Summer read: Toby is a general practitioner and Sophie is a practice nurse. They’re also a couple, and often debate the value of NPs vs GPs.
First published July 21, 2022
A nurse practitioner (NP) is a nurse who has additional training to diagnose disease and prescribe medication. A general practitioner (GP) is a doctor working in general practice. A practice nurse is a nurse who works in general practice. Here, we are referring to primary care nurse practitioners.
In May, after months of media coverage of health worker shortages, every school of nursing in the country co-signed a proposal for more government funding with the aim of doubling the number of NPs trained each year. The proposal was viewed as a potential solution to the GP shortage (alongside the existing nursing shortage). Last week, the proposal was declined by the Ministry of Health. But can NPs really be a substitute for GPs?
What follows is a heavily edited amalgamation of real conversations between a nurse and a GP – while they were driving – about primary care NPs.
Toby: “An NP does everything a GP can, at a much lower cost.” Whenever NPs are promoted in the media this same nonsensical language is used. Nobody suggests that you can become a surgeon or gastroenterologist without going to medical school. But my profession is not taken seriously. So it is accepted at face value that a nurse with some extra training can do our job. NPs are not cheaper GPs, and to say so is an insult to both!
Many of my colleagues are five to 10 years from retirement. We aren’t training enough GPs to replace them and keep up with increasing demand. More doctors need to go into general practice, but it isn’t attractive enough to medical graduates. Partly because of stuff like this! Society tells us we are lower-status, disposable workers compared to hospital specialists. GP registrars also take a massive pay cut when they enter the specialty. Being a GP can be a lucrative career, but to compete, GPs generally need to become practice owners, which isn’t required of hospital doctors, who also get large amounts of protected paperwork time and education money that we don’t.
If an NP can do everything a GP can for cheaper, who’s going to hire a doctor? It will become harder still for GPs to negotiate remuneration and working conditions that are competitive with hospital specialists. NPs will consume all of the straightforward work, leaving GPs with only the most complex, difficult cases, but there will be no compensatory increase in our pay. If we do not see patients regularly for minor problems, it will be much harder to build a trusting therapeutic relationship, which is our greatest strength. Being a GP will become less attractive to medical graduates who will shun my profession or move to Australia. We gain no ground if we train NPs, but lose an equal number of GPs in the process.
Sophie: NPs prescribe all the same tablets and perform all the same procedures for all the same problems. They are highly trained, work independently like GPs and have the same legal responsibilities. Why are you so hostile to the idea that a highly trained health professional could do your job simply because they are ultimately “just” nurses? You work until 7pm grumbling about how busy you are. Complaining about being the rubbish dump of the health system for the problems nobody else wants to deal with. Why do you push help away like a rabies patient rejects water?
Toby: There is no comparison between the training of an NP and a GP. Medical school is astonishingly competitive. You need a high A+ average across eight university papers as well as an excellent score in a general intelligence and empathy exam. After that it’s five more years of rigorous university studies. Dozens of exams. Three years rotating through specialist medical, surgical and psychiatric teams with one-on-one teaching by specialist consultants. As a new graduate doctor there are a further two years, minimum, again moving through the full spectrum of speciality services. Finally there are three years working in a GP role in an apprenticeship model, with another set of theoretical and practical examinations to pass.
Sophie: Sure, but NP training is rigorous too. They complete a three-year nursing degree, followed by a minimum of four years of clinical experience in primary care, not including experience elsewhere. Along the way they complete a master’s degree followed by a supervised practicum diagnosing and treating illness. Only after 300 hours of clinical experience and development of a portfolio may they apply for NP exams and interviews to become registered.
Toby: Three hundred hours sounds like a lot, but it works out to fewer than 40 eight-hour days.
Sophie: It’s an unfair comparison anyway. Plenty of doctors who graduate near the top of their class eventually go into general practice, but it’s also the back-up plan for doctors who don’t make it in other areas of medicine. Either because they are not proficient enough to make it into a competitive speciality training programme, or because they have shitty communication skills and nobody else wants them. You’re comparing some of the most exceptional highly trained nurses with a group that represents the full spectrum of doctors.
Anyway, we don’t need to debate the training. We can look at real-world consequences. Studies show that NPs have equally good patient outcomes, but some patients prefer them to GPs.
Toby: Early in my career I refused to prescribe antibiotics for a tickly throat. Two days later, we received a two-page complaint. The patient was apparently dumbfounded by my lack of empathy. Healthcare is bewilderingly complex. Too many variables exist to measure the overall quality of a provider. One doctor might get excellent patient satisfaction scores. That’s not an endorsement if they get there by overprescribing antibiotics and birth the multi-resistant superbug that dooms humanity. Harold Shipman’s patients really liked him! Besides, the literature is mixed. There are studies showing that NPs are less cost-effective, with lower patient satisfaction scores, and their patients need to go to ED more often.
Toby presents this article for consideration.
Sophie: That’s not a study, Toby, that’s a news article. There are multiple systematic reviews of multiple randomised controlled trials showing that nurse practitioners have equal or better patient outcomes and patient satisfaction at the same cost overall. NPs are skilled, safe and qualified. Toby, you have to let go of the conditioned response which is, “I learnt more than a nurse, and I spent more money to do so, so I am inherently more qualified than an NP.” Your $100K of debt took you down a pathway to a career; just because another pathway can lead to the same career doesn’t make it less valuable.
Toby: Sure, but again, only a fraction of the most exceptional nurses have become NPs. We cannot be confident this will hold when NPs are being mass-produced. Besides, who’s to say that NPs and GPs are seeing equivalent patients? Ranking surgeons by how often they slice into the wrong tissue or their patients die after surgery is a terrible way to do it. More talented surgeons are likely to attract more difficult cases. This is the same problem.
Sophie: Normally you are so passionate about scientific evidence. Your whole profession is based on research like this. You can’t ignore this batch just ’cause it threatens your worldview. You might as well be a homoeopath! These studies are randomised and controlled to account for this. You know what that means, right?
Toby: General practice is about people. Building relationships with your patients and their families. Across decades. It’s art as much as science. My profession has accumulated intangible knowledge caring for families over generations. How can all that nuance be captured in a study?
Sophie: You must realise that the medications and therapies you prescribe every day often have a weaker evidence base than the literature showing that NPs are as proficient as GPs.
Ultimately, I don’t think you are ready to accept that NPs are as valuable as GPs. Until you come to terms with that, you cannot reasonably suggest how they might be implemented. There are NPs who’ve worked independently in emergency and primary care settings for over a decade. Doing the job of a doctor. Imagine an NP who’s been in the game 35 years; surely the training pathway early in the career becomes irrelevant. Why should that NP be paid half as much? It’s just another way that female-dominated professions are systemically valued less for doing the same work.
Toby: GP is female dominated too! There were three men in my group of 16 training GPs! Many of my colleagues feel that GPs are paid less than many hospital specialities precisely because general practice is female dominated, while hospital specialties are often male dominated.
Sophie: That might be true in terms of raw numbers of trainees, but it probably isn’t true in terms of practice ownership and leadership roles.
Toby: There is no intention from the government to pay NPs the same as GPs. Every article and interview I come across, it’s the same message, phrased differently: “NPs do the same job as a GP, for cheaper.” Is that really how NPs want to be viewed? As cheap labour? Not only is that statement factually incorrect, it’s self-contradictory. If NPs really are interchangeable with GPs, we’d be happy to pay them the same. It’s simple fairness. And if NPs cost as much as GPs, they aren’t the bargain-bin solution they are made out to be.
Frankly, I wouldn’t mind if NPs were paid as much as GPs. I wouldn’t mind if they all get a free trip to Disneyland! But you need a proportionally large extra incentive to keep GP attractive relative to other medical specialities. Otherwise the number of GPs will dwindle away!
Sophie: What would it take, then? What hurdles would a nurse need to overcome for you to be happy that they are the equivalent of a GP?
Toby: I suppose if an NP were to complete their master’s programme, then did the same two years of house officer training, and the same three-year training programme that a GP does, that might get me closer to being comfortable saying they were interchangeable.
Sophie: See? This is exactly what you aren’t considering. The bottleneck when it comes to training more doctors is that there aren’t enough spaces in medical and surgical teams to occupy more medical students and house officers. One key advantage of NPs is that you can generate a prescriber without needing to compete for those training spaces.
Toby: It’s frustrating that the moment I express any scepticism toward NPs it sounds like I hate them. Doctors almost universally believe a large number of NPs trained to a high level in diagnosis and treatment, with the communication and cultural safety skills to back it up, would be a blessing. I’m excited to work alongside NPs. The problem is the way they are being sold to us.
Doctors diagnose disease and decide how to treat it. Nurses assess patients and administer and monitor the treatment. These roles overlap tremendously and both do vastly more. But very roughly, at least in traditional hospital systems, this is how it works.
Doctors might assess a patient for 15 minutes during a rushed ward round, but nurses are at the bedside 24/7. Nurses know which chalky tablets catch in a dry throat and which kids’ medicine has the taste of rancid pineapple and the texture of thin snot. Doctors understand these details too, but differently. I might have been told, over a GlaxoSmithKline-funded panini, that elderly arthritic hands struggle with a certain kind of asthma puffer. It’s not the same as watching crooked fingers fumble with a plastic catch in real time.
NPs are selling themselves short! Saying that NPs are merely GPs you pay less doesn’t capture their real value. That they approach clinical problems from a different perspective. NPs and GPs can synergise, they can check each other’s blind spots. You will never persuade me that NPs have the breadth of knowledge that GPs have, but that doesn’t mean they aren’t valuable. Our health system is going to need nurse practitioners to survive. But we shouldn’t introduce them in a way that devalues our current healthcare workforce.
Sophie: But that is just it, Toby, NPs don’t devalue your workforce. If you accept them, their ability and their value as comparable to your own then you can be better off long term. NPs and GPs can argue together for pay that is competitive with other diagnosers and prescribers. We could call them medical GPs and nurse GPs. The more of you there are, the more power you will collectively hold.
The debate ends as the pair stop at a petrol station for a pie.