Word Salad, Verbiage Matters: California resists push to lift limits on nurse practitioners during Covid-19 pandemic

Just as cabbage makes for a good salad, verbiage can either make or break a good argument. In the case of this article (1), some of the verbiage is concerning. I agree with the notion of collaboration. I’ve written about this before in a previous Authentic Medicine blog (2).  This current blog is not to bash mid-level providers nor talk politics. This is about some of the content within the article that is concerning to me. It’s inherent dishonesty. And don’t get me started on using a crisis for personal gain and the ethics that surround this. In the article, an example of concerning verbiage: 

In 28 states plus the District of Columbia, nurse practitioners can practice much like a physician: They can provide primary care, write prescriptions, and see patients.

            Does this mean that they are really practicing medicine under the guise of practicing advance practice nursing? I think this is the big lie here. Then look at the language used regarding an example of a particular Nurse Practitioner (NP) in the article: 

Luckey, 54, is certified in both family medicine and psychiatric medicine and has been practicing for 26 years.

            The verbiage here indicates this advance practice nurse practices medicine. Particularly, both family medicine and psychiatric medicine. This is concerning on a number of fronts. Physicians to do the same would need to do both a 3-year family medicine residency and a 4-year psychiatry residency. Why the double standard? Part of that I think has to do with the verbiage. Is it practicing medicine, or is it practicing advance practice nursing of the family or of the psychiatry patient? The verbiage matters! The language gives away the inherent beliefs of this particular group. The fact that this particular NP uses the verbiage of practicing medicine indicates the inherent belief that this is in fact what they do: Practice medicine under the guise of advance practice nursing. Verbiage matters!

            The article describes that the California Medical Association does not want the state to go full practice authority (FPA) versus requiring physician collaboration for NPs. When you think about it, it’s a known fact that mid-level providers don’t have the rigors of medical school (programs require as little as 500 clinical hours), there isn’t a standardized accrediting body such as the ACGME and ECFMG for foreign medical graduates, nor are there rigorous standardized tests such as USMLE Steps 1, 2CK, 2CS, and 3. It’s also well known that curriculums are vastly different whereby medical school is rooted in the basic sciences and advance practice nursing school is rooted in nursing theory. I’ve been through both, so I think I can speak to this with credibility. One is the medical model and the other the nursing model. Two distinct disciplines. How has it come to pass that those educated in the nursing model can cross lanes and practice in the medical model: i.e. practice medicine? With this notion alone, this is enough to justify collaboration. How can you have independent practice in another discipline for which one wasn’t trained without collaboration from practitioners in that other discipline? In other words, how can advance practice nurses practice medicine while being trained not in the medical model but in the nursing model, practice without collaboration from physicians who were trained in the practice of medicine? 

            Next, I want to reference a particular statement in the article to demonstrate the difference between the medical model and the practice of medicine versus the nursing model:

Shortness of breath, one hallmark of Covid-19, is also the hallmark of a panic or anxiety attack. Luckey said her extra years of schooling trained her to distinguish between the two in ways other providers can’t.

What other providers? What ways? The medical model teaches physiology and pathophysiology of all body systems down to the basic sciences, molecular and genetic level, and we are taught to identify symptoms and determine differential diagnoses so as not to miss anything. This statement identifies the nursing model whereby it is felt that only advance practice nurses could identify shortness of breath as either COVID-19 versus anxiety. Who are these other providers that can’t do that? Physicians??  Physicians would see SOB and think respiratory failure, COPD, heart failure, kidney failure, DKA, sepsis, thyroid storm, pain, internal trauma, pneumothorax, PE, metabolic acidosis, drug reaction, substance abuse to name a few. I think that statement shows the ignorance and lack of appreciation that advance practice providers have for physicians and medical education. The ANA states that nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations (4,5). Thus, nursing is I learned it back in the day was the diagnosis and treatment of human responses to actual or potential health problems (4,5). So, in the nursing model, the anxiety would be the human response and the subject of treatment. When the focus becomes the disease process causing the human response that is the point where the nursing model crosses lanes into the medical model. The nursing model isn’t inherently conducive to practicing within the medical model. One only has to look at the difference in the differential diagnoses list between the nursing model practicing medicine vs the medical model practicing medicine. 

Lastly, this is nothing more than a power grab by attempting to take advantage of a pandemic crisis for FPA??  The old strawman argument rears its ugly head again. There is reference to NPs practicing in geographic areas physicians aren’t, thus full practice authority is the only way to counteract this. However, the main point is missed. This is not a nursing problem to solve. This is a physician problem to solve. One discipline doesn’t solve problems in another discipline. For example, the primary care physician shortage, this again is not a nursing problem to solve. The argument that FPA will be the only way to solve the physician shortage and practice to rural areas is the strawman argument. The focus is not on the physician shortage or practice areas/rural areas as this article would have you believe, the real argument is for power: FPA. Strawman. 

Verbiage matters!  

References:

  1. (https://www.statnews.com/2020/04/17/california-resists-push-to-lift-limits-on-nurse-practitioners-during-covid-19-pandemic/?fbclid=IwAR1bQJUa_e5JPDqzscN6DPcren545wuy2MKQCz7EU1A8eXgl4RUNUaqIU9U)
  2. https://authenticmedicine.com/2019/06/clinical-supervision-a-positive-thing-for-all-practitioners-and-physicians/
  3. https://en.wikipedia.org/wiki/American_Nurses_Association
  4. https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/

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Robert Duprey MD

Robert is a 2nd career physician (MD); a combat Veteran with the US Army; a former psychiatric nurse practitioner; an independent researcher; a medical writer; and now having passed USMLE Steps 1, 2CK, 2CS, and 3, is a residency applicant. 

  3 comments for “Word Salad, Verbiage Matters: California resists push to lift limits on nurse practitioners during Covid-19 pandemic

  1. Aaron Levine
    April 22, 2020 at 5:55 pm

    There is a new proposal to allow NP to perform the administrative duties of PMR physicians. For those not familiar with PMR, Medicare established rules for inpatient rehabilitation units (IRF). This required the medical director have training and/or experience in rehabilitation. Generally, this meant completion of a PMR residency, or a neurologist, orthopedist or rheumatologist. There was some loosening last year to allow an internist without expertise to become the medical director. This involves documentation. CMS now wants to allow NPs to complete the administrative duties of the medical director. As CMS pays the hospital for the directorship, hiring a lower cost NP allows the hospital to profit from the change.

    From the PMR discussion board:

    CMS Releases FY 2021 IRF Proposed Rule:

    The Centers for Medicare and Medicaid Services (CMS) has released an ill-timed and shocking FY 2021 IRF proposed rule that includes a proposal to amend the IRF coverage requirements to allow non-physician practitioners (NPPs) to perform certain duties that are currently required to be performed by a rehabilitation physician.

    CMS is requesting public comments on the proposal by June 15, including specifically whether commenters believe that quality of care in IRFs will be impacted by this proposal and any specific evidence that may help inform the issue.

  2. MARK OBRIEN
    April 21, 2020 at 1:24 pm

    So in litigation, who is the expert witness? Profession of like practice. Are they citing nursing standards or medical standards? Who established medical standards? Physicians. Are they the nursing profession practicing medical standards? Evidence based medicine? Medical or nursing evidence?

    • arf
      April 23, 2020 at 1:21 am

      Good question. As far as I’ve ever seen, they hide behind nursing standards when it comes to accountability.

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