1. Contests of Expertise within Primary Care
MEDICAL WORK/NURSING WORK
LaTonya J. Trotter, MPH, MA
OPR Notestein Seminar

2. PROVIDING HEALTH CARE
• 32 Million  Primary Care
• 20 Million  “Less Profitable” Poor

3. HEALTH CARE
Science
Nursing Medicine
Disease
Clinical Decision Making

4. WHAT IS A NURSE PRACTITIONER?
Diagnose
Treat
✚ =
Bachelors Masters Nurse
Practitioner
4 years 2 years
650 clinical hrs

6. Commitment to Primary Care
Access for uninsured and medicaid
Cost effective
PROFESSIONAL CLAIMS

7. What is a nurse practitioner?
Physician extender?
Junior doctor?
Independent Clinician
Mid-level Practitioner?

8. How “good a Dr.” is the NP?
• Flynn, B C. 1974. “The effectiveness of nurse
clinicians’ service delivery.” American Journal of
Public Health 64(6):604–611.
• Mundinger, M O et al. 2000. “Primary care
outcomes in patients treated by nurse
practitioners or physicians: a randomized trial.”
JAMA: 283(1):59–68.
• Laurant, M et al. 2005. “Substitution of doctors
by nurses in primary care.” Cochrane Database of
Systematic Reviews (Online) (2):CD001271

9. What we don’t know…
• NPs may do something different, but what?
• How organizations might use the NP
• Role of interaction
What do they do?

10. Hidden Population
• 180,000 NPs 800,000 MDs
• 376,000 MDs Primary Care Specialties

11. Hidden Population
26 States = Autonomous
48 States = Rx
Source: The 2012 Pearson Report, The American Journal for Nurse
Practitioners, NP Communications LLC.

12. Hidden Medical Practices
• Hospital
• Technological Innovations
• Acute Care / Cure
• Outpatient / Home
• Practice Innovations
• Chronic Disease Management

13. Questions
• How do NP’s practice?
• How may patients be differently seen?
• How are NP practices constructed through
negotiation?
• Spaces of difference in healthcare delivery

14. NP Training
• NP’s are Nurses, not “Junior Doctors”
– School of Nursing
– Textbook audience is Nurses
• Practice / Vocationally Oriented
• Unique Expertise: Social Quandries

15. Methodology
• 18 months of Ethnographic Observation
• Community-Based Practice
– Nurse-Managed
– NPs are primary providers

16. Site
• Program for All Inclusive Care for the Elderly
(PACE)
• Medicaid/Medicare enrollees
• Social Work, Homecare
• Interdisciplinary Teams = Interaction

17. A Tale of Two Teams

18. “…started realizing I didn’t want to
be a hospital nurse…you really don’t
have a lot of autonomy.”
Blue Team
NORAH, CRNP

19. Norah
“…And once I see how they do it—
once I see how it’s managed, I’m
good to go.
“Like consultants rather than
collaborators. I grab them when I’m
stuck.”

20. “I never really did this kind of NP
work, where you’re really in charge.”
“PC docs refer to rheumatologists, NPs
refer to medical docs”
Black Team
SARA, CRNP

21. NP Expertise
• Norah was “ideal” NP
• “Whole Case”
• Sarah was lacking
• Failed to Invest in local expertise

22. Physician Role
• Positioned “outside” the clinic
• Physicians and NPs not interchangeable
• Physician only “saw” medical concerns

23. Conclusions
• NP Expertise of “whole case”
• Medicalize the Social
• “Medical competence” is not enough
• Need to reorient our understanding of
physician practice

24. Implications
• Clinician shortage? Not “the” answer
• Living critique of medicine
• NP practices as alternatives for primary care

25. Acknowledgments
• Elizabeth Armstrong, Mitchell Duneier, King-to
Yeung
• NSF Graduate Research Fellowship
• Princeton’s Center for Health and Well-being