A 70-year-old woman who had been a patient of mine for years saw me in my office. I had diagnosed her with polymyalgia rheumatica, an inflammatory condition that, in her case, affected her hips and shoulders. Pretty much everything was fine with her, but in one of those revealing, “by the way, doctor” afterthoughts, she mentioned that she was worried about her husband. He was the editor of a major magazine and had been scrupulous about meeting deadlines through-out his career. But he had missed one recently. Even more concerning was that he didn’t seem to care. So this distinguished-looking man, age 72, came in my office a few days later. My neurologic exam didn’t reveal anything of concern except when it came to the serial sevens, the test that involves patients subtracting in sevens starting at 100. He got stuck at 93.
By itself, serial sevens isn’t diagnostic, and people who are not good with numbers may have some difficulty with it. But the test remains a quick and easy way to assess concentration and memory. That this obviously intelligent gentleman got stuck after only one subtraction was concerning. When I asked him about missing a deadline, he told me he didn’t know why he didn’t care. I ordered a CT scan of his brain. The radiologist called back with urgent news: the scan showed that he had a large (the size of a plum) meningioma, a tumor that originates in the meninges, the membranes that cover the brain; his was impinging on the frontal lobes where higher order thinking takes place. It was surgically removed and over time he became more self-aware, recognizing his previously aberrant behavior.
Here is another case that has stuck with me. He was a 50-year-old male, somewhat disheveled appearing. His problem was loose stools. He had been through the gastro-intestinal gauntlet: visits with specialists, upper and lower GI studies, stool studies looking for evidence of infection. But so far, there had been no resolution. As we talked and as I was conducting my exam, he was sucking on hard candies. It was odd and off putting. He told me that the candy-sucking habit was his way of coping with the dry mouth from the radiation treatments he had received for laryngeal cancer. I had an aha moment: The candies were the sugar-free Sorbees, which are sweetened with sorbitol, a sugar substitute that is an osmotic agent and can function as a laxative. I suggested that he stop with the candies and find other ways to deal with his dry mouth, such as frequently sipping on water, breathing through his nose rather than mouth, and stopping antihistamines that he was taking for allergies. Soon afterward, the loose stools—and all the GI workups—stopped.
A third case involved addressing a major case of polypharmacy. He was a new patient, an Asian gentleman who looked exhausted and was struggling with fatigue and dizziness. I saw that he was on a dozen different medications, including two different generic beta blockers, a calcium blocker, digoxin, and an SSRI for depression. He had an irregular heart rhythm, and a ECG showed a Mobitz I second degree heart block (Wenckebach)—the electrical signals to his heart were impeded, resulting in a slow and irregular heart beat. I stopped one of the beta blockers as well as the digoxin and SSRI. His heart rhythm returned to normal. The fatigue and dizziness went away.
I am sure that every internist and family practitioner reading these anecdotes has encountered something similar—a puzzling patient that is the occasion for a diagnostic epiphany. These are the intensely satisfying, salient episodes of intuition informed by our long hours of medical training.
One response to the dire shortage of primary care in many parts of the country is to allow nurse practitioners to establish practices independent of physicians. The appeal of this approach is understandable. We’ve been discussing the shortage of primary care physicians for decades. Getting young doctors to go into primary care is harder than ever because the pay is meager relative to what they can earn as specialists. Nurse practitioners are increasingly well trained. There is hardly a doctor in the country who isn’t working with nurse practitioners in some capacity.
But would a nurse practitioner have recognized, diagnosed, and addressed the issues in the three cases I have just described? Are they comfortable delving into complex polypharmacy issues and stopping medications prescribed by physicians? Can they recognize Wencke-bach and its importance on an ECG in the office? I would argue probably not.
“Nurse Practitioners Are Valuable Members of the Team—But They Aren’t Doctors.” That was the headline on a letter by Kenneth Dinkage, MD, that was published earlier this year in Medical Economics. “Although it is true that one should think of horses when hearing hoof beats, one also needs to be aware of the existence of zebras, and that requires the type of training that only a physician undergoes,” wrote Dinkage. The training of a primary care physician is markedly more involved and much, much longer than the training for a nurse practitioner. For a board-certified family practitioner, it totals 21,000 hours. At between 3,500 to 6,000 hours, a nurse practitioner’s training is a fraction of that.
Here in Pennsylvania, advanced practice registered nurses are pushing for a change in state law so they could practice independently from physicians without the collaborative agreements that are currently required. The American College of Physicians, the national organization for internists that has its headquarters in Philadelphia, has opposed the change. While recognizing the value of advanced practice nurses, the internists’ organization is correct in saying that independent practice is a “solution in search of a problem”; there is no evidence that it would fix problems that collaborative agreements are causing.
One argument for independent practice is that nurse practitioners charge less. But they also tend to order more diagnostic tests than physicians, so the savings are not as large as they might appear.
As medicine and pharmaceutical regimens become more complex, we need more, not fewer, excellent primary care physicians. The current fragmentation of care is troublesome. And, frankly, so is the lack of critical rea-soning. I have experienced it firsthand as a hospital patient and have seen it when family members have gotten medical care.
I am not against new models of primary care. A primary care physician overseeing several nurse practitioners and physician’s assistants is an excellent way of increasing access to care without sacrificing quality. But the desperate need in American health care for a more holistic view of the patient and coordinating and communicating with multiple specialists when patients have complex or chronic diseases cannot be met by replacing primary care physicians. In fact, the unmet need will get even greater if we do that.