Primary care choices expand

Primary care choices expand

by Daniel Simmons

In many ways, Ruby Houck resembles the small-town doctor of American myth — except she’s a nurse practitioner.

“I’ve lived in rural Nebraska most of my life,” says the longtime nurse. “I wanted to stay in this community and offer quality hometown health care, so I followed my dream.”

In 2000, she opened her own clinic in Bertrand, Neb., a town of 750 people where, Houck says, the residents didn’t have a local place to go for primary care.

She's enjoying the authority to make beneficial changes to her practice and she likes that she has more time for patients who need it most.

"I can take as long as I want, without someone saying I need to speed up my time with patients," she says.

Physician extenders expand coverage

Nurse practitioners, along with physician assistants, which are often called physician extenders because they can help increase productivity, are providing the type of care that used to be the sole domain of doctors.

And while the number of doctors going into primary care declined by a third between 1998 and 2008, physician assistants and nurse practitioners working in the field has grown by about 75 percent in the past 10 years.

The change is improving access to quality health care, enhancing communication with patients and increasing the sheer number of providers to fill some of the gaps, Houck says.

Jan Towers, director of health policy for the American Academy of Nurse Practitioners, says nurse practitioners were on the rise, with about 8,000 graduating annually, even before the shortage of doctors.

"We come from a nursing framework to begin with, so there's that certain Mother Teresa aspect that attracts us to primary care," she says. "Having the autonomy and being able to be affective in our care is definitely a draw."

Eighty percent of nurse practitioners specialize in primary care, compared to about 35 percent of the 6,000 certified physician assistants who graduate each year.

Most physician assistants have followed the lead of medical doctors and have gone into specialties where they make more money, says James C. Williams, a physician assistant working in primary care in Indianapolis. "There's a huge need for P.A.s to stay in primary care," he says. "We're here to improve access and to provide good, quality care."

Patients get more choices, care

Some Angie's List members have already adapted to the changing landscape and are seeking out the best provider that fits their health care needs.

Ted Ulinski, a recent transplant to Bernalillo, N.M., had seen the same medical doctor in Maryland for the previous 35 years, be it for asthma or an irregular heartbeat. "[My doctor] saved my life several times," says the 59-year-old retired government engineer.

It took some time, but Ulinski eventually found a worthy replacement with nurse practitioner Harriet James of Enchanted Hills Family Health Care in Rio Rancho, N.M.

"She's on the ball," he says. "An office visit lasts as long as it takes, with no pressure or scheduling squeezes. If I have any questions, they're answered."

Other members like Mike Garrett of East Lansing, Mich., prefer a physician assistant over a doctor. He's seen Jennifer Weston of Sparrow Family Medical Services in Lansing, Mich., for more than six years and likes the attention she gives to his overall health. "It's always nice to have someone really take the time to listen to your concerns," he says.

Stephen Hanson, president of the American Academy of Physician Assistants, says physician extenders typically have more time to spend with patients thus giving doctors more time for the cases that are most demanding.

When patients get their needs met, feel cared for and get their questions answered, they rapidly become comfortable, no matter what type of provider is in an exam room. "It also helps when your supervising physician is supportive and extends trust to you in a visible manner," he adds.

Practice under supervision

But for nurse practitioners like Houck who want to practice on their own, it hasn't come without obstacles. For one thing, Nebraska law requires she work under a collaborative agreement with a doctor who practices within 75 miles of her clinic. Just 12 states and the District of Columbia allow nurse practitioners to operate fully independent practices.

Finding a doctor to agree to partner was a struggle for Houck. She says she contacted at least 50 doctors who all declined her offer.

"Many said they were already too busy," she says. "Some said they didn't think a clinic was needed in the small town."

Houck eventually found a doctor to work with. For the most part, she says she doesn't mind the requirement, as she encounters patients with problems beyond what she's trained to treat such as bone fractures, pregnancies and neurological ailments, which she refers to the doctor.

The Nebraska Medical Association is opposed to nurse practitioners operating independently. Dale Mahlman, executive director of the NMA, says they have concerns over the delivery of care.

"I don't think there's any question they follow two very different educational tracks," he says. The American Medical Association's policy guidelines state nurse practitioners must be part of a medical team under the supervision of a physician.

Craig Bartruff signed on to be Houck's collaborating doctor about nine months ago, when the previous doctor she worked with moved away. He says he feels confident in the care she provides and knew she could run her own clinic.

"She has the skills and experience," says Bartruff, who believes nurse practitioners bring a more holistic approach, emphasizing preventative care. "I think it's something doctors don't always have a good handle on," he says.

Doctor, physician extender relationships

Because nurse practitioners work under their own license with their own malpractice insurance, some consider the requirement to partner with doctors a burden, which can cause tension among providers.

"Traditionally, physicians have been the captains of the medical ship," Towers says. "Now that there are lots of other providers, I think doctors feel like they're losing control."

Dr. Barry Silbaugh, CEO of the American College of Physician Executives, says overall he feels nurse practitioners and physician assistants work collaboratively with doctors. He doesn't believe most doctors feel they're losing control especially as a new generation embraces the changes.

"Many young physicians tell us they enjoy multidisciplinary teams," he says.

Primary care Dr. Robby Gulati, who works at Wishard Hospital in Indianapolis and who's Williams' supervising physician, says he doesn't view physician extenders as competition to doctors.

"I feel I always get a helping hand in a physician assistant or nurse practitioner," Gulati says.

Hanson says physician assistants typically integrate well into physician-led teams.

"All in all, I think our working relationship has been a pretty good one because we've been attached at the hip for four decades," he says, adding they take some of the same college courses with doctors. "We tend to build close relationships with doctors — it starts from the moment we begin training."

Complementary, not contradictory professions

Silbaugh expects there would be less tension among nurses and doctors if they trained together. The American College of Physician Executives recently opened its membership to clinical affiliates of doctors, including physician assistants, nurse practitioners and registered nurses. Members can attend professional ACPE conferences and have access to the same journals and health care news updates that traditionally would have only gone to physicians.

Silbaugh says it's too early to gauge the impact, but he's hopeful it will help health care professionals relate to one another.

Angie's List member Jeanine Callahan and her family have been going to Herndon Family Medicine in suburban Washington, D.C., since 1991. She describes the highly rated practice as successfully weathering the changes in primary-care medicine.

It has grown to include nurse practitioners, massage therapists and physical therapists in addition to a stable of primary-care doctors, Callahan says. But the quality of care has never declined. "We like all of their physicians and nurse practitioners," she says.

Dr. Janice Ragland, a partner at the clinic and president of the Virginia Academy of Family Physicians, says the clinic's success begins with the attitudes of its employees. "We hire people who respect others and that's how we act," she says.

Ragland emphasizes teamwork, and says she sees the varied training doctors, physician assistants and nurse practitioners bring to the table as complementary, not contradictory. "We each have different insights," she says.

Silbaugh agrees. "As physicians, we oftentimes are also teachers, and we need to make others feel they're a valued part of the team."

— additional reporting by Jackie Norris and Michael Schroeder


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The number of doctors going into primary care declined by a third between 1998 and 2008, while physician assistants and nurse practitioners working in the field has grown by about 75 percent in the past 10 years.

Leave a Comment - 4


Susan Beidler


Astersia, there is more than one acceptable way to hold an otoscope.
Brian, you are absolutely correct, all types of health care professionals are needed. You are absolutely incorrect in your statement that all NPs should function within the framework of a physician led team. Rather than suggesting this is propaganda, review the evidence based literature and you will find that NPs have been practicing autonomously for more than 4 decades; providing high quality, safe, and cost effective care. Regarding your last statement: many NPs are PCPs and as such provide 24/7 care with full liability.



There is need for all types of health professionals in our health care system. Yet NPs should only work within the framework of a physician led team. Their experience and training is meager in comparison to a physician, and to claim otherwise is a patent lie. Such propaganda pieces like these fed by the NP leadership do a disservice to patients and NPs alike. If NPs view themselves as doing what doctors do, then why don't they take full call responsibility, cover their patients 24/7, accept full liability risk (and the payments) and all the other undesired aspects?



Ms Houck is holding the otoscope incorrectly. She should cause an ear injury. How is one to have confidence in the care if the training is not up to par on such a simple thing?

Chuck Andrews


I recently submitted a review of WhiteGlove House Call Health, a relatively new organization that provides house call services for routine medical needs. The providers are nurse practitioners and to date I have been very pleased with the quality of the care they provide and their use of technology (web and mail) to communicate and follow up. I hope to see more organizations like this in the future.

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