How nurse practitioners are bridging the gap between family doctors and the ER

Jane Cassie had gone through a "frustrating" years-long journey looking for the right family doctor.

The breast cancer survivor rarely felt like she was being given the time and attention needed to address her complex needs, thanks in part to the so-called "10-minute, two-problem rule," which meant any visit could be no more than 10 minutes long and could only address a maximum of two issues.

"It was always kind of a Band-Aid solution; they didn't really have the time to get involved any more than that," she told White Coat, Black Art host Dr. Brian Goldman.

Recently, however, a friend suggested she contact a different type of health-care provider: A nurse practitioner.

Her first visit to the Axis Primary Care Centre, a nurse practitioner-led clinic (NPLCs) in Surrey, B.C., was a revelation, she said.

"I was impressed right away — it was an hour visit with her. OK, I hadn't had that much attention ever from a GP," she said. "And from there, she did my entire [medical] history. She was able to get everything down."

Nurse practitioners, or NPs, are registered nurses who have completed additional training, education and nursing experience. It enables them to diagnose and treat illnesses, prescribe medication and do other tasks similar to a doctor that a regular registered nurse 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 just three in the province. 

Prior to the clinic's opening, Health Minister Adrian Dix said B.C. "has not made the best use of nurse practitioners" compared to other provinces and territories. The new clinics are part of the strategy to help close that gap.

Cassie says she feels healthier today than she has in the last seven years — and that she believes her NP provided her with better care than a GP ever has.

"I am living with total joy," she said. "I really feel that this is a definite way to go. 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 the association Doctors of B.C. "But pragmatically speaking, that's what ends up happening."

That's thanks to a litany of stressors in the province, he said, including doctor shortages — some compounded by older doctors retiring faster than newer, younger peers can succeed them — as well as the COVID-19 pandemic and B.C.'s opioid crisis.

The shortage isn't just a B.C. problem. Nearly five million Canadians aged 12 or older reported not having access to a primary health care provider, according to a 2020 Statistic Canada report.

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

As of 2019, there were a total of 6,159 nurse practitioners in Canada, according to the Canadian Institute for Health Information (CIHI), with the designation seeing an 8.1-per-cent growth rate from 2015 to 2019, making it the fastest growing sub-group of nurses.

However, the first NPLCs in Canada only opened in 2008 in Ontario. There are currently 25 operating 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, B.C., the Northwest Territories and Nunavut, which allow them to admit, treat and discharge hospital patients. They don't have those privileges in Quebec and are restricted in the other provinces.

Those differences are due to factors like population, burden of disease and how each region's health services are designed overall, said Babita Gupta, CIHI's program lead for health workforce information.

But she also noted that Quebec has been looking into how to expand the role of NPs in the province in the coming years.

Nurse practitioner-led clinics

In most parts of Canada, nurse practitioners can work either in hospitals or community settings, including in clinics where they form most of the primary-care providers.

Lexi Grisdale, a nurse practitioner and clinical director at Axis, says they're not looking to replace the current primary-care structure in B.C., but rather "addressing a gap" for those who cannot find a family doctor and cannot rely solely on walk-in clinics or emergency departments.

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

Their patients run the spectrum, from young families and working professionals, to 90-year-olds who might need help with planning palliative care — "and everything in between," said fellow NP Jane Narayan.

'Turf war'

But Marchuk says a "turf war" of sorts has arisen between family doctors and nurse practitioners in some parts of Canada, explaining that much of it stems from the different ways each is paid by their provincial health authorities.

Family doctors bill their health authority per visit, and aren't typically compensated for spending more time and attention on a single patient — a model known as fee-for-service.

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

Anne Clemens found that out the hard way when her doctor of 46 years retired. A nurse told her informally that she would have a better chance getting a new doctor by not disclosing all of her health issues, she said, lest she be considered a "difficult" client.

"I thought, at one point, difficult meant, you know, personality-wise … that you'd be cantankerous. But no, the interpretation was that, 'I don't want to have too many issues,'" she said.

Most nurse practitioners, meanwhile, are either paid by salary or on contract. While they have targets for people served, they don't bill per visit, so can spend more time per patient in some situations.

Clemens ultimately went with a nurse practitioner as her new primary-care provider, at a clinic in B.C. where nurse practitioners work in tandem with GPs.

"She empathized with me immediately. And she cares about people," she said of her first visit. "I thought I'd won the lottery."

The fee-for-service system was developed when health care was "far less complicated," said Chow.

"There were far less treatments. There was far less diagnostic imaging and other things," he said. 

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

He said the 10-minute, two-problem rule came about, in part, because of this.

Levelling the playing field

As for Grisdale and her team at Axis, they say they are focused on doing their part to help ease a health-care system already under heavy strain.

"I'm looking at [this] from a very holistic background, in hopes of preventing things that will cost the system millions [or] billions of dollars down the line," said Grisdale. "And keeping people, you know, employed and in the workforce, and happy and engaged with their families, and great social support."

Marchuk agrees. "We all have strengths and we all have weaknesses. But together we work for the same common good in terms of outcome," he said.

Chow said figuring out "a level playing field" for how family doctors, nurse practitioners and other health professionals are paid ultimately helps everyone involved better focus on how to best address patients' needs — instead of worrying about their next bills.

"We've got to sit down at the table and work this out," he said. "So that all the team members are treated respectfully and in a way that's sustainable."

Written by Jonathan Ore. Produced by Rachel Sanders.