Doctor-nurse practitioner collaboration can be fruitful

A team of health care professionals calls for the two to work better together.

By Damon Adams, amednews staff. Oct. 7, 2002.

When David Mehr, MD, sees patients in the clinic or nursing home, nurse practitioner Melba Hall stands ready to help. The Missouri family physician views Hall as a vital partner to providing quality health care.

"Melba and I have a very strong collaborative relationship," said Dr. Mehr, an associate professor in family and community medicine at the University of Missouri-Columbia. "She contacts me about problems, and I contact her. We alternate visits on patients with diabetes. If I'm not in the office, she will see some of my patients."

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A recent analysis of the work relationship between doctors and nurse practitioners said such collaborative efforts can improve patient care. In an article in the September/October issue of Health Affairs, a team of family physicians and nurse educators called for studying, training and deploying a collaborative, integrated work force.

"We need to break out of these turf wars and do some good research and planning on how these work forces can work together. If patient-centered care is the real goal, we've got to learn as physicians to work with nurse practitioners," said Bob Phillips Jr., MD, lead author and assistant director of the Robert Graham Center: Policy Studies in Family Practice and Primary Care in Washington, D.C.

Dr. Phillips, two others from the Graham center and two nurse educators looked at the relationship. In their analysis of published articles, the authors trace nurse practitioners from their start in 1965 to their role in health care today. They said nurse practitioners have moved toward more independent decision-making, but physician and nursing organizations have sparred over practice control and reimbursement.

In the last 15 years, state practice laws have steered away from requiring physician supervision of nurse practitioners, they said, adding that nurse practitioners have some prescriptive authority in each state.

Patients benefit from the combination of nurse practitioner and physician skills, the authors found. Studies of physician-nurse practitioner teams demonstrated cost and quality improvements in nursing homes, emergency rooms and surgical inpatient settings. But the work relationship is hindered by regulatory variations and skirmishes between organizations.

"There are a lot of physicians with deep scars from scope-of-practice battles," Dr. Phillips said.

The authors offer some suggestions to achieve effective collaboration:

Revise payment systems.
Define shared authority and accountability.
Stipulate integrated education and certification requirements. Educate new generations of physicians and nurse practitioners for collaborative and patient-centered care.
Fund health services research focused on integrated care models.
Assess and plan the work force jointly.

"This is all about delivering the best care for patients," said co-author Doreen Harper, a nurse practitioner and a dean and professor at the University of Massachusetts-Worcester Graduate School of Nursing. "This is about moving away from a parochial mindset to one that looks at how nurse practitioners and doctors can work more collaboratively."

The American Academy of Family Physicians said nurse practitioners should not function as independent health practitioners but work in a collaborative arrangement under a practicing, licensed physician's direction.

"Every team needs a quarterback or captain that brings it all together, and that's what we do," said AAFP Board Chair Richard Roberts, MD.

"It would be good for us all to work together, and we're certainly willing to do that," said Jan Towers, PhD, a nurse practitioner and health policy director of the American Academy of Nurse Practitioners.