Published September 23rd, 2020, this article (1) is a retort to a recent position statement from the American Academy of Emergency Medicine (AAEM) (2). The AAEM Sep 3rd, 2020 statement advocated for “physician-led patient care and training.” It also states that terms such as “resident,” “fellow,” and “fellowship etc” be reserved for use currently as they are in physician training and not be professionally appropriated by other groups. Retort is defined as “to say something in answer to a remark or accusation, typically in a sharp, angry, or wittily incisive manner.” The Emergency Nurses Association (ENA), American Association of Nurse Practitioners® (AANP), American Association of Critical-Care Nurses (AACN) and the National Association of Pediatric Nurse Practitioners (NAPNAP) statement (1) is that they “strongly oppose the view that emergency care is solely “physician-led” or that physicians should dictate education and practice standards for advanced practice registered nurses (APRNs).” I and many others postulate that those with the most education and training be the leaders of emergency medicine, or any other branch of medicine. This is not a conundrum, this is commonsensical.
Who is the captain of the ship? The captain! The captain is the one with the most education, experience, and training. Who is the leader on an airplane? Again, the captain, and again, the captain is the one with the most education, training, and expertise. Who is a leader on a construction crew? The foreman. Who is the foreman? The one with the most education, training, and expertise. Who is the leader in a college department? The department chair. Who is the department chair? The one with the most education, training, and expertise.Who is a leader of a baseball, basketball, or football team? The captain? Who is the captain? The one with the most experience, training, and expertise. Who is the leader of a research crew? The principle investigator. Who is the principle investigator? The one with the most training, education, and expertise. Who is the leader in a kitchen in a fancy restraint? The head chef. Who is the head chef? The one with the most training, experience, and expertise. Who is the leader of a Mcdonalds night crew? The manager. Who is the manager? The one with the most training and expertise. Who is the leader of nursing care on an inpatient med/surg unit? The head nurse. Who is the head nurse? The one with the most education, expertise, and training. Who oversees nursing care on a particular shift on the same med/surg unit? The charge nurse. Who is the charge nurse? The one with the most experience, education, and expertise. And on and on and on. Get the point yet? So who is the leader of a healthcare team? The physician. Who is the phsycian? The one with the most education, training, expertise, and experience in practicing medicine.
I’m a believer that all members of the healthcare team add value to the team, but there has to be a line drawn. Having been through both nurse practitioner (NP) training and medical school, they don’t compare. I’ve written about this before in a prior blog in terms of apples and oranges (3). I respect the training I went through as an NP for what I was supposed to do as member on a physician-led team. But the rhetoric and talking points being put through by the authors of the article here aren’t necessarily true. It (1) states:
APRNs undertake rigorous preparation through their education and clinical training through nationally accredited graduate programs, as well as pass national board certification exams. APRNs practice in accordance with the scope of practice determined by national standards and state law.
While considered advanced practice nursing, it is more rigorous and intense than registered nurse (RN) training, but it still is nursing training. But it is not nearly as rigorous as the medical school training. Apples and oranges again. At the time, I had been an RN for 15 yrs before becoming an NP, as it was designed for, but now a days, it is that anyone with a pulse and wallet can be accepted and even with no prior nursing experience or nursing degree. The NP programs are no longer rigorous. The clinical training hours are minimal. Mine was a total of 624 hours. And mind you, this was considered advanced practice nursing clinical training and not medical training. Programs get accredited with little to no effort and the curriculum is rife with fluff courses such as nursing theories and other non-medical oriented courses. The national board certification exams was one 150 multiple choice question with first order MCQ’s. Whereas physician exams are numerous (USMLE Steps 1, 2CS, 2CK, 3), before you can even take board certification examinations. And physician scope of practice is in accordance with education, training, and residency specialty training and not through legislation. It is well known that NP scope of practice is being determined through legislation and not through education and training. So if medicine is apples and nursing is oranges, can you really have an orange as the leader on a team of apples? You have to be an ignoramus to not be able to fathom the difference in education, training, and expertise. It is not saying that all members are not valuable on the team, because they are, but as far as the leader of the team as the most educated, experienced, trained, and expertise, physicians far outweigh NPs.
The position statement (1) further states “APRNs in emergency care should practice to the full extent of their education and clinical training.” No one has been able to give the operational definition of this notion. What the hell does it even mean? I was an NP for 8 yrs prior, and I can’t even understand what it is referring too. If the extent of education and clinical training means 624 clinical training (orange training and not apple training), fluff courses, limited physiology, pathophysiology, and pharmacology, then the full extent of clinical training dictates NPs not be the leaders on healthcare teams over and above physicians.
The position statement (1) further states the notion of physician-led care “constructs barriers that limit APRNs, diminishes a true interprofessional approach and limits access to care.” This is rhetoric and talking points by these groups that want full practice authority (FPA). They are nothing more than talking points and strawman arguments for FPA. Physician-led care is not a barrier, and nor does it limit APRNs, nor does it limit access to care. This is the liar liar pants on fire rhetoric.