Ask a Nurse - or Do You Really Need a Doctor?

There is a shortage of doctors providing primary care in the United States.  No matter how you look at the statistical projections of the growing population and the growing proportion of us who will be older and bear a greater burden of chronic disease, it is clear that we will need more doctors.  And, no matter how you look at projections of the supply of doctors, and especially those providing primary care, it is clear that the supply will fall well short of demand.

A colleague of mine recently sent me an article from one of the leading trade publications outlining the many reasons today's physicians find the practice of medicine frustrating and stressful, including ever-increasing and time-consuming government regulations that are seen as mostly inane and useless.  The other major stressor is constant worry about being sued any time there is an adverse outcome.  We live in a culture of blame, and when a patient experiences an adverse health outcome, the finger of blame will naturally point at his doctor.

So, at just the time when we need more doctors, today's physicians are less satisfied with their work, which means they are deciding to work less, retire earlier, and dissuade their offspring from choosing this profession.

Perhaps, as a society, we should be trying to reverse the trend and make the medical profession more attractive.  But wait.  There is another possibility. Physicians aren't the only ones who can do this job.  There are nurse practitioners.  They can do many of the things doctors can do in primary care. They will work for less money.  What a deal!

If someone can do a job as well as the last person for less money, that has great appeal as a "value proposition."  And the value proposition is important in healthcare when the percentage of our GDP that we spend on it has reached the high teens.

So what about nurse practitioners in primary care?  Do they do as good a job for less money?

To answer that question, we need a lot of data.  We need data on costs and outcomes.  And we need data on outcomes both short-term and long-term.  I'll come back to that in a bit.

If you have a cold or a sore throat and go to a retail clinic or urgent care center staffed by nurse practitioners, you will probably get a lower bill than if you went to see a doctor.  That suggests a favorable value proposition.  But sometimes things are not simple and straightforward, and sometimes you need someone with a deeper understanding of your problem.

Last week a woman sustained a minor head injury and went to an urgent care. The nurse practitioner looked her over and told her she should go to the hospital emergency department.  She followed that advice.  After waiting several hours - because it was Monday, and emergency departments are often crazy busy on Mondays, which means long waits for those who are not critically ill or injured - she saw a doctor.  The doctor took a history and did a proper neurologic examination.  Drawing on a deeper understanding of head injuries and a thorough familiarity with what the scientific literature tells us about the proper way to evaluate patients with head injuries, the doctor told the patient she did not need a CAT scan of the head - which was the main reason she had been sent to the ED.

So now the patient has a visit to an urgent care, to which has been added a visit to an ED, where she had to wait a long time, and for which she will get a second bill, higher than the first one.  How's the value proposition now?

About now you may be thinking, couldn't we just teach the nurse practitioner how to do a better job evaluating the patient with a minor head injury?  Sure we could. We could teach the nurse practitioner how to do a better job at just about anything.  That would take some time, though.  And the reason doctors are more expensive than nurse practitioners is that it takes longer to train someone to that level.  You see where I'm going with this.

To the best of my knowledge, there are very limited data on outcomes in primary care - and no long-term outcomes data - comparing physicians with NPs.  Such an absence of data leaves me free to answer the question based entirely on my opinions - which, as you know, are invariably carefully considered, unassailable in their logic, brilliant in their exposition, and wise beyond compare.  Oh, and they are always correct.  *Now extracting tongue from cheek, not without considerable difficulty.* 

My internist is a fellow who was several years ahead of me in training.  When I go to see him, I know he will follow all guidelines-based recommendations for primary and secondary prevention of chronic diseases.  I know a primary care nurse practitioner would do the same thing.  I admit to preferring the physician over the nurse, because if I have questions about the science underlying the recommendations, I know which one is more likely to be able to answer them to my satisfaction.

I am also aware that sometimes I need an internist to do more than follow guidelines and recommendations for my healthcare.  Sometimes I need him to figure out what is wrong with me.

And there is something else that comes into play here.  Sometimes knowing more and having a deeper understanding leads to doing less.  (Recall the simple example of the minor head injury.)  Very often a smart doctor can figure out what is wrong with you by taking a focused history, asking all the right questions, and doing a careful physical examination for signs of disease.  The doctor may be 93% sure about what is wrong with you without doing any tests.  Imagine how much money could be saved if you trust his clinical judgment and give him permission to refrain from spending any of your money on tests to raise the diagnostic certainty from 93% to 99%.

I have worked side-by-side with nurse practitioners for nearly three decades, including some I've thought were very capable.  I am still waiting to meet a nurse practitioner I might judge to be an astute diagnostician.

This is hardly surprising.  One can become a nurse practitioner by starting as an RN/BSN and taking an online master's degree program, while an internist has four years of medical school and three years of residency after the bachelor's degree.  To expect the two to have similar abilities in the aspects of practice that rely on a foundation of education in the sciences is quite unreasonable.

Let us begin with the assumption that, among bachelor's-degree RNs, only the best and the brightest decide to go on to earn master's (or doctoral) degrees and become nurse practitioners.  Now I'm going to look at that population of students and ask a simple question.  How many of them would do well in the year of organic chemistry required of pre-meds and commonly used as a "weeder" course?  My daughter Rose is very bright and hard-working.  I know this because I lived with her in the same household for nearly two decades.  And I saw how hard she had to work to get grades in organic chemistry last year that would meet with the approval of a medical school admissions committee.

Do you have any children still in school?  Think about the smartest kid in your child's class.  Maybe it's your kid.  That kid could go to medical school or law school or choose any other of a number of career paths.  Now remember, she's the smartest kid in the class.  When you are older and sick, what do you want her to be?  Do you want her to be the consultant other doctors call when they are trying to figure out how to keep a perplexing illness from killing or disabling you? Or do you want her to be the lawyer your family calls when things don't go well and they want to find out whether your doctors are to blame?

I believe the bottom line is very simple.  If we want excellent medical care in the United States, we need excellent doctors.  If we want excellent doctors, we must understand the importance of getting the best and brightest of our nation's youth to choose this profession.  Some of my older colleagues believe the "golden age" has passed for the medical profession, and the practice of medicine will never be as enjoyable or rewarding as it once was.  I believe we can and must bring back that golden age.