Nurse practitioners
are wonderful, but they’re not doctors.
September
18, 2019 ALAN ADLER, MD
A
70-year-old woman who had been a patient of mine for years saw me in my office.
I had diagnosed her with polymyalgia rheumatica, an inflammatory condition
that, in her case, affected her hips and shoulders. Pretty much everything was
fine with her, but in one of those revealing, “by the way, doctor”
afterthoughts, she mentioned that she was worried about her husband. He was the
editor of a major magazine and had been scrupulous about meeting deadlines
through-out his career. But he had missed one recently. Even more concerning
was that he didn’t seem to care. So this distinguished-looking man, age 72,
came in my office a few days later. My neurologic exam didn’t reveal anything
of concern except when it came to the serial sevens, the test that involves
patients subtracting in sevens starting at 100. He got stuck at 93.
By
itself, serial sevens isn’t diagnostic, and people who are not good with
numbers may have some difficulty with it. But the test remains a quick and easy
way to assess concentration and memory. That this obviously intelligent
gentleman got stuck after only one subtraction was concerning. When I asked him
about missing a deadline, he told me he didn’t know why he didn’t care. I
ordered a CT scan of his brain. The radiologist called back with urgent news:
the scan showed that he had a large (the size of a plum) meningioma, a tumor
that originates in the meninges, the membranes that cover the brain; his was
impinging on the frontal lobes where higher order thinking takes place. It was
surgically removed and over time he became more self-aware, recognizing his
previously aberrant behavior.
Here is
another case that has stuck with me. He was a 50-year-old male, somewhat
disheveled appearing. His problem was loose stools. He had been through the
gastro-intestinal gauntlet: visits with specialists, upper and lower GI
studies, stool studies looking for evidence of infection. But so far, there had
been no resolution. As we talked and as I was conducting my exam, he was
sucking on hard candies. It was odd and off putting. He told me that the
candy-sucking habit was his way of coping with the dry mouth from the radiation
treatments he had received for laryngeal cancer. I had an aha moment: The
candies were the sugar-free Sorbees, which are sweetened with sorbitol, a sugar
substitute that is an osmotic agent and can function as a laxative. I suggested
that he stop with the candies and find other ways to deal with his dry mouth,
such as frequently sipping on water, breathing through his nose rather than
mouth, and stopping antihistamines that he was taking for allergies. Soon
afterward, the loose stools—and all the GI workups—stopped.
A third
case involved addressing a major case of polypharmacy. He was a new patient, an
Asian gentleman who looked exhausted and was struggling with fatigue and dizziness.
I saw that he was on a dozen different medications, including two different
generic beta blockers, a calcium blocker, digoxin, and an SSRI for depression.
He had an irregular heart rhythm, and a ECG showed a Mobitz I second degree
heart block (Wenckebach)—the electrical signals to his heart were impeded,
resulting in a slow and irregular heart beat. I stopped one of the beta
blockers as well as the digoxin and SSRI. His heart rhythm returned to normal.
The fatigue and dizziness went away.
I am sure
that every internist and family practitioner reading these anecdotes has
encountered something similar—a puzzling patient that is the occasion for a
diagnostic epiphany. These are the intensely satisfying, salient episodes of
intuition informed by our long hours of medical training.
One
response to the dire shortage of primary care in many parts of the country is
to allow nurse practitioners to establish practices independent of physicians.
The appeal of this approach is understandable. We’ve been discussing the
shortage of primary care physicians for decades. Getting young doctors to go
into primary care is harder than ever because the pay is meager relative to
what they can earn as specialists. Nurse practitioners are increasingly well
trained. There is hardly a doctor in the country who isn’t working with nurse
practitioners in some capacity.
But would
a nurse practitioner have recognized, diagnosed, and addressed the issues in
the three cases I have just described? Are they comfortable delving into complex
polypharmacy issues and stopping medications prescribed by physicians? Can they
recognize Wencke-bach and its importance on an ECG in the office? I would argue
probably not.
“Nurse
Practitioners Are Valuable Members of the Team—But They Aren’t Doctors.” That
was the headline on a letter by Kenneth Dinkage, MD, that was published earlier
this year in Medical Economics. “Although it is true that one
should think of horses when hearing hoof beats, one also needs to be aware of
the existence of zebras, and that requires the type of training that only a
physician undergoes,” wrote Dinkage. The training of a primary care physician
is markedly more involved and much, much longer than the training for a nurse
practitioner. For a board-certified family practitioner, it totals 21,000
hours. At between 3,500 to 6,000 hours, a nurse practitioner’s training is a
fraction of that.
Here in
Pennsylvania, advanced practice registered nurses are pushing for a change in
state law so they could practice independently from physicians without the
collaborative agreements that are currently required. The American College of
Physicians, the national organization for internists that has its headquarters
in Philadelphia, has opposed the change. While recognizing the value of advanced
practice nurses, the internists’ organization is correct in saying that
independent practice is a “solution in search of a problem”; there is no
evidence that it would fix problems that collaborative agreements are causing.
One
argument for independent practice is that nurse practitioners charge less. But
they also tend to order more diagnostic tests than physicians, so the savings
are not as large as they might appear.
As
medicine and pharmaceutical regimens become more complex, we need more, not
fewer, excellent primary care physicians. The current fragmentation of care is
troublesome. And, frankly, so is the lack of critical rea-soning. I have
experienced it firsthand as a hospital patient and have seen it when family
members have gotten medical care.
I am not
against new models of primary care. A primary care physician overseeing several
nurse practitioners and physician’s assistants is an excellent way of
increasing access to care without sacrificing quality. But the desperate need
in American health care for a more holistic view of the patient and
coordinating and communicating with multiple specialists when patients have
complex or chronic diseases cannot be met by replacing primary care physicians.
In fact, the unmet need will get even greater if we do that.
Alan Adler, MD, recently retired from his position as senior
medical director for utilization management and precertification at
Independence Blue Cross in Philadelphia. A graduate of Tufts Medical School,
Adler founded the primary care residency program at Hahnemann University
Hospital in Philadelphia and was the first medical director for Horizon Mercy,
a Medicaid managed care plan in New Jersey. He is a longtime member of the
MANAGED CARE Editorial Advi-sory Board. In retirement he is working as a consultant,
traveling, and spending time with his grandchildren.
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