Same Practice, Different Worlds

Family doctors and nurse practitioners are forming uneasy alliances. Weighing up ideological baggage

By Wendy Banks

On Sue LeBeau's first day at medical rounds in the hospital where she at the North Bay General Hospital where she works as a nurse practitioner, the reception was frosty. "I was presenting our role in the clinic, and many of the physicians there wouldn't even look at me. They just stood there with their arms crossed."

According to a study recently published by the Ontario Medical Association (OMA) and the Registered Nurses Association of Ontario (RNAO), that coolness isn't unusual. Nurse practitioners (NPs) are relative newcomers on the Canadian medical scene and many doctors have reacted to their advent with less than glowing enthusiasm, although the relationships are gradually improving.

"Both GPs and NPs say that there is resistance to NPs by some doctors," the report states. "This is based, they believe, on the fear that NPs will take work away from GPs. This [fear] is ... based on uncertainty about what NPs truly do."

Dr Anthony Rockel begs to differ. He works in a private practice in a small community in Newfoundland and nurse practitioners have been part of his practice since the 70s. He appreciates and respects them and he's not afraid that they're out to get his job. What he's worried about are the policy makers who are determining nurse practitioners' future roles. "What bothers me is the ideological baggage," he says. "Healthcare planners have all kinds of agendas that they're not articulating yet. They want to shove us into teams, and they haven't really defined how they're going to work, or who's going to take responsibility."

"My feeling is that they think this is going to be a cost-saving measure, that family doctors are an expensive luxury, that nurse practitioners can do most of our work just as well as we do," says Dr Rockel. "If this is the message that's going to be put across to the public, it's going to turn more people off going into family medicine. Because what's the point of going through all that slog if you're going to be valued the same as someone who's done less training than you, and has a different emphasis?"

According to Dr Ted Boadway, the executive director of health policy for the OMA, the disrespect doctors feel from government is a question of semantics. "I think that's carelessness on the government's part," he says. "I don't think they're really down on family doctors a bit, but I don't think they think enough about how their message is going to be received out there in the real world."

He doesn't believe that health planners will try to replace physicians with nurse practitioners. "There's work for everybody. Our problem is going to be caring for the people we've got, because our care needs are going to rapidly increase over the coming years."

PROCEED WITH CAUTION
As for fears that the government is considering using nurse practitioners as a cost-cutting measure, Dr Boadway has a surprising answer. "Actually, that isn't so. It's turning out that nurse practitioners cost more per service than do family doctors." But he does agree that some of doctors' concerns about nurse practitioners are valid. For example, NPs tend to take on the less seriously ill patients, and many aren't on call evenings or weekends. "Imagine a community where there are six family doctors," he says, "and then you parachute in three nurse practitioners, and all of a sudden there's not enough work for everybody, so a couple of the doctors leave, and there are only three family doctors to cover the nights." Their workload increases, and their practice suffers. "You have to be careful where and how you introduce nurse practitioners."

The OMA, the College of Family Physicians and the RNAO have received a grant to provide start-up facilitation to family doctors and nurse practitioners working together in Ontario. Since 1998, 402 NP positions have been funded by the Ontario Ministry of Health and Long-Term Care (MoHLTC) in Community Health Centres, the Underserviced Area Program, long-term care facilities, Aboriginal Health Access Centres, Primary Care Networks and Public Health Units. The MoHLTC. The provincial government invests $1.7 million annually for the NP education program.

A HAPPY ENDING?
And, in clinics and hospitals, relations continue to improve one partnership at a time. For Sue LeBeau, the cool atmosphere at her hospital has warmed considerably as doctors discover that she has a specific and practical role to play in their system. "The physicians here are quite receptive to us now. It's been a pleasure to work with them. There are always a few sources of resistance, but that's okay; it forces us to make sure that our practice is up to par. It's a very satisfying collaboration."