LETTERS * CORRESPONDANCE

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Nurse practitioners and family medicine As the nurse practitioner (NP) whose practice was stopped by the College of Physicians and Surgeons of Alberta (CPSA) I was interested in Dr. Peter P. Morgan and Lynne Cohen's article "Should nurse practitioners play a larger role in Canada's health care system?" (Can Med Assoc J 1992; 146: 10201021, 1024-1025). Public allegations made by the college that I was "practising medicine without a licence" have not resulted in any charges being laid in the past 13 months. Nurses continue to provide health care in isolated communities where physicians have chosen not to live. Does a plane ride -

For prescribing information see page 1086

south destroy our skills? Is it setting that creates skill? If Northern health care calls for the practice of medicine, then why is medicine not being practised by physicians in all settings? Perhaps medical acts that can be delegated to a nurse who has a nursing degree are not the sole domain of medicine. Are there double standards that are reinforced by the arbitrary and differential application of legislation? If Northern residents do not deserve equality in health care are they worth less? Is this the message we want to convey? I have never considered the care that I provide to be substandard or not as good as a physician's. I cannot ethically provide care if I devalue myself. I have always provided the same standard of excellence regardless of setting, recipient or accessibility of colleague support, working with authority, responsibility and accountability. Excellence is not within the mandate of licensing bodies or government legislation and does not depend on the presence of another professional; it is the basis of self-respect. The documented delegation of responsibility to nurses in isolated areas that has been signed by provincial colleges and nursing associations has never existed in Alberta. What is the definition of a medical act? Who can say that health care as evidenced in Northern nursing is the practice of medicine? It is not clear whether delegation of medical responsibility to nonmedical personnel is a legal or an ethical matter. Has the documented delegation merely permitted the medical profession to retain its authority and predilection for urban practice while avoiding

responsibility for and accountability to rural and Northern Canadians? Is this a self-serving issue of money or power? The CPSA's perception of omnipotence is demonstrated by its interference in an area of professional jurisdiction of the Alberta Association of Registered Nurses. Respect for this body's ability and legislated authority to license my practice would have resulted in a more positive outcome for the patients, my physician colleagues and me. The CPSA, whose role is physician accountability, is also accountable for its actions - to the public and to its members. The abuse of power is never appropriate and certainly not by a professional association. The comment "We're not angry about [Atcheson's] dismissal because it has provided us with the opportunity for open dialogue with the college" made by Mary Pat Skene, president of the Alberta Association of Registered Nurses, implies an inherent flaw in the system if abuse and destruction of people's lives is required to create an opportunity for dialogue. The practice that existed will be the model of the future, and the CPSA ended it without regard to its creative and visionary value. It is to be hoped that the peremptory behaviour by this licensing body will cease. I hold the CPSA accountable for its actions in my nursing practice; I launched legal action June 1, 1992. Joyce Atcheson, RN, NP, MHSc Athabasca, Alta.

Dr. Morgan and Ms. Cohen raise three issues and by implication CAN MED ASSOC J 1992; 147 (7)

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question the role of the family physician in Canada's health care system.

Family physicians do not or cannot care for patients as well as NPs. In response to the statement that "[NPs] combine the skill of a physician with the caring of a nurse" we feel that the quality of caring about patients is not the exclusive skill or attitude of any of the members of the health care team. The physician-patient relationship is a cornerstone of family medicine and the main attraction for many of us who choose family medicine as a career. Family medicine residents are taught about its importance, and Weston, Brown and Stewart,' in a three-part series concerning patient-centred interviewing, underscored this principle of family medicine. Family physicians are deeply concerned about the quality of the physician-patient relationship and consequently invest considerable time and energy on a daily basis to nurturing it. It is not possible to have an effective relationship with someone with whom we have little or no communication. If the opportunity to nurture this relationship during minor medical consultations were denied, there would be serious danger to it when it is vitally necessary - when there are major medical problems. Unless family physicians and NPs work in a milieu that fosters such relationships the family physician will lose the opportunity to add to "the working capital of trust," a concept that McWhinney2 has discussed. NPs can "cure" as well as family

physicians. One of the hallmarks of family medicine is the uncertainty inherent in dealing with people and their problems. How much of a person's presenting problem is bi982

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omedical and how much biosocial is always at issue. The reason given for the visit by the patient is often not the true one and is rarely captured by the notation on the booking sheet or by the billing code. In our group practices the average number of diagnoses for each visit is at least 1.6. Diagnoses incorporate perspectives that go beyond the traditional categories of the International Classification of Diseases. When we add to these perspectives special skills in obstetrics, emergency medicine, surgery and the care of the elderly we have an effectiveness that cannot be duplicated by anyone without similar training, knowledge, attitudes and skills. Why have the NP programs in the United States (where there are more NPs than in Canada) not been seen as the solution to that country's problems in primary care? Spitzer and colleagues3 did not compare the family physician with the NP; they compared the general practitioner (GP) with the GP plus NP. Since few, if any, GPs work alone, it would be more accurate to state that two teams were compared: GP plus office assistant and GP plus NP. The outcomes appear to have been similar; however, we believe that a clearer definition of family physician and NP roles might have a more positive impact on people's lives. NPs are said to have a particular interest in health education and preventive services. Most family physicians of our acquaintance consider these matters to be a fundamental part of family medicine. The Canadian Family Physician and CMAJ frequently publish articles on these topics. The principles of health education and illness prevention are contained in the principles of family medicine as defined by the College of Family Physicians of Canada.4 The myth that family physicians are not interested in health education

and preventive services comes perhaps from a hospital-based nursing perspective in which physicians have limited scopes of practice and may not be able to

demonstrate their commitment to these principles. We see problems in health maintenance and illness prevention as a failure of the system to persuade the public and government to adopt proven solutions. Educators, family physicians and nurses have significant opportunities to collaboratively promote change. NPs are more cost-effective. Morgan and Cohen quote Spitzer as saying that "when you crunch the numbers, NPs still aren't as productive as doctors." This position is supported by the statement that in the United States health maintenance organizations are moving toward the view that family physicians are more cost-effective. Because of the medicolegal climate in the United States we feel that such a move would be unlikely if it were felt that a lower standard of care would ensue. The issue of total cost is of interest. Shirley Galloway, a Winnipeg NP, is quoted as stating that the NP can do the job for between $35 000 and $50 000 yearly. What job are we talking about? She appears to have omitted $50 000 yearly for office overhead, plus $20 000 for the benefits (paid holidays, in-service education and pensions) that family physicians have to provide for themselves. In this light the savings are illusory. Spitzer's point regarding the economic objectives of NPs is well taken. We look forward to the day when Canada adopts policies similar to those of Britain, in which nurses become an integral part of the family medicine team. Also, Morgan and Cohen do not take the issue of cost to its logical conclusion: an appropriately trained family physician will provide 80% of the services of the LE I er OCTOBRE 1992

so-called primary care specialist (including ambulatory pediatrics), thus greatly reducing the need for expensive specialists and their accompanying investigations. We believe that optimal care is provided by the patient's own family physician with appropriate support from other health care providers and consultants. The family physician should be encouraged in various ways to function within this team concept, to do more and not less. We believe that the addition of another group of health professionals in independent practice would not be helpful to Canada's health care system; rather, it would be more costly and would contribute to the already burgeoning problem of fragmented care.

health care professions of Canada must work together to provide optimal care for patients and their families. I have an excellent working relationship with my nurse colleagues and consider their traditional role to be an underuse of their potential. There are countless times in my professional career when I have asked for and received input from nurses, input that has positively affected the eventual outcome of the patient's condition. However, I find that some aspects of the article represent a complete misunderstanding of what family medicine and family physicians are all about. Not once, for example, in the article is the term "family physician" used. Instead, all we read is "general practitioner" or "GP." To suggest that John Mackel, MD, FCFP a GP is equivalent to a family Past president physician is a remarkable overAlberta Chapter in sight 1992. With the new reCollege of Family Physicians of Canada quirements in Canada a postgradDavid Moores, MD, FCFP Chairman uate student will become licensed Department of Family Medicine by only one of two routes: certifiUniversity of Alberta cation by the College of Family Robert Hartog, MD, FCFP Physicians of Canada or by the President Alberta Chapter Royal College of Physicians and College of Family Physicians of Canada Surgeons of Canada. We are no Edmonton, Alta. longer in the business of turning out GPs by training them in a References 1-year rotating internship. For a 1. Weston WW, Brown JB, Stewart MA: long time the departments of famPatient-centred interviewing [three ily medicine in Canada have been parts]. Can Fam Physician 1989; 35: training family physicians in 147-151; 153-157; 159-161 2. McWhinney I: A Textbook of Family 2-year residency programs. I beMedicine, Oxford U Pr, New York, lieve that a definition of the dif1989: 12-25 ference between a GP and a fami3. Spitzer WO, Sackett DL, Sibley JC et ly physician would, at this time, al: The Burlington randomized trial of be highly appropriate. the nurse practitioner. N Engl J Med 1974; 290: 251-256 4. College of Family Physicians of Canada: General Information and Regulations on Program Accreditation and Examination: Family Medicine, Emergency Medicine, Care of the Elderly, CFPC, Toronto, 1990

I was deeply disturbed by some aspects of Morgan and Cohen's article. I consider myself an advocate of interdisciplinary collaborative health care. I believe that the OCTOBER 1, 1992

Unlike general practice, family medicine is not a collection of bits and pieces of established specialty disciplines but encompasses a distinct body of knowledge appropriate to the needs of a changing society. While having its roots in general practice and maintaining a relation to the scientific aspects of the traditional specialties, family medicine is centred on the family as the basic social unit. The discipline is health-oriented as

well as disease-oriented; it emphasizes the importance of disease prevention and health maintenance as well as curative medicine.'

This is our definition of our specialty, and we have an obligation to live up to that definition. I take exception to the inferences in the article that family physicians do not have a "very comprehensive understanding of people in their community roles and in their family roles." That is the very essence of our training programs. I challenge the position attributed to Doug Geekie, CMA's former director of communications and government relations, that "the NP is the better professional for routine primary care, mainly because nurses have more time than doctors to spend with patients and can develop a close relationship with them without costing the system as much." On what evidence does he base this assertion? I also suggest that Dr. Michael Rachlis, who is quoted as saying that "if NPs and other nonphysician health personnel were used to their full potential, we could get by with many fewer GPs," is somewhat divided in his observations, since later in the article he states that the Kaiser Permanente Clinic in California "uses few NPs, claiming they are less productive than physicians." As we move through the 1 990s health care delivery will continue to change. The pressure on our inpatient services will grow, and we will most likely be providing more and more of our care in the home and in related outpatient facilities. The need for interdisciplinary health care will continue to increase, and as part of this increase an expanded role for NPs is logical and reasonable. However, let us not forget the family physician, who has been and Will remain, in my opinion, the key coordinator of health care delivery in Canada. CAN MEDASSOCJ 1992; 147(7)

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Nurse practitioners and family medicine.

LETTERS * CORRESPONDANCE We will consider for publication only letters submitted in duplicate, printed in letterquality type without proportional spa...
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