Anurse is a doctor’s best friend, according to Marvin M. Lipman, Consumers Union’s chief medical adviser. This advice was given to him by a hospital ward’s head nurse when he was a third-year medical student making contact with patients for the first time, along with the suggestion that’d he’d do well not to forget it.
Over the years, those words continued to echo in Lipman’s mind. In part because hospital nurses work for the institution and many doctors work for themselves, occasional conflicts between the two are inevitable. When encountering such situations, he has generally tended to take the side of the nurse, sometimes to the chagrin of his fellow physicians. But he explains that his loyalty comes from the many times he has seen nurses go that extra step to make a patient more comfortable or more at ease.
Fortunately, tension that can mar the doctor-nurse relationship has become far less frequent with the increasing movement of nurses beyond hospitals. Here are the main types of nurses you might encounter in outpatient settings:
Nurse midwives. Lipman recalls that he first became aware of this type of nurse with the help of Ingeborg, a German nurse midwife to whom he remains eternally grateful. It was 1956 and, fresh from an internal-medicine residency and six weeks of U.S. Army basic training, he had arrived in Munich after an exhausting 16-hour flight.
Without so much as a welcome, let alone time to unpack, he was notified that he was POD (physician of the day). The title was not just an honorific; it meant he was on duty. Almost immediately, the first patient arrived: an enlisted man’s wife in the final stage of labor. Lipman’s anxiety level rose when he recalled that he had not delivered a baby — or even seen a delivery — since the third year of medical school. He breathed a sigh of relief as Ingeborg burst through the door and took over.
When he returned to civilian life two years later, he became a supporter of the Maternity Center Association (now the Childbirth Connection; www.childbirthconnection.org), which used to train and certify nurse midwives and now works to improve the quality of maternity care.
Visiting nurses. Through the late 1960s and 1970s, nurses began branching out and occupying positions in municipal and state public-health departments. The Visiting Nurse Associations of America was officially launched in 1983 and included in its mission providing home health care for patients too ill to visit outpatient facilities.
The VNA took an active part in developing the modern approach to hospice care, transforming it from a service that provided a place to die to one that addressed many end-of-life issues and allowed patients to remain in their homes. In a quiet and slowly evolving manner, nurses had become patient advocates, bringing compassion and comfort together with high-level care to segments of the population that were underserved by physicians.
Nurse practitioners. Although the origins of this specialty can be traced to the 1960s, nurse practitioners represent the most recent entry of the profession into the actual practice of outpatient medicine. NPs are registered nurses with an advanced degree — typically a master’s or a doctorate — and clinical training in primary care and various subspecialities. They are licensed by the state in which they practice and can perform many of the same duties as physicians, including prescribing medication. (Some states allow NPs to practice autonomously, while others require some degree of physician involvement.)
Studies have found that their ability to diagnose illnesses, order and interpret tests, and treat patients is equivalent to that of primary-care physicians. They also tend to spend more time with patients during routine office visits than physicians, and they might be more likely to discuss preventive health measures. As of 2010, 140,000 NPs were working in the United States.
Nurse practitioners are poised to become even more visible with the passage last year of the Patient Protection and Affordable Care Act, which could add nearly 35 million people to the ranks of the insured. Since that influx of patients coincides with a substantial shortage of primary-care physicians, NPs are likely to play a key part in filling the gap.