In spite of the drama and rhetorical excess, the health care legislation signed recently by the president is a modest piece of work. For most Americans, alterations in the health care landscape will be minor and gradual, rather than dramatic.
But for 32 million Americans currently without health insurance, the change will be significant. In a few years they'll have, for the first time, a privilege that should be part of every civilized American life: regular affordable access to a primary care physician.
If they can find one. Doctors are already far from abundant in many parts of the country, and the noble effort to provide basic health care for all Americans will create practical access challenges.
Some 28 states are responding to the potential shortage of physicians by considering legislation that would expand the independence and prescription privileges of nurse practitioners.
Would this be a good time to re-evaluate our attitudes regarding whom we allow to administer primary medical services and to consider expanding the "scope of practice" of health care professionals like nurse practitioners?
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Sure, says comedian Dennis Miller, and why don't we let stewardesses go up to the cockpit and take a turn at the aircraft controls from time to time?
But Miller's snarky comment -- he manages to insult nurse practitioners, flight attendants, and probably women in general -- doesn't tell us much about medical practice, or about flying, for that matter.
For clarity: What is a nurse practitioner? She -- most of them are women -- is a registered nurse who has undergone significant advanced education and clinical training. She has a master's degree or a doctorate, and the current trend is toward requiring increasingly higher levels of credentialing. The profession continues to mature, and the training is becoming more systematic. According to the American Academy of Nurse Practitioners, about 135,000 NPs are currently practicing in the United States, and about 8,000 new NPs graduate every year from 325 college and university programs.
NPs practice according to the regulations of the state in which they are licensed. Generally they work under the supervision of a physician and their prescriptive privileges are limited. Their professional organizations lobby regularly for more independence from physicians and for more authority to prescribe drugs.
Physicians are pushing back. In October, the American Medical Association issued a lengthy statement on nurse practitioners, arguing that expanding practice privileges to anyone besides physicians will "expose patients to unnecessary health risks." Predictably, the document smacks of turf protection, and many NP professional organizations have taken exception.
Are NPs as well educated as physicians? No. But if we're going to seriously rethink how we do medicine in our country, we should note that a great deal of ordinary health care doesn't require the extensive education and highly honed skills of a doctor. In fact, doctors are overqualified for many of the routine chores they perform in their offices, particularly tasks related to health maintenance and disease prevention.
Much of this basic medical work could be performed at less expense by well-trained, independent nurse practitioners. Another plus: In general, NP training includes an emphasis on patient education and personal responsibility for one's own health. Given that we're a country in which many of our maladies are self-inflicted, the NP focus on prevention of disease could serve us well.
Back to Miller's airplane metaphor: Like medicine, a great deal of flying isn't rocket science; the hard part is takeoffs and landings and good judgment about weather. In between pilots perform a great deal of routine flying.
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Don't get me wrong: If my airplane is ditching in the Potomac, I want Capt. Sully Sullenberger at the controls. But he's overqualified for a lot of his flying. A well-trained "stewardess" could do it.
Let's extend more independent responsibility for health care to well-trained nurse practitioners. They might even teach us to take on some of that responsibility ourselves.
-- Crisp teaches in the English Department at Del Mar College in Corpus Christi, Texas. E-mail him at jcrisp@delmar.edu .
