Vive la Différence

I read with some interest a recent op-ed titled Nurses Are Not Doctors, largely because I was intrigued by the self-evident title.  The author (Sandeep Jauhar) is a physician, and he was lamenting New York legislation that will soon allow nurse practitioners to practice primary care without physician oversight.  As I read the piece, though, I couldn't help thinking of that French expression (which is usually used in a different context): vive la différence!

This particular battle has been fought -- and is still being fought -- across the country, resulting in a patchwork system where nurse practitioners have fairly full autonomy in some 17 states plus D.C., and varying degrees of restriction and physician oversight in others.  Physicians claim that patient safety would be jeopardized if they aren't overseeing nurse practitioners, while the nurse practitioners think they can handle most primary care situations just fine on their own, including prescribing.


It's interesting to me that nurse practitioners seem to be very active in trying to expand their scope of practice, while physician assistants appear to be taking a more subtle approach, agreeing to work as part of a physician-led team but happy to get broadly delegated authority.  And the desire to get a wider scope of practice is not limited to these two types; for example, pharmacists wouldn't mind getting ability to prescribe and possibly diagnose, as they can in some other countries.

Like most things, I suspect the truth is somewhere in the middle, although I confess I tilt more towards the NP's side.  The fight revolves around how to best increase issue of access to primary care.

Some of the facts are clear.  The U.S. has one of the lowest ratios of primary care physicians to specialists among the OECD countries.  The annual rate of visits is much higher for specialists than for primary care physicians, something that wasn't true even ten years ago.  And, of course, specialists make much more than primary care physicians -- almost twice as much on average, with some specialists making a lot more.

Surveys of medical school students' career intentions show continued low interest in primary care, which is not surprising not only because of the perceived lower income and worse work/life balance but also because residency slots are limited -- and often not even offered by larger and most prestigious hospitals.  Only about 30% of medical school graduates are filling primary care residency slots.

Some of the projections are slightly less clear, but still generally dire.  HRSA projects a shortage of 20,000 primary care physicians by 2020, while the American Association of Medical Colleges projects twice that.  In total, AAMC says there will be a shortage of some 91,500 physicians by 2020.

Not everyone agrees with these projections.  Physicians/policy wonks Scott Gottlieb and Ezekiel Emanuel proclaimed No, There Won't Be a Doctor Shortage.  They think we can get by through making physicians practice more effectively, and by expanding the scope of practice laws for nurse practitioners and pharmacists to help deliver primary care, along with making better use of technology.  It's the kind of thing Dr. Jauhar is opposed to.


There is evidence that nurse practitioners can provide care just fine, and more cost-effectively.  A 2013 study in The Journal of Nurse Practitioners (OK, perhaps not an unbiased source) surveyed the literature on NPs versus MDs and found outcomes the same or better for NPs.  In California, the Bay Area Council just released a study that claims expanding NP scope of practice could save $1.8b over 10 years while increasing use of preventive services. 

A survey done by Karen Donelan and colleagues and reported in NEJM found strong support among both physicians and nurse practitioners that the latter should be able "to practice to the full extent of their education and training," but they disagreed on most everything else, especially NP scope of practice.  Why am I not surprised?

As I read about physicians criticizing nurse practitioners' training, I keep wondering: why are only something like 80% of physicians board-certified?  It supposedly provides clear benefits, yet one-fifth of physicians don't have the advanced training their own specialty societies say they should have? 

This fight over scope of practice may usually be framed around patient safety, but it's about the money, of course.  Most physicians may not want to get into primary care themselves (and I can't resist noting that Dr. Jauhar is actually a cardiologist), but they don't want that money going to anyone else either.

If the physicians' argument is going to be patient safety, though, they're not starting with a very impressive record.  I've written on patient safety before (Patients Come Second) and on health care's often unfortunate culture (Health Care Culture Wars).  I wish I could say there were encouraging signs, but, if there are, I'm not seeing them.

The Commonwealth Fund's 2014 State Health System Scorecard found that "on a significant majority of measures, the story is mostly one of stagnation or decline. In most parts of the country, performance worsened on nearly as many measures as it improved."

Similarly, The Leapfrog Group's latest hospital safety score found only "incremental improvements," with (only) one-third of hospitals making improvements of 10% or more, and an overall improvement of only 6.3%.  Leah Booker, the President and CEO of the Leapfrog Group, was happy just to see any movement at all, which should be depressing. 



The supposedly self-policing state medical boards don't seem to be doing much policing (as I wrote about a few years ago).  Analysis of the recent Part B data released by CMS has already found numerous cases where physicians who lost their license in one state or were barred from state or federal programs continued to practice -- and collected millions from Medicare alone.  CBS News recently reported on the questionable (over)use of spinal fusions, including ones from physicians who had prior bad histories.  An investigation article by the Syracuse Post-Standard focused on the persistent problem of bad behavior by doctors, citing in particular the issue of a local surgeon who allegedly would slap sedated patients on their buttocks while also verbally insulting them. 

I am not making that last example up.

It's not that there are some bad doctors -- there are some bad members in every profession -- as it is that they are tolerated by their colleagues and coworkers, even long after it is clear their behavior is bad for patients.  Physicians protecting other physicians, even when incompetent, is sometimes called the "white coat of silence," and it is not acceptable. 

Perhaps once physicians get around to improving this kind of bad behavior and requiring the kind of practice-specific training for themselves that they say nurse practitioners should have, then I'll have more sympathy for their arguments.

We have kind of a Goldilocks situation.  Some people happen to get the right care from the provider best trained to provide it, while others get less than ideal care from providers who aren't trained to treat their condition -- and still others have trouble getting access to care at all.


We should be seeking to ensure access to the right care from the most appropriate providers, and worrying less about fitting certain kinds of providers into practice limits based more on historical precedents or cultural stereotypes than on competence or training.  It's about really making a patient-centered health system, not simply trying to maintain a physician-centered medical system.

No, nurses are not physicians.  Neither are nurse practitioners or physician assistants.  For that matter, though, internists are not cardiologists, and cardiologists aren't neurosurgeons.  Nor are physicians nutritionists or personal trainers.  Each type of professional brings their own set of skills and knowledge to helping patients, and we should celebrate and fully utilize those.  Vive la différence indeed!