Should NPs become COMPLETELY independent?

[BS, NP]

wow....there are some well-informed folks on here.....yeah...no one should be downplaying another profession......that doesn't help.....I think it is truly a semantic debate here....be it DOCTOR is a professional title but we all know a euphymysm for a medical caregiver.......who here has not been called 'doc' by your patients???...but....who should be called physicians?? some seem to think we should.....well, if we're arguing for rights as advanced practice nurses why would we WANT to be called a physician....we have to be careful what we are asking for here....it is becoming a slippery slope.....we may lose the support of those who are well established and on our sides....we are NOT physicians....some NPs argue that doctors of chiropractic and optometry carry the title physician while they don't fully care for the entire patient in the same medical manner.........let the non allopathic and osteopathic practitioners of optometry and chiropractic have the title I suppose....traditionally they always have.....fighting for the same or similar RIGHTS is a different story....

I've been giving it alot of thought and really trying to see the big picture......people are getting so hung up on titles and credentials and wording and program curricula......arguing who's better a PA...an NP.....a physician...??? I used to have the theory that if you took an NP, a PA and a physician right out of school.....I think the physician is hands down more prepared, more skilled, more educated.......but, 10 years 15 years down the road....how much does experience and insight and continued learning and study develop each practitioner? could the PA end up being the brightest and most informed and best medical decision maker...?? yes, I think so....could it be the physician, the NP? sure.....doesn't it depend on all kinds of factors that take priority after education? drive? ability to integrate knowledge and medical literature? experiential and acuity exposure in practice? etc...etc.....

I think the definition on this site sums it up well........ A Nurse Practitioner (NP) is a registered nurse with advanced academic and clinical experience in diagnosing and managing most common acute and chronic illnesses either independently or in collaboration with a physician.

we just want to do what we are doing and be who we are and be rightfully recognized and legitimized for it, no???

no we don't have the same training as physicians.....could we safely take on the primary care needs of the population.......sure.....I think we could..........aren't we pretty much doing that now.....as it is....???? won't we still call on our physician and NP and PA colleagues for insight and expertise and experience when ours falls short.....???? yes...I think we will.......

I guess I kind of enjoy basically being independent and still legal having an attachment to a physician who in many cases knows more than I do......

I guess I don't need to be able to say I'M INDEPENDENT to boost my ego.......while some seem to have that need.....

I've heard some folks make a few decent arguments as to why dissolve of collaborative practice agreements is a good and/or founded thing......such as: a rightful move based on our experience and quality and scope of practice; would free up care for those who have independent clinics should something happen to their physician supervisor (death or move or stop practicing)

I guess the facts are coming in and I'm still on the fence......

can anyone else offer other reasons for why this move is so necessary or deserved....???? thanks........

[Sugah Britches]

Apologies to the OP, this thread has been side tracked!

To answer your question... I don't know. With the current agreements as they are, a majority of NPs are already practicing independently. Most collaborative agreements require a retro chart review, this may good for PI but it doesn't provide the security net that many think is necessary. I believe it was Elkpark that referred to it as a Fig Leaf... great analogy.

[core0]

Apologies to the OP, this thread has been side tracked!

To answer your question... I don't know. With the current agreements as they are, a majority of NPs are already practicing independently. Most collaborative agreements require a retro chart review, this may good for PI but it doesn't provide the security net that many think is necessary. I believe it was Elkpark that referred to it as a Fig Leaf... great analogy.

The other thing that a collaborative agreement provides is a defined resource. If the problem is outside of the scope of practice then there is a defined avenue to address the issue. Without a collaborative agreement the NP either has to try to get someone who does not have any formal agreement to act as a resource or send the patient to the ER. Collaborative agreements are a two way street.

David Carpenter, PA-C

[Jstand]

The other thing that a collaborative agreement provides is a defined resource. If the problem is outside of the scope of practice then there is a defined avenue to address the issue. Without a collaborative agreement the NP either has to try to get someone who does not have any formal agreement to act as a resource or send the patient to the ER. Collaborative agreements are a two way street.

David Carpenter, PA-C

This implies that every primary care provider would need a collaborative agreement with any specialist that one of their patients might need, doesn't it? They are constantly encountering problems that are outside of their scope of practice. Does this mean that a "defined resource" is needed for every such problem that might be encountered?

[jjjoy, LPN]

Hmmm...

on the one hand, I'm tempted to say "Most NP programs provide/require less depth of knowledge of biochemisty, anatomy and more so why should they have the same level of independence? If you want all of the priviledges of being a medical doctor, then get your MD!" But then I remember I was surprised when I discovered many years ago that private school teachers aren't required to obtain a state teaching credential. And that you don't need to be a psychologist, you could be a LCSW, to indepedently practice and be reimbursed by insurance for psychotherapy. Professional regulation is ever changing.

[Jstand]

Hmmm...

on the one hand, I'm tempted to say "Most NP programs provide/require less depth of knowledge of biochemisty, anatomy and more so why should they have the same level of independence? If you want all of the priviledges of being a medical doctor, then get your MD!" But then I remember I was surprised when I discovered many years ago that private school teachers aren't required to obtain a state teaching credential. And that you don't need to be a psychologist, you could be a LCSW, to indepedently practice and be reimbursed by insurance for psychotherapy. Professional regulation is ever changing.

I don't think that any NPs are asking for all of the priveleges of being a medical doctor. They simply want to be able to practice within their scope without their career being controlled by a medical doctor. You might say that there is some overlap between the two, and I suppose that there is. The problem is that physicians have a predetermined way of thinking about his and therein lies their hangup. They think that this is territorial infringement. I see absolutely no reason not to think outside the box on this one and give NPs the right to practice independently from physicians nationwide. Competition always improves quality and price and it typically gives people a wider range of options. There is no reason that these capitalist principles can't work in this scenario. I find it ever more comical that primary care physicians tell us what short supply they are in on the one hand, and then they continually tell us that it is unfair for NPs to be allowed to practice independently because they aren't competent to do so. Am I the only one that sees the fallacy in this argument? If someone isn't competent, they why on earth would you fear their competition?

[Spacklehead, MSN, NP]

If someone isn't competent, they why on earth would you fear their competition?

Now don't be silly, it's not about them feeling that NPs are competition for them - it's the fear that we won't take care of our patients' health concerns properly.

[AbeFrohman, BSN, RN]

This implies that every primary care provider would need a collaborative agreement with any specialist that one of their patients might need, doesn't it? They are constantly encountering problems that are outside of their scope of practice. Does this mean that a "defined resource" is needed for every such problem that might be encountered?

It doesn't imply that because legally, a physician has unlimited scope of practice. A family doc can do heart surgery if he wanted, but don't because it's outside their expertise, a hospital wouldn't credential them to do so, and BCBS won't pay for it unless you did a residency in it in some cases. But this is how FP and IM docs can work in EM in rural areas and why some FP docs also do c sections ( very rare but doable).

Look up a MD scope of practice, they allowed to practice anything under medicine the same way a PA can practice anything their SP does without additional training because they are both trained as generalist first, whereas a NP is not.

But I see your point and MDs do get consults all the time. It's easier for them I believe, however, because they know a guy they went to school with who is a cardiologist now or have some other connection. But they rarely have to consult docs within their specialty because they have more training/experience than the NP, who might just need a little reassurance they are doing the right thing because they haven't done it 100 times like the MD has. The MD needed just as much help probably when they were an intern or PGY2.

This is why I like the Maine model where independent practice is granted after a period of supervised practice. The NP won't always need that crutch.

[Jstand]

It doesn't imply that because legally, a physician has unlimited scope of practice. A family doc can do heart surgery if he wanted, but don't because it's outside their expertise, a hospital wouldn't credential them to do so, and BCBS won't pay for it unless you did a residency in it in some cases. But this is how FP and IM docs can work in EM in rural areas and why some FP docs also do c sections ( very rare but doable).

Look up a MD scope of practice, they allowed to practice anything under medicine the same way a PA can practice anything their SP does without additional training because they are both trained as generalist first, whereas a NP is not.

But I see your point and MDs do get consults all the time. It's easier for them I believe, however, because they know a guy they went to school with who is a cardiologist now or have some other connection. But they rarely have to consult docs within their specialty because they have more training/experience than the NP, who might just need a little reassurance they are doing the right thing because they haven't done it 100 times like the MD has. The MD needed just as much help probably when they were an intern or PGY2.

This is why I like the Maine model where independent practice is granted after a period of supervised practice. The NP won't always need that crutch.

I agree with you that having an experience requirement is a great model, but I do believe that the semantics applies to your comparison of scope of practice to expertise. The legality of it is really irrelevant. The legalities are all self imposed licensing statutes. A PCP simply isn't qualified to do heart surgery so whether they are legally allowed to is irrelevant. You seem to make your argument based on an inexperience NP as well. I would say that experienced NPs rarely have to consult within their scope of practice which equals specialty for the MD.

[Jstand]

Now don't be silly, it's not about them feeling that NPs are competition for them - it's the fear that we won't take care of our patients' health concerns properly.

How silly of me, you must be right. They wouldn't put money ahead of their patients' health concerns now, would they?

[BS, NP]

Yes it is semantics but it is in the semantics that confusion and misunderstanding occurs.... A physician is a Doctor of Medicine...

Can a nurse be a physician? NO.. not unless they attend and graduate medical school

Can a nurse be a Doctor? Yes.. The field of medicine does not solely own the distinction of Doctor... I know numerous PhDs and Doctorates that would be offended at the notion a physician is the only one worthy of being called Dr.

I know that it sounds petty but clarity is necessary for effective collaboration and communication.

no...it doesn't sound petty....I agree with you totally and hope I made that point.....anyone who achieves doctoral education deserves that title......just as any physician (only) who works that hard to complete medical school should be the sole carrier of the title physician.......you're right.....the only way to be a physician is to go to med school.....

[BS, NP]

The problem is though, just because you think you could safely provide primary care doesn't necessarily mean you actually can. Like wowza mentioned, there are no well-done long term studies looking at this data (and these types of studies are essential in the field of primary care where it's usually chronic long-term conditions that are managed and performing a 6-month study, for example, is almost as useless as doing no study at all). There just isn't any valid data suggesting that NPs/DNPs provide care equivalent to that provided by a board-certified attending. Evidence-based decisions don't usually occur in politics though.

do me a favor and don't take my quotes out of context......I was trying to have an honest and thoughtful post here......and clearly outlined some differences between NPs and physicians.......I don't appreciate your condescending remarks.....you dgenthusiast, among others never have anything positive to say about NPs.....I'm not vouching for independence.......but, clearly you don't know anything about the multitude of studies that HAVE in fact ranked NP care right up there with physicians in quality, safety and efficiency......(in PRIMARY CARE)......not sure what journals you're reading.....aside from studies.....do you work with any NPs or PAs.....what is your experience with their care?

[BS, NP]

Simple answer to the question of whether NPs should become completely independent: No. But that's not how politics works. I believe there are a number of states that already allow independent practice though, from what I understand, from the population of NPs, it's very few that practice independently without any physician oversight (correct me if I'm wrong about that).

no, I believe you are correct....not many practicing independently........but, why do you have such a problem with this when those who have been practicing independently have shown no decline in safety and no increases in malpractice premiums....is this not evidence of good practice...?