Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

The AAFP picks a fight with nurse practitioners

Brian Klepper, PhD
Policy
October 5, 2012
198 Shares
Share
Tweet
Share

The American Academy of Family Physicians (AAFP) recently issued a new report describing its vision of primary care’s future. Not surprisingly, the report talks about medical homes, with patient-centered, team-based care.

More surprisingly, though, it makes a point to insist that physicians, not nurse practitioners, should lead primary care practices. The important questions are whether nurse practitioners are qualified to independently practice primary care, and whether they can compensate for the primary care physician shortage. On both counts the AAFP thinks the answer is “no.”

AAFP marshals an important argument to bolster its position. Family physicians have four times as much education and training, accumulating an average of 21,700 hours, while nurse practitioners receive 5,350 hours.

It is unclear how this plays out in the real world but, intuitively, we all want physicians in a pinch. Researchers with the Cochrane Database of Systematic Reviews reviewed studies in 2004 and 2009 comparing the relative efficacy of primary care physicians and nurse practitioners. They wrote “appropriately trained nurses can produce as high quality care as primary care doctors and achieve as good health outcomes for patients.” But they also acknowledged that the research was limited.

There is no question that nurse practitioners can provide excellent routine care. For identifying and managing complexity, though, physicians’ far deeper training is a big advantage. In other words, difficult, expensive cases are likely to fare better from a physician’s care.

AAFP can hardly be blamed for wanting to dispel the notion that physicians are exchangeable with nurse practitioners. But does anyone seriously think that nurse practitioners will displace primary care physicians? Well, in some venues, yes. In the onsite and retail clinic sectors, some firms – not mine, but others – see nurse practitioners as cheaper labor and just as good as doctors. This approach, championed most aggressively by the big box drug retailers like Walgreens and CVS, bets that, in the market, lower short term cost will beat higher long term value. While AAFP may argue, correctly, that nurses don’t equal doctors, the prospect of a protracted battle with powerful Fortune firms is daunting.

At the same time, AAFP’s focus on nurses appears to ignore the more important fact that specialists now provide a significant percentage of primary care services. An August 2012 Archives of Internal Medicine study found that 41% of primary care office visits were provided by specialists. (This study defined internists and obstetricians/gynecologists as specialists, so the numbers may be inflated.)

A more robust study three years earlier examined more than a billion patient encounters between 2002-2004 and found higher numbers. Nearly half (46.3%) of specialist visits were for preventive care or routine follow-up of patients who the specialist had previously seen. New referrals accounted for only 30.4% of all visits. Many of these visits could be handled competently and far more cost-effectively by a generalist.

To some degree, patients’ use of specialists for primary care reflects the primary care physician shortage. But a different problem is more pernicious: patients – particularly if they’ve had a previous condition, like a heart ailment – often believe that specialists are more qualified.

Which brings us to a difficult question. Why has AAFP taken a public stance against nurse practitioners extending primary care services, but ignored specialists usurping a significant portion of primary care business?

One answer is that primary care has become demoralized and insecure, the result of decades of being treated as a lower caste in medicine, and that nurses are less formidable opponents than specialists or corporations.

Primary care is in decline because it has been compromised by a health care industry that wants direct patient access to lucrative downstream services. But primary care’s leadership also has complicity, because it has failed to compellingly convey primary care’s value and allowed others to define it. It has been meek in defining models that can drive efficiencies, or in highlighting the mechanisms of scale essential to market power. Nor has it partnered with more influential groups, like business leaders, whose interests – lower costs and better outcomes – are aligned with its own.

Fighting with nurse practitioners will buy primary care physicians little. Worse, it distracts precious resources from approaches that can keep health care businesses from distorting primary care’s appropriate role and specialists from encroaching on primary care’s work. Focused on the wrong problems, primary care will continue to flail.

Nothing will change in primary care or the larger health care system until there is a new results-based activism in policy and the market. Primary care must receive reimbursement that is commensurate with its measurable full-continuum value, allowing it to invest in clinical decision support tools and management capabilities, and presenting it as a meaningful, data-driven answer to the monstrous health care cost crisis.

Brian Klepper is Chief Development Officer of WeCare TLC and blogs at Care and Cost.

Image credit: Shutterstock.com

Prev

Cause of death: Defensive medicine

October 5, 2012 Kevin 11
…
Next

MKSAP: 72-year-old man is evaluated for fatigue and dyspnea

October 6, 2012 Kevin 0
…

Tagged as: Primary Care, Public Health & Policy

Post navigation

< Previous Post
Cause of death: Defensive medicine
Next Post >
MKSAP: 72-year-old man is evaluated for fatigue and dyspnea

More by Brian Klepper, PhD

  • a desk with keyboard and ipad with the kevinmd logo

    The FDA’s epic regulatory failure

    Brian Klepper, PhD
  • a desk with keyboard and ipad with the kevinmd logo

    Why reform needs to start at cancer care

    Brian Klepper, PhD
  • a desk with keyboard and ipad with the kevinmd logo

    Will fee for service ever go away?

    Brian Klepper, PhD

More in Policy

  • Healing the damaged nurse-physician dynamic

    Angel J. Mena, MD and Ali Morin, MSN, RN
  • Deaths of despair: an urgent call for a collective response to the crisis in U.S. life expectancy

    Mohammed Umer Waris, MD
  • Breaking down the barriers to effective bar-code medication administration

    Amy Dang Craft
  • The locums industry has a beef problem

    Aaron Morgenstein, MD
  • Canada’s health workers are sounding the alarm. We must act, now.

    Ivy Lynn Bourgeault, PhD
  • Race categorizations are worsening health inequities for the South West Asian North African (SWANA) communities

    Guleer Shahab, MPH
  • Most Popular

  • Past Week

    • Nobody wants this job. Should physicians stick around?

      Katie Klingberg, MD | Physician
    • The real cause of America’s opioid crisis: Doctors are not to blame

      Richard A. Lawhern, PhD | Meds
    • Healing the damaged nurse-physician dynamic

      Angel J. Mena, MD and Ali Morin, MSN, RN | Policy
    • The struggle to fill emergency medicine residency spots: Exploring the factors behind the unfilled match

      Katrina Gipson, MD, MPH | Physician
    • Deaths of despair: an urgent call for a collective response to the crisis in U.S. life expectancy

      Mohammed Umer Waris, MD | Policy
    • Breaking the stigma: Addressing the struggles of physicians

      Jean Antonucci, MD | Physician
  • Past 6 Months

    • The hidden dangers of the Nebraska Heartbeat Act

      Meghan Sheehan, MD | Policy
    • The vital importance of climate change education in medical schools

      Helen Kim, MD | Policy
    • The fight for reproductive health: Why medication abortion matters

      Catherine Hennessey, MD | Physician
    • Nobody wants this job. Should physicians stick around?

      Katie Klingberg, MD | Physician
    • Resetting the doctor-patient relationship: Navigating the challenges of modern primary care

      Jeffrey H. Millstein, MD | Physician
    • The real cause of America’s opioid crisis: Doctors are not to blame

      Richard A. Lawhern, PhD | Meds
  • Recent Posts

    • Lazarus: the dead man brought back to life

      William Lynes, MD | Conditions
    • Revolutionizing COPD management with virtual care solutions [PODCAST]

      The Podcast by KevinMD | Podcast
    • What I think it means to be a medical student in the wake of AI

      Jackson J. McCue | Tech
    • It’s time for C-suite to contract directly with physicians for part-time work

      Aaron Morgenstein, MD & Corinne Sundar Rao, MD | Physician
    • The psychoanalytic hammer: lessons in listening and patient-centered care

      Greg Smith, MD | Conditions
    • From rural communities to underserved populations: How telemedicine is bridging health care gaps

      Harvey Castro, MD, MBA | Physician

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 57 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

CME Spotlights

From MedPage Today

Latest News

  • Sam Neill's Rare Lymphoma
  • Day in the Life of a Doctor: Treating a Patient With Septic Shock
  • Paxlovid May Lower Long COVID Risk, VA Study Suggests
  • Digital Inhalers May Improve Uncontrolled Asthma Management
  • Another Win for Zolbetuximab in Advanced Gastric/GEJ Cancer

Meeting Coverage

  • Switch to IL-23 Blocker Yields Deep Responses in Recalcitrant Plaque Psoriasis
  • Biomarkers of Response With Enfortumab Vedotin in Advanced Urothelial Cancer
  • At-Home Topical Therapy for Molluscum Contagiosum Gets High Marks
  • Outlook for Itchy Prurigo Nodularis Continues to Improve With IL-31 Antagonist
  • AAAAI President Shares Highlights From the 2023 Meeting
  • Most Popular

  • Past Week

    • Nobody wants this job. Should physicians stick around?

      Katie Klingberg, MD | Physician
    • The real cause of America’s opioid crisis: Doctors are not to blame

      Richard A. Lawhern, PhD | Meds
    • Healing the damaged nurse-physician dynamic

      Angel J. Mena, MD and Ali Morin, MSN, RN | Policy
    • The struggle to fill emergency medicine residency spots: Exploring the factors behind the unfilled match

      Katrina Gipson, MD, MPH | Physician
    • Deaths of despair: an urgent call for a collective response to the crisis in U.S. life expectancy

      Mohammed Umer Waris, MD | Policy
    • Breaking the stigma: Addressing the struggles of physicians

      Jean Antonucci, MD | Physician
  • Past 6 Months

    • The hidden dangers of the Nebraska Heartbeat Act

      Meghan Sheehan, MD | Policy
    • The vital importance of climate change education in medical schools

      Helen Kim, MD | Policy
    • The fight for reproductive health: Why medication abortion matters

      Catherine Hennessey, MD | Physician
    • Nobody wants this job. Should physicians stick around?

      Katie Klingberg, MD | Physician
    • Resetting the doctor-patient relationship: Navigating the challenges of modern primary care

      Jeffrey H. Millstein, MD | Physician
    • The real cause of America’s opioid crisis: Doctors are not to blame

      Richard A. Lawhern, PhD | Meds
  • Recent Posts

    • Lazarus: the dead man brought back to life

      William Lynes, MD | Conditions
    • Revolutionizing COPD management with virtual care solutions [PODCAST]

      The Podcast by KevinMD | Podcast
    • What I think it means to be a medical student in the wake of AI

      Jackson J. McCue | Tech
    • It’s time for C-suite to contract directly with physicians for part-time work

      Aaron Morgenstein, MD & Corinne Sundar Rao, MD | Physician
    • The psychoanalytic hammer: lessons in listening and patient-centered care

      Greg Smith, MD | Conditions
    • From rural communities to underserved populations: How telemedicine is bridging health care gaps

      Harvey Castro, MD, MBA | Physician

MedPage Today Professional

An Everyday Health Property Medpage Today iMedicalApps
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

The AAFP picks a fight with nurse practitioners
57 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...