OP/ED: Nurse practitioners the prescription for doctor shortage

January 2014

The following op/ed ran in the San Diego Union-Tribune on December 25, 2013.

Nurse practitioners the prescription for doctor shortage
By Jettie Deden-Castillo 3 p.m. Dec. 25, 2013

Nearly 50 million Americans have gone without health insurance at some point in the past year. As the Affordable Care Act kicks in, promising a flood of new patients, health-care experts are already trumpeting disaster from a shortage of physicians, particularly primary care. In California alone, 42 of our 58 counties don’t have as many physicians as the federal government says we’ll need.

Will our health-care system crash, as CNN predicted in early October?

Fear not. I have the solution. When I first became an obstetrics/gynecology nurse practitioner (NP) in 1979, the vision was for nurse practitioners to manage the care of routine, healthy patients and free up physicians to take more complicated cases. It’s time to return to that vision. An NP can function much like a primary-care physician, but with the heart of a nurse. Doctors treat disease. We treat patients.

“Don’t you ever ask about sexual issues?” I once asked an MD colleague. His response: “I’m just there to do their Pap smear.” What a disservice to his patients. I want to know my patients so I can take care of them. Are they married or single? Do they have children? Do they work? All of these are important factors in maintaining health and well-being. Certainly there are doctors who take this approach as well. But for nurses, caring for the whole patient is our calling. It’s why we went into nursing, and it’s what we learn to do every day of our professional lives.

“Can I tell you something I’ve never told anyone in my whole life?” I call this the doorknob question, because patients usually ask it just as I put my hand on the doorknob to leave the exam room. They trust me enough to reveal sexual abuse, incest or some other burden they have carried alone for decades and which they would not share with their doctor. Often these same patients suffer from chronic pelvic pain or other conditions that might not have clear physical causes. I make sure they get the care they need.

While nurses are already well trusted by the public, the qualifications of nurse practitioners may not be well understood. Nurse practitioner is a masters level degree, which comes on top of the minimum four years’ education to become a registered nurse. Since I became an NP I’ve had 34 years’ experience. Studies have shown higher satisfaction rates among primary-care patients treated by NPs than doctors, and even better outcomes. We can do much of what an MD can do — for example, diagnose, write prescriptions, insert IUDs and perform biopsies.

More than one patient has told me the difference between seeing an NP or an MD was that the NP had more time to spend with them, when in fact the appointment times were exactly the same. It was the patient’s perception that the NP took more time because the NP talked to them more. When I worked a 12-hour shift in urgent care I saw up to 30 patients a day. I gave my business card to each one and told them to email me with problems or questions at any time. I might get one email back per day. Most just said thank you. But I gave them something tangible, and they knew I was there if they needed me.

So what happened to that initial vision for using NPs to make primary care more efficient? Mission drift. Some physicians can be hesitant to fill their schedules with all difficult cases. Meanwhile, NPs have enabled them because we’re eager to learn more and challenge ourselves. It seems also that some physicians see our success as a threat to their status. However, the looming shortage of primary-care physicians as the ACA kicks in may force the issue.

There’s an old truism: Use the least amount of medicine to get the desired result. My prescription for the physician shortage: Let NPs — and other advanced practice providers such as physician assistants and Certified Nurse Midwives — manage the care of healthy, young and routine patients. Let MDs handle the more difficult diseases and surgeries for which only they have the training, knowledge and expertise. This arrangement should not threaten the status of MDs. It should only elevate it. Meanwhile, we NPs can contribute our special talents as caregivers. Our patients will be in good hands.

Deden-Castillo has been an OB-GYN NP for 34 years and is now treasurer of the United Nurses Associations of California/Union of Health Care Professionals.