It works a lot like the dental hygenists in the dentists' offices. They work under the supervision -- more like in partnership, in actual point of fact -- with the MDs and DOs. They see a lot of patients with common illnesses or injuries, at reduced fees. There is always a doctor available, in case the nurse-practitioner sees something unusual, or in case the patient asks to see a doctor. The fee goes up if the doctor is called in by the patient. There are, of course, certain procedures and conditions that are booted to the doctor at once.

They are trained to a certain level of skill, including giving injections, treating minor injuries, and doing examinations, including standard annual physicals and healthy-baby checks. Some are qualified to xray. In the cases of diseases with known diagnostic tests and set treatments, like strep, they are also allowed to write prescriptions (say, for amoxycillin) within the limits of the diagnostic protocols. Most people are fine with that.

In North Carolina, in a very innovative partnership with libraries that had rural outreach programs, nurses rode on the bookmobiles They took medical screening equipment, audio and video tapes for the semi- and illiterate along with TV/VCRs and cassette players, a loaning collection of books on nutrition and heath practices, and print materials to distribute free, and they made the rounds to rural areas that otherwise were unserved by medical people. I haven't kept up with the program, but I hope it's still going.

We get into trouble with this kind of innovation when it comes down to diagnoses that may involve pharmaceutical treatment. In many places, only MDs are licensed to dispense prescription drugs of any kind. This makes the nurse-practitioner's role much more circumscribed, and less effective.

The other thing has to do with doctor attitude and patient education. If you have a doctor who's not too wrapped up in his/her own ego to let some of these things go to qualified NPs, it will work. If you have a doctor who, also, respects his/her assistants as qualified professionals in their own right and not just some form of highly-educated servants, it will work. I'm lucky enough to go to a medical group who behave in this way. But they also take time off to do medical missionary work, so that also kind-of tells you that they aren't in it primarily for the money.

As far as patient education goes, that also comes from the doctor. Many patients are reluctant to "just see a nurse". (In the case of nurse-midwives, the patronizing attitude demonstrated by many male obstetricians toward their female patients contributed a lot to the rebellion of the patients and made midwifery more attractive. When the patients rebelled, the money followed them. The case is unique, but instructive.) Patients need their doctors to demonstrate by word and deed that the nurse-practitioners are valued and respected members of the medical care team, and are not just there to take temperatures. Then the patients will have enough faith in the NPs to make such a system work.