COMMENTARY

Improving Family Medicine: Expanding Nurses' Role

Kenneth W. Lin, MD, MPH

Disclosures

December 19, 2016

Editorial Collaboration

Medscape &

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Hi, everyone. I'm Dr Kenny Lin. I am a family physician at Georgetown University Medical Center in Washington, DC, and I blog at Common Sense Family Doctor.

As a full-time faculty member in our department of family medicine, I have formally and informally advised many medical students interested in primary care careers. Students are commonly discouraged from entering family medicine because we make less money than most subspecialists, and they perceive a lack of respect for family medicine within academic medical centers. Students may also hear from subspecialists that family physicians will eventually all be replaced by registered nurses, because practicing in primary care isn't very complex and its tasks don't require a medical degree.

In response, I explain that being an excellent generalist can be just as intellectually challenging as being the world's expert in rare and obscure diseases of the fifth left toenail. I point out that nurses play an essential role in many medical specialties. Just as registered nurses have worked hand-in-hand with family physicians for decades, the long-term presence of nurse practitioners on cardiology teams and nurse-anesthetists in operating rooms hasn't caused cardiologists and anesthesiologists to become obsolete.

But there is more than a kernel of truth to the claim that many key primary care tasks do not require a physician's expertise. And because the current shortage of family physicians is expected to grow as retirements exceed the number of medical school graduates entering this specialty, more and more we will count on nurses to take on advanced roles in patient-centered medical homes.

In my own practice, the registered nurse role has evolved from phone triage, vaccine administration, and medication refills to overseeing preventive care and management of chronic conditions, such as diabetes and hypertension. In fact, our nurse performs some tasks better than any of our doctors ever did, such as making sure that adults over 65 and smokers receive pneumococcal vaccinations, and ensuring close follow-up for patients with poor blood pressure or blood sugar control.

Primary care and nursing faculty from the University of California, San Francisco, recently argued in the New England Journal of Medicine that with appropriate training, nurses could take the lead in "three important emerging primary care functions"[1]:

  • Behavior change and medication adjustment for chronic conditions;

  • Leading care management teams for patients who are high utilizers of care; and

  • Managing transitions of care between the medical home, specialist outpatient, and hospital settings.

This collaborative vision of high-functioning teams composed of primary care physicians and registered nurses is the basis of the executive summary of an upcoming Josiah Macy Jr Foundation conference report, "Registered Nurses: Partners in Transforming Primary Care."[2] However, as one of the conference co-chairs has observed,[3] some significant obstacles still need to be overcome to achieve this vision. More than 3 in 4 nursing schools have limited or no primary care curricula and do not require clinical practicums in primary care. The scope of practice regulations in some states makes it difficult or impossible for nurses to follow clinical protocols or standing orders without direct physician supervision. And finding ways to adequately pay primary care nurses—who, like physicians, are currently paid less than those in subspecialist fields—for these increased responsibilities remains a challenge, especially for small practices.

But between those who believe that expanded roles for nurses in primary care will end up destroying family medicine or saving it, you will find me firmly in the latter camp.

This has been Dr Kenny Lin for Medscape Family Medicine. Thank you for listening.

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