Strategies to Optimize the Physician and APRN Relationship 

Dr. Buch:
Welcome to Clinician’s Roundtable on ReachMD.  I’m your host, Dr. Peter Buch.  And today to discuss strategies on how advanced practice registered nurses, or APRNs, and physicians can better work together to improve patient outcomes is returning guest, Dr. Wendy Wright.  She is a nurse practitioner and the founder of Wright & Associates Family Healthcare. 

Dr. Wright, thanks for joining us today. 

Dr. Wright:
Thank you so much, Dr. Buch.  It’s truly my pleasure.  And this is a topic that I couldn’t wait to talk with you about today. 

Dr. Buch:
Perfect.  Let’s dive right in, Wendy.  What are some likely reasons conflicts arise between APRNs and physicians?

Dr. Wright:
Thank you so much for that question.  One of the places I do believe that conflict arises is more on an organizational level between our professional organizations or maybe even systems in which we work, and I think that while that sometimes kind of plays down into the day-to-day workings of nurse practitioners and physicians, I think that for the most part the relationships that exist between all of us is pretty collegial.  I practice differently than you, and I suspect you practice differently than me, but at the end of the day, if we can get our patients to the same place—and while we may disagree on that management—there are often more than one way to do something, and I think that those day-to-day relationships oftentimes are really collegial. 

Dr. Buch:
I’m going to throw something at you that I’ve heard along the way from physicians, “APRNs and PAs are stealing my patients away.”  How do you address that? 

Dr. Wright:
Well here is how I address it.  There are 350,000 primary care providers, physicians, NPs, and PAs who have left this business in the last two to three years.  There are so many people out there in such need of health care that no one in my opinion is stealing anyone’s patients because patients are not to be stolen.  They’re not my patients, and they’re not yours.  And if people feel that they’re not getting the care that they need from me or from you, they have every right to go where they feel like that care is best for them.  So I have no desire whatsoever to take someone else’s patients.  And oftentimes people transfer into the clinic.  I have no idea why they’re coming to me.  Or they transfer out.  You and I can’t meet the needs of every single person.  And we’re not going to be perfect for every patient that’s out there. 

But I guess I would just go back to the fact that my clinics are growing at 150 new patients a month.  I’m not advertising.  Why is that?  Because people are waiting four, five, six months to get in with primary care because there are not enough of us.  I think if we concentrate on taking care of people who need health care, we all will have more work than we need.  I mean, I don’t know what your schedule is like, but people are waiting months to get into mine, and I suspect it’s the same for you. 

Dr. Buch:
Not unusual at all.  And moving on to the next question, might physicians perceive themselves as more medically trained?  And how do you address that issue? 

Dr. Wright:
Sure.  Certainly, Peter, if we go based solely on hours of training and length of medical school, then certainly I would agree with you that physicians have more training and more education in that domain, but I would then say to you as a nurse of 32 years and an NP of 30, I would maintain that I have more medical training than some of my physician colleagues in certain areas.  I bring to the table such a set of skills, and you bring to the table your set of skills, and if I were to say to you, “Who has more training in the management of hep C patients and fatty liver?”  That is absolutely going to be you.  But I bet if you said to me, “Who has more training in the management of patients with resistant hypertension who also have diabetes and chronic kidney disease?” I suspect you’d probably say me because that is what I’ve spent the last 30 years doing.  So yes, I can agree we all trained differently and that when you look solely at hours, yes, you have had more hours, but I think what we need to focus on is what each of us bring to this table and that we each bring a set of really valuable skills, that when we work together and we work as colleagues, that we can really get these patients to where they need to be and give them the best health outcomes. 

Dr. Buch:
That’s perfect.  And what I would say to you is that within our GI practices, we may have APRNs and PAs who specialize in hepatitis C and who specialize in fatty liver disease who actually may be seeing more patients than we gastroenterologists.  It really depends how you run the practice. 

Dr. Buch:
For those just tuning in, you’re listening to Clinician’s Roundtable on ReachMD.  I’m Dr. Peter Buch, and I’m speaking with Dr. Wendy Wright about issues that may arise between APRNs and physicians. 

So looking towards some solutions, Wendy, how can strong organizational leaders improve the environment between APRNs and physicians? 

Dr. Wright:
One of the things that I learned, Peter, over the years is that it’s really helpful to lead from within and that I often will say that if we’re not at the table, we’re going to be on the menu.  Each of us needs to have a place at that table.  Each of us needs to represent the work that we can do and the things that we can bring to these organizations and to the patients in which we serve.  And I think when we each have the place at the table, and we can communicate about what we are able to bring, great things are going to come because the goal here is to really have the right provider seeing the patient in need of our services at the right time.  And that may be you; that may be me; that may be our physician assistant colleague.  It may be a pharmacist.  At the end of the day, if we can all lead within and we can have those places at the table to have these conversations, I think we can absolutely improve that relationship. 

And I’ll tell you, in 30 years of my career, I have worked with some of the most amazing physicians who have been so incredibly supportive.  And sometimes they will say to me, “I have no idea what role you are going to play here,” and I will say to them, “Then let us work it out together.  And you be comfortable with the role, I’ll be comfortable with the role, and together we’re going to do some really great things.”  And so I think that strong organizational leaders really can come from within to promote better relationships between all of us. 

Dr. Buch:
The important byline here is communication.

Dr. Buch:
Now Wright & Associates is a family healthcare practice and employs only APRNs.  Can you tell us how you’ve developed your collaborative relationship with local physicians? 

Dr. Wright:
Well so yes.  I opened this clinic in 2007 with seven patients, me, the nurse practitioner, and one part-time NP, and we’re at about 6,500 primary care patients now and 11 nurse practitioners.  All of the NPs, we have RNs, we have medical assistants, we have PT on site, we have lab on site, so we are really a full-service primary care practice, but I will tell you that the relationships that I have developed in our community are honestly lifelong with my physician colleagues.  I’ve been in the same community for 30 years, and I will tell you that the physicians that I work with—now, I don’t work alongside them, but that doesn’t matter—I have great relationships with the specialists in the community and even other family practice physicians, and I will tell you why.  One is because I am respectful of all of the work that they do, and they too are respectful of the work that I do.  Specialists will often say to me, “I love seeing your patients that come from your clinic.  Your notes are amazing.  You’ve done the work.  You’ve put the time in to try to work this up.”  And I think that goes a long way in developing those relationships that are mutually respectful. 

And so I honestly have maybe once in 30 years had a physician that I felt was disrespectful of the work that we were doing, but I was quick to say, “If there’s something that we are not doing that would make you happier, please tell me because we are always looking to improve our practice.”  And after that the relationship became very good, but I think it’s—Again, you hit the nail on the head—It’s communicating with people in the community.  And if I hear things out there from patients who say, “Well, you know, this is what was said about you,” if there seems to be a theme, then I’m not shy, as you can tell, and I’m willing to pick up a phone and say, “Talk to me about what your concerns might be.”  But I have always had great relationships with the physicians in our community. 

Dr. Buch:
And before we conclude, Wendy, are there any other thoughts you’d like to share with our audience today? 

Dr. Wright:
Yes.  I would say to you that there are lots of people with limited or no access to care.  There are patients who have such social determinants of health and issues that really prohibit them from getting the care, and if we can all work to that top of our education and top of our training and not worry about control or power or titles or money and just focus on the reason that all of us went into this, at the end of the day, everyone, including ourselves, are going to be happier and so much better served.  Again, it’s all about giving people access and choice of care, and I think that when people have relationships like you and I have, it only serves to improve the care that we provide to our patients.  So thank you for giving me this opportunity.  I am always honored to be in your presence and to work with you on programs like this. 

Dr. Buch:
And likewise for you, Wendy.  It’s an honor to work with you always.  Those were some great take-home points.  I want to thank my guest, Dr. Wendy Wright, for sharing her insights.  Dr. Wright, it was a pleasure speaking with you today. 

Dr. Wright:
Oh, it was a pleasure speaking with you as well.  Thank you again for your time. 

Dr. Buch:
I’m Dr. Peter Buch.  To access this and other episodes in our series, visit ReachMD.com/CliniciansRoundtable where you can Be Part of the Knowledge.  Thanks for listening, and see you next time.