Feature Article March 28, 2002
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Nurse Practitioners and primary care reform in Ontarioby David BrisonNurse Practitioner Mary Woodman is one of a relatively rare breed in Ontario. There are only about 500 nurse practitioners in the province, and very few of them work in rural practices -- except perhaps in the far north. Further, her role in the Sharbot Lake Medical Centre is more intensive than the role of nurse practitioners in the other pilot projects in primary care reform. She is full time and collaborates with only three doctors: Dr. Peter Bell, Dr. Doug Black, and a resident in family practice from Queens. In addition, she is able to draw on the full range of diagnostic and treatment skills she learned in the ten-month advanced program for experienced nurses a program that culminated with a one-year residency, spent, in Marys case, in Sharbot Lake.
I visited with Mary just after she had finished the Saturday clinic. This clinic came about as part of the plan to provide increased access to primary care. It is for problems that are urgent and emerge during the weekend; appointments are not necessary. As patients with life-threatening emergencies are instructed to call the ambulance and go directly to a hospital emergency room, Mary doesnt usually have to handle emergencies, which would be difficult to do while she is alone at the clinic.
Prior to becoming part of a pilot project for primary care reform, a physician was on call on the weekend and would come into the clinic to see patients. People were, according to Dr. Bell, often reluctant to disturb the on-call physician. The Saturday clinic is used more often and does seem to provide more access for patients. The doctors and nurse practitioner also take the extended weekday clinic hours (from 5:00 p.m. to 8:00 p.m. appointments necessary) on a rotational basis. There are still on-call hours for the doctors and nurse practitioner. However, the first point of entry, and one that screens many calls, is with another Nurse Practitioner who is working at a province-wide telephone triage service.
Many rural physicians burn out as a result of heavy on-call responsibilities. The triage service, coupled with extended hours and use of Nurse Practitioners, are attempts to make on-call less demanding for doctors, while at the same time providing after-hours access for patients.
Mary takes every fourth clinic. On a typical Saturday, she sees about 12 people for various problems: bad coughs and colds; acute pain; bladder infections; lacerations, sometimes caused by chainsaw accidents but more frequently by knife cuts; and during the summer, embedded fish hooks.
Nurses dont do suturing (stitches), but it is part of Nurse Practitioner training, and Peter Bell continued to teach Mary how do it during her residency. She will call a doctor if the laceration is deep, but generally handles it on her own. Nurse Practitioners have a limited list of pharmacological medicines that they can prescribe, such as common antibiotics, immunizations, and birth control pills. Mary can also prescribe medications under a medical directive from Peter Bell, for another range of areas such as womens health (one of her specialities),
Nurses also typically dont diagnose, and a major focus of the 12-month Nurse Practitioner training is on advanced health assessment and diagnosis. Mary uses the diagnosis skills she learned in training and during her residency, and in addition directly treats patients both pharmacologically and without medication. She also provides education on medical problems, and finds that she does a lot of counselling with patients. Treatment skills were an important part of her program.
Mary had 20 years of nursing experience before she enrolled in the advanced Nurse Practitioner program. She first got her nursing diploma at St. Lawrence in 1977, completed her Bachelor of Science degree at Queens in 1996, and then enrolled in the Nurse Practitioner program at Queens. Students in the advanced program are carefully selected from the nursing ranks.
When Peter Bell first negotiated with the province, through the pilot project on primary care reform, he did not want to have the Nurse Practitioners job too well defined. It was important, he thought, to be able to tailor the job to the needs of the clinic and the special expertise of the Nurse Practitioner. He had a good idea of Marys special skills because she was just completing her residency in Sharbot Lake at the time.
Mary had worked for a number of years in a high-risk obstetric clinic in Kingston. In Sharbot Lake, Mary specializes in womens health and works quite independently in that field. In addition, she has developed a broad range of diagnostic and treatment skills. When Mary was assigned to Sharbot Lake for her residency, she wasnt too pleased that she would have to travel each day from Kingston, where she lives with her husband and three children, ages 16, 19, and 29. However, it has worked out really well for her. Peter Bell is an excellent teacher, having had over the years 170 residents in family practice, and is very willing to teach. I have benefited tremendously from that. I like the range of practice that I get a chance to engage in. There is the opportunity to look after different generations in the same family.
The work is much harder and time consuming than the nursing I did. I cant leave my work at the office when I go home, and I regularly work 50-60 hour weeks. However, the clinic is a nice place to work. I respect the physicians. One of the special things about this clinic is the wonderful group of women who work here. Together they make it a special and very rewarding place, Mary said at the conclusion of our interview.
