Responses to the 2013 Question of the Year
Chapman, Susan A. RN, PhD, MPH
Dr. Chapman is associate professor, University of California, San Francisco (UCSF), School of Nursing, Department of Social and Behavioral Sciences, and research faculty, UCSF Center for Health Professions, San Francisco, California.
Correspondence should be addressed to Dr. Chapman, UCSF School of Nursing, Department of Social and Behavioral Sciences, 3333 California St., Suite 455, San Francisco, CA 94118; telephone: (415) 502-4419; fax: (415) 476-6552; e-mail: firstname.lastname@example.org.
My initial response to the questions “What is a nurse?” and “What is a doctor?” is that these are the wrong questions to be asking at this moment in time. As we stand on the verge of implementing major health insurance changes from the Affordable Care Act (ACA), we should be talking about having an adequate, well-trained, multidisciplinary health care workforce ready to care for a population that is aging, has high rates of chronic illness, and will have comprehensive health care insurance coverage, in many cases for the first time ever. With the expected influx of patients as a result of ACA insurance reform and Medicaid expansion, there are real concerns about whether we will have enough providers, particularly in primary care. Should we increase production of doctors, nurses, or other professionals in response to this expected demand?
Unfortunately, some see this as a time to defend professional turf rather than as an opportunity to reexamine scope-of-practice regulations and ensure that all health professionals are allowed to practice to the limit of their education and competence. Instead of reviving the “turf wars” between doctors and nurses, we need to focus together on meeting the needs of the population and leveraging new models of care as we determine how many more of which health professionals are needed. Policy leaders and health care payers acknowledge that we need a different way of providing care, along with reducing cost. To meet the triple aim of better care, better health, and reduced costs, we need new models of primary care that include teams of providers from a variety of health professions.1
Each health profession (doctors, nurses, dentists, pharmacists, social workers, physical therapists, and countless others) brings unique competencies and skills to patient care. But that care is often provided in silos and is neither coordinated nor patient-centered. Care increasingly takes place in outpatient centers, in the community, and in patients’ homes. Many patients’ needs cannot be fully met by just one group of professionals, nor does it make sense for only one type of professional to lead patient care in every setting. Health care teams need to be inclusive of the range of health professionals who can contribute to better patient care and outcomes. For example, medical assistant coaches may help patients with diabetes self-management.2 The lowest-paid, least-trained caregivers—home care and personal care aides, and family members—provide most of the home care for frail seniors and persons with disabilities. Yet, rarely are these caregivers considered part of the health care team, despite their intimate knowledge of their patients.3
How do we provide the best of what each care provider has to offer, appreciate his or her unique contributions, and still work together? In my experience, the doctors and nurse practitioners on the front lines of care in community clinics spend little time focusing on their professional differences or on the hierarchy within the team. Rather, they appreciate the different skills and competencies that each type of provider brings, and they acknowledge that many different providers are needed to provide truly patient-centered care.
Finally, how do we teach our incoming workforce to provide care in a different model, with interdisciplinary knowledge and mutual respect? At my academic institution I recently facilitated a series of interprofessional education sessions with students from all our health professions programs. These were brand new students, fresh, eager, and relatively unencumbered with professional baggage. When we went around the room to ask what each knew about the other professions, I heard some interesting initial responses. “Doctors are diagnosticians, nurses are humanitarians, dentists take care of teeth, pharmacists count pills.” In case discussions, the students were open to having the professional with the best set of skills and knowledge do what is needed for patients. Their attitude was one of openness, respect, and eagerness to learn more about each other’s practice. They wanted to do more learning together in clinical practicums. This is a good sign.
Right now, we have an opportunity to shape perception and practice so that every profession can be called humanitarian, so that oral health is about more than teeth, and so that pharmacists provide patient education and medication management as full-fledged members of the health care team. The policy changes we face—and our country’s needs for health care—demand that we stand shoulder to shoulder to meet them. Instead of continuing to debate about “what is a doctor” and “what is a nurse,” we should be asking how we can draw on our mutual commitment and enthusiasm to best address together the urgent patient and client care needs of our time.
1. Berwick DM, Nolan TW, Whittington J. The triple aim: Care, health, and cost. Health Aff (Millwood). 2008;27:759–769
2. Ruggiero L, Moadsiri A, Butler P, et al. Supporting diabetes self-care in underserved populations: A randomized pilot study using medical assistant coaches. Diabetes Educ. 2010;36:127–131
3. Coffman JM, Chapman SA Envisioning Enhanced Roles for In-Home Supportive Services Workers in Care Coordination for Consumers With Chronic Conditions: A Concept Paper. Philip R. Lee Institute for Health Policy Studies and the Center for Personal Assistance Services, UCSF, and the Center for Labor Research and Education,. UC Berkeley