OPINION: “Nurses Are Not Doctors …” by Dr. SANDEEP JAUHAR


APRIL 2014 – EARLIER this month, the New York State Legislature passed a bill granting nurse practitioners the right to provide primary care without physician oversight. New York joins 16 other states and the District of Columbia in awarding such autonomy. (Most states still require nurse practitioners to work with physicians under a written practice agreement.) The bill’s authors contend that mandatory collaboration with a physician “no longer serves a clinical purpose” and reduces much-needed access to primary care.

Support for such measures has been widespread. Four years ago the Institute of Medicine called for dropping regulations that prevented nurses from practicing “to the full extent of their education and training.” Last year the president of the American Association of Nurse Practitioners argued that the current diversity of health professionals rendered “hierarchical, physician-centric structures unnecessary.”

As a physician, I couldn’t disagree more. Though well intentioned, such proposals underestimate the clinical importance of physicians’ expertise and overestimate the cost-effectiveness of nurse practitioners.

branding direct primary care bookThe impetus behind the new law, which will take effect next year, is the dire shortage of primary-care physicians. A big reason for this scarcity is money. Primary care pays the least of all the medical specialties, and interest in it is at a record low among medical students and residents. At the same time, as baby boomers are starting to retire and the Affordable Care Act adds millions to the rolls of the newly insured, the need for primary-care physicians is growing.

Nurse practitioners have been promoted as a cost-effective way to meet this need. Medicare currently reimburses nurse practitioners only 85 percent of the amount that it reimburses primary-care physicians. Paying less for the same work would appear to be a way to save health care dollars.

But are nurse practitioners actually more cost-effective? There is a dearth of good recent empirical research on this question, but some studies have suggested that the answer is no. Nurse practitioners, though generally praised for being sensitive to patients’ psychological and social concerns, appear to order more diagnostic tests than do their physician counterparts. In one study, published in 1999 in the journal Effective Clinical Practice, primary-care patients assigned to nurse practitioners underwent more ultrasounds, CT scans and M.R.I. scans than did patients assigned to physicians. The nurse practitioners’ patients also had 25 percent more specialty visits and 41 percent more hospital admissions.

These differences are costly. According to the study, they “may offset or negate any cost savings achieved by hiring nurse practitioners in place of physicians.”

There are many reasons the nurse practitioners may have ordered more tests and expert consultations. But it seems most plausible that they did so to compensate for a lack of training. Nurse practitioners receive approximately 600 hours of clinical instruction during their entire formal education, which is less than physicians receive in just the first year of a three-year medical residency.

Medical school graduates, after two years of classroom instruction and two years of clinical training, are not considered fit to practice medicine independently. Yet in New York State next year, nurse practitioners with perhaps even less clinical education will be allowed to do so.

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