A Legal Precedent Perhaps?

It is no secret that I do not support Full Practice Authority(FPA) for nurse practitioners(NP). In my opinion, it is the practice of medicine without a medical license. Period. The fact that certain state and/or national nursing organizations have managed to finagle politicians into passing this egregious law is more indicative of exceptional lobbying than it is confirmation of quality medical care, which brings me to my next point.

Part of their effective lobbying has been the repetitive claim of their poorly done “studies” purporting “equal or better outcomes” compared to primary care physicians. Add to that the variability and vagueness of the definition of “advanced practice nursing” and a gaping hole of interpretation is created that has given them “license” to practice however they see fit. Of the states and U.S. territories that have been granted FPA, where are the follow-up studies that prove that the quality of care promised during the NPs legislative pursuit for FPA has indeed measured up? There are none. That’s correct. No nursing or legislative regulatory body, upon the passage of FPA, has followed through to evaluate or assess whether patients have been managed appropriately as pledged. No auditing of any state nursing board to review for increased complaints of NP mismanagement nor any investigation validating those complaints; no review by an objective party of malpractice data(increased lawsuits or claims settled) collected over a select number of years; no survey by hospital facilities of increased visits to the ED, categorized by complaint, by NPs before and after FPA; no statistical analysis of increased or decreased morbidity/mortality rates in hospital departments that permit NPs to practice unsupervised, etc. This would be especially relevant since a majority of new NPs today are products of online degree mills with inconsistent and subpar educational standards. Nothing prevents NPs from practicing in a full practice authority state. NOTHING. So how has it been determined that the standard of care has measured up as claimed? PRESUMPTION. Legislators, physicians and medical facilities assume that care is adequate by the sheer number of states with FPA. That’s it. Proclamation of quality surmised because surely these laws would not have been passed if the standards were not met, right? Wrong. I’ve stated this many times: absence of evidence is not evidence of absence, it just means no one bothered to look.

Complicating the picture are the use of “collaborating” physicians. Per MY definition, collaborating physicians are simply doctors who get paid(some inexplicably do it for free) to provide little to no supervision. The fact is, they are being utilized for their licenses and to accept liability, which they foolishly do. The irony is that in the majority of states with FPA, a collaborating physician is REQUIRED by the state, the nursing board(BON) and/or the nurse practitioner’s liability insurance carrier. Surely one must ask that if a NP is indeed “independent” as stipulated by FPA, why this directive? Could it be an indication that the state, BON and malpractice insurance carriers are themselves concerned about the NPs ability to practice unsupervised? Of course it is, otherwise there would be no reason to make such a decree. As a physician, I collaborate with colleagues frequently. I am neither mandated nor do I have to compensate them for the privilege of doing so. It is baffling to me why no one questions the logic of this edict and why doctors continue to allow themselves to be used in this way. The purpose of this type of “collaboration” cannot be more obvious, which is for physicians to be the scapegoat should a lawsuit arise while simultaneously sanctioning NPs to practice medicine without being held to the medical standard. Nowhere is this better exemplified than in the case of Warren vs. Dinter (https://www.medicaleconomics.com/news/physician-found-liable-malpractice-patient-he-never-treated#:~:text=The%20Minnesota%20Supreme%20Court%20ruled,to%20or%20treated%20the%20patient.&text=In%20the%20case%2C%20Warren%20v,prerequisite%20for%20a%20malpractice%20action.), in which two doctors were found culpable, including the collaborating physician. Although MINNESOTA IS A FPA STATE, the NP was dropped from the case. As far as I am concerned, the collaboration dictum validates my perception that despite the extremely influential lobbies of their organizations, NPs are not ultimately trusted to practice COMPLETELY on their own. Use whatever euphemism one may like, independence has only one meaning, and NPs are not practicing it. 

Along the same vein, my colleagues who agree to be remote “medical directors” for nurse practitioner practices or businesses do nothing but add to this irresponsible “collaboration”. Chart reviews are worthless, especially when selected by the NP, as some physicians permit. Although a state law may require only 10% of charts to be reviewed, a physician can review more; however, most do not. The review is only as good as the documentation. What good is a chart review if a patient is diagnosed by an NP with a UTI because she had burning dysuria, only to present later to an ED with pelvic inflammatory disease(PID)? The medical director has no idea any of this occurred because a sexual history was never documented, a relevant review of systems never completed and a pelvic exam never performed. This lackluster “supervision” is not only slovenly, it does nothing to protect the patient, making the doctor just as complicit in the poor care by aiding and abetting the illegal practice of medicine.

Medicine is considered the highest standard of healthcare provision in the United States. Supervision and oversight restrictions of non-physician practitioners exist to protect the health and safety of the public from anyone practicing below that standard. These regulations are neither “outdated” nor “unnecessary” except by those seeking to undermine the practice of medicine for their own unsavory reasons. It is immaterial that full practice authority has been permitted in 23 states and some U.S. territories. It is a bad law that never should have been enacted because, by its very nature, it is illegal. Some laws just need to be revoked. In my opinion, the legality of FPA should be challenged in a court of law. What legislators do not understand, perhaps the courts will.

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