How nurse practitioners bridge the gap between family physicians and emergency rooms

Jane Cassie had gone through a “frustrating” journey of several years in search of the right family doctor.

The breast cancer survivor seldom felt she was being given the time and attention to meet her complex needs, in part thanks to the so-called “10-minute, two-problem rule,” which meant that any visit could not last more than 10 minutes and could only address a maximum of two problems.

“It was always kind of a band-aid solution; they didn’t really have time to get involved more than that,” she said. White coat, black art host Dr Brian Goldman.

Recently, however, a friend suggested that she contact a different kind of health care provider: a nurse practitioner.

Her first visit to Axis Primary Care Center, a nurse practitioner-run (NPLC) clinic in Surrey, British Columbia, was an eye-opener, she said.

“I was immediately impressed – it was a one hour visit with her. Okay, I had never had so much attention from a GP,” he said. she declared. “And from there she did all my [medical] the story. She managed to bring it all down. “

Nurse practitioner Simrin Sangha meets her patient Jane Cassie at the Axis Primary Care Clinic. (Ben Nelms / CBC)

Nurse practitioners, or NPs, are registered nurses who have completed additional nursing training, education, and experience. This allows them to diagnose and treat illnesses, prescribe medications, and perform other doctor-like tasks that a regular RN cannot.

Nurse practitioner-led clinics are also a relatively new option for those living in British Columbia. The Axis clinic opened in September 2020 and is one of only three in the province.

Before the clinic opened, Health Minister Adrian Dix said British Columbia “has not made the best use of nurse practitioners” compared to other provinces and territories. The new clinics are part of the strategy to close this gap.

Cassie says she feels healthier today than she has been in the past seven years – and that she thinks her PI has provided her with better care than a GP. never did.

“I live with total joy,” she said. “I really think that’s a way forward. I think nurse practitioners are a solution to the problem.”

The 10-minute-two-problem “rule” has never been an official guideline among family physicians, says Dr. Matthew Chow, president of Doctors of BC. “But pragmatically, that’s what ends up happening.

That’s thanks to a litany of stressors in the province, he said, including physician shortages – some made worse by older physicians retiring faster than newer, younger peers. may succeed them – as well as the COVID-19 pandemic and the opioid crisis in British Columbia.

The shortage is not just a problem in British Columbia. Nearly five million Canadians aged 12 or older said they did not have access to a primary health care provider, according to a 2020 Statistics Canada report.

Dr. Matthew Chow is the President of Doctors of BC, a voluntary association that advocates for physicians in the province. (Jimmy Jeong)

Nurse practitioners first appeared in the 1960s, but became a regulated profession in 1997.

In 2019, there were a total of 6,159 nurse practitioners in Canada, according to the Canadian Institute for Health Information (CIHI). -group of nurses.

However, the first NPLCs in Canada did not open until 2008 in Ontario. There are currently 25 in that province today, according to Stan Marchuk, president of the Nurse Practitioner Association of Canada.

According to CIHI, nurse practitioners have “full hospital privileges” in Ontario, Manitoba, British Columbia, Northwest Territories and Nunavut, which allows them to admit, treat and leave. discharge hospitalized patients. They do not have these privileges in Quebec and are restricted in the other provinces.

These differences are due to factors like population, disease burden and the way each region’s health services are designed overall, said Babita Gupta, CIHI’s program manager for information. on health workers.

But she also noted that Quebec is looking to expand the role of NPs in the province in the coming years.

Clinics run by nurse practitioners

In most parts of Canada, nurse practitioners may work in hospitals or community settings, including clinics where they train most primary care providers.

Lexi Grisdale, nurse practitioner and clinical director at Axis, says they are not looking to replace the current structure of primary care in British Columbia, but rather to “fill a gap” for those who cannot find a family doctor and can not rely solely on walking -in clinics or emergency departments.

Axis Primary Care Clinic is one of three nurse practitioner-run clinics in British Columbia. Nurse practitioners also work in other hospital and community settings, including with family physicians and other primary care providers. (Ben Nelms / CBC)

The clinic has rooms and equipment to administer a variety of treatments, from stitching wounds to supporting new moms by helping to teach breastfeeding techniques, she said. In addition to eight NPs, the staff includes three registered nurses, a social worker, a clinical advisor and support staff.

Their patients span the spectrum, from young families and working professionals to people in their 90s who might need help planning for palliative care – “and everything in between,” NP colleague Jane Narayan said.

“War of the territories”

But Marchuk says a sort of “turf war” has occurred between family physicians and nurse practitioners in parts of Canada, explaining that much of it stems from the different ways each is paid by their health authorities. provincial.

Family physicians bill their health authority per visit and are typically not paid to devote more time and attention to a single patient – a model known as fee-for-service.

These limits can also have the unintended consequence of making it more difficult for people with multiple or complex health conditions to find a new doctor.

Stan Marchuk is the President of the Nurse Practitioner Association of Canada. (Submitted by Stan Marchuk)

Anne Clemens discovered it the hard way when her 46-year-old doctor retired. A nurse informally told her that she would have a better chance of having a new doctor by not disclosing all of her health issues, she said, for fear that she would be considered a client ” hard “.

“I thought at one point hard meant, you know, from a personality standpoint… you’d be cantankerous. But no, the interpretation was, ‘I don’t want to have too many problems. she declared.

Anne Clemens, pictured here in Coquitlam, British Columbia, has found a primary care nurse practitioner after her family doctor retired for 46 years. (Ben Nelms / CBC)

Most nurse practitioners are either paid by salary or by contract. Although they have goals for the people served, they do not charge per visit and therefore may spend more time per patient in some situations.

Clemens eventually chose a nurse practitioner as his new primary care provider, at a clinic in British Columbia where nurse practitioners work in tandem with general practitioners.

“She immediately sympathized with me. And she cares about people,” she said of her first visit. “I thought I won the lottery.”

The fee-for-service system was developed when healthcare was “much less complicated,” Chow said.

“There was a lot less treatment. There was a lot less diagnostic imaging and stuff,” he said.

“But now that things are more complicated, you know, people can see the benefit of being able to spend more time with someone. The whole structure and payment model hasn’t kept pace. “

He said that the 10-minute, two-problem rule was in part due to this.

White Coat host, Black Art, Dr. Brian Goldman visits Axis Primary Care Clinic on Tuesday, November 2, 2021. (Ben Nelms / CBC)

Level the rules of the game

As for Grisdale and his team at Axis, they say they are determined to do their part to help alleviate an already strained healthcare system.

“I watch [this] from a very holistic context, hoping to prevent things that will cost the system millions [or] billions of dollars down the line, ”Grisdale said. “And keeping people, you know, employed and in the workforce, happy and engaged with their families, and great social support. “

Lexi Grisdale, Harvinder Sihota and Jane Narayan are shown at Axis Primary Care Clinic on Tuesday, November 2, 2021. (Ben Nelms / CBC)

Marchuk agrees. “We all have strengths and we all have weaknesses. But together we are working for the same common good in terms of results,” he said.

Chow said that finding a “level playing field” for how family physicians, nurse practitioners and other health care professionals are paid ultimately helps everyone involved to better focus on how best to meet the challenges. patient needs – instead of worrying about their next bill.

“We have to sit down at the table and sort this out,” he said. “So that all team members are treated with respect and in a sustainable manner.”

Written by Jonathan Ore. Produced by Rachel Sanders.

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