Several comments to this blog have addressed the inclusion of nurse practitioners as possible leaders of medical homes (only if the state certifies NPs for independent practice).  Because of the first two comments, I must clarify that I am not talking about NPs working with physicians, but rather my comments refer to NPs in independent practice. Here is one physician comment:

Dr Block makes a good point. There seems to be some cognitive dissonance on the part of those trying to bolster primary care, while at the same time accepting a much broader role for midlevels delivering it.

Either the comprehensive care is complex, difficult, and best provided by an extensively trained (and expensive) physician, or it’s usually straightforward, algorithm driven, not particularly complex, and best provided by a less expensive midlevel (with much less training).

Arguing those providing comprehensive care should be paid more, then arguing that we should have midlevels delivering a lot more comprehensive care seems schizophrenic. And it’s not convincing.

A nurse practitioner answers:

An interesting topic and comments that follow. It is obvious that even many “medical people” do not understang the role of the nurse practitioner since their comments are minimalizing and denigrating – Jiffy Lube? Fine – keep on thinking that NPs are “simple” and can’t handle “complex” patients. We want to work together with you so that we can care for the many patients that don’t have providers. It’s ok for NPs to care for the un or underinsured but don’t let them care for the patients with real insurance. There is no evidence that NPs order any more tests or referrals than any other provider.

We as NPs will continue going into primary care when many physicians completely avoid it and are leaving in droves. We want to partner with you – not so that you can supervise us – but so that we can collaborate and bring best practices to our patients. Is it not possible that NPs have areas of specialty where we are better equipped to handle a certain situation or patient? Perhaps you all have worked with what you consider substandard NPs – has that not happened with your physician colleagues?

Bob Doherty addressed this issue on Friday – Do internists have confidence in their own training when compared to NPs?

H.R. 2350 goes beyond ACP policy, in that it would allow NP-led practices to qualify as PCMHs, not just for demonstration projects as proposed by ACP, but under a permanent Medicare PCMH benefit, starting in 2011. ACP’s top physician leadership made the judgment that H.R. 2350 merits the College’s strong endorsement, even with the more expansive NP language, since perhaps 95 percent of the bill is based on ACP policy.

In the days since ACP endorsed the bill, some ACP members have expressed concern that ACP’s support will further blur the lines between general internal medicine and advanced practice nursing, making it even harder to persuade young people to go through the extra years of training to become a physician But if internists truly believe in the value of their training, shouldn’t they also be confident that they will be able to show such value in a medical home model where the outcomes of care can be measured?

My bet is that the PCMH will help support the value of internal medicine training by providing a consistent way to measure the outcomes, effectiveness and efficiency of care provided by internists, even when compared to nursing-led PCMHs that operate within the limits of their licenses and against the same evaluation benchmarks. And, as I’ve written about before, our chances of getting primary care legislation could be irreparably weakened if physicians and nurses are viewed as being in competition with each other, rather than as allies on the need for more of both.

I understand the politics behind the inclusion of NPs as potential PCMH leaders.  As I have written many times, the problem stems from the semantic drift that the term primary care has undergone over the past 3 decades.  I recently wrote about the levels of primary care.  My rant was meant to emphasize our collective confusion over this term.

If we mean routine episodic care or routine chronic disease management then we probably have the primary care that politicians conceive.  Internists do these things as part of their overall more comprehensive care.

I will try to define the problem once again.  The value of a well trained physician comes from recognizing the long tail events. The long tail zone – when do I enter it

We do not measure long tail events as a quality measure, because it would be very difficult to enumerate such events.  So we have a classic important concept which is not easily measured.  I will continue to insist that diagnostic errors are extremely important.  I heard a colleague state that diagnostic errors are the most common reason for malpractice lawsuits.  Yet our current quality measures ignore diagnosis.

Well trained physicians excel at diagnosis.  I remember during training that the greatest praise for one of our heros was that he was a great diagnostician.

Our primary care debate often ignores this issue.  I doubt that many NPs have the diagnostic acumen of well trained internists and family physicians.  I might argue that long tail diagnosistics define a different level of expertise than the concept that primary care currently represents. 

So I am personally against the NP clause, but understand the political necessity.  Politics requires the art of compromise.  In supporting HR #2350 I am willing to compromise, but I do not have to be completely happy.

Related posts:

1. In which I respond to angry comments
2. Dazed and Confused – Levels of primary care?
3. DrRich is right and wrong
4. The semantics of primary care
5. Are retainer practices the model for PCMH?

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