Ok TEXAS NP's, wake up and smell the coffee!!!

MikeFNPC, MSN · Feb 8, 2019

Example letter that anyone (MD, DO, PA, NP, person in general from any state) can send to [email protected].

Texas Medical Board,

I am licensed as a nurse practitioner (APRN) in Texas, and I oppose the Texas Medical Board adopting rule 193.21 as published in the Texas Register on January 25, 2019.

This rule would severely limit the practice of APRNs who have safely and regularly read and interpreted radiologic studies, and also diagnose and treat patients based upon these radiologic studies. It also unfairly restricts physicians who wish to delegate this ability to APRNs they trust and work with daily in order to provide the best team-based care possible. For example, in my practice, the clinic is in a rural community, it’s myself and an MD. Regularly, the MD takes 2 weeks off for CME and vacation. During that 2 weeks, this is a sole NP clinic. We have x-ray at the clinic, and do several a week. Not only does this ability prevent unnecessary hospital and ER visits, but it provides urgent/emergent treatment to be initiated without delay. If this rule passes, then I can assure the TMB that the Texas residence of this community will suffer not only delay of care but feasibly even death especially in the case of acute heart failure, bowel obstruction, and pneumonia.

There is no evidence that APRNs who read, interpret and diagnose medical conditions based upon radiologic studies has resulted in increased danger to Texas patients. Imposing arbitrary and punitive regulatory restrictions on the physicians I work with and at the same time restricting my role on the health care team will disrupt the lives of the patients I care for every day.

I beseech the Texas Medical Board to reject rule 193.21 for the good of all Texas patients.

Respectfully,

Michael Ryan MSN, APRN, FNP-C

djmatte, ADN, MSN, RN, NP · Feb 8, 2019

Looks good, but I would proof read some of it for grammar before sending.

Jory, MSN, APRN, CNM · Feb 11, 2019

CNMs can get an ultrasound certification. This includes interpretation limited to their patient population. If you have a certification vs no certification, I don't see how that would apply.

In terms of mammograms and other imaging? Who would not wait for a report?

Jory, MSN, APRN, CNM · Feb 11, 2019

On 2/8/2019 at 1:31 PM, MikeFNPC said:
For example, in my practice, the clinic is in a rural community, it’s myself and an MD. Regularly, the MD takes 2 weeks off for CME and vacation. During that 2 weeks, this is a sole NP clinic. We have x-ray at the clinic, and do several a week. Not only does this ability prevent unnecessary hospital and ER visits, but it provides urgent/emergent treatment to be initiated without delay. If this rule passes, then I can assure the TMB that the Texas residence of this community will suffer not only delay of care but feasibly even death especially in the case of acute heart failure, bowel obstruction, and pneumonia.

I live in a rural community as well, not every primary care office here has x-ray technology in house and they send all of those patients to the ER to be evaluated...the PHYSICIANS send them...if acute heart failure, bowel obstruction, and pneumonia is suspected, they need to be sent to the ER anyway. You are not going to be treating any of those in the office.

I can see the point of this decision...did you receive imaging interpretation as part of your education/clinicals and were you tested on this material on your boards? Do you have a certification to do so? If not..well...not a good idea.

Hotcorner17 · Mar 13, 2019

Just curious, why do NPs think they are appropriately trained to interpret radiologic studies? Physicians spend 5+ years after medical school focused on learning the very complicated interpretation of medical imaging. And do not fall for, “I only read x-rays” line. Any radiologist will tell you a chest radiograph is extremely difficult to read accurately. How many pulmonary nodules are missed that turn in to malignancy? How many metastatic bone lesions or myeloma are missed on routine xrays for limb pain? How many subtle findings are missed? For example, on a wrist radiograph are NPs comfortable distinguishing cppd, rheumatoid, gout, slac arthrosis, disi vs visi alignment, sl widening, lunate impaction vs abutment, etc, etc. The access to care argument falls on its face in modern times. All imaging is available to have formal interpretations in minutes time with pacs systems. It is a major disservice to your patients.

babyNP., APRN · Mar 13, 2019

^^I see this is your first post, welcome to allnurses. Are you a NP?

To answer the question about NPs interpreting xrays, it depends on your training. In my 10 years of experience (6 as RN, 4 as NP) in the NICU, I've been viewing xrays and going to xray rounds at 5 large academic centers.

I now work at a community hospital and I am floored at the radiology reads sometimes. I once had a radiologist write that the respiratory diagnosis was possibly 1 of 5 different things...I think the radiologist was just listing off every respiratory disease in the newborn! I would never claim to know what a radiologist knows. But I can and do interpret xrays at my job.

djmatte, ADN, MSN, RN, NP · Mar 13, 2019

1 hour ago, Hotcorner17 said:
Physicians spend 5+ years after medical school focused on learning the very complicated interpretation of medical imaging.

All physicians? Or radiologists? Because last I checked, the years offer med school are dedicated to some form of specialty which may involve imaging involving that specific area, but far from anything more broad in scope.

Hotcorner17 · Mar 13, 2019

10 hours ago, babyNP. said:
^^I see this is your first post, welcome to allnurses. Are you a NP?
To answer the question about NPs interpreting xrays, it depends on your training. In my 10 years of experience (6 as RN, 4 as NP) in the NICU, I've been viewing xrays and going to xray rounds at 5 large academic centers.
I now work at a community hospital and I am floored at the radiology reads sometimes. I once had a radiologist write that the respiratory diagnosis was possibly 1 of 5 different things...I think the radiologist was just listing off every respiratory disease in the newborn! I would never claim to know what a radiologist knows. But I can and do interpret xrays at my job.

First, your conflating your years of experience to those of a new np grad. It sounds as if you may have some good experience but that in no way means all nps out of training are anyway prepared to read diagnostic studies. Not to mention the bill does not limit the scope to xrays.

Second, I am sorry you experienced poor reads. However, anecdotal stories really have no place in determining policy. I am sure many have experienced subpar care from np and physician providers. The question is simply does np training have sufficient education to support the policy of allowing radiological interpretations? The answer is very clear they are vastly inexperienced compared to a radiologist and really is no good reason for it with modern remote interpretations available reliably and quickly. Lets put it this way, if you have brain mri do you want your neurologists np reading it or the radiologist who reads 50-100 mri a day?

Hotcorner17 · Mar 13, 2019

2 hours ago, Hotcorner17 said:
First, your conflating your years of experience to those of a new np grad. It sounds as if you may have some good experience but that in no way means all nps out of training are anyway prepared to read diagnostic studies. Not to mention the bill does not limit the scope to xrays.
Second, I am sorry you experienced poor reads. However, anecdotal stories really have no place in determining policy. I am sure many have experienced subpar care from np and physician providers. The question is simply does np training have sufficient education to support the policy of allowing radiological interpretations? The answer is very clear they are vastly inexperienced compared to a radiologist and really is no good reason for it with modern remote interpretations available reliably and quickly. Lets put it this way, if you have brain mri do you want your neurologists np reading it or the neuroradiologist who reads 50-100 brain mri a day?

babyNP., APRN · Mar 13, 2019

3 hours ago, Hotcorner17 said:
First, your conflating your years of experience to those of a new np grad. It sounds as if you may have some good experience but that in no way means all nps out of training are anyway prepared to read diagnostic studies. Not to mention the bill does not limit the scope to xrays.
Second, I am sorry you experienced poor reads. However, anecdotal stories really have no place in determining policy. I am sure many have experienced subpar care from np and physician providers. The question is simply does np training have sufficient education to support the policy of allowing radiological interpretations? The answer is very clear they are vastly inexperienced compared to a radiologist and really is no good reason for it with modern remote interpretations available reliably and quickly. Lets put it this way, if you have brain mri do you want your neurologists np reading it or the radiologist who reads 50-100 mri a day?

Like I said, it depends on your training. I don't think that a new grad NP should necessarily be given full reigns to interpret/diagnose xrays without backup. And you're right that not all NPs have the same training- perhaps there should be some sort of certification.

In regards to your analogy about brain MRIs, that's an extreme example. I can't picture a NP with lack of training (or even with training) to read a brain MRI and have no other backup and write a report. We're talking about rural medicine for a fractured bone or diagnosing pneumonia. Are you really going to make a patient drive 3 hours to get to a doctor? I don't think many folks would even mind restricting interpretation to xrays only and leaving higher diagnostic imaging to a higher level (although I could be wrong).

What is your background?

Hotcorner17 · Mar 13, 2019

Why would someone need to drive 3hrs? Clearly they don’t have to take their xrays to a radiologist in person. A rural NP can certainly order imaging studies and then be read remotely. There is simply no reason for someone not formally trained, boarded and continually tested to read imaging cases with availability of remote interpretations. Again, I can only imagine how many subtle findings are missed by someone not formally trained to read these cases. Or even not so subtle findings misinterpreted. Mass treated as pneumonia, missed rib lesions, pathologic fractures missed on limb cases.

Ok TEXAS NP's, wake up and smell the coffee!!!

Comments on Rule §193.21 can be emailed to [email protected] or mailed to Ms. Rita Chapin to P.O. Box 2018, Austin,Texas, 78768-2018. Comments are effectively due on February 22. Earliest date of adoption of this rule is February 24.