It’s pragmatic: APRNs should be able to practice independent of doctors

The health care system, particularly the area of primary care, is undergoing a radical re-evaluation of the way primary care access can be improved.

Volpintesta, Edward, GP doc in Bethel

Volpintesta

Because of the lack of primary care doctors, many patients seek their primary care in emergency rooms. Not only does this divert the time and attention of the emergency room doctors away from true emergencies, but it is also very expensive.

Advanced Practice Nurses (APRNs) have the potential to fill the primary care shortage. They have been petitioning for several years to expand their scope of practice particularly in the area of primary care. Although physicians have been in favor of establishing collaborative relationships with APRNs, most feel that a nurse’s training, as good as it may be, doesn’t prepare them sufficiently for independent practice.

But primary care is a different matter, and it seems reasonable that appropriately trained APRNs could practice independently.

The question that arises is what is so different about primary care that APRNs should be licensed to practice it independently?

The answer to this lies in the radical transformation that primary care has undergone in the past 20 or so years. The forerunner of today’s primary care doctor, the general practitioner (GP), did just about everything from delivering babies to taking out appendices. But the rapid expansion of medical science and new surgical techniques made it impossible for them to keep up.

In addition, the threat of medical malpractice suits made many primary care physicians think twice about the risks they took on in performing surgery or in handling difficult medical cases.

Today, primary care physicians work mainly in the areas of diagnosis and prevention, and coordination and maintenance of care. Many primary care doctors, who in the early years of their careers had treated a wide variety of illnesses, now find that their days are filled mostly with uncomplicated respiratory illnesses, some bone and joint problems, depression, maintenance of diabetes, stable heart disease and hypertension.

Many only maintain an office practice and no longer take care of hospital patients or nursing home patients.

This new model of primary care makes it reasonable to assume that well-trained advanced practical registered nurses (APRNs) practicing independently could provide many facets of the care that primary care physicians are now doing.

Nurse practitioners practicing independently in primary care is not a new idea. According to The Washington Post (March 24), about 6,000 nurse practitioners already have independent primary care practices. They can practice independently in 16 states, and proposals are under way to expand that number to 30.

Experts predict a shortage of about 60,000 primary care physicians by 2020. Since it takes about 11 years to train a primary care doctor, it is doubtful that enough physicians will be trained to reduce the shortage significantly by then. And since it is unlikely that APRNs and primary care physicians will overcome the professional differences that have divided them and that hindered the establishment of collaborative practices, it seems that the time is right for APRNs to be given the opportunity to practice independently — particularly in the area of primary care.

For those against granting independence to the nurses, their paranoia must be tempered with pragmatism. The health system is inefficient, and the time is right for innovation.

Clearly, as the Institute of Medicine recently recommended, the APRNs should be allowed to practice within the limits of their education and training.

Edward Volpintesta, M.D., has been a general practitioner in Bethel since 1975.

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