Doctor shortage fuels nurse practitioners' push for bigger role

Nurse practitioners - like Irene Cavall in North Carolina - are gaining support in their drive to play a larger primary care role.
Nurse practitioners - like Irene Cavall in North Carolina - are gaining support in their drive to play a larger primary care role. Ron Vick/Kaiser Health News/MCT

TYRRELL COUNTY, N.C. — There are no doctors in rural Tyrrell County, N.C. There's only Irene Cavall, a licensed nurse practitioner and the sole source of primary care for 4,000 residents spread out over 600 square miles.

It's been that way since the county's lone doctor moved away two and a half years ago. Cavall sees as many as 40 patients a day at the Columbia Medical Center. It's about 40 miles west of the Outer Banks; an ambulance ride to the nearest hospital takes 25 minutes.

There are limitations to her work. By state law, she works under the supervision of a doctor, albeit one many miles away, and calls him and specialists as needed. For 15 years, however, Cavall has been helping patients with a range of routine problems — from colds to management of diabetes — that don't always require a doctor. As she said, doctors "don't need to give someone a Tylenol."

Nursing leaders say that large numbers of practitioners such as Cavall will be needed to fill gaps in primary care left by an increasing shortage of doctors, a problem that would intensify if Congress extends health insurance to millions more Americans. Advocates say that nurse practitioners have the extra education and training needed to perform a variety of services, including physical exams, diagnosis and treatment of common ailments and prescribing drugs.

However, the American Medical Association and doctors' groups at the state level have been urging state legislators and licensing authorities to move cautiously, arguing that patient care could be compromised.

This battle has been waged for years, even as nurse practitioners grew rapidly in number — there are 125,000 or more — and expanded their responsibilities. What's different now is the increasing conflict as pressure grows to use nurse practitioners and other so-called physician extenders, including physician assistants, certified nurse midwives and pharmacists. The Association of American Medical Colleges estimates that there will be a shortfall of as many as 46,000 primary care doctors by 2025.

The AMA sparked harsh criticism from nursing groups when it released a report in October bluntly questioning whether nurse practitioners "are adequately trained to provide appropriate care." To back up its claims, the report cited recent studies that questioned the prescription methods of some nurse practitioners, as well as a survey that found that only 10 percent of the nurse practitioners questioned felt well-prepared to practice primary care.

The nation's largest doctors' group concluded: "The time is ripe for legislators, health care policy analysts and nurses to thoroughly assess the quality of NP training in relation to the scope-of-practice expansions sought at the state level."

The American Nurses Association and more than two dozen other nurses' organizations termed the AMA report misleading, saying in a letter in December that it "contains numerous factual misrepresentations." They rebuked the AMA for its "attempt to change the perceptions of NP practice as anything other than fully qualified professionals working within a legally established scope of practice."

Fueling the debate, the nonpartisan Brookings Institution's Engelberg Center for Health Care Reform issued a report in September by 10 experts that said one way to curb health care spending was to encourage states to permit "greater use of nurse practitioners, pharmacists, physician assistants and community health workers."

Nurse practitioners started out decades ago under the close supervision of physicians, with tight restrictions on what they could do, but they've successfully pushed state licensing agencies and legislatures to grant them more autonomy and broader duties. The AMA report said, for example, "all states now allow NPs some degree of prescribing privileges," and 12 have granted them authority to prescribe independent of doctor oversight.

Several states are considering laws to restrict or expand nurses' scope of practice. For example, in Colorado, one bill would allow nurse practitioners in addition to physicians to issue medical orders that direct patients' care at any facility. Another bill there would eliminate a nurse's right to declare a patient terminally ill.

Most states require nurse practitioners to obtain masters' degrees in nursing, but education and training requirements vary. Cavall, 60, has a master's, and she was a registered nurse for several years before she became a nurse practitioner.

She feels very qualified to take care of patients in Tyrrell County. "If you come from a background where you've seen just about everything, that gives you a really good basis for ... delivering that care," she said.

(Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization that isn't affiliated with Kaiser Permanente.)


Coverage of the nation's health-care debate


Side-by-side comparison of health care bills

Letter to Congress from Families USA

A survey on individual health insurance


Kaiser Health News on McClatchy

1:19 a.m.: Senate Dems win key 60-40 vote on health care

Health bills would raise taxes well before changes roll out

Check out McClatchy's politics blog: Planet Washington