The Extinction of the Primary Care Clinic Nurse

The Passenger Pigeon. The Dodo bird.  The primary care clinic nurse.  All are extinct, driven out existence by a changing habitat, competition and over-hunting. Ask the average person when they’ve last seen these species and you’re likely to get the same baffled look that your columnist’s spouse gives when she’s asked about her compliant husband who does what he’s told.

Yet, this columnist wasn’t aware of the primary care nurses’ total absence until a recent conversation with a nurse-colleague who has been helping smaller physician-owned outpatient offices develop local care management programs.  “There are no ‘nurses'” she said. “They’ve all been replaced by office assistants and the docs are trying to get them to do the patient education.”

Which makes sense. While articles like this have been lauding health care “teams” made up of physicians and non-physician professionals for years, the fact is that poor reimbursement, the allure of other specialties and lifestyle has long-hollowed out these clinics, often leaving a skeleton crew of part-time medical assistants shuttling patients in and out of the patient rooms.  True, some of the larger health systems with a stake in primary care have kept nurses in the mix, your columnist thinks that’s merely part of a market-preserving loss-leader strategy.

This columnist looked for medical literature on the topic.  He can’t find any surveys or other descriptions on how nurses have largely disappeared from the primary care landscape.  If he’s wrong, he wants to hear from his readers.

If true, what are the implications?

  • In large swaths of the primary care landscape, there is no “build or buy.”  It’s invent or buy.
  • What’s more, younger PCP’s are even less familiar with the notion of an office-based nurse, let alone partnering with one.  Physician knowledge may have gone extinct too.
  • No wonder the Patient Centered Medical Home hasn’t caught on.
  • Jaan Sidorov, MD, is a primary care internist and former Medical Director at Geisinger Health Plan with over 20 years experience in primary care, disease management and population-based care coordination. He shares his knowledge and insights at Disease Management Care Blog, where this post first appeared.

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    5 replies »

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    2. I also think reimbursement is the issue. Other professions that bill for services can also bill for assistant services; Doctors cannot bill for the time a Nurse spends with the patient, they have to pay a salary. Nurses salaries being what they are, and they are not that high in Medical Offices, are significantly higher than the Med Techs that replace them. If the structure for paying Nurses changed, it is possible we would see a return to employing them as primary Medical Office staff again in the future.

    3. Disappeared since when? I’ve been a physician for 30 years, before which I was a medical assistant who did virtually everything a nurse did. For as long as I’ve been running primary care medical offices, medical assistants have been around. Nurses are over qualified and over paid for what needs to be done on a day-to-day basis in PC offices. Physicians and mid-levels are always close at hand if questions arise. It a good thing for cost containment and doesn’t cut corners.

    4. Your are correct, they have gone by the wayside just like hospital nurses have. The sad thing is that it is going to happen to primary care docs as well. It happened to psychiatrist in the 90’s. the counseling was given to lesser paid psychologist and prescribing given over to the primary care doc. It will start happening to the primary care doc in the next 10 years, we will be replaced by midlevels and specialist will continue to remain “special”. I just have to hang in there for 10 more years.

    5. I agree. I have worked in health care for about 6 years now and the reimbursement is so low with programs like medicare, doctors can not afford to pay highly trained staff. In our clinic we pay “office assistants” to do things like height, weight, and blood pressure because they are cheaper and you don’t need a degree to do it.

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