What role should nurse practitioners play in fixing healthcare?

A recent look at some of the news stories around health care do not paint a pretty picture for Family Medicine. In Ottawa, a truly wonderful 41-year-old Family Physician (whom I had the pleasure of meeting when I was OMA President) is closing her family practice due to burn out. The BC government is on the defensive over the shortage of Family Physicians. Medical School graduates are avoiding Family Medicine. The list goes depressingly on, but the point is clear. Family Medicine is in crisis. Jumping into this environment is former Ontario Deputy Health Minister Bob Bell and his colleagues. To fix Family Practice, they recommend expanded use of Nurse Practitioners (NPs), allowing them to work independently to replace much of what family doctors do. They claim that NPs can independently provide care for rosters of 800 patients, and collaborate with Family Doctors only for more complex patients. The authors reference a British Medical Journal (BMJ) study that suggests this will be “cost-saving.” Read: Dr. Gandhi: Corporatization of medicine continues unabated Bell doubles down on his beliefs that NPs can replace family doctors on Twitter by cherry picking data, in this case a Cochrane review: "Cochrane Library study identified 18 randomised trials evaluating impact of nurses as substitutes for doctors. Findings suggest care delivered by nurses, compared to care by doctors, probably generates similar or better health outcomes." One wonders if Bell and his colleagues bothered to read the reviews. If they had, they would have seen that the BMJ study on “cost-effectiveness” admitted: “…it was not possible to draw conclusions about the cost-effectiveness of the complementary provider specialized ambulatory care role of nurse practitioners because of the generally low quality of evidence.“ For those of you not versed in medical literature those phrases are the author’s way of saying they did studies where the results couldn’t be relied upon to be reproducible. Using these to promote a belief that allowing NPs to work independently to replace family docs is…puzzling. Bell’s belief that Family Docs are easily replaceable is nothing new. He planned on actually ending his career as a general practitioner. Apparently he thought he could easily slide back into it after having done it for a couple of years early in his career, then gone on be an orthopedic surgeon for another few decades before getting involved in health administration and the MOH. Read: Dr. Gandhi: COVID is not over and it won't ever be In South Mississippi, the Hattiesburg Medical Clinic, an Accountable Care Organization that is very similar in structure to the proposed Ontario Health Teams (OHTs), did exactly what is Bell and his colleagues are proposing. Fifteen years ago, based on ongoing shortages in Family Physicians, NPs and Physician Assistants (collectively referred to as Advanced Practice Providers or APPs) were hired and allowed to work separately and independently with physician colleagues. Did this work? In a word: Nope. A comprehensive analysis of their findings (minimum of 11 years of data over a large patient population) was published in the Journal of the Mississippi State Medical Association. You can read the details for yourself but here are some highlights: the cost for looking after patients who did not have end stage renal disease (i.e. were on dialysis) or were not in nursing homes was $43 a month higher per patient for those who were looked after by APPs than family docs when the data was adjusted for complex patients, the cost of having an APP look after them, rather than a family doc was $119 per month higher (!) these costs were attributed to ordering more tests/more referrals to specialists and MORE emergency department use (yes MORE) physicians performed better on nine out of 10 quality metrics in the review In short, doing what Bell and his colleagues are suggesting led to poorer overall health care outcomes at an increased cost. Now to be completely clear, I personally have worked with NPs in a number of ways. I strongly believe they are an essential part of the healthcare team and provide a valuable service. In my practice, they have assisted me in providing care to my patients. When I had a couple of “cardiac kids” in my practice, I dealt exclusively with the NPs on the cardiology team at the Hospital for Sick Children (never once spoke to a Cardiologist or Cardiovascular Surgeon). When the Royal Victoria Hospital in Barrie had NPs on their oncology service, I discussed issues around cases with them exclusively. The NPs were at all times incredibly helpful to me and my patients. NPs definitely have a role to play. I would also point out that the Hattiesburg Medical Clinic feels the same way. They strongly valued their NPs, and still have them on staff. But they have modified the way they provide care to ensure that all patients now have a Family Doctor but the visits to the clinic now alternate between the Doctor and the APP. On days when only an APP is in house, telemedicine back up by physicians is provided. We need to build a better Family Practice system. In order to do so, NPs can and should play an essential role. That role however, is not taking on independent rosters of patients. It is working as valued members of a team that looks after a patient population, where each patient has a Family Doctor. Dr. Sohail Gandhi is a former president of the OMA and opinions are his and not necessarily the opinions of the OMA Board. This article is a reprint from his blog site: justanoldcountrydoctor.com. Read: Dr. Gandhi: Crisis at Trillium Health Partners demands an intervention

What role should nurse practitioners play in fixing healthcare?

Register for free access or login.

Related Topics