Recently a colleague, knowing my strong stance against Full Practice Authority (FPA) for nurse practitioners, asked me a question. In light of FPA being recently granted in Florida, he believes that FPA in all 50 states is inevitable. He asked me if that were to happen, would I then be willing to compromise. I kindly responded in the negative. For me to be accommodating on the issue of FPA is akin to asking me to concede my ethics. That will never happen. He then asked me to elaborate as to why I would not. My paraphrased answer:

“No compromise. Ever. But understand that I still consider supervision from a distance, supervision. That means the NP/PA can still check in with the doc and update on what they have done. There can be pre-emptive, agreed upon interventions that may cross over into the practice of medicine–hence, the physician’s involvement. Medicine looked very much how NP education looks today. No consistency. Some apprenticeships, some formal training, supervision for a variable amount of time. Non-standardized. And patients suffered because of that lack of standardization. So our (physicians) education became structured, using the Johns Hopkins model. It’s worked pretty well. But that is medicine. So how is it determined that NPs/PAs can now practice independently since theirs is another discipline? If they are managing the patient completely w/o the involvement of a physician, is that not still the practice of medicine? What regulatory body in medicine, science or nursing decided that because they have practiced long enough, they can practice solo? What objective, high quality data confirmed that this practice is equivalent to medicine and safe? Use FPA, Optimal Team Practice (OTP) or whatever euphemism you desire–it is still the practice of medicine. Without a medical license. For the record, there was no regulatory body–it was an arbitrary decision by legislators untrained in science, medicine or nursing. And our responses as physicians is to state that ship has already sailed, so f**k it? It really upsets me that in all the years FPA has existed, not one regulatory body has ever followed up in any state to see if the care is what it was supposed to be. Not even a nursing body. Because FPA has been around for years, there is an assumption that everything is ok. Surely if there was a problem claims would have increased, right? No, not if no one dies or recognizes the death was a result of negligence/malpractice. Who keeps track of the “in-betweens”? The ones who survived in spite of? No one. If the patient has not been told that they have been mismanaged, just how are they supposed to know? Clairvoyance? Who monitors the NPs to ensure they are remaining within their scope of practice(SOP)? It’s certainly not docs who know nothing about NP SOP. It’s not the BON unless the NP is reported. And if the NPs are from an online degree mill, who knows or cares? No one asks. There are so many NP programs no one can keep track, so they refer to the NP certificate which is easy to obtain. So how do we know if they are within their SOP? WE DON’T. It’s based on an honor code–up to the NP to know and stay within it. Is that good enough for you? It isn’t for me. So no, there is no compromise. We all should respect the differences in our training and disciplines and stop trying to blur the lines.

It truly is baffling to me why the only litmus test that exists for legislators in determining the safety and quality of FPA is that it exists in other states. That’s it. None to date have requested data as to how FPA states have performed since the law was enacted–from any nursing regulatory body, licensing agency or malpractice liability insurance company. I find this to be slovenly, irresponsible and completely unacceptable. Just plain lazy. Their job is to protect their constituents and they can’t be bothered to do the homework to ensure that the laws they passed are working sufficiently to protect the public? Why aren’t nursing bodies taking the lead on this? Why is it being ignored?

Why aren’t my physician colleagues, who I submit have a greater duty to protect the public, concerned as well? An attending fresh out of residency will be vetted to the gills–it is automatic and expected. Any problem in residency, such as being placed on a performance improvement program, will garner enough anxiety in new employers to scrutinize the potential hire with a fine-tooth comb to ensure the physician is fit for duty. But an NP, straight off an online degree mill, with no nursing experience whatsoever, is hired to work in an ED, as a “hospitalist”, in a cardiology clinic, neurology clinic, hematology/oncology clinic, etc. without further inspection because he/she possesses a certificate that confirms they have completed an NP curriculum. No one asks if their “clinical” rotations were actually hands on or “shadowing”. What is more concerning is that those doing the hiring almost never assess if the NPs scope of practice enables him/her to work in any of those settings in the first place. The NP may be left to his/her own devices with little to no supervision. Even permitted to perform consults although they do not possess the skills to see patients on their own, let alone engage in specialty evaluations. It’s criminal. And my colleagues are complicit because they do not educate themselves on this aspect of their hires which is not only derelict, it places their licenses at risk. They are blissfully unaware until the s**t hits the fan. Maybe it is their license that is affected, but it is the patient paying the ultimate price. Nursing and medicine. Two completely different disciplines possessing their own unique gifts, skills and expertise and which works best when utilized symbiotically. Conflating them is not in the best interests of patients. Make no mistake, FPA is the practice of medicine…without a medical license.

My perspective is not a popular one, with nurse practitioners or some physicians. As a result of my position, I have been doxxed, stalked, cursed at, called names and multiple attempts made by some nurse practitioners to intimidate me, get me terminated or discredit my name and reputation. I’ve even been accused of not being a real physician. All of this activity does not occur because I am wrong, it is done to shut me up. Obviously, it has had no effect. When others choose to engage in intimidating behavior, I view it as a desperate action. They are fearful. They are insecure. All characteristics of bullies. It is not my problem, it is theirs; therefore, I allow it to remain theirs. 

Dammit, we took an oath. That wasn’t meaningless gibberish, it was an oath that represented our medical ethics. A promise. Our word of honor. Does this not mean anything anymore? I know the burden to protect the public is a heavy one to carry, I feel it also. However, I refuse to be encumbered by the weight that will befall me should I violate my moral code. F**k that noise. I will continue to oppose FPA because it is wrong. It is that simple to me.

“There comes a time when one must take a position that is neither safe, nor politic, nor popular, but he must take it because his conscience tells him it is right.”–Martin Luther King, Jr.

Natalie Newman MD

Dr. Natalie Newman is a residency-trained, board-certified emergency physician who has been practicing for over 20 years. She graduated from California State University in Sacramento, California with a degree in Biological Sciences. She then attended medical school at Case Western Reserve University in Cleveland, Ohio on an Army scholarship. As a graduating senior, Dr. Newman was presented with the Marjorie M. and Henry F. Saunders award for her compassionate care of patients within the family structure. After her graduation, she was accepted into the Emergency Medicine Residency at North Shore University Hospital in Manhasset, New York. Upon her graduation, Dr. Newman entered active duty service with the U.S. Army. Her first assignment was at Womack Army Medical Center in Fort Bragg, North Carolina. During her stint in the Army, Dr. Newman was deployed to Bosnia-Herzegovina(formerly Yugoslavia) where she was Chief of the Emergency Department at Eagle Base in Tuzla, Bosnia. She had the honor of serving under the command of Colonel Rhonda Cornum(now a retired brigadier general), a urologist, pilot and former prisoner-of-war during the Persian Gulf War. While in Bosnia, and as the only American female physician in the Balkans at that time, Dr. Newman was assigned as the official physician for Queen Noor of Jordan during a humanitarian visit to a local hospital in Bosnia. After her return home to the U.S., she was promoted to Major and completed the rest of her Army service at Fort Bragg. Dr. Newman subsequently returned to her home state of California. She has worked in rural facilities, community hospitals and trauma centers. She has also served as a ship physician for a major cruise line and also provided physician services at the Coachella/Stagecoach Festival in Indio, California for three years. Dr. Newman participates in public speaking engagements discussing the value of education, of which she is passionate. She continues to practice clinically as a traveling physician.

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8 Responses

  1. Estelle Farrell,DO says:

    Well done. Adding in the oath of Maimonides is essential. Do APPs ( as they are collectively called now) have an oath they take upon graduation? The osteopathic and Hippocratic oaths are a core value to how many of us practice.

  2. Kurt says:

    Again, I’m a Dr. Newman fanboy. I am in a rural area and practiced for 32.5 years before retirement. I had an NP for 20 years that was assigned to me and the clinic placed us in the same office area which is their practice. She had an issue, could get right at me and we’d work the problem out. If one of her patients was admitted, I could easily dig into the records and get a handle what was going on quickly. This model works extremely well and I have issue with total independent practice too. (She was older than me so retired a few years before me. I went without an NP thereafter as my time was limited.)
    Now allegedly, patient visits were “supposed” to alternate between “me” and her. That didn’t always happened and didn’t bother me much. Some patients liked her more in the office than me (which was o.k.) but understood I would be the one that took care of them in the hospital if they ended up there. In fact I was only too happy to give up pap smears as many women preferred my female NP to do the procedure.
    Fine by me as if I wanted to spent the majority of my time in between women’s legs, I would’a been a groinacologist! 🙂
    My NP got the needed service done for patients. That’s what counted.
    One of my surgeon partners mentioned the group had a P.A. that removed a nevus that turned out to be a melanoma on the path report. He (the P.A.) asked how much more tissue should “he” remove from around the lesion site to one of our surgeons! Suffice it to say, the surgeon who was a very well trained woman, stepped in and took control of the situation. Made sure she took care of the patient with the further imaging required and the subsequent surgery needed to best eliminate the problem.
    Suffice it to say, that P.A. was let go later for this and other reasons. I found out even further out he was disciplined for “improprieties” with a female patient at a different employer. I believe he lost his license.

    • Natalie Newman, MD says:

      The relationship that existed between you and the NP is exactly how it was done years ago. I remember those days well. It was efficient. Within that model, NPs did have a significant amount of autonomy although they were supervised. That autonomy was achieved through teamwork, trust and respect for the differences in education and training between the two disciplines. When outpatient medicine was practiced this way, it worked fabulously for the patients. What you describe is the teamwork that the NPs claim they desire. But they don’t. FPA is the complete antithesis of that team approach.

      It truly is unfortunate the AANP and other nursing organizations have managed, through brilliant PR and lobbying, to fabricate a story that legislators, physicians, non-physician practitioners and many in the public have fallen for hook, line and sinker.

  3. Joe Smegma, DO says:

    Nice job Dr Newman! Training and medical standards matter. Years of medical school , internship and residency training do matter!! Please continue the fight. They don’t know what they don’t know!! Patients suffer.

  4. Alfred M. Sadler Jr. MD FACP says:

    Excellent essay. As a physician who has been involved with the PA Profession from the beginning, I agree with the first respondent who is a PA-C and apparently understands the PA role very well – practicing medicine but not trying to do so independently. Some in Nursing leadership have been advocating “independent practice of primary care” and practicing “at the top of their license”. I’m not sure what either of those actually mean except that they covertly want to practice medicine. What we need is “interdependence” in health care and in society more generally. Please don’t lump PAs and NPs together. I admire your many accomplishments and congratulate you on speaking your mind. Best regards!

  5. Jesse L.Belville,PA-C says:

    Thank You Dr.Newman;
    As a PA-C I am fully behind you.
    I am not anMD or DO. I was to supplement my Physician employer/Supervisor seeing less complicated patients,routine follow ips,answering questions so my Physician supervisor had time for his more complicated patients,hospital rounds,. I am there to help,Not Replace. Unfortunately Nursing is very political and wants to take over All of Medicine. Many PA’s have bought into that.Necessary or those NP’s will take all our jobs is the cry..
    No Guts,No Glory. Patients will pay the price. Hope its not any of your loved ones…
    Keep up the Fight. I support your stand!

  6. Martha C. says:

    Wonderful post, Dr Newman. Full of Truth that we all need to hear.

    I see the damage that the influx of NPs has wrought on our communities in Texas.

    Wonder why a patient has had numerous imaging studies, multiple antibiotics, multiple visits and still no one knows why they have this ‘weird abdominal pain’? Look no further than the ‘provider’. NPs are unsure of their dx – so they order a myriad of tests and medications to cover their own lack of experience and plain ineptitude.

  7. Pat says:

    Beautifully, devastatingly stated, as ever.

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