Like so many primary-care providers strapped for time, Tricia Angulo-Bartlett crams as much as she can into a 15-minute patient visit. At one last week, she counseled Amy Tucker about her coming surgery, evaluated her chronic sinusitis and scribbled a few prescriptions, taking time to explain the side effects and directions of each one.
Along the way, she managed to ask about Tucker's twin boys. Then Angulo-Bartlett was off to dictate her notes and on to the next patient. She'll see 26 in a typical day.
Such is the life of a busy nurse practitioner, a group of providers that is increasingly helping deliver primary care amid a national shortage of family doctors. Their days may only get busier if congressional health care reform delivers what it promises - insurance to an estimated 47 million Americans, who would be added to an already strained system of primary care.
"It's very problematic to make massive health care reform without addressing this issue first," said Shannon Reedy, who co-directs the adult/gerontological nurse practitioner program at the University of Maryland's nursing school. "If you add more people to a system that is already burdened, it's only going to burden it more."
Nurse practitioners, with their focus on preventive care, make a logical fit to fill the gaps, say some observers. They are also far cheaper than doctors to train and pay - Medicare reimburses them at 85 percent of what is paid doctors. The American Academy of Nurse Practitioners has an ad promoting the fact it has "125,000 solutions to the primary care shortage," referring to the number of nurse practitioners nationwide.
While expanding care will be challenging, nurse practitioners can be a vital resource, and relying on them for more patient care is key among reform proposals, said Jonathan Weiner, professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health.
Overhauling the health care system is an opportunity to reinvent primary care through a concept known as a "medical home," which rewards primary care and places it at the core of patient medicine, he said. Using nurse practitioners as part of a team approach, cutting down on paperwork with electronic medical records and encouraging more people - doctors and nurse practitioners alike - to go into primary care can cut costs and keep people healthier, he said.
"It can work if we reform the system," Weiner said. "We need more supply, but we have to be smart about how we use that supply."
But others insist that just as there are not enough doctors, there is also a shortage of nurse practitioners. And some physicians say nurse practitioners don't have the expertise to handle the load.
"That's using paraprofessionals to do a professional's work," said Dr. Ronald C. Sroka, president of MedChi, the state's medical society. "They will not save money. We will have more tests performed because of lack of experience and more referrals to specialists. It will cost more."
Nurse practitioners say they don't aspire to be doctors, and moreover, that there is a place for various medical professionals when trying to keep patients well.
"I think there are a lot of physicians who have wonderful things to say about the NPs they work with. They see the bigger picture, that we don't have a choice, that we have to take care of people and there aren't enough primary care providers to do that," said Reedy. "There is room at the table for everyone."
In Maryland last year, about 3,200 nurse practitioners were in the field, an increase from nearly 1,500 in 2000, according to the state's nursing board. The roles and responsibilities of nurse practitioners vary by state, but everywhere the field requires a master's degree and national certification. In Maryland, they must have signed agreements with a doctor specifying their duties and responsibilities. The state's nursing board approves the agreements.
Nurse practitioners appear to have all the responsibilities of a doctor - they can diagnose, treat and prescribe medicine. But at the core, their mission is different, said Reedy.
"We still teach [patients] disease management, but we would prefer not to treat disease; we would prefer to keep people healthy. I'm sure many physicians feel the same way, but that is the core of our training as nurses."
The primary-care doctor shortage has been years in the making. From 1997 to 2005, the number of graduates going into family practice declined by 50 percent, the New England Journal of Medicine found. A 2007 study by the Maryland Hospital Association and MedChi found that by 2015, 32 percent of the state's physicians are expected to retire. The report found Central Maryland was the only region in the state that had enough primary-care physicians to meet demand.