Family Physicians Rap 'Stopgap' Use of Nurse Practitioners

A report that warns against "stop-gap" substitutions of nurse practitioners for primary care physicians may have rekindled the long-smoldering border skirmish between the clinician associations.

The report, Primary Care for the 21st Century, was issued this month by the American Academy of Family Physicians, and reaffirms its support of physician-led, patient-centered medical homes as the best method of transforming primary care delivery.

In sharp contrast, the AAFP says advocating "independent practice by a single health professional," namely nurse practitioners in place of physicians, "flies in the face" of studies supporting the cost-effectiveness and quality outcomes of the physician-led care team approach.

"We are not trained to do the same things, so to imply that one can substitute for the other is just incorrect," Roland Goertz, MD, chair of the AAFP Board of Directors, told HealthLeaders Media. "The educational backgrounds are different. Even nursing leadership says 'we are not trying to be doctors,' but policy setters tend to simplify things, which is a kind way of saying it."

Goertz says physicians are also concerned that the public could be "easily confused" if caregivers aren't transparent about their roles and scope of practice. "If you ask a patient when they went in for care and they saw someone with a white coat, the vast majority of the time they're going to think it was a physician that provided the care," he says.

"You have to be clear about who is providing care and what the training is that has substantiated that ability to provide that care. Our organization has nothing against creativity and entrepreneurism in the delivery model but we believe you have to be careful when changing abilities and skills and knowledge without understanding that there is a huge difference between the training models."

Goertz says the intent of the report is not to restart the long-running scope-of-practice debate with nurses' associations but he also acknowledged that the report would do exactly that.

"What tends to happen is it becomes you are warring with the nurses again,'" he says. "That is not the point of the report. The point is we have a better model that uses everybody appropriately and the proof is in the model."

Lisa Summers, CNM, a senior policy fellow, at the American Nurses Association, told HealthLeaders Media there is "a basic level of agreement" with the AAFP on the increased need to shift focus away from the costly and inefficient illness care model and toward primary care and preventive medicine.

Beyond that she says is "where the contention comes in."

"I have mixed feelings when reports like this come out," she says. "The bottom-line feeling at the ANA is that these turf battles that these kinds of reports turn into don't do a lot to benefit moving ahead the agenda of coordinating care, a shared goal of providing the best care for patients. That is our focus: How do we build truly integrated teams that keep the patient at the center of focus?"

Summers says that organizations and stakeholders as varied as the Joint Commission and AARP have for several years developed accrediting guidelines and policy statements addressing access to primary care that refer more broadly to the role of "clinicians" and move away from the physician focus.

"What this report points out to me is that it is a continued effort by organized medicine to preserve the status quo by focusing on physicians," she says. "Folks are beginning to reject this antiquated notion that they only way to deliver high-quality, patient-focused care is to have this captain-of-the-ship model."

Summers also takes "exception" with the report's contention that the shortage of primary care physicians is the primary driver for independent practice for nurse practitioners. 

"That certainly is part of what is driving the discussion, but all kinds of health policy think tanks have come out in the last couple of years with policy statements supporting the need to remove barriers for advance practice registered nurses," she says.

"So what is behind those proposals and that support isn't just the shortage. It's the fact that there are decades of evidence to support the safety and quality of care by nurse practitioners and other advanced practice nurses."

"People are beginning to realize that the restrictions we have now on autonomous practice don't do anything to increase the quality of care. We know they impair access. They lead to duplication of services. Once you slow down and duplicate services, you start increasing healthcare costs."

Summers says the scope-of-practice debate will always be around and continually evolving, and not just for doctors and nurses, but for all clinicians.  "No intelligent healthcare professional practices 'independently' in the way they are suggesting in this report," she says.

"We talk about independent practice as the ability and responsibility of any provider to use the knowledge skills judgment and authority that they have to practice to the full extent of their licensure and education. That is true about anybody, registered nurses, psychologists, pharmacists. This report sets up a false dichotomy between team-based care and APRN's practicing 'without a physician on staff.' "

"That is an odd way to frame it, because when we talk about meeting the needs of patients, anybody who has experienced the healthcare system realizes there is no one individual provider who can do everything a patient needs."

Summers says nurse practitioners are well equipped to provide primary and preventive care and manage chronic diseases and when the needs of the patients fall outside of their expertise they will refer to a physician, just like a family physician will refer patients to a specialist.

"It no more reasonable to talk about APRNs practicing without a physician on staff than it would be to talk about a family physician practicing without a cardiologist on staff," she says.

Goertz says much of the tension in the scope-of-practice debate is found at the 20,000-foot-level between rival policymakers, and not at the point of care delivery, where "you have these understandings in place."

"If you are talking about on-the-ground activity where the teams are taking care of patients, there is not a lot of contentiousness about this. Everybody understands the patient is the focus of attention. In the actual act of delivering care, I don't see a line-in-the-sand problem," he says.

"Where I see it is in the higher level of leaders of some nursing schools who want to essentially change the model of care delivery and they have already succeeded in doing that to a certain extent. Our issue is that there is not one single profession that can solve this problem. We all need to work together and the patient-centered medical home is a far better model than simply expanding nurse practitioners."

That is all we are trying to say. Since there is a difference in education and training, we need to honor those differences and work within them."