Why Nurse Practitioners Should Not Do Primary Care Without Physician Oversight
“She said my back pain was caused by micro kidney stones.”
So said my newest patient after her previous primary care provider, a nurse practitioner retired.
“Micro kidney stones?”
I didn’t know what else to say. Having practiced as a board certified primary care doctor for a decade, I’d never even heard this term.
Nurses Are Not Doctors
So the NY Times opinion piece that “Nurses Are Not Doctors“, penned by Dr. Sandeep Jauhar, author of Doctored: The Disillusionment of an American Physician, resonated with me. The fact that 17 states have legislated nurse practitioners the right to practice primary care medicine without physician oversight is very worrisome. There is a primary care crisis. We do need more primary care providers. Though nurse practitioners can fulfill some of the demand they cannot do so without doctor oversight. Though on paper it seems like what primary care doctors do is easy, in fact when digging a little deeper, one finds out these two specialties are not the same though some states view them as such.
It boils down to training. Primary care is a cognitively challenging specialty. The amount of training doctors receive is far greater than that of nurse practitioners.
- Forty years ago, in a paper in American Scientist, Herbert Simon and William Chase drew one of the most famous conclusions in the study of expertise:
There are no instant experts in chess—certainly no instant masters or grandmasters. There appears not to be on record any case (including Bobby Fischer) where a person reached grandmaster level with less than about a decade’s intense preoccupation with the game. We would estimate, very roughly, that a master has spent perhaps 10,000 to 50,000 hours staring at chess positions…
- But the ten-thousand-hour research reminds us that “the closer psychologists look at the careers of the gifted, the smaller the role innate talent seems to play and the bigger the role preparation seems to play.” In cognitively demanding fields, there are no naturals. Nobody walks into an operating room, straight out of a surgical rotation, and does world-class neurosurgery.
The issue is also making the right judgement calls. Primary care is where most patients present for the first time to the health care system. With their constellation of symptoms, it is the listening, examining, and diagnostic skills of the primary care provider that makes the difference between ordering the right tests, the right treatments, and if needed, the right referrals or ordering too many unnecessary tests, prescribing inappropriate treatments, or generating extra referrals.
So how many hours of training do nurse practitioners receive? Per the oped piece.
- Nurse practitioners receive approximately 600 hours of clinical instruction during their entire formal education, which is less than physicians receive in just the first year of a three-year medical residency.
- Medical school graduates, after two years of classroom instruction and two years of clinical training, are not considered fit to practice medicine independently. Yet in New York State next year, nurse practitioners with perhaps even less clinical education will be allowed to do so.
Primary Care Is Not Simple Or Easy – Doctor Training Is Different
If primary care was so simple and easy, perhaps these concerns of inadequate training would be overblown. Who doesn’t know the symptoms of a bladder infection? Heartburn? Seasonal allergies? Either doctors or nurse practitioners can play the role well.
What differentiates doctors from nurse practitioners is our training, clinical experience, disciplined thought process, and a framework to problem solve provide a depth of understanding that simply is lacking in nurse practitioner training. Patients don’t present with the classic textbook description of an illness. Though medical school professors reminded us that when evaluating symptoms and to diagnose the more common and obvious ailment — “when you hear hoofbeats, think horses not zebras”, the world has gotten more complex. Outbreaks of once eradicated childhood illnesses spread by international travel to our shores. Patients are living longer with chronic illnesses and on multiple medication regimens. Can nurse practitioners make the correct judgement calls on increasingly complex patients in primary care?
Understanding what you know is as important as admitting what you don’t know. Micro kidney stones?
What Do Patients Want? What is the Job to be Solved?
Finally, one other perspective one might consider is “what is the job that the customer has hired me to do?
As Professor Clayton Christensen of Harvard Business School noted in the Milkshake Marketing piece, we need to think about solving people’s problems in this way:
- “the jobs-to-be-done point of view causes you to crawl into the skin of your customer and go with her as she goes about her day, always asking the question as she does something: Why did she do it that way?”
- “Several major companies that have succeeded with a jobs-to-be-done mechanism: FedEx, for example, fulfills the job of getting a package from here to there as fast as possible. Disney does the job of providing warm, safe, fantasy vacations for families. OnStar provides peace of mind… Nobody, for example, has managed to copy IKEA, which helps its customers do the job of furnishing an apartment right now.”
When she has symptoms, she is trying to find a solution to allow her to feel better or to remove any worry or anxiety generated by the new symptom. This is when she seeks care with a primary care provider. Sometimes understanding the cause of these symptoms is clear. The treatment straightforward. Other times, the diagnosis may not be clear. The work-up requiring more thought.
Both the patient and the provider cannot know prior to the encounter whether the resulting diagnosis, work-up, and treatment is simple or complex. When a patient has a new problem, the job she is trying to solve is for someone to help her. Whether the solution is simple or complex will depend on the provider’s ability to determine it as well as the patient’s illness.
Policy Makers Are Mistaken. Nurse Practitioners Are Not As Capable as Primary Care Doctors
Yet, policy makers believe that nurse practitioners are as capable as primary care doctors in discerning these clinical differences. Policy makers believe nurse practitioners can practice independently from doctors and be free of oversight in the cognitively demanding specialties of internal medicine and family medicine.
I don’t. The observation of deliberate practice of 10,000 hours and the reality that primary care sees both simple and complex problems in an unpredictable manner coupled with the double standard of different training and different certification training suggests that nurse practitioners are not ideally suited to be front-line providers free of physician oversight. Should nurse practitioners want this independence, they should be held to the same certification standards as doctors.
Nevertheless, if policy makers feel primary care is a job that nurse practitioners free of physician oversight can solve for patients seeking initial care, then they might wish to allow nurse practitioners to expand into another specialty: