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Friday Mar 29, 2013

Overtime: Finishing the Story on Scope of Practice

Once again, the media is reaching out to get family medicine‚Äôs perspective on an important health care issue. 

I recently was interviewed about scope of practice issues by The Washington Post.

As a result of that opportunity, I was invited to be on "The Diane Rehm Show,"  a Washington-based radio program that is distributed by National Public Radio and SIRIUS satellite radio. It reaches more than 2 million listeners nationwide.

Happily, AAFP staff members were able to arrange for me to drive to a Knoxville, Tenn., radio station rather than flying to Washington, and I was able to link in and be a part of the discussion. 

The show's other guests were Mary Agnes Carey of Kaiser Health News; 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 the sole physician, and we had a lively discussion about scope of practice, including whether or not nurse practitioners should be allowed to practice independently.

Unfortunately, there is never enough time to provide all the needed information. I applaud all our members who participated through e-mail, tweets and other social media. It is important, however, to address a couple of issues that needed more time than provided in this hour-long program. Many aspects of this discussion can be misunderstood or misrepresented, so I want to be sure that all of our members -- as well as other health professionals -- hear these points.

Primary care is being defined by some in creative ways, and even in this broadcast, the suggestion was made that nurse practitioners can do everything we do as family physicians. I made it very clear that although many different professionals can provide some primary care tasks and services, nurse practitioners are not family physicians. Both members of the team play critical roles, but we are not interchangeable.

Family physicians are intensely prepared for practice through a nationally standardized process of education, training and certification. Family physicians have a clear and consistent path from undergraduate through residency. By the time they graduate, each and every family physician has an undergraduate degree and a total of 21,000 hours of didactic and clinical training. They also have passed national exams at several stages in their training.

Depending upon the state and system, an NP may or may not have an advanced degree, may or may not have extensive clinical experience, and may or may not be receiving ongoing recertification. Examples of individual NPs with many years of clinical experience being able to provide independent practice cannot be used to overcome an inconsistent and non-standardized educational and training system for NPs as a whole. Moreover, a Health Affairs blog this week pointed out that 63 percent of all NPs are older than 45 years and 15 percent are older than 60 years.  In hard numbers that means of the 155,000 NPs in the United States, 98,000 are older than 45 and 23,000 are older than 60. This means the most experienced NPs likely will soon leave the primary care workforce, emphasizing the need to standardize education and training for their replacements.

Regulatory frameworks are not designed to limit access. Instead, they are in place to ensure patient safety. That is one mechanism by which patients receive the right care from the right provider at the right time. No health care professional can function within their scope of training without a regulatory framework. In scope-of-practice bills all over the country, states are pursuing different kinds of legislation regarding different processes from different providers, which further fragments our already broken health care system and creates more silos of providers.

Despite these changing, yearly legislative discussions, the AAFP consistently has championed the physician-led, patient-centered medical home. We need to be creative in developing these teams in each state given different situations. But the end result must be the right care from the right professional at the right time. Health care team members do not have to be in the same building or practice, but they do need to be involved with connecting the health care pieces throughout each community and system. Only family physicians are uniquely and consistently trained to provide leadership for this type of team-based care.

One of the other guests said during the broadcast that NPs can diagnose and make the right referrals. This concept of treating diseases based on specialty has contributed to the high cost and poor outcomes of our system. Family physicians have the education, training and experience to be able to manage many problems that often are sent by nurse practitioners to high-cost specialty care.

Not everyone with a broken ankle needs to see an orthopedist.

Not everyone with congestive heart failure needs to see a cardiologist.

And not everyone with COPD needs to see a pulmonologist.

I could go on.

We must be the next layer of care and referral when an advanced practice registered nurse reaches the limit of his or her scope, not a limited-practice specialist.

Finally, much is made of the "wealth of research" that supports similar outcomes between care provided by nurse practitioners and family physicians. Although often quoted, this data has been carefully evaluated, and it has several flaws in its methodologyPerhaps most important is that majority of the studies included in this review were from collaborative and not independent NP practices. Generalizing outcomes from nurse practitioner care alone is impossible with this kind of data. Moreover, much of the data comes from studies done after a diagnosis has been made. You cannot compare outcomes produced from following a treatment protocol for a diagnosed problem with those from the process of taking an undifferentiated problem, making the diagnosis and implementing a treatment plan.

There obviously are many other points that are important in these discussions. However, our impact improves when we speak with the same facts and emphasis. Decisions our citizens and politicians make should be with facts in hand, not based on the strong emotion of personal belief or anecdote. This is the essence of informed consent and good communication.

Thank you for your support, keep listening and keep tweeting.

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

Comments:

Dr. Blackwelder, I appreciate your willingness to address this issue. Just a few month from graduation from FM residency, I am concerned about the disparity in communication about the role of NPs and how to be a part of the conversation. What I do know is that we should not be apathetic, and you have given me motivation to be a part of the debate. Thank you for your input on this very important issue. Sincerely, Scarlet Sparkuhl Delia D.O.

Posted by Scarlet Sparkuhl Delia D.O. on March 29, 2013 at 11:52 PM CDT #

Your commitment to the "...the road less traveled" is appreciated. We share a common interest in providing family medicine services as the most logical solution for underserved families in the USA and internationally. If family medicine held the high ground on the original scope of practice, there would be no discussion regarding equivalency of nurses with physicians. This path is still available. For over 20 years we have provided a FAMILY MEDICINE-OBSTETRICS fellowship where the central goal is the ability to perform a Cesarean section. Over 60% of graduates practice rurally, but some have gone on to positions of leadership in training programs, mission hospitals, and urban FQHC's. Board certification in Family Medicine Obstetrics, and Advanced Life support in Obstetrics[ALSO] distinguishes our physicians from primary care without OB-Gyn training. Internationally, this curriculum allows entry to most hospitals whereas generic primary care certifications are viewed as suitable for ambulatory care only. In preparation for mission hospital service, Medicos collaborates with the Department of Surgery to teach a surgery skills lab twice a year. There is a weekly high risk OB clinic to maintain quality for the never ending stream of women who lack access to timely prenatal care. There are daily cases of office surgery and urgent care due to the open access 7d/week avialability. Over ninety percent of graduating fellows 1992-2012 have obtained Cesarean privileges. [Rodney WM, et al. Fam Med Nov 2010; 42: 712-716]. The fellows have a " clinical home" in a full service family medicine center in Memphis. The offices are bilingual Spanish-English. Services include independent point-of-care OB-Gyn-Abdominal ultrasound, AFI-NST, Colpo-cryo-LEEP; Full GI endoscopy including IV sedation analgesia. Physicians are expected to read their own ECG's and Xrays asking for consultation when needed. Over these years, the consultation rate has been less than 5%, because there is on site supervision each day. All fellows are expected to enter their notes into the electronic medical record[EMR]. Keyboard skills are required. An internet based prenatal database and a delivery outcomes database are supported by the fellows. That scope of practice is not contested by nurse practitioners.

Posted by Wm MacMillan Rodney MD on April 04, 2013 at 08:02 AM CDT #

Your commitment to the "...the road less traveled" is appreciated. We share a common interest in providing family medicine services as the most logical solution for underserved families in the USA and internationally. If family medicine held the high ground on the original scope of practice, there would be no discussion regarding equivalency of nurses with physicians. This path is still available. For over 20 years we have provided a FAMILY MEDICINE-OBSTETRICS fellowship where the central goal is the ability to perform a Cesarean section. Over 60% of graduates practice rurally, but some have gone on to positions of leadership in training programs, mission hospitals, and urban FQHC's. Board certification in Family Medicine Obstetrics, and Advanced Life support in Obstetrics[ALSO] distinguishes our physicians from primary care without OB-Gyn training. Internationally, this curriculum allows entry to most hospitals whereas generic primary care certifications are viewed as suitable for ambulatory care only. In preparation for mission hospital service, Medicos collaborates with the Department of Surgery to teach a surgery skills lab twice a year. There is a weekly high risk OB clinic to maintain quality for the never ending stream of women who lack access to timely prenatal care. There are daily cases of office surgery and urgent care due to the open access 7d/week avialability. Over ninety percent of graduating fellows 1992-2012 have obtained Cesarean privileges. [Rodney WM, et al. Fam Med Nov 2010; 42: 712-716]. The fellows have a " clinical home" in a full service family medicine center in Memphis. The offices are bilingual Spanish-English. Services include independent point-of-care OB-Gyn-Abdominal ultrasound, AFI-NST, Colpo-cryo-LEEP; Full GI endoscopy including IV sedation analgesia. Physicians are expected to read their own ECG's and Xrays asking for consultation when needed. Over these years, the consultation rate has been less than 5%, because there is on site supervision each day. All fellows are expected to enter their notes into the electronic medical record[EMR]. Keyboard skills are required. An internet based prenatal database and a delivery outcomes database are supported by the fellows. That scope of practice is not contested by nurse practitioners.

Posted by Wm MacMillan Rodney MD on April 04, 2013 at 08:02 AM CDT #

Dr. Blackwelder: Just in case you in doubt about whether there is a family medicine doctor who opposes the use of NPs in medicine---I am one. I think the Academy should have the courage to visibly oppose the use of Nps except in very controlled and regulated circumstances ---if you need specific examples of the kind of nightmares unrestricted use of Nps causes , I can provide essentially an endless case series from my work here in northeast Montana

Posted by pete council on April 15, 2013 at 07:46 AM CDT #

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.