Physicians, Nurses Continue Primary Care Debate

Cheryl Clark, December 23, 2010

Two Perspective articles in the New England Journal of Medicine fan the flames of discord about whether scope-of practice should be expanded for nurse practitioners in the face of a primary care physician shortage, especially in rural areas.

Predictably, nursing groups are for the expansion. But some organized physician groups, such as the American Medical Association, have been opposed.

"Although nurses are critical to the healthcare team, there is no substitute for a physician's education and training," American Medical Association President Cecil B. Wilson, MD wrote in a letter. In states that allow nurses to practice without physician supervision, "physicians and nurses continue to work in the same urban areas, so increasing the independent practice of nurses has not helped to resolve the problem of shortages in rural areas," he wrote.

The first Perspective article is co-authored by University of Miami president Donna Shalala and others at the University of Pennsylvania School of Nursing and the Robert Wood Johnson Foundation Initiative on the Future of Nursing. 

It points to the wide state-by-state disparity in what nurse practitioners and advanced practice nurses are allowed to do, with or without physician supervision.

"This variance appears not to be correlated with performance on any measure of quality or safety," the authors write. "There are no data to suggest that nurse practitioners in states that impose greater restrictions on their practice provide safer and better care than those in less restrictive states or that the role of physicians in less restrictive states has changed or deteriorated."

The authors wrote, "If we are to bridge the gap in primary care and establish new approaches to care delivery, all healthcare providers must be permitted to practice to the fullest extent of their knowledge and competence," they wrote. "This will require establishing a standardized and broadened scope of practice for advanced-practice registered nurses – in particular nurse practitioners – for all states."

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