Doctors and nurse practitioners: beyond the turf wars

Research shows nurse practitioners are as good as MDs at primary care, where there is a big shortage. But who knows about it?

A few days ago, I got an email asking me to sign a petition on the White House website, urging the Obama administration to “remove barriers that prevent advanced practice registered nurses from practicing to their full scope.” In plain English, the petitioners are asking the feds to relax restrictions on the ability of nurse practitioners to work independently, free of physician supervision.

For the most part, and not surprisingly, doctors’ representatives are not big on this. The American Medical Association (AMA), American Academy of Family Physicians (AAFP), and other physician groups oppose it. And, for the most part, media outlets portray this issue as a turf battle between self-serving nurses and territorial doctors, instead of a potential solution to a problem that is big and getting bigger—the shortage of primary care physicians.

Operating on late-night autopilot, I signed the petition. The next day, I thought about the idea some more and wondered what it really seeks to accomplish, because individual states—not the federal government—are responsible for oversight of nurses’ scope of practice.

Some local reporters who understand that, including Sherry Jacobson at The Dallas Morning News, have focused on the progress of state legislatures working to address the issue. Another reporter, Michael J. Mishak of the Los Angeles Times, noted in his piece that implementation of Obamacare, with more people gaining healthcare coverage, will exacerbate the shortage. And he quoted a California state senator and optometrist, Ed Hernandez, who provided a compelling illustration of the impact of the primary care shortage:

Hernandez, who said he would introduce his legislation and hold a hearing on the issue next month, said his own experience as an optometrist shows the need to empower more practitioners. He said he often sees Medicaid patients who come to his La Puente practice because they have failed their vision test at the DMV. Many complain of constant thirst and frequent urination. ‘I know it’s diabetes,’ he said. But he is not allowed to diagnose or treat it and must refer those patients elsewhere. Many of them may face a months-long wait to see a doctor.

Unfortunately, most media outlets only offer predictable editorial treatment, the he-said/she-said variety. For example, The Sacramento Bee ran a Q&A on March 29th in which a physician goes up against Hernandez and a colleague, who, respectively, present arguments against and for increasing the primary care autonomy of nurse practitioners and other non-physician providers.

The turf war cliché—nurse practitioners giving their side, doctors shooting them down—ignores sound research demonstrating that advanced practice nurses deliver the same or better primary care patient outcomes as MDs. That was the finding of a pivotal journal article published in 2011 that was widely covered in the trades, but practically ignored by the consumer press.

In a nutshell, the researchers did a systematic review—the highest level of scientific evidence—of more than 100 studies examining the impact of advanced practice nurses on primary care patient outcomes, compared with that of MDs. They concluded that, “a collaborative effort will ultimately lead to higher quality health care and better health care systems.” What this implies is that, instead of working under the supervision of physicians, advanced practice nurses should work alongside them, as competent members of a multi-disciplinary primary care team. A more sophisticated approach to covering this subject would dig a little deeper into that conclusion, and ask the experts what its practical implications might be or what a “collaborative effort” might look like in the real world. This might elicit important details concerning the financial structures of such collaborations, which could help inform public debate and guide future research into its long-term viability within the changing US healthcare system.

The conclusion of that systemic review should have, at least, been a launching pad for a more diverse and high profile base of interview subjects in resulting stories, especially stories framing the issue in the context of implementation of the Affordable Care Act. Shannon Pettypiece did her homework for a recent article for Bloomberg Businessweek, including the perspective of John Rowe, an MD and a professor in the Department of Health Policy and Management at the Columbia University Mailman School of Public Health; the former chairman and CEO of Aetna, Inc.; and the former president and CEO of what was then called Mount Sinai-NYU Health.

Rowe also sat on the committee that developed the landmark Institute of Medicine report, “The Future of Nursing: Leading Change, Advancing Health.” Among other recommendations, the scope of practice portion of the report included the following:

Because one of the greatest barriers to nurses’ capacity to transform the health care system is the patchwork of state regulations, the committee finds that the federal government is particularly well situated to enact effective reform of the practice of APRNs by disseminating best practices from across the country and creating incentives for their adoption.

I’m not suggesting that the media—or anyone, for that matter—endorse one position or another. Both sides make valid points. I’m suggesting that there’s more to this debate than a turf war. And the general public—patients, voters, and petition signatories—should know that.

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Sibyl Shalo Wilmont is a healthcare journalist and emergency department nurse with insider experience in the pharmaceutical industry, academic medicine, and patient advocacy. She is a graduate student in Hunter College's dual-degree Master's in Community/Public Health Nursing/Master's in Public Health program. Follow her on Twitter @nursesibyl. Tags: , , ,