Response to WSJ Article, "Should Nurse Practitioners Be Able to Treat Patients Without Physician Oversight?"

This post was written in response to the WSJs article, "Should Nurse Practitioners Be Able to Treat Patients Without Physician Oversight?"

As much as some would like you to believe that this is not about turf protection, make no mistake, it is exactly about protectionism and nothing in the interest of the patient. The latest buzz words are now “team-based care” where nurse practitioners, physicians, and other members of the health care team, are working for the common goal of better health outcomes while the inefficiencies of today’s healthcare system vanish. The problem with this presumption is that there is no defined model of team-based care.

So what then is team-based care? If you ask a physician what team-based care is, they would say it is where they are in charge of the team and tell what the other members to do. They hold the most hours of in-patient training and in doing so can care for every patient and every condition without anyone else telling them how to do it. Plain and simple. Captain of the ship.

If you ask a nurse practitioner about team-based care, they will refer to a theoretical model where all members of the team are active participants in the provision of care for that patient. True collaboration takes place where providers seek solutions collectively and the right provider is caring for the patient at the right time and place. Precious time is spent developing the communication strategies of the team, the team composition and conflict resolution.

To simply state that the “…University of Missouri Department of Family and Community Medicine conducted a recent study of all comparative research on the topic and concluded ‘substitution of physicians by independent nurses providing comprehensive primary care is not an approach supported by the literature’” is disingenuous at best. First, this purported study simply used the data from an established systematic review published by the Cochrane Library of Systematic Reviews – “Substitution of doctors by nurses in primary care” by Laurant et al. (http://webcache.googleusercontent.com/search?q=cache:Ffm3TsFaMgQJ:www.aafp.org/online/etc/medialib/aafp_org/documents/about/congress/2010/res605background.Par.0001.File.tmp/SubstitutionofPhysiciansbyNursesinPrimaryCare2011.pdf+&cd=1&hl=en&ct=clnk&gl=us). Because the American Academy of Family Physicians (AAFP) didn’t like the outcome of the peer-review process, they decided to fund a second review and essentially re-write the results so that it favored a fictitious outcome, thereby minimizing the contribution of NPs. To date, their “new” study has yet to be published in any peer-reviewed journal that I am aware of.

The next talking point is to highlight how NPs order more tests. There was one small study that observed this (well over 10 years ago), however the study did not focus on patient outcomes. Therefore, this has very little applicability to draw any significant conclusions about healthcare costs or anything else for that matter. 

Finally, nurse practitioners do not want to be physicians nor do we purport to be. NPs are not taking a “shortcut” to medicine or trying to fool patients into thinking we are something we are not. It is our goal to be recognized for the unique clinicians that we are – melding nursing and medicine together to care for the whole patient. Nurse practitioners are among the majority of providers caring for the health disparate and doing so in an evidence based, culturally competent, and high quality manner that NPs bring to every patient encounter. The pillars of health promotion, health education, wellness, and disease management make nurse practitioners uniquely qualified for the aging population. And when there is a patient with multiple health issues whose body and/or mind are not responding to the latest recognized treatment, it’s good to know that a physician is waiting for the handoff. Or are they? 

A Great Time Saver

As the case for nurse practitioners is becoming increasingly obvious across the spectrum, predictably, the turf battles are rearing their ugly heads. Here is a blatant example of the rhetoric and follows a formula that I am going to reveal to spare any future time wasting reading them.

• Refer to the physician shortage and mention "Obamacare" 
• State the obligatory, "nurse practitioners are valued as part of the health care team" 
• Point out the differences in education and training (for example, physicians have 1 billion hours of training where NPs have nothing even remotely close to that) 
• Make the inference that quality of care will somehow suffer because of the differences in education/training (though there is not one shred of evidence that proves this)
• Make sure NOT to mention anything about patient outcomes being the same or better when NPs are primary care providers
• If there is mention of outcome studies, be sure to highlight how they are "old" studies with small numbers of patients
• Conclude by saying something with the phrase "physician-led team"

There you have it! I hope with this post, I was able to save the reader time wasted reading the same old argument. 

As a bonus, for on-line stories that allow readers to comment, I am going to save you time from reading the barrage of denigrating comments by summarizing here:

• Blah blah blah...as a medical student blah blah blah....physicians should stop teaching NPs/PAs etc
• Blah blah blah...(make statement about NP education yet have no clue about it)...blah blah
• And finally, state that NPs won't see the poor and underserved and prefer to practice in the "better" practices with insured patients 

Of course, this is not the sentiment of most and the one's who truly want to improve health care understand that. 

Health Policy Observations

My apologies in advance for this post as I'm sure it is a bit all of the place. I wanted to just jot down some of my thoughts on the "nurse practitioner vs. physician debate." There has been many articles recently written about this, so here are my thoughts: (these of course are my own thoughts and not representative of my affiliations)

• Above all else, nurse practitioners want to practice at the "top of our licenses." That is, to our full education and training. Imagine having access to the most wonderful car in the world - that can not only take you to wherever you want to go, in great comfort and with with excellent gas mileage, but not having the keys to start it. That is the restriction of the collaborative agreement. NPs have the education and training to care for patients in their specialty. However, without a collaborative agreement with a physician, we can't use any of it. We are stuck in the proverbial parking lot without keys. 
• Nurse practitioners DON'T want to replace or supplant any profession. Yet inherently, there is the insinuation of NPs "taking over" or "replacing" others. I guess I would be defensive if someone told me that I would be replaced by someone else too. 
• Yes, we all get that physicians have more hours of training.
• I laugh at the pilot and flight attendant analogies. 
• We are not the enemy.
• Collaboration is not a dirty word. I refer back to my post written nearly five years ago, Collaboratus. Working together in the interest of the patient. Novel concept? It shouldn't be. 
• I really laugh at the "if you want to be called doctor, then go to medical school." I haven't heard that one before. 
• When NPs practice, physicians aren't in the room watching over them waiting for them to make a mistake or miss something.
• Who "owns" quality of care? Every single licensed provider has a vested interest in the quality of care they deliver. With more and more available data points, patients will judge and decide who provides their care. 
• Decreased costs. There is an assumption that since NPs are paid less than physicians, then costs should go down. My counter for pay parity: patients are receiving treatments (with similar or higher quality) and THAT will decrease costs.
• NPs can only take care of "simple" things. Not true. No condition is simple. We treat patients, not conditions. Nothing is simple and we recognize and understand that as we partner with our patients.  

Please no more "us vs them." Stakeholders far and wide agree, that the way we provide healthcare in this country must change. It will be much better for all involved if we go at it together. Ok, I feel a little bit better now.

New Year, New Post

Hello Everyone and thanks for reading my blog. It has been a while since my last post - not for a lack of topics to post about - but due to an insane schedule that I have been keeping. Here in New York, we have been through he effects of SuperStorm/Hurricane Sandy, another presidential election, and the tragedy of the unfathomable nearby Newtown Connecticut shootings.

There is so much also going on in healthcare and the aforementioned happenings are also intertwined in the landscape - from emergency preparedness, state health insurance exchanges as part of the Affordable Care Act, and mental health respectively.

Specific to nurse practitioners, there have been numerous articles written about us (and the interesting negative commentary that always follows and isn't worth commenting on anymore). We have also seen the merger of two national nurse practitioner organizations into one large one. CMS announced that there will be increased Medicaid reimbursement for certain physician providers but seemingly omitted nurse practitioners from the higher rates. 

I will try my best to offer my commentary on the latest news, issues, and trends as I have been doing since 2008, the inception of A Nurse Practitioner's View. There has been many changes since then (I am so glad to see more NP Bloggers out there) and some things have stayed the same (i.e. an article published about NP guided care, then cue the demeaning and disparaging remarks). NPs are among those front and center and I look forward to sharing my view and perspective in this new age of healthcare. As always, there will be no advertisements on this blog and I am no longer accepting any guest posts (thanks to everyone who submitted over the last few months). 

Repost: Different States, Different Rules

One of the biggest areas of frustration for students, stakeholders, and nurse practitioners are the seemingly lack of consistency among state regulations regarding NP practice. The rules in one state may not necessarily apply in the next (and even neighboring state). I have known NPs that lived near state borders, licensed in both states, yet had completely different sets of rules regarding what they can/can't do, requirements for collaboration versus autonomy and prescribing ability.

Barton Associates created this free interactive tool that lets you visually compare all 50 states' (plus DC) NP scope of practice. It is ultra handy and can help one decide whether to practice in one state that is very prohibitive compared to one that offers autonomy.

 There is also a push for the APRN Consensus Model whose aim is to have consistency among the states when it comes to regulations.  

 If moving out of the state isn't feasible, well, the alternative is to become involved, active, and supportive of  a national and local  nurse practitioner organization (it is helpful to be supportive whether your state is autonomous or not since there are constant threats to your practice!)

 An example of the advocacy that membership affords was evidenced this past week. The American Academy of Family Physicians (AAFP) put out their white paper, "Primary Care for the 21st Century." I looked forward to reading this report based on the title and hoped that I would find innovation and new ways of enhancing care for our patients based on the primary care model. To my surprise (and dismay), I found myself reading the executive summary and seeing terms like "nurse practitioners are not doctors"   and "the ideal practice ratio of nurse practitioners to physicians is 4:1" and on. Huh? "How is this a report about primary care?" I thought.

 Then I realized that it wasn't, it was an attack on a profession by another wrapped in a pretty looking monograph with old data. It might as well have been called "Lets Denigrate the NPs Under the Auspices of Solving the Ills of the Health Care System Report." At least I would have known what to expect.

 To be completely honest, I really couldn't read it beyond the executive summary (I looked at the Table of Comments and further became ill). Luckily, one of our national NP organizations (the AANP) did read the whole thing (I am unsure if they became ill or not) and responded. Here is one of the benefits of advocacy for nurse practitioners that benefits all nurse practitioners.

 All areas of the health care sector must better work together to achieve outcomes that are truly patient-centric. Do reports like the one referenced above help? I am highly doubtful. We have real issues to deal with and turf wars will continue to distract from them.

This post was first published at Online Nurse Practitioner Programs. 

Repost: Let Us Be Heard

I started this blog, A Nurse Practitioner’s View, 3 years ago because there were very few health stories that even mentioned nurse practitioners as part of the health care landscape. Right before I started the blog, I would respond to other health policy articles published on the Web by writing comments to the websites – only to be subjected to baseless and factually incorrect statements. It was soon thereafter that I decided I would write my own perspective on health policy, trends, and news. I also felt it important from a credibility aspect to not blog anonymously but to put my name on it.

I recall those few early blog posts that I proudly wrote and would feverishly check my blog visitor stats to see if people were reading. Well, it was a bit slow going in the beginning with about 10 – 15 readers but as they say, “if you build it, they will come.” Today, the blog enjoys hundreds of visits a day, has a Facebook following, has enabled me to be “discovered” to blog at Online Nurse Practitioner Programs, and I have communicated with people across the country.

I hold a sense of satisfaction that today, nurse practitioners are readily referred to in articles as one of the possible solutions to the healthcare system (not that I attribute it solely to my blog of course) through the body of evidence and hard work that each nurse practitioner performs every day. We have also seen great advocacy efforts at the Federal and State level by our nurse practitioner organizations, and let us not forget the IOM landmark report,The Future of Nursing published in 2010.

While there is still opposition out there about the role nurse practitioners should perform (and I imagine this will always be the case in some way), we are part of that conversation. You can imagine my utter disappointment when I read yesterday’s New York Times front page article, “Doctor Shortage Likely To Worsen With Health Law” and the only mention of NPs was towards the end of the article:

“Dr. Smith said building more walk-in clinics, allowing nurses to provide more care and encouraging doctors to work in teams would all be part of the answer. “

Did you catch that? “Allowing nurses to provide more care.”  I assume that’s the part referring to nurse practitioners. Today, in 2012, I would think that when there is talk about the current and future state of health care, the conversation about health care would be more inclusive of the actual professions comprising the health care system.

Our health system simply cannot continue with the status quo and present the primary solution being “graduate more doctors.” New care models, health information technology enabling more efficient and cost-effective care, increased patient engagement, enhanced payment structure and yes, even the use of nurse practitioners must be the embedded in that conversation.

Now is the time for nurse practitioners to be heard. I invite every nurse practitioner, nurse practitioner student and patient partnered with a nurse practitioner to write to the NY Times to present a viable alternative to “graduate more doctors.” With over 160,000 nurse practitioners across the United States, now is not the time for silence, but is the time for all stakeholders to understand the solution that NPs offer (and will be even more so when out-dated and unnecessary practice barriers are removed).

I am writing and e-mailing (letters@nytimes.com) my letter today to the NY Times to shine some nurse practitioner light on the gloom and doom scenario presented in the article on the future of health care providers. Please consider joining me in writing one too. Let us be heard.

This post was first published at Online Nurse Practitioner Programs. 

Modernizing Nurse Practitioner Regulations

It's been a busy last few months as the legislative agenda has heated up of the NP organization where I am the Chair-Elect. I have been to some fundraisers and legislative visits to try and garner support from lawmakers to sponsor and support the bill that will eliminate statutory collaboration between a physician and nurse practitioner in New York State. The bill is known as the NP Modernization Act.

We have been at this for about the last 5 years and up until now, there has not been much forward movement. While we had a sponsor for the bill and many co-sponsors, it was stuck in both the Senate and Assembly's Higher Education Committee (where all of the professions in NY state are regulated). The bill basically sat idle in these respective committees. We finally experienced a breakthrough after countless visits and grassroots efforts. The IOM Future of Nursing report absolutely helped make the case for increasing access to care as did the positive press that nurse practitioner partnered continues to receive. Some of the lawmakers were willing to act upon the bill albeit with some amended language.

Since then, the bill has been reported out of the Assembly's Higher Education Committee and should soon be on the floor for full Assembly vote. The same must also happen in the Senate and if it passes the Committee, will go to the Senate floor for a vote. We are staying positive that we will see movement in the Senate but this is one of the significant challenges right now. Oh, and the legislative session ends in 3 days. The bill must then be signed by the governor for to take effect. If it doesn't pass in this legislative session, the process starts all over next year since bills have a 2 year life cycle and this is the second year of the current bill. All is not lost however, since any legislative victories carry some momentum the next go-around.

Of course, there is opposition to the bill. Organized medicine largely does not support the bill and I'm sure that even some nurse practitioners aren't thrilled with it. But in the end, the NP Modernization Act in New York will allow enhanced access to care (while the Patient Protection and Affordability Care Act hangs in the balance of the Supreme Court). And at the end of the day, this is what it is all about - giving patients the opportunity and allowing them to choose care that is delivered in partnership with a nurse practitioner.

On another note, I will be in Orlando Florida this week attending the American Academy of Nurse Practitioners Annual Conference. You can follow updates from the conference on Twitter at #AANP12 plus I will be tweeting from @StephenNP.