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Tuesday Jun 18, 2013

Physician, NP Roles Still Not Interchangeable

The Wall Street Journal devoted an entire section of its print edition to six big issues related to health care.

The Journal posed questions, and then asked advocates on either side of the issues to weigh in. Thus, readers benefit from point-counter-point discussions on subjects such as circumcision, expanding residency programs, organic diets and pay-for-performance programs.

The Academy was invited to "square off" (that's The Journal's phrasing) with the American Association of Nurse Practitioners (AANP) on the subject of scope of practice. First, I would encourage all of us to be cautious with using such confrontational words when framing this important discussion.

This is not about turf, or better/worse, or good/bad. It is about teams, which also include physician assistants, who have not been a routine part of the scope of practice conversation. We must create and implement efficient physician-led teams to meet the triple aim of better patient outcomes, improving the health of our patients and lower costs.

This isn't the first time the AAFP and individuals representing nurse practitioner (NP) organizations were invited to the same debate.

Back in March, I discussed scope of practice on the "The Diane Rehm Show,the Washington-based radio program that is distributed by National Public Radio and SIRIUS satellite radio. I was joined by 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 disappointed that the tenor of that program was heavily weighted toward the NP perspective, and did not allow me to present the other side of this important issue.

That same month, AAFP Director Wanda Filer, M.D., participated in a Politico Pro policy forum that also featured Angela Golden, D.N.P., president of the AANP.

This week's Wall Street Journal health care report paired me with Golden, which means the Academy and NP organizations have now debated the topic in person, in print, online and on the air. Although the venues have changed, the debate has not. You can read Golden and my essays here.

But the short version is this:

  •  The AANP argues that about one-third of states already allow nurse practitioners to treat patients without physician oversight, so the other states should, too. This argument overlooks the fact that not all NPs are created equally. Unlike standardized physician training and licensing, requirements for NPs vary from state to state. Nurse practitioners' coursework and training ranges from 3,500 to 6,600 hours, and the actual clinical aspects of that education and training vary tremendously. Accreditation can come from one of three groups, each with different criteria.
  • Primary care physicians complete 21,000 hours of standardized education and training, including passing exams that are overseen by one certification body. NP organizations often dismiss the disparity in the amount of training their members receive compared to physicians and suggest that the extensive rotations required by medical schools are "peripheral" to the care we deliver. The truth is that those rotations broaden our clinical experience and strengthen our diagnostic skills in ways no other group can claim.
  • Nurse practitioners like to point to the primary care physician shortage and say they can fill that void. This overlooks a couple of key points. One is that our country also faces a shortage of nurses. Most important, though, is that access to care issues still exist in the states that already allow independent practice for NPs. This is a critical point as the push for independent practice is specifically being made an answer to the need for more primary care. The evidence shows it is not the answer.

There is no question that nurse practitioners, physician assistants and others are each vital parts of our health care team. But they are not physicians. Each member of the team provides needed skills, and brings their education, training and experience to bear. Although some tasks and services can be shared, the roles each of us play are not interchangeable. The medical expertise of primary care physicians must be a part of the team-based care patients need and deserve.

I welcome your thoughts below on this ongoing debate.

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


I agree that NPs,PAs, and physicians are not interchangeable. However, allowing for a devil's advocate position, the nonphysician providers are much less expensive and take much less time to train. If I were an organization looking to provide primary care, I would most assuredly hire the lower cost alternatives to physicians. If NPs are given the privilege of operating independently, this makes them even more attractive. If not, perhaps the physician simply becomes a medical supervisor for the practice, much like the relationship of anesthesiologist and anesthetist. Unfortunately the major factor is going to be cost in these situations,not quality.

Posted by Perry williams on June 19, 2013 at 10:47 AM CDT #

Honestly, the AAFP has to a large degree brought this problem on itself. For the past decade, the unremitting message has been that patients should get their healthcare from a team, not from a doctor, and that they should see a PCMH, not a board-certified family physician. And now we're surprised that they believed us? It's a little late to go back and say that oh, we just meant certain teams and certain PCMHs. This is the inevitable result that many of us predicted when the AAFP decided to promote teams and PCMHs at the expense of the physician-patient relationship. The AAFP played right into the hands of the insurers on this one. Addendum: The non-stop mantra that family physicians' practices are so profoundly dysfunctional that they need to be "transformed" has not done our specialty any good with the general public. Many of us who are very proud of our practices are deeply offended by this attitude: we know, because our patients tell us, that our practices are the one part of the medical system that works for them. The demand to transform is coming solely from the large insurers and the AAFP. Is that patient-centered?

Posted by on June 19, 2013 at 11:15 AM CDT #

Here is the problem with the AAFP position: "Demand for primary care is growing as our population grows and ages and as more people gain insurance coverage. Earlier research has shown that teams of professionals that include physicians, nurse practitioners and physician assistants can do much to meet demand for care, improve access to care, ensure patients get the full range of medical and nursing care, and have a positive impact on controlling health care costs.” This is from the Robert Graham Policy Brief posted on the same day as this blog post. It doesn't say Physicians should be the team leaders, but instead puts physicians, NPs and PAs on the same level when read from the perspective of a lay person. So it is no wonder everyone outside of our specialty see us as on equal ground as nps and pas. When we keep telling everyone there is no I in TEAM, then don't be surprised when they see all the players as equal. Maybe AAFP should change the discourse from Primary Care Provider to saying that everyone should have a "Personal Doctor". Small changes like that can have big effects on the national psyche. Do you want your own PERSONAL DOCTOR or a provider?

Posted by Kin Snyder on June 20, 2013 at 06:04 AM CDT #

Reading the above comments and the point-counterpoint essays brings to mind what many in the public/private arena have been whispering for years: If you take politics and profitability out of the equation, the problems of health care delivery would be solved overnight. This is a true simplification of a very complex issue. It is my opinion that the push for mid-level independence is really about financial equity and status. As health care pundits are pushing to achieve The Triple Aim, let's not forget to focus on the most important stakeholder, the patient. We need to stop the debate of who, when, where and how and just do it. There is plenty of room in the sandbox for all the health care providers in the U.S. to play in including many alternative care practitioners( who also go to school, train and pass certification exams for competency in their chosen field). If mid-levels want to practice medicine without a net, then they also must accept the risk that physicians manage daily, the medico-legal responsibility when things go wrong. You cannot have your cake and eat it too. No punting when the waters get rough. I have been working with many mid-level practitioners for years. They work incredibly hard and provide excellent value-based care. Many do not want this added responsibility. They just want to help patients. We all need to shift the health care delivery debate back to value-based care for patients. The patients will decide where to get their care based on quality, safety and outcomes through transparency and accountability.

Posted by Dale Block on June 20, 2013 at 07:19 AM CDT #

Good discussion, won't be solved overnight. Let me add another issue- the movement for NPs to get their doctorate. The program combines some health care policy, statistics, research, but no added clinical training. These NPs have the title of 'Doctor' which will confuse patients. They have broader background learning but no more clinical hours for this degree. I still struggle with how to fit those with this advanced degree in with the workload of patient care.

Posted by Lindley Gifford, MD on June 20, 2013 at 08:06 AM CDT #

With all due respect, Dr Blackwelder is incorrect. This fight is about "turf", which some of us call the Medical Profession. Our NP opponents are being well-funded by corporations and NGOs in order to replace independent professionals with lesser-trained rule-followers, at 50-75 cents on the dollar. They will do this by getting legislatures to give them permission to practice medicine with a nursing license. That means they have to get enough votes to pass such a measure. In the legislature, this is known as "winning". Preventing less-qualified persons from holding themselves out as equal to (or better than!) physicians is necessary, not only for the public's safety and for quality, but to prevent Medicine form going the way of Education (where corporations and government have collaborated to take professional educators out and put barely-trained "teachers" in their place, in order to run a profitable business model with no real expectation of quality outcomes). We have seen this tragic play in Education; we should not sit through it again. Stopping the corporatization and de-professionalization of medicine is crucial to our patients and our members. Something that I and my colleagues would call "good". I agree that 90% on NPs want (and and currently do) work in the team concept. Unfortunately, it is the other 10% driving the political train. Failure to understand that this is a political contest with an aggressive opponent has already cost us precious ground. We must go on the attack, stop playing nice and stop worrying about hurting someone's feelings. This will take more time, more late nights, and more funds, but most of all, it will take moral courage. Otherwise, we will gradually and ultimately be replaced with non-physicians who sold their message better than we did. I call that "bad".

Posted by Jim Taylor on June 21, 2013 at 11:42 PM CDT #

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