Roles in Healthcare: A Who's Who Guide to the Gray Area

With all of the posturing over who has more training hours, patient-satisfaction scores, positive outcome measures, and cost-effective care, something has been lost in the Dr. Nurse/Dr. Physician debate: Role of the Discipline.

First, let's get the "I-became-a-(MD/DO/NP/CNS)-because-I-want-to-help-people" out of the way. All of the health disciplines help people. So do any number of customer-service driven fields. The practice of any healthcare discipline is both an art and a science where assessment, diagnosis, and intervention are the foundation of every patient encounter.  Likewise, we have moved toward the partnership model of healthcare that includes patient-ceneted care, interpersonal communication, and collaboration with peers. There is significant overlap in scope of practice among many licensed independent providers - chiropractors, physical therapists, and osteopaths, or psychologists, social workers, and psychiatrists are just two of many groupings where this occurs. Why one person chooses a particular path over another is not so much due to the "what" of these care concepts, but to the "how" of delivery.

What is medicine? When you boil it down, the primary purpose in the practice of medicine is treatment of disease. Physicians care for patients through provider-driven interventions to eliminate, cure, or manage acute and chronic disease processes from common to obscure. To be successful at identifying and treating the full range of pathologies for a given system, a physician must have a comprehensive understanding of expected functioning in the system of focus, variants of compensatory measures within and in relation to other body systems, all potential pathological manifestations with their associate therapies, and the interactions of treatment modalities the individual may be employing for all conditions in the body.

When patients complain that all their physician wants to do is order a bunch of tests and offer pills or surgery, they are basically stating that the MD is doing their job.  While holism plays a larger role in DO training than it does with MDs, compartmentalization is a necessary framework for specialty care.  There are so many aspects of endocrinology, neurology, and gastroenterology, that to expect the specialized and general clinician to know all about all systems is unrealistic and unfair.

Physicians also take a lot of criticism for not focusing on more than the barest of nutritional education or other self-directed lifestyle modifications. These are not topics that are emphasized as part of medical training unless pertaining to specific disease processes, such as renal failure or diabetes.  Medicine is interventional at the disease level, thus the training is focused at that level of care.  Of course prevention is included in scope of practice, but there are far more ways for the body to go wrong than there are to go right. Because illness can manifest, complicate, and hide throughout the body, the training to identify and treat must be equally complex. We do not pay them to talk, we pay them to act.

What is nursing? When you boil it down, the primary purpose in the practice of nursing at the advanced level is health promotion and disease prevention.  Nurses care for patients through education, communication, self-care strategies, identification of risk factors, and community-based care of the well person.   To be successful  in this role, engaging in primary (decrease incidence of disease), secondary (decrease prevalence of disease), and tertiary (decrease disability of disease) prevention interventions are performed at both the individual and community level. An understanding of normal and expected health status is essential in this role in order to initiate interventions or refer to the appropriate provider and level of care. "Common diseases occur commonly," thus expected age-related or other predictable illnesses are the focus of prevention and management.

The principles of health promotion and disease prevention also apply at the organizational level and are used to conduct research for quality improvement and to identify gaps in system processes to guide implementation of appropriate solutions. Even at the entry RN level, there are independent aspects to this practice. The nursing diagnosis and individualized treatment plan are determined by the bedside nurse and are typically aimed at providing comfort measures to prevent adverse events and promote healing. From the bedside to the boardroom, nurses run the hospital and are greater in number than any other type of provider. The multiple levels of licensure and practice scope are also unique in comparison to other health disciplines, thus making the role of mentor, educator, collaborator, and researcher essential to fulfill the advanced practice role.

Those who complain that NP training hours do not match those of medical school are basically stating that nurses are not trained to be physicians.  This is 100% true. NP training hours do match the necessary education required to meet the role of the NP. Medical school is not necessary to provide comprehensive, quality well-care, nor is it necessary to conduct process-improvement research and implementation in the clinical setting.  Nursing is rooted in holism. NPs are well prepared to treat mild to moderate levels of complexity in a community, urgent, and acute-care environment, and to provide tailored education on lifestyle considerations for optimal health. While the rare, esoteric, and significantly complex patterns of disease are discussed in NP training, the management of these conditions are beyond the scope of the role, and are included as a basis for referral to the appropriate provider. You cannot practice what you do not know - expert NP clinicians practice nursing, not medicine.

There is role overlap between nursing and medicine, particularly in the tertiary level of preventative care.  Certainly there are NPs that successfully treat complex conditions and physicians who focus on prevention.  Each discipline offers post-graduate training and fellowships to encourage life-long learning. The question is not which type of clinician is better so much as it is which type clinician is most appropriate and better trained for a given set of circumstances.

A patient needs a medication to lower their blood pressure. Does the patient really care if the prescriber views it as treating a disease process versus viewing it as promoting systemic wellness and preventing adverse disease consequences? If it works, probably not. Does this generally healthy patient, who suffers from situational anxiety, could stand to loose 20 pounds, get a few more hours of sleep, and cut down on the nightly ounce of bourbon, require MD care?  An NP is better suited to manage the hypertension and provide tailored education on essential nutrition, exercise, and rest patterns that could result in resolution of the disease and discontinuation of the medication. The NP is trained to do this more effectively and at a lower cost than an MD. This is where nursing is the best choice.

But lets say this person needs 3 different medications to control his blood pressure to just shy of normal. His nightly bourbon is actually 8-ounces and he has the lab values and physical finding to prove it. Sometimes he pops a friend's xanax before going to parties to calm his nerves. He experiences intermittent chest-pain several times a week, and can't get his shoes on anymore because his legs and feet are too swollen. This patient just entered the gray area. An NP could work with this patient, but the complexity of his issues also make referral to an MD appropriate. This is where nursing or medicine can be a good choice, and likely a combination of both.

Now lets have some fun and say this patient also has atrial fibrillation that has resulted in three cardioversions in the past year, recent onset of Type II diabetes, and is a 2-pack-per-day smoker with one hospitalization for pneumonia in the past 6 months. He is not interested in changing habits, has a history of skipping follow-up appointments, and often misses doses of medicine. He has been to the ER twice for thoughts of suicide with one attempt. We now have several chronic diseases effecting multiple systems in a non-compliant patient. Promotion and prevention are still important, but treatment of disease is the priority.  This is where medicine is the best choice.

So lets sum it up: Nurse practitioners should provide care when health promotion and disease prevention are the primary goals of the patient. Physicians should provide care when treatment of disease is the primary goal. Both are appropriate when these goals meet in the middle and each is performing according the purpose of their role. Rather than considering the tired "Us vs. Them," the more accurate perspective should be "Us and Them" on the side of the patient.