By Lynn Bonner
Cindy Cross was diagnosed with breast cancer about 15 years ago and found compassionate medical care when she first visited Michelle Taylor Skipper’s office in Laurinburg.
Cross has been a patient of Skipper’s ever since, and her two adult daughters see her, too. In Skipper, Cross has found a trusted medical provider who goes out of her way to answer questions during unhurried appointments. “She’s a phenomenal doctor,” Cross said. “I would rather go to her than anyone.”
Skipper has a doctorate degree in nursing practice. An advanced practice registered nurse, she diagnoses and treats patients in Laurinburg one day a week. She also directs the Doctor of Nursing Practice program at East Carolina University in Greenville.
But there are limits to what Skipper can do.
She was frustrated, for instance, by what she viewed as regulatory bureaucracy when she wanted to see patients at a mobile medical center that rolled into her town of St. Pauls in Robeson County. She couldn’t treat the patients because the doctor in charge at the mobile center was not listed as her supervisor on the documentation nurse practitioners must maintain.
“I was never able to care for my own community as a nurse practitioner because of those barriers,” she said during an interview at the church in St. Pauls that her late husband led. “Super frustrating.”
When Kohn retires, Skipper said, she will have to retire too, or find another doctor to supervise her and agree to monthly quality improvement meetings.
“When he retires and I change supervising docs, I have to start a relationship with that physician like I was a brand new graduate.”
A debate over state law
State law requires advanced practice registered nurses like Skipper to have a medical doctor as a supervisor. “Advanced practice registered nurses” is an umbrella term covering four nursing specialists who hold advanced degrees: nurse practitioners, certified nurse midwives, clinical nurse specialists, and certified registered nurse anesthetists. Together and separately, these groups of nurses have tried for years to convince the legislature to allow them to practice independent of doctors’ supervision.
Many nurses, including Skipper, want autonomy for advanced practice registered nurses written into law via legislation, and most legislators back it.
Nurse practitioners and the doctors who supervise them don’t have to collaborate on the treatment of each patient. Skipper describes her professional relationship with her supervisor, OB/GYN Dr. Harvey Kohn, as more like a partnership. Skipper has her own patients. Kohn sometimes checks her patient charts, when she isn’t there to review lab results, for example. But he’s not double-checking her work, she said. It’s not uncommon for advanced practice nurses to open their own medical practices. Their supervising doctors must be available for consultation but don’t have to work on site. In some cases, doctors work for the practices under contract. Doctors do not have to routinely review patient charts.
The nurses maintain that cutting this thin thread of supervision will attract more advanced practice nurses to rural areas with doctor shortages. Doctors, however, want to maintain their role as supervisors, and dispute the claim that advanced practice nurses will help relieve shortages of health care providers in rural areas. Opposition from doctors’ groups has helped stonewall efforts to provide more leeway for advanced practice registered nurses.
Twenty-four states and Washington, D.C., allow nurse practitioners to diagnose and treat patients without doctors’ supervision. Supporters see a new opportunity that could win advanced practice nurses autonomy in North Carolina. A legislative committee on Medicaid expansion and health care access is digging into questions of current and anticipated shortages of medical workers.
Doctors are concentrated in urban counties. In 68 of the state’s 100 counties the number of primary care doctors per 10,000 residents fell below the overall state rate of 7.06, according to 2019 data from the Sheps Center for Health Services Research at UNC. Two small counties had no primary care doctors. Nurse practitioners are more widely distributed, although they are also easier to find in urban counties and those with major hospitals. One county in the state’s northeast corner, Camden, had no nurse practitioner in 2020, according to Sheps Center data.
The state is adding nurse practitioners more quickly than it is primary care doctors, according to the Sheps data.
Dr. Karen Smith, a family doctor with her own practice in Hoke County, said it’s important to continue to require collaborative agreements between doctors and nurse practitioners.
Although a federal study using information from 2010 found that nurse practitioners were more likely than primary care physicians to practice in rural areas, Smith cited information from the American Medical Association from three states that showed allowing nurses to practice independently doesn’t increase the likelihood they’ll work in rural areas.
“It has been a difficult struggle to encourage nurse practitioners and physician assistants to serve in our rural areas,” she said.
Smith is medical director for the Hoke County health department and supervises the nurse practitioner and physician assistant who work there. The mix of experience and education on the team are important to patient treatment, she said.
It’s important as the supervisor for her to know what advanced practice providers are comfortable doing, she said. For example, she said, the advanced practice providers she supervises are not comfortable prescribing opiates. And understanding how those providers work informs Smith about often they need to meet to review patient charts.
“If the experience, education, skills and comfort level mean we are going to review charts every week, we’ll review charts every week,” she said.
Different approaches in different communities
Certified registered nurse anesthetists, or CRNAs, must work under a doctor’s supervision, but what that looks like depends on the hospital. Eleven hospitals in the state have only CRNAs who do the work of anesthetizing patients, monitoring them in the operating room, and waking them up, said Stacy Yancey, president of the NC Association of Nurse Anesthetists. Some hospitals in the eastern part of the state have anesthesiologists, medical doctors, who work during the day, with CRNAs on duty nights and weekends, she said, and a majority of plastic surgery practices and endoscopy centers hire only CRNAs.
Yancey works for a staffing agency, and has experience working in a variety of settings. In a rural hospital, she’s responsible for assessing patients before surgeries, administering anesthesia, and waking them up.
When she works in a hospital with an anesthesiologist, that doctor does the preoperative assessments and fills out all the forms.
Again, depending on the hospital, the anesthesiologist may not enter the operating room. At some hospitals the anesthesiologists come into the operating room shortly before or while Yancey is administering general anesthesia; those doctors leave when the patient is stable, and Yancey stays there.
“Sometimes they will come and check on me during long cases to see if I need anything,” Yancey said.
“The standard of care in the O.R. is the same no matter who is providing the anesthesia,” she said, and a law allowing CRNAs to work without supervising doctors would clear up gray areas.
Skipper, the nurse practitioner from St. Pauls, is convinced that advanced practice nurses from rural areas will want to stay there, as she has. Independence for advanced practice nurses will also advance entrepreneurship, she said.
Schquthia Peacock, a nurse practitioner in Cary, has co-owned her practice with a doctor for 22 years. “I have had my own panel of patients – patients who call me their primary healthcare provider,” she said.
The decision to become a practice owner was sudden and came shortly after the medical practice where she had taken a job went bankrupt.
“We didn’t want to lose the practice and the patients,” she said. “We felt it would be best to continue the practice as it was.”
The office is arranged so Peacock, her physician partner and the nurse practitioners the practice employs can meet during the work day to discuss patient care. “We call it a collaboration,” she said. “We consider ourselves a team working toward patient care.”
Jennie Mayo, a patient of Skipper’s in Laurinburg, chooses care from nurse practitioners. “They listen to me,” she said. “Doctors sometimes dismiss you.”
Mayo first saw Skipper in 1992. Mayo left the state in 2010 but sought out Skipper again upon returning to Laurinburg in 2017.
“We just hit it off,” Mayo said. “She’s funny. She remembers you.”
“I was lucky enough that she took me back,” Mayo said. “In a small town, it’s often hard to find a family doctor, an OB/GYN – it’s hard to find medical care.”
Mayo knows that advanced practice nurses are pushing to be able to practice independent of doctors’ supervision. She thinks they should have that autonomy.
“They’re educated adults and perfectly capable of making informed medical decisions,” she said.