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A terrible thing to waste

Nurse Pracitioner 
November 18, 2010 -- Recent press items highlight the ongoing conflicts about the future role of nurses in U.S. health care, particularly whether advanced practice nurses (APRNs) can practice independently of physicians, in light of the extension of health insurance coverage to 32 million more Americans under the new health care reform law. As usual, nurses, scholars, policymakers, and patients seem to welcome the expansion of nurses' scope of practice, while some physician groups claim that the APRNs need physician "supervision," despite the ever-growing body of research indicating that APRN care is at least as good as that of physicians. Today, physician Pauline Chen's "Doctor and Patient" column offered a positive, if somewhat vague, endorsement of the potential contributions of nurses in primary care, in the wake of a new report by the highly regarded Institute of Medicine calling for APRNs to be given the authority to practice independently and nursing education to be standardized. Chen even quotes two nursing leaders! On October 5, in a Kaiser Health News article posted on the MSNBC web site, Andrew Villegas and Mary Agnes Carey provided a more specific account of the IOM report, though unfortunately it quoted no nurses (!) and failed to counter the unsupported safety concerns of the physicians it did quote. On August 3, Katherine Hobson posted an item on the Wall Street Journal's Health Blog reporting that yet another study, this one from Health Affairs, had shown that the care of nurse anesthetists presents no greater risk to patients than the care of anesthesiologists. And on April 14, the Associated Press issued a comprehensive and mostly fair article by Carla K. Johnson about recent legislative efforts to expand U.S. APRNs' scope of practice in anticipation of the expansion in health coverage. Johnson also described the fierce resistance of physician groups trying to protect their turf. We thank those responsible for these pieces, all of which make at least some contribution to the current discussions of APRN practice and U.S. health care reform.

A need for many hands

A terrible thing to waste

The "same level of services as anesthesiologists at potentially lower cost"

"People are not stupid"

A need for many hands

The piece by regular Times contributor Pauline Chen, a surgeon, is headlined "Nurses' Role in the Future of Health Care." Chen begins by telling a story about a patient she met during her training. Apparently, as the patient struggled to recover from a major operation, the "surgeon in charge" consulted so many "specialists" that the patient's chart became huge. The senior surgeon noted that this showed that "when the ship seems to be going down, you've got to get all hands on deck." Chen uses this idea, here and at the end of her piece, to suggest that we can't afford to ignore the potential contributions of nurses. That's certainly a helpful sentiment coming from an influential physician, though it may imply that desperation is the main reason to value nurses, when the main reason is actually that nurses are valuable, and they would be whether we had a health care crisis or not.

Chen notes that as this year's major health care reform law, the Patient Protection and Affordable Care Act, takes effect, "it has become increasingly clear that the ship known as our health care system is in the process of sinking." Chen ascribes this state of affairs mainly to "the sheer volume of patients it must serve." She says that the health system, already overloaded with a rapidly aging patient population, will have to absorb some 32 million newly insured patients, even as a third of current physicians will retire in the next decade, "and the physician deficit will increase from just over 7,000 to almost 100,000, with shortages in all specialties, and not just primary care." It's not clear where Chen is getting those figures, but in an case, she actually proceeds to urge us to consider nurses.

But like crew members frantically moving deck chairs, policy makers, medical center administrators, third-party payers and even doctors and patients have remained focused on one thing: the physicians. In all the discussions about adjusting the number of medical schools and training slots, rearranging physician payment schedules and reorganizing practice models, one group of providers has been conspicuously missing.

The nurses.

Chen notes that nurses are "the largest sector of health care providers, with more than three million currently registered; but few have led or even been involved in the formal policy discussions regarding the future care of patients." To address this, she says, the Institute of Medicine and the Robert Wood Johnson Foundation assembled a panel of experts who met for two years and last month finally released their report, "The Future of Nursing: Leading Change, Advancing Health." Chen says the massive report "lives up to its name" and relies "on the evidence amassed over the last 50 years in clinical trials on the efficacy of nursing care," rather than the "diatribes that usually creep into discussions about the roles of different health care providers."

Chen notes that among the report's recommendations are "what amounts to a rebuke of the current piecemeal education of nurses and a debunking of the notion that physicians are the only ones who should lead (and be reimbursed for) any changes in the current health care system." And on these topics, Chen proceeds to consult two nursing leaders! Catherine L. Gilliss, president of the American Academy of Nursing, praises the report:

"I don't think any group has a lock on advocacy," Dr. Gilliss said, "and I don't believe that any one group is restricted from reaching out and being in the patient's world, making home visits, doing a little something out of the ordinary. There's a need for many hands, and this may be nursing's shining moment."

Catherine GillissChen places this last statement at the end of her column--it underlines the "all hands" idea with which she started--and again, although we know desperation is an APRN selling point, we're uncomfortable with what it implies about the quality of nursing care. And it is a little ironic that a nursing leader would have to stress that it's OK for nurses to be more in "the patient's world," as if they were not there already. But Gilliss's statements will probably strike Chen's readers as reasonable and positive, so they are helpful. Chen's reference to Gilliss (right) as "Dr."--an honorific she has commendably bestowed on nurses before--is a bit of a mixed blessing, because in the absence of a specific statement that Gilliss is a nurse, some readers may assume she is a physician.

Chen also spends significant time on the work of Mary Naylor (below), "a principal investigator in the Transitional Care Model program and a professor of nursing at the University of Pennsylvania." Chen says part of the IOM's "blueprint" for reform is Mary Naylor"innovative nursing-led services" like that Philadelphia program, "where nurses are assigned to elderly hospitalized patients deemed to be at high risk for relapse."

For up to three months after discharge, the nurse makes home visits, accompanies the patient to doctors' offices and collaborates with the primary care physician and family caregivers. In early trials, the program has significantly decreased hospital readmissions and costs by as much as $5,000 per patient. But because not all third-party payers and institutions are willing to enroll patients in a nurse-directed program or pay for new nursing services, not all patients who are eligible for the special care can enroll because they won't be reimbursed.

Chen quotes Naylor as saying that "we don't recognize how critically important it is to maximize the contributions of everyone," presumably meaning such programs need more recognition and funding. The Times's own record in recognizing these programs has been mixed, ranging from Milt Freudenheim's very good June 2010 piece on geriatric care, which highlighted Naylor's program, to Lesley Alderman's awful article from the same month about discharge planning, which ignored nurses. Chen's description here is good, except for her odd references to "doctors' offices" and the "primary care physician," which exclude the APRNs who can and do provide primary care that is at least as effective as physician care, as decades of research show.

Here Chen does get closer to recognizing that one major element of the IOM report is its recommendation that APRNs be given more recognition for their ability to direct care and practice without physician oversight. But she is still vague enough that most readers will probably not understand how sharp that debate is or, again, that there is already a large, well-defined group called APRNs who provide high-quality practitioner care. Perhaps Chen is trying to rise above such inter-professional disputes or avoid annoying physician colleagues by expressing direct support for the APRN position; after all, we wouldn't want any diatribes to creep into our discussion of professional roles.

Chen says the IOM report was "just as forceful in urging nurses to revamp the way they are educated, citing the decades-long struggle within the profession to define what exactly a nurse is." She notes that "registered nurse" can refer to everyone from those with doctorates to those with "two-year associate's" degree training (which typically takes more like three years to get today). Chen explains that the report recommends increasing the number of nurses with bachelor's degrees to 80 percent from the current 50 percent, and doubling the number with doctorates, in the next decade. And, she notes, the IOM report recommends adding nursing residencies. (This idea is already being successfully implemented in some places.) Chen's description of the educational problems in nursing is valuable. She does not add that it's hard for many physicians like her, with their doctorates, to regard nurses who do not have a bachelor's degree as professional peers. We assume she's being polite.

Winding up, Chen notes that the IOM's expert panel will soon reconvene to discuss how to implement their recommendations, but they "will have their work cut out for them," because groups like the American Medical Association argue that the report undervalues physician training and the "importance of physician-led teams in ensuring patient safety." The AMA says increasing the responsibility of nurses is not the "answer to the physician shortage." (We might adjust that statement only slightly, to say it's not just the answer to the physician shortage.) Chen closes with the Gilliss quote about the "need for many hands," suggesting that she supports giving nurses some greater responsibility, but again, she is describing the issues in very general terms, so her readers will probably not understand the nature of current APRN practice or the high quality of APRN care.

Still, on the whole, Chen's piece is a fair and sympathetic endorsement of the IOM report's call for nursing reform and empowerment.

A terrible thing to waste

Donna Shalala quoteThe Kaiser Health News story by Andrew Villegas and Mary Agnes Carey provides a more focused and detailed account of the IOM report's significance for APRNs. It has some good elements, but the most glaring problems are that it quotes no nurses--in an article about a report urging nursing empowerment--and that it allows physicians to argue that APRN care is unsafe, yet does little to counter that idea, merely quoting IOM panel member Donna Shalala on the need to use all resources to meet health care needs.

The article, "Nurses need a more independent role, report argues: But doctors have repeatedly opposed the idea, citing potential safety risks," leads with the central idea that the IOM report "may give nurses with advanced degrees a potent weapon in their perennial battle to get the authority to practice without a doctor's oversight," even though many physicians oppose the idea, "citing potential safety concerns." In particular, the story says, the IOM report recommends that states and the federal government remove "regulatory and institutional" scope of practice barriers that still limit what advanced practice nurses ("those with a master's degree") can do. Of course, many APRNs have doctorates, and in a few years, it appears that most new graduates in the U.S. will. The piece does offer a Donna Shalalagood summary quote from Iowa pediatric NP Cheryll Jones:

A qualified health care professional is a terrible thing to waste.

The piece further explains the IOM report. The "committee" that produced the report was "a collaboration among nurses, doctors, health care business leaders and academics that studied the issue for two years." The report recommends that we "reimburse advanced practice nurses the same as a physician for providing the same care," and the piece quotes committee chair Donna Shalala (right), the former U.S. Department of Health and Human Services secretary, as saying that "when you do the same job you ought to be paid the same." The piece also explains that the IOM report "calls for nurses to be allowed to admit patients to the hospital or to a hospice and for the Federal Trade Commission and the Department of Justice to review existing scope of practice provisions for 'anticompetitive' practices." Shalala is quoted as saying that we must cooperate to enhance the role of nurses if we are to improve the health system.

We cannot get significant improvements in the quality of health care or coverage unless nurses are front and center in the health care system -- in leadership, in education and training, and in the design of the new health care system. We can't be fighting with each other if we really are going to have a high quality system that we can afford.

The specific recommendations illustrate just how aggressive the report is in urging that APRNs be given parity with physicians, at least in some respects. And Shalala's quotes are fine, strong endorsements of expanding nurses' role in the system. The article might have explained what the reference to what "we can afford" means here; we assume it means that APRNs are less expensive to train and in clinical practice, since, as Shalala suggests, their pay is significantly lower.

Nurse-led clinicThe piece also provides some helpful background. It notes that experts say more physicians, nurses, and others will be needed to provide care to all those who will get coverage under the new health care law, citing an Association of American Medical Colleges report projecting that in 2015, "there will be a shortage of nearly 63,000 doctors across all specialties in America." Noting that "nurses' groups say that they can help ease" that physician shortage, the piece goes on to provide detail about how the health reform law tries to support "nursing education and nurse-led clinics." It explains that recently announced HHS grants under the law include "$31 million to 26 nursing schools to increase full-time enrollment in primary care nurse practitioner and nurse midwife programs and $14.8 million for nurse managed health clinics." The piece adds that "a registered nurse heads the newly formed National Health Care Workforce Commission," set up to advise Congress under the new law, but inexplicably the piece does not name that nurse, as if straining to preserve the irony of not naming a single nurse in a report about the importance of nursing. He is Peter Buerhaus, RN, PhD, a Vanderbilt nursing professor and prominent nursing scholar who has conducted valuable research on nurse-to-patient ratios, though he has also conducted flawed research purporting to show that nurses already have a great public image, consistent with the views of his funder Johnson & Johnson. In any event, initial members on the 15-member Commission also include one other nurse and five physicians; we guess it's a start.

Unfortunately, none of this generally helpful material tells readers why APRNs are qualified to provide good care, nor about all the research showing that their care is at least as effective as the care of physicians. That would have been good, because in describing the ongoing legislative scope of care battles, which the piece does at length, it gives physicians significant space to make their unsupported arguments that APRNs are unqualified to practice independently, with no response from a nurse or anyone else. The piece explains that for years APRNs have "butted heads" with physicians in states across the nation, citing as examples Colorado, which "recently became the 16th state to allow nurse anesthetists to work without a doctor's oversight," and Michigan, where "nurses are pushing for legislators there to allow advanced practice nurses to prescribe drugs." Here's what the article says about the positions of the physicians resisting these changes.

Doctors maintain that even with an advanced degree, these nurses do not have the same education that physicians get in medical school and residency programs and that patient safety could be compromised. They are also wary that their practices could see significant patient losses if the nurses were allowed to practice more independently.

Dr. Rebecca J. Patchin, a former nurse who is now an anesthesiologist and member of the American Medical Association's Board of Trustees, said that physicians must be involved to help protect patients. "We think that care in the operating room or care in the office is best done with physician involvement and oversight," Patchin said. "Due to that additional training that they have ... when or if a complication occurs they are better equipped to handle it." ...

Dr. Alexander Hannenberg, president of the American Society of Anesthesiologists, said the clashes between nurses and doctors scare the public. "It's exactly what people worry about when they worry about what health reform will bring," he said. "Patients and voters say 'If you're talking about taking the docs out of my health care, I want no part of it.'"

So naturally, with all of that, you might think nurses would get equal space to explain how well-qualified they are. But if you thought that, you would be wrong. Nurses might have pointed out that apart from the correct statement that APRNs' education is not "the same," there is no support for anything the physicians say. And of course, the research belies the physicians' claims, which is why they never mention that and are forced to rely on the "years of formal education" argument and made-up quotes from "patients and voters." "Former nurse" Patchin, who has been making the years of education argument for years, overlooks that

(1) quality of care is not solely dependent on years of study, but also on the care model, and the nursing care model is at least as good as the physician model; and

(2) graduate-prepared APRNs receive years of formal and clinical training, including undergraduate health training that physicians do not get, which the research shows is sufficient to provide excellent care.

Health care is not just a matter of how much disease pathology you can cram into your head; what you are willing and able to do with your knowledge matters a great deal. We did enjoy Hannenberg's assertion that because conflict and change can be scary, we have to leave scope of practice rules the same--how convenient for those who benefit from the current system! The piece does make that point pretty clear in noting that physicians are "wary" of losing patients if nurses can practice more independently.

On the whole, the Kaiser/MSNBC piece has helpful information on the IOM report, but its failures to give nurses a voice and to counter physician safety claims are major flaws.

The "same level of services as anesthesiologists at potentially lower cost"

Nurse anesthetistThe Wall Street Journal Health Blog item was not afraid to state forcefully what the Times and Kaiser/MSNBC pieces did not. The blog post's headline is "Study: No Problems If Nurse Anesthetists Work Unsupervised By Docs." Katherine Hobson begins her post by pointing to the controversial nature of such studies.

It's only Tuesday, but we're ready to award the weekly prize for the sentence-from-a-press-release-most-likely-to-prompt-a-comment-storm to this line, describing new research published today in Health Affairs:

The new study confirms that certified registered nurse anesthetists (CRNAs), who receive high-level training, are able to provide the same level of services as anesthesiologists at potentially lower cost.

We can't understand why anesthesiologist Rebecca Patchin failed to mention this study in her Kaiser/MSNBC comments! WSJ blogger Hobson explains the legislative battles behind this, noting that 14 states have opted out of Medicare's requirement that physicians "supervise" anesthesia services (she notes that "California opted out last year, but that move is being challenged in court by two physicians' associations.").

In the study, the Research Triangle Institute (RTI) "analyzed inpatient mortality and complication rates from 481,440 hospitalizations covered by Medicare in both opt-out and non-opt-out states between 1999-2005." The researchers found no evidence that "patients are exposed to increased surgical risk if nurse anesthetists work without physician supervision." The researchers controlled for the fact that anesthesiologists "tended to work on more complex cases than did nurse anesthetists," and concluded:

We recommend [Medicare] return to its original intention of allowing nurse anesthetists to work independently of surgeon or anesthesiologist supervision without requiring state governments to formally petition for an exemption. This would free surgeons from the legal responsibilities for anesthesia services provided by other professionals. It would also lead to more cost-effective care as the solo practice of certified registered nurse anesthetists increases.

The blog says that the study "was funded by the American Association of Nurse Anesthetists," and in another telling sign, a note at the bottom reveals that the post "has been updated to include the funding source for the study." Who could have complained about that omission? But of course, study funders are an important source of information about a study, and it's appropriate to include that. Even more important, though, would be identifying any flaw in the actual research. There is no sign of that here.

The blog does not consult nurses or physicians, but it does quote study co-author Jerry Cromwell, a senior fellow in health economics at RTI. Cromwell

tells the Health Blog that the two types of providers receive about the same amount of actual anesthesia-related clinical and classroom training, though of course physicians get additional training in med school and residency on other physiological systems and specialties. "Certainly [physicians'] training is very valuable in managing ICUs and managing pain control," he says. But at the level of the operating room, "those skills, from a statistical standpoint, don't seem to have any effect."

Nurse anesthetistThe piece goes on to explain that CRNAs must have a "bachelor of science degree in nursing or science-related field, one year of critical care experience before a two- or three-year master's program in anesthesia, a certification exam and a year of residency." It also says that in 2008-09, "the average salary offered for CRNAs recruited through staffing firm Merritt Hawkins was $189,000 and for anesthesiologists, $344,000."

There is a lot of helpful information here in a small space, underlining how well-trained CRNAs are, and, frankly, how well-paid they are, though of course they are paid far less than the anesthesiologists whose work this study shows is no better. Cromwell's comments about the relative training of the two professions are also revealing. Of course it's helpful to point out that the actual anesthesia training between the two groups is comparable. Cromwell also says that physicians get "additional training in med school and residency on other physiological systems and specialties," but he fails to note that CRNAs get years of health training in undergraduate nursing school that the physicians do not get, and much of it is different from physician training, since nursing is not a subset of medicine. Most CRNAs also reinforce their undergraduate education by practicing in the clinical setting before entering their MSN programs, an opportunity physicians do not have.

Cromwell also suggests that physician skills are valuable in "managing ICUs and managing pain control," but neither physicians nor APRNs "manage" ICUs--ICU nurses manage ICU nurses, and they are the ones who take the lead in most of the care provided there. Nor are advanced practitioners, despite their prescription authority, solely responsible for "managing pain control." Direct care nurses do that in giving most of the drugs, monitoring their patients, making adjustments based on their skilled observations, and consulting with advanced practitioners as needed. One thing that isn't mentioned here is whether, apart from years of training, the nursing practice model--which focuses on close and constant patient monitoring--might be a special asset in anesthesia care.

On the whole, this blog post is a concise and strong account of a recent entry in a long list of studies showing that APRNs are capable of practicing without physician supervision.

"People are not stupid"

Carla K. Johnson's Associated Press report, headlined "Doctor shortage? 28 states may expand nurses' role," is a fairly comprehensive discussion of the battles over APRN scope of practice at the state and federal levels. Despite some distortions and misstatements, it offers a good deal of helpful material about APRN skills and actually permits nurses to respond to physicians' unsupported safety claims.

The piece begins with some flashy, sloppy statements designed to get your attention, starting with the first sentence:  "A nurse may soon be your doctor."

These nurses with advanced degrees want the right to practice without a doctor's watchful eye and to prescribe narcotics. And if they hold a doctorate, they want to be called "Doctor."

Of course "doctor" can mean anyone with a doctorate, but given that most of the public equates "doctor" and "physician," the statements above may feed the inaccurate impression that advanced practice nurses really want to be physicians. Some do want to be called "doctor," but that doesn't mean they want to be physicians. Also, the "without a doctor's watchful" eye makes it sound like physicians are currently watching APRNs like hawks, or parents, which understates APRN autonomy everywhere, but especially in the settings where APRNs may practice without any physician collaboration at all.

The piece explains the basics of APRN practice and how it might expand under the new health care law, particularly through the "nurse-managed clinics" that are slated to get more funding. Then it moves on to the nurse-physician conflicts.

The medical establishment is fighting to protect turf. In some statehouses, doctors have shown up in white coats to testify against nurse practitioner bills. The American Medical Association, which supported the national health care overhaul, says a doctor shortage is no reason to put nurses in charge and endanger patients.

Nurse practitioners argue there's no danger. They say they're highly trained and as skilled as doctors at diagnosing illness during office visits. They know when to refer the sickest patients to doctor specialists. Plus, they spend more time with patients and charge less.

This isn't a bad summary of the two basic arguments, though the statement about referring the "sickest patients" to "doctor specialists" may suggest to some that APRNs are somehow less qualified than primary care physicians to manage serious illness, which is false. Any competent primary care provider would refer a patient to a specialist if necessary. But the piece actually provides details about APRN qualifications, explaining:

The best U.S. study comparing nurse practitioners and doctors randomly assigned more than 1,300 patients to either a nurse practitioner or a doctor. After six months, overall health, diabetes tests, asthma tests and use of medical services like specialists were essentially the same in the two groups.

Mary MundingerThis is presumably the influential 2000 study led by Mary Mundinger (right) and colleagues at Columbia University that was published in the Journal of the American Medical Association. The piece goes on to quote UCLA public health expert Jack Needleman:  "The argument that patients' health is put in jeopardy by nurse practitioners? There's no evidence to support that." Needleman notes that other research has "shown that nurse practitioners are better at listening to patients," and that they make good decisions about specialist referrals. And the piece says that the New York-based Macy Foundation, which studies the education of health professionals, "recently called for nurse practitioners to be among the leaders of primary care teams" and for the removal of regulatory barriers--a foreshadowing of the later IOM report.

The Chicago-based AP report also introduces Chicago NP Amanda Cockrell, who says NPs are "constantly having to prove ourselves." She "tells patients she's just like a doctor 'except for the pay.'" We actually hope she doesn't tell them she's "just like" physicians, which does not necessarily advance the interests of APRNs. The piece explains at least a few respects in which she is not "just like" physicians. First, the piece compares Cockrell's training to that of physicians, noting that she had four years of "nursing school" and "three years in a nurse practitioner program," which may include the one-year residency many APRNs now get. But the piece does not explain that these were (we assume) university programs, even though it mentions the "four years in undergraduate school" that physicians get, in addition to their four years in medical school and three years in residency training. Cockrell notes that "only a few" Physician rushingpatients would rather see a physician than her, and she also stresses that patients get (in the piece's words) "real advantages by letting her manage their care" because NPs' "uphill battle for respect makes them precise, accurate and careful." She spends 40 minutes on physical exams; her physician colleagues schedule 30. Patient Joseline Nunez is happy:

I feel that we get more time with the nurse practitioner," Nunez said. 'The doctor always seems to be rushing off somewhere.'

The report describes the legislative aspects of the "uphill battle" in some detail. At the federal level, the piece explains that Medicare has paid NPs only 85% of what it pays physicians, but the new health reform law raises the rate of nurse-midwife reimbursement to "100 percent of what obstetrician-gynecologists make." The piece explains other relevant features of the new law, including greatly increased funds for "nurse-managed health clinics that offer primary care to low-income patients" and "for hospitals to train nurses with advanced degrees to care for Medicare patients." The American Nurses Association hopes the raise for midwives is a good sign; the ANA's Michelle Artz says it's a "crack in the door" that may lead to "100 percent for everybody."

On the state side, the piece notes that laws about NP scope of practice vary. In Montana, NPs need no physician involvement in their practices at all, but many other states "put doctors in charge of nurse practitioners or require collaborative agreements signed by a doctor." In Florida and Alabama, NPs cannot prescribe controlled substances; a Florida bill to change that is "stalled in committee," even though patient Karen Reid "said she was left in pain over a holiday weekend because her nurse practitioner couldn't prescribe a powerful enough medication and the doctor couldn't be found." Also:

Dying hospice patients have been denied morphine in their final hours because a doctor couldn't be reached in the middle of the night, nurses told The Associated Press.

Awesome! So what stands in the way of greater autonomy for these well-qualified NPs?

The American Medical Association is fighting proposals in about 28 states that are considering steps to expand what nurse practitioners can do. "A shortage of one type of professional is not a reason to change the standards of medical care," said AMA president-elect Dr. Cecil Wilson. "We need to train more physicians."

The report focuses on Massachusetts, whose 2006 health care overhaul was a model for the federal reform law, noting that the state responded to the "long waits for primary care" for the newly insured by requiring health plans to "recognize and reimburse nurse practitioners as primary care providers," which "Mary Ann Hart, a nurse and public policy expert at Regis College," said "greatly opens up the supply of primary care providers." But a recent study by the Massachusetts Medical Society found that the primary care shortage remained, and "the medical society still believes nurse practitioners should be under doctor supervision." The piece says the physician group supports "a team approach to medicine that includes nurse practitioners and physician assistants, whose training is comparable."

"We do not believe, however, that nurse practitioners have the qualifications to be independent primary care practitioners," said Dr. Mario Motta, president of the state medical society.

Apparently, we're just supposed to take his word for it, because as always, there is no actual evidence in sight. However, that does not seem to stop the reporter from taking at face value what we assume is the group's claim that the training of NPs and "physician assistants" (PAs) is comparable. That is incorrect. NPs have four-year undergraduate science degrees in nursing; PAs have undergraduate science prerequisites, but they can be English majors. NPs are trained to join an autonomous profession with a history that goes back centuries and that does not depend on physicians. PAs began training in the 1960's to assist physicians, as their name makes clear, and we are not aware that any can practice with true autonomy. In addition, APRNs typically have years in the clinical setting before obtaining their graduate degree. As we understand it, physicians assistants do not.

The piece explores the naming issue that journalists often seem to find entertaining. The piece reports that most states allow NPs with doctorates to use the title "Dr.," though some do not. It says that the "feud over 'Dr.'" is "no joke,'" since nurses plan for most new NPs to have doctorate of nursing practice (DNP) degrees by 2015, and to that effect the piece quotes Polly Bednash, executive director of the American Association of Colleges of Nursing. The report also says "many" NPs use the title "Dr." "with pride," noting that Arizona NP Linda Roemer uses "Dr. Roemer" as part of her email address. The piece explains:

The AMA argues the title "Dr." creates confusion. Nurse practitioners say patients aren't confused by veterinarians calling themselves "Dr." Or chiropractors. Or dentists. So why, they ask, would patients be confused by a nurse using the title?

Roemer's reported response:  "I don't think patients are ever confused. People are not stupid." In fairness, those other practitioners are not generally providing care that seems as similar to physician care as APRNs are. But it does seem unlikely that anyone is going to be "confused" if a nurse identifies herself as a nurse. It's also not clear how a patient would be harmed even if he or she was confused, in light of the research about the quality of APRN care. The "with pride" statement, along with the earlier note that NPs with doctorates "want to be called" doctor, does make it sound a little like APRNs are status-obsessed, when they are really most concerned about being permitted to practice in accord with their training and skills. On the whole, though, the report does a fairly good job of providing information responding to the physician concerns about the safety of NP practice; many pieces report physician comments and stop.

These four pieces take different approaches in describing the growth in APRN practice and the effects of recent legislation. But all show that APRNs continue to make progress in persuading the public to see them for the highly qualified practitioners they really are.


See the articles:

"Doctor and Patient: Nurses' Role in the Future of Health Care," by Pauline Chen, in the New York Times posted November 18, 2010;

"Nurses need a more independent role, report argues: But doctors have repeatedly opposed the idea, citing potential safety risks," by Andrew Villegas and Mary Agnes Carey, posted on the Kaiser Health News site on October 5, 2010;

"Study: No Problems if Nurse Anesthetists Work Unsupervised By Docs,"by Katherine Hobson, Health Blog: Wall Street Journal's blog on health and the business of health, posted on August 3, 2010;

"Doctor shortage? 28 states may expand nurses' role," by Carla K. Johnson, from the Associated Press, printed April 14, 2010;



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