Point-Counterpoint: Nurse practitioners, A Solution to America’s Primary care Crisis

This makes me so mad. Lies, rhetoric, data manipulation, and talking points. In my last blog, I emailed the author of the article for the sources supporting the statements of ‘quality studies’ and ‘mountain of evidence.’ I actually received a response and obtained the reference: 

https://www.aei.org/research-products/report/nurse-practitioners-a-solution-to-americas-primary-care-crisis/

The title of the reference is actually telling of the bias contained within: Nurse practitioners: A solution to America’s primary care crisis. The counterpoint to this is that this is not a nursing problem to solve! This is a physician problem. 

The very first sentence of the key points section is trying to make a point that people don’t have access to primary care and the assumption is that nurses can solve a physician problem:

tens of millions of Americans do not have adequate access to primary care (particularly in rural areas)

The counter point is this: This is a physician, and not a nursing problem to solve. The nursing discipline never asked physicians if their input would be welcome. Also, the notion of NPs going to rural areas has been disproved, that nurse practitioners (NPs) don’t in fact go to rural areas.

The 2nd sentence in the key points section makes reference to the elusive body of research and claiming equality and superiority of NPs: 

A large and growing body of research shows that the quality of care provided by nurse practitioners is as good and, in some cases, even better than the care provided by primary care physicians.

The counterpoint is this: Much of this research is misinterpretation, data manipulation, bias, flawed methodology, and outdated. The notion of ‘better than’ is simply not true. One is trained in medicine and the other in nursing. How can you compare an apple and an orange and call an orange superior at being an apple than the apple itself?

The third sentence in key points section of the article makes reference to the notion that somehow state laws that require physician collaboration or supervision is restrictive:

many states, nurse practitioners are held back by laws that restrict their scope-of-practice

The counterpoint is this: Not true. I was an NP in states with both full practice authority and those requiring physician collaboration or supervision, and there was no difference in what I could or couldn’t do. Nothing restricted my ability to practice on physician led teams as was the intended role of the NP. 

The fourth sentence in key points section of the article makes reference to how everyone should change and bend over backwards to the militant movement to remove physician collaboration and supervision and again the notion that this somehow limits scope of practice:

Lawmakers, hospital administrators, health care systems, and others involved in assuring access to primary care should remove restrictions on nurse practitioners that limit their scope-of-practice,

The counterpoint to this is: ‘Assuring access to primary care’ is a strawman argument for FPA. There is nothing in states that require collaboration or physician supervision that limits access to primary care. To make the leap from collaboration to limited access to care, does not pass the logic test. In addition, collaboration and supervision requirements are not restrictions, they are safeguards put in place and they do not limit scope of practice. If anything, it enhances scope of practice in that it makes practice safer. When you have someone with whole bunch more education and training giving guidance, knowledge, and wisdom, you have safer smarter practice. This does not limit scope of practice. This is again a strawman argument for FPA and rhetoric. 

This was only the first four sentences of the key points and you can already see the rhetoric, bias, and talking points devoid of substance that passes the logic test. What have I gotten myself into reviewing this document??  The dang thing is 30 pages including references and I only write for leisure. I can probably write about 10 blogs from this one article. Let’s just dissect the first paragraph. What follows in italicized font is the document point followed by regular text as the counterpoint separated by a colon. I’ll limit this blog to the first paragraph only (I’ll write more in later blogs) and you can get the picture of the content of the whole document. I’m not anti-NP or anti-nursing. I used to be both, but I am anti-lies which is what I see my former profession promoting.

For the past few decades, the United States has not produced enough primary care physicians: True, but this is a physician problem to solve not a nursing discipline. How arrogant to think one discipline can simply start taking over problems in another discipline and usurp the role. Here’s a better idea – nursing should solve the problem of bedside RN shortage, RN quality of life, and current poor-quality online diploma mill NP programs! Those are nursing problems to solve, not the physician shortage.  

Moreover, too few physicians practice in rural and medically underserved areas, and the number of people lacking adequate access to primary care has increased: And????? Research shows that NPs don’t go to rural areas either. And again, lack of adequate access to primary care physicians is a physician problem to solve. 

Meanwhile, studies have piled up pointing to the high quality of care that nurse practitioners (NPs) provide and increasing numbers of policy-influencing bodies have recommended expanding the use of NPs in primary care: and these studies are often outdated, flawed/poor methodology, misinterpreted data, and misrepresented conclusions. 

Yet, barriers to the expanded use of NPs persist, and, consequently, tens of millions of Americans lack adequate access to primary care services: I call BS on this! Barriers?? What barriers?? Collaboration and supervision by a physician who has 95% more education and training? To make the leap from collaboration/supervision to a barrier doesn’t hold water. Furthermore, the leap to this then causing lack of adequate access to primary care is actually a bridge too far. As if to say physician collaboration and supervision causes lack of adequate access to primary care. Flawed argument. 

This report describes and integrates new evidence from a research program focused on the primary care workforce, NPs’ role in primary care, and the potential for NPs to help solve the problem of Americans’ access to quality primary care: I’ll take a look at this evidence in this report to see just how sound the research being touted here is. And again, this is a physician problem to solve and not a nursing problem. 

That’s enough for now. The more I read this, the more frustrated I become. I mean what right does a different discipline have inserting itself into solving problems of another discipline. This is nothing more than an opportunistic plague affecting modern medicine. I mean, why don’t the social workers solve the pharmacist’s problems? How about the occupational therapists solving the psychologist’s problems? How about the mental health therapists solving the medical assistant’s problems? How about the licensed practical nurses solving the dietitian’s problems? How about the physical therapists solving the registered nurse’s problems? How about the radiology technicians solving the pharmacy technician’s problems? So why are nurses given credence for trying to solve a physician problem? As if there aren’t enough apples in the apple tree so the oranges jump up and try to solve the apple shortage with more oranges. 

Time to stop writing for now. 

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Robert Duprey MD

Robert is a 2nd career physician (MD); a combat Veteran with the US Army; a former psychiatric nurse practitioner; an independent researcher; a medical writer; and now having passed USMLE Steps 1, 2CK, 2CS, and 3, is a residency applicant. 

  6 comments for “Point-Counterpoint: Nurse practitioners, A Solution to America’s Primary care Crisis

  1. arthur gindin MD, retired neurosurgeon
    June 28, 2020 at 6:28 pm

    Well done!

  2. June 24, 2020 at 7:49 pm

    Just wait until the homeopaths and herbalists start lobbying for primary care rights!

    • Michael G Knapp, DO
      June 28, 2020 at 10:33 am

      They already have done it. Arizona

  3. Michael Ciampi
    June 23, 2020 at 10:25 am

    All great points.

    As you pointed out, independently practicing NPs would be the solution to the shortage of primary care in rural areas, so that problem should already have been solved.

    Fast forward a couple decades, and now the PAs in our state have successfully lobbied for independent practice…because there is a shortage of primary care in rural areas. I don’t think anyone pointed out the incredible irony.

  4. stuart
    June 23, 2020 at 8:48 am

    Good post.

    What we’re seeing is the inevitable, completely predictable response to the total failure of the AAFP and other primary care societies to address the problems our specialties face. Indeed, they have spent more than two decades working to make primary care as unattractive as possible as a career option for new physicians.

    All indications are that they have learned nothing from the current medical crisis and have absolutely no intention on changing the disastrous path they are on.

    • Kurt
      June 24, 2020 at 3:51 pm

      Stuarts comments are absolutely true.The AAFP and other primary care societies have gone along with government mandates, EHR, value based care, accountable care, etc. etc. etc. The bottom line is once a patient leaves the office they can do whatever they want and aren’t held accountable for a da#n thing. Go right on eating s#it, smoking and drinking too much without impunity yet hospitals and doctors get dinged if the jerks are readmitted within 30 days with a recurrent condition! The uncompensatable burden placed on a primary care doctor nowadays is obscene. Used to be possible to do office work, hospital work, take call and have a family life. Now that is totally impossible unless one is in a DPC environment. DPC will only work for those that get in on the ground floor. Problem is that most rural areas are too poor to support that practice model. EHR is a total failure as far as helping a physician to see patients period. I pity the fools who go into primary care medicine and will never forgive Obama for ramming EHR down our throats. Well, it’s my opinion it’s too late now to do anything to save FP/primary care. Only residents they’ll get are those who don’t match and the ones who willfully go into it will regret doing so within 5 to 10 years. Me, I don’t care anymore as I am retiring July 1st and want nothing to do with medicine. Costs too much to maintain a license. State licensing fees, DEA, MOC, CME it’s not worth it. Come July 1st I’ll be a civilian and am not renewing the medical license as it comes due September 1st. That would be money not well spent.
      NP’s? I bet the plaintiff’s attorneys are frothing at the mouth for new and easy malpractice cases to prosecute. I had one for 20 years and she worked in my area and did a good job. Grabbed me anytime there was a question about anything to use my expertise. Heck, she was the one that found the Pheo!! I’m here 32.5 years and never diagnosed a pheochromocytoma myself!

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