Duke Nursing Grads at the Front Lines of Change

Nurse practitioners are setting up their own practices, and some are getting backlash

from Duke Nursing magazine

In January 2003, newly minted nurse
practitioner Kathy Patterson, MSN'02,
joined Yanceyville Family Practice, a humble one-physician office smack in the
middle of rural Caswell County, N.C.

Patterson and Brett Williams, MD, a
longtime health care provider to the small town of Yanceyville, served close to
3,000 patients from around the agriculture-based county and neighboring
southern Virginia.

"We saw four generations of single
families says Patterson.

The practice served as a medical home to many.
The duo pulled together rich and detailed family medical histories and provided
diagnosis, treatment, disease management, and health education to a population
that had few health care options.

When Williams retired for health reasons in
2006, the Burlington-based community hospital that owned the practice wasn't able
to find a family physician to replace him and decided to close the practice.

"I was told I was going to be laid
off in six weeks," says Patterson. "I said, 'You can't do that to our
patients. We're the only private practice in the county.'"

The community wasn't happy about it
either. Patients called the hospital to complain and wrote letters and
petitions asking that the practice be kept open. Patterson negotiated with the
hospital to keep the practice open for six more months while she worked with a
consultant, attorney, and insurer to buy it from the hospital.

Without missing a beat in patient care,
Patterson took ownership on March 31, 2007, renamed it Yanceyville Primary
Care, and has been growing the practice ever since.

"We fill a very big need," she
says. "People come to me because I'm an NP and the type of care NPs
provide."

 

Health
Care's Changing Face
 

Patterson represents a changing face of
health care in which nurse practitioners (NPs) are playing increasingly crucial
roles as leaders on the front lines of primary care. They're opening their own
practices in rural areas where physicians are few, and giving residents of more
populated cities an alternative to MD-run practices, often at a lower cost.

An additional 40 million people are expected
to have health insurance beginning in 2014 when the Affordable Care Act is further
implemented; the first of the baby boomer generation reached retirement age
last year; and no help is in sight to relieve the national shortage of family
physicians. A growing number of nurse practitioners are stepping in to help. In
fact, the Affordable Care Act provides funding for nurse-managed primary care
clinics and promotes the full participation of nurse practitioners as key care
providers.

"We don't have enough people or
money to care for the growing and aging population with traditional models of
health care," says Lloyd Michener, MD, professor and chair of the Duke
Department of Community and Family Medicine. "We need to design a
workforce that draws on all available fields to their fullest abilities. Having
nurses involved with primary care is very important."

Nurse Practitioners provide many of the
same functions as physicians, including diagnosing and managing acute and
chronic illness, prescribing medications, and interpreting tests and lab work. Advocates
say that having NPs treat patients with less complicated health issues frees up
physicians to spend more time with the sickest patients.

About thirty-five states currently allow
NPs to work independently without physician oversight. The remaining states
vary in what they require for physician input. North Carolina requires NPs to
maintain a collaborative relationship with a supervising physician, although it
requires them to meet face-to-face just once every six months. Patterson's
collaborating physician is Janet Lehr, MD, a family physician in Durham.

"We collaborate on cases as needed
by phone and fax," says Patterson. "She doesn't come on site."

 The
American Academy of Nurse Practitioners says organizations including AARP, the
CATO Institute, and the Brookings Institution are advocating for the removal of
restrictive regulations regarding NPs.

Not so fast, say some in the medical
community, who argue that nurse practitioners—who are trained at the masters
degree level—are not adequately prepared to treat patients without physician
oversight.

While citing the value of nurses in
health care, the American Medical Association said in an October 2010 statement
that "increasing the responsibility of nurses is not the answer to the
physician shortage. Physicians have seven or more years of postgraduate
education and more than 10,000 hours of clinical experience. These additional
years of physician education and training are vital to optimal patient care."

Michener points out that, "NPs are
not doctors and never claim to be. Nurse practitioners bring a family and
whole-person view to health care and help meet patient and community need."

Some MDs Fear Competition

Jolyn
Fergon, DNP-current,
learned
in 2003 the extent to which some physicians will go to prevent nurse practitioners
from opening competing practices.

She had worked for several years as an NP
in an OB-GYN practice in affluent Palm Springs, Calif., population about
45,000, when she announced she would be opening her own women's health care
practice. Under California law, she was not required to have any physician
oversight.

The outcry from the OB-GYN community was
fierce, she says.

"It was a rough couple of years,"
says Fergon. She added that a group of OB-GYNs—including her former boss complained
to the state medical board that she was not qualified to run a practice without
physician supervision. The state investigated the practice but found nothing
out of order.

"We also were grilled by Medicare
and Medicaid who wanted all of our tax returns and bylaws," she says. "That
first year cost me nearly $20,000 in legal fees."

Every investigation came up clean, yet
the opposition continued, says Fergon "as they tried to run me out of
town."

When she hired an OB-GYN to satisfy some
in the medical community who insisted there be a physician on staff, others
claimed it was illegal to have an NP employ a physician.

Fergon won that battle too, and today her
Advanced Women's Health Care practice employs three MDs, several nurse
practitioners, and several certified nurse midwives for what has grown into a
three-office practice, including an office in an underserved community in Yucca
Valley.

"They finally got tired of fighting
me," says Fergon. "We do the most deliveries by far in the area, and
the three physicians who gave me the most grief have moved on."

Fergon says one factor that has allowed
her practice to flourish is that "we spend a lot of time with our
patients. If a practice is too big, you don't know the patients, and the
patients don't know you.

"I love running my own practice,"
she adds. "My family has been amazingly supportive through all of this."

 

Welcomed
With Open Arms
 

Competition was far from the case in
Oak City, N.C., population about 400, in rural Martin County. Elizabeth Lum Huston, FNP'11, was
welcomed with open arms at The Oak City Community Clinic which the town opened
in October with a $56,000 grant from The Golden Leaf Foundation. The clinic is
a satellite office of the three-county Martin-Tyrrell-Washington District
Health Department.

"In Martin County they don't
even have an MD in the system," says Huston. "Doctors just don't stay
in this area."

In fact, there are just five medical
doctors in the three-county area. Huston's consulting physician is a
private-practice physician in Williamston, about 15 miles away. North Carolina
regulations require that Huston meet with him once a month for the first six
months and that he review a minimum of 10 cases. After that, Huston is required
to meet with him face-to-face just once every six months. She says she consults
with him by phone and fax on a regular basis.

The clinic is open on Thursdays and
is staffed by Huston, a registered nurse, and a clerk. It provides full primary
care services, and Huston can provide referrals for services not available at
the clinic. For the rest of the workweek, Huston provides care at the county
health department clinic in Williamston.

According to a recent health assessment,
the infant mortality rate in Martin County is the second worst in the state,
and Oak City's obesity rate is 58 percent. Diabetes, hypertension, kidney
problems, and other chronic diseases are common in this farming community.

"I am doing a lot of outreach on my
own time and letting the Oak City community know I'm here for them," says Huston.
"I really want to bring everything to bear that I learned at Duke to
improve the health of my community, and I think in two to three years I'll have
tangible data. I love working in rural areas." She sees 20 to 30 patients
a day.

Huston says nurse practitioners play a
vital role in health care because "we're taking care of patients that MDs
don't want to, or have time to take care of. Doctors are leaving primary care
in droves and we're moving into these positions."

To
help alleviate the tension that sometimes exists between NPs and MDs, Huston
says "We need to sell ourselves better. Many people don't really know what
nurse practitioners are or the role we can play. We are different because many
of us have 20 years of clinical experience at the bedside."

Says Michener, "Too often the mutual
respect that exists between nurses and doctors gets lost in the discussion
about practice. All are talented professionals working on behalf of patients.
We need to teach that and exemplify that."