Nurses Expand Roles as Debate Grows Over Care

Depending on what side you take in one of the hottest debates in medicine, Rene D’Aiuta is either a pioneer or a menace.

As her colleagues in nursing see it, D’Aiuta, a nurse practitioner, is blazing a trail for her profession by helping to manage chemotherapy treatment in a 42-bed unit at Memorial Sloan-Kettering Hospital here. Until recently, nurse practitioners did not take responsibility for supervising acute inpatient care.

But in the eyes of many doctors, this diminutive, 36-year-old graduate of Columbia University represents an imminent threat because she is doing a job that once was handled entirely by resident physicians--until New York state imposed strict limits on the number of hours they could work.

It was the likes of D’Aiuta that the American Medical Assn. had in mind in December when it issued a 30-page statement warning that nurses are not adequately trained to carry out many functions they now perform independently of doctors. The AMA declared that “replacing physicians with lesser prepared personnel may increase the medical risk to patients and the ultimate cost of care.”

Indeed, one of the chief reasons many AMA members are upset by the Administration’s health care reform proposals is that President Clinton often has expressed support for allowing nurses to assume roles in medicine once reserved for physicians.

In California and a few other states, AMA doctors have been so alarmed by the professional advancement of nurses that they even printed up political action committee fund-raising brochures that referred to non-physician practitioners as “quacks” and warned: “Don’t let reform fowl up health care.”

Not surprisingly, this dispute is seen in some quarters as a feminist cause, since most doctors are men and most nurses are women.

“The doctor-nurse relationship echoes the man-woman relationship in society,” said Joan Swirsky, a feminist writer for a publication known as Revolution: The Journal of Nursing Empowerment. “Men are trying to maintain the status quo.”

But the issue is far more complex than a simple battle of the sexes.

At the heart of the escalating tug of war is an effective effort by the nursing lobby to win wider recognition, as well as the legal right to prescribe drugs, to admit patients to hospitals and to receive direct reimbursement from Medicare, Medicaid and insurers.

Already, nurses have persuaded legislatures in Alaska, Oregon and some other states to grant them some of these rights. Clinton’s health care reform legislation promises to further expand their prerogatives. In 1991, for example, nurses with advanced education won the right to furnish medications to patients in California.

In part, nurses are winning more responsibility because of a widely held belief that health care costs will go down if, in some instances, doctors--who earn an average of $170,600 a year--are replaced by nurses, whose average annual income is $43,600. But the AMA has even challenged the cost-saving argument, insisting that there is no proof that nurse-provided care is cheaper.

The tension between doctors and nurses also may be the inevitable result of a trend in which, as physicians have become more specialized in recent years, nurses with advanced degrees gradually have inherited more responsibility for primary and preventive care.

“The real issue,” American Nurses Assn. President Virginia Trotter Betts said recently in a bitter letter to AMA Executive Director James S. Todd, “is that for decades, medical doctors have largely abandoned primary care in favor of specialties, yet some in your profession continue to object to anyone else picking up the pieces.”

As many nurses see it, the AMA has suddenly realized that this trend could rob some physicians of jobs, particularly in an era when policy-makers in Washington are searching for ways to deliver more primary and preventive care at lower cost.

As Jerelyn Weiss, director of advanced practice nursing at Memorial Sloan-Kettering, explained: “The problem now is that physicians are seeing the need to turn away from specialties and devote more time to primary care. But who answered the need when there weren’t physicians who wanted to go into these areas? Who can be trained in two years instead of eight? Whose salary is half of the minimum wage of physicians? And who has been shown to do equal or better work? Nurse practitioners.”

Still, nurses emphasize that they are not trying to usurp the many complex and invasive procedures for which physicians are singularly trained. “Nobody is saying that physicians are to be replaced, but there are some kinds of care that can be delivered without a physician,” explained Rhonda Anderson, president of the American Organization of Nurse Executives.

Changes in the traditional doctor-nurse relationship began several decades ago with the advent of new educational opportunities for nurses. Nurses traditionally had been trained in hospitals. But most now earn four-year college degrees, and some even seek advanced education by earning master’s and doctorates.

Advanced degrees spawned a new occupation known as advanced practice nursing, which now includes nurse practitioners, nurse midwives, clinical nurse specialists and nurse anesthetists. By some estimates, there are 100,000 advanced practice nurses among the nation’s more than 2 million nurses.

Advanced practice nurses see their training as different--but not inferior--to that of physicians. While doctors learn to treat illnesses, nurses with advanced degrees say they have learned to treat patients using a holistic approach that emphasizes wellness and prevention.

The AMA contends that the state educational requirements for credentialing of advanced practice nurses are still not consistent and that fewer than 40% of those who are certified as advanced practice nurses have advanced degrees. Furthermore, the AMA insists, a physician’s eight-year course of study is far superior because “it is more extensive in the depth of clinical judgment and in scientific rigor.”

In most instances, the role of nurse practitioners has expanded to provide services that physicians were not inclined to perform.

That trend began in rural areas where physicians were in short supply and where nurse practitioners now provide care for all but the most seriously ill patients. Over time, nurse practitioners also began serving a similar function in urban areas where doctors did not want to work, particularly among the homeless.

Eventually, advanced practice nurses also moved into mainstream health care, running clinics specializing in preventive care and women’s health where patients are seeking an alternative to traditional medicine. They also entered into the delivery of psychotherapy to persons who cannot afford a $150-an-hour psychiatrist.

It is now estimated that in about one-third of the nation’s hospitals, nurses provide comprehensive “case management,” acting as the ombudsman who brings together various elements of specialty treatment for the patient. Many health maintenance organizations rely heavily on nurse practitioners. And in some towns, such as San Mateo, Calif., nurses even serve as hospital chief executives.

In most cases, the AMA has not objected to these developments as long as the nurse practitioners were acting in consultation with physicians, performing a role known as “physician extenders.”

But as the trend has grown--even into acute-care settings such as Memorial Sloan-Kettering’s oncology department--the expanded role of the nurse practitioner is becoming more controversial.

D’Aiuta and her fellow nurse practitioners answer to the hospital’s staff physicians and residents, who visit the unit once or maybe twice a day. The AMA says that it does not object to such an arrangement as long as the nurse is kept under “close supervision” by physicians.

But because new physicians rotate through D’Aiuta’s unit every four to six weeks, as is customary in teaching hospitals, and because the care is delivered in accordance with strict treatment protocols, there is little doubt that nurse practitioners here have more independence than the AMA would like.

D’Aiuta’s supervisors said she and her fellow nurse practitioners provide continuity and stability for patients. Or to put it another way, they are the first persons consulted by bedside nurses when something goes wrong.

“The doctor is out of the middle now and the nurse practitioner knows what she needs to know,” observed Patricia Mazzola Lewis, chairwoman of Memorial Sloan-Kettering’s Division of Nursing. “The ultimate constant for the patient is the nurse practitioner.”

The AMA asserts that the argument that nurses can provide cheaper care is weak because residents historically worked 80 hours a week--a shift equal to two 40-hour-a-week nurse practitioners.

But Lewis countered that even though Memorial Sloan-Kettering is paying more in salaries, the nurse practitioners are saving money in other ways and providing better care for the patients. For example, she said, the constant presence of nurse practitioners eliminates a tendency of newly arrived doctors to order unnecessary tests.

“We also cut a day off their stay at the beginning because we get their treatment going instead of waiting for physician rounds,” Lewis said. “The nurse practitioner gets the ball rolling. Patients are much more satisfied with the care because it’s consistent.”

In the opinion of her fellow nurses, D’Aiuta, who earns about $70,000 a year, represents an affront to the physician establishment not necessarily because she is doing work once performed by a doctor but because her expanding role raises questions of how medical bills will be computed in the future.

If the nursing lobby has its way, doctors eventually will be restricted from charging the government or insurance companies for services performed by nurse practitioners who work independently. Instead, nurses would be reimbursed separately for their work.

Nurses think that doctors are resisting direct reimbursement for them because, under the current system, doctors benefit financially from services performed on their behalf by nurses. Direct billing of nursing services is seen as a way to cut costs for consumers and increase income for nurses.

After years of resisting such changes sought by nurses at the state level, the AMA has become alarmed by the Clinton Administration’s expressed support for wider prerogatives for nurses. In addition, because Nurses Assn. President Betts is a former aide and friend of Vice President Al Gore, it appears to the doctors that nurses have an inside track at the White House.

Still, the nursing lobby is nowhere near achieving its goal of direct reimbursement.

While some insurers currently reimburse advanced practice nurses directly for their services, it is not yet an industrywide practice. And a few states are still resisting a 1989 federal directive requiring them to provide direct Medicaid reimbursement for certified nurse midwives, family nurse practitioners and pediatric nurse practitioners.

Illinois, in fact, does not even recognize nurse practitioners.

Even the Clinton Administration’s plan for health care reform stops short of providing advanced practice nurses all the powers they seek. The key provision of the Administration bill dealing with nurses is so vaguely worded that it could be subject to many interpretations:

“No states may, through licensure or otherwise, restrict the practice of any class of health professionals beyond what is justified by the skills and training of such professionals.”

At minimum, according to nurses’ lobbyist David Keepnews, the Clinton bill would “put the burden of proof on the states to justify any limitations they place on advanced practice nurses.” But it is still an open question whether such a provision can survive intense opposition from the powerful AMA lobby.