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Do nurse practitioners pose a threat to family physicians?

NO

Correspondence: Dr Bourgeois-Law, University of Manitoba, Continuing Medical Education, S203-750 Bannatyne Ave, Winnipeg, MB R3E 0W3; e-mailbourgeoi{at}cc.umanitoba.ca

Before answering that question, we might well ask ourselves why the question is coming up now, at this particular time. After all, nurse practitioners (NPs) are not a new concept. Both NPs and physician assistants (PAs) were first introduced in the United States more than 40 years ago as a response to the shortage of physicians.¹ The number of NPs and PAs gradually increased, and they now play a substantial and accepted role in American health care. The quality of the care they provide has been well documented.² Recently, NPs have again become controversial in the United States with the introduction of NP-run clinics in big-box stores, most notably Wal-Mart.^3,4 Nurse practitioners are far from becoming numerous enough to take over the American health care world, however, as the number of graduating NPs in the United States actually decreased by 20% from 1998 to 2005,¹ a decline that has been attributed to a general shortage of nurses and a decreased interest in nursing as a career.

In Canada, NPs are being asked to extend the services provided by physicians, both in specialty medicine and in primary care. The first NP-governed clinic opened in Sudbury, Ont, last year.⁵ Constraints on the expansion of NPs in Canada include the lack of a funding model, the lack of opportunities for clinical training and practicums at a time when medical schools are dealing with both increased enrolment and the need to provide opportunities for international medical graduates to upgrade their skills, and to some extent, resistance from physicians. As is the case in the United States, this resistance is more to NPs as autonomous health care providers than to NPs per se.

Sorting out concerns

The danger here is that concerns about the expanding role of NPs, or PAs for that matter, obscure the real threat to family physicians. After all, very few physicians truly practise independently any more. They increasingly work in multidisciplinary groups, such as Ontario’s Family Health Teams, for the benefit not only of their patients but of themselves and their families. Fewer residents are choosing full-service family medicine as a career. Family physicians cannot, and increasingly are not willing to, do it all. They are also less willing to go to underserviced areas than NPs and PAs are.⁶ In that regard, international medical graduates are no different from Canadian graduates. While many start their careers in rural areas as a means of entering the system, most return to urban areas as soon as circumstances permit.

The real threat to family physicians is not NPs. While there are undoubtedly some NPs who want to replace family physicians, most of those who feel that way have felt frustrated at being unable to use all their skills. Nurses are not necessarily enamoured of a movement toward NPs that is driven by a political agenda aimed at solving the shortage of physicians but that does not consider the shortage of nurses nor value nurses for their unique skills and contributions.⁷ Health care funders have a vested interest in encouraging competition among various autonomous primary care providers. While in a privately funded system lower costs and thus increased profits provide the motivation, in a publicly funded system, in addition to costs, the concern is to ensure an adequate number of "warm bodies" (a term I once heard a recruiter use as in, "I need a warm body for that town") where they are needed.

Developing new partnerships

We should not deny or downplay the issues between NPs and family physicians. These issues have been debated in both the United States⁸ and in the United Kingdom. An editorial that appeared in both the British Medical Journal⁹ and Nursing Times candidly addressed the underlying gender and sociocultural issues in the dysfunctional health care family. As the authors so aptly put it, "For decades we understood the professions as a conventional nuclear family, with doctor-father, mother-nurse, and patient-child. But our hope for total wisdom and protection from father is forlorn, our wish for total comfort and protection from mother unachievable, and the patient has grown up. A new three[-way] partnership should displace this vanishing family."⁹ Developing that 3-way partnership will take time. Yes, the politics can get dirty. In some provinces, nurses and government bureaucrats with nursing backgrounds have tried to stop the introduction of PAs for the same reasons that some physicians have attempted to stop the expansion of NPs. As Winnipeg site coordinator in 2004 for the first PA students from the Canadian military, I encountered the same concerns from nurses about PAs as physicians had expressed about NPs. But PAs do not pose a serious threat to NPs, just as NPs do not pose a serious threat to family physicians.

The time has come for both family physicians and NPs to focus on what they have in common, that is, a concern for patients’ well-being and a desire for respect and acknowledgment of their unique and often difficult roles. These 2 groups need to unite in order to address the real threat: a system that often demonstrates little respect for primary care providers, whether physicians or nurses. Together physicians and NPs need to demand a health care system that is truly patient centred, one that listens to the opinions and concerns of its front-line providers because they know the system best and that does not treat its practitioners as commodities.

CLOSING ARGUMENTS Studies have shown that nurse practitioners and physician assistants can provide a substantial proportion of primary care and that they tend to be more willing to practice in underserviced areas. Nurse practitioners are viewed as a threat by some family physicians who fear that the nurses will usurp their role; however, the need for primary care providers is such that the various practitioners must learn to work together for the benefit of patients. The underlying gender and sociocultural issues between nurses and physicians must be brought into the open and discussed if they are to be fully resolved. Nurse practitioners and family physicians face a common threat: a health-care system that places its political agenda before patients’ safety and well-being and that does not adequately value its primary care providers.

 

Footnotes

Competing interests

None declared

Cet article se trouve aussi en français à la page 1673.

The parties in this debate will refute each other’s arguments in rebuttals to be published in an upcoming issue.

References

1. Hooker RS. Physician assistants and NPs: the United States experience. Med J Aust 2006;185(1):4–7.[Medline]
2. Mundinger MO, Kane RL, Lenz ER, Totten AM, Tsai WY, Cleary PD, et al. Primary care outcomes in patients treated by NPs or physicians. A randomized trial. JAMA 2000;283(1):59–68.[Abstract/Free Full Text]
3. Nelson J. Redi or not, here come retail health clinics. Tex Fam Physician Online 2006;57(2, Available from: www.tafp.org/news/TFP/2006TFP2/5.asp. Accessed 2008 Jan 11.
4. Bohmer R. The rise of in-store clinics: threat or opportunity? N Engl J Med 2007;356(8):765–8.[Free Full Text]
5. Canadian Broadcasting Corporation News. First nurse practitioner-governed clinic opens in Sudbury. Toronto, ON: CBC News; 2008. Available from: www.cbc.ca/health/story/2007/08/31/nurse-clinic.html. Accessed 2008 Jan 11.
6. Grumbach K, Hart LG, Mertz E, Coffman J, Palazzo L. Who is caring for the underserved? A comparison of primary care physicians and nonphysician clinicians in California and Washington. Ann Fam Med 2003;1(2):97–104.[Abstract/Free Full Text]
7. McIntyre M. Realities of Canadian nursing: professional, practice, and power. 2 ed. Ottawa, ON: Lippincott, Williams & Wilkins; 2005.
8. Phillips RL, Harper DC, Wakefield M, Green LA, Fryer GE. Can NPs and physicians beat parochialism into plowshares? Health Aff (Millwood) 2002;21(5):133–42.[Abstract/Free Full Text]
9. Salvage J, Smith R. Doctors and nurses: doing it differently. BMJ 2000;320(7241):1019–20.[Free Full Text]

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