As U.S. relies more on nurse practitioners, we need to learn more about them
Nurse practitioners are assuming a more prominent role in primary care. Maryland is the latest state to allow this group to practice independently, and the Veterans Health Administration may soon follow suit.
The drivers for this trend are clear: the expansion of health insurance in the U.S. and our aging population, both producing heavy demand for primary-care services; shortages of primary-care physicians in many parts of the country, especially in rural areas; an urgency to lower care costs in the system; and pharmacy chains and big-box retail stores looking to use primarycare medicine (staffed primarily by nurse practitioners) as a “loss leader,” in part to build brand loyalty for their health-related products and services.
We could benefit from knowing more about nurse practitioners. Scattered studies in the primary-care sphere show that, in some cases, nurse practitioners perform on a par with their physician counterparts. These findings tend to focus on lower-level acute and chronic-disease care, which is traditionally the primarycare work to which NPs have been consigned. We also have sporadic studies that show patient satisfaction and care utilization among NPs comparing favorably with primary-care physicians. But at present the overall body of research lacks integration and examines a limited scope of primarycare medicine.
Ardent supporters of using NPs may feel that enough evidence already exists to justify independent NP practice in all types of primary-care medicine, not just the simpler variety. Spurred on by conditions in the primary-care environment that are driving greater NP practice freedoms, they may believe it is better to push ahead and let the research catch up later. This is a mistake. Similarly, those who assert that NPs cannot fully replace primary-care physicians must understand that the absence of a large, integrated body of data proving otherwise does not justify their conclusions either. Thinking it does is another mistake.
The future viability of primary-care physicians depends on synergizing their own strengths with a growing workforce segment—nurse practitioners—that thinks and acts a lot like them. Otherwise, disruptive innovations like retail clinics and urgent-care centers will act unilaterally and erode their market share and influence.
It is also important to know more about nurse practitioners as a group of workers, i.e. the quality of their everyday work lives, the types of relationships they establish with patients, and how they adapt to being almost exclusively salaried employees. There is some research showing that nurse practitioners are satisfied with the autonomy and intellectual challenge afforded them in practicing primary-care medicine, but they may also be concerned about the potential social isolation of their jobs, fewer deep interactions with physician colleagues, becoming overextended in their work, and a lack of organizational support.
Two key issues bearing on these questions are the nature of their work and where it is done. For example, as an increasing number of NPs are employed in retail clinics, which typically provide a limited array of services for patients, they might be working by themselves, doing highly repetitive work, and adhering to standardized care guidelines that limit professional discretion. They also may have to perform non-clinical work as the de facto managers of the clinic, work they may not wish to do.
If they are working in physician offices, which most currently are, their daily schedules can be loaded with very routine patient-care issues, freeing up their physician colleagues to do the complex care that builds a strong provider-patient relationship, and leaving NPs to do the more impersonal, episodic primary-care work. In these ways, many NPs may not get enough opportunities, intellectual challenges, or care continuity in their jobs to develop deep bonds with many of their patients, or to cultivate the full range of skills and experience to deliver higher-intensity care confidently. These realities may undermine the long-term job satisfaction and career fulfillment of NPs as a group.
Primary-care medicine in the U.S. needs nurse practitioners to meet its growing demands. But we must get to know these professionals better, through a lot more systematic research across a range of topics that speaks to their future roles in an evolving primary-care system.
Timothy Hoff, Ph.D., is a professor of health systems management and health policy at Northeastern University, Boston, and a visiting associate fellow at Oxford University. He studies disruptive innovation in the U.S. primary-care system.