Let nurses fill the gap
November 30, 2011 |  by Lisa Watts
Illustration: SIS / Dave Cutler

Illustration: SIS / Dave Cutler

Julie Stanik-Hutt sounds calm enough as she sits down in her North Wolfe Street office in Baltimore to talk health care. But you hear an urgency as she starts to punctuate her points with statistics. One percent of today’s medical school graduates go into family practice. Patients wait an average of three weeks for a doctor’s appointment. As many as 34 million newly insured patients will soon need primary care, as do a ballooning number of aging baby boomers. Obesity, smoking, and sedentary lifestyles continue to increase the incidence of chronic conditions such as heart disease and diabetes.

The solution, some have argued, is to encourage more young doctors to choose family practice by relieving more of their medical school debt and offering other incentives. But Stanik-Hutt, director of the master’s program at Johns Hopkins’ School of Nursing, has another idea, one that requires no costly incentives: Let nurse practitioners and other advanced practice nurses handle primary care needs while physicians specialize in more complex care.

An acute care nurse practitioner and a critical care clinical nurse specialist herself, Stanik-Hutt recently co-authored research that bolsters her case. Published in Nursing Economics, the study compares the quality of care provided by advanced practice nurses with that of physicians, looking at patient outcomes in studies published from 1990 to 2008. Stanik-Hutt and co-author Kathleen White, an associate professor and former director of Johns Hopkins’ Doctor of Nursing Practice program, began with nearly 30,000 research articles that they winnowed to an aggregate of 75 studies, to compare such measures as length of hospital stays, rate of readmissions, and number of complications following treatment. They found that care by advanced practice nurses (nurse practitioners, nurse midwives, and clinical nurse specialists, each with at least master’s degrees and board certification) to be of at least comparable quality, safety, and effectiveness to that of physicians. The study was funded in part by the Tri-Council for Nursing, an educational alliance of four nursing organizations including the American Association of Colleges of Nursing.

“Patient outcomes are where the pedal hits the metal,” Stanik-Hutt says. “It truly proves the quality of care if the patient gets better quicker, doesn’t get admitted to the hospital, has fewer complications, those kinds of things.”

The two professions approach illness from fundamentally different perspectives, she says. “Physicians are trained and educated to deal with complexities. They know the minutiae of disease pathology, they do surgery, they deal with unusual diagnoses. Theirs is a scientific approach. Nurses’ strong area of expertise is a focus on patients in their environment. So we are comfortable working with the patients and their families, offering health prevention and other education. We do a lot to help patients manage their conditions themselves. We take a behavioral approach.”

Stanik-Hutt argues that this holistic focus is well suited to today’s pressing health concerns. “When you think about the care we need in greatest numbers, it’s primary care, someone you’ll see over the years for common chronic illnesses. With a nurse practitioner’s bent toward education and prevention, we can make a real dent in heart disease, for example, which is the nation’s leading cause of death.”

The supply is ample—50 percent of graduating nurse practitioners go into family practice—and advanced practice nurses receive lower salaries than doctors. Physicians have drifted from family practice in part because they seek better pay, which seems fair, Stanik-Hutt says. “It takes a longer time to train physicians—four years of medical school and then residencies—so let them go into cardiology or such specialties farther downstream.”

In today’s typical general practice, a group of physicians sees patients, assisted by one or two nurse practitioners or physician assistants. Flip the model, say nursing advocates. Create practices staffed by a group of advanced practice nurses with one or two doctors available for consultation. “We are trained to pass along those patients that we know we’re not qualified to treat. Most physicians who work with nurse practitioners know that,” Stanik-Hutt says.

Twenty states, including Maryland, allow such models. Nurse practitioners can see patients and prescribe medications without a physician’s oversight. But varying state regulations complicate things. For example, Stanik-Hutt can write a prescription in her Maryland cardiology practice, but her patient may not be able to fill it if he sends it to a mail-order pharmacy in a state such as Florida, where pharmacists can only fill prescriptions written by physicians.

Stanik-Hutt says the simmering issue is about to boil over. “Look at the impending numbers, all the baby boomers who are aging, the technological advances that are keeping people alive longer, the increase in chronic illnesses like diabetes, the epidemic of childhood obesity. We’ve got to empower people; teach them how to improve their health; help them stop smoking, become more active, lose weight. We’ve got to get ahead of this.”