Role of nation's nurses could be upgraded by changes in U.S. health care

June 28, 1993|By Los Angeles Times

WASHINGTON -- When Dr. Claude Harwood retired in 1990 after 34 years as an old-fashioned family doctor in rural Glasco, Kan., population 600, his patients faced an uncertain future: There was no physician in town to replace him.

Instead, he turned his practice over to two nurse practitioners -- nurses with advanced medical training who in many states can even write prescriptions.

"There were a few people who said: 'I'm not going to a nurse, I want a doctor,' and a few wondered how they would get their medicines, but as a whole, the town has been very supportive and receptive," said Debbie Folkerts, one of the nurses who has since assumed the practice by herself in the town 35 miles north of Salina.

Ms. Folkerts, whose patients are mostly farmers and retirees, frequently treats conditions such as hypertension, diabetes, respiratory illnesses, congestive heart failure, acute trauma and injuries from accidents. She stays in close contact with a supervising physician 22 miles away. In an emergency, Ms. Folkerts sends her patients via ambulance to the regional hospital.

For many nurse practitioners and physician assistants -- who are trained to deliver primary care -- the Glasco solution answers one of the most vexing health delivery problems plaguing the nation as it attempts to reform the system: the dearth of primary care physicians, particularly in rural communities and inner cities.

Nurses and physician assistants are lobbying the Clinton administration to be included more often as front-line care-givers, arguing that they can perform many of the same services as physicians -- and at a lower cost.

Of the nation's 2.1 million registered nurses, 400,000 already are providing some level of primary or preventive health care services, according to the American Nurses Association.

Similarly, more than 25,000 physician assistants in the United States practice in almost all health care settings and in every medical and surgical specialty, according to the American Academy of Physician Assistants.

The White House health care reformers seem to like the idea of an enlarged role for these groups. First lady Hillary Rodham Clinton, architect of the Clinton administration's health reform effort, has spoken on numerous occasions of the boost nurses are likely to receive under the new plan -- much to the discomfort of the medical establishment.

Do ". . . patients want to risk going to someone who is not trained to look at the fine nuances of disease processes and physiology?" Dr. James Todd, executive vice president of the American Medical Association, asked.

But those who support an expanded role for nurses in the coming years say that doctors are simply feeling threatened by the possibility that they will have to share some of their authority in the medical community, as well as their income.

"It's turf, turf, turf," says Art Caplan, a University of Minnesota medical ethicist who worked with the White House health reform task force. ". . . Authority and prestige are the issues."

Nurses say there should be no reason why they cannot perform such common tasks as well- and ill-baby care, Pap smears, depression counseling, prescribing antibiotics for ear infections, prenatal care, delivery for a normal pregnancy and diagnosing and treating hypertension.

Similarly, physician assistants are trained to perform many of the same functions as physicians, including minor surgery.

Physician assistants say they are content to work under the direction of a physician, but would like to have the authority to write prescriptions.

Exactly how nurses and physician assistants will be used in the coming reform is still unclear. But they will almost certainly be doing a lot more than they are now.

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