Erica Ogni’s workday starts early and is chock full, with as many as two dozen patients trooping through her exam room at South County Health Medical and Wellness Center in East Greenwich during a typical shift.
Ogni is not a doctor; she’s a nurse. More specifically, a nurse practitioner who can diagnose illnesses, prescribe medications, order tests and interpret the results.
And, as a shortage of doctors persists, her days are getting busier.
Right now, she’s providing care to more than 1,600 people regularly, and dealing with more who arrive at the clinic without an appointment looking for urgent care. Often, those people ask her for referrals to a primary care doctor for themselves or loved ones.
Many times, Ogni will take on an existing patient’s family members, too.
“I feel really bad for all of these patients [who] don’t have primary care, scrambling trying to find somebody,” Ogni said. “[There are] more people going to the emergency room and express care clinics and bombarding those areas because they don’t have a primary care to go to.”
Indeed, as primary care doctors have become more scarce in Rhode Island, Ogni and hundreds of other nurse practitioners are being tabbed to pick up the slack. They treat patients in the same way as doctors with tasks such as conducting exams, giving medical advice and writing prescriptions without much supervision from doctors.
The R.I. Department of Health doesn’t track how many nurse practitioners are licensed in Rhode Island, but the number has most certainly grown in recent years. In 2024, there were 3,415 licensed advanced practice registered nurses – a classification that includes nurse practitioners – up from 1,907 in 2019, according to RIDOH data.
Meanwhile, finding a doctor has only become more challenging, as many have retired and others have left the state because Rhode Island’s low reimbursement rates make it difficult to cover the costs of operating a practice. Few new doctors are taking their place.
For some, nurse practitioners – who must undergo more extensive training than registered nurses – represent a temporary cure, allowing patients to see a medical professional for routine exams and treatment.
But others say the increased reliance on nurse practitioners and other advanced practitioners is problematic. Lobbyists at the American Medical Association are against expanding the scope of the nurse practitioner’s clinical role because their training is less extensive than that of doctors.
There are also doubts that the state’s pipeline of new nurse practitioners is big enough to meet the need. Even finding the clinical training that nurse practitioner students need has strained higher education programs.
Some observers also say that even if Rhode Island retained all of the primary care doctors, nurse practitioners and physician assistants who trained in the state, there still wouldn’t be enough to accommodate the need for care.
Estimates from health care professionals show that hundreds of thousands of Rhode Islanders don’t have access to primary care providers – a gap that’s expected to take years, if not decades, to close.
Amid that, the number of nurse practitioners is expected to continue to grow. The U.S. Bureau of Labor Statistics projects that there will be a 46% increase in nurse practitioners between 2023 and 2033, adding more than 135,000 new jobs nationwide.
To treat patients, nurse practitioners must become a licensed registered nurse, earn a graduate or doctorate degree and complete hundreds of hours of clinical training – a process that can take six to eight years. By comparison, doctors must earn their bachelor’s degree, attend a medical school and complete a residency program, which can take up to 12 years.
Despite these differences, health care professionals say nurse practitioners have continued to earn trust as crucial members of primary care teams.
Physicians and nurse practitioners typically collaborate to provide care. Nurse practitioners handle routine visits while doctors step in for more-complex cases. But their duties can vary dramatically depending on what their specialties are, whether it’s psychiatric mental health, caring for older patients or even inmates at correctional facilities.
“I get frustrated when there is an idea of a cage fight between [nurse practitioners] and doctors,” said Dr. Ateev Mehrotra, a physician and chair of Brown University’s Department of Health Services, Policy and Practice. “If you go through a typical primary care practice, you are going to see nurse practitioners and physicians working as teams and other kinds of practices.”
[caption id="attachment_488946" align="aligncenter" width="515"]
OPPOSITE DIRECTIONS?
The number of nurse practitioners in Rhode Island has climbed steadily since 2020, according to data provided by the R.I. Executive Office of Health and Human Services, while the number of primary care doctors has decreased, although there are differing estimates of the actual number working full time. / SOURCES: The R.I. Executive Office of Health and Human Services; Kaiser Family Foundation
via Warren Alpert Medical School presentation[/caption]
STEPPING UP
When Pamela Lauria started working as a nurse practitioner 27 years ago, she didn’t expect to have her own set of patients.
It happened gradually as Lauria, who practices at Providence-based Coastal Medical Physicians Inc., helped doctors administer basic care for many patients. Then it became necessary as the practice started losing doctors.
Now Lauria, who is also a state senator from Barrington, handles the care of 1,300 patients who she sees and coordinates follow-up treatments for.
Like in Lauria’s case, nurse practitioners’ growing importance has been a steady shift, as health care leaders say a lack of primary care providers has evolved into a crisis for Rhode Island.
It’s difficult to get a handle on how many primary care doctors are currently based in Rhode Island. Data from the Kaiser Family Foundation pegged the number at 2,381 in 2024, down sharply from 2,918 a year earlier, according to a presentation by faculty members at Brown’s Warren Alpert Medical School.
But a recent Brown University study estimated there are about 520 full-time primary care doctors in Rhode Island, and almost 300 more would be needed to properly care for the state’s population.
Right now, about 303,000 Rhode Islanders don’t have access to a primary care provider, according to Denise Coppa, a nurse practitioner at Brown University Health and associate nursing professor at the University of Rhode Island.
“It’s very frustrating,” Coppa said. “Those 303,000 patients that don’t have primary care providers are going to show up in the [emergency department], have strokes, heart attacks, complications from diabetes – all things that could be prevented if they were seen on a regular basis.”
It’s no wonder nurse practitioners and physician assistants – who have a smaller scope of practice and work under a doctor’s supervision – have taken on a growing portion of primary care visits.
The nurse practitioner role has proven popular among nurses looking to step up their responsibilities.
“It’s an interesting and exciting role for a number of nurses who think they can do more,” said Betty Rambur, a nursing professor at the University of Rhode Island. “There is a drive, and now that people are aware of it, they know what they can do with their talents and how they can serve society more broadly.”
A study co-authored by Mehrotra analyzed 276 million primary care visits across the U.S. between 2013 and 2019, and found that the percentage of patients who saw a nurse practitioner rose from 8.9% to 17.3% in that period, while the number who saw a doctor declined from 42.4% to 33%.
“I can tell you it’s everywhere,” Mehrotra said of health care’s growing reliance on nurse practitioners. “If you talk to the average Rhode Islander or American, they see it all the time.”
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UNDER EXAMINATION: Erica Ogni, right, an adult-gerontology nurse practitioner, gives a checkup to patient Lexi Palumbo at South County Health in East Greenwich. Ogni and other nurse practitioners are taking on
more patients these days.
PBN PHOTO/ELIZABETH GRAHAM[/caption]
SCOPE CREEP?
Not everyone thinks it’s a good idea, though.
The American Medical Association is one of the most outspoken critics. Specifically, the group has expressed worries about “scope creep” – or nondoctors expanding their responsibilities beyond their typical roles and their training.
While acknowledging nurse practitioners are essential members of health care teams, the AMA says that their training and education differ significantly from that of physicians, who get as much as 20 times more clinical training.
And not all nurse practitioner programs are created the same, the AMA argues. More than 60% of nurse practitioner programs were partially or fully online in 2019, meaning students get less in-person training, and some can start practicing in as little as 18 months, the AMA says.
While doctors undergo a very structured residency selection process and years in residency training, the nurse practitioner clinical training of 500 to 720 hours is much less standardized, according to the group.
The AMA says increasing the scope of responsibilities and granting independent authority to nurse practitioners could threaten patient safety and lead to fragmented care.
Mehrotra, for one, is unconcerned about scope creep at this point.
While he acknowledges that some doctors are wary about competition from nurse practitioners, who are paid far less to do similar jobs, and nurse practitioners’ growing responsibilities make some doctors question why they went through a decade of training, in his experience as a physician at Beth Israel Deaconess Medical Center in Boston, doctors and nurse practitioners work well together.
When there is a consultation for neurosurgery at the medical center, the patient will often meet with a nurse practitioner for an exam. Then the patient will see an attending doctor at the hospital, followed by Mehrotra. In cases when Mehrotra refers a patient to a specialist, the first evaluation will be conducted by a nurse practitioner working in that field, with a doctor helping if it’s a more complicated case.
“I focus less on the two letters behind their name and much more about the person,” Mehrotra said. “I work with NPs who are awesome and work with some who I don’t really like working with, and the same thing with doctors.”
When it comes to quality of care, Mehrotra says several studies have shown there is no definitive evidence of any noticeable difference between care provided by a nurse practitioner and a doctor.
Dr. Edward McGookin, president of Coastal Medical, which now operates as Brown Health Medical Group Primary Care, says nurse practitioners, physician assistants and doctors often work on teams and divide up care as they see fit.
“Somehow, this sense of social confidence in the way physicians are trained has not carried over to the way the advanced practitioners are trained, and it’s unfortunate because it’s unfair,” he said.
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SPACE PROBLEMS: Denise Coppa, a Brown University Health nurse practitioner and University of Rhode Island associate professor, says it’s been difficult to find places for student nurse practitioners to get clinical training.
PBN PHOTO/ RUPERT WHITELEY[/caption]
TRAIN AND RETAIN
McGookin says he would like Brown Health Medical Group Primary Care to employ more nurse practitioners – the group hired 16 advanced practitioners between October and January alone.
The problem: While several local colleges offer nurse practitioner programs, the lack of openings for clinical training has held back the number of people who are able to enter the workforce.
“There’s only a certain pace you can go, so just getting people through school alone is not enough,” McGookin said.
In order to become a licensed nurse practitioner, students need as many as 720 hours of clinical time in which they shadow professionals in real health care settings similar to the hands-on training of a medical residency.
But at URI, the struggle to find placements for students forced the university to close its acute care nurse practitioner program a few years ago. Now URI has reduced its graduating class of nurse practitioners to 13, down from the usual 30 graduates.
Why the lack of openings for clinical training? Because clinics have found taking on students can be a burden – tying up a nurse practitioner who is teaching the student. Caseloads may be reduced, and the trainer may not be compensated.
Thundermist Health Center, which treats 62,000 people at multiple locations in Rhode Island, stopped taking students for clinical training after unrelated financial woes nearly forced the organization’s closure last year.
This was a huge blow to URI’s program, which sometimes had 15 to 20 students in clinical training at Thundermist each semester.
Coppa, the director of the nurse practitioner programs at URI, said other clinics have been resistant, too. “For the most part, we are cajoling, pleading with them,” she said.
To address the problem, Lauria submitted legislation last year to establish a primary care training sites program within the RIDOH, providing $2.7 million in grants to sites that provide primary care training for physicians, nurse practitioners and physician assistants.
The allocation, which was eventually made part of the fiscal 2025 budget, would increase the number of training slots by 50% for nurse practitioners, physician assistants and physician residents, Lauria says.
Care Transformation Collaborative of Rhode Island – a group focused on improving the state’s primary care system – announced in February that was partnering with the RIDOH to launch the training sites program.
There’s little doubt that the health care sector has a lot of work to do to beef up the workforce.
Dr. Jeffrey Borkan, co-chair of the Care Transformation Collaborative, says training programs for doctors, nurse practitioners and physician assistants would have to double in size to fill the labor needs, and it could take decades to accomplish.
Then those workers must be retained.
A study published last year in the Rhode Island Medical Journal – both Borkan and Coppa were contributors – found that a majority of primary care professionals trained in Rhode Island don’t plan on working in the state.
Just 15 of the 106 medical students who completed primary care residencies in the state during the 2022-23 academic year planned to practice in Rhode Island, the study found. At that same time, 48 of the 144 nurse practitioner and physician assistant graduates of primary care programs in Rhode Island planned to stay in the state.
Raising the insurance reimbursement rates for primary care providers so they match those for specialty care and those in neighboring states would likely help keep newly trained workers in Rhode Island, said Borkan, a family medicine doctor with Care New England Health System.
Much like for doctors, higher reimbursements could translate to better pay, more incentive to work in primary care and improved job satisfaction.
But while Rhode Island medical practices were expecting reimbursements between 2.9% and 3.4% this year, Gov. Daniel J. McKee proposed a 2.3% annual rate increase in his fiscal 2026 budget proposal, down from the 3.3% included in the state’s 2025 budget.
McKee did recommend the R.I. Office of the Health Insurance Commissioner include primary care workers in its biennial rate review, which could lead to higher reimbursement rates at some point.
McGookin says there also needs to be investment in building the ranks of pharmacists, social workers and care managers, people who can help advanced practitioners focus on treating patients.
“The bigger and broader the primary care workforce is, the better it will be for Rhode Islanders,” McGookin said. “And I personally have not the slightest qualm about whether I’m seeing an advanced practitioner or a physician for my primary care needs. What I want is someone who’s well trained, conscientious, a good communicator, who takes the time to listen, and I think advanced practitioners fill that bill beautifully.”
That said, the rise in advanced practitioners shouldn’t be seen as the solution to the shortage of primary care doctors, Lauria says. “I wouldn’t say that this is a great alternative,” she said. “We’re not trying to take over where a physician’s role typically was.”
Whatever her role, Erica Ogni, the nurse practitioner at South County Health Medical and Wellness Center, certainly works hard at it.
She starts her workday at 5 a.m., meticulously preparing notes on the dozens of patients she’s scheduled to see each day. Once at the office, her days are packed with anywhere from 18 to 24 appointments, each taking up to a half hour as Ogni gathers medical histories and talks about changes in health condition. There may be diagnoses or discussions about preventive care, ordering tests or prescribing medications.
Not surprisingly, Ogni endorses any move to increase reimbursement rates for advanced practitioners, particularly as they’ve grown more crucial for filling gaps in Rhode Island’s primary care landscape.
“I know we’re doing the same work, if not more,” Ogni said.
