Do nurse practitioners pose a threat to family physicians?

What is unique about our profession?

Let us first look at what is unique about the medical profession. Every day, physicians devote themselves to questioning, examining, investigating, diagnosing, and prescribing treatment. Bit by bit, other practitioners seeking to expand their scopes of practice are claiming a share of the pie. In the process, they are infringing on our territory. Physiotherapists question, respiration technologists examine, chiropractors investigate, and pharmacists prescribe. The only practice that remains the exclusive domain of physicians is diagnosis. Cold comfort.

And then along come NPs. All on their own they question patients about their health, examine them if they see fit, order tests, and even perform invasive procedures, diagnose straightforward and common medical conditions, and prescribe treatments and fine-tune treatments already in progress.

What’s left?

Under current regulations, NPs must work in cooperation with physicians and refer to these physicians when situations are beyond the scope of their competency. Physicians vouch for the activities of their NPs, even though they do not supervise them directly. With all of the privileges granted to NPs, problems can progress for a long time before these NPs perceive that these problems are beyond the scope of their competency. And what role is then left for a family physician? Is it just to refer patients to specialists when NPs have reached the limits of their expertise? Is this really what is in store for us?

Essence of family medicine: continuity of care

Caring for a patient and building trust over years of visits takes the therapeutic relationship to another level. The notion of continuity of care is intrinsic to family medicine and enables family physicians to do more than simply treat diseases. The relationship is already weakened when patient care requires the involvement of many specialists. If this relationship is further diluted by visits from an NP, what then? It spells the end of a closeness that sometimes heals more effectively than science can.

We might ask ourselves also how medical clinics should be using NPs. In my opinion, they need NPs to play a supporting role in caring for patients. In my experience, the new Quebec model of front-line care, with groups of family physicians and nurse practitioners working together, demonstrates the appropriateness of physician-nurse cooperation and its efficacy in terms of patient care and follow-up. Do we need to duplicate roles? If NPs take the lead, will responsibilities not start to overlap?

Eventually NPs will want to work as autonomous health care providers. This is already starting to happen; NP-run clinics are opening without physicians. This is the first step on a slippery slope at the bottom of which NPs become, essentially, substitutes for family physicians.

A matter of money

What really smarts is the fact that it takes 5 years to train these “supernurses” compared with 7 years to train a family physician. How is it possible to achieve the same standard of expertise by 2 such different paths? Is it possible to determine the equivalency of 2 forms of academic training that are so different in terms of content and duration? Nurses arrive on the job market 2 years before physicians. Their work costs much less than the work of physicians. Half as much in fact. For governments grappling with ever increasing health care costs, the NP alternative starts to become very attractive.

Clearly, there is a shortage of physicians, but there is also a shortage of nurses! Robbing Peter to pay Paul never works. The Quebec Ministry of Health and Social Services predicts that within 3 years, Quebec will be short 4900 nurses. In 7 years, Quebec will be short 7300 nurses. Who will we find to replace them?

Ally or adversary?

Nurse practitioners specializing in front-line care are a threat to family physicians. They will not provide the support and reinforcement for which everyone hopes. They will dispute and lay claim to the same areas of practice as family physicians.

This is why NPs pose a threat to family physicians: they are in direct competition for physicians’ areas of expertise. We all agree that access to health care must be our top priority. I am of the opinion that improved health care will first be achieved through making better use of existing human resources and optimizing the role of each health care professional, not through overlapping responsibilities.