A Commentary on: “As Nurse Practitioners Try To Shake Free Of Doctors, Kansas Physicians Resist”

This article has been floating around various news feeds for a couple days now and I thought it could use a more formal response. In my opinion, the Kansas State Legislature, The Kansas Medical Society, and Kansas Physicians (MDs), have it right by requiring collaborative practice agreements between Nurse Practitioners (NPs) and MDs. However, I believe this article as with so much rhetoric and political bias against MDs, attempts to gain the sympathy of the NPs in lieu of objective data. I mention objective data for a reason. It’s lacking. It’s lacking in this article. It’s lacking in sources mentioned2in the article, and it’s lacking in general in the argument against collaborative agreements for full practice authority (FPA). It’s lacking in describing exactly how NPs are not able to practice to the full extent of their education and scopes of practice. One example I’d like to highlight is where the article references the National Academy of Medicine: 

“No studies suggest that (advanced practice nurses) are less able than physicians to deliver care that is safe, effective, and efficient,”2

What’s the point of this statement anyway? Because no studies exist, we have to accept the antithesis of this statement suggesting equality, superiority, or safety? Isn’t that like being asked to accept the null hypothesis without data? Am I having a research flashback about Type II errors3? That would be erroneous on a number of fronts. From a 2014 systemic review4:

“The available evidence continues to be limited by the quality of the research considered”……”The slowly growing number of studies, assessing substitution of physicians by nurses is still substantially limited by methodological deficiencies.”3

Thus could it not be equally stated in an alternative hypothesis?:

No studies suggest that (advanced practice nurses) are a viable substitution to physicians to deliver care that is safe, effective, and equally efficient to that of residency trained board certified physicians

Just saying. On a closer look at the referenced source from the article from the National Academy of Medicine,The Future of Nursing Focus on Scope of Practice, the actual quote is as follows:

No studies suggest that APRNs are less able than physicians to deliver care that is safe, effective, and efficient or that care is better in states with more restrictive scope of practice regulations for APRNs. In fact, evidence shows that nurses pro­vide quality care to patients, including preventing medication errors, reducing or eliminating infec­tions, and easing the transition patients make from hospital to home.

This is worth mentioning because you could paraphrase it like this:

No studies compare the ability of APRNs to do the MD’s job but there is evidence that nurses can do a nurse’s jobs. 

However, none of this is cited evidence in this consensus model opinion. I’m finding this typical in various writings on the topic. Literature is not supported by evidence or facts. The terms “evidence shows….”is often not backed up with actual evidence. As if it’s a strong thing to say assuming no one will look deeper than face values for the actual evidence. In this case, both the news article and reference lack objective evidence. But back to the original article, it attempts to offer anecdotes and snippets as support for ceasing collaborative practice agreements. This non-evidence is not even worth further mentioning. 

In summary, there is a general lack of objective evidence supporting the discontinuation of NP/MD collaborative practice agreements. As stated earlier, I believe the Kansas State Legislature, The Kansas Medical Society, and Kansas Physicians have this one right. Have a great day. 


  1. https://www.kcur.org/post/nurse-practitioners-try-shake-free-doctors-kansas-physicians-resist#stream/0
  2. http://nationalacademies.org/hmd/~/media/Files/Report%20Files/2010/The-Future-of-Nursing/Nursing%20Scope%20of%20Practice%202010%20Brief.pdf
  3. Banerjee A, Chitnis UB, Jadhav SL, Bhawalkar JS, Chaudhury S. Hypothesis testing, type I and type II errors. Ind Psychiatry J. 2009;18(2):127–131. doi:10.4103/0972-6748.62274. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2996198/
  4. Martínez-González et al. Substitution of physicians by nurses in primary care: a systematic review and meta-analysis. BMC Health Services Research 2014, 14:214 http://www.biomedcentral.com/1472-6963/14/214

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