Letter Takes Issue With Wording in AAFP Report on Nurse Practitioners

AAFP Board Chair Responds to Concerns

Dear AAFP Leaders:
I would like to protest formally the proclamation that was made by the AAFP in an attempt to discourage independent nurse practitioners because it is also an outright slur on us independent family physicians, many of whom would profess that our independent method of "team" practice is more efficient, and better for the patient, than the "politically correct," (as of this moment) newly minted patient-centered medical homes (PCMHs) proclaiming to be "better medicine" without -- we presume -- sufficient impartial evidence to make that claim.

[Pen and glasses on letter]

While I totally agree that nurse practitioners do not have sufficient background to shepherd the total care of patients and agree with discouraging that movement, you at the AAFP did not have to make your point by lumping them together with us as independent physicians and make your own protest carry that slant. You could have dwelled on the quality and depth of knowledge issue -- but you didn't. I would go so far as to request a serious, well-worded retraction on your part.

We, as independents, do "practice in teams." These are ad hoc teams, composed of people we have referred to, worked with, and know intimately, including their strengths and weaknesses. These are specialists, subspecialists, ancillary personnel, social service agencies, and all manner of community resources, hospital and otherwise, whom we utilize every day in our very personal work with patients. We know them well and they provide continuity, which is more than you'll get with large, fragmented "teams," which the eventual PCMHs will have. And because we get direct feedback from our patients, we simply won't re-refer if the specialist/ancillary is not

  1. competent,
  2. nice,
  3. thorough,
  4. affordable and convenient.

We have always been natural patient-centered medical homes.

I have not seen a double-blind, placebo-controlled trial studying the inferiority of my office (and those of my like-minded colleagues) versus a large group practice, or any new PCMH, in outcomes but especially in the process of taking great care of patients.

Pepi Granat, M.D.
Dale E. Michels, M.D.
Pennie Marchetti, M.D.
Mike Safran, M.D.
Roxanne Cech, M.D.
Scott Macleod, M.D.
Thomas L. Horton, M.D.
Brooks Lawrence, M.D.
Bruce Carlson, M.D.
Jeffrey H. Baker, M.D.
Shane A. Avery, M.D.
RJ Oenbrink, D.O.
Ron Baird, D.O.
Patrick Hayden, M.D.
Raphael Argueta, M.D.
John Watts Haresch, M.D.
Alan T Falkoff, M.D.
Rodney Snead, M.D.
Robert Cater, M.D.
Michael Gaines, M.D.
Pedro Ballester, M.D
Ben Brewer, M.D.
Matthew Levin, M.D.,
Karen S. Evans, M.D.
Kathleen Saradarian, M.D.
Floyd Bradd, III, M.D.
James W. McNabb, M.D.
E. Michael Robie, D.O.
Aubra Houchin, D.O .
Lucille A. Buglisi, M.D.
Gordon T. Hill, M.D.

The AAFP Responds

Dear Colleagues,
Thank you for contacting the AAFP regarding your concerns about the recent report "Primary Care for the 21st Century." Please know that I and the AAFP take our obligation to support members practicing in all settings very seriously, especially family physicians in solo practice. You play a critical role in the health care system. Having been a solo practitioner in a small Texas town, I have specific passion for your practice environment.

I first apologize for any phrasing of the report that is taken to imply nonsupport of the solo setting. I can assure you that in no way is the report stating anything that is intended to be anti-solo practice. I ask you to not take one comment out of context and assume that your Academy does not support you. The entire report supports a physician-led, patient-centered medical home. When read in context, the report’s obvious implication is that nurse practitioners are not trained or educated to the extent physicians are to practice independently:

In the report, the AAFP cautions against substituting nurse practitioners for physicians as a stop-gap answer to the primary care physician shortage. Such a solution flies in the face of multiple studies that demonstrate the best, most efficient care is provided by teams of health professionals in the patient-centered medical home led by physicians, not independent practice by a single health professional.

It is my understanding that the last sentence of this paragraph is the offending section. I want to explain the rationale for it being stated this way. As you know, the AAFP has been a strong supporter of the patient-centered medical home, believing that it represents the "new model of care" as called for in the 2004 Future of Family Medicine report. Five years later, the results are impressive for practices that have undergone this transformation as evidenced in a paper recently released by the Patient-Centered Primary Care Collaborative, "Benefits of Implementing the Primary Care Patient-Centered Medical Home: A Review of Cost & Quality Results, 2012." The "data demonstrates that the PCMH improves health outcomes, enhances the patient and provider experience of care, and reduces expenses, unnecessary hospital and emergency department utilization." Importantly, these are improvements in both quality and cost efficiency of care as compared to these same practices before they completed the transformation to the PCMH. Outcome data also indicate that the solo practice setting can do very well as a PCMH and, in many instances, better than large groups because of their "nimbleness." I have personally met numerous solo practice AAFP members who are excellent examples.

The phrase "not independent practice by a single health professional" specifically counters the October 2010 Institute of Medicine nursing report, which recommends that all states grant "independent practice" to only the advanced nurse practitioner without any attention to others who must help provide care, such as your office staff, nurses, and others who make up the care team. It is then clearly stated that this single act does not and cannot address the primary care shortage and that a physician-led team (whether solo or in other settings) is the best answer and why.

Since I have fielded virtually all the media calls and interviews for this report, I can tell you that none of the reporters I have talked with have asked anything about solo practitioners not being part of the answer, and none have interpreted that section to be anti-solo practice.

Again, I want to assure you that our latest report is inclusive of solo physician practices because others in your office (a nurse, medical assistant, front office staff, etc.) can and should constitute a highly functioning team that can work continuously to improve care quality and help in addressing health care costs. Others to whom you might refer patients constitute the "medical neighborhood" and are certainly an extension of the practice-based team.

We can all improve the way we provide and deliver care each and every day, no matter what our practice setting. I regret that you take umbrage at a phrase that was in no way meant to disparage solo family physicians or their practices, but to point to the importance of a physician-led, patient-centered medical home team.

Roland Goertz, M.D., M.B.A.
AAFP Board Chair