Argument against full practice authority

Riburn3, BSN, MSN, APRN, NP · May 4, 2017

It's not surprising the head of the Texas Medical Association would be against this. Especially when there is a bill stuck in committee to give APRN's more autonomy in Texas. His job is to protect physician interests.

If I were to critique this article from an objective standpoint, it wouldn't hold up in even an undergraduate nursing program as a reference. It is almost purely opinion and lacks peer reviewed content to justify his claims. He cites a single small sample size study published almost 20 years ago to justify his position. When in the medical field is that ever acceptable?

Since that time, many more states have obtained full practice authority and there are numerous recent studies readily available that show NP's are about the same as physician's in terms of overall quality. Think about how much primary care and the medical system has changed since 1994 when the studies he cites were conducted. It looks like he had to do some really deep digging to cherry pick his claims, ignoring a whole slew of evidence to the contrary.

He also makes an argument that most NP's are working in the states most populous counties which is true, but it's probably a chicken and egg scenario where the current practice environment influences this since we are required to be tethered to a physician, and most physicians also work in these counties. If an NP in the state of Texas could just move to a rural area and open up shop without all the extra red tape that is required, my guess is thousands would do so in a heart beat. I live close to New Mexico (which is independent practice) and this is very common in more rural areas where you have NP led primary/urgent care clinics.

Full disclosure, I work in Texas and I really don't mind the current practice environment, but I also have 3 great collaborative docs that I work with. For me personally gaining independent practice would just remove a lot of hospital credentialing red tape and make it so I don't have to hunt down providers to make sure they cosign my notes on time. The real change will be for primary care providers that want to open up shop in Iraan, Texas or other similar rural locations without the silly requirements currently in place. Ultimately, not much will change in the large urban areas that are already physician dominated, and the model won't change much there either.

All in all, the argument that hurts NP's the most is they have a lot less training and education than a physician, but lots of research shows that in practice, all the extra education doesn't translate into better outcomes. That's why there are poorly authored articles like the one you linked that have to resort to opinions and cherry picked outdated research to try and justify their claims. Unfortunately Texas has one of the largest medical associations in the country, and I doubt they every get this bit of legislation out of committee.

hogger · May 5, 2017

He does not present a very good argument. Neither side has done (questionable if they ever will) enough studies to compare all the outcomes. As part of an in house research presentation I had to do my third year of IM, we put together all of the information from np/md/do comparisons and put it on a posterboard for a presentation at a conference. The conclusion we reached (even though we just gathered data from secondary sources) was that NPs are just as good as managing the common/simple complaints, but no data was found on more complex issues. Most of the studies pretty much covered just Htn, lipids, run of the mill primary care stuff. Did have one that was very thorough and compared inpatient issues as well but the fine print at the end stated it compared physician/NP teams to physicians only, not just physicians vs NPs. There is no conclusive data either way for everything. Some of the nursing studies pump that they are as good at everything we are just by basic parameters but it does not really hit where it counts, which are more complex illness and patient's with tons of stuff going on. How anybody would put together a thorough study of everything beats me. Closest I have seen are levels of morbidity comparisons but again how does one really measure that?

I left out any personal experiences since that's null and void to the argument, but have had way more unnecessary referrals from NPs than from physicians (for GI stuff at our teaching hospital).

For anybody to state there is conclusive data for equal care in all aspects is silly, unless one can present info for every single condition out there, which probably isnt possible. But for the most common stuff, yeah, NPs can have it, it does not take 7 years post under grad to treat blood pressure and lipids. More of the complex stuff it sort of does.

allnurses Guide · May 5, 2017

Neither side has done (questionable if they ever will) enough studies to compare all the outcomes. Most of the studies pretty much covered just Htn, lipids, run of the mill primary care stuff.
For anybody to state there is conclusive data for equal care in all aspects is silly, unless one can present info for every single condition out there, which probably isnt possible. But for the most common stuff, yeah, NPs can have it, it does not take 7 years post under grad to treat blood pressure and lipids. More of the complex stuff it sort of does.

It is not possible to study every single outcome but there is also no need to study every outcome. Of course the major published studies have evaluated outcomes on hypertension, hyperlipidemia, and diabetes: not only are these diseases some of the most common chronic illnesses they are associated with (by far) the largest morbidity and mortality (as well as financial) burden on the healthcare system. There have been many studies that have looked at other outcomes in specialized settings on an international stage (you mentioned GI, and there are studies that have compared outcomes in everything from abdominal pain management to colonoscopies).

There are also a number of factors of independent practice that exist outside of outcomes data: decreasing the cost of healthcare, increasing access to healthcare, etc.

There is a growing body of evidence that supports NPs providing quality care. There is extant data that demonstrates NPs also provide cost-effective care and improve access to care. The physician argument is that NPs require oversight but I have yet to see any compelling data that has led them to that conclusion, aside from the length of schooling/training (which has some merit, but should also be demonstrated in outcomes). In most cases, NP/PAs working under collaboration/supervision of physicians essentially practice independently with very limited actual "supervision".

All medicine should be practiced collaboratively and NPs are not designed to replace physicians. The overall goal of independent NP practice is to expand access to quality and affordable healthcare. Not all NPs should practice independently and most won't but it does give experienced NPs an opportunity to open their own clinic and run their own business.

Lets all be honest here that the major issue with independent practice for NPs for most opposing physicians is a financial one.

Bluebolt · May 5, 2017

Lets all be honest here that the major issue with independent practice for NPs for most opposing physicians is a financial one.

Trust me, we all know. The physicians know, the NPs know, the RNs know, hell the server in the cafeteria knows. It's always been about ego and exclusive financial gain for MDs/DOs.

Who vehemently rips apart the idea of autonomy or independent practice of another provider without any significant research or evidence that their care is harmful to patients? Everyone believes that it's simply a 6th sense of premonition that medical school grants them and to just trust them, they know it'll be disastrous!

pro-student · May 6, 2017

I think this article actually makes the most cogent arguments I've ever heard on the issue (which is basically the only cogent argument). True NP autonomy and access to care has not been well studies or established. Rather, it's assumed that more providers means more patients will get seen. This ignores the complexity of healthcare delivery especially funding and distribution. No provider can afford to see people for free for any length of time. Most people who lack access to healthcare are not unable to get to a provider but rather unable to pay. Yes, I realize this isn't always true but most often that is the case. NP autonomy does nothing to address this issue.

Again, the author makes a good point that most providers are concentrated in urban areas and in specialties vs primary care. NPs, in general, are very similar to physicians in that they tend to want to live/work near cities and are not terribly interested in primary care. This forum is replete with posts of "can I practice in a hospital as an FNP/primary care NP" and "how do I get into X, Y, or Z specialty." As a group, I don't think NPs are any more interested in primary care than physicians it's just that we graduate much more FNP/AGNP/PNP in primary care specialties.

All that to say, I think the author entirely misses the point of NP autonomy which is able elimination unnecessary oversight. With or without collaborative practice agreements, NPs work within their scope of practice. Removing requirements for such agreements isn't going to make them stop practicing as part of the healthcare team, it's just going to mean they don't have to pay some MD to sign a paper that says they will. The NP who has a patient that is beyond his or her scope is still going to refer regardless if there is a paper on file that says they have to.

stickit34 · May 6, 2017

Thank you everyone for your response!

Pro-student, I have to agree with you on some points in that there does seem to be a pattern with NPs. I have also noticed that a majority of NPs tend to specialize, just like physicians, and most tend to serve in metropolitan and suburban areas (hence, saturation in many areas). I believe if more NPs were willing to travel to rural and under-served areas, and there were studies regarding the care provided in a full practice authority state, that it could make a solid argument for full practice authority. It will only help promote the profession more.

I also completely agree that the main reason why physicians are against full practice authority is a financial one. I can see their frustration though in regards to education and the length they take to achieve it as compared to our education, as well as a comparison of what our curriculum entails versus what theirs requires. It's easy to point and say that another's education is not enough when they don't fully understand the concept of our profession.

hogger · May 6, 2017

Overall the current supervision way is silly. I am not against it being done away with. Would really be easier not to have to worry about charts being signed for no reason. If I ever have co worker NPs in the same clinic they would have their own liability maintained by the hospital only and without my worthless sig on the chart, so if they mess up I won't be dragged to court with them for their fault. That part I am not contending with since it will more than likely happen state by state sooner or later. There are enough PCP patients for everybody at this moment and more than likely more NP will be pushed into federal funded work places anyway and the commercial patients will be shuttled to IM/FP physicians. The market will play its capitalistic game for benefit of patients. I more contend that many APCs think they can often do everything a fully trained IM physician can with less education. They maybe can the easy 80% of cases, but the other chunk requires a very deep knowledge of basic science to understand, as I have not found many APC have (some probably do, the self motivated ones). The physician control over NP practice is completely monetary due to the way it is set up to bring docs in money for signing charts. If any control at all was to be maintained it would be better done as we do with PAs where we sign off individual skills and tasks they are able to perform, but that is another story.

The way the nurses tout these studies is somewhat unethical though, since to the uneducated eye they make it seem they= physician, which is just not true and I feel for patients that are misled into that thinking. So the political and monetary sin hammer swings both says.

I also cannot leave out the note that NPs claim they are here to reduce healthcare costs, yet, many also argue for equal pay for services rendered to that of physicians. This also shows the nursing lobby has monetary motives which are at least as great as the physicians.

On a third note, was it not the nursing lobby which posted prohibitory statements against medical students whom have graduated medical school providing medical care without a residency in severely rural and underserved areas? While touting that new graduate NPs with much less training should be completely autonomous? I would pick a newly minted MD/DO over a newly minted NP any day of the week, with or without residency as one to supervise due to the magnitude of clinical hours and training required to graduate medical school (6k+ vs I think 500-1200 hours). this is another showing of unscientific thinking on the part of the nursing lobby.

But at least we do agree that its silly to have docs sign charts for no reason other than to collect a buck.

TicTok411 · May 6, 2017

Mine is a collaborative state and in such I have a physicians name on a piece of paper somewhere and that is the extent of his involvement in my practice. I know other states have "supervised" practice and I am left wondering how many or are any actually supervised. A friend of mine down south who is in a supervised state never even sees her supervising physician.

The whole supervision seems more about stamping authority or marking territory by the AMA. I get it. If I were an MD I would be 100% on their side, but I am on the NP side of the fence. However,I am not 100% on board the full autonomy argument.

NPs are being pumped out faster than jobs can be found and the main culprit are these for profit online programs. The quality of our peers has taken a dip (a big one depending on who you ask). So, I am in favor of supervision model for new graduates. Sorry, I have seen a few graduates from GetDegreeFast.Com and I would not let them watch my dog much less refer a family to them for care. But this is all just my two cents.

allnurses Guide · May 7, 2017

I think we agree on a number of points, but I do want to point out there are two sides to most of these problems. In the end its strange that the majority of NPs and PA and MDs and DOs have good professional relationships in practice and these debates simply become more complicated on the national level.

My few points:

The way the nurses tout these studies is somewhat unethical though, since to the uneducated eye they make it seem they= physician, which is just not true and I feel for patients that are misled into that thinking. So the political and monetary sin hammer swings both says.

As mentioned this is clearly a two way street: physicians arguing that NP-provided care is not only of less quality than physician care it is also dangerous to the lay public with absolutely zero data is also unethical. Ironically, physicians also argue that NPs lack the scientific background in the same breath they are ignoring a significant body of research.

I also cannot leave out the note that NPs claim they are here to reduce healthcare costs, yet, many also argue for equal pay for services rendered to that of physicians. This also shows the nursing lobby has monetary motives which are at least as great as the physicians.

I agree there is a problem here and it's a difficult one and while there are other ways to reduce the cost of healthcare while being paid the same rate. In primary care, as those working in it realize, the profit margin on that with is razor thin.

Of course lobbies have monetary motives. As far ad lobbies go: 2016 data shows the AMA at 19.4 million and the ANA at 1.7 million. The ANA is not out-lobbying the ANA on any topic especially one this financially driven.

On a third note, was it not the nursing lobby which posted prohibitory statements against medical students whom have graduated medical school providing medical care without a residency in severely rural and underserved areas?

It was actually the AAPA (physician assistant lobby) at least when this issue of "assistant physicians" came up in Missouri, joining the main opposition lead by the AMA and the ACGME.

Riburn3, BSN, MSN, APRN, NP · May 8, 2017

Here is the clinical focus data for NP's provided by the AANP.

AANP - NP Fact Sheet

Over 80% of NP's have a degree with a focus on primary care, and as you can see, a large percentage of NP's work in primary care (much more than physicians and PA's).

When I last checked, only about 10% of all new physicians and PA's were going into primary care. This is a nice chart showing the breakdown of what all physicians are doing now.

http://www.aafp.org/dam/AAFP/documents/media_center/charts-graphs/no-pricare-phys.pdf

Only 14% work in family/general practice, and another 16% work in internal medicine. It's entirely possible for physician's in both specialties to work only in acute care.

This article below talks about how a primary care shortage of physicians by 2025 is a very real threat, and one of the limiting factors is the 5-10 years it takes to train physicians, and many of them don't want to then go into a field with slim margins and long hours. What providers take less time to train and still performs competently in primary care?

Significant Primary Care, Overall Physician Shortage Predicted by 225

This article shows how only 2% of medical students consider primary care.

https://well.blogs.nytimes.com/2012/12/20/where-have-all-the-primary-care-doctors-gone/?_r=0

I could go on and on and on. The reality is the medical lobby wants to protect their financial interests, but they have this problem where no new physician wants to practice in the field themselves. It isn't worth it for them to take out between $250,000-500,000 in tuition and loans over 8 years of undergrad and medical school to land a job that will pay them less than what CRNA's are making.

I would be interested to see some data on where NP's are working in states with independent practice versus states with collaborative agreements. I would imagine when your state requires you to be tethered to a physician, and the majority of physicians work in specialties, it makes sense that more APRN's in those states work in specialties as well. It's hard to blame NP's in these states for "choosing" specialties when there isn't much of a choice to begin with.