Why are some doctors so threatened by nurses? One recent example of such physician angst can be found in the American Medical Association’s (AMA’s) response to a recent report on the future of nursing by the highly respected Institute of Medicine (IOM). Among the IOM’s recommendations are that “nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States."
Being a “full partner”, the IOM report notes, “transcends all levels of the nursing profession and requires leadership skills and competencies that must be applied within the profession and in collaboration with other health professionals. It includes “care environments” (hospitals and medical offices) and the policy area. Nurses must “have a voice in health policy decision-making and be engaged in implementation efforts related to health care reform”, the report argues. They must be “leaders throughout the system”.
What? Full partners? The AMA was quick on the trigger: “A physician-led team approach to care —with each member of the team playing the role they are educated and trained to play—helps ensure patients get the high quality care and value…”
In case one doesn’t understand who plays which role and why, the AMA helpfully compared and contrasted the educational backgrounds of nurses and doctors, noting that "[p]hysicians have seven or more years of postgraduate education and more than 10,000 hours of clinical experience, most nurse practitioners have just two-to-three years of postgraduate education and less clinical experience than is obtained in the first year of a three year medical residency."
True enough. But educational attainment is not the sole criteria for judging who knows best what a given patient needs at a particular moment. There is a weight of evidence (here and here, for example) supporting the view that—in nearly all primary care settings, at least—nurse practitioners can deliver the same quality of care as physicians. Although the definition and complexity of “primary care” varies, it includes a range of comprehensive services, from the first “point of contact” for patient assessment, to diagnosis, to continuing care and treatment of a wide range of ailments. According to the IOM report, U.S. primary care is provided by 287,000 physicians, 83,000 nurse practitioners, and 23,000 physician assistants.
Although requirements vary widely, at least 11 states already allow nurse practitioners to practice independently (without physician involvement). Such nurses prescribe medications, while other states require a greater or lesser degree of physician involvement. (The IOM report advocates sweeping reforms of such “scope of practice” barriers). Furthermore, some doctors, bucking the tide, decry the hierarchical structure in medicine as dangerous to patients
It may be that the AMA was too agitated by the “partnership” idea to read the rest of the IOM report, which contained a series of thoughtful ideas about the future of nursing and health care. Here are the “takeaway” messages: Nurses should (1) have the authority to practice to the full extent of their education and training, (2) achieve higher levels of education and training through an improved education system, and (3) be full partners, with physicians and other health care professionals, in redesigning health care in the U.S. The report also points to the urgent need for a 21st century healthcare data collection and information infrastructure.
The report also notes what patients and former patients already understand: that nurses’ “regular, close proximity to patients and scientific understanding of care processes” gives them a unique perspective on patients.
In that context, the report adds that, “while most nurses are registered nurses (RNs), more than a quarter million nurses are advanced practice registered nurses (APRNs), who have master’s or doctoral degrees and pass national certification exams. Nurse practitioners, clinical nurse specialists, nurse anesthetists, and nurse midwives all are licensed as APRNs." Message to doctors:
Nurses are smart, well-educated professionals and can do more than you might assume.
The report is not all an “I (heart) nurses” document, however. It notes that some nurses are not ready to meet these new challenges and will require more training as the nation’s health care needs evolve.
The AMA should welcome this effort to shore up our stressed out health care system. Physicians have their own issues. For example, the years of training come at a cost, both to doctors and to society. As the AMA notes on its website, the Association of American Medical Colleges (AAMC) estimates that the average indebted medical school graduate in the class of 2009 carries a medical education debt of more than $156,000. The result is fewer primary care physicians (as doctors flock to practice more lucrative medical specialties, such a cardiology, hematology and the like), as well as fewer physicians from the lower income and minority communities. Even more worrisome, there is an increase in “unsafe physician behaviors," as debt-worn doctors moonlight to earn extra money, grow cynical about the profession, and suffer depression.
So, why do some doctors, with their truly impressive academic and clinical credentials, push back so hard on this issue? This post on a physician’s blog offers a hint. The doctor notes that, in primary care, “physicians, nurse practitioners and physician assistants tend to do the same type of work, and if anything, physicians tend to have shorter appointments than ’midlevel practitioners,’ reflecting their higher level of training and justifying their higher salaries."
It appears that some doctors may feel professionally threatened by some nurses. But the health care system is changing dramatically and patients need both doctors and nurses to perform the functions they were trained to perform, at the level they were trained to perform them. As the IOM points out, health care specialists must collaborate in order to find the way forward. And even physicians may need a partner to help them figure it out.