The war between NP and FP?

I work with Nurse Practitioners (NPs). I love them. Okay, I’ve said it. The rest is smoke and mirrors, controversial headlines, the gnashing of teeth and more. Where do I start? All I can write about is my own observations. My own experience with NPs in acute and comprehensive primary care has been exemplary. So, if my own colleagues have their nose out of joint with what may or may not occur in Alberta’s future, I apologize in advance for what I am about to write. This is very much my opinion, nothing more, nothing less. All I know is what I’ve seen.In the past I worked with nurses in rural and remote communities whose skill sets easily outstripped most urban family physicians. The joke was that if they moved to “the big city” they would legally not be able to perform many of the tasks that they were expert in, procedures they were “forced” to do, as there was no other medical professional around to do them. These were veteran medical professionals who served their communities extremely well. Can NPs provide a similar role in the delivery of primary care? Our premier in Alberta loves to throw out (crazy) ideas and watch the response. Many of her ideas might be considered highly contentious, polarizing, and their legitimate implementation improbable. But she puts them out there nonetheless and certainly gets tongues wagging. The new planned initiative to pump millions of dollars getting NPs up and running independent practices was met with instant backlash from the family practice community. Is this plan even possible? Do we even have enough NPs in Alberta, in Canada for the matter, to pull this off? I am not an expert in health economics and don’t profess to have any surefire answers to our province’s health crisis, but this is what I have observed.NPs can function extremely well in several rolesNP have had roles in sub-specialty medicine for quite some time. They are excellent at dealing with the day-to-day management of problems, interaction with patients and families, as well as monitoring and trouble-shooting issues and concerns in real time. They are well-suited in handling specific problems in complex patients. NPs can (sometimes) outperform FPsNPs are generally very attentive to detail and extremely meticulous in their documentation. If at times FPs “cut corners” to manage higher volume, NP are less likely to do so. I receive absurdly abbreviated and poorly presented referrals from some FP colleagues which I would consider embarrassing. Rarely would this come from an NP. NPs are generally great team playersTheir training has “set them up for success” in managing within a team. I don’t want to generalize too broadly, but my observation is that NPs are usually good communicators who are more likely to ask for help and more readily collaborate than their FP and specialist colleagues. With experience, NPs can function independentlyNewly minted FPs in the first five years of practice struggle to practice if they don't have a lot of support. An experienced NP can function at the equivalent role of most FPs. There are certainly exceptions to this. Not all NPs are created equal. But neither are FPs. This all sounds very positive and wonderful. Lollipops and gumdrops! What are the problems? Two NPs for every well-seasoned FP? At the extreme, this may be true. It might cost the system more in the end. High quality care is expensive. And where are all these NPs coming from? If we can’t graduate enough FPs, how are we going to train and graduate all these thousands of NPs? NPs are “slower” and use more resourcesI do see my NP colleagues:ordering more tests seeing fewer patients than I do writing more elaborate notes requesting more follow-up visitsequivocating over DX / DDX and referring more patients when unsure So what!! (I am a 35+ year veteran of primary care). The same list would probably hold true for my junior FP colleagues. Too expensive!The problem is not really about nurse practitioners versus family physicians. The problem is how to pay for their services. NPs are likely better suited to an ARP contract/sessional fee/hourly rate rather than FFS. So be it. Maybe all FPs should be on ARP contracts or blended models of payment which incentivize efficient and appropriate care. Their contractual journey might help FPs with their own financial plight. In the end, this is all about money and resources. Is this a wise use of our limited health budgets? Is this a prudent use of our finite resources? Secondarily, it’s a bit about ego. Primary care physicians have felt beat down, underappreciated and undervalued. All this talk of NPs being the saving grace further undermines all their hard work and dedication. This hurts! Is it fair to blame NPs for all of FPs’ woes? There is so much of primary care that could be accomplished without FPs or NPs. Dare I say that MOAs, LPNs, RNs are underutilized in managing so much of the minor, non-acute issues that bog down primary care. Did I just say that? Out loud? There is a role for everyone in fixing our primary care crisis. These are my observations. Knowing I may be in for a firestorm, I remain open to all your comments. Dr. Ted Jablonski is a performing artist and writer who has retired his family practice to focus on sexual medicine and transgender health in Southern Alberta with two feet still on the front-line trenches of acute primary care.

The war between NP and FP?

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