Group practice: Does every doctor need a nurse?

If you're in a group practice, should you have a clinical assistant dedicated to you or should you share these staffers with your colleagues? The question seems simple, but the answer is not. About all that practice management consultants agree on is that no solution fits every practice.

Kenneth Bowden, a consultant in Pittsfield, MA, favors the sharing approach because it enables doctors to get along with fewer assistants. "I think it's more cost-effective if you hire enough nurses or medical assistants to do the job and fit them to the job," he says. Bowden acknowledges that doctors would rather have their own clinical assistant, but he believes this approach leads to problems, like favoritism and difficulty scheduling vacations.

Michael D. Brown, an Indian-apolis consultant, maintains that a four- or five-doctor primary care group runs most efficiently with "half a body per doctor" on its clinical staff. He makes an exception for practices where the nurses do additional tasks, such as lab and X-ray work. There, he says, it makes sense to have a one-on-one ratio of doctors to assistants. But in most cases, the extra cost of dedicated nurses will reduce the doctors' income, he argues.

"On busy days, the doctors can use a 'float MA' in addition to their own assistants. This full-time MA can go wherever she's needed, and that's really efficient for practices. It keeps things moving very nicely.

"Practices tend to be more successful when there's adequate clinical staff," he adds. "Otherwise, the doctor's going to be slowed down and will be doing things that could be delegated. That wastes his time and makes the practice financially inefficient."

Cliff Fetters, a family physician in Indianapolis, certainly agrees with this view. Fetters has not one, but two RNs who work solely with him. They help him handle 35 to 40 visits a day. Partly as a result, he earns about 20 percent more than his three partners, each of whom has just one dedicated clinical assistant.

More practices have RNs than you might think

The conventional wisdom is that RNs in primary care offices have gone the way of Marcus Welby. They're too expensive, the reasoning goes, and most of them are working for hospitals, which have a nursing shortage. According to consultants, most primary care practices are now hiring licensed practical nurses and medical assistants, who cost 25 to 50 percent less than RNs do.

But Flora Nielsen, a former president of the American Association of Office Nurses, says that many outpatient practices still have RNs. "Some doctors feel very strongly about having at least one RN, with the rest a combination of LPNs or MAs," says Nielsen. Ken Bowden and Michael Brown both say that RNs are available to primary care offices in their regions (New England and Indiana), either because hospitals are laying them off or because they've burned out on hospital work.

How does your choice of an RN, an LPN, an MA, or a CMA (certified medical assistant) affect practice economics? According to Brown, RNs are worth more because they can do more, including some medical decision-making. Some doctors would also prefer to have RNs give injections, he adds.