Profession

Growing ranks: Benefits of collaboration with nurse practitioners

Those benefits include freed-up time for patients with more complicated health problems.

By Jay Greene — Posted March 12, 2001

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Team Players

Team Players

Physicians' interaction with allied health care professionals and how it's is freeing doctors to, once again, practice medicine to the fullest.
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Family physician Rodney Hough, MD, and nurse practitioner Joan Rice work together as colleagues, referring and consulting on patients within the confines of Brookwood Family Medicine in Carlisle, Pa. They work under a broad collaborative agreement that helps determine which type of patients Rice sees and when a referral or consultation is necessary.

Walter Koltun, MD, a colon and rectal surgeon, and Marjorie Lebo, a nurse practitioner, also work together at Milton S. Hershey Medical Center at Penn State University in Hershey, Pa. Dr. Koltun performs the surgeries while Lebo handles most of the typical pre-op and post-op duties.

Dr. Hough and Dr. Koltun are among hundreds of physicians who have enlisted the help of allied health professionals in their practices. Both physicians say their collaborative team approaches -- in which physicians and nurse practitioners work side by side in the same office -- provide good quality care for their patients while giving them more time to spend on serious medical cases. They also said their practices' bottom line has benefited from the use of allieds.

"We treat them here as colleagues. They are invaluable," said Dr. Hough, who has employed nurse practitioners for six years. "They have areas of strength and nonstrength. The key is trust. They are smart enough to know not to exceed their bounds."

Nationally, the number of nurse practitioners has increased over the past 10 years from 30,000 to about 65,000, according to the American Academy of Nurse Practitioners. Some 85% work in ambulatory settings and the majority are in primary care, the AANP said.

Nurse practitioners are projected to nearly double to more than 100,000 by 2005 despite the emerging shortage of nurses, while physicians are expected to increase only about 10%, to about 700,000, according to a Sept. 2, 1998, study published in JAMA.

Patients choose

In most primary care practices that employ nurse practitioners, patients making appointments are given the choice of seeing a physician or a nurse practitioner. Under general guidelines, triage nurses send a large range of symptoms to nurse practitioners, Dr. Hough said. Because most primary care clinics in the area employ nurse practitioners, the vast majority of patients are used to seeing them, he said.

"I do a lot of health maintenance-type activities," said Rice, a nurse practitioner for 25 years. "Our goal is to keep patients well. When I first started, I did a lot of routine well-baby checks and physicals. As I progressed, I learned to do lots of procedures. ... Now I am pretty experienced in everything. I see my own patients and operate relatively independently."

With the exception of surgery, nurse practitioners are allowed under state regulations to provide many of the same services performed by physicians. These services include diagnosing and treating acute and chronic health care problems; performing prenatal, well-child, well-woman and adult care checkups; diagnosing and managing minor trauma including suturing and splinting; prescribing medications; and teaching health promotion and disease prevention to patients.

"Nurse practitioners and physicians working in collaboration under the same roof is a big success story," said Harold Sox Jr., MD, chair of the department of medicine at Dartmouth-Hitchcock Medical Center, Lebanon, NH.

That sentiment is echoed by Dr. Koltun, who says the addition of Lebo two years ago to his unit's surgery team has enabled him to increase surgeries by 30%. Without a nurse practitioner, Dr. Koltun said he would spend an additional three hours per patient just filling out paperwork. "It's a great system for me, and the patients perceive that they have added access to caregivers."

Like most surgical teams that use nurse practitioners, Dr. Koltun will first meet with the patient and decide on the course of action. If it is surgery, Lebo performs the patient history and physical and orders tests and lab work. "She educates them in stomal management and then she manages issues for discharge and outpatient care," he said. "She will come to us for advice on problems she sees."

Along with managing the surgical patients, Lebo provides education and training for dozens of medical students and residents who rotate through the colorectal unit at Hershey every year.

"There is a lot of communication between myself and the physicians because we work very intensively with patients for a short period of time," said Lebo, a nurse for 18 years. "We try to make sure all bases are covered."

Once patients are discharged from the hospital, Lebo sees many of them during a Friday clinic she shares with the chief resident. "The doctors come in to see patients as well, but it is my call whether I bring something to them," she said. However, each time a patient is seen, a memo is generated on the visit and circulated among all physicians and other providers involved, Dr. Koltun said.

Most physicians who work directly with nurse practitioners say the collaborative team care model is effective and efficient and serves patients well. But they also agree that it provides the one key ingredient to successful patient care: physicians who are on site whenever nurse practitioners see a patient.

"I do not support the kind of independence where nurse practitioners are free to set up their own shop apart from physicians. They don't have the depth of knowledge and training that a physician has," said Dr. Hough. "Sometimes you have to visually look at a patient. Consulting from afar is not the same as seeing a patient in person. There would be quality problems."

George Thomas, MD, a cardiologist in Bradenton, Fla., and chair of the AMA's International Medical Graduate section, said his group considered hiring a nurse practitioner.

"We decided against it," Dr. Thomas said. "Our patients are very sick. Nurse practitioners can't consult with our patients or do surgery."

Collaboration, not independence

The AMA has long supported collaborative arrangements with nonphysicians, but the Association and specialty societies believe some nonphysician groups have begun to expand outside the boundaries of their education and training.

Some physician groups are concerned that the long-term goal of nurse practitioners is to practice independently of physicians. Each year, state medical associations and specialty societies oppose legislative bills that seek to expand the scope of practice of nurse practitioners and other allieds. The AMA in December 2000 approved $125,000 for a study that aims to review quality, education and scope of practice of nonphysicians and physicians working in multidisciplinary settings. The report is due in June 2002.

Thirty-four states allow nurse practitioners to practice in collaborative relationships with physicians, said Jan Towers, PhD, director of health policy for the American Academy of Nurse Practitioners. But none of those states requires a physician to be physically present in the office with the nurse practitioner, she said. "There is nothing in the laws that require nurse practitioners to have daily encounters with physicians," Dr. Towers said. "It all depends on the practice setting. Some states require written agreements with physicians that spell out the collaborative plans. Each team works it out."

Dr. Sox cautions that gains nurse practitioners have made over the past 10 years in expanding their scope of practice threaten to undermine the collaborative relationship. "The nursing profession has successfully persuaded state legislatures to change nurse practice laws to allow nurse practitioners to practice with very minimal supervision -- in some cases, essentially no supervision."

For her part, Rice acknowledges nurse practitioners must clearly understand their scope of practice and work closely with physicians. "It is rare I need a second opinion, but it happens," she said. "We don't want to deal with something we don't understand or are unprepared to manage."

Despite training nurse practitioners in 1975 when he was a clinical instructor at Hershey Medical Center, Dr. Hough said he was initially opposed to hiring one because he didn't think they were qualified. "Now that I started working with them, I think it is great," he said. "Each doctor has to work it out their own way."

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ADDITIONAL INFORMATION

Educational differences

Physicians and nurse practitioners are working together in practices across the country. Yet, significant education differences still separate the two and show why physicians believe collaboration is better for patients than nurse practitioner independence.

Physicians

  • Four years of college.
  • Four years of medical school.
  • Minimum three years in a residency program. Additional years required if subspecializing.
  • State medical license. Optional board certification.

Nurse practitioners

  • Four years of college with a bachelor of science degree in nursing or related field.
  • One and a half to two years of graduate school to obtain a master's degree as a nurse practitioner.
  • State nursing license. Optional board certification.

Source: Harvard Medical School

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