I found a link to this article on salary.com. Thought it might be interesting to some of you.
Shortage of Doctors Forces
New Roles for Nurse Practitioners
By Andrew Blackman
From The Wall Street Journal Online
On a recent Wednesday morning, a handful of patients sat hunched over clipboards or staring into space in a 12th-floor waiting room on Manhattan's Madison Avenue. Unobtrusive paintings decorated the walls, and dog-eared magazines were strewn over small tables. The hush of the softly lit room was broken only by a receptionist booking an appointment.
There was just one thing missing from this quintessential doctor's-office scene: doctors.
Columbia Advanced Practice Nurse Associates, or Capna, is run by nurse practitioners -- nurses who are trained to be full primary-care providers. They diagnose conditions, prescribe treatments and make referrals to specialists -- everything traditional doctors do.
Founded 10 years ago as a project of the Columbia University School of Nursing, Capna has been in the vanguard of changes that have brought new respectability to nurse practitioners. In 1994 it was the first nurse-run clinic in the country to win full privileges to admit patients to hospitals. Three years later came another first: Insurance companies began compensating the practice at the same rate as physicians.
Now some experts believe that nurse-run operations like Capna may be critical to the future of health care in the U.S. As medical science creates new treatments to keep us alive longer, the country will need ever more health-care personnel to avoid coverage gaps. Nurse practitioners are quicker and cheaper to train than doctors, and there's already a huge pool of registered nurses in the U.S. who could become practitioners with just a few years' study.
"I believe that the nation is likely to be facing shortages of physicians in the coming years as the population ages," says Edward Salsberg, director of the Center for Workforce Studies at the Association of American Medical Colleges in Washington. "One of the solutions is to make more effective use of nurse practitioners. They're going to be in high demand across all specialties."
Indeed, some argue that nurse practitioners may be better suited than doctors to meet the growing needs of U.S. health care. More Americans are suffering from long-term illnesses like asthma, diabetes or hypertension, where lifestyle can play a vital role in treatment. Nurse practitioners are trained to place a strong emphasis on preventive care, asking patients about their habits and educating them about their choices.
Once a Stopgap
Having nurses provide primary care isn't a new concept. The first official nurse practitioners started work back in 1965, providing checkups and other simple care in rural areas where doctors weren't available, or in poor neighborhoods where people lacked health insurance and couldn't afford to see a doctor.
"Many patients and families in rural and deprived areas had no access to care except from nurses," says Loretta Ford, who started the first nurse-practitioner program with a physician, Henry Silver, at the University of Colorado in 1965. "The idea was to make these nurses more clinically competent. The focus was on prevention, high-level wellness and community-based care."
Now, instead of being a stopgap, nurse practitioners are winning over patients who could just as easily see a regular physician. In many states, they can set up practices and operate independently. (Some states allow them to operate practices but mandate that they work in partnership with a physician.)
Why the change? As their job has evolved over the past four decades, nurse practitioners have become more educated and better prepared to take on an independent role. A candidate must first become a registered nurse, which requires, at a minimum, a bachelor's or associate degree in nursing. Then they must complete a master's degree in a particular specialty, such as psychiatry or pediatrics.
Next year, the Columbia School of Nursing will introduce a four-year "doctor of nursing practice" doctoral program that teaches much broader skills, such as evaluating clinical studies and setting up independent practices. As they gain these new skills, nurse practitioners are branching out beyond primary care to fill a growing need for personnel in many areas of medicine, including specialties such as long-term care providers for the elderly.
"Nurse practitioners are very quickly becoming a real cornerstone of the delivery system," says Mr. Salsberg of the Center for Workforce Studies.
According to a quadrennial survey conducted by the Department of Health and Human Services, the number of people with the title of nurse practitioner rose from zero in 1965 to 20,000 in 1988. By 1996, the number had doubled to 40,000, and by 2000 it had reached 62,373.
But those numbers don't reflect the full picture. The total number of certified nurse practitioners in 2000 -- including many people who work as nurse practitioners but who don't have that specific title -- was 88,186. While the 2004 number isn't available yet, nurse-practitioner organizations estimate the total is well over 100,000.
As the number of nurse practitioners booms, the population is getting older -- which may make the nurses vitally important to health care in the coming years. While Mr. Salsberg says there is no great shortage of physicians today, he is very concerned about meeting the demand for care by 2015 or 2020.
"The aging of the population is beginning to contribute to an increase in demand for physicians," he says. "Demand is also rising as the nation becomes wealthier. And we've invested large amounts in interventions that allow people to live longer, fuller lives."
Focus on Prevention
The changing nature of health care may also play to nurse practitioners' strengths. Ann O'Sullivan, a nurse practitioner who teaches at both the School of Nursing and the School of Medicine at the University of Pennsylvania, explains that traditional medical training prepares physicians to excel at diagnosis and treatment, while a nursing education focuses more on care and prevention.
That emphasis makes nurse practitioners perfectly suited to handle long-term illnesses -- which are on the rise as the population gets older. Mary Mundinger, dean of the Columbia University School of Nursing and founder of Capna, says the majority of Capna's patients have chronic conditions like asthma, diabetes and hypertension. "These are diseases that aren't going to be cured," she says. "The way you're going to save money and save life is to manage the disease and avoid hospitalizations."
One of Capna's practitioners, Janice Smolowitz, had a patient with asthma. Instead of just giving her a nebulizer, Ms. Smolowitz asked a lot of questions and eventually found that the patient was living in a basement apartment with roaches, and that the poor air was probably making her asthma worse. So Ms. Smolowitz wrote a medical letter of necessity to help the patient get subsidized housing. Then she asked to examine the patient's kids to see whether they had any problems, too. (They didn't.)
"I can put all these medical things in place, but what this person really needs is some fresh air," Ms. Smolowitz says.
Patients say they appreciate the different style of care. Michele Rosenthal, a 36-year-old public-relations professor, says she has had "a lot of illness" over the past decade. She had seen seven primary-care physicians over that time before settling on Caroline Hewitt, a nurse practitioner at Capna.
"To me it comes down to the relationship you have with the doctors," she says. "Many doctors just want to get you in and out of the office. They have no bedside manner. I don't think nurse practitioners have the same psychological approach. They're more for the patient."
For her osteopenia, or reduced bone density, Ms. Rosenthal says Ms. Hewitt not only arranges regular bone-density scans, but also asks her about her diet and gives her detailed nutritional advice. "Caroline is comprehensive rather than being focused on one particular problem," says Ms. Rosenthal. "She'll ask me, 'What else have you got going on in your life?' "
Ms. Rosenthal has also been impressed with the amount of time she has to ask questions, and with the answers she receives. "I've had so many doctors who've said to me, 'You don't need to know about that.' But as a patient you do need to know, even if it's just to make you feel safer," she says.
William Spears started out using Capna occasionally for flu shots at times when his investment-management business demanded that he spend time in New York, away from his home in Connecticut. On one such visit, he recalls the nurse saying, " 'While you're here, why don't I take your blood pressure?' "
When it turned out to be high, she wouldn't let him leave until he booked another appointment. On the follow-up visit, the nurse prescribed medication and sent him to a cardiologist.
"It's the thoroughness and the time they spend that makes the difference," he says. Mr. Spears has been a patient at Capna for five years, and says he schedules checkups twice as often as he did with previous primary-care providers.
One problem that nurse practitioners still face, however, is image. No matter how much knowledge they acquire or what rave reviews they get from patients, for many people the image of a nurse is still that of a junior partner to the all-knowing physician. "When I told my mom I was going to see a nurse practitioner, she said, 'But you need a doctor,' " Ms. Rosenthal recalls.
Perhaps reflecting this image problem, nurse practitioners still lag behind physicians in terms of pay, earning about $60,000 a year on average, compared with more than $100,000 for primary-care physicians. And despite nurse practitioners' extensive training in providing care, some still worry that physicians' extra diagnostic training in medical school could help them recognize a rare disease that a nurse practitioner might miss.
Yet studies have shown that when it comes to patient outcomes, nurse practitioners are just as good as doctors. One study, published in the Journal of the American Medical Association in 2000, looked at 1,316 patients who had no regular source of care, and randomly assigned some of them to a Capna nurse practitioner and some to a physician. In tests and interviews after six months and then a year, they found no significant differences in the health of the patients. Other studies of nurse practitioners and physicians over the past 20 years have shown comparable patient outcomes.
With the facts out there, says Dr. Mundinger of Capna, her practice isn't trying "to show we can do as well as physicians. We're trying to show we have a different style, and that style is going to save money and save life."
Dr. Mundinger chose Capna's exclusive Madison Avenue address -- the Art Deco building is sandwiched between Emporio Armani and a Coach store -- for the competition. She says she "wanted to go where there's a physician every 12 inches" and find out whether people would still opt to see a nurse.
So far, the experiment has been successful. Capna -- which also operates a practice in Washington Heights in northern Manhattan -- altogether has more than 2,000 patients, with 90 new patients joining each month. The practice has three nurses, two of whom rotate between offices.
Dr. Mundinger hopes the nursing doctorate, which she devised at Columbia, will advance the role of nurse practitioners even further. She sees graduates of the new program setting up and running their own independent primary-care practices, as well as taking on a variety of functions in hospitals and other settings.
For example, doctors of nursing might coordinate home care and long-term care for elderly patients. And given the demands on physicians' time, Dr. Mundinger believes, many graduates will fill an important role as "hospitalists." These specialists look after physicians' patients when they check in to the hospital, so that doctors don't have to spend time making rounds.
"A nurse practitioner is the best person for that job, because they're going to want to know everything about you, and they'll find things that way," Dr. Mundinger says. "And surgeons like it because they get to spend all their time in the operating room. As soon as they've put in the last stitch, the NP can take over."
Dr. O'Sullivan, who operates a primary-care practice in collaboration with a physician, thinks nurse practitioners and doctors may help patients best working in tandem.
She gives the example of talking to a patient who needs to stop smoking. A physician will likely focus on physiological factors, such as the effect that continued smoking will have on the patient's heart, liver and lungs. A nurse, on the other hand, is more likely to focus on psychological factors, asking when the patient feels the need for a cigarette, why they feel that need and devising ways to quell the urge.
Dr. O'Sullivan says that some patients may respond well to the physician's approach, and others to the nurse's. "You tend to get better outcomes when there's a combination," she says. "Patients hear the message a little bit differently and a little more often. [The nurse practitioner and physician] tend to reinforce each other."
Mr. Spears, the Capna patient, says he has learned from his experiences that the combination of nurses and doctors can be powerful. He draws an analogy to his own experience as a business-school graduate who's in partnership with a lawyer. Because of their different backgrounds, he says, they tend to approach the same issue in very different ways. Neither is necessarily better, but the combination seems to work well.
"I suspect there's also a difference in how a nurse is trained to treat a patient and how a physician is trained to treat that same patient," he says. "Maybe the future of health care is to find a way to combine the different skills of each one."