Nurse practitioner growth changes patient care in Minnesota

There was no doctor in the house when Sam Talbot arrived at his clinic for a recent physical, but then that was the plan.

The 30-year-old ecology researcher chose for his primary care one of the state's first clinics staffed solely by nurse practitioners — who have the training beyond registered nurses to diagnose patients, order tests, prescribe drugs, stitch wounds, and perform most tasks traditionally ascribed to family doctors.

"I don't particularly like going to the doctor," Talbot said. "Nurse practitioners feel a little bit less threatening."

Nurse practitioners, or NPs, are becoming vital to Minnesota's medical system, which is seeing the demands of an aging patient population outpace the existing supply of doctors. Since the state Legislature in 2014 enacted the first state licensing standards for advanced practice registered nurses, the number of licensed NPs has increased by more than a third from 3,864 to 5,619.

The Minnesota Department of Employment and Economic Development lists nurse practitioner as the seventh fastest growing profession in the state — based on a 10-year projection that the supply of NPs will increase 26 percent.

"We really haven't seen an initiative that has caught on this broadly in the nursing profession, probably ever," said Connie Delaney, dean of the University of Minnesota's School of Nursing, which based on full-time student enrollment has the nation's largest doctoral training program for nurse practitioners.

"This is all about continuing to build the workforce," she said. "In about another dozen years, 20 percent of Minnesotans are going to be over 65. That's scary."

Clinic groups have incentives to advance the NP trend. State economic data show that nurse practitioners make $108,000 per year on average, while family and general practitioners make $190,000 — a 76 percent difference. But insurance companies typically pay only 15 percent less to clinics when basic care is provided by NPs instead of doctors.

Patients seem happy as well, as multiple studies in the U.S. have shown higher satisfaction ratings when primary care is provided by NPs instead of doctors.

Nurses by training and experience tend to be empathetic and look beyond patient's initial complaints to their broader health and happiness, said Jane Anderson, who directs the university's NP clinic and was the first NP hired to the Fairview system 27 years ago.

"Once [patients] understand what we do, they tend to come back," she said.

The transition has raised safety concerns to some, because doctors complete five to 10 times more hours of clinical practice during their education than nurse practitioners. The Minnesota Medical Association, which represents the state's doctors, opposed the legislation giving independent practice rights to NPs, though a spokesman said the organization has softened its stance.

Two recent, high-profile medical errors both involved NPs. One reused syringes at an Allina dermatology clinic and put hundreds of patients at risk of disease transmission. The other missed signs of sepsis in a woman who returned to a hospital ER after childbirth and died from the infection.

While many NPs are excellent, the sepsis case is one example of why the state should reconsider the autonomy it granted to them, said Dr. Julie Anderson, who practices family medicine in St. Cloud.

"They should have more, not less, oversight," she said. "I can say with confidence that if an ER physician would have seen the patient, she would have had a better chance of surviving her sepsis."

NPs are thought to be able to handle more than 80 percent of the primary care usually provided by doctors. Several studies have found they provide equivalent levels of care, but a few have shown poorer outcomes, including a 2013 Mayo Clinic report that NPs sent more patients unnecessarily to hospitals.

A study published last week showed that elderly Medicare recipients were actually less likely to need hospital readmissions if NPs provided their primary care, but more likely to receive good chronic disease management if doctors were in charge.

The takeaway is that NPs and doctors are different, and that medical groups should employ them to complement one another, said Peter Buerhaus, the lead author and director of the Montana-based Center for Interdisciplinary Health Workforce Studies.

"You can have the best diagnosis and the best prescription, but if you don't understand why patients may not be taking their medications or may not be doing things that are important to their health, then that expertise gets wasted," he said. "NPs are good at figuring out those issues."

Nursing leaders in Minnesota said the debate over independence is academic, because NPs — like doctors — are responsible for understanding the scopes of their practices and not exceeding them. And in most cases, especially in Minnesota where most clinics are operated by large medical groups, doctors and NPs collaborate.

"We understand where our scope starts and stops and where we need to be in partnership with another profession," said Judith Pechacek, who directs the university's doctor of nursing practice program. "None of us can live in isolation."

At the university clinic, for example, a nurse practitioner might manage a patient's underlying hypertension, but refer related heart problems to a doctor.

Talbot said convenience motivated him to go to the university's NP clinic, just off 35W near U.S. Bank Stadium. He also gets nervous around doctors and ends up with elevated blood pressure readings, so he opted for something that could be more comforting.

"Half my family are nurses," he said.

The demographics of students entering NP programs at the university, or a dozen other Minnesota schools, are changing. More than one in 10 are now men. But the typical profile is a woman who has worked in clinics or hospitals as a registered nurse for years. While that doesn't count as official training, advocates said that balances out the lack of residency training that doctors complete.

Michele Anderson sought her NP degree after years of working as a hospital nurse and seeing patients struggle with mental illness because they couldn't get appointments with psychiatrists to get medications refilled. After graduating from the U in May, she will join a mental health counseling practice in Minneapolis.

"I know that I can't necessarily make the wait list go down just by being one nurse practitioner," she said, "but I can at least add to the volume of providers out there."

Anne Rodekuhr said NP training is more focused, whereas doctors rotate through multiple specialties that might not apply to their practices.

The nurse will graduate with her doctorate in May and hopes to practice in family medicine or oncology in the Twin Cities or Rochester, where she has already worked in hospitals and clinics.

Nursing education "is valuable in other ways," she said. "You learn to deal with different patients and to form clinical relationships. Yes, I didn't complete a surgery rotation, but then I'm not going to be doing surgery."

Jeremy Olson • 612-673-7744