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Tuesday Jun 18, 2013

Physician, NP Roles Still Not Interchangeable

The Wall Street Journal devoted an entire section of its print edition to six big issues(online.wsj.com) related to health care.

The Journal posed questions, and then asked advocates on either side of the issues to weigh in. Thus, readers benefit from point-counter-point discussions on subjects such as circumcision, expanding residency programs, organic diets and pay-for-performance programs.

The Academy was invited to "square off" (that's The Journal's phrasing) with the American Association of Nurse Practitioners (AANP) on the subject of scope of practice. First, I would encourage all of us to be cautious with using such confrontational words when framing this important discussion.

This is not about turf, or better/worse, or good/bad. It is about teams, which also include physician assistants, who have not been a routine part of the scope of practice conversation. We must create and implement efficient physician-led teams to meet the triple aim of better patient outcomes, improving the health of our patients and lower costs.

This isn't the first time the AAFP and individuals representing nurse practitioner (NP) organizations were invited to the same debate.

Back in March, I discussed scope of practice on the "The Diane Rehm Show,the Washington-based radio program that is distributed by National Public Radio and SIRIUS satellite radio. I was joined by Ken Miller, Ph.D., R.N., C.F.N.P., associate dean at Catholic University School of Nursing; and Sandra Nattina, M.S.N., A.P.R.N., N.P., past president of the Nurse Practitioner Association of Maryland. I was disappointed that the tenor of that program was heavily weighted toward the NP perspective, and did not allow me to present the other side of this important issue.

That same month, AAFP Director Wanda Filer, M.D., participated in a Politico Pro policy forum that also featured Angela Golden, D.N.P., president of the AANP.

This week's Wall Street Journal health care report paired me with Golden, which means the Academy and NP organizations have now debated the topic in person, in print, online and on the air. Although the venues have changed, the debate has not. You can read Golden and my essays here(online.wsj.com).

But the short version is this:

  •  The AANP argues that about one-third of states already allow nurse practitioners to treat patients without physician oversight, so the other states should, too. This argument overlooks the fact that not all NPs are created equally. Unlike standardized physician training and licensing, requirements for NPs vary from state to state. Nurse practitioners' coursework and training ranges from 3,500 to 6,600 hours, and the actual clinical aspects of that education and training vary tremendously. Accreditation can come from one of three groups, each with different criteria.
  • Primary care physicians complete 21,000 hours of standardized education and training, including passing exams that are overseen by one certification body. NP organizations often dismiss the disparity in the amount of training their members receive compared to physicians and suggest that the extensive rotations required by medical schools are "peripheral" to the care we deliver. The truth is that those rotations broaden our clinical experience and strengthen our diagnostic skills in ways no other group can claim.
  • Nurse practitioners like to point to the primary care physician shortage and say they can fill that void. This overlooks a couple of key points. One is that our country also faces a shortage of nurses. Most important, though, is that access to care issues still exist in the states that already allow independent practice for NPs. This is a critical point as the push for independent practice is specifically being made an answer to the need for more primary care. The evidence shows it is not the answer.

There is no question that nurse practitioners, physician assistants and others are each vital parts of our health care team. But they are not physicians. Each member of the team provides needed skills, and brings their education, training and experience to bear. Although some tasks and services can be shared, the roles each of us play are not interchangeable. The medical expertise of primary care physicians must be a part of the team-based care patients need and deserve.

I welcome your thoughts below on this ongoing debate.

Reid Blackwelder, M.D., is President-elect of the AAFP.

Posted at 04:31PM Jun 18, 2013 by Reid Blackwelder, M.D.

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