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Thu May 29, 2014
Mass. Considering Allowing Nurse Practitioners To Practice Primary Care
There’s a doctor shortage in Massachusetts. The traditional ‘family doctors’—the primary care physicians people go to for annual checkups or when they get injured or sick—there just aren’t enough of them. It’s actually a national problem. And with so few doctors, some states are looking to nurses for help.
At the graduation ceremony for Simmons College in May, 53 nurses received Masters degrees from the School of Nursing. Kaitlin Thomas-Frost was one of them. She says she knows she’s in the vanguard of a changing field.
"I mean, we are going to see so much—so much—movement and push forward in this profession in general," Thomas-Frost said.
Thomas-Frost is planning on working at a community health center as a nurse practitioner. Nurse practitioners are nurses with masters degrees and advanced training.
"What we actually do for patients: We assess, we take a history, we diagnosis, we prescribe and interpret diagnostics," she said.
But a lot of what nurse practitioners do depends on what state they work in. For example, if Thomas-Frost were to get a job in New Hampshire, she’d be able to practice primary care without the oversight of a doctor. She could even open her own clinic. But cross the state line into Massachusetts, and she would need a doctor to supervise her care of patients. That’s because, unlike for doctors, what nurses can and cannot do is regulated at the state level. Some states, like Massachusetts, are considered more restrictive than others. But a debate is underway at the State House over whether to ease these rules.
"Competency does not change with state boundaries," said Stephanie Ahmed, president of the Massachusetts Coalition of Nurse Practitioners. "Either you are competent or you are not."
Ahmed says having nurse practitioners do primary care is a win-win situation for everybody.
"Nurses, as the most prevalent of healthcare providers, would be best positioned to impact an ailing healthcare system," she said.
An ailing healthcare system, and a physician shortage—as the demand for primary care increases because of state and federal laws that require all Americans to have health insurance, there are not enough doctors to meet the needs of a growing patient population. According to the Association of American Medical Colleges, it’s expected that by the year 2020, there will be 45,000 too few primary care doctors to look after America’s aging and growing population.
But in many states, nurse practitioners are filling that gap. The New York state legislature is the latest to grant nurse practitioners the right to practice without a doctor’s oversight, which Ahmed says makes sense.
"This model of oversight doesn’t exist anywhere else," Ahmed said. "So you don’t see psychiatry overseeing the psychologists. Optometry being overseen by ophthalmologists. That doesn’t exist. It only exists in nursing."
But primary care doctor George Abraham says such oversight exists for a reason. At his office at St. Vincent’s Hospital in Worcester, he says he disagrees with advocates who say nurses could be the solution to a doctor shortage in the Commonwealth.
"That is sort of a simple-minded view that if we plug a body in there, we will address the shortage issue," Abraham said.
Abraham is the head of the American College of Physicians for Massachusetts, an organization that advocates for internal medicine doctors. If nurse practitioners in the state are allowed to practice without a doctor’s oversight, Abraham says the quality of patient care will be affected.
"Primary care also involves very complex challenging patients with multiple medical problems, multiple medications, the elderly who have multiple complexities of care, so primary care is a huge spectrum of people, and it’s the more complicated patients, that’s where they will run into trouble just because they have not had the education to back them up," he said.
To become a licensed physician, doctors must spend thousands of hours training in a clinical setting, but nurse practitioners are required to have only 500 hours of clinical training. Abraham says nurse practitioners should work on physician-led teams so that when they need help they can ask for it.
"The role of physicians is not so much to supervise or micromanage a nurse practitioner, but as much as when there are more complex patients they’re to be able to supervise, or in other words, be a resource, but at the same time allow them to practice on their own," he said. "Where they are more comfortable making a decision they are able to do that, but where they always have somebody to fall back to."
But Ahmed says nurse practitioners are fully trained to do primary care. She’s a nurse practitioner herself, and she says data shows that health outcomes for patients treated by nurse practitioners are similar to those treated by physicians.
"More hours of training doesn’t necessarily mean that someone is going to have better outcomes or be more equip to deliver care," Ahmed said. "It means literally they have more years of training."
But having more years of training means something to Jason Lizotte, one of Abraham’s patients. Lizotte is 39 years old and has a complicated health history. He suffers from heart disease and spinal damage. He sees a lot of specialists, and Abraham is the point person for his care.
"I don’t think a nurse practitioner could adequately take care of my needs from a primary care setting," Lizotte said. "I think that my case, if you will, is too complicated for a nurse practitioner."
Lizotte is a registered nurse, though he says he no longer works as an RN because of his medical problems. He says before he met Abraham, he bounced around a lot to clinics and to primary care doctors he didn’t like, mostly because he felt rushed.
"I do believe that there is a shortfall of physicians … where patients are not getting time with their doctors," he said.
Lizotte says in his experience, nurses spend more time with their patients, and although he prefers a doctor for his needs, he says nurse practitioners should be allowed to work independently in primary care, without doctor supervision. It’s only one patient’s opinion, but he says when it comes to doctor shortages, nurses could be part of the solution.
Legislation that would allow nurse practitioners to have more autonomy is being reviewed by a conference committee at the State house. The new rules are included in the senate budget which should be on the Gov. Deval Patrick's desk by June 30.
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