Think twice before throwing doctors to the wind
Pugno used the example of studying biochemistry in medical school, a subject he had already covered in his undergraduate pre-med courses. When he encountered it again at the graduate level, he came to understand the subject with new depth and a new appreciation for its practical significance. “I learned what the structure of the penicillin molecule looks like, and how it interferes with the biochemical process of bacterial cells forming the wall of the bacterium, and how penicillin interferes with that formation so that the bacteria dies,” Pugno said. “The nurse practitioner learns: for this bacterium, you give this dose of penicillin, and it kills it.”
Many nurse practitioners reject the premise that this level of education is a requirement to provide high-quality primary care. “One of the physicians I work with,” said Golden, of the American Association of Nurse Practitioners, “remembers being in the class where he had to identify every subatomic particle in a cell. But he said to me that he has yet to have to do that for any patient, nor has he had to explain it to any patient. So, did he need to do that [coursework]? I don’t know.”
Many doctors acknowledge that, in a majority of instances, such expertise does not have an immediately applicable worth in a primary care setting. But they say that it does make a difference in those cases where patients do not exhibit common combinations of symptoms or reactions to treatment. “By understanding how penicillin works, I’m more aware of the other drugs that work the same way,” as well as those that don’t, said Pugno. Thus, a doctor would be more likely to know, “if you’re allergic to penicillin, what other drugs might give you trouble. Or if the bacteria is resistant to penicillin, what other drugs it’s likely to be resistant to, and what drugs kill the bacteria in a different way and are more likely to be effective in this situation.”
Molly Cooke, president of the American College of Physicians, a practicing general internist, and professor at the University of California, San Francisco, said a medical education is designed in many ways to prepare doctors for encounters with unexpected or puzzling cases. “What we aim for in the education of physicians is a sufficiently deep conceptual understanding, not just of what’s known, but an understanding, or at least an appreciation, of what we don’t really know a lot about,” said Cooke. “That supports both routine expertise — ‘This looks like A and I’m going to treat it like A’ — but also the discrimination to say, ‘This doesn’t look enough like A to make me comfortable managing it as A.’”
Cooke cited the example of an unusually difficult patient who is paraplegic, wheelchair-bound, and suffers from chronic pain and psychological problems. After a bout of flu led to a bacterial infection and sent him to the emergency room, he was prescribed two separate rounds of antibiotics, but his condition only worsened. When the patient returned to Cooke’s practice, he was initially scheduled to see a nurse practitioner, who explicitly requested that the patient see Cooke directly, as the nurse practitioner did not feel comfortable with the complexities presented by the patient. Cooke said that her ability to correct the diagnosis and treatment was largely contingent on her detailed understanding of the pulmonary system, the various infections that could affect it, and the various pharmacological treatments available — many of which, in this instance, did not appear and interact in routine, expected ways.
Breadth of experience
Another aspect of medical education that doctors frequently point to is the fact that clerkships and residencies require rotations with several different subspecialties and in several different hospital settings. Some nurse practitioners say that such breadth is extraneous to understanding how to provide primary care, which is where their education is more narrowly focused.
“Yes, physicians do spend more time in training,” said Debra J. Barksdale, president of the National Organization of Nurse Practitioner Faculties, professor at the University of North Carolina, Chapel Hill, and a clinical nurse practitioner. “Not all of that training is devoted to primary care, however. Our training tends to be more focused. My whole program was focused on primary care, so I didn’t have to cover all of the other acute care practice that’s happening in the hospital.”
But many physicians say that their training with numerous specialties and in numerous settings allows them to manage patients with conditions that, while they do not demand attention from a specialist, are in complex ways related to that specialty. Nurse practitioners, they say, are more liable to refer such cases to a number of different specialists. Blackwelder, of the AAFP, gives the example of a patient with chronic conditions affecting multiple systems: the heart, the lungs, and the skeleton.
“The reality is that family physicians see more people with heart disease than do cardiologists,” said Blackwelder. “I take care of acute and chronic orthopedic problems…A good family physician will be able to say, ‘I can mange your heart disease right now, and I can mange your emphysema, and I can handle your arthritis. And I can do it today, and I can take care of all of that in my office.’ Versus a nurse practitioner who might say, ‘OK, I’ll hook you up with a cardiologist for your heart problem, and I’ll hook you up with a pulmonologist, and I’ll send you to an orthopedist.’”
In those instances when attention from specialists is needed, Blackwelder and others say that a physician is more likely to be better prepared to counsel the patient as to the possible outcomes of the specialists’ treatment, as well as to act as a sort of translator between the patient and the specialists. “The health care system is complex,” Pugno said. “The constellation of specialists is complex. And the primary care physician has the greater depth and broader view to be able to more efficiently direct a patient to the right specialist,” and to more comprehensively coordinate, interpret, and apply the care that is indicated.
Doctors say that this ability is a direct result of having spent substantial amounts of time practicing and training with different subspecialists during their years as students and residents. Blackwelder and Pugno both suggested the example of needing to send a patient to surgery, and explained that they participated directly in a broad range of surgical procedures during their training, from appendectomies to hip replacements to operating on gunshot wounds. “So, while I don’t do those as a family physician,” Blackwelder said, “I’ve been a part of them, I’ve worked with the physicians who do them. I know what the patient goes through, and I know the kinds of questions that will be asked.”
Pugno and Blackwelder added that this level of knowledge and experience goes a long way in assuaging the anxieties of a patient encountering a complicated condition or, even more so, a complicated set of interacting conditions. Because they have more first-hand knowledge of the kinds of experiences undergone by such patients, they can better counsel them as to the variety of possibilities involved — the nature and likelihood of complications, for example. “That experience,” added Pugno, “allows you to relate things to your patient in more depth — but, most important, you can give them the perspective and the context that lets them know what’s really going on.”
Working together?
In spite of these differences, nearly every doctor and nurse we interviewed agreed that the quality of care improved significantly in team-based practices with various kinds of health care professionals available to care for a patient together. The principal difference is that physicians believe such teams ought to count on a primary care doctor to handle those instances where their skills and experience exceed those of a nurse practitioner. “Every member of the team is critical,” said Blackwelder. “Every member has roles they can play. Some of those roles overlap. But you can’t just substitute one member of the team for another.”