Health Matters Blog

What Midlevel Care Means For You

by Richard Fletcher

Richard A. Fletcher, RN, MSN, FNPI get called ‘doc’ by a lot of my patients even though they know I’m a nurse practitioner and not a physician. Part of the reason I guess is because I’ve been treating the Putney community for so long that some families have only received primary care from a midlevel provider like me. “I know you’re a nurse practitioner, but you’re my doctor,” I’ve been told.

The term midlevel doesn’t exactly describe what a nurse practitioner is, but it’s the one most commonly used when referring to this growing field of health care professionals. Advanced Practice Nursing is the overarching name because we are registered nurses who have furthered our training to a master’s degree level. That term also applies to nurse midwives, nurse anesthetists and other multiple specialties. All nurse practitioners are board-certified, as required by the state of Vermont. We can set up our own practices, have hospital privileges, make diagnoses and prescribe meds. Physician assistants are another type of midlevel provider.

Nurse practitioners as a profession dates back to the 1960s when, like now, there was a shortage of new physicians going into primary care, particularly in pediatrics. A pilot program was established at the University of Colorado (Nina Trumper, who was part of Brattleboro Pediatrics Group, was one of its first graduates) and other schools soon followed with their own master’s level programs. The World of Nurse Practitioners website says today there are more than 300 NP degree programs in the United States and around 120,000 active nurse practitioners providing care to millions of Americans.

Another factor contributing to the increase in midlevel providers is the cost of health care. Nurse practitioners and physician assistants can provide high-quality primary care services at a lower salary level than an M.D., thereby contributing to government initiatives focused on controlling costs for the community at large. When the state of Vermont tracks the number of health care providers that should be in a particular community, they now incorporate nurse practitioners as well as physicians into that formula because they can save money when hiring new primary care providers without sacrificing the high level of care.

Because we’re nurses, nurse practitioners take a very holistic approach that is well-suited to the primary care setting. Nursing school trains us to look at the whole person – physically and psychologically – and we never give that up; we just add this other new focus. We’re not psychotherapists but our training enables us to evaluate a patient’s mental health and emotional status. A lot of primary care these days is prescription writing for psychiatric medicines. If the problem is beyond us we can refer them to a psychiatrist, or if someone has great social needs in the community, we’ll do what we can or we’ll refer them to a social worker.

For very difficult, complex patients, certainly in acute settings, it’s very appropriate to see physicians. Physicians have more extensive training. When you’re in primary care, you’re evaluating patients and making diagnoses. If they have a symptom, you look for why they have a symptom and maybe you find a tumor which can’t be treated in a primary care setting. So the patient sees a surgeon to remove it, and then maybe an oncologist if they need chemotherapy. From then on, that part of their life gets managed by the specialist but the patient is coming back to his or her primary care provider for high blood pressure, diabetes or other factors outside the specialists’ area.

Look for the role of midlevels to continue to increase in the future. Medicaid and Medicare cover our care in almost every setting. Nurse practitioners perform a number of regular procedures once done solely by doctors. Pharmaceutical companies have even changed the language in their television commercials to say “talk to your health care provider” instead of doctor as an acknowledgment of our ability to prescribe meds. And as new doctors emerge, many of them are doing their rotations with Nurse Practitioners who have twenty years of experience, so over time we’re going to be an even better team. The team at Putney Family Healthcare also includes another nurse practitioner, Maggie Lake, FNP and Dr. Kari Dickey, who recently joined the practice allowing us to accept new patients from Putney and other nearby communities.

Richard Fletcher, RN, MSN, FNP is a nurse practitioner at Putney Family Healthcare, which is part of BMH Physician Group, and is the founder of the Putney Free Clinic. He has also previously been the Vermont State Representative of the American Academy of Nurse Practitioners, and President of the Vermont Nurse Practitioners Association.

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