By Christina E. Sanchez • THE TENNESSEAN • June 17, 2010
Jim Cheeks wears a white lab coat, carries a stethoscope to listen to your heart and writes prescriptions for what ails you.
But Cheeks isn't a doctor. He is a family nurse practitioner who co-owns a primary care practice, Mount Juliet Family Care, without an onsite doctor.
Cheeks and co-owner Bruce McLaughlin are part of a growing movement of nurse practitioners breaking out to start independent primary care practices. With fewer years of schooling and less debt, they enter the work force at five times the rate of primary care medical residents.
Nurse practitioners believe they could be part of the solution to the growing shortage of primary care doctors and ever-expanding health-care costs. But some question whether they have sufficient training to ensure that patients are safe.
"Physicians train for as long as they do for a reason. It's to look for underlying issues and provide comprehensive medical care," said Kasey Dread, executive director of the Nashville Academy of Medicine, a chapter group of the Tennessee Medical Association. "It's about patient safety, from the physician's perspective."
"In a family practice I do most things a general practice physician does, and there is not a lot I wouldn't feel comfortable treating," said Cheeks, who opened his practice six years ago.
"More and more, we will become the primary care provider for more patients. Nurse practitioners are very competent and capable to manage routine health issues."
Doctors oversee care
The nation is expected to see a shortage of about 140,000 primary care doctors by 2025, and medical schools aren't turning out enough future doctors to fill the gap. Nurse practitioners say they are prepared and competent to help. They are registered nurses trained in advanced nursing practices at the master's or doctoral level. An estimated 135,000 nurse practitioners work in the United States today, an increase of more than 60 percent since 2005.
In Tennessee, nurse practitioners are required to contract with a supervisory doctor, who doesn't have to be present during patient visits but must sign off on 20 percent of patient charts each month. The supervisory doctor can be held liable for any discrepancies by the state Board of Medical Examiners. Nurse practitioners also are held responsible under their licensing board rules. Under state law, nurse practitioners can write any prescription, including narcotics, just as doctors do and can see anyone for any health issue.
About two years ago, the Tennessee Medical Association created a committee to examine whether the state laws were strong enough to protect patients, said Dr. F. Michael Minch, president-elect of the industry organization.
"The way the laws are put together, right now, seem to function very well," said Minch, who headed the committee. "We didn't see any incidences where patients were harmed."
Minch said the medical association offered guidance to doctors on the issue.
"The crux of the matter is there should be an ongoing interaction between physician and nurse that allows for consultation," he said. "As we come up on the primary care shortage, particularly in primary care, we are going to need them, but there should be an effective relationship."
Dr. Karen Duffy, of Madison Minor Medical Center, doesn't like the idea of nurse practitioners in private practices. After one bad experience that almost led to a malpractice suit, she won't use them in her practice.
"Primary care physicians need to know so much about so many things," said Duffy, who has been practicing for 27 years. "A patient can walk through your door and on the surface seem fine, and really be very, very ill. They have not had enough experience."
She agrees a solution is needed for the doctor shortage but doesn't believe that includes nurse practitioners.
"I know the way things are going that is being pushed by insurance and government because it's cheaper," Duffy said.
Profession is growing
Cheeks said insurance companies, including Medicare and TennCare, are willing to reimburse him as a primary care provider, though sometimes at a lower price.
"Medicare reimburses at 85 percent of the physician fee schedule," he said. "Many will reimburse for the same level of service."
Listed as primary care providers on insurance networks, Cheeks and his partner have expanded to two clinics — the one in Mt. Juliet and another in Watertown. Among four practitioners and staff, they have about 18,000 patients.
"There would be a lot of nurse practitioners doing this, if more physicians were willing to fill the supervisory role," Cheeks said. "If you take the handcuffs off of nurse practitioners, it will immediately improve the availability of primary care providers without hurting physicians' practices."
Patients such as Katy Johnston increasingly are choosing nurse practitioners, who have an estimated 600 million patient visits each year, according to the American Academy of Nurse Practitioners. By comparison, physicians' offices have about 902 million visits each year, according to data from the Centers for Disease Control and Prevention.
Johnston went to her first nurse practitioner appointment six years ago, not fully understanding the differences between the advanced nurse and a physician. She was looking for a woman provider close to home and wanted to feel like she wasn't rushed — not always the case with her previous primary care providers, she said.
She found Jane Case, a nurse practitioner for the Vanderbilt Clinic in Green Hills.
"It's been seamless for me. She writes prescriptions, she makes my referrals and she sits with you like a family member to answer all your questions," Johnston said.
Case has been a primary care provider for 10 years, building a base of 4,000 patients.
She sees about 20 patients a day for sick visits, stress concerns, well-woman exams and chronic disease management.
Case also was in the first graduating class this spring in Vanderbilt University's Doctor of Nursing Practice, a doctoral-level program for nurse practitioners.
Education costs less
The American Academy of Nurse Practitioners wants all nurse practitioners to have doctoral-level degrees by 2015 to bring them on educational par with other health-care providers, such as pharmacists, medical doctors and psychologists.
With the doctoral degree, a nurse could spend six to eight years in school, including undergraduate, master's and beyond. Nurse practitioners' average debt for schooling is about $64,000. Doctors usually do four years of undergraduate work, four years of medical school and two to three years of required residency training, acquiring an average of $141,000 in debt.
About 120 Doctor of Nursing Practice programs, five-semester doctoral degrees, exist around the country, and Vanderbilt is the only one in the Nashville area. The University of Tennessee Health Science Center in Memphis and Union University in Jackson also offer the degree.
Another 161 programs are in the planning stages, said Donna McArthur, director of the Vanderbilt program and nurse practitioner.
Case hopes that the future of health care includes collaboration between doctors and nurses of all levels and specialties.
"Health-care reform will be a blessing for so many because there are so many who are in need, but there will also be more patients who need care," Case said. "And as for how our role will change — we'll be seeing or at least helping more patients."