Monday, March 21, 2011

Family Medicine: Collaboration at the Confluence with Family Nurse Practitioners

"Excuse me, Doctor, could you sign this prescription for me?", said the nurse practitioner quietly after interrupting my encounter with a patient in our Millersburg, PA rural training site.  It was 1977 when I was a second year Family Practice resident, and I had not seen a clinical nurse practitioner since medical school on a team oriented elective at a community health center in Arizona.  Now I was her clinical collaborator (?) and I was confused.  Was I supposed to be supervising her?  Who was she?  (Who am I as a family physician? wasn't even answered yet).  What does she know or not know?  What do I know or not know?

Fortunately, I was curious, like George (see post Could Curious George be a Family Doctor? ).  "I'm not sure what I'm supposed to do.  What's your diagnosis?  Can I see the patient?" I said to her.  "Yes, Doctor, it looks like otitis media in this eight year old boy," she said respectfully.  She led me to the other hallway and introduced me to the mother and the patient. 
The patient had an upper respiratory infection and otitis media (ear infection).  The prescription was for Ampicillin.  I signed it after verifying the diagnosis.  I remembered the Family Nurse Practitioner, Pat, in Marana, AZ during my medical student multidisciplinary team elective.  She was the leader of the health care team in that community health center with the transient National Health Service Corps physician, a general internist, trained at Johns Hopkins in Baltimore, MD.  This was a similar setting in many ways, but I was in a different role and needed training about that role.

At sign out rounds with my faculty that day, Dr. William Hakkarinen, (the innovative rural Family Physician recently- 2/15/2011; Vol 41, No. 3 featured in a Family Practice News story "Family Physicians Reflect on Four Decades") I asked,"How does this work with the nurse practitioner?"  He explained how we collaborate with the nurse practitioners just like we relate to the physician assistants back at the main family practice center in our residency.  He trusted the judgment of the family nurse practitioner and was confident in her ability to know when to seek input.  She, however, couldn't prescribe on her own, so needed the physicians to review and sign her prescriptions.  We had a thorough discussion about all the implications and ramifications of collaboration with physician extenders, as they were categorized in our Department of Family and Community Medicine at the Hershey Medical Center of Penn State University.  (WHERE CHOCOLATE RULED).

In 1979 when I returned to my native Ohio to start practice as a Family Physician, I wondered why no one had a FNP or PA in their practice.  I was a supporter of the concept of physician extenders and a believer in the important role they could play in health care.  Fifteen years later, as President of the Ohio Academy of Family Physicians, I was fortunate enough to testify before the state legislature in support of the enabling legislation to allow nurse practitioners and physician assistants to be licensed in Ohio.  At that time I was also serving as Director of the Physician Assistant Program and Department Chair in the Kettering College of Medical Arts.  Now I work with Family Nurse Practitioners almost daily and teach Family Nurse Practitioners in my private practice office.  Our legal relationship with them in Ohio is described as "collaboration".  We need them.

At the confluence of the disciplines of medicine and nursing, we need to better define how we collaborate with each other as Family Physicians and Family Nurse Practitioners for the good of patients and our disciplines.  So what is collaboration?  What do I mean by confluence?  How might we connect for collaboration?  Who wins?  Who loses?
Here are definitions that may be helpful as we think of collaboration at the confluence of our disciplines.
Collaboration:  Definition from Wikipedia 3/19/2011
Collaboration is a recursive[1] process where two or more people or organizations work together to realize shared goals, (this is more than the intersection of common goals seen in co-operative ventures, but a deep, collective, determination to reach an identical objective) — for example, an intruiging endeavor[2][3] that is creative in nature[4]—by sharing knowledge, learning and building consensus. Most collaboration requires leadership, although the form of leadership can be social within a decentralized and egalitarian group.[5] In particular, teams that work collaboratively can obtain greater resources, recognition and reward when facing competition for finite resources.[6]

Confluence: Definition from Wikipedia 3/19/2011
In geography, a confluence is the meeting of two or more bodies of water. It usually refers to the point where two streams flow together, merging into a single stream. It can be where a tributary joins a larger river, called the main stem, or where two streams meet to become the source of a river of a new name, such as the confluence of Bell Creek and Arroyo Calabasas, forming the Los Angeles River. In a broader sense, the merging of any two streams is a confluence.[1]

Family Physicians and Family Nurse Practitioners are engaged at the confluence of their commitment to serve patients.  They are critical for the delivery of primary care in America.  As we collaborate in many settings with varying scopes of practice, the leadership and followership need will vary.  Our flexibility over the years has generally helped our ability to respond to patient needs.  With millions of patients wanting for basic primary care, we now aren't fulfilling the needs of our nation and face an overwhelming increment of more need in the near future.  Instead of blending at the confluence of our primary care scopes of practice to serve more patients, the two disciplines seem to be jockeying for power and financial position. In the era of health care reform as the payment reform discussions overshadow the access to care and basic services concerns, we family physicians and our family nurse practitioner colleagues need to move into creative collaboration mode.  

At the confluence of these two citizens of two great disciplines is the legal mandate to "collaborate" (at least in Ohio where this is written).  How this occurs is important but not included in the training or the literature of either Family Medicine or Family Nurse Practitioners.  When I asked 5 different Family Nurse Practitioners and 5 students in the field how much of their curriculum focuses on learning about and understanding collaboration with physicians, the answer is:  None.  Zero. Are we still in 1977?  Are we avoiding something that may be depriving our patients of health care?

Nurses still care.  I believe that Family Nurse Practitioners still care, too.  Physicians need to be around people like that since our discipline is getting a bit jaded by the mechanistic aspects of healthcare reform and the reimbursement debate.  How do we enhance our collaboration skills?  I think we should start with our hearts.  It's a good way to overcome limiting beliefs, if we still have any doubts about each others position in health care delivery (Heart, Mind and Brain).  In Family Medicine, we have some big hearted physicians who care a lot but are getting bogged down with work responsibilities that detract from caring for and about patients. We can enhance our caring potential by working with Family Nurse Practitioners, who have nursing hearts (the biggest in health care, I think) and primary care clinical skills (each, as us, with one unique scope of practice).  Our teamwork in our health care teams over time will fill in the gaps of who leads and who follows- issue by issue, patient by patient.  Our primary care skills will support the merging of our streams of collaboration through recursive experiences, discussions and processes as we seek together to serve those who need primary care.

Who loses?  Those who would waste scarce, valuable resources in a misguided misalignment with the health care needs of America.  Who wins?  Everyone else, especially patients and their families, employers, Family Physicians and Family Nurse Practitioners.

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