Wednesday, July 27, 2016

Doctors and nurses are battling (again), but does it have to be this way?

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 residency and fellowship positions) 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 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 back? 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 a 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?


DrJHO7 said...

For the record I'll say that APN's should be working with physicians. I prefer "collaboration" to "supervision." Teamed-based care is the path forward for our health system in many practice settings, and it is effective and rewarding when done right, better for clinicians and better for patients. So, the VA has a physician manpower problem. APN's say they can handle 85% of what a physician can handle in terms of the breadth of pathology we see, what to do and when. They're probably right. But does that mean they should practice (medicine) independently? I don't think so. Patients deserve better. Even with a medical education and a residency behind me, I have still grappled with considerable uncertainty in taking care of patients and I can't imagine what that would be like with significantly less preparation. Knowledge and experience matter. I currently work in an inpatient setting with many NP's. We collaborate and we support each other. We work in an environment of mutual appreciation. The VA needs to be creative and think outside the bunker, re: solutions that work toward maintaining collaboration and support between its physicians and APN's so their patients can get the best care.

PCP said...

That we are even having this conversation at all is evidence of the incremental liberal insanity that permeates the issue of health care delivery(amongst many others).
That ACPs position is as permissive as it is, and repeats the fickle on one hand then on the other sermon is further evidence of how leadership is clueless about the future welfare of its membership.
Here's a prediction. Primary care delivery is well on its way shifting from General Internists as the delivery backbone to APN as its delivery backbone. That shift will be mostly complete by 2025. That will have been a massive disservice to the american public, but who really cares about them, right! Highly priced shoddy care would be the outcome. We are well on our way. Thanks ACP, for your as usual weak position on a matter of paramount importance to your membership.

Yasir Anzar said...

Team based practice with understanding of each other's scope of competence enhances the chance of providing better health care to the patient. We should not forget that ultimate target is the best quality of care for the patient. At times, patients demand to see an MD rather than a PA or a Nurse practitioner. Hence, we have to come across as a team for patient's comfort sake.

Harrison said...

So as I read the ACP suggestion, the VA is supposed to reorganize into primary care teams, like a PCMH model. And each team will be chaired by a primary care physician, and each VA patient will be assigned to a team. And the team will guide the patient through the process and be sure that communication happens with community doctors and with pharmacies and that tests are done and that the patient gets what they need.

But what the VA is suggesting, and has opened now to public comment, is that instead of reorganizing their entire care model they simply allow more professionals to work in the role of primary care physician.

Bob, I think your approach is Ivory Tower, and the VA rule proposal is based in the practicalities of the day.

I think that APRN's can offer primary care to patients, and they do so in many settings already.

I think it is unfair for physicians to refer to them as substandard in any way. Some are. Of course. Some physicians are too. Of course.

Some PCMH teams will be functional and some will be dysfunctional.

Those points are irrelevant.

APRN's following guidelines and best practices can provide great care to patients, just like primary care physicians can.

To me, that is all that the VA rule change is suggesting, and hoping to act on to expand access to VA patients.

So the question then becomes, does a federal organization operating under federal rules have to abide by state to state variations in licensing laws?

I don't know the legal precedents for this, but it seems like a logical rule change for the VA.


victorgettinger said...

I think H Robinson said it very well. Of course there will be APRNs who will be in over their heads just as there are MDs who lack the necessary knowledge base to know what they don't know. To my mind the problem is monitoring the clinician to ensure they actually know when they the don't know. Who will be there to decide this? Will it be a physician, an admin person, a nurse or maybe the funeral director who prepares the patient for his/her final rest after ANY clinician made a wrong decision leading to the patient's demise. I expect that could happen with an APRN maybe more commonly than a well trained IM but I have seen some really awful (and dangerous) MDs. We have a PCP shortage that will only get more dire under the ACA as it enrolls more people. We need to give the APRNs a chance to step up to the plate to help remedy this growing problem. For better or worse, it is the only way the APRNs can truly show their value and improve the dismal access to care problem in the country especially in the grossly under staffed VA system.

Unknown said...

The ACP alternative puts the APNs as the gatekeepers. It relies on the nurse knowing when to refer to the physician. However, you can't know what you don't know. It might not often be obvious to the the mid level provider that a key part of the puzzle is missing or something isn't quite optimal. As an anesthesiologist, I often hear that the nurses should take care of the easy cases, but I need a sprinkling of easy cases in my week to keep my sanity. Isn't the physician suicide rate high enough?