No one likes to get sick, but it does help matters when you like the person treating you. In that respect, Alice Heflin considers herself lucky: She has a great rapport with her primary care provider, Jan DiSantostefano. “Sometimes, when you first visit a health-care provider, you don’t connect with them. I connected with Jan immediately,” recalls Heflin, a 44-year-old Carroll County resident who has been seeing DiSantostefano for about eight years. “Jan is a good listener. She answers your questions. You never get the impression she’s trying to speed you through your appointment to see the next patient.”
With the abundance of top-notch medical professionals in the Baltimore area, Heflin’s satisfaction isn’t too unusual, except for one thing: DiSantostefano isn’t a doctor. She’s a nurse practitioner, a relatively new category of health professional being used by more and more people as primary care providers.
In January 2003, there were 2,259 certified nurse practitioners (NPs) in the state of Maryland, a 60 percent increase since 1997, says Janet Selway, a nurse practitioner and former president of the Nurse Practitioner Association of Maryland (NPAM). And the demand for nurse practitioners is expected to continue to climb as managed care and an aging population increase the need for health-care providers. Undoubtedly, much of what makes NPs attractive to health-care organizations is their lower cost. The average annual NP salary in Maryland is $63,882; the national median income for internists, $140,000.
But for most patients, there’s no difference in price between seeing an MD or an NP—in fact, there’s not much of a difference in any aspect that a patient can see during a normal visit. Here in Maryland, NPs can give physicals, diagnose chronic and short-term health problems, order and interpret lab tests, give referrals, and provide emergency care. While many work in family practice, in Maryland they can be certified in seven other specialties, including psychiatry and neonatal care. More and more often, they are turning up in areas as diverse as cardiology, substance abuse, and transplantation.
This wasn’t the original idea. The first NP training program was created in 1965 at the University of Colorado as something of a stopgap measure—faced with a dearth of doctors, the medical community wanted to give experienced nurses enough training to serve as primary-care providers in underserved areas, and for poor and rural children in particular. Over time, the role of nurse practitioner became broader and increasingly respected, and nurse-practitioner training programs opened at universities around the country. (Locally, the University of Maryland, Johns Hopkins, and Coppin State all offer NP training programs.) Later, as traditional insurance companies gave way to managed care and its cost-cutting strategies, nurse practitioners, sometimes called “physician extenders,” gradually became an integral—and cost-effective—part of today’s primary-care team.
Today, NPs work in virtually any setting that a physician would, including private practices. DiSantostefano has worked at Westminster’s Airpark Primary Care for 10 years. She practices acute care of the “I’ve-got-a-cold-I’ve-got-a-cough” variety, she says, along with a fair amount of family and women’s health. Last year, she treated 4,500 patients.
But make no mistake, NPs aren’t doctors. There are key differences between the two professions, though many are of a behind-the-scenes variety that patients never see or notice.
The first, of course, is education. Nurse practitioners are advanced practice nurses with masters’ degrees or higher who have completed a certification program in their specialty. Typically, a doctor has had eight years of school—four of undergraduate, four of med school—followed by a two-year residency. Nurse practitioners generally have six years of school—four undergrad, two graduate.
Then there’s accountability. NPs work within very specific parameters according to a written agreement signed with a collaborating physician. The agreement, which is sent to and kept on file at the Board of Nursing, spells out the NP’s role in a particular job and what functions he or she can perform independently.
The agreement also details the collaborating physician’s role in the partnership: The collaborating physician must accept the NP’s referrals, must establish and review drug and other medical guidelines with the NP, and must participate with the NP in periodically reviewing and discussing medical diagnoses. The collaborating physician also needs to be available for consultation, and must designate an alternate physician in his or her absence.
Collaborating physicians typically work out of the same practice, in the same department, or for the same organization as the NP they partner with, which makes collaboration easy. (In DeSantostefano’s case, for instance, she has a collaborating agreement with Airpark’s two physicians.) But by law, the collaborating physician does not have to be on site or supervise the NP’s work in person. “The letter of agreement is a collaborative one, not a supervisory one,” says Anna Osztreicher, an NP who coordinates a diabetes and pregnancy education program at Sinai Hospital, and who is the Baltimore district director of NPAM.
Some physicians’ organizations, such as MedChi, the Maryland State Medical Society, have argued that this legal freedom creates an environment where NPs could be practicing beyond their abilities—and for many years, there has been something of a turf war between MedChi and NPAM over just what NPs should and shouldn’t be allowed to do.
Chief among concerns was a proposal to allow patients in HMOs to designate NPs as primary care providers. Currently, if an HMO subscriber chooses to see an NP for primary care, in most cases, the subscriber officially selects the NP’s collaborating physician as provider. If that physician should leave the HMO, the consumer loses access to their NP. Similarly, if the NP decides to work under another physician within the network, the consumer needs to select that other physician as a provider to continue seeing the NP.
For years, NPAM had been trying to introduce legislation allowing NPs to be primary care providers in HMOs. And for years, MedChi had fought to defeat it, arguing that such legislation would limit patient access to doctors—if HMOs had the choice, MedChi reasoned, they would discourage their subscribers from going to doctors and coerce them into choosing less-expensive nurse practitioners as their primary care providers. Eventually, MedChi said, seeing a doctor for primary care could become well-nigh impossible in the cost-conscious HMO system.
This year, however, a compromise seems to have been struck: In collaboration with NPAM, MedChi supported a state bill enabling consumers who belong to HMOs to select NPs as their primary care providers, as long as the patient is told who the NP’s collaborating physician (who must work at the same location) is and how to contact him. The bill has passed both senate and house.
With this new legislation, “we’re not ghosted behind physicians,” says Deb Baker, an acute care NP at Johns Hopkins and NPAM president. “[For NPs], it’s a visibility issue more than anything. Our patients will be able to find us and stay with us more easily.”
Despite the sometimes tumultuous history between their respective professional organizations, however, most NPs and MDs have a great deal of respect for each other. “Their [letter of agreement] details which procedures they can do on their own, and which must be performed under direct supervision,” says Susan Dulkerian, MD, director of nurseries at Mercy Medical Center, who supervises 15 NPs. “Our NPs confer with the attending physician on every treatment plan. The system is set up so that they can practice safely and provide excellent care. And they do.”
Beyond education and professional freedom, many NPs and their patients see another big difference between nurse practitioners and doctors. Some NPs say that they approach patient care differently than many physicians do. “It’s actually part of how we are trained,” says Todd Ambrosia, an NP who teaches at the University of Maryland School of Nursing and works at the school’s faculty practices. “Ours is more of a wellness schedule—more holistic, more mind, body, spirit—than a
Nursing education emphasizes health counseling, patient education, and disease prevention, says Selway, who teaches at the Johns Hopkins School of Nursing. “NPs integrate both nursing and medical skills during a patient encounter,” she says. “Our goal is not only to diagnose and treat the health care problem, but to use nursing skills to minimize any negative emotional or physical impact the problem might cause.”
This is probably part of why nurse practitioners score high on patient satisfaction surveys. It’s certainly worked for Deborah Harrell, a Dundalk resident who began seeing Selway at the Anne Arundel Family Health Center in Brooklyn about four years ago.
“Janet was the first nurse practitioner I’d ever seen,” says Harrell. “When I went to her office, I was comfortable—not tense like I usually was in a doctor’s office. She spent more time with me than [doctors] had in the past and she asked me more questions.”
Harrell, who works at Baltimore- Washington International Airport, first came to Selway when she began coughing and having trouble breathing. “I thought I just had bronchitis,” Harrell, 37, recalls.
But in the course of their visit, Selway talked with Harrell about her work history. Harrell worked outside the airport as a baggage handler. Previously, she had worked in a coffee plant where she breathed in coffee dust every day for four years. “I had the dust all over me. I’d come home and I’d be blowing it out of my nose,” Harrell recalls.
Selway suspected that Harrell’s exposure to fumes at the airport and the coffee dust might have brought on a condition called chronic cough asthma. She sent Harrell to a pulmonary specialist who confirmed the diagnosis. Harrell now works inside the airport in security, so she’s no longer exposed to exhaust fumes, and has started carrying an inhaler. She is breathing a lot easier these days.
It is that same philosophy that keeps Alice Heflin coming back to DiSantostefano’s office every week for her three allergy shots. In the past seven years, DiSantostefano has treated Heflin for conditions including an allergy to sulfites (a common food preservative), a deadly allergy to bee and wasp stings (which requires her to carry an epinephrine pen), and for type-2 diabetes.
Heflin recently received an e-mail from DiSantostefano about an article that said some epinephrine pens might contain sulfites as a preservative. For Heflin, this could be dangerous: The pen could bring on one allergic reaction while trying to prevent another.
“Jan wanted me to know so I could see if my brand was using this preservative,” says Heflin. “She is so thorough and has such good follow-through . . . I would rather see her than a physician. To me, she’s just as good as a doctor.”