Editorial

Primary Care Dilemma: Career Ladders Without Rungs

David Pratt, M D

ast spring, as I was making my medical director’s rounds of rural health centers in upstate New York, I chatted over coffee with a nurse who had just finished a L family nurse practitioner training pro-

gram. She was excited about and proud of her recent achievement. In quiet tones she confided that some of the patients in the practice, after learning about her new skills, had asked her to be their primary care provider (in apparent preference to two excellent internists). She was amazed and pleased. I shared her pleasure, but was not surprised by her patients’ responses. She is a competent, experienced nurse. It was logical that she rise to a higher level of patient responsibility. Upward mobility is an accepted principle in much of the U.S. work scene. Perhaps this nurse’s astonishment reflected her skepticism about the legitimacy of career advancement in outpatient care. The regrettable truth is that in primary health care career ladders either are too short or have no rungs.

What if this nurse practitioner develops a prac- tice, gains five year’s experience in primary care, and she then decides she would like to move to the next level of responsibility-the family physician? Would a medical school accept her nursing training and clinical experience as even partial preparation for matriculation? I doubt it. More likely she would be required to take perhaps two years worth of under- graduate courses. Then, if she were accepted, four more years of medical school and three years of residency training in family medicine would follow. Why? Because this is how the stilted, calcific medical academia operates.

Isn‘t it true that nurse practitioners have valued skills, experience, and talents? Don’t they share patient loads with physicians? In rural America, these providers are called on to give compassionate, high- quality care, often with limited day-to-day supervi- sion. The nurse practitioner’s unique nursing per- spective is deeply appreciated by those they serve. It seems unbelievable that all of these realities would be discounted simply to meet the standards of tradi- tional medical education. Are experience, dedication, and competence worth nothing?

The remote and imperious academic medical establishment is having a difficult time meeting the general health needs of rural Americans. Over time, society has sought leadership from medical schools to address the myriad health problems that face this nation. Schroeder, Zones, and Showstack (1989) pointed out that these schools have met many of our needs, especially those employing advanced technol- ogy. Unfortunately, they often have failed to offer answers to more thorny, social health dilemmas. Most medical schools are still caught in the specialty training mentality of the 1970s, reinforced by pay- ment realities (Colwill, 1990). Perhaps the most glaring failure of the medical schools is the dwindling supply of primary care specialists, especially in rural areas (Politzer, Harris, Gaston, & Mullan, 1991). We do not have enough family medicine physicians now, and the future doesn’t look promising (Department of Health and Human Services, 1990).

The author thanks Walter A. Frank, Laurie Bank Berry, and Alison C. Young for their thoughtful criticism and comments.

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Even if medical schools experienced an epiphany today and launched an all-out drive to increase the number of primary care physicians, the pipeline effect would delay any perceptible increase until the turn of the century. Given that there are more than 1,900 health professional shortage areas needing approximately 4,000 doctors, one wonders if the U.S. population can wait to see if the medical schools can bring incremental change in the physician supply mix (Office of Technology Assessment, 1990). In rural areas the number of office-based primary care providers actually decreased by 8 percent from 1963 to 1986 (Barnett & Midtling, 1989).

primary care providers that does not rely on the ritualized, traditional path? I believe there can be. Medicine might well look to developing career ladders that could help meet this serious supply problem. The ranks of mature, nurse practitioners are rich with individuals who have time proven, practical experience in excellent primary care. It seems to me it would be possible to design a fast track for producing family medicine practitioners by giving mature family nurse practitioners, for example, four years of additional training (two years of medical school- perhaps years two and three-plus two years of family medicine residency). This plan presupposes that the nurse’s training counts for undergraduate preparation and also accepts the nurse’s outpatient clinical skills as solid preparation for residency. Could these fast track nurses get fully comfortable with the rest of clinical family medicine in two years? I believe they could.

The product would be nurse/physicians with eclectic, empathetic clinical preparation. Fast track programs would ideally be designed to expand the knowledge and skills of nurses and return them, as physicians, to their original practices. This is most desirable in underserved areas, where many commu- nities have given up on the hope of recruiting a doctor. It is easy to imagine scholarship and repay- ment programs predicated on the return assumption. A much more ambitious program with a similar intent is working at the Institute of Health Sciences at Palo on the Layte Gulf in the Philippines. There, career ladders that cross the nursing and medical disciplines are encouraged and supported. Students from the Palo program have had high pass rates on the standard certification examinations given in the Philippines (Lepreau, Koh, & Olds, 1990).

Is there another way to address the shortage of

Because the fast track in primary care would be new to the United States, careful evaluation elements would need to be built into the design, process, and outcome of the program. Difficult questions about qualification for board certification would need to be worked out by the professional societies with juris- diction. These societies would need to be mindful of the objectives and goals of the fast track.

objections.

physician anyway, the nursing hierarchy will argue. Perhaps. But look at their practice as I do every day. They work alongside, in place of, and together with physicians. Many are involved in diagnosis and treatment (the medical model) having de-emphasized the “nursing process” to varying degrees. But most, happily, have maintained the nurturing elements so central to vibrant nursing.

My colleagues in medicine will cry, ”Foul!” Since when, they will argue, was nursing education prepa- ration for medical school? I’m not sure it was ever intended to be, but the nurse practitioners I work with are often university graduates and challenging intellectual partners. Their clinical training and medical knowledge are impressive, and they comfort- ably share major responsibility for the care of our sickest patients. Physicians also will call the fast track heresy based on their own travail in training. They need to recall what they knew when they first walked on a hospital floor as intimidated students. If they were like me, they had meager exposure to sick people. Seasoned nurse practitioners would be very different students in medical school, especially on clinical rotations.

removes vital practitioners from their current practice sites. True. Also true is the fact that nurse practitio- ners are more readily trained than physicians. They also will return with enhanced skills. Though the problems with my proposal are apparent, the fast track begins to move rapidly toward meeting a serious professional shortage. The fast track offers an innovative alternative to relying solely on the lum- bering, hopeless hierarchy of the medical schools to increase the numbers of primary care physicians. The fast track graduates could be the first product of what may be emerging as the new medicine-a profession willing to shake the shibboleths, work interdepen- dently, listen more closely to society, and embrace profound change.

As I write this, I can already hear the chorus of

No right thinking nurse practitioner wants to be a

Some detractors will point out that the fast track

Pratt 247 Full 1992

References

Bamett, P.G., & Midtling, J.E. (1989). Public policy and the supply of primary care physicians. journal of the American Medical Association, 262,2864-2868.

education and service delivery of primary care: Education of physicians to improve access to care for the underserved. In Proceedings of the Second Health Resources and Sewices Administration Primary Care Conference (pp. 319-324). Colum- bia, MD Health Resources and Services Administration.

Department of Health and Human Services. (1990). Seventh report to the president and Congress on the status of health personnel in the United States (DHHS Publication No. HRS-P-OD-90-1).

Colwill, J. (1990). Barriers to an enhanced linkage between

Rockville, MD: Health Resources and Services Administra- tion.

education in the Philippines. Journal of the American Medical Association, 263,1624-1625.

America (OTA Publication No. OTA-H-434). Washington, DC: Government Printing Office.

Primary care physician supply and the medically underserved. Journal of the American Medical Association, 266,

Lepreau, F., Koh, I., & Olds, R. Community-based medical

Office of Technology Assessment. (1990). Health care i n rural

Politzer, R.M., Harris, D.L., Gaston, M.H., & Mullan, F. (1991).

104-1 09. Schroeder, S., Zones, J., & Showstack, J. (1989). Academic medicine

as a public trust. journal of the American Medical Association, 262,803-812.

Thomas A. Bruce, MD

Dr. Pratt raises a number of interesting and important issues about medical-nursing joint practice and about multidisciplinary education and training in the health professions.

shortages of primary care physicians, especially in isolated rural areas, will become much worse with the reduced entry of medical graduates into the field. This vacuum will be filled one way or another, and the most likely route will be by nonphysician care givers.

My guess is that many nurse practitioners and nurse midwives will be (and are) excellent primary care providers. To do their job properly, however, they need to be part of a team-just as physicians do. When an acute emergency or complicated medical, surgical, or psychiatric problem is encountered, information or assistance that is needed to provide adequate care should be able to be obtained through a quick telephone call. The willingness and capacity of physicians to work collaboratively and in tandem will determine the degree to which such a system works-and the degree to which American rural health care benefits. In most instances, I believe that it will be much to the advantage of consulting physi- cians to provide the medical support that is needed.

need for more flexible entry points into medical

On one thing I think we agree fully-the current

To an extent, I also agree with Dr. Pratt about the

education. I suspect that he underestimates the degree to which one can do this today. I know of medical schools that will accept postbaccalaureate or graduate students into advanced standing, depending on their performance on standardized basic science examina- tions. Only occasionally do candidates have the existing knowledge that is necessary for pathology or pharmacology, but it is not uncommon for entering students to have requirements waived for anatomy, biochemishy, physiology, and sometimes even micro- biology.

Fast tracks for medical postgraduate (residency) training probably needs more deliberation. It still is possible in many areas to enter practice after one year of residency training (internship). Such a fast track may be least of all desirable, however, for those in isolated practice settings and I would not personally recom- mend it.

is the rather elitist or paternalistic view that a move from nursing to medicine is climbing a rung on the ladder. These are different professions, each bringing unique strengths to the health care field. Occasionally physicians change their focus, too-moving from emergency medicine to anesthesiology, from internal medicine to psychiatry, or from family medicine to public health. Many of these changes require three or

Where I have a real problem with Dr. Pratt’s logic

The journal of Rural Health 248 Vol. 8, No. 4