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Last week’s article on nurse practitioners prompted diverse responses. Most of them were enthusiastic, but a couple were decidedly dissatisfied.

The article argued that nurse practitioners should not be required by legislation to establish formal relationships with family physicians as a condition of their right to practice. Secondly, it argued that the system should experiment more broadly with letting various health professionals expand their roles.

Those who were positive agreed that nurse practitioners should not have a legislated obligation to link to a family physician. Nurses are regulated by the College of Nursing of Nova Scotia. In the past 15 years there have been 163 proceedings that resulted in reprimands, suspensions, or revocations of license.

One observed that experienced nurses in senior roles are often an important source of development advice for newly minted physicians.

In addition, most of the responders focused on the broader idea of more flexibility in roles for health professionals.

For example, one correspondent describes “a program of Clinical Assistants in Mental Health and Addiction services in the Eastern and Northern zones. The candidates are currently in the initial phase: assessment and training. So far so good, not an overall solution but a big help to an overwhelmed system in these two zones.”

Another idea, widely used elsewhere, is Family Practice Anesthetists. They are fully licensed and certified family physicians who have done one year of extra training. They can handle a lot of the load that would otherwise require anesthetists with several more years of training.

Two correspondents expressed serious concerns. They were not about the explicit issue of what the legislation should require but rather viewed the article as promoting a further deterioration of the status of physicians.

Worries expressed included:

  1. Nurse practitioners take work away from family physicians. They don’t always keep the family physician informed about changes they make to treatments. Delivering care through nurse practitioners is more expensive than through family physicians.
  2. When the family physicians are notified of decisions—say a prescription—by a pharmacist or nurse practitioner, they have to review it for no fee and may be responsible if things go badly.
  3. The article was promoting more power for nurses’ unions who already have too much. Management of the healthcare system is dominated by nurses. Nova Scotian nurses are among the highest paid in the country, while doctors are among the lowest.

Not all of the assertions in the correspondence are accurate.

Nevertheless, there are valid issues.

  1. When a doctor sees a patient, she gets a fee for service. The economic pressure is to get it done as quickly as possible. The time allotment is 15 minutes. A nurse practitioner is paid a salary and has no reason to hurry. He is supposed to spend 30 minutes with each patient, but still gets paid if there are not enough patients to fill the day.
  2. Family physicians in Nova Scotia continue to be poorly paid. The government made some useful interim steps last March, but more needs to be done.
  3. In some of our rural areas, the population is shrinking but the workload is not because those remaining are much older than the provincial average.
  4. Decision-making is still far too concentrated at the top of the NSHA pyramid. A position of Vice President and Chief, Zone Operations has been established, but it will not be filled until June. It is not clear whether or how this will result in downloaded decision making.
  5. When there is an unexpected departure from a small group of practitioners outside of Halifax, be they specialists or family physicians, it takes a long time for a replacement to be found. Given that we are already understaffed in many areas, there is no bench strength.
    The added seats at Dalhousie Medical School are welcome, but it takes a long time for them to graduate active practitioners.
  6. Family physicians and many specialists are independent business operators. The province is a contractor, not an employer, and cannot direct them to move to the areas of greatest need. Many feel no responsibility for succession planning. This makes resource planning difficult for health authorities.
  7. Patients and their families view doctors as their core resource. Nurse practitioners and others are viewed as welcome adjuncts, but complaints are focused on the shortage of doctors.

Family physicians are understandably concerned about their pay and working environment. They should view the growing contributions of other health care professionals as part of the solution, not part of the problem.

To make it work, all of the health professions need to understand that collaboration is more than a “nice to have.” And the health authority needs to be much nimbler and more responsive in its decision making.

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