Trend Toward More Nonphysician Care

[NRSKarenRN, BSN, RN]

many nurses believe that interdisciplinary practice is the most effective strategy for providing high quality care. all clinicians then contribute what they do best.

trend toward more nonphysician care: expert interviews with linda h. aiken, phd, rn; marilyn w. edmunds, phd, np; and harriet l. hellman, cpnp

http://www.medscape.com/viewarticle/447839

susan yox, rn, edd, with reporting by laurie barclay, md, and daniel j. denoon

jan. 14, 2002-editor's note: patients are being cared for by nonphysicians more often than they were a decade earlier, according to the results of a study published in the jan. 9 issue of the new england journal of medicine, by benjamin g. druss, md, mph, and colleagues. this report of trends of care by nonphysician clinicians in the united states shows that in 1997, 36.1% of patients saw nonphysicians, compared with 30.6% in 1987 (adjusted relative risk [rr], 1.42; 95% confidence interval [ci], 1.35 - 1.50). however, this trend was driven by an increase in the proportion of patients seeing both physicians and nonphysicians (30.9% in 1997 vs. 23.5% in 1987; rr, 1.49; 95% ci, 1.40 - 1.58). in fact, the proportion of patients seeing only a nonphysician clinician declined during that time period (5.3% vs. 7.2%; rr, 0.81; 95% ci, 0.70 - 0.93).

the investigators and the editorialist suggest that this trend represents a change in the structure of healthcare, which could represent an improvement in coordination of care or increased fragmentation of health services. overall, the nonphysician care provided appears to be good, and the increase in use was driven by patient demand.

to learn more about what this trend means for nonphysician clinicians, especially nurses and nurse practitioners, medscape's susan yox interviewed linda h. aiken, phd, rn, the editorialist for the nejm study, the claire m. fagin leadership professor of nursing, professor of sociology, and director of the center for health outcomes and policy research at the university of pennsylvania, philadelphia; marilyn w. edmunds, phd, np, a nationally known nurse practitioner (np) who has been on the faculty of several np programs and has had an independent parish practice in ellicott city, maryland, for many years; and harriet l. hellman, cpnp, who owns a practice and provides pediatric primary care in eastern long island, new york, to the underserved and latino community.

medscape: according to the nejm study, more people are seeing nonphysician clinicians, and a growing number of patients see both physicians and nonphysicians. the study authors suggest that this could mean either that care is becoming better coordinated or that it is becoming more fragmented. what do you think? do you believe more interdisciplinary care is good for patients? why or why not?

dr. aiken: the findings reported by druss and colleagues suggest to me that healthcare is becoming more integrated. nonphysician clinicians, especially nurses but also others, have a strong commitment to integrating services and providing care of a holistic nature. the increase in health promotion that accompanied increases in visits to nonphysician providers suggest that nonphysician caregivers are filling gaps that will enhance continuity of care and health outcomes for consumers who still see physicians. consumers seek a broader array of health services than physicians have time, inclination, or expertise to address. interdisciplinary care is a more efficient and effective strategy for providing care of high quality since all providers contribute what they do best.

in addition to societal issues that led patients to ask for a wider range of healthcare options, there are specific changes that encouraged these changes to happen, particularly the consolidation of healthcare services into larger and larger organizations in which physicians and nonphysicians work together. this demands more interdisciplinary practice.

ms. hellman: care is becoming better coordinated by healthcare systems that are being visionary or reactionary (dependent on one's perspective) and using all providers-physicians and nonphysicians-as the patient's needs indicate. fragmentation is a function of passi ng the proverbial buck. when we care about people and we care about their healthcare, we do not say, "that is not my job," but we step up to the plate. quality care demands quality providers and teamwork, without egos attached.

medscape: do you believe that nonphysician clinicians, particularly nurses and nps, provide different kinds of care than that traditionally provided by physicians? can you offer some specifics of the care that may be better provided by nurses and/or nps? does this mean a lesser role in patient care for physicians?

dr. aiken: research documents differences in practice patterns between advance practice nurses and physicians that are generally complementary. physicians specialize and concentrate on diagnosing and treating illnesses while nurses focus on helping patients adhere to complex treatment regimens or needed behavioral changes that offer the best change for treatments to be effective nurses are problem solvers. they help patients maximize function in daily activities despite illness or limitations. they teach patients and families how to control unpleasant symptoms of illness or [effects of] treatment. physicians tend to undertake more procedures and prescribe more drugs than advanced practice nurses who employ more techniques such as counseling, teaching, skills training, and symptom management. both roles are needed. the best care is a combination of physician and nonphysician interdisciplinary care.

physicians aren't losing their role at all. the finding that most consumers who visit nonphysicians also see a physician emphasizes the important role of physicians in the healthcare team. one of the positive suggestions is that physicians are now recognizing that consumer requests go beyond what they can fulfill themselves and they are encouraging or referring to this interdisciplinary workforce. these changes must have occurred at least with the implicit agreement of physicians.

ms. hellman: nonphysician providers such as nps and clinical nurse specialists view healthcare...from a different perspective than physicians. we view it as family-oriented, community-based, and reality-driven with an educational focus, based on the assumption of personal responsibility for one's own care and the care of one's family. some physicians adopt the same philosophy in theory, but the reality is that it is nursing practice that demands continual assessment and education. that takes time, effort, and money. nurses/nps do not shy from that challenge. it is elemental in our practice.

medscape: what about quality? are there outcome studies documenting that the care provided by nonphysician providers is of as high quality as the care provided by physicians?

dr. edmunds:in a meta-analysis of np outcome studies [published in the nov./dec. 1995 issue of nursing research], "nps received higher patient satisfaction and health promotion scores in comparison to mds,...np patients reported greater compliance with treatment and resolution of pathological conditions in comparison to mds,...nps were equivalent in quality of care, prescription of medications, functional status, number of visits per patient, use of emergency room, referrals/consultants, and patient knowledge,..." and "nps ordered slightly more laboratory tests than mds." several extensive studies of the literature have concluded that np care is equivalent to or sometimes better than physician care.

medscape: what is the bottom line? where do we need to focus our efforts in improving care? how can physician and nonphysician clinicians work best together?

dr. edmunds: the impetus behind np and physician assistant role development was not on interdisciplinary care, but that nonphysician providers would reduce healthcare costs because the cost to educate these providers was less than physician education, they would be more likely to p ractice where physicians would not, and that payment to nonphysician providers would be less than to physicians. research suggests that many nonphysician providers would prefer to practice in rural areas or areas in which there are no physicians. however, reimbursement policies have tied these clinicians to physician practices. thus, costs and practice sites have been skewed by policy in a way counter to that [which might] be found in an open market. with the documented competency of these clinicians and the increasing demand for healthcare services, the overregulation of nps and other nonphysician providers institutionalizes a system that fails to capitalize on the potential contributions of these providers.

dr. aiken: the bottom line and ultimate goal of all health services is patient-centered care and improved health outcomes. if organizations and providers would genuinely put patients first, interdisciplinary care would evolve naturally, as it is the most effective and efficient way to provide continuity of care of high quality. organizational arrangements that promote interdisciplinary care have more satisfied consumers and more satisfied physicians and other health professionals. our educational institutions need to train new entrants to the health professions together, and organizations should design work to facilitate interdisciplinary care.

ms. hellman: the american healthcare system is in chaos. physician and nonphysician clinician collaboration is vitally important to our health care future. this must not be an economic turf war, but must originate in our recall of why we became healthcare providers originally. we wanted to help people who were hurting. we do that best as teams-with all participants contributing their expertise.

n engl j med. 2002;348(2):130-137, 164-166

susan yox, rn, edd, is site editor of medscape nursing. laurie barclay, md, is a freelance writer for medscape. daniel j. denoon is senior medical writer at webmd

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many patients prefer nurses to doctors

by daniel denoon

webmd features reviewed by gary vogin, md

april 4, 2002 -- if you see a nurse practitioner instead of a doctor, will you get proper care? yes, a british study says -- and odds are you'll like it better.

since the days of florence nightingale, there's been a debate over what a nurse should be. trained nurse practitioners offer primary care. and that care appears to be just as good as what doctors can provide, according to an article in the april 6 issue of the british medical journal.

full story--3 pages:

http://my.webmd.com/content/article/18/1685_53050.htm?lastselectedguid={5fe84e90-bc77-4056-a91c-9531713ca348}