Nurses to the rescue?

A comprehensive policy instead of “zero sum”

Robert Phillips, director of the Robert Graham Center, a research organization that is sponsored by the AAFP, agreed that, as the physician shortage intensifies, nurses should play a heightened role in healthcare delivery.

He worried, however, that relying more heavily on nurses could effectively waylay plans to train more primary care physicians. The anxiety of primary care physicians — that they stand to be replaced by advanced practice nurses — has been reinforced by some recent reports calling for physician training resources to be diverted away from primary care and toward specialty medicine.

Bleich argued that giving nurses a greater role in the short-term would not necessarily involve substituting advanced practice nurses for primary care doctors.

“One of the big myths that gets perpetuated is that nurses are trying to take the place of physicians,” he said, “and that’s just not the case. There is an overlap, which is a positive thing for patients.”

When asked if giving nurses more autonomy meant less of a role for physicians, Hassmiller said, “We certainly hope not. Our position is that we need more nurses and more primary care doctors.”

But Phillips pointed out that there is already a shortage of so-called “bedside nurses,” or nurses that have not received advanced training, and that incentivizing more nurses to pursue advanced degrees would exacerbate that problem, essentially shifting the shortage down the line.

Researchers have demonstrated that the dearth of nurses will likely grow even worse than the projected physician shortage; they estimate that there will be 260,000 too few nurses by the year 2025.

It isn’t enough to produce more physicians, or more nurses, Phillips said. The U.S. will need to do both. “We need to be looking at getting supply and distribution right for physicians, nurses, and all other members of the team,” he said.

And the body of evidence on the subject indicates that, when both advanced-practice nurses and primary care physicians are practicing in a healthcare delivery environment, referral rates and costs go down while patient outcomes improve. Advocates on both sides of the issue agreed that this is the best-case scenario for a delivery model in the future.

Gilliss said that it was certainly within the country’s capacity to meet all of the healthcare workforce needs in the long term, and that producing more nurses should not mean producing fewer physicians.

That would mean ramping up training for physicians, advanced practice nurses and bedside nurses simultaneously. One of the foundational pillars of the Institute of Medicine report, Hassmiller said, was that educational opportunities should be increased for nurses in all fields.

Additionally, Gilliss said, when viewed from a patient-centered perspective, a policy that sought to produce more healthcare workers across the board would carry significant advantages for the public.

“Right now, there’s a service that people aren’t getting,” she said. “That’s the coordination of care [between healthcare professionals].” If there existed the capacity for some nurses to be in charge of organizing every patient’s healthcare, the quality of care would improve, as well as the patient’s experience, she said.

Gilliss maintained that viewing healthcare workforce policy as a zero-sum equation where either doctors or nurses are forced to lose out would be a mistake, and that the U.S. should strive to produce more physicians and more nurses. She said that increasing education and training would come with costs, but that the costs of a long-term shortage of physicians or nurses would be greater.

“I think it would be silly to assume that adding more [healthcare workers] would not cost more,” she said. “It’s a matter of priorities.”

Needing a different starting point?

Disputes that pit doctors against nurses will likely continue, Gilliss said, as long as the discussion is premised on the need to cut costs, rather than on the need to improve the care delivered to patients.

A similar roadblock has also been apparent in the debate over the burgeoning physician shortage. There, too, the lack of political will to come to grips with the cost of meeting the growing medical needs of an aging and growing population has stymied action.

In both the long-term and the short-term, Gilliss said, the place to start is with an evidenced-based discussion of what strategies will bring the best care to the most patients.

Next week: the pros and cons of trying to meet the doctor shortage by increasing reliance on medical graduates and practicing physicians from other countries.