Liar liar pants on fire: Joint Statement on the Role of Advanced Practice Registered Nurses

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. 

References:

  1. https://www.aanp.org/news-feed/joint-statement-on-the-role-of-advanced-practice-registered-nurses
  2. https://www.aaem.org/current-news/joint-statement-post-graduate-training-of-np-and-pa
  3. https://authenticmedicine.com/2020/09/fruitology-in-california-the-doctor-is-out/

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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.

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3 Responses

  1. J. R. Nye says:

    From the perspective of a somewhat knowledgeable future patient who makes inferences about medicine from being a lawyer sometimes working to reform the business of healthcare (and regardless of whoever it is that leads the system, it needlessly killed my mother in 2006):

    In my opinion, those that equate talent in real life to training on cadavers and pigs are stealing valor. The topic of discussion in this post also, in reality, seems to me to be something very different (i.e., money or control which equates to money) between the combatants than what is of crucial importance to a patient.

    Najam Azmat, a surgeon who didn’t know stents other than “two weekend courses practicing on cadavers and pigs,” was recruited to be the professional piece of a cath lab in rural Georgia. Immediately the nurses raised the alarm to hospital administration stating, “[i]t’s completely obvious that he’s not been trained to do these procedures.” The response from “Harmon Raulerson, then manager of Satilla’s Heart Center,” TO THE NURSE was “[T]hen teach him.”

    Azmat is currently in prison after devolving to working in a pill mill. Sentenced in 2014, Dr. Azmat is scheduled to be released in April of 2023.

    For the heart center involved, was this what we are defining as a physician led team?

    On another front, I can offer the example of a Certified Registered Nurse Anesthetist who “specialized” in ophthalmic anesthesia who practiced completely autonomously in a facility for 10 years (with 15 years prior to that doing OB anesthesia to hearts in a hospital environment) before the eye center was acquired by a healthcare behemoth. This CRNA was then happy to be a team player teaching the fully educated physician anesthesiologists showing up on the scene how to do the ophthalmic anesthesia the surgeons were expecting. When the physician anesthesiologists started to express opinions on how things should be run, the real captains of the ship (i.e., the surgeons – actually not [insert Captain of the Ship Doctrine analysis here]) caused a “do not lecture this bird how to fly” memo to be issued from the main campus of the mother ship.

    Another anecdote provided by our CRNA heroine, after 30 years of practice people who can judge all sorts of talent needed for acute healthcare situations expressed that knowledge in the context of their own procedures or those of their families. One example: an anesthesiologist, now retired, as a surgical patient selected not only the surgeon but also looked through all of those physician anesthesiologists employed at said healthcare behemoth who may have been randomly assigned to that OR on the day of his procedure to request this CRNA. Happens a lot. And those who are in a position to do so (physicians, advance practice nurses, etc) regularly make similar arrangements for friends and family. Pity those fools who do not have a back channel.

    Interestingly, this CRNA was the product of a certificate program where she was paid a stipend to attend. So, she is still “only” a CRNA with a BSN. We can have a separate discussion about the “big education racket” if anyone is interested. This CRNA is now a victim of this racket in a sense that if she were recruited for her demonstrated real life talents to work in certain states to improve the local quality of care, the patients in those states would be denied since a masters degree is now a threshold to licensure. And as Dr. Duprey points out, these advanced degrees in many cases are the product of what one may describe as paper mills. Paper mills don’t cause the death and destruction of pill mills, but mills they arguably be.

    So going back to the business of healthcare, I was in a conversation just yesterday with an ER physician regarding her tech company being built to wrest control of patients from the bean counters. She actually pointed me in directions that led me to this post. Regarding her efforts to raise capital (I’m on the investor side and do not represent her or her company), I introduced the notion that she might be casting too small of a net. With demographic pressures and the implications for access to care, I inquired about reaching beyond physicians to the APN community. And that led to an interesting exchange.

    Expressing her sentiments as a libertarian she indicated that if someone wanted a window washer to perform his/her appendectomy then that was fine by her. So that she understood my sense of the issue, I replied that my concern was very different. My concern was related to physicians as being both market participants and also having influence over legal definitions as to what constitutes “the practice of medicine.” As a result, the discussion for me is never about a window washer performing surgery. The discussion is about a rent seeking profession (probably should call it an industry to note the presence of the bean counters and their bonus expectations) defining window washing as the practice of medicine, charging $ thousands per hour for window washing (negatively impacting access to window washing services), then hiring a less accomplished window washer than was previously available (because the original was “un artiste” and marginally more expensive) to perform the window washing services while the physician team leader and the administration of the facility supervised (and compensated for it) from the call room or the golf course.

    Maybe an effective way to get to the best system (for the patients) is that which percolates to the surface from this thought experiment: 1) healthcare providers with an acute understanding of the local talent and facilities; 2) going under the knife; 3) who are paying out of pocket, and 4) in a legal environment with no cap on non-economic damages for professional negligence.

    And to be fair, if things are off the tracks in healthcare, just imagine those professions (law comes to mind) where the consequences of mishap do not, at least directly (suicide is up, after all), lead to funerals.

  2. Elle Vigore says:

    Excellent commentary. Love that a nurse practitioner who decided to go back to medical school wrote this. Completely validates his perspective. No fluff here. If you want to see fluff go look at an online NP curriculum. Or even better look at the one year “doctorate” DNP curriculum. Now that’s fluff. Thank you for writing this and publishing!

  3. arthur gindin says:

    Your “comment” page has been diverted to “fluff.”

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