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Nurse Practitioners: Can They Fill The Gap?

Californians will find out today how much healthcare might cost them under the state's health insurance exchange.
Kenny Goldberg
Californians will find out today how much healthcare might cost them under the state's health insurance exchange.

Studies show fewer than a third of doctors nationwide practice primary care. And most medical students want to go into more lucrative specialties. That could mean trouble ahead, as health reform promises to expand access to tens of millions of Americans who are currently uninsured.

Some suggest nurse practitioners could fill the gap. But many doctors in California don't like that idea.

Jeannie Miller is a long-time nurse practitioner at Neighborhood Healthcare. It's a network of community clinics headquartered in Escondido.


On a recent weekday morning, Miller walked into one of the clinic's examination rooms.

"Hello, I'm Jeannie Miller. I'm a nurse practitioner at the clinic. What brings you to the clinic today?

"...Ah, I have a sore throat…." said the patient.

Miller works in family medicine and women's health. She and the other nurse practitioners here aren't primary care doctors, but they perform many of the same duties.

"We have complete management of our patients," said Miller, "whether all the things that are needed during the actual visit, managing medications, referrals, patients if they have problems, they call. They're your patients."


Dr. James Schultz is Neighborhood Healthcare's medical director. He said their 14 nurse practitioners and 58 doctors are on the same team.

" We treat 'em as colleagues here," Schultz pointed out. "I mean they're on a pretty even footing with us, as far as, you know, we're co-managing a lot of patients. And there's areas that they're better at than I am, and there's areas that I'm better at than they are. And together, I think we can do a good job for the patients."

There are some 950 nurse practitioners in San Diego. They work in a host of healthcare systems and community clinics.

What they can't do in San Diego or anywhere else in California is practice independently. Unlike 24 other states, California requires nurse practitioners to work under a doctor's supervision.

That rubs some practitioners the wrong way.

Karen Macauley teaches in the nurse practitioner program at the University of San Diego. She's also works as a nurse practitioner at an internal medicine clinic in Hillcrest.

"If you truly look at the research and the evidence that is out there," Macauley said, "nurse practitioners can provide just as competent, if not better care, than physicians do."

Macauley says nurse practitioners can do nearly everything an MD can do.

The fact is, however, nurse practitioners don't have the same level of education as medical doctors. They become nurse practitioners through a master's degree program, that usually takes from one to three years to complete.

Doctors, after obtaining a bachelor's degree, spend four years in medical school, then at least three years in an internship and residency program.

Dr. Albert Ray practices family medicine at Kaiser Permanente, and is a past president of the San Diego County Medical Society.

Ray is against the idea of allowing nurse practitioners to work independently in California.

"We're not trying to be rulers over the nurse practitioners," said Ray. "We're just trying to make sure that we keep them safe, and practicing within their license, and that we as physicians working with them, deliver appropriate access and good quality care."

Karen Macauley said the status quo isn't going to cut it under health reform, when millions of new patients will need care.

"If they can't have access to getting into actually be seen for a cold, or a cough, or whatever their ailment, where will they go?" asked Miller. "Most likely, they'll go back to the emergency department, what's happening right now."

The American Academy of Family Physicians says if current trends continue, the shortage of primary care doctors will reach 40,000 within ten years.

The Institute of Medicine says to meet the increased demand for primary care, limits on nurses' scope of practice should be removed.