Key Issue for Facilitation: Who Provides Primary Care and How?

 A very real problem that is immediately relevant and requires facilitation was highlighted in the May 16, 2013 New England Journal of Medicine. As between primary care physicians and APRNs (Advanced Practice Registered Nurses) what is the appropriate scope of practice for each professional, what degree of supervision should be mandated if any ( primary care teams),and should the two professions be paid the same fees for delivering the same services?

We are facing a known primary care physician shortage as more people are expected to try to access services. How should their need for services be met? The Institute of Medicine, having departed somewhat from its usual objective stance, collaborated with a group that is advocating for a particular result in favor of advanced practice registered nurses, and released a study report on the subject.

A subsequent survey of the two professions revealed significantly polarized answers by profession to the key questions. While there appeared to be agreement that the professions should practice to the full limit of their scope of practice, they differed on what that scope is and the basis for any conclusions drawn about proper scope.  NEJM recommends a facilitated dialogue to try to find workable common ground and called for shared training so that dialogue and mutual understanding begin much earlier in the professional lives of the primary care practitioners. Ruling out use of worn out, inflammatory langauge and getting past preconceptions are recommendations made to improve dialogue. 

Neutrals reading this are surely nodding their heads "yes," as th e latter recommendations are classic features of mediation process. Additionally, I would prepare the dialogue by helping the groups define the scope and goals of the conversations over time. Who really does need to be in the conversations (knowing the power of the absent to derail agreements)? Relevant discussion items are: What will be the definition of primary care? What will primary care services entail in the future? What market forces will affect answers to that? How can transition to new forms of practice be planned in a way that preserves human resources and protects morale and quality? How will success be measured? Setting up better listening as part of the conversations, along with possible reframing of the issues would be important. Let's hope that we can get going on this effort!

Virginia, by the way, was cited in NEJM for its new law and regulations which are the product of facilitated dialogues that created agreed specifications for primary care teams. Stay tuned to news as to how that works.



Jeanne Franklin