The AAFP is vigorously objecting to some of the policies of the National Board of Medical Examiners, or NBME, related to health system reform. Specifically, the Academy is taking the NBME to task regarding its policies equating physicians with graduates of programs in clinical advanced practice nursing and graduates of physician assistant master's programs based on their scopes and depths of practice.
In a strongly worded letter from AAFP Board Chair Ted Epperly, M.D., of Boise, Idaho, to NBME President and CEO Donald Melnick, M.D., the Academy said it is "surprised and disappointed" by recommendations in the draft document "Policies of the National Board of Medical Examiners Regarding Health System Reform," which was approved in principle by the NBME membership in March.
The Academy strongly urges the NBME to "immediately reconsider" its recommendations and change its policies.
The Academy letter points to several sections of the NBME policies that indicate equivalency between primary care physicians and advanced practice nurses and notes that when AAFP leaders met with NBME representatives in September 2008, the NBME agreed to cease making such statements.
"At that time, you expressed regret and remorse for having made statements that both misled the public and permitted militant members of the nursing community to equate the 'certification' of a graduate from a doctor of nursing practice, or DNP, program with that of a primary care physician," says the letter. "The content of these policy statements, unfortunately, once again seems to suggest equivalence between primary care physicians and advanced practice nurses."
Epperly was more direct when he told AAFP News Now, "They absolutely reneged on what they told us."
The Academy letter points to a guideline policy in the NBME document that states, "National standards should apply uniformly to all clinicians providing the same or similar services, without regard to professional or educational background." The letter then cites an example in the NBME document's supporting text that says "physicians, graduates of master's or doctoral programs in clinical advanced practice nursing, and graduates of physician assistant master's programs might share licensure assessment related to primary comprehensive care."
"In other words, you equate both the scope and depth of practice of primary care physicians with those of advanced practice nurses," says the Academy's letter.
Expanding on the equivalency issue, the AAFP also objects to NBME statements alleging that physicians and nurse clinicians have "comparable scopes of practice" and suggesting that licensing authorities for both "should be required to create common means of assessing proficiency for entry to and continuation in practice."
"Here again, the NBME is suggesting equivalency between the services provided by a nurse with as few as 1,000 hours of clinical training and those provided by a primary care physician with several years and more than 14,000 hours of clinical training," the letter says. "We believe that this position by the NBME once more has the potential to endanger the health of the public."
In the letter, the Academy insists that the NBME "cease and desist this misguided effort to delude the American people" into thinking they receive the same breadth and depth of care from a nurse as they do from a physician.
"The NBME must clearly state that doctors of nursing practice are not equivalent to primary care physicians, that their scope of practice is substantially more narrow than that of physicians, and that they should, therefore, be assessed very differently than physicians," says the letter.
Epperly went a step further when he told AAFP News Now, "To do any less than this is a purposeful and willful misleading of the public."
The Academy letter also objects to the NBME document making reference to "common national minimum standards" that could be used to assess practitioners through a common instrument. According to the AAFP, this statement equates physician and nursing practice by setting a "floor" of competence.
"The medical profession continues to advance its efforts for 'practice improvement' through an array of vehicles put forward by its professional associations (and) its certifying boards and (through) the development of national benchmarks for quality patient care," says the letter. "Concepts of maintenance of certification and the principles of lifelong learning are today's vehicles for assuring quality of care, not standards low enough to be met by all providers."
The Academy concludes, "We are distressed that the NBME has chosen to take such an extreme stance in its policies. …The AAFP and the NBME should be working together to improve this nation's system of health care delivery. Regrettably, the NBME has chosen instead to promote an agenda of misleading the public regarding the unique value that primary care physicians bring to the American people."