Nurses to the rescue?

Physician resistance

Efforts to lift state restrictions on nurses have met with significant opposition, however, mostly from groups representing physicians, such as the American Medical Association and the American Academy of Family Physicians (AAFP), who argue that nurses do not receive sufficient training to take on responsibilities that have traditionally been the domain of physicians.

“Granting independence is going the wrong direction,” said Perry Pugno, director of the division of medical education at the AAFP. “They simply don’t have nearly enough training. It would be irresponsible.”

Much of the debate centers on training. AAFP has reported that family physicians receive a minimum of 20,700 hours of training during medical school and residency. The highest level of training available for a nurse, by contrast, requires no more than 5,350 hours of training, a difference of nearly 75 percent.

Pugno agreed that there are things that advanced practice nurses are well-trained to do, including handling simple acute issues, like ear infections, and stable chronic illnesses, like controlled asthma. He maintained, however, that nurses do not have the training required to “go beyond the straight-forward” and treat patients with multiple illnesses or irregular symptoms that require a nuanced diagnosis.

He gave the example of a sore throat. When a nurse sees a patient with a sore throat, he said, it is within the nurse’s capacity to consider a handful of diagnoses, such as a virus or strep throat. A physician, alternatively, would consider a broader range of potential causes, like a retropharyngeal abscess, gonorrhea, and diphtheria.

“Similarly, the physician has the training to bring a wider range of therapies to the treatment plan, a wider knowledge of how those therapies affect other health conditions or medication regimens the patient may have, and the expertise to blend therapies so the patient has the best outcome for one condition without complicat[ing] another health issue,” he continued in an email.

Additionally, many physicians, including Gary Floyd, who has served on the Texas Medical Association’s Council on Legislation, have called attention to fundamental differences in the way nurses and physicians are trained. They point out that, while physicians receive substantial scientific training on disease and anatomy, nurses’ training tends to focus on “care and comfort.” The lack of scientific training in nursing education, they argue, means that, when it comes to diagnosing and treating disease, patients are better off in the hands of a physician.

“I think there is a fundamental difference between nursing school curriculum and medical school curriculum,” said Floyd. “Most of the physicians I know did not learn the specifics of diagnosing and treating a patient until residency.”

Floyd added that the years a physician spends in residency training is the time when “you see a lot of what’s normal, and the more normal you see, the easier it is to pick out what’s not normal.”

But Hassmiller argued that the vast majority of Americans have very basic primary care needs that could be handled by nurse practitioners, especially in the absence of doctors. And Gilliss of the AAN argued that part of nurses’ education is training them to understand what issues they are prepared to handle, which they are not, and when to consult a physician.

Pugno asserted, however, that knowing when a patient’s needs exceed the capacity of a particular healthcare worker is yet another thing that physicians are better trained for than nurses.

“It’s not a matter of trust,” he said in an email. “It’s a matter of threshold and perspective, both of which are lower and narrower for nurses compared with physicians.”

Floyd added that it is especially important in the primary care environment for a healthcare worker to be able to recognize when a simple-seeming problem is actually more complicated.

But Michael R. Bleich, the dean of the School of Nursing at Oregon Health & Science University, said that he saw the prospect of a large segment of the population receiving no care at all as the physician shortage intensifies as being “much scarier” than the idea that nurses would not be able to make that distinction and potentially misdiagnosis an illness.

The real question, he said, is “[S]hould we provide no care or should we allow nurses to move into that arena?”

Hassmiller agreed, and pointed out that nurses are already stepping up to deliver primary care in the absence of physicians.

“There are plenty of areas in this country where the shortage of physicians is so acute that the only provider the population has access to is a nurse practitioner or a physicians’ assistant,” Hassmiller said. “That’s the reality.”