Different Kind of Caring




The first line of defense in the battle for your good health is often not your doctor.Trying to get a routine appointment with your primary care physician? Dollars to doughnuts, you won't be donning a johnny any time soon. A national shortage of primary care doctors has, in many instances, led to frustrating lead times for some patient visits. But many patients now have another choice when booking an appointment: seeing a nurse practitioner.

A growing presenceNurse practitioners have become an increasingly familiar sight in a variety of healthcare settings, from family practices to cardiac care centers. Since nurse practitioners first came on the healthcare scene in the 1960s, their numbers have grown to about 135,000 nationwide, according to the American Academy of Nurse Practitioners.

Nurse practitioners are nurses with advanced training, typically a master's degree. The particulars of the type of care they are allowed to provide can vary from state to state and from institution to institution. Here in New Hampshire, state regulations allow nurse practitioners to carry out many of the duties that doctors do: they can perform physical exams, order tests, diagnose conditions, develop a plan of care and prescribe medications within their scope of practice, says Linda Reed, APRN, family nurse practitioner at Family Care of Concord, an affiliate of Concord Hospital.

"In New Hampshire, depending on the nurse practitioner's experience and training, there's no real specific restriction as to what they can see," Reed says. "It's somewhat setting-specific, but it really is a matter of what you're trained to do and what you have experience enough to do."

Indeed, some nurse practitioners perform cardiac catheterizations or administer anesthesia, while others do not perform invasive procedures, says Kristine Ziemba, APRN-BC, clinical director of the Women's Cardiac Center and associate clinical director of the Cholesterol Management Center at the New England Heart Institute of Catholic Medical Center. "It really depends on the practice" and the nurse practitioner's experience and comfort level, she says.

The nurse practitioner will see you nowIn some states nurse practitioners must work under a supervising physician, but that is not the case in New Hampshire, which "probably has the most liberal nurse practitioner regulations of just about any state," Reed says. "In most states nurse practitioners have to run cases by a physician [for approval]. In some states nurse practitioners can't write a prescription, not even for penicillin," she says.

In contrast, some Granite State nurse practitioners run their own practice, with no physician involvement. Within an institution, however, rules might dictate that doctors must review the work of nurse practitioners. Most often in New Hampshire health centers there is a collaborative relationship between doctors and nurse practitioners, Reed and Ziemba say. "I see patients in the office without a physician there," Ziemba says. "They're my cadre of patients and I manage their treatment plan. They only see me and I only speak with my supervising physician if there's a complicated situation that I don't feel comfortable dealing with on my own."

A holistic approachMany nurse practitioners offer their own special brand of patient care, often taking time to educate patients and emphasize prevention as well as cure. "We have a very holistic approach," Ziemba says. "It's the nurse in us."

It's not that doctors don't care, she says, but nurse practitioners are "nurses before anything else," and a certain attitude usually accompanies the nursing profession, Ziemba says. Plus, in some practices nurse practitioners are allotted more time than doctors-as much as double - to spend with each patient. "Patients really like that," Ziemba says. "They feel like you're listening and like you care - and you do. You have a little more time to actually express that part to them." Nurse practitioners can take the time to consider the patient as a whole person, she says, and how their condition might affect their lifestyle and family.

The slower, holistic approach "is a philosophy that hopefully won't change," Reed says. "Historically, the people who have gone into being nurse practitioners have been nurses for a pretty decent chunk of time," she says, enabling them to hone their skills, become comfortable dealing with patients and build a solid base of knowledge from years of interacting with patients before pursuing advanced training. But Reed worries that as schools offer fast-track training programs that allow students to become nurse practitioners without first gaining substantial experience as a nurse, the unique blend of caring that nurse practitioners offer will suffer. At a minimum, "it will take them longer to get to that place," Reed says. NH

Hassle-free healthNurse practitioners, who today provide care for patients in just about every medical setting including psychiatry, emergency medicine, pediatrics and surgery, can also be found in urgent care centers, where patients can arrive without an appointment when minor illness or injury strikes during hours when many primary care offices are closed or when a patient simply can't get a timely appointment with a primary care physician.

In fact, in the Granite State, where nurse practitioners are allowed to practice independently, some urgent care clinics have been originated by nurse practitioners, according to Kristine Ziemba, APRN-BC, clinical director of the Women's Cardiac Center and associate clinical director of the Cholesterol Management Center at the New England Heart Institute of Catholic Medical Center.

Unlike hospital emergency departments, which remain the right choice for patients suffering from life-threatening conditions such as heart attack symptoms or severe bleeding, urgent care centers only serve patients with less serious health trouble. Urgent care is for patients whose minor cuts, sprains, coughs and the like require a healthcare professional's attention but are not true emergencies.

That limited scope means urgent care centers have less overhead and expensive back-up support than emergency rooms, enabling some patients who appropriately choose urgent care over the emergency room to benefit financially: most insurance companies only charge an office or clinic co-payment for an urgent care visit, rather than a more costly emergency-room fee.

Urgent care is aimed precisely at those patients who would probably be placed at the back of an emergency room queue, which helps the centers get patients to an exam room more quickly. Patients are generally seen on a first come, first served basis and can expect to spend less time warming the seats in the waiting area than they would in an emergency room.

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