Health

Doctors 'supervise,' but most nurse practitioners work independently

Nurse Practitioner Aura Veliz examines 5-month-old Johnny Ceballos during a well baby visit at Aurora Medical Center in San Fernando.
Nurse Practitioner Aura Veliz examines 5-month-old Johnny Ceballos during a well baby visit at Aurora Medical Center in San Fernando.
Elizabeth Aguilera/KPCC
Nurse Practitioner Aura Veliz examines 5-month-old Johnny Ceballos during a well baby visit at Aurora Medical Center in San Fernando.
Nurse Practitioner Aura Veliz points at herself on one of many bulletin boards at Aurora Medical Center in San Fernando that show all of the babies whose mothers received prenatal care at the Center.
Elizabeth Aguilera/KPCC
Nurse Practitioner Aura Veliz examines 5-month-old Johnny Ceballos during a well baby visit at Aurora Medical Center in San Fernando.
Dr. Carlos Rodriguez and Nurse Practitioner Aura Veliz co-own Aurora Medical Center in San Fernando. Veliz is the main care provider at the clinic. Dr. Rodriguez is officially her supervisor but he is only there once a week.
Elizabeth Aguilera/KPCC
Nurse Practitioner Aura Veliz examines 5-month-old Johnny Ceballos during a well baby visit at Aurora Medical Center in San Fernando.
President of the California Association of Nurse Practitioners Donna Emanuele works at an urgent care center in Palmdale staffed only by nurse practitioners. She created this poster that she keeps behind the door in the nurse practitioner office.
Elizabeth Aguilera/KPCC


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Nurse practitioner Aura Veliz flirts with 5-month-old Johnny Ceballos as she gives him a well-baby check up. The baby giggles and smiles at her as she bends his limbs, feels the top of his head and listens to his heart.

He’s one of dozens of patients Veliz sees every day, many of whom are pregnant or new moms and infants.

Veliz is certified as both an OB-GYN and family nurse practitioner at Aurora Medical Center in San Fernando. She’s also a co-owner of the clinic with the doctor who - as required by law - is her supervisor.

But most days Veliz works alone, like she has for the past 13 years.

"I’m the one who reviews the lab results, I’m the one who prescribes the medications when they need it, then I start seeing my patients, I go in the room by myself, of course," she says.

The question of nurse practitioners' autonomy has become a political issue, as State Senator Ed Hernandez (D-West Covina) champions a bill that would let them operate without a doctor's direct supervision as long as they are part of a medical group. Hernandez' bill was shelved last month and will be considered again next year. 

The bill faces fierce opposition from doctor groups that cite inexperience, patient safety and oversight concerns. But as Veliz' and others' stories attest, many nurse practitioners are to a great extent already operating fairly independently.

A typical partnership

On a recent morning Veliz rushes from exam room to exam room – cooing over newborns, checking babies' arms and legs and listening to fetal heartbeats with ultrasound machines. In her office she writes prescriptions on her computer.

One of her patients is 31-year-old Heather Torres; she’s 27 weeks pregnant and has asthma.

Torres says she appreciates being cared for by a nurse practitioner.

"They do all the same things, it's just the title," she says. "The actual doctors are quicker, much quicker visits when you are not ready to deliver yet. She takes a little more time.  That’s always appreciated."

Still, there are instances in which Veliz needs a doctor's assistance.

As they discuss Torres' asthma, Veliz tells her, "Next time I'd like you to see Doctor Rodriguez." 

Dr. Carlos Rodriguez is the obstetrician who owns the clinic with Veliz and is her official supervisor. He has his own practice in nearby Mission Hills.

Rodriguez - who will deliver Torres' baby - only spends two or three hours a week at the San Fernando Clinic. And he leaves almost all of the routine prenatal care there to Veliz. But when something out of the ordinary comes up - like Torres’ asthma - Veliz will bring Rodriguez in earlier than usual.

Rodriguez describes his relationship with Veliz as a partnership and says he mostly stays connected by the internet or by phone.

"I have access through the internet to all the patients, I come to the clinic once a week but I’m constantly being called in consultation when there is something unusual," he said.

Veliz and Rodriguez's working relationship is quite typical, according to Donna Emanuele, president of the California Association of Nurse Practitioners.

This setup works because nurse practitioners can do many of the things a primary care doctor does, Emanuele says.

"Nurse practitioners are registered nurses with advanced education and training that prepares them at the masters level and/or doctorate level to perform additional functions outside of the registered nurse role," she says.

"Many physicians refer their patients to us"

In fact, Emanuele says that when primary care doctors get overloaded they’ll ask nurse practitioners for help.

"Many physicians refer their patients to us and then we work collaboratively with them to say Mr. so and so or Mrs so and so was here for a visit for this particular problem," she says.

Nurse practitioners help fill the gap in areas that don’t have enough primary care doctors, such as some inner city neighborhoods and rural areas, notes Emanuele, who is part of a team of nurse practitioners who staff an urgent care center in Palmdale, in the high desert north of the San Fernando Valley.

They handle everything from colds and runny noses to broken bones. If a patient has more critical needs the nurses call a specialist or one of the doctors who supervise them. Those doctors are not on site; they have their own practices elsewhere.

"There are four physician colleagues who own this medical practice although they don't manage the care of the patients at all through here," says Emanuele. "But if we need to consult or refer any type of patients to them we usually pick up the phone."

Nurse practitioner Aura Veliz in San Fernando says she operates the same way, just like doctors do when they need help with a tough case.

"I could not do it alone," she says. "I love calling a cardiologist and saying I just found the murmur and I’m concerned, or a hematologist and saying this patient's hemoglobin just dropped to six and I need to send her to you."

Critics of the bill that would allow nurse practitioners to work without a doctor's supervision acknowledge this is how many nurse practitioners practice. But the measure's opponents - led by the California Medical Association - still worry the bill would give inexperienced nurse practitioners too much authority and would endanger patients by fragmenting health care.

Sen. Hernandez is working with the bill's critics to try to satisfy their concerns. The Senate has already passed it and it’s currently pending before the Assembly Health Committee, which is expected to resume its work on the measure next year.