Editor's Note: This article originally appeared in Duke Nursing magazine
Durham, NC - In January 2003, newly minted nurse practitioner Kathy Patterson, MSN'02, joined Yanceyville Family Practice, a humble one-physician office smack in the middle of rural Caswell County, N.C.
Patterson and Brett Williams, MD, a longtime health care provider to the small town of Yanceyville, served close to 3,000 patients from around the agriculture-based county and neighboring southern Virginia.
"We saw four generations of single families says Patterson.
The practice served as a medical home to many. The duo pulled together rich and detailed family medical histories and provided diagnosis, treatment, disease management, and health education to a population that had few health care options.
When Williams retired for health reasons in 2006, the Burlington-based community hospital that owned the practice wasn't able to find a family physician to replace him and decided to close the practice.
"I was told I was going to be laid off in six weeks," says Patterson. "I said, 'You can't do that to our patients. We're the only private practice in the county.'"
The community wasn't happy about it either. Patients called the hospital to complain and wrote letters and petitions asking that the practice be kept open. Patterson negotiated with the hospital to keep the practice open for six more months while she worked with a consultant, attorney, and insurer to buy it from the hospital.
Without missing a beat in patient care, Patterson took ownership on March 31, 2007, renamed it Yanceyville Primary Care, and has been growing the practice ever since.
"We fill a very big need," she says. "People come to me because I'm an NP and the type of care NPs provide."
Health Care's Changing Face
Patterson represents a changing face of health care in which nurse practitioners (NPs) are playing increasingly crucial roles as leaders on the front lines of primary care. They're opening their own practices in rural areas where physicians are few, and giving residents of more populated cities an alternative to MD-run practices, often at a lower cost.
An additional 40 million people are expected to have health insurance beginning in 2014 when the Affordable Care Act is further implemented; the first of the baby boomer generation reached retirement age last year; and no help is in sight to relieve the national shortage of family physicians. A growing number of nurse practitioners are stepping in to help. In fact, the Affordable Care Act provides funding for nurse-managed primary care clinics and promotes the full participation of nurse practitioners as key care providers.
"We don't have enough people or money to care for the growing and aging population with traditional models of health care," says Lloyd Michener, MD, professor and chair of the Duke Department of Community and Family Medicine. "We need to design a workforce that draws on all available fields to their fullest abilities. Having nurses involved with primary care is very important."
Nurse Practitioners provide many of the same functions as physicians, including diagnosing and managing acute and chronic illness, prescribing medications, and interpreting tests and lab work. Advocates say that having NPs treat patients with less complicated health issues frees up physicians to spend more time with the sickest patients.
About thirty-five states currently allow NPs to work independently without physician oversight. The remaining states vary in what they require for physician input. North Carolina requires NPs to maintain a collaborative relationship with a supervising physician, although it requires them to meet face-to-face just once every six months. Patterson's collaborating physician is Janet Lehr, MD, a family physician in Durham.
"We collaborate on cases as needed by phone and fax," says Patterson. "She doesn't come on site."
The American Academy of Nurse Practitioners says organizations including AARP, the CATO Institute, and the Brookings Institution are advocating for the removal of restrictive regulations regarding NPs.
Not so fast, say some in the medical community, who argue that nurse practitioners—who are trained at the masters degree level—are not adequately prepared to treat patients without physician oversight.
While citing the value of nurses in health care, the American Medical Association said in an October 2010 statement that "increasing the responsibility of nurses is not the answer to the physician shortage. Physicians have seven or more years of postgraduate education and more than 10,000 hours of clinical experience. These additional years of physician education and training are vital to optimal patient care."
Michener points out that, "NPs are not doctors and never claim to be. Nurse practitioners bring a family and whole-person view to health care and help meet patient and community need."
Some MDs Fear Competition
Jolyn Fergon, DNP-current, learned in 2003 the extent to which some physicians will go to prevent nurse practitioners from opening competing practices.
She had worked for several years as an NP in an OB-GYN practice in affluent Palm Springs, Calif., population about 45,000, when she announced she would be opening her own women's health care practice. Under California law, she was not required to have any physician oversight.
The outcry from the OB-GYN community was fierce, she says.
"It was a rough couple of years," says Fergon. She added that a group of OB-GYNs—including her former boss complained to the state medical board that she was not qualified to run a practice without physician supervision. The state investigated the practice but found nothing out of order.
"We also were grilled by Medicare and Medicaid who wanted all of our tax returns and bylaws," she says. "That first year cost me nearly $20,000 in legal fees."
Every investigation came up clean, yet the opposition continued, says Fergon "as they tried to run me out of town."
When she hired an OB-GYN to satisfy some in the medical community who insisted there be a physician on staff, others claimed it was illegal to have an NP employ a physician.
Fergon won that battle too, and today her Advanced Women's Health Care practice employs three MDs, several nurse practitioners, and several certified nurse midwives for what has grown into a three-office practice, including an office in an underserved community in Yucca Valley.
"They finally got tired of fighting me," says Fergon. "We do the most deliveries by far in the area, and the three physicians who gave me the most grief have moved on."
Fergon says one factor that has allowed her practice to flourish is that "we spend a lot of time with our patients. If a practice is too big, you don't know the patients, and the patients don't know you.
"I love running my own practice," she adds. "My family has been amazingly supportive through all of this."
Welcomed With Open Arms
Competition was far from the case in Oak City, N.C., population about 400, in rural Martin County. Elizabeth Lum Huston, FNP'11, was welcomed with open arms at The Oak City Community Clinic which the town opened in October with a $56,000 grant from The Golden Leaf Foundation. The clinic is a satellite office of the three-county Martin-Tyrrell-Washington District Health Department.
"In Martin County they don't even have an MD in the system," says Huston. "Doctors just don't stay in this area."
In fact, there are just five medical doctors in the three-county area. Huston's consulting physician is a private-practice physician in Williamston, about 15 miles away. North Carolina regulations require that Huston meet with him once a month for the first six months and that he review a minimum of 10 cases. After that, Huston is required to meet with him face-to-face just once every six months. She says she consults with him by phone and fax on a regular basis.
The clinic is open on Thursdays and is staffed by Huston, a registered nurse, and a clerk. It provides full primary care services, and Huston can provide referrals for services not available at the clinic. For the rest of the workweek, Huston provides care at the county health department clinic in Williamston.
According to a recent health assessment, the infant mortality rate in Martin County is the second worst in the state, and Oak City's obesity rate is 58 percent. Diabetes, hypertension, kidney problems, and other chronic diseases are common in this farming community.
"I am doing a lot of outreach on my own time and letting the Oak City community know I'm here for them," says Huston. "I really want to bring everything to bear that I learned at Duke to improve the health of my community, and I think in two to three years I'll have tangible data. I love working in rural areas." She sees 20 to 30 patients a day.
Huston says nurse practitioners play a vital role in health care because "we're taking care of patients that MDs don't want to, or have time to take care of. Doctors are leaving primary care in droves and we're moving into these positions."
To help alleviate the tension that sometimes exists between NPs and MDs, Huston says "We need to sell ourselves better. Many people don't really know what nurse practitioners are or the role we can play. We are different because many of us have 20 years of clinical experience at the bedside."
Says Michener, "Too often the mutual respect that exists between nurses and doctors gets lost in the discussion about practice. All are talented professionals working on behalf of patients. We need to teach that and exemplify that."