"Nurse practitioners (NPs) are worthy professionals and are absolutely essential to patient care. But they are not doctors," cardiologist Sandeep Jauhar writes in a controversial New York Times op-ed.
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Jauhar's comments come in response to the New York State Legislature's decision to grant NPs the right to provide primary care without physician oversight, joining 16 other states and the District of Columbia with similar laws already on the books. The bill's authors assert that mandatory collaboration with a doctor "no longer serves a clinical purpose" and obstructs much-needed access to primary care.
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"Though well intentioned, such proposals underestimate the clinical importance of physicians' expertise and overestimate the cost-effectiveness of [NPs]," Jauhar writes.
He notes that a key driver of the new legislation is the anticipated dearth of primary care providers (PCPs) as baby boomers start to retire and the Affordable Care Act adds millions to the rolls of the newly insured. At the same time, medical residents and student interest in primary care is at a record low, largely a byproduct of the profession's low salary compared with other specialties.
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NPs are often touted as a cost-effective solution to the PCP shortage, Jauhar notes. Medicare reimburses NPs at 85% the rate of PCPs. "Paying less for the same work would appear to be a way to save health care dollars," he points out.
Yet, good empirical research on the relative cost-efficacy of NPs is sorely lacking. Research has suggested that while NPs are more attuned to patients' psychological and social concerns, they tend to order more diagnostic tests than do their physician counterparts.
In one study—from 1999—patients assigned to NPs underwent more ultrasounds, CT scans, and MRI scans than did patients assigned to doctors, and had 25% more specialty visits and 41% more hospital admissions. The differences, according to the study, may "offset or negate any cost savings achieved by hiring nurse practitioners in place of physicians."
Jauhar writes that NPs may compensate for lack of training by ordering more tests. NPs receive 600 hours of clinical training during their entire formal education—"less than physicians receive in just the first year of a three-year medical residency," he notes, adding that medical residents, even after two years of classroom instruction and two years of clinical training, are considered unfit to practice medicine independently.
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Greater independence for NPs "does not seem fair or wise," Jauhar writes, adding that he does not "want to see a two-tiered system of primary care develop in this country."
Although primary care often seems straightforward, the specialty is "also about finding the extraordinary in what may appear to be routine," he says. As one doctor recently opined in an online physician community, "It's the ability to differentiate those pale shades of gray in patient care that counts."
"To do so consistently, I believe, requires a doctor's expertise," Jauhar agrees, adding, "There is an essential place for NPs in medicine, but it is as part of a physician-led team."
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Many other health care organizations and advocacy groups disagree with Jauhar's stance.
Four years ago, the Institute of Medicine called for regulations that allow nurses to practice "to the full extent of their education and training." Last year, the American Association of Nurse Practitioners made the case that the current diversity of health care providers made "hierarchical, physician-centric structures unnecessary" (Jauhar, New York Times, 4/29).
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