February 2001 • Volume 7 Number 2
Time for more cooperation among health professional groups?
BY CINDY McCANSE
Prescriptive authority for nurse practitioners, psychologists, pharmacists ... many physicians can't even think about the idea without gritting their teeth and sending their blood pressure through the roof.
Susan Kinast-Porter, M.D., and Bradley Fedderly, M.D., of the Wisconsin AFP discuss a landmark scope of practice agreement negotiated by their chapter. Yet to hear AAFP President Richard Roberts, M.D., J.D., of Madison, Wis., tell it, it's high time for health professional groups to bury their collective hatchets, look for ways to cooperate rather than deprecate, and get on with the business of providing the best possible health care for patients.
"Many of you are worrying about whether nurse practitioners should be prescribing drugs," Roberts told physicians, health policy-makers, lobbyists, Academy leaders and others during a lunch presentation at the recent State Legislative Conference in New Orleans. "You shouldn't be worrying about that -- you should be using that. Instead of pushing down, we need to reach up" he said.
And reach out, was the lesson conveyed by Bradley Fedderly, M.D., of Milwaukee and Susan Kinast-Porter, M.D., of Monroe, Wis., in their panel discussion of a landmark scope-of-practice agreement negotiated last year by the Wisconsin Academy of Family Physicians. Fedderly chairs the WAFP Legislative Affairs Committee. Kinast-Porter chairs the chapter's Committee on Resident & Student Affairs.
A lesson in creativity
In February 1995, Fedderly explained, the Wisconsin Department of Regulation and Licensing, acting on behalf of the state's advanced-practice nurses, pressed for and won legislative approval of administrative rules allowing APNs prescriptive authority. Although collaborative arrangements between APNs and physicians did exist, no language clearly defining the nature of those relationships was included in the statute, to the chagrin of many physicians.
The APNs went back to the legislature last year, asking for yet another scope-of-practice expansion -- this time, independent authority to order and interpret certain diagnostic tests -- sparking a firestorm from physicians of all specialties across the state. It was in this atmosphere that the WAFP decided to seek a solution amenable to all.
"We had to take into consideration the fact that many of these nurses worked with physicians," said Kinast-Porter. "We weren't trying to turn the clock back entirely, we were just trying to make things realistic and safe."
In formulating their response to the proposed legislation, WAFP leaders applied the following four principles:
- focus on improving the quality of patient care and increasing access to high-quality care;
- remain consistent with AAFP policy whenever possible;
- forge stronger relationships with others interested in the health of patients, including nonphysician health care professionals; and
- work to facilitate conflict solutions rather than pose obstacles to resolution.
They came up with alternative wording that allowed the proposed scope-of-practice expansion (score one for the APNs) but also set down the precise nature of the collaborative relationship that must exist between nurse and physician in order for APNs to exercise that expanded scope (score one for the physicians). It also called for documentation of that relationship by both parties.
What it boiled down to, Kinast-Porter noted, was simple: "Both groups wanted some assurance that if we worked together, we'd each be better serving our patients."
On the horizon
Future hot topics for the state's FPs, according to Fedderly, include pharmacists lobbying to administer immunizations at their pharmacies and an oldie but goodie -- prescriptive authority for psychologists.
Apparently the state's pharmacists plan to vie for the ability to order all but the routine series of childhood immunizations for their clients, with the vaccines most likely to be administered by a pharmacy tech or the like.
"The major concern is that even in physicians' offices, immunizations are not given without a physician, physician's assistant or APN present," explained Fedderly. "If an immunization was given at a pharmacy and there was an untoward reaction, such as a life-threatening allergic reaction, would the pharmacist know what to do?"
As for granting prescribing rights to psychologists, such a move would most definitely affect the state's family physicians and their patients, Fedderly added.
"This issue is particularly hot for FPs because primary doctors see the lion's share of mental illness -- at least at the point of entry into the medical care system -- and yet many insurance companies don't recognize an FP's ability to diagnose and treat mental illness," he said. Bringing another practitioner group into the mix can't help but further muddy the reimbursement waters. But, again, the biggest risk would be to patients receiving medications from practitioners who lack the extensive training of physicians.
Even with all that's at stake, the WAFP will strive to take the same constructive tack on any future scope-of-practice issues as it did with the APN issue, Fedderly noted. The Wisconsin Medical Society, he added, approached the APN matter with animosity and wound up burning bridges with nurses' groups. It's an important lesson, said Fedderly: "You just never know who you're going to need for a friend in the future."
FP Report is published by the AAFP News Department.
Copyright © 2001 by American Academy of Family Physicians.
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