When you go to a doctor’s office for a stomachache, sore throat or back pain, it’s becoming more likely that the person treating you won’t be a physician but a nurse practitioner.
Even Dr. Thomas Whalen, chief medical officer for Lehigh Valley Health Network, sees a nurse practitioner when he is sick. He has no issue with that. In fact, he called his nurse practitioner “spectacular.”
Nurse practitioners are playing an increasingly important role in health care as the number of primary care doctors, especially in rural areas, has thinned out.
“The future supply of primary care physicians looks bleak, whereas the future supply of nurse practitioners is increasingly rosy,” Whalen said.
Despite the need, Pennsylvania nurse practitioners say they’re held back from practicing in desperately underserved areas because they’re required to find a partnering doctor to work with. Pennsylvania lawmakers are considering legislation that would eliminate that requirement. But the proposal has failed to pass twice in recent years because of strong opposition from doctors’ associations, which see the rule as critical to ensuring the best care for patients, especially those with complicated health problems.
While nurse practitioners are comparable to doctors in the way they treat common health problems, they aren’t trained to diagnose complicated health issues, said Dr. Danae Powers, president of the Pennsylvania Medical Society, which supports Pennsylvania’s collaborative agreement requirement.
“The concern is a patient comes in and has a problem that’s not obvious,” she said. “If the individual doesn’t have training or expertise, a patient could end up with something missed or getting a delay in necessary care.”
Doctors go through longer and more in-depth training, she said, four years of medical school after obtaining a bachelor’s degree and another three to seven years of training at a hospital. Nurse practitioners must have a master’s degree, which means two to four years of graduate school after getting a bachelor’s degree.
“It’s important when you have patients being evaluated that they have someone in the chain that has the highest level of training to pick up on the complicated issues,” Powers said. “They’re the seatbelt. You don’t want to end up in a situation where the seatbelt was missing.”
Kathleen Gray, a nurse practitioner who teaches at Moravian College, said nurse practitioners often ask doctors and other health care workers for advice, a practice that doesn’t require a formal agreement. The problem is that nurse practitioners who want to practice in remote areas have trouble finding a doctor to sign the formal collaborative agreement, which makes the shortage of primary care providers more severe.
That shortage is acute in the old industrial and coal towns that dot Pennsylvania, long drives from urban centers. Nurse practitioners could meet the demand in such places. According to the Pennsylvania Coalition of Nurse Practitioners, they are twice as likely as physicians to practice in rural areas.
In 2016, 1 in 4 health care providers in rural America was a nurse practitioner, compared to fewer than 1 in 5 in 2008, according to a study published in Health Affairs.
But finding a collaborating doctor isn’t just a problem in rural areas. Nancy Fickert, a nurse practitioner, said she couldn’t work in the mental health clinic on Moravian College’s campus because she couldn’t find a psychiatrist to collaborate with her.
State Sen. Camera Bartolotta, R-Washington, who introduced the bill this year to eliminate the agreement requirement, said she’s heard from many nurse practitioners who have trouble finding collaborating physicians.
“There aren’t general practitioners in small towns anymore. When you do find them, they’re geriatric themselves and ready to retire,” she said.
Bartolotta expects the Senate to vote on the proposal this month.
Despite the previous failed attempts, nurse practitioners have been building support across the state for the legislation.
LVHN and St. Luke’s University Health Network, which rely on nurse practitioners to provide primary care, and the Hospital and Healthsystem Association of Pennsylvania support eliminating the requirement.
The debate over how much power nurse practitioners should have to run their own practices is happening in numerous states. While Pennsylvania and New Jersey require a formal partnership document between a doctor and a nurse practitioner, about half the states don’t. South Dakota, Maryland and Nebraska got rid of the requirement in the last five years.
Across the country, medical students are choosing specialties over the broader practice of primary care. Since the 1970s, the percentage of internal medicine students practicing primary care has decreased from 54% to 12%, according to a 2017 report in the American Journal of Medicine
By 2020, the country will face a shortage of 20,400 primary care physicians, the report said. Meanwhile, the number of primary care nurse practitioners is expected to grow by 30% from 2010 to 2020. There are about 22,000 nurse practitioners nationwide and more than 80% of them are trained in primary care, with that percentage growing, according to the American Association of Nurse Practitioners.
Doctors say the answer to the primary care shortage isn’t in giving nurse practitioners more autonomy but in giving medical students incentives to work in primary care.
Heavy medical school debt in the hundreds of thousands of dollars and lower salaries in comparison to specialists make primary care unattractive to medical students, said Powers, of the state Medical Association.
“It’s very hard to ignore the economics,” she said. The answer shouldn’t be to allow nurse practitioners to take over for doctors, because that would hurt patient care, Powers said. Raising salaries and lowering debts would boost the number of primary care physicians, she said.
Primary care doctors earn about $195,000 a year, making them the second lowest paid physician type after pediatricians, according to the 2015 Medscape Physician Compensation Report. Orthopedic doctors on average earn $421,000 a year.
Nurse practitioners make about $100,000 a year.
Whalen, at LVHN, said the salary situation is unlikely to change for primary care doctors.
“There’s nothing on the immediate horizon where we’re planning to compensate primary care physicians at the same level that we compensate an orthopedic surgeon or a neurosurgeon,” he said. “And that’s a strong driving force for choice for medical students for what fields they go into.”
The waning interest in primary care isn’t just about the money. When medical students see nurse practitioners working as primary care providers, they may feel threatened, Whalen said.
They think, ”‘If the nurse practitioner can do 95 percent of what I’m doing, what’s my future hold?’” Whalen said.
He and others admit that ego may play a role, too — that younger doctors may see primary care as a field for nurse practitioners.
Nurses say they don’t want to take over primary care. They just want to run their practices without obstacles.