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Nurse practitioner Ranjit Lehal works at the New Canadian Clinic in Burnaby, providing care for government-assisted refugees.Deborah Baic/The Globe and Mail

Rosemary Graham remembers her first shift as one of the province's pioneering nurse practitioners as if it were yesterday.

After many years doing just about everything at a nurse's station in Dawson City, Ms. Graham was in the big city, reporting for work at the Evergreen Community Health Centre in the heart of Vancouver's busy Joyce-Kingsway area.

She wasn't in Yukon any more, and she was nervous.

"I'd never worked in an urban setting," Ms. Graham recalled this week. "I was really afraid that people would find out I didn't know what I was doing."

Her apprehension didn't last long.

"Early on, I was doing some suturing, and I was thinking, 'Oh yeah, I can do this.' I remember being surprised that I could do things well."

Today, eight years later, an ultraconfident Ms. Graham is solidly ensconced as a key member of Evergreen's medical team, treating patients with complex problems for whom physicians on the fee-for-service treadmill are hard-pressed to find large chunks of time.

Her roster totals 550 patients, many with past difficulties in the health-care system, she said. "They need a longer, more comprehensive approach." At the same time, her presence allows the clinic's two physicians to focus their own priorities better.

Ms. Graham was one of the first to take advantage of British Columbia's relatively late entry into the brave new world – at least in Canada – of salaried nurse practitioners, touted by many as a cure for the province's chronic shortage of family doctors and a cost-effective way to deliver better health care.

Since B.C. began graduating NPs in 2005, at a rate of 45 a year, however, the project has had a bumpy road, its progress continuing to trail more advanced programs in Ontario and Alberta.

Insufficient funding at the beginning left many NPs unable to get jobs. The government recently announced a substantial injection of $22.2-million to pay for nearly 200 positions over the next three years, but there is no guarantee that kind of money will be there in the future.

As well, physician representatives remain strongly opposed to adding nurse practitioners, who are autonomous care providers, into the health-care mix.

"The trouble is, they don't want to work under any direction from physicians. Therein lies the problem," said Shelley Ross, president of the B.C. Medical Association. "We don't want them coming in as another level of doctor. We want them coming in as part of the team, with physicians making the final decisions about a person's health."

Yet NPs require six years to earn their degrees. By the time they graduate, they are considered qualified to perform up to 80 per cent of the activities of a family doctor, including diagnoses, treatment, ordering lab tests, prescribing medication and admitting patients to hospitals, if necessary – all that on salaries of about $100,000 a year, financed by regional health authorities, far below the average income of doctors.

"The position of the BCMA is totally unrealistic," said Barb Mildon, president of the Canadian Nurses Association.

Sabrina Wong of the Centre of Health Services and Policy Research at the University of B.C. says there should be more NPs, not fewer.

"They are not so good at moving all people through the system, but they are trained specifically for primary care, gerontology and mental health. They are needed in these fields."

Ms. Graham, who is president of the B.C. Nurse Practitioner Association, said NPs can do much to improve primary health care, particularly in easing the backlog of patients unable to find family doctors.

And they are cost-effective, she added.

"But we are looking at not just reducing costs, but also providing good outcomes and patient satisfaction. The challenge continues to be funding."

Meanwhile, nurse practitioners continue their work in a variety of settings across the province.

Ranjit Lehal works at the New Canadian Clinic in Burnaby, where she provides primary care for government-assisted refugees.

"They have significant health-care needs," Ms. Lehal said on Friday.

"Many of them don't speak or understand English, so visits are often very long. I don't know how else they would receive the comprehensive care we can give them. For me, it's incredibly satisfying."

In Trail, two family practice clinics, including one where B.C. Health Minister Margaret MacDiarmid once worked, have managed the difficult feat of integrating nurse practitioners with fee-for-service physcians. Doctors report no loss of income, despite the number of patients now seen by NPs.

On Thursday, with one of the doctors away, NP Lori Verigin said her patients included a lot of guys with colds, several with flu, one with an ear infection, a woman with cancer and an 83-year old with chronic obstructive lung disease.

"It's always a mixed bag." Added cost to the health-care system: zero.

At the same time, preliminary research shows that since Ms. Verigin was added to her clinic's care team, visits to emergency by their patients have declined by 43 per cent, she said.

And in Prince George, NP Linda Van Pelt concentrates on patients with complex health problems, many related to mental health. With more time, she can work closely with them, helping them stay in the system.

"You are helping to improve lives of people who wouldn't otherwise have access to health care," she said.

But if required, she does the mundane, too, from asking a patient to say "ah" to cleaning out ears. "You betcha!" Ms. Van Pelt said.

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