Physicians' Stance on Nurse Practitioners is Dangerous

The Hatfields and the McCoys. East Coast hip hop artists and West Coast hip hop artists. The Red Sox and the Yankees.

Perhaps it's time to add physicians and advanced practice registered nurses to the list of history's longstanding, heated rivalries.

The American Academy of Family Physicians released a report last week arguing that despite the primary care shortage in the United States, "substituting NPs for doctors cannot be the answer. Nurse practitioners are not doctors, and responsible leaders of nursing acknowledge this fact."

Of course, the American Academy of Nurse Practitioners immediately fired back, saying that "the ongoing attempts by the AAFP to limit the ability of NPs to practice to the full extent of their education and training only serves to increase the already overwhelming hardships placed on millions of Americans who are struggling to gain access to high quality healthcare."

If all of this sounds familiar, that's because it is. It's the old he-said-she-said argument that keeps raging, despite the fact that a growing number of states allow for licensure of independent nurse practitioners, despite the fact that organizations from the National Center for Policy Analysis to the Institute of Medicine have called for the expansion of APRN's scope of practice.

But what makes this report a little different—and maybe a little dangerous—is that it puts forth the idea that nurse practitioners provide second-rate care.

"The interests of patients are best served when their care is provided by a physician or through an integrated practice supervised directly by a physician," report says. "We must not compromise quality for any American, and we don't have to."

"The subtext is 'don't get fooled,'" into getting second-class care, Lisa Summers, CNM, DrPH, a senior policy fellow at the American Nurses Association, told me. "The thing that bothers me about that is that it feeds into this [idea that] there are two classes of care."

She says she finds such a position odd, considering that so many AAFP members "work in practices that depend very heavily on nurse practitioners to provide primary care."

Personal anecdote time: I've been going to the same primary care practice for many years, and I have seen the supervising physician exactly once. I have never felt like my healthcare was compromised. My three-year-old daughter, who has several complex medical issues, most often sees an NP for her primary care visits.

When something has been outside their scope of expertise, every one of them—without hesitation—has referred my daughter or me to the proper specialist.  Of course they do. That's the function of primary care.

So, why would the AAFP suggest otherwise? I wouldn't expect my primary care physician or the PA that I usually (and prefer) to see to perform surgery, and I trust any member of our care team to make appropriate referrals.

Summers says the AAFP paints the picture that because APRNs didn't go to medical school, they'd miss something. But what if the opposite were true? Nurses are "so well-versed in the normal and evaluate so thoroughly" that they may be especially attuned to atypical symptoms, Summers says.

And they're so used to being part of a team that they don't hesitate to refer care to a specialist. Moreover, I have yet to hear about epidemics of patients who have been harmed by second-rate care by APRNs.

But ultimately, making arguments about "who does it better" is also counterproductive. That's because with the move toward ACOs and patient-centered medical homes, team-based care is fast becoming a way of life. And although the AAFP report ostensibly calls for team-based care (with physicians in the lead, of course), it doesn't seem very useful to suggest that some members of that team aren't up to snuff.

"If we're really going to shift to this team-based care," Summers says, "it's unfair to the public to write these sorts of things that call into question the skills and capabilities of any member of the healthcare team."