Ornery Opinion: California Should Lift Onerous Nurse Practitioner Limits

I’ve seen this floating around social media recently. I respectfully disagree with the author of the article, physician Kathryn Hallsten that restrictions on nurse practitioners (NPs) in California are onerous. California is one of only 28 states that restricts NPs by requiring that they practice and prescribe with physician oversight. Onerous is defined as “involving an amount of effort and difficulty that is oppressively burdensome.” Ornery is defined as bad-tempered and combative. Nothing about physician collaboration is oppressively burdensome or ornery for that matter. I wish these lies and rhetoric would stop. Here’s where the article turns ornery:

restriction reduces access to care, increases cost, decreases the use of primary care services and boosts hospitalization and emergency department visits

Nothing in this statement is backed by evidence and is simply rhetoric. As is so often the case, these statements are not backed in evidence, but mere rhetoric of a political agenda.

Reduces access – how? I fail to see how safeguards and safer practice by having physician oversight reduces access. 

Increases cost – how? Costs of what? I fail to see how physician oversight on NPs increases costs. 

Decreases the use of primary care services – what the #$#%^?? This is outright BS. Nothing about physician collaboration or oversight decreases patients use of services. 

Boosts hospitalization –  More BS. If anything, physician collaboration reduces hospitalization, but I can’t cite a source on this. But neither does the article. 

“Nowhere is access more affected than in rural areas, which are generally underserved by physicians.” Not true. Other evidence I’ve written about before shows NPs in fact don’t go to rural areas. This is a strawman argument for full practice authority. “So long as California law tethers nurse practitioners to physicians, fewer can serve rural populations.” NPs don’t go to rural areas as the article suggests. And then there is this “A proven solution and a step toward addressing these problems is expanding nurse practitioners’ scope of practice to the level of their training.”  Expanding scope of practice NOT with training, but through legislation is dangerous. 3% the training and education of a physician, but want equal practice capabilities. And the part of that statement that really bothers me is “to the level of their training.” This is akin to “top of their license.” What does that even mean anyway? Part of the article I do agree with, that is often lost and forgotten:

Every doctor and every nurse practitioner has limits to their knowledge and abilities, and knowing these limits and seeking counsel when necessary is one of the most important concepts for any medical professional to grasp.

This is the essence of what the NP role was founded on, by having physician lead health care teams. This is how I practiced what I was an NP. But the article quickly turns to uncited studies:

Studies demonstrate that the quality of nurse practitioner care is comparable to that of physician care; there is no difference in the quality of care when there are no physician oversight requirements.

I’d like to see this study to review. 

Overall the article makes the case for full practice authority based on the author’s positive experience of working with NPs who knew what they didn’t know and were able to collaborate when necessary. How ironic. The very thing being argued against is the very thing that yielded the positive experience. 

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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. 

  5 comments for “Ornery Opinion: California Should Lift Onerous Nurse Practitioner Limits

  1. Phillip Shaffer
    July 27, 2020 at 7:24 am

    “Studies demonstrate that the quality of nurse practitioner care is comparable to that of physician care; there is no difference in the quality of care when there are no physician oversight requirements.”

    This is a common refrain, often stated as “100s of studies show NPs are just as good as physicians.”

    Not true. Yes studies have been done, possibly numbering in the 100s, however they are uniformly poor. Sometimes comparing outcomes over periods as short as 2 weeks. Sometimes assuming (incorrectly) that a non-siginificant p number means equivalence. Very often comparing totally trivial tasks – such as whether physicians and NPs could follow a pre-existing algorithm. At times this is so silly as whether, if a patient said they smoked, offering stop-smoking classes. ALWAYS they compare physician groups to NPs-with-oversight groups. NEVER do they compare physician groups to NPs without oversight. NEVER do they compare ability to assess a patient and develop treatment plans. Never do they compare ability to interview patients, and examine them. The only comparison of this sort I am aware of is the results of the USMLE Step 3 exam, which of course is highly targeted on ability to sort through patient problems and develop a plan of treatment, or further work up. When DNP candidates (the cream of the crop) took this exam over a period of 5 years, the results were stunning. Physicians have a 97+% pass rate, the DNP candidates had a 42% pass rate.
    Conclusion =they are acceptable at following an algorithm once set out for them, they are very very poor at starting from square one and evaluating, diagnosing, and treating patients

  2. arthur gindin
    July 26, 2020 at 8:10 pm

    The article demonstrates the problem better than the writer realizes.

  3. Marsha Mckay DO
    July 26, 2020 at 5:39 pm

    I am so tired if cleaning up NP mistakes. They are not even close to physicians.

    • Kuurt
      July 30, 2020 at 7:57 pm

      I had a great experience with my NP I was assigned to. When she had a tough problem, she came to me immediately and we worked it out. We had a good time in the process too. No, not in the interpersonal sense but became good friends with her, her husband and her mom and dad. Her records were great and I could deal with an admitted hospital patient who mainly saw her through her records.
      We’re both retired now as she first exited as she was older than I and me July 1st of this year. Just got an entertaining email from her today too. I don’t miss the stress of practicing primary care medicine though. Hospital, call and office practice. Took the life out of me!

  4. Jesse Belville,PA-C
    July 26, 2020 at 5:10 pm

    Very good,clear and with good back up info..
    Now if your fellow PHYSICIAN’s would listen ….
    And ACT. State and Federal levels.
    Hope they do..

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