Lay Down Your Weapons

Tracy_Cardin_NP

Maybe it’s the way I was raised, to be polite and sensitive to others; I am a southern girl in so many ways, but I have been a southern expat for some time now weaned on Midwestern practicality.

Recently the Nurse Practitioners Modernization Act was introduced in New York. As of January 1st, this law will allow nurse practitioners (NPs) with greater than 3,600 hours of experience to practice without a written practice agreement with a supervising physician. Seventeen states currently have no collaborative practice requirements with physicians. The idea behind this type of legislation is to improve or promote healthcare access for patients who may otherwise not be able to see a physician. The requirements are often viewed as a barrier to practice, as well as a disincentive to registered nurses (RNs) who otherwise would be motivated to pursue advanced certification. NPs easily argue that having to have a physician collaborator often limits their ability to provide care in rural or underserved areas where physicians are unavailable. Furthermore, NPs point out that collaborative agreements do nothing to ensure quality care, nor enhance their skills or expertise as providers.

Naturally physician groups feel differently. They argue that granting more independence and less documented supervision won’t increase access because NPs and physician assistants (PAs) are no more likely to practice in underserved areas than doctors. Multiple physician groups, but most notably the American Medical Association (AMA), have a long history of obstructing NP advancement. The Sheppard-Towner Maternity and Infancy Act of 1921 was the first federal legislation passed to provide public funds for maternal and child health programs. Part of this act provided money to public health nurses in midwifery. This bill expired in 1929 after major opposition from the AMA, advocating for an establishment of a single standard in obstetrical care.

This opposition has continued on a regular basis. For example, in 1993, the AMA publicly questioned the qualifications of APNs, claiming that these providers are not qualified by their education or training to practice independently or to be the first point of contact for patient’s health care needs. The AMA believes that all patients require that a physician be responsible for the overall care. After much legislative effort on the part of several national nursing organizations, advanced practice nurses (APNs) became Medicare providers in 1998. In 2000, the AMA put forward the Citizen’s Petition in an American Medical Society attempt to put constraints on APNs that received reimbursement from Medicare. This petition to the Health Care Financing Administration (HCFA) was endorsed by 49 physician groups and asserted that HCFA never issued its carriers any guidelines for physician-APN collaboration that would ensure that NPs and certified nurse specialists (CNSs) did not provide care outside their scopes. And the AMA has continued their long history of opposition by rejecting the designation of Doctor of Nursing Practice for nurse practitioners as they feel that the title of “Doctor” could be confusing to patients.

So who is right? Are NP/PA providers “dumbing down medicine” as one ill-mannered but spirited heckler noted at my recent SHM chapter event? Or are we the next most necessary building block in safe, effective care for the millions of people who need it? 63% of hospitalist groups employ NP/PAs in their practice. They surely do this for positive reasons. It won’t make me popular, but I think both extremes of position are short sighted and provide barriers to the care we deliver. I personally understand why an APN would want to get rid of a collaborative practice agreement, as I don’t think this agreement enhances my practice, or changes the care I deliver in any conceivable way. However, at the same time, I don’t feel like I would be comfortable, in an inpatient environment, never having a physician available to consult. If there are no physicians available because of access then I think an APN or a PA is a fabulous, quality option.

Furthermore, I think it’s ridiculous that a physician has to be “responsible” for the overall care of every patient. There are a variety of patient populations, both inpatient and outpatient, who would derive superior benefit from having an NP/PA deliver, and yes, direct their care.

So what about the patient? Always they are the first casualty in these wars of ideology. Patients benefit from having multiple types of providers who collaborate in their care. I know for certain that I bring something special to the care of a patient that a physician may not have. Conversely I often feel a physician brings a perspective that I lack. Does a patient benefit if I disparage a physician for being cavalier in his attention to detail? Or when a physician implies the NP or PA might not be competent in their ministrations? No. NO. This erodes an already fragile relationship with patients, who are vulnerable to fears both real and imagined that they cannot trust their providers, that the providers are not caring, or are inattentive. The best of all worlds is one of mutual respect, collaboration and understanding of each discipline’s strengths. Multidisciplinary care is becoming part of medical school curriculum for a reason; it is superior. It simply is.

I recognize that the people on the edge of mainstream dialogue are responsible in so many ways for the privileges that I have – silly things like voting, and the ability to do my job and get reimbursed for it – but I wish we could make this same progress with intelligent and sensible dialogue that places the patient in front.

Tracy Cardin

Tracy Cardin, ACNP-BC, SFHM is the Associate Director of Clinical Integration at Adfinitas Health and also serves on SHM’s Board of Directors. Prior to this, she was the Director of NP/PA Services for the University of Chicago and worked in private practice for a group of excellent pulmonologists/intensivists for over a decade. She has been a member of SHM for over ten years and has over twenty years of inpatient experience, which seems incredible as she cannot possibly be that old! Her interests include integration of NP/PA providers into hospital medicine groups and communication in difficult situations.

In her free time, she likes to run and lift, read and write and hang out on the front porch of her semi-restored Victorian house with her dear family and friends while drinking a fine glass of red wine and listening to whatever music suits her whimsy.

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