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Tuesday Sep 03, 2019

Not All Clinicians Are Trained Equally

"You never have the story right and exact. And then you always try to bore me with your yakkity yak."
-- Run-DMC

[training dial concept]

If you follow health policy, particularly at the state government level, you know that so-called scope-of-practice debates are commonplace and quite intense. My earliest engagements with health care policy centered on an ophthalmology versus optometry scope-of-practice fight in my home state in the early 1990s.

I am wading into these waters primarily due to an article I read recently in the Washington Examiner titled "Daily on Healthcare: Nurse practitioners fight for more freedom."(www.washingtonexaminer.com) The article was co-written by Kimberly Leonard, an excellent health care reporter with a solid health policy foundation. However, there were two particular sentences in the article that caught my attention:

  • "Twenty-eight states have restrictions on nurse practitioners by disallowing them from doing their jobs without getting sign-off from a doctor."
  • "If they are allowed to operate on their own, they say, they can help reduce health care spending, improve access to medical care, and address the doctor shortage at a time when the U.S. population is aging and demand for health care is growing."

First, no one is "disallowing them from doing their jobs." This is hyperbole. Second, I have grown tired of hearing these unsubstantiated claims that if policymakers would just loosen the reins and allow "X" to practice independently, the primary challenges of access and cost would be solved. Health care trends in states that have allowed NPs unrestricted practice clearly disprove these claims.

According to The Seattle Times,(www.seattletimes.com) "Since 1973, nurse practitioners in Washington have enjoyed a level of autonomy largely on par with (that of) primary care doctors."

So, how have access and cost been impacted?

First, per capita spending on health care was not impacted -- at least, not in a positive way. According to the Kaiser Family Foundation,(www.kff.org) during the 20-year period from 1993 to 2013, per capita spending in Washington increased from $2,751 to $7,609. By comparison, the United States per capita spending average increased from $2,996 to $7,703 during the same period. Thus, per capita spending in Washington increased from 92% to 99% of the national average. Hmmm. That seems odd because we are constantly being told by the NP community and their advocates that allowing NPs unrestricted practice would have the opposite effect on costs.

What about access? Has independent practice by NPs addressed access issues in Washington?

Well, not exactly. According to the Health Resources and Services Administration,(data.hrsa.gov) Washington -- a state with 39 counties -- has 27 geographic health professional shortage areas for primary care. It is safe to say, based on these statistics, that NPs probably have not increased access or reduced per capita costs in the state of Washington in the past 45 years.

They probably just need a little more time, right?

Let's start by establishing what should be an indisputable fact: There is no equivalency between a physician and a nonphysician health professional. This does not mean that nonphysicians are not valued members of the health care team (they are), or that there isn't a need for their services (there is), and I certainly am not attempting to diminish their skills and talents. However, it is a demonstrable fact that every physician, regardless of specialty, has successfully achieved significantly more hours of didactic and clinical education than every nonphysician provider. This is not debatable, it is simply a fact. Here's the proof.(www.tafp.org)

[education chart]

Family physicians, in almost all cases, must complete 11 years of education and training, including more than 20,000 hours of didactic and clinical training, before they practice independently. On average, a family physician has twice the number of years and greater than 15,000 more hours of education and training than their NP colleagues.

Now consider that many in the nurse practitioner community think they should be able to practice independently after 2,800 hours, or 14 percent of the hours required for physicians.

[hours chart]

The concept of "equivalency" being promoted by the NP community is based on a series of hand-picked literature reviews and analysis that, according to the NP community, show that care provided by NPs is "equivalent" to care provided by a physician. There are some problems with these studies, but my primary complaint is that most of them involve care provided in team-based or collaborative arrangements in which NPs are working with physicians.

My other complaint is they do not have control groups. How do we know that patients weren't also seeing a physician or physicians during this time period, or whether they would have had similar outcomes without seeing anyone? I once hit a three-pointer while being guarded by four-time NBA All-Star Mark Price(en.wikipedia.org) when we were kids in Oklahoma, but this did not make me an NBA All-Star, too.

To quote former AAFP President Reid Blackwelder, M.D., "All members of the primary care team are valuable, but they are not interchangeable."

That was a blunt takedown of the NPs' treasured talking points -- in one state -- regarding access and cost, but I should clarify my thinking. I am a big, big fan of team-based care, and I think there is a growing need for NPs and PAs in team-based care models. I recently wrote about my concerns with the "hero-versus-helper" mentality that controls the U.S. health care system. We should encourage teams, and those team members should all contribute to the full extent of their training. This same thinking is reflected in AAFP policy, which supports an inclusive, team-based care model that recognizes the contributions of all team members:

"The AAFP encourages health professionals to work together as multidisciplinary, integrated teams in the best interest of patients. Patients are best served when their care is provided by an integrated practice care team led by a physician."

It is important to note that we encourage health professionals to work together. This crucial language stands in stark contrast to the language used by the nonphysician community. Christine Sinsky, M.D., and Thomas Bodenheimer, M.D., M.P.H., have a great article in the July/August issue of Annals of Family Medicine titled "Powering-Up Primary Care Teams: Advanced Team Care With In-Room Support."(www.annfammed.org) One of my colleagues with AAFP News wrote an excellent article on the study, "Researchers Push Primary Care Teams to 'Power Up.'" I understand that team-based care still has its challenges, but the future is collaboration -- physician-led collaboration.

I would like to close by addressing one of my biggest pet peeves, which is the assertion that NPs are more likely to practice in rural, underserved communities. This is patently false. According to the Agency for Healthcare Research and Quality,(www.ahrq.gov) family physicians and nurse practitioners practice in rural communities at almost identical percentages. Here is the breakdown:

[population chart]

I also reject the notion that rural communities should settle for less qualified, less comprehensive sources of care. We should be identifying policies that can put a family physician or a family physician-led team in every community, and we should do much more to assist rural communities with the recruitment and retention of physicians, preferably family physicians. There is no justification for telling the good men, women and children of rural America that they should accept a less qualified health care professional instead of a primary care physician based solely on their ZIP code.

As an aside, these statistics make clear that almost all pediatric and adult medicine provided by physicians in small, rural communities is provided by family physicians. It's pretty astonishing, really.

Well, I am so glad that you all came to my TED Talk, and I look forward to your comments, thoughts, and -- probably -- one or two lectures on this post.

Meanwhile, it's September, and that means college football season is here. I hope your team of destiny has a great season and loses to Oklahoma in the national championship game in January. And, as always, BEAT TEXAS!

Wonk Hard

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"We're not doctors!"

This, of course, is a famous scene from "Spies Like Us."(www.youtube.com) I'm reminded of it because something similar plays out every single day in our health care system -- everyone wants to be called "doctor." Although it is true that holders of terminal degrees are allowed the privilege of being called "doctor," in the health care setting, we need a little more transparency to alleviate confusion and ensure that patients are fully aware of who the individuals on their care team are. It is confusing, and patients lack clarity about the variety of individuals who are working in any given health care setting.

The AAFP continues to support "truth in advertising" laws(www.ama-assn.org) that would require all health care professionals to identify their level of training, education and licensing, not simply the title of "doctor." For example, patients should know whether you are a doctor of medicine, doctor of osteopathic medicine, doctor of pharmacy, doctor of philosophy, doctor of education, doctor of jurisprudence, Doctor Love or Dr. Dre. You get what I mean.

Posted at 09:53AM Sep 03, 2019 by Shawn Martin

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Shawn Martin, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.

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