Can, Should, or Will NPs Replace Primary Care Physicians?

Article Outline

• Support for NPs Replacing PCPs
• Rationale Against NPs Replacing PCPs
• Copyright

Erin J. Bagshaw, RN, MSN, CANP, is the president of Northwest Nurse Practitioner Associates, Inc, in Washington, DC. The practice opened in 2004 and is the first NP-owned and -operated practice in Washington, DC, as well as the first NP practice to be granted staff privileges at Sibley Memorial Hospital. She is past president of the Nurse Practitioner Association of DC, recipient of the 2007 State Award for Excellence in Care and Contribution in Practice from AANP, and sits on the APRN committee for the DC Board of Nursing.

Sharon P. O'Neill, JD, MSN, CRNP, is a pediatric and family nurse practitioner, attorney, and an assistant professor at the Johns Hopkins University School of Nursing. She coordinates the family nurse practitioner program at Johns Hopkins, lectures on nursing practice and the law, and works part-time as a PNP in the International Adoption and Development Clinic and as an attorney in the Office of Professional and Regulatory Affairs at the Kennedy Krieger Institute in Baltimore. She also is a student in the doctor of nursing practice program at the Catholic University of America.

It has been said that the U.S. primary care system is on the verge of collapse. A recent survey indicates that less than 2% of medical students are choosing to go into primary care. More physicians are refusing to accept Medicare patients as a result of inadequate reimbursement. All of this is happening within the context of an aging population, unprecedented numbers of chronically ill, and a nursing shortage.

As the nation ponders a fix for this broken system, the role of the primary care nurse practitioner (NP) has come to the forefront. Are NPs part of the solution, or are they the whole solution?

Back to Article Outline

Support for NPs Replacing PCPs 

Erin J. Bagshaw

As a primary care provider who solely takes care of 3000 patients (and growing), I think the “can” part of this question has been answered. I believe there are now more than 10,000 NPs practicing independently, as well as countless others who, although they may work with a physician counterpart, are often left to run the practice solo. To say differently at this juncture is like trying to catch a plane that already took off.

The “should” part to me has always been like a dance. The dance goes like this: Step one, explain what we do, highlighting our strengths without insinuating that we are better than any other providers. Step two, show confidence in our decisions and be perfectly willing to discuss supporting medical evidence and know that we will be questioned. Step three, turn around and promote the uniqueness of what makes the NP the perfect storm as a primary care provider.

We carry with us two parts into the room, the advocate/nurse and the diagnostician/NP. Patients recognize both a difference and a similarity at the same time. We are great at our roles, studies prove it, the law supports it, and patients returning to our care maintain it.

The “will” part rests in the hands of the patient, the health care system, and the way we as a profession position ourselves within this tide. I, like many of you, know many wonderful physicians; I also know some who do not practice within the standard of care and are never questioned. Do I think the physician PCP will go away? Probably not, and that is OK by me; it doesn't need to be an either/or situation. I just want to be included and recognized for the care I provide—and keep dancing.

Back to Article Outline

Rationale Against NPs Replacing PCPs 

Sharon P. O'Neill

NPs cannot, should not, and will not replace primary care physicians. Support for the contrary view puts NPs in direct conflict with physician groups that do not understand the NP role and fuels arguments that NPs need to function under practice agreements that define scope of practice with physician input. In the primary care setting, the NP focuses on physical/psychosocial assessment, and managing acute minor illness and chronic illness. At times, competent management of acute clinical problems and complex patients requires consultation with primary care and specialist physician colleagues, because the NP recognizes scope of practice issues and wants to minimize malpractice exposure.

NPs bring to primary care a holistic approach that includes health maintenance, disease prevention, and health promotion, which are the hallmarks of nursing. This is nursing's strength (and not necessarily the strength of physicians) and the greatest contribution to interdisciplinary patient care. NPs are not trained to be physicians. The 500-hour clinical practice requirements for NP certification does not compare to education and residency requirements for physicians. While the current push toward the doctorate in nursing practice (DNP) increases practicum experience, it does not completely resolve the experience and educational gap from a medical model point of view. The same holds true for the recent unilateral decision that NP graduates of DNP programs need to prove competence by taking portions of the medical boards.

Both NPs and physicians need to find common ground for managing the primary care needs across the health care spectrum. The patient benefits from the strengths of both NPs and physicians. Neither group can address problems in our nation's health care system in isolation, believing that they can, should, or will become the sole provider of primary care.