There are no doctors in rural Tyrrell County, N.C. There is only Irene Cavall, a licensed nurse practitioner and the sole source of primary care for 4,000 residents spread out over 600 square miles.
It鈥檚 been that way since the county鈥檚 lone doctor moved away 2 陆 years ago. Cavall sees as many as 40 patients a day at the Columbia Medical Center. It鈥檚 about 40 miles west of the Outer Banks; an ambulance ride to the nearest hospital takes 25 minutes.
Nurse practitioner, Irene Cavall checks Sacha Pledger鈥檚 blood pressure. Nurses are gaining support in their drive to play a larger primary care role. (Ron Vick/Kaiser Health News)
There are limitations to her work 聳 by state law, she works under the supervision of a doctor, albeit one many miles away, and calls him and specialists as needed. But for 15 years, Cavall has been helping patients with a range of routine problems, from colds to management of diabetes, that don鈥檛 always require a doctor. As she says, doctors 鈥渄on鈥檛 need to give someone a Tylenol.鈥
Nursing leaders say large numbers of practitioners like Cavall will be needed to fill gaps in primary care left by an increasing shortage of doctors, a problem that would intensify if Congress extends health insurance to millions more Americans. Advocates say nurse practitioners have the extra education and training needed to perform a variety of services, including physical exams, diagnosis and treatment of common ailments and prescribing drugs.
But the American Medical Association and doctors鈥 groups at the state level have been urging state legislators and licensing authorities to move cautiously, arguing that patient care could be compromised. This battle has been waged for years, even as nurse practitioners grew rapidly in number 鈥 there are 125,000 or more 鈥 and expanded their responsibilities. What鈥檚 different now is the increasing conflict as pressure grows to use nurse practitioners and other so-called physician extenders, including physician assistants, certified nurse midwives and pharmacists. The Association of American Medical Colleges that there will be a shortfall of as many as 46,000 primary care doctors by 2025.
Doctors Push Back
The American Medical Association sparked harsh criticism from nursing groups when it released a report in October bluntly questioning whether nurse practitioners 鈥渁re adequately trained to provide appropriate care.鈥 To back up its claims, the report cites recent studies that question the prescription methods of some nurse practitioners, as well as a survey that reported only 10 percent of nurse practitioners questioned felt well prepared to practice primary care.
The nation鈥檚 largest doctors鈥 group concluded: 鈥淭he time is ripe for legislators, health care policy analysts and nurses to thoroughly assess the quality of NP training in relation to the scope-of-practice expansions sought at the state level.鈥
Responding to the AMA in December, the American Nurses Association and more than two dozen other nurses鈥 organizations termed the report 鈥渕isleading,鈥 saying it 鈥渃ontains numerous factual misrepresentations.鈥 Their letter rebuked the AMA for its 鈥渁ttempt to change the perceptions of NP practice as anything other than fully qualified professionals working within a legally established scope of practice.鈥
The president of the American Society of Anesthesiologists says the key issue is supervision聽鈥淲e understand that in most fields of medicine, non-physician providers play an important role and they certainly have in anesthesia for more than a century,鈥 says Dr. Alex Hannenberg, who practices in the Boston area. 鈥淭he safest and high quality care requires that a physician be providing oversight of the nurse practitioner.鈥
Debate over national health overhaul legislation has heightened the sense of urgency about primary care and given nurses ammunition for their argument. 鈥淭he biggest group of clinicians that will be in shortage with universal (insurance) coverage will be those who provide primary care 鈥 and that鈥檚 what nurse practitioners are so extraordinarily good at,鈥 says Mary Mundinger, dean of the Columbia University School of Nursing.
There is precedent: Massachusetts鈥 2008 health insurance overhaul recognized the 5,600 nurse practitioners as primary care providers who would be reimbursed through private insurance and Medicaid at the same rates as doctors. The nurses, however, must work under written protocols that designate a physician who can provide medical direction.
Support For Nurses
Nurse practitioners are gaining support. In a Jan. 14 report, the Center for American Progress, a liberal think tank, said maximizing use of the 鈥渆ntire health care workforce鈥 would also 鈥渋ncrease quality while decreasing costs.鈥 Ellen-Marie Whelan, senior health policy analyst at the center, said in an interview that nurses 鈥渟hould be part of managing chronic illness, helping a patient navigate the system, helping coordinate among providers.鈥
鈥淭he fear that there鈥檚 a safety concern, I think we just have to look at the evidence, look at the numbers,鈥 Whelan said. 鈥淣urse practitioners have been trained to know where their limit is. Since the beginning 鈥 now it鈥檚 been over 40 years 鈥 there鈥檚 just been so much evidence to say that there鈥檚 nothing to fear and in many cases, there鈥檚 higher quality.鈥
In September, the nonpartisan Brookings Institution鈥檚 Engelberg Center for Health Care Reform issued a report by 10 experts that said one way to curb health care spending is to encourage states to permit 鈥済reater use of nurse practitioners, pharmacists, physician assistants, and community health workers.鈥 Meanwhile, a blue-ribbon committee working under the aegis of the Institute of Medicine and Robert Wood Johnson Foundation is planning to make extensive recommendations later this year on the future of nursing.
Nurse practitioners started out decades ago under close supervision of physicians, with tight restrictions on what they could do. But nurses have successfully pushed state licensing agencies and legislatures to grant them more autonomy and broader duties. The AMA report said, for example, 鈥渁ll states now allow NPs some degree of prescribing privileges,鈥 and 12 have granted them authority to prescribe medicine independent of doctor oversight.
This year, several states are considering laws to restrict or expand nurses鈥 scope of practice. For example, in Colorado, 聽would allow advanced practice nurses in addition to physicians to issue medical orders that direct a patient鈥檚 care at any facility. Another bill there would eliminate a nurse鈥檚 right to declare a patient terminally ill.
Most states require nurse practitioners to obtain a master鈥檚 degree in nursing, but education and training requirements vary. Cavall, 60, has a master鈥檚, and, prior to becoming a nurse practitioner, she was a registered nurse for several years. She feels very qualified to take care of patients in Tyrrell County. 鈥淚f you come from a background where you鈥檝e seen just about everything, that gives you a really good basis for delivering that care,鈥 she says.