No community is immune to the physician shortage and the strain they place on an already-stretched thin healthcare system. But perhaps nowhere is it felt more strongly than in rural communities, especially those positioned hours from the nearest metropolitan area. Unfortunately, the trend is unlikely to fade anytime soon, as the demand for primary care is expected to increase as the population ages.
One of the reasons for the difficulty in obtaining primary medical care can be traced to the cost and time commitment involved in becoming a licensed physician. With four years in college, four years in medical school, and a three- to seven-year medical residency, the average cost of becoming a doctor in the U.S. is nothing short of exorbitant. When you consider that most specialists enjoy higher salaries than primary care physicians, it’s little mystery why physicians would choose specialized care over primary care.
Even among physicians who choose to practice non-specialized care, the fact is most would rather do so in a major or mid-sized metropolitan area over a rural community. Many studies suggest that, over the last 20 years, physicians have become overworked, with nearly one-third working 60 to 100 hours per week. And those hours tend to pile up even more rapidly in rural and low-income areas.
To counter the effects of decreasing access to physicians, many rural communities are turning to advanced practice providers, such as nurse practitioners, physician assistants, nurse midwives and clinical nurse specialists, to help fill in the gaps, whether in the primary care setting or as a hospitalist.
While it depends in many cases on regulations that vary from state to state, many of these advanced practice providers are licensed to provide most if not all of the same routine duties as a physician, from administering vaccines to performing patient physicals to writing prescriptions for controlled substances.
“They might not have admitting privileges, but there is absolutely no reason a nurse practitioner or physician assistant can’t be an effective hospitalist, serving as the eyes and ears for doctors to help make treatment decisions,” says Debby Renner, PhD, an interim CNO for HealthTechS3. “But the benefits of having an APP as your hospitalist go way beyond that. They can provide consistency of care, foster a really close working relationship between provider and nurses, and they’re going to encourage better communication from the patient.”
Recognizing the major role these advanced practice providers can play in combating the physician shortage and improving access to quality care, lawmakers across the country are considering expanding their scope of practice—and autonomy.
But, understandably, these efforts are up against considerable pushback from physician groups, who point out that the sizable gap between physician education and training requirements and those of advanced practice providers—and what that might mean for patient safety.
“If we also start with the safety of the patient and what’s in the best interest of the patient, we’ll settle this controversy quicker,” Jay Epstein, MD, a Florida anesthesiologist and state chair of the American Society of Anesthesiologists’ Committee on Governmental Affairs, told HealthLeaders Media.
Renner says advanced practice providers can slot in easily where the care is routine and uncomplicated, such as office visits for simple infections, refill requests, routine physicals and wellness exams. “They are perfectly capable of handling the vast majority of healthcare interactions,” she says. “If they run into something odd or unique or something they know is above their skill level, they will consult with their physician. In my 30 years as a nurse, I haven’t seen a nurse practitioner overstep their bounds.”
Recruiting Challenges Remain
Similar to physician, nursing and executive recruitment, advanced practice providers pose the same recruiting challenges to rural and community access hospitals. Incentives can sweeten the pot, including school loan repayment and covering relocation costs.
But providing the right culture, one that values and respects the profession, might be the greatest incentive of all, says Renner.
“In my experience, physicians are the gatekeepers,” she says. “If they want advance practice providers, they’ll have them. If they don’t, it probably won’t work.”
To overcome this challenge, Renner has two suggestions. First, be prepared to talk financials with your physicians. “You have to be acutely aware of how this hiring decision could impact your physicians’ income,” she says. “Be prepared for it, because you’ll have that conversation sooner or later.”
Second, she suggests creating a robust onboarding program that focuses on relationship building between the physician and the advance practice provider.
“Some of the most successful nurse practitioners I know spent a lot of time with their doctors in the first four to six weeks on the job,” she says.
Even something as simple as language matters in creating a welcoming culture, as the American Association of Nurse Practitioners points out in an online position statement.
For example, the terms “mid-level provider,” “physician extender,” “limited-license providers,” “non-physician providers” and “allied health providers” are misleading, inaccurate and confusing, says the AANP.
“As it would be inappropriate to call physicians ‘non-nurse providers,’ it is similarly inappropriate to call all providers by something that they are not,” the position statement continues. “Best practices call for clearly informing patients and referring to each health care provider by their individual title to recognize their unique but overlapping roles.”
But Renner draws the line at APPs who insist on being called “doctor,” even when their credentials allow it.
“I could make people call me Dr. Renner, but I don’t, because I know that’s confusing,” she says. “You have to look at the population you’re serving. People in rural communities don’t have any frame of reference for a nurse practitioner who insists on being called doctor. To them, ‘doctor’ means MD or DO, and we have to respect that.”