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Friday, Sep 29, 2006
Posted on Sun, Jun. 25, 2006
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The nurse is in: Nurse practitioners filling void in primary care

JOANN LOVIGLIO
Associated Press

KENNETT SQUARE, Pa. - In a bustling medical office in this Philadelphia suburb, Marguerite Harris and her staff of eight provide prenatal care and child immunizations, write prescriptions and diagnose and treat ailments from diabetes to the sniffles.

Though it may sound like a typical doctor's office, it is not: No one on staff at Project Salud is a doctor. The medical center is run by nurse practitioners - registered nurses with specialized training and advanced degrees - whose numbers have risen from about 30,000 in 1990 to about 115,000 today.

Increasingly, patients are being treated by health care professionals with N.P. after their names instead of M.D. or D.O. Nurse-managed primary care centers such as Project Salud have increased in number to about 250 nationwide today, from a small handful 15 years ago.

"We've grown," said Harris, a nurse practitioner at Project Salud since 1974. "We've come a long way since the early days, the knockdown drag-outs with doctors who thought we were overstepping our roles."

The change is attributed to factors that include a drop in the number of doctors choosing primary care as their specialty, a falloff that is expected to continue.

From 1998 to 2005, medical school surveys showed, the percentage of third-year residents intending to pursue careers in general internal medicine dropped from 54 percent to 20 percent, according to the American College of Physicians. Many new doctors, saddled with high student loans, are choosing more lucrative specialties.

The supply of general practice physicians is falling just as the baby boomer population is aging and in greater need of medical care.

Nurse-run medical centers are bridging the gap. They can perform many of the duties of primary care doctors, such as performing physical exams; diagnosing and treating common health problems; prescribing medications; ordering and interpreting X-rays; providing prenatal care, family planning services and gynecological exams; and giving immunizations.

Some physicians' groups are concerned about the trend.

The American Medical Association is against giving full autonomy to nurse practitioners, stating as its official policy position that a physician should be supervising nurse practitioners at all times and in all settings.

An AMA spokeswoman said the association would not provide additional comment on its position. She cited an upcoming vote on a related policy regarding in-store medical clinics, which are typically run by nurse practitioners.

"There is an element within the physician community that gets a little antsy ... They think it's going to take away revenue and business from them," said Dr. Jan Towers, the Washington-based director of health policy for the American Academy of Nurse Practitioners. "Really, there's more than enough for everybody."

For their part, patients like the less rushed, more holistic style of care they receive from nurse practitioners.

"It got to the point where my doctor was in such a hurry, he wouldn't even look me in the face," said Diane Gass, a North Philadelphia resident who has been a patient at her neighborhood nurse-run health center since it opened about a decade ago. "I felt uncomfortable, like he thought I wasn't good enough for him to spend time with me."

Gass, 61, was one of the first patients at the Health Connection center when it opened in 1996, and her nurse practitioner took four hours during the first visit taking her medical history and getting to know her.

She believes that approach saved her life.

"For years, the doctor was treating me for ulcers but I was in such pain," she recalled. "The nurse kept asking me questions about the pain and about my medical history, and we got to the bottom of what was really going on: I had a gallstone."

One outpatient procedure later, Gass' gallstone - and her chronic pain - were gone for good.

"That right there showed me this was the place I was going to be, until I can't open my eyes anymore," she said. "When I go to that office, I feel like I'm going to a close member of my family - that's the warmness they give you."

A 2000 study in the Journal of the American Medical Association concluded that patients who receive primary care from nurse practitioners fare just as well as those treated by doctors and report similar levels of satisfaction with their care.

Primary care performed by nurse practitioners is expanding beyond the role of "last resort" for the uninsured and underinsured to people who are seeking out that kind of care, said Tine Hansen-Turton, executive director of the National Nursing Centers Consortium, a Philadelphia-based industry group.

Nurse practitioners have steadily been gaining greater acceptance by insurers and state regulators.

In about half of the states, nurse practitioners - who frequently have lower fees for office visits than doctors - are now recognized by insurance carriers as primary care physicians.

In all but seven states, they can practice either independently or with remote collaboration with doctors. In all states except Georgia, they have some level of independent authority to prescribe medications; some states do prohibit nurse practitioners from prescribing narcotics.

In about 20 years, Project Salud has grown from seeing about 800 patients to more than 2,000 patients. It treats Mexican immigrants working on Chester County's mushroom farms, as well as affluent, white suburbanites.

Nurse practitioners are filling the primary-care void in cities, too. PHMC Health Connection, Gass' nurse-run primary care center in North Philadelphia, has built a 2,000-patient base in 10 years, mainly by word-of-mouth.

"Nurse practitioners take time to build collaborative relationships with patients that create trust, which leads to better outcomes," said nurse Nancy Rothman, who runs the center. "As people get older and have multiple chronic illnesses, you really need somebody to look at you holistically."

Nurse practitioners first appeared about 40 years ago in pediatrics, and quickly expanded into obstetrics and gynecology, family medicine and adult primary care. About 5,000 to 6,000 nurse practitioners, largely with master's degrees, graduate annually from colleges and universities.

"One of the statistics that stands out is that we (nurse practitioners) see our patients twice as often as similar practices of physicians," Hansen-Turton said. "Doing primary care well is the foundation for saving health care dollars - working on improving health early instead of, for example, paying for coronary surgery and bypasses later."

ON THE NET

American Academy of Nurse Practitioners: http://www.aanp.org

National Nursing Centers Consortium: http://www.nncc.us

American Medical Association: http://www.ama-assn.org

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