Nurses Frequently Do Doctors’ Jobs

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The next time you go to see a doctor, odds are good that you’ll actually see a nurse. Today, about 160,000 advanced-practice nurses — registered nurses (R.N.’s) with additional training — are giving checkups, delivering babies, caring for pregnant women, and administering anesthesia in the operating room. Some work alongside doctors in private practices and hospitals; others see patients on their own. The trend is growing because of a shortage of family doctors, as well as a meteoric rise in health-care costs. In under-staffed hospitals and clinics, nurses enable doctors to spend more time on difficult cases. And at salaries that average about 40 percent of primary-care physicians’, advanced-practice nurses can in some cases save money for medical groups and insurers. The savings, however, aren’t usually passed along to the consumer.

At least one health maintenance organization (HMO), Oxford Health Plans Inc., of Norwalk, CT, has begun a pilot program that allows members to choose an advanced-practice nurse instead of a doctor as a primary-care
provider — the first line of defense when you get sick. These nurses are able to prescribe drugs and admit patients to the hospital. They work closely with physicians at Columbia Presbyterian Medical Center in New York City, referring patients who need a specialist or emergency care. And, perhaps most surprisingly, they are reimbursed at doctor rates.

But is an advanced-practice nurse really qualified to provide primary care? The American Medical Association (AMA) says yes, as long as she’s certified by a national nursing organization in her area of expertise, which can range from primary care to gynecology to pediatrics, and licensed as an R.N. The AMA also recommends that an advanced-practice nurse work closely with a doctor.
Advanced-practice nurses are trained to conduct physical exams, diagnose and treat minor illnesses and injuries, order lab tests and X rays and interpret results, and counsel patients. Some physicians who care for women say that a well-trained advanced-practice nurse is as competent as a general physician when it comes to taking a Pap smear or diagnosing vaginitis or menstrual discomfort. “An advanced-practice nurse who regularly performs colposcopy [when doctors look at a woman’s cervix to rule out cancer], for example, will generally do it better than a physician who performs them only sporadically
because she does it so often,” says Mitzi Krockover, M.D., medical director for the Iris Cantor-UCLA Women’s Health Center and an assistant clinical professor of medicine at the University of California at Los Angeles.

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Research backs up claims of advanced-practice nurses’ competence. A recent review of 210 studies comparing the care given by doctors and nurses-such as resolution of medical problems and patient satisfaction — found that nurses perform as well as physicians. Studies also indicate that nurses tend to take a more detailed medical history before recommending therapy, and are more likely to suggest alternatives to medication — even when they have the authority to prescribe drugs. Despite this, nurses don’t have the training of primary-care doctors, and may not be able to diagnose serious illnesses with more ambiguous symptoms, such as cancer or heart disease. “Nurses aren’t trained to son out complexities,” says M. Roy Schwarz, M.D., an immunologist and former group vice president for professional standards at the AMA. Although nurses are taught to refer patients to doctors when necessary, a consumer should demand to see a physician if she has any symptoms that persist, such as headache, chest pain, or change in the color or consistency of the stool; or if her symptoms are vague and nonspecific. Whether you’re being treated in a public, private, or HMO setting, you have the right to see a doctor. Your best bet for assessing your advanced-practice nurse’s competence is to make sure she’s a a licensed R.N. and certified within her area of expertise. You should also check her educational background; a nurse with a master’s degree obviously has more training than one with only a bachelor’s or associate’s degree. Finally, she should be able to name a physician that she uses for referrals. Dr. Schwarz advises asking whether a physician will review her diagnoses and treatment plans. “If the answer is yes, you can relax,” he
says.

Even if you are happy with your advanced-practice nurse, consider consulting a doctor periodically (every two to three years if you’re healthy; every six months to a year if you have a chronic illness, like diabetes, or if your age, lifestyle, or family history puts you at higher risk for certain disorders).

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