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Project Salud

June 26, 2006 -- Recent Associated Press pieces have highlighted the growing roles nurse practitioners play in primary care in the United States. Today, the CNN site posted an unsigned AP piece headlined "The nurse is in: Nurse practitioners filling void in primary care." The Pennsylvania-based article explores how NPs have moved into a variety of primary care roles as fewer physicians have chosen to do so. One such role is that of nurse-midwives, whose care a May 11 AP piece examines. "Midwives offer women special deliveries" was posted on the Boston Globe site, and it focuses on Connecticut midwifery practices. The article, by Amanda Cuda, details some ways in which midwives' care of pregnant women differs from that of physicians. Both pieces give readers a sense of the growth in NP practice and some of the important benefits NPs provide, though both could have done more to explain how highly skilled NPs are, and the tangible effects their care has on patient outcomes, particularly for underserved populations.

The Pennsylvania piece marvels that "no one on staff at Project Salud is a doctor." That's because veteran NP Marguerite Harris and her staff at the Kennett Square clinic provide comprehensive primary care, from prenatal management to treating diabetes. The piece notes that NPs can perform "many" of the duties of primary care physicians, but fails to note which ones they supposedly can't perform. The piece goes into some of the standard information about the growth of NP practices, particularly nurse-managed primary care centers, of which there are now about 250 in the U.S.

The piece suggests that the growth in NP primary care practice is linked to the decline in physicians choosing primary care even as the baby boomers age--thus "the void" NPs are filling. NP Harris reportedly says that "[w]e've come a long way since the early days, the knockdown drag-outs with doctors who thought we were overstepping our roles." In fact, the American Medical Association continues to mount an aggressive legislative and public relations campaign to limit and undermine NP practice, efforts that are likely to intensify as the standard NP degree becomes a doctorate in coming years, which will obviously weaken the AMA's credentialist argument. And that's nothing compared to the attitudes of many physicians in the U.K., who appear to delight in suggesting that NP care resembles having flight attendants fly planes. Indeed, this piece itself makes clear that "some physicians' groups are concerned about the trend" toward expanded NP roles. It notes that the AMA opposes "full autonomy" for NPs, arguing that physicians should be "supervising" them at all times and in all settings. The piece quotes "Dr. Jan Towers, director of health policy for the American Academy of Nurse Practitioners," as suggesting that such physicians fear NPs will take their "revenue and business."

Towers says that "there's more than enough for everybody," and there certainly is a huge need for primary care. But it may be that physicians' financial concerns are not entirely unfounded. It's one thing for NPs to handle care for an overwhelmingly uninsured population--which Project Salud and countless other NPs have long done, though the piece fails to say so. But we expect it's quite another when the middle class starts getting some sense of NP care at Target or their suburban office parks. In this context, the AMA's intense campaign against NP care at "quick clinics" and its use of an "ex-nurse" physician to make unfounded attacks on NP care are easier to explain.

However, this piece commendably notes that a 2000 study in the Journal of the American Medical Association found that NP primary care was as good as that provided by physicians. The piece also explains that NPs--who typically charge less--have increasingly gained acceptance from insurers. And it closes with a quote from Tine Hansen-Turton, executive director of the National Nursing Centers Consortium:

One of the statistics that stands out is that we (nurse practitioners) see our patients twice as often as similar practices of physicians...Doing primary care well is the foundation for saving health care dollars -- working on improving health early instead of, for example, paying for coronary surgery and bypasses later.

The piece might have benefited from more detail on this point, perhaps making explicit what nurses do with the extra time they spend with patients (e.g., diagnostic probing, patient education), but this is still a pretty powerful statement--especially with no physician reaction.

The Connecticut AP piece focuses closely on how nurse-midwives care for prenatal and postpartum women. It suggests that expecting mom Pam Luise chose to use a certified nurse-midwife some years ago because she was afraid of needles and other hallmarks of standard invasive care. Luise wanted a more "natural" delivery, and she chose nurse-midwife Katy Despot. The piece stresses that CNMs "tend to focus on how pregnancy affects each woman physically and emotionally." Luise explains that Despot was so calm and reassuring at her delivery that she used no medication. Luise used Despot for further births without physician involvement. Another patient, Rhonda Simner, likes Despot's holistic, noninvasive approach, which allowed her to deliver naturally even though she was well past her due date. Simner also points to the continuity of care midwives provide during delivery. The piece explains that Despot is in practice with two OB-GYNs, and that patients have the option of seeing her, one of the physicians, or a combination, which tells readers that NPs can and do work collaboratively with physicians.

The Connecticut article also includes discussion of CNM care generally. It reports that CNMs attended over 300,000 births in the U.S. in 2001. And it quotes two CNM leaders, whose comments highlight some of the differences between CNM and physician care. The piece reports that Mary Ellen Rousseau, director of the Yale School of Nursing's "midwifery specialty" graduate program, says some women may prefer CNMs because their care is more personalized: "The biggest part is building a relationship with the women...The doctors are high-tech. We're low-tech, high-touch." We see the point, though suggesting that CNMs are "low-tech" may suggest that they are not so technically skilled, when in fact they typically have at least master's degrees. We know of nothing inconsistent between high-tech and a strong care relationship; the issue is when and how a care provider uses high-tech methods.

The piece also quotes Debbie Cibelli, co-owner of a local midwifery practice and former chair of the state's chapter of the American College of Midwives. Cibelli (like Tine Hansen-Turton in the Pennsylvania piece) points to the greater time nurse-midwives generally spend with patients: "Most [nurse-midwife] prenatal visits with patients are 15 to 20 minutes. Physician visits tend to be about five minutes." The piece also notes that nurse-midwives "spend a lot of time educating patients about the birth process," which enhances the relationship between midwife and patient.

Overall the piece offers a good account of the intangible or even emotional reasons a patient might choose a CNM. However, it could have said more about the tangible effects the CNM care model can have on patient outcomes and public health generally. To its credit, the piece reports that Pam Luise got through her delivery with no medication. But it does not explain that (assuming Luise was not simply gritting through excruciating pain) not using certain medications can actually improve the chances of a good outcome for mom and baby, as can avoiding invasive procedures like caesarian sections. In general, avoiding unnecessary interventions and high-tech procedures is often associating with better outcomes and cost savings. Moreover, the fact that the CNMs spend more time with patients and focus on education is not just nice. It can have a tremendous positive effect on patient outcomes. Lastly, in fairness, the piece might have sought physician comment on some of these points.

We commend the AP for these generally helpful pieces.

See the AP article on the CNN site "The nurse is in: Nurse practitioners filling void in primary care" (download) and the piece on the Boston Globe site "Midwives offer women special deliveries"

Also see more information about Project Salud.

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