The New Doctors in the House

How nurses are evolving into far bigger roles at hospitals.

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Nightingales are soaring. Gone are the days when medical etiquette had nurses standing at attention when doctors entered the room or silently bowing their white-capped heads when their own experience called a physician into question. Nurses have broken the bounds of their crisp, white aprons to assume substantial authority. Witness today's nurse practitioner addressing the critical shortage of primary-care physicians in the United States and other developed countries. These registered nurses, armed with advanced degrees in specialized areas like pediatrics, women's health, or adult disease management, care for a wide range of common medical conditions and wield a prescription pen with virtually the same independence as any M.D. 

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The founder of the modern nursing profession, Florence Nightingale, would be pleased. It was the unmet needs of soldiers dying like flies on foreign soil during the Crimean War that in 1854 led this young, highly educated British nurse and her team of like-minded women to volunteer their services at the war's front lines. More soldiers were dying from infectious diseases like typhus and cholera than from battlefield injuries. Nightingale systematically improved their diet, sanitation, clothes, and bedding and tended to their emotional needs. She became known as the Lady with the Lamp because of her nightly rounds to tend to her wounded charges. Mortality rates plummeted, and the nurses won the heartfelt respect of their patients, skeptical military doctors, and the public back home.

Need also propels today's evolution of nursing. We simply lack sufficient primary-care doctors to attend to the growing ranks of aging baby boomers and patients of all stripes who increasingly demand support with wellness and disease prevention. This shortage is particularly prevalent in rural America, where populations in more isolated areas can find barely half of the number of primary-care physicians they need. Nurse practitioners have stepped in to help fill this void.

This century has seen a steady increase in the number of N.P.'s—now more than 150,000 out of the 2.6 million registered nurses nationwide. Their ranks are sure to swell in numbers and stature: Nurse practitioners, along with physician assistants, figure prominently in healthcare reform as a way to increase access and lower costs. More and more nursing schools are offering doctoral-level training for N.P.'s. Today, 23 states authorize N.P.'s to work without physician involvement. Expansion of the doctor of nursing practice degree will probably make that 50.

Advanced care. Trained to take medical histories and perform physical examinations, N.P.'s screen for disease risks and diagnose and treat the common complaints that make up 80 percent of primary care. They can manage chronic diseases like asthma and high blood pressure, with outcomes similar to physicians'. N.P.'s can work as midwives or lead home health or hospice teams. Others with advanced training in cancer or heart disease might work in specialists' practices overseeing treatments and attending to patients' primary-care needs.

As in most fields, advanced training brings higher salaries. R.N.'s can earn between $45,000 and $95,000 a year; nurse practitioners, between $80,000 and $120,000. As with nursing generally, the hours are regulated and controllable, with flexible shifts that accommodate personal life.

Some M.D.'s will be threatened by this new breed of doctor in the medical house. But with fewer medical students choosing primary care, nurses are moving into a gap rather than pushing out existing physicians. And as we've seen with midwifery, there are patients who prefer the care of an N.P.

As in the past, nurses are recasting their profession to meet pressing needs, not by morphing into M.D.'s but by being nurses plus. Their inbred professional focus on team collaboration and their attention to the whole patient and to the surrounding environment of home and community are well suited for primary care. If physicians are uncomfortable ceding territory to their new colleagues, like the military doctors facing the Lady with the Lamp, it will be so only at first. The need for N.P.'s is great, and nurses have long shown how to shine.