The Department of Veterans’ Affairs proposal to allow Advanced Practice Registered Nurses (APRNs) to have full and independent practice authority, preempting state laws that hold them back, has triggered another ugly fight between the medical and nursing professions. The American Nurses Association supports it, the AMA opposes it.
The fight over the VA’s proposal continues a long-standing battle that plays out regularly in state legislatures, as nurses have sought to expand their “scope of practice” and eliminate existing “physician supervision” requirements, while state medical societies have battled back.
Both sides, of course, frame the issue as being about quality and access, not about who is in control. Physicians argue that being licensed as an MD or DO requires a higher level of education and patient care experience (four years of medical school and at least 3 years of supervised direct patient care training in a residency and fellowship position) that makes them uniquely qualified to take care of patients, especially those with more advanced conditions, while nurses argue that their different but unique training and skills—especially those that have been trained as Advanced Practice Registered Nurses—make them at least as qualified to treat most patients, with equal or better outcomes. Both cite conflicting studies to support their positions.
I have personal experience in how hard it is to find common ground between the two professions or, for that matter, within the medical profession itself. Three years ago, the American College of Physicians published a position paper in the Annals of Internal Medicine, Principles Supporting Dynamic Clinical Care Teams: A Position Paper of the American College of Physicians, which I co-wrote with my colleague Ryan Crowley on behalf of ACP’s Health and Public Policy Committee. I know Ryan would agree with me that it was one of the more challenging papers we have written. Throughout the two years of research and writing the document, we struggled to find positions that would enjoy the support of ACP’s own membership, which were themselves not entirely on the same page on how hard to push back against efforts to expand nurses’ scope of practice, but also to move closer to finding common ground with the nursing profession.
There was almost universal agreement among ACP’s leadership that physicians have unique training and skills that make them especially qualified to exercise advanced clinical leadership responsibilities for team-based care. But there was also recognition that APRNs, NPs, and other non-physician professionals are essential members of the team, and, in some cases, they may have been held back from practicing to the full extent of their training and skills by overly restrictive internal supervision requirements and overly restrictive state laws. Some of ACP’s members favored a more hard-line, physicians-should-always-be-in-charge stance, while others were open to a more nuanced approach that emphasized collaboration and sharing of clinical responsibilities within teams, putting less emphasis on who should run the show. During the process of writing the paper, we engaged in a constructive dialogue with respected members of the nursing profession, seeking to find common ground where possible or, at least, to avoid using words (like physician “supervision”) that we learned from them were viewed as offensive, creating rhetorical barriers to achieving agreement.
In the end, I think the paper struck exactly the right balance, affirming that physicians do have more unique and more advanced training and skills that make them especially qualified to exercise clinical leadership responsibilities for a team, while supporting the important and essential contributions of highly trained APRNs, NPs, PAs, clinical pharmacists and others in sharing patient care responsibilities, with all members of the team being allowed to practice to the full extent of their training. In other words, we came up with a nuanced approach to the issues of clinical leadership responsibilities within a team rather than defining the issue as being about who is in charge.
The problem is that the VA’s proposal is anything but nuanced, because it frames the issue as a binary choice: are you for or are you against allowing APRNs to practice independently, pre-empting any state law licensure laws that hold them? Presented this way, is it any surprise that it has led to another divisive fight between the medical and nursing professionals?
ACP, for its part, thinks there is a better way. In our comments on the VA proposal, submitted Monday, we offered an alternative to the VA’s proposal that tries to move the discussion away from considerations of “independence” and “hierarchy” to how to organize high-functioning, patient-centered clinical care teams that use everyone’s skills to the maximum extent of their clinical training and skills, based on the principles in our 2013 paper. Our alternative offered the following key points:
- While ACP does not support the VA's proposal to broadly preempt state licensing laws to grant full independent practice authority to APRNs, we propose an alternative that matches patients with the health care professionals on the team who have the training and skills needed to meet their care needs, modeled on the recommendations in ACP’s 2013 position paper.
- We express support for veterans being able to have access to a personal physician who accepts clinical responsibilities for care of the “whole person,” consistent with the Patient-Centered Medical Home model. In a press release that summarizes our recommendations to the VA, ACP’s President, Dr. Nitin S. Damle observed that “While internal medicine physicians have unique training to exercise clinical leadership responsibilities for the team and to care for adults with complex illnesses and diagnostic challenges, patients might appropriately be seen by other members of the clinical care team -- including nurses -- depending on their specific clinical needs and circumstances with physicians being available for referral or consultation as needed."
- Because primary care encompasses various activities and responsibilities, it is simplistic to view primary care as a single type of care that is uniformly best provided by a particular health care professional. To illustrate, our letter observes that an advanced practice registered nurse providing primary care commensurate with his or her training may consult with or make a referral to an internal medicine physician, a family physician, or another physician specialist when presented with a patient with significantly complex medical conditions.
- Effective clinical care teams allow each member of the team to practice to the full extent of their training and experience, ACP observed. While ACP does not support pre-emption of state licensing laws, it strongly encourages states to examine their laws to ensure that all clinicians are able to practice the full extent of their training and skill while practicing within a dynamic clinical care team.
- Our letter notes that especially in physician shortage areas, it may be infeasible for patients to have “an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care. They may also be unable to have immediate on-site access to other team members who may be located some distance from where the patient lives and accesses medical care. In such cases, collaboration, consultation, and communication between the primary care clinician or clinicians who are available on site and other out-of-area team members who may have additional and distinct training and skills needed to meet the patient's health care needs are imperative. We suggested the even if a physician and APRN are not physically co-located, the patient should have access to a “virtual” clinical care team through use of telemedicine, electronic health records, regular telephone consultations, and other technology to enable the on-site primary care clinician and all members of the health care team to effectively collaborate and share patient information. Telemedicine and telehealth technologies can help virtual clinical care teams provide clinical consultation and decision support as well as patient education, remote monitoring, and other services.”
I am under no illusion that ACP’s approach will be the basis for truce between the medical and nursing professions on the VA’s proposal or, more broadly, over the other raging battles over preserving, changing, or superseding state laws that set limits on what nurses can do independently. These fights will go on, precisely because they present the issue as “either/or” choices. I am hopeful that ACP’s nuanced approach of trying to move the discussion towards how both professions can work together, rather than fighting against each other, will eventually bridge some of the differences over leadership, supervision, and scope, especially at the level where care is actually delivered, when teams of clinicians, highly trained in their own disciplines, work closely and collaboratively together while focused solely on what is best for their patients.
Today’s question: What do you think of the VA proposal and ACP’s alternative?