Should your next family doctor be a nurse practitioner? As the shortage of family doctors in the U.S. increases, nurse practitioners (NPs) are turning up in growing numbers in family-medicine practices and independent clinics across the nation.
Currently, there are more than 234,000 nurse practitioners licensed in the US; 79% provide primary care, according to the American Association of Nurse Practitioners.1 NPs are nurses with advanced training; they’re licensed to assess patient health, order and evaluate medical tests, prescribe medications and develop care plans.2 Proponents say their basic training as registered nurses means that many are also good at inspiring patients to make healthy choices. “Nurses are trained to take a holistic approach.
And for health conditions like diabetes where motivating people to make healthy choices every day is so important, that can make a big difference,” says Virginia Valentine, APRN-CNS, BC-ADM, CDE, FAADE, a clinical nurse specialist and a member of the clinical associate faculty at the University of New Mexico in Albuquerque. A diabetes specialist, she practices in a nurse-managed clinic, Sage Specialty Care, in Albuquerque.3
Some people prefer a physician for their primary care and others need to work with a primary-care doctor or specialist for more complex health problems like diabetes management, she notes. “But every day, people tell me “I love talking to you. You see me as a whole person.” Nurses are trained to take a holistic approach. And for health conditions like diabetes where motivating people to make healthy choices every day is so important, that can make a big difference.”
Valentine notes that patients often feel as if they’ve spent more time with an NP during an office visit compared to time spent with a doctor—a sign that they may feel a different connection with this new breed of a healthcare practitioner. “People feel like we’re spending more time with them and that may be true, but in a lot of practices advanced-practice nurses see as many patients as physicians,” she says. “I don’t think its more minutes, it's more time in terms of listening.”
More Americans than ever get their routine health care from an NP. Between 1998 and 2010, the number of older adults who saw an NP grew 15-fold in some states, according to a 2013 study from the University of Texas Medical Branch, in Galveston.4 Should you see an NP for your primary care if you have diabetes? Here are four things to consider:
To earn the advanced practice registered nurse (APRN) credential – a title that includes certified nurse practitioners as well as certified nurse midwives, nurse anesthetists, and nurse specialists—a nurse must have a bachelor’s degree as well as a master’s or doctorate in nursing.5 That can take 5 ½ to 7 years and could include up to 5,350 hours of training and hands-on practice with patients.6
By law, an NP’s “scope of practice” is almost as broad as a family doctor. NPs can order, perform and interpret medical tests; diagnose and treat short-term conditions; manage on-going, chronic conditions like diabetes and high blood pressure; prescribe medications and other treatments; and counsel and educate patients and their families about preventing diseases and managing health conditions, according to the American Association of Nurse Practitioners.7
In 22 states and the District of Columbia, NPs can diagnose and treat patients without a physician’s oversight. And in many of those states, NPs can prescribe medications without a doctor’s involvement. In other states, NPs must have a formal relationship with a physician in order to practice.8 Find out what NPs can do in your state by checking the website of the American Association of Nurse Practitioners state-by-state map and list.
NPs can provide 80-90% of the health services provided by primary-care doctors, according to the Kaiser Permanente Foundation.9 In most states, NPs work in primary-care practices run by doctors. But even in states where NPs have their own clinics, patients also see MDs when needed, Valentine says. “Someone with a chronic health problem that is not responding to treatment, such as resistant high blood pressure or a person with complex medical issues may need the diabetes management care and expertise of a primary care doctor or a specialist,” Valentine says. “That’s also true for someone with diabetes who has complications and may need to see an endocrinologist, cardiologist, ophthalmologist or another specialist for advanced care.”
Recent studies suggest that people with diabetes do as well—and in some ways, slightly better—under the care of an NP compared to a family physician:
Blood sugar benefits on par with a doctor’s care. In a recent Yale School of Medicine study 10 in the March 2018 issue of the American Journal of Medicine, researchers tracked 19,238 military veterans with diabetes for five years. Most—78%— got their primary health care from a doctor, but about 14% saw a nurse practitioner and about 7% saw a physician assistant most of the time at routine health visits.
The three types of practitioners prescribed oral diabetes medications when their patients’ blood sugar levels reached about 7.5% and added a second drug if A1cs rose to an average of about 8%. Nurse practitioners recommended insulin a little sooner—when a patient’s A1c reached about 9.4%, versus 9.7% for doctors.The bottom line: “Diabetes management by nurse practitioners and physician assistants was comparable to management by physicians,” the researchers conclude.
Fewer hospital stays for diabetes-related health problems. People with diabetes who got their primary care from a nurse practitioner, instead of from a doctor, were up to 10% less likely to land in the hospital with problems like uncontrolled high blood sugar, episodes of low blood sugar, urinary tract infections, dehydration and pneumonia in a September, 2015 study from the University of Texas Medical Branch in Galveston. It was published in the journal Medical Care.11
Researchers analyzed the Medicare records of 345,819 older adults with diabetes for up to four years; 93,443 got all of their primary care (such as check-ups, help with for short-term illnesses and management of diabetes and other chronic conditions) from nurse practitioners (NPs).
The other 252,376 saw a family doctor, general internist or geriatrician. Study participants who lived in small towns and rural areas got the biggest benefits in terms of sidestepping avoidable hospital stays. That may reflect easier patient access to NPs – in person and on the phone – that keeps small problems from becoming emergencies, says study co-author Mukaila Raji, M.D., M.S., FACP, Professor and Director of the Division of Geriatric Medicine at UTMB.12 “Early treatment can potentially prevent a mild acute problem—such as a bladder infection or early pneumonia— from progressing to such severity that hospitalization is required,” she says.
More self-care and education. In a 2008 study from the University of Medicine and Dentistry of New Jersey of 846 people with diabetes, those who got their primary care from medical practices with nurse practitioners on the staff were more likely to check their A1C and cholesterol levels than those without NPs on staff.13
And a 2014 University of Nebraska study of 136,432 people with chronic health problems such as diabetes, high blood pressure and heart disease found that NPs offered health education about healthy eating, exercise, weight loss and stress reduction more often than family doctors did.14
Plenty of Americans are already receiving health care from an NP. In one recent survey15 of healthcare consumers the journal Health Affairs, nearly one in four said their primary healthcare provider is an NP or another non-physician healthcare provider like a physician assistant. And 81% had received care from one of these professionals at one time or another. If you’re not among them, you may be soon.