Top Doctors: The Super Nurse

Bob Smithing is always eager to see patients at his Kent clinic. On a typical day, he might check in with a patient recovering from depression, adjust the prescription for a patient with high cholesterol, perform a Pap smear and insert an IUD during a gynecological exam. “It’s the best job on earth,” Smithing says.

He’s not a doctor, though: Smithing is a nurse practitioner (N.P.), a profession that may well be the future of primary care in many areas, especially poor or rural places that traditionally have trouble attracting doctors. And it’s a profession that’s been mentioned by both President Barack Obama and rival candidate John McCain as having a role in their health-care reform plans.

Not quite sure what a nurse practitioner is? Think: nurse on steroids. Alternatively, think someone who can do as much, but not all, of what a primary care doctor does for patients, but with a little more time and at a little less cost. In 10 states, including Washington, nurse practitioners can work independently and have their own practice; in 27 states, they must work in collaboration with a physician; and in 11 states, they must work under the supervision of a physician. Regardless of the state, most at present do work in collaboration with a physician, according to Nurse Practitioner Alternatives, Inc., which provides education for nurse practitioners around the country. The majority of nurse practitioners, about 85 percent, work in primary care. That includes adult, pediatric and geriatric care, along with other areas such as women’s health, and neonatal and acute care. Some work in mental health, midwifery and family care.

Nurse practitioners emphasize preventive care and treating patients holistically. They perform physical exams, diagnose and treat illnesses, manage chronic illnesses, and can order tests such as X-rays, blood work and electrocardiograms. They can also prescribe physical therapy, suture wounds, cast fractures and perform procedures such as skin biopsies. And they have prescriptive powers. Nearly all nurse practitioners hold advanced degrees (some with doctorates) in nursing. Their numbers are growing: In 1995, there were 44,200 nurse practitioners in the United States. By 2005, there were 82,622, a growth of almost 9.5 percent a year. As of 2007, 120,000 were practicing in the United States; and as of 2008, 4,635 nurse practitioners were practicing in Washington, in a wide variety of settings.

“Most are in primary care, in the community setting, providing I guess what you would say are essential preventative and clinical care,” says Deonne J. Brown-Benedict, DNP, a family nurse practitioner and assistant professor at Seattle University. “The emphasis is on health promotion, risk reduction, disease prevention and the management of common acute problems and chronic conditions.” Studies consistently show high levels of patient satisfaction with nurse practitioners, both Smithing and Brown-Benedict say.

“People don’t tell me that the reason they want to see me is because I’m a nurse practitioner. They tell me that I listen, that I work with them as an equal partner in health care and that I spend time with them,” Smithing says.

Smithing opened his first practice with several fellow nurse practitioners in 1985, in what he thinks is one of the first nurse-practitioners-only clinics in the region. “We wanted to demonstrate a nurse practitioner practice could be in a competitive urban environment. [Now] I have some patients where we’ve had 20-year anniversaries together.”

He’s gratified that people nowadays seem familiar with the idea of nurse practitioners, Smithing says. “Gone are the days when people said, ‘Oh, you’re a practical nurse.’”