Addressing the Shortage of Primary Care Providers
Linda H. Aiken, PhD, FAAN, FRCN, RN, is the Claire M. Fagin Leadership Professor in Nursing, a professor of sociology, and director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing. She conducts research on the health care workforce and quality of health care in the U.S. and globally. Aiken is a research manager supporting the Future of Nursing: Campaign for Action and a National Advisory Committee member for the Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative.
The May 16, 2013 issue of the New England Journal of Medicine features two very different examples of policy analysis on the important issue of the primary care workforce, plus a thoughtful editorial. John Iglehart, a national correspondent for the Journal and a widely acknowledged neutral and astute observer and reporter of contemporary health care, wrote an immensely valuable synthesis and integration of research and published professional opinion on the risks and rewards of expanding the role of nurse practitioners to address the perceived national shortage of primary care. Iglehart organized succinctly the themes and sources of agreement and disagreement emerging from a comprehensive review of 62 published research papers, policy reports, and professional and stakeholder opinions and positions.
In contrast, the second article by usually thoughtful polling enthusiasts seems off the mark and of questionable usefulness. How surprising is it that two-thirds of a very small sample of U.S. primary care physicians agree with the statement that primary care physicians provide a higher quality examination and consultation than nurse practitioners? Is this an example of cognitive dissonance? Nurse practitioners who are required to have a minimum of a Master’s degree have as many years of education as primary care physicians in many peer countries with better health outcomes than the U.S., which must be disconcerting to some U.S. primary care doctors.
The authors of the polling paper and accompanying editorial suggest that this negative response from primary care doctors is important evidence that expanded roles for nurses in primary care will not happen. However, it can just as easily be argued that fully one-third of physician respondents apparently disagree that their care is of higher quality than that of nurses and 40 percent of the physicians polled practice with and presumably have confidence in nurse practitioners—a pretty significant minority that could tip over into a majority in the relatively near future. Iglehart cites the research literature that overwhelmingly concludes that primary care by advanced practice nurses (APRNs) is safe. Indeed, I follow this literature closely and don’t remember a single study out of hundreds showing that patients were adversely affected by receiving primary care from APRNs.
Do we care that some primary care physicians express negative sentiments about expanded roles for nurses? After all, 16 states and D.C. have already granted full legal scope of practice to APRNs, and the National Governors Association is recommending expanded scope of practice in other states to address access and cost issues. Business interests, as evidenced by the rapid growth of retail clinics staffed largely by APRNs, are betting that any public debate over the quality of APRN care has been resolved. And most importantly, consumers are voting with their feet by choosing care by APRNs in large numbers and in a variety of settings. The editorial rightly questions whether it would have been more useful to hear from consumers than from physicians as the nation moves forward to bolster access to primary care.
However, we should care about the publication of simplistic polls about complex issues, especially in legitimate scientific journals and especially polls of physicians who may be perceived by some consumers as trusted authorities because of the potential for scaring some consumers by the equivalent of yelling fire when there is not one.
Funders should resist trying to get cheap, quick answers to complex questions, and be more open to supporting rigorous research, especially now that federal sources of support for health services research on health outcomes of workforce composition are almost non-existent. There is no comparison at all in the value of the poll in the May 2013 issue to empirical research papers published in the Journal, for example by Druss and colleagues using the National Medical Expenditure Panel Survey providing national estimates of the use of health services for the U.S. population to document that a growing proportion of patients—already a third of patients by 1997—making ambulatory visits annually to non-physician providers. Or my paper published by the Journal in 1979 (Aiken LH et al., 1979. The contribution of specialists to the delivery of primary care. N Engl J Med 300:1363-1370) reporting on the results of 3-day diary information from a national sample of 10,000 physicians and more than 400,000 patient encounters showing convincingly that the primary care crisis of the time was overstated because one in five Americans was getting primary care from a specialist physician and patient satisfaction was high.
Health services research, as embattled as it is because of lack of funding, remains the mainstay of good decision-making about the national health care workforce.