Nursing groups across the country are pursuing legislation that would allow them to practice without a doctor's supervision.
According to a recent report in the Washington Post, the new guidelines being proposed would allow for "tens of thousands of nurses to set up primary-care practices that would be virtually indistinguishable from those run by doctors."
THE TAKEAWAY: Nurses say they can and should cover most primary-care needs; a doctor differs.
Our nurse guests, Angela Golden and Mary Chesney, stressed that they and their non-physician colleagues already carry a lot of the weight in health clinics, and that they are well prepared to do it.
"I think what's important for the public to know is that every day, advanced practice registered nurses are making those decisions — deciding on drugs, the dosages, what they're going to do," Chesney said. "And that part of the practice is not supervised."
Golden said the country can look to states where nurses already practice independently: "The key here is to remove barriers so that patients have access to a quality health care provider. And in 16 states, that already happens. Our physician colleagues will say they are saying 'no' for safety issues, but we know from those 16 states that safety is not the issue ... the evidence clearly shows that we provide good quality, safe, effective care for those patients across the United States."
Golden and Chesney objected to rules that require them to have a signed agreement with a physician, outlining a commitment to consult in situations where they would consult anyway. "Right now, in Minnesota we have tremendous shortages, for example, in [psychiatric] mental health treatment," Chesney said. "We have psych mental health nurse practitioners and clinical nurse specialists who are scattered across Minnesota and who could be prescribing and managing psychotropic medication for patients ... in their own practice." Instead, such practitioners have to pay fees to physicians to get their signature on consulting agreements.
"Why would a family nurse practitioner need a piece of paper when a family physician does not?" asked Golden. "A family physician is delivering babies and is expected professionally to go to their obstetrician colleagues if there's a problem, yet nobody expects them to have a piece of paper stuffed in a drawer to do that professional piece for good patient care. And that's really all we're asking for."
But another guest, Dr. Julie Anderson, said the consulting agreement "goes beyond the piece of paper."
"Physicians have realized for a while now that we can't practice alone," she said. "It takes a team approach. It's really important to focus on coordinating our care with each other."
Anderson said the different members of that team should concentrate on their own strengths. "Our nurse practitioners have the time to meet with patients about prenatal counseling," she said. "They have time to educate our patients on diabetes management, more time than I can dedicate ... That is where they shine. In order for us to all work together, we need to focus on our areas of expertise.
"All of us should be collaborating with each other. ... Family physicians have many agreements with their obstetricians, just like a midwife."
A caller named Rhonda identified herself as a family nurse practitioner at the University of Minnesota and said she wanted to clear up misconconceptions about the levels of training required for doctors and nurse practitioners.
"It's really frustrating for me when I listen to these discussions involving advanced practice nurses and physicians," she said, "because the education of advanced practice registered nurses is always so downplayed by physicians. ... Before you become an APRN you have to have worked as a registered nurse, and that experience is also invaluable. And you're constantly hearing physicians talk about, 'Oh, we have 15,000 hours of training, and APRNs only have a master's degree and 500 to 1,500 hours of training,' when in fact this is not the case. And when you look at physicians who come from other countries, many of them don't have that undergrad degree before they go into medical school. They graduate medical school after four years and then they do a three-year residency training. If we're really comparing hours to hours as far as education is concerned, the argument is inaccurate."
Dr. Anderson countered, "I train a lot of the nurse practitioners from the local schools here in Minnesota, and they do heavily rely on us physicians training them ... We're trained to recognize what's normal when a patient comes in, and what's not normal. ... I spend a lot of my day working with our P.A.s and our nurse practitioners and helping them with those difficult cases.
"That's where our training, I guess, differs. We know what's normal and what's not, and when to refer and when not to refer."
• Nurse Practitioners, Doctors in Tug-of-War Over Patients. "The U.S. faces a shortage of more than 13,000 physicians, a gap expected to grow to 130,000 by 2025, according to the Association of American Medical Colleges. That could leave 7 million Americans living in areas without enough primary-care doctors." (Bloomberg BusinessWeek)
• Amid Doctor Shortage, Hospitals Turn To Dwindling Supply Of Nurses, Physician Assistants. Clinics are working to figure out how to help patients that will now be insured under the Affordable Care Act. (Forbes)
• When the Nurse Wants to Be Called 'Doctor.' As more nurses are going back to school for a doctoral degree, doctors are fighting for their title back. (New York Times)
• The Family Doctor, Minus the M.D. A look at one clinic that employs nurse practitioners instead of doctors. (New York Times)