‘I Can't Do This Alone’: Stroke Care Requires Physician-NP Collaboration

The reason neurologist Dr. John McBurney, MD collaborates with nurse practitioners comes from a cellular level. “In a typical stroke, 32,000 neurons are lost every second. If I were alone, I could not do this work,” he says. 

Dr. McBurney works alongside Alexandria Gibbons, NP and Jessica Rice, NP in Greenville, South Carolina, treating critically ill adults who have been hospitalized for stroke. Often they are running back and forth between inpatient floors and the ED, armed with alteplase and responding as a team to every code ‘S’ — critical events that require all hands on deck. 

The current and projected landscape of stroke care in the U.S. is dismal. The neurologist shortage is expected to increase to 19% by 2025, an alarming prediction given that every four minutes a person dies of a stroke. The team’s home state of South Carolina is designated a “neurology desert,” especially in the treatment of Alzheimer’s Disease and other dementias. Dr. McBurney sees a bright and sustainable future for neurology, building towards the comprehensive 24/7 stroke center, staffed in shifts by a few neurologists and many NPs, all working in a collaborative fashion. 

Dr. McBurney enjoys working with nurse practitioners because, unlike working with resident physicians, there is no yearly turnover with a new class, leading to increased expertise and rapport between team members. “I work with two really talented nurse practitioners,” he proudly states. 

Alex is a former ICU nurse, and Jessica is a nurse educator. Dr. McBurney has a deep appreciation and respect for the nursing profession because he supported his own undergraduate education by working as a nursing assistant. “I’m not threatened by them. It’s not an ‘I profit, you lose’ situation. It’s more like we work together and both benefit,” he says. 

When this stroke team works collaboratively, patients are ultimately safer and better cared for. “Jessica is able to follow up on comorbidities. She knows a lot of things that are outside of neuro that I don’t know. General medical stuff like if the patient has a UTI, she knows what the best antibiotic would be to treat it. We have our own strengths and weaknesses and we complement each other. We definitely have each other’s back and a lot of trust is involved,” says Dr. McBurney.  

One Friday at work is seared into the team’s memory. Two patients simultaneously suffered strokes and the only possible way to handle them successfully was to split up. “We communicated by phone and ran the codes simultaneously,” Dr. McBurney remembers. “Both patients did well because we worked on parallel tracks.” 

Jessica notes that by working in tandem, response times are better and the safety and survival of patients improve. She appreciates that the physicians in their practice enjoy teaching and are encouraging to NPs. Her advice to fellow NPs looking for a good team fit? “Never be afraid to ask a question and if you are, maybe [working with that physician is] not the best fit for you.” Jessica hopes that physicians can understand that “we are just as good at our jobs as you are at yours.” 

Alex supports Jessica’s sentiments that NPs and physicians have different expertise and approaches to patients that can be complementary. “Dr. McBurney really understands the value of having NPs on the neurology service,” she says. “He’s very appreciative of my input and is always willing to teach pretty much anyone, all types of providers.” Her advice for NPs and physicians is to learn more about one another and their shared field. “NPs are going to be more involved in specialty fields as there is growing need, and we need to make sure everyone is prepared for that.” 

Dr. McBurney emphasizes the need for institutional support as the critical foundation for a positive and constructive physician-NP relationship. He encourages hospital-employed physicians to have a conversation with leadership on how they are viewed as either a “profit center” or an “overhead cost.” Depending on whether the physician or NP charts/makes the charges, they get the RVUs. 

“I think this whole thing on who gets credit kind of misses the point. What’s important is [that the institution] look at the global work output, and not try to parse it into one person or another,” explains Dr. McBurney. “It’s realizing there’s a service aspect to this, and not just a money-making aspect. That’s where I think it gets kind of sideways with people thinking they’re in competition with one another. What should really matter is [whether] the patient got the care that they need.” 

And Dr. McBurney gives credit where it is due. “We couldn’t do what we’re doing without NPs and for us to do more moving forward, we have to hire more. In our hospital system, we’re trying to empower nurses by having them be the ones to call a code ‘S’ based on their observations. We also don’t criticize nurses for judgment calls; even if it’s the wrong call, it’s the best call they could have made at the time.” 

With tens of thousands of neurons at stake, there is no time for blame on a neurology service. 

“A mistake is a learning opportunity and a chance to refine our processes,” Dr. McBurney admits. “Honestly, whenever there’s a conflict, most of the time it’s the physician that’s wrong. It’s a different culture, a complementary culture that has incredible strengths.” 

Are you in a positive physician-NP working relationship? What other best practices do you use to promote interprofessional teamwork in your clinical setting? 

Illustration by Jennifer Bogartz

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