Examining the growing nurse practitioner role in health care

Nurse practitioner Christopher Galloway examines Elizabeth Hug last month at Elemental Care Center in Crest Hill, Ill.

Elizabeth Hug had a choice: wait months to see a doctor to treat her fibromyalgia or visit a nurse practitioner in the same office immediately.

She decided sooner was better than later. She liked the nurse practitioner, Christopher Galloway, so much that she continued to see him, even when he went into private practice in Crest Hill, Ill. He was caring, accessible and a good listener, she said.

Hug, her husband and two teenage children now visit Galloway regularly — instead of a primary care doctor.

“It’s kind of a different experience,” Hug said. “They just seem to know how to talk to people differently.”

It’s an experience that’s becoming increasingly common, as the number of nurse practitioners in Illinois skyrockets, and some begin to work independently of doctors under licenses that became available in June. More nurse practitioners can mean more access to care amid a national shortage of primary care physicians. Nurse practitioners can handle many of patients’ most common complaints, but at a lower cost, their supporters say.

But the profession’s growth has come with controversy. Some doctors’ groups are concerned medical providers are using nurse practitioners to cut costs at the expense of patient care. Nurse practitioners, they say, are not as well trained as doctors to identify certain conditions and may miss important red flags. And they’re particularly troubled that some who’ve earned their doctorate degrees in nursing practice use the title “doctor,” which could be confusing for patients.

A growing field

Illinois has more than 12,000 nurse practitioners, up nearly three-fold from 2012. Nurse practitioners are a type of advanced practice registered nurse, which are nurses with additional training, education and certification. They’ve long been providers at many urgent care clinics, but increasingly are showing up in primary care, specialty practices and hospitals. More than 400 Illinois advanced practice registered nurses have licenses to practice independently of doctors under a state law passed in 2017.

After becoming registered nurses, nurse practitioners must have master’s degrees in nursing and at least 500 direct patient care hours to be nationally certified. Medical doctors complete four years of medical school and spend at least three years getting hands-on experience as residents, while some specialists do more.

Nurse practitioners, nurse anesthetists and nurse midwives — which are all types of advanced practice registered nurses — earned a median of $113,930 a year in 2018, according to the Bureau of Labor Statistics. Doctors and surgeons earned a median of $208,000 a year.

In 2017, Illinois Gov. Bruce Rauner signed a bill allowing Illinois nurse practitioners who meet certain requirements to work without a formal relationship with a doctor. They can’t prescribe certain medications, such as opioids, without a doctor, and they can’t sign death certificates.

Twenty-two states allow nurse practitioners to work with total independence from doctors in their own practices, and 16 states, including Illinois, allow independence with some restrictions, according to the American Association of Nurse Practitioners.

To practice without an agreement with a physician in Illinois, advanced practice registered nurses must have an additional 250 hours of continuing education and at least 4,000 hours of clinical experience after attaining national certification.

The American Medical Association opposes legislation to allow nurse practitioners to work independently, saying in a statement they’re “valuable members” of physician-led health care teams, but “not a substitute for physicians.”

“Patients’ best interests are optimally served when they are treated in a physician-led team-based model of care,” the association said.

Displacing doctors

Nurse practitioners are taking on roles doctors have filled in the past. For example, Edward-Elmhurst Health in the western suburbs decided in November to lay off about 15 of its urgent care doctors and instead use nurse practitioners, sources said.

Edward-Elmhurst Spokesman Keith Hartenberger said in a statement any advanced practice clinicians, such as nurse practitioners, will work under a doctor’s supervision. He declined to confirm the number of people affected, but said the decision to “move to a team model” was driven by “feedback from our patients that they are looking for a lower-cost alternative for walk-in care.”

Most of the care provided at Edward-Elmhurst’s immediate care clinics is for low-level conditions such as sore throats, earaches and urinary tract infections, Hartenberger said.

“These visits are well within the scope of an advanced practice clinician’s license, and this model is being used by other centers throughout the nation,” he said.

Edward-Elmhurst is working with those affected by the change to find “alternative placement,” Hartenberger said.

Putting patients at risk?

Physicians for Patient Protection, a national group that advocates for physician-led care, has criticized Edward-Elmhurst’s plans, saying they’re emblematic of a bigger problem.

Health systems “see these nurse practitioners and physicians assistants as a cheaper labor force and have totally disregarded patient safety in the name of saving dollars,” said Dr. Amy Judice Townsend, a board member of Physicians for Patient Protection, who practices in Texas. “There are a lot of things that come in that are routine, but some things … you have to have clinical experience to recognize it’s not something that’s just run-of-the-mill.”

A 2014 study published in the journal JAMA Internal Medicine found advanced practice clinicians ordered more medical imaging tests for patients than primary care doctors.

Chicago doctor Amber Price, who has her own practice, Willow Pediatrics and Lactation, said she has seen patients who were misdiagnosed by nurse practitioners. One child she saw early in her career had a serious problem that required hospitalization, but had been diagnosed with pink eye by a nurse practitioner, she said.

“Doctors make mistakes, but we don’t miss obvious things,” said Price, who is a member of Physicians for Patient Protection.

Doctors groups have similar concerns about physicians assistants, who perform many of the same tasks as nurse practitioners but have different training and education. But there are far fewer physicians assistants in Illinois than nurse practitioners — about 3,700. Physicians assistants’education is modeled on medical school curriculum, while nurse practitioners’ education is in nursing.

What’s in a title?

Physicians for Patient Protection also worries about confusion caused by nurse practitioners who use the title “doctor” because they’ve earned doctorates in nursing practice. Though the title is technically correct, some physicians worry patients will assume all who use it are medical doctors.

“It’s deceptive to patients,” Townsend said. “Patients, when they’re introduced to someone as a doctor in a clinical setting, are assuming the knowledge base is in clinical practice and that’s not the case.”

It’s a issue that could become more prevalent, now that the National Organization of Nurse Practitioner Faculties, which acts as a resource for nurse practitioner education programs, wants to see all nurse practitioner programs offer doctorates of nursing practice by 2025.

Nurse practitioners point out that the initials after their names show their credentials, such as APRN, and Illinois law requires those who use the title doctor to “clearly state” they’re not medical doctors. The law also prohibits advanced practice registered nurses from using the titles “doctor” or “physician” in advertising.

Galloway, the Crest Hill nurse practitioner who’s been treating Hug for years, said he uses the title “Dr.” because, like medical doctors and many professors, he earned the highest degree in his field. If anything, he said, medical doctors should be called physicians, not doctors, to clear up any confusion.

Affordable option in shortage

Nurse practitioners say fears about the quality of care they provide are unfounded.

“Nurse practitioners have been providing care for over 50 years, and we’ve got 50 years of data that reinforces the fact that nurse practitioners are educated and trained to provide the care in these settings,” said Sophia Thomas, president of the American Association of Nurse Practitioners.

When advanced practice nurses are involved in emergency and critical care, patients have shorter stays, shorter waits for consultation or treatment and improved mortality rates, satisfaction and cost savings, according to a 2017 review of 15 studies published in Human Resources for Health. A 2014 study in the journal Nursing Outlook found states that allow nurse practitioners to practice without a doctor’s supervision have lower hospitalization rates and better health outcomes.

Nurse practitioners also are often the most viable option for patients because of the shortage of doctors, Thomas said. As Baby Boomers age, the U.S. is expected to see a shortage of between 21,100 and 55,200 primary care doctors by 2032, according to the Association of American Medical Colleges.

There still are far more doctors in the U.S. than advanced practice registered nurses — 756,800 compared with 240,700 nurse anesthetists, nurse midwives and nurse practitioners in 2018, according to the Bureau of Labor Statistics.

But the number of advanced practice nursing jobs is expected to grow 26 percent from 2018-28 — much faster than the average growth rate of 7 percent for doctors, according to the bureau.

Many people decide to become nurse practitioners instead of doctors because they’re already registered nurses who want to build on their educations rather than start over, because they’re attracted to nursing, or because going to medical school takes longer and costs more than earning a master’s degree in nursing, said Susan Swart, executive director of the Illinois Society for Advanced Practice Nursing.

“Physicians understandably are concerned about this change, but I think the reality is it is a supply and demand issue,” said Hazel Seabrook, a managing director at consulting firm Huron, who has worked as a nurse. “There aren’t going to be enough primary care physicians or physicians, period, in the coming years, so what do we do as a health care system to plug the gap?”

About 19 percent of consumers surveyed said they had trouble scheduling a new patient visit with a primary care physician in the last year, according to a national survey of 1,500 people conducted last year by the Texas Medical Center Health Policy Institute. City dwellers had a tougher time, with 32 percent saying they had trouble scheduling an appointment, though that may have had to do with insurance issues rather than a shortage of doctors.

Providers who rely on nurse practitioners also are reacting to cost pressures, Swart said.

“Everybody is challenged to provide the best care they can at the best cost savings,” Swart said. “If they have the ability to free up physicians to provide care for more complex patients, then utilizing an advanced practice registered nurse in those voids makes a lot of sense.”

The lower cost of nurse practitioners is part of the reason Midwest Express Clinic relies heavily on them at its 17 locations in Illinois and Indiana, said Kaitlyn Steinberg, director of clinical operations at the company and a family nurse practitioner. Midwest Express has physicians at a few of its locations.

“We’re able to provide more affordable prices for our patients without sacrificing the quality of care,” Steinberg said.

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