the partnership with physicians around the country.

BETTY ANN BOWSER: When the nurse-managed 11th Street Family Health Services Center was started 15 years ago by Drexel University, the neighborhood was a medical wasteland.

Patty Gerrity saw a pressing need.

PATTY GERRITY, 11th Street Family Health Services Center: There was one physician in the neighborhood, and he was known for giving you what you wanted, meaning people went to him for painkillers and drugs. And we found that most of the patients went from emergency room to emergency room. They didn’t have one continuous source of primary care.

BETTY ANN BOWSER: Gerrity’s clinic is considered a good example of successful nurse-managed care, because the program focuses on the whole patient and uses health care workers from across different disciplines. The clinic offers physical fitness instruction, yoga classes, dental services and cooking classes to teach patients how to eat right.

WOMAN: When you are wanting to add more flavor, we can add red pepper flakes and more curry powder to our recipe, too. That won’t add calories.

WOMAN: We haven’t seen you for a while.

BETTY ANN BOWSER: There isn’t much disagreement over expanding the scope of practice of nurse practitioners these days. The controversy starts when the conversation turns to just how much more of a role is appropriate.

Here at the University of Pennsylvania School of Nursing, Associate Dean Eileen Sullivan-Marx says nurses are capable of doing a lot more primary care than they have been allowed to do in the past.

EILEEN SULLIVAN-MARX, University of Pennsylvania: Everyone wants their private doctor, their general practitioners, the ‘Dr. Welby,’ if you will. What I’m saying is that nurse practitioners are the ‘Dr. Welbys’ of today.

Nurse practitioners cost less to prepare for society. It doesn’t cost as much for medical school. We can prepare nurse practitioners. It takes one to two years following a bachelor’s degree. Nurse practitioners’ salary simply aren’t as costly as physicians’ salaries.

BETTY ANN BOWSER: Some physician groups do not want to see nurse practitioners take over the job of the family doctor.

In a written statement, the AMA said physicians have more years of preparation than nurses and, “There is no substitute for education and training, and doctors are vital to optimal patient care, especially in the event of a complication.”

The American Academy of Family Physicians, led by Dr. Roland Goertz, doesn’t see nurses taking over the role of a primary care physician either.

DR. ROLAND GOERTZ, American Academy of Family Physicians: You wake up tomorrow, and you feel awful. I think that patient, for the best care possible for that patient to receive, needs to go to a setting, a practice that has all the team members available, including the team members that has the maximum training.

BETTY ANN BOWSER: Nurse practitioner Maria Irrera-Newcomb, who works at the 11th Street Clinic, says she’s had more than enough training, with two to three years of postgraduate work, to do basic primary care. She rejects the notion that people like her are trying to take over the job of the family doctor.

MARIA IRRERA-NEWCOMB, 11th Street Family Health Services: I think that physicians have a role in specialties and in primary care. I think there is definitely — there’s patients that, as they get very, very complicated, that we — as a nurse practitioner, you find that, OK, well, now I need a little bit more help, a little bit more — this is a little bit more difficult management, more internal medicine. And then we refer patients as needed.

BETTY ANN BOWSER: Not only is there disagreement over the scope of practice. There is a confusing patchwork quilt of state regulations governing what nurses can do.

Seventeen states and the District of Columbia allow them to treat patients independently. The rest require a doctor’s involvement in the treatment process.

And just training more people to work as nurse practitioners has its own set of problems. In 2008, an estimated 30,000 qualified applicants were turned away from schools that educate nurses.

Dr. John Rowe co-authored a recent report on the future of nursing for the Institutes of Medicine.

DR. JOHN ROWE, “The Future of Nursing”: Because there just aren’t enough seats in the schools. There aren’t enough nursing schools. The schools aren’t large enough. They don’t have enough clinical rotations with hospitals for the nurses to get their clinical experience. And, very importantly, there aren’t enough faculty. There aren’t enough nurses with doctoral level degrees who can teach.

BETTY ANN BOWSER: Colleges and universities that train nurses are looking for ways to expand their programs. And the new federal health care reform law generally supports those efforts.

But, in the end, it will be up to the states to write the rules that govern what nurse practitioners can do.