'Physicians and Nurses Are Not Interchangeable,' AAFP Tells IOM

February 09, 2011 04:30 pm News Staff

The AAFP, along with several other medical specialty organizations, has called on the Institute of Medicine, or IOM, and the Robert Wood Johnson Foundation, or RWJF, to clarify recommendations promulgated in an IOM report on nursing that call for removing scope-of-practice barriers for advanced practice registered nurses, or APRNs, in all states.

The IOM released the report on the future of nursing, which was sponsored by the RWJF, on Oct. 5. The report advocates greatly expanding the role of nurses via a variety of mechanisms, including by eliminating scope-of-practice barriers.

In a Jan. 19 letter to the IOM and the RWJF, the Academy, along with the American College of Physicians, the American Academy of Pediatrics, the American Osteopathic Association, and the American College of Obstetricians and Gynecologists, emphasizes that "physicians and nurses are not interchangeable."

"Optimal care for patients is provided by physicians, nurses and other health professionals working together in a team-based model of care delivery. We believe there needs to be clarification and further interpretation of the recommendation that scope-of-practice barriers for advanced practice registered nurses, or APRNs, be removed in all states," the letter states.

The AAFP and the other organizations are urging the IOM and the RWJF to take several steps, including clarifying that the education and training of physicians and of APRNs is substantially different and in no way equivalent or interchangeable. Although APRNs can provide some core components of primary care in the context of team-based care, the training and skills of physicians practicing in a primary care specialty are necessary to handle the full range of patients' primary care needs, says the letter.

In addition, the letter asks the IOM to affirm that all health care professionals should work collaboratively in team-based models, such as the patient-centered medical home model. The goal should be to encourage care models that use every member of the team to the full capacity of his or her training and skills, rather than to promote changes that could lead to divisive relationships and more physicians, nurses and other health care professionals practicing independently of one another.

The Academy also asks the IOM and the RWJF to acknowledge that evidence shows the United States is facing a critical shortage of primary care physicians and training more APRNs and other nonphysicians will not, by itself, solve the nation's primary care shortage. Instead, public policies should promote recruiting, training and retaining more primary care physicians, nurses and physician assistants to meet the increased demand for health care.

"We understand the IOM committee's report is in final form, but we suggest that the requested clarifications be expressed in the ongoing public relations and implementation initiative to promote acceptance of the report's recommendations," the letter says. "Unfortunately, some aspects of the report allow a blurring of the distinctions in training between physicians and nurses and promotion of independent practice by nurses."

This, in turn, could undermine the IOM's vision of collaborative, team-based care that uses all of these professionals to the full extent of their skills and training, states the letter.

The AAFP and the other organizations say that the term "scope of practice" in the first recommendation of the IOM report is being viewed as a "red flag" because it can be interpreted as advocating solo independent practice of nurses to replace physicians in the delivery of all components of primary care.

"Because of the potential for confusion, we believe it is important that the IOM clarify its intention in this regard, emphasizing that recommendations about 'scope of practice' of nurses relate to those areas that are consistent with their training and experience, and that the term 'independence' should not be misinterpreted to suggest that all aspects of primary care can be provided by a nurse practitioner in the absence of a team-based system that also includes one or more physicians," the letter says.

In the letter, the AAFP and the other organizations express concern that there is a prevailing impression that just educating more nurses is the key to solving the nation's health care workforce needs.

"A shortage of primary care physicians already exists, and, as noted in the IOM report, a critical shortage of bedside practicing nurses also exists. The increasing demand for primary care will require more primary care physicians, more nurses -- including APRNs -- and more physician assistants," says the letter.