I have been pondering the vigorous responses to what I thought was a pretty benign and sort of old news post about how advanced practice nurses can deliver high quality protocol-driven diabetes care.  I feel my job in this blog is to present data and to summarize how I think the data are to be applied to clinical practice.  Occasionally I rant about the shortcomings of the health care systems around the world when it comes to chronic disease especially when applied to diabetes.  And part of that rant is the payment systems that do not permit the rational building of multidisciplinary teams for the care of chronic diseases.

 At the risk of stirring up a hornets’ nest, I will try to put some perspective on the issues raised both by the respondents to the post and the general issue of the role of advanced practice nurses within the health care system.  Let me begin by pointing out that since barbers competed with surgeons, the borders of medical practice have been porous and physicians have always had competition: oral surgeons versus maxillary-facial surgeons, psychologists versus psychiatrists, and podiatrists versus orthopedic surgeons, to mention a few current ones.   Even within the profession, there are strong feelings about who should be doing what: back surgery by neurosurgeons or orthopedic surgeons, percutaneous vascular interventions by radiologists or cardiologists, as examples.

 So it is no surprise that the advent of advanced practice nurses has ignited controversy since its inception in 1965.  Advanced practice nurses evolved because market forces could not provide primary care to underserved individuals especially inner city and rural areas.  The vast majority of advanced practice nurses work in community health centers alongside primary care physicians.  These centers deliver care to the underserved that the fee-for-service market has been unable to serve.    

And the science is there.  There are literally hundreds of articles that demonstrate advance practice nurses can deliver high-quality care especially in the primary care setting in conjunction with primary care physicians. 

 Nurse anesthetists evolved because there were not enough anesthesiologists willing to staff small rural hospitals.  One post suggests that there are issues of competition and quality between nurse anesthetists and anesthesiologists. Regarding financial competition the median income of US anesthesiologists is over $335,000, that of nurse anesthetists less than $100,000 or about $28,000/year above the average outpatient nurse’s salary.

 If one asserts that the quality of care delivered by nurse anesthetists is inferior to that delivered by anesthesiologists or is only equivalent when they are under physician supervision, then there is an obligation to present data to demonstrate that fact.  I have no experience in this area, but I was unable to find data to support that contention.  In fact, there are considerable data that support nurse anesthetists’ outcomes are not inferior to anesthesiologists’ under the circumstances that they practice in  Please see the websites summarizing data listed below:

Nurse anesthetists’ outcomes

http://content.healthaffairs.org/content/29/8/1469.abstract

Nurse anesthetist salaries

http://www1.salary.com/Certified-Nurse-Anesthetist-Salary.html

Anesthesiologist’s income

http://www1.salary.com/anesthesiologist-Salary.html

Nurse anesthetist’s legal issues

http://www.aana.com/aboutus/Documents/legalissuesnap.pdf

 A couple of posts suggested that the data on the effectiveness of advanced nurse practitioners could be biased because the journals that published the data or that the environment of their practices was limited.  Here are two articles that seem, at least to me, objectify the data on the outcomes achieved by advanced practice nurses.  One is from the nursing literature and one from the Agency for Health Care Research and Quality (“AHRQ”) within the US Department of Health and Human Services:

 Systemic review of advanced practice nurse outcomes

https://www.nursingeconomics.net/ce/2013/article3001021.pdf

Chapter reviewing advanced practice nurse articles for AHRQ

http://www.ahrq.gov/qual/nurseshdbk/docs/O'GradyE_APRN.pdf

 There is no question that the complex nature of modern medical practice requires a mixture of talents and training.  Not my favorite President, Ronald Regan, had on his desk a sign that said: “It is amazing what you can accomplish when you do not care who gets the credit.”  About sixty per cent of primary care practices involve chronic diseases that are excellent candidates for protocol-driven care.  This leaves the physician to supervise those patients that require his or her special training and skills.

 Patients are increasingly being called upon to be active in self-care from diabetes or blood pressure monitoring to measuring their INRs at home.  Self-care involves time, talents and skills that are more generally found on the nursing side of medical care rather than the physicians’ side.  All in all well-coordinated teams of varying configurations will deliver the best primary care.

http://www.ndep.nih.gov/media/teamcare.pdf

Well taken.  Your concerns about administrators substituting lesser-trained personnel to save money must be addressed by clear quality measure. I also worry about "guilds".  Whether they are made up of associations of advanced practice nurses, nurse anesthetists or of anesthesiologists, their goals to promote their members can conflict with the interests of the patients and they promote “parallel play” rather than truly functioning teams.  The Institute of Medicine has recommended joint educational experiences among medical, nursing and other health professional students in order that they may gain experience working together and learning each other’s strengths and abilities.  As a medical educator I see practical limitations in achieving this goal given the differences in the duration of training involved.

I am actually more in favor of the type of communication training now used extensively in the airline industry.  Their studies suggested that a significant number of accidents and near misses were the result of undue reticence by others in the cockpit to question the captain’s decision.  Improving this communication is now part of their training including in simulations.  Similar observations have been reported among surgery teams and efforts have been made in the training of surgical teams to improved communication.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1877003/