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COMMENT Loretta C. Ford, R.N., Ed.D. Dean and Director of Nursing University of Rochester Medical Center March 1978 Over the past two years, the Institute of Medicine's Committee to Study an Integrated Manpower Policy for Primary Care reviewed informa- tive and analytical papers prepared by project staff members and grappled with the conceptual and contextual problems of defining primary care and setting forth recommendations for this report. Upon reviewing the final draft of the report, I find myself, as a nurse practitioner and educator, with certain reactions and reservations. This comment explains those reactions and expresses concern about some of the recommendations, particularly those dealing with the relationship of the physician to the nurse practitioner. Throughout the report, recognition is given to the "goodness of fit" between the kinds of health problems for which people seek services and the roles of non-physicians, nurse practitioners, and physician assistants as providers of primary care. Emphasis on teamwork, equal reimbursement, accountability for all professionals, and the need for a data base and research to determine manpower needs are all laudable aspects of the report. However, there are noticeable imbalances and incongruities that I am compelled to mention. Despite the heroic efforts of some committee members to balance the health vis-a-vis illness content, the medical and economic issues permeate the report without adequate consideration for addressing the unmet needs of people. The maintenance of health, early management of health problems designed to prevent hospitalization or institutionalization, and the creation of incentives for self-care received too little attention. Incongruities also are apparent between the content of the report and some of the recommendations. I take particular exception to Recom- mendation #19 which singles out medical acts in delivering primary care and specifically calls for physician supervision of nurse practitioners. The effective domain for which professionals other than physicians are primarily responsible, for example, nursing acts or pharmacy acts, is not mentioned. My review of 24 state nursing practice laws, which were changed to accommodate expanded role functions, reveals that only two statutes have used the phrase "physician supervision." -105-
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Primary care is a complex, problem-oriented issue that does not lend itself to solution through the skills and controls of one disci- pline. True interdisciplinary behavior must be learned by the providers with an acceptable distribution of power, control, and accountability. Some explorations of new and evolving relationships which are worthy of continuing study are described in the publications of the National Joint Practice Commission and the Academy of Nursing.* In summary, my major concern is that incongruities exist between the text of the report and some of the recommendations; this will limit the usefulness of the report in establishing cogent public policies for health. Instead of taking the giant steps for preparing teams of health professionals to deliver primary care to all the people of this nation, only small steps will be taken and token changes made. Once again, we will experience "dynamics without change" in health policies. *Together: A Case Book of Joint Practices in Primary Care, National ~ .- Joint Practice Commission, editor Berton Roueche, Chicago, 1977. Primary Care By Nurses: Sphere of ResDonsibilirv and Arrn''nt~hi ~ i For American Academy of Nursing Annual Me City, 1977. Joint Practice in Primary Care: Definitions and Guidelines, National Joint Practice Commission, Chicago, adopted September, -106-