Think twice before throwing doctors to the wind
April 9, 2014 — Remapping Debate has reported before on the shortage of physicians already facing the nation, a shortage that promises to become more acute as time goes on. Rather than deal with that shortage, the trend is to find ways to replace physicians with cheaper alternatives, a practice known in other industries as de-skilling.
First things first
A signature feature of the way public policy tends to be decided in the United States these days is to place funding decisions ahead of any other kind of planning process. In shorthand, the only question asked is, “What can we do given what we can afford?” The alternative, of course, is the look-at-the-best-options method. This first asks, “What achieves the best result independent of cost?” Only once that is determined is a second question asked: “What, if anything, do we want to give up in the name of cost savings?”
The differences in the two approaches are considerable. With the second, the public gets a clear sense of trade-offs, facilitating an informed, democratic decision. With the first, the trade-offs are largely invisible and the scope of debate narrow (with any deviations from a cost-cutting regime promptly dismissed as “impractical”).
As Remapping Debate began to explore the question of the increasing role of nurse practitioners — in lieu of physicians — as the lead providers of people’s primary health care, we found that questions of cost and access were crowding out more basic considerations: What are the differences in training between physicians and nurse practitioners? How can those differences have an impact on patient care? What, in the end, would be best for patients?
Though our reporter encountered significant resistance to having these questions squarely answered, we think his article provides important illumination as to these questions.
In the world of primary care medicine, however, the replacements — most notably nurse practitioners — themselves have a significant level of training. In a growing number of states, nurse practitioners are being allowed to practice independently rather than, as traditionally has been the case, under the supervision of a physician.
Our reporting for this story shows, however, that there really are significant differences in training between physicians and nurse practitioners and that — strikingly — a host of nurse practitioners we spoke with were unwilling or unable to explain why those differences would not translate to physicians having at least some greater level of skill, on average, in primary care practice.
To become licensed as a nurse practitioner, a person must obtain one of two graduate degrees: a Master of Nursing Science or a Doctor of Nursing Practice. While nursing education groups have been trying to increase the number of nurse practitioners pursuing doctoral degrees, master’s degrees remain more common among nurse practitioners.
Both normally require a student to be certified as a registered nurse before entering graduate study. The usual route is through a four-year bachelor’s degree in nursing, although alternatives are available (such as associate degrees).
There are substantial quantitative differences between a standard medical school program, which all physicians must complete, and graduate programs in advanced nursing practice. The differences are most immediately evident in the number of hours that a nurse- or doctor-in-training spends in clinical practice. The second two years of medical school (the “clinical years”) involve approximately 6,000 hours of training in a care setting. This is known as a clerkship, during which students rotate through the various parts of a hospital setting (operating room, emergency room, intensive care unit, and so forth).
After completing their four-year graduate degree, doctors-in-training must complete a residency program in a hospital or a clinical setting, during which they diagnose and treat patients with an increasing degree of responsibility and autonomy. The minimum length of a residency is three years, which is the amount commonly completed by primary care doctors, such as family physicians and general internists. A three-year residency amounts to 9,000 hours of clinical practice. Thus, the combined hours of clinical training acquired by a newly licensed physician add up to around 15,000.
By contrast, graduate nursing programs require only a minimum of 500 hours of clinical practice. Though many demand more, even these have significantly less clinical training than a medical program — according to Kitty Werner, executive director of the National Organization of Nurse Practitioner Faculties, the average is around 700 hours.
Nurses do receive significantly more clinical training in the typical undergraduate program than physicians: pre-medical undergraduate degrees usually do not involve any clinical practice, whereas bachelor’s degrees in nursing include rotations through a number of clinical settings. However, this clinical practice is oriented more toward bedside nursing services than toward diagnosis and treatment (the latter being the focus of clinical practice in both medical and advanced nursing education). Moreover, the number of hours involved in undergraduate nursing education varies significantly from state to state and from program to program.
Even more intensive nursing programs leave graduates with far fewer hours of training under their belt than doctors coming out of residency. For example, take the combination of undergraduate and graduate nursing degrees from two highly ranked universities. A Bachelor of Science degree from the University of North Carolina School of Nursing (ranked 4th in the nation by U.S. News & World Report) includes 1,351 clinical hours. On the graduate level, the Master of Nursing program at the University of Iowa (ranked 11th in the nation) requires 535 hours of clinical practice. Thus, a nurse practitioner freshly graduated from these programs would have acquired 1,886 hours of clinical experience — 13,000 fewer than a doctor freshly graduated from a residency.
That there are quantitative differences between medical and advanced nursing education is undisputed. But do these gaps translate into actual differences in the quality or the safety of health care, particularly in the provision of primary care?
According to many in the nurse practitioner field, the answer is no — and this is why, they say, nurse practitioners ought to be allowed to provide primary care free of scope-of-practice restrictions or mandated relationships with physicians. Advocates of expanded practice say that the training of nurse practitioners is perfectly sufficient to provide a full range of primary care services, and to be able to identify when a patient needs more advanced care from a specialist. Nurse practitioners commonly point to studies that have concluded that outcomes for patients treated by them are similar if not identical to outcomes for patients treated by doctors, and that nurse practitioners sometimes perform better in realms like patient satisfaction.
“We end up in these conversations with physicians’ groups who try to assert that because the education is not exactly the same, or because potentially physicians have more hours in a particular place in their curriculum than nurse practitioners do, then clearly they have to be better providers,” said Geraldine “Polly” Bednash, the CEO of the American Association of Colleges of Nursing (AACN) and also a nurse practitioner. “And yet that totally ignores the evidence about the quality of care delivered by nurse practitioners.”
Bednash, like some other nurse practitioners and nursing advocates we interviewed, is willing to acknowledge that the extra years of training that doctors possess “has made them a different primary care provider” — but not “a superior primary care provider.” Surely, however, leaders in the field have to have some sense beyond unspecified “difference” to describe the practical utility of the thousands of hours of additional training for doctors — and differently focused training at that. Yet, asked what the difference could be, Bednash said that she didn’t know. “I don’t think anyone’s ever measured that and said, ‘See, they [physicians] do better here.’”