An Education…About Nurse Practitioner Education that Physicians Need To Know

Recently a news report made the rounds on social media regarding truth and transparency in healthcare. The story involved two nurse practitioners(NPs) who had misrepresented themselves as doctors to the parents of the now-deceased victims. For quite some time, I have been aware of the medical establishment’s(particularly physicians) ignorance regarding NP education. That ignorance has led to them making several presumptions about NP practice that are incorrect. During the flurry of conversations following the WGN news report, it became even more apparent just how much physicians do not know. That lack of knowledge places physicians in a very precarious legal situation. Allow me to elaborate and educate.

Nurse practitioner curriculums are based on a focus, that is, a particular population group. That focus is narrow. For instance, a pediatric nurse practitioner in primary care(PNP-PC) is permitted to care for children generally from newborn to eighteen years of age. However, they can not care for acutely or critically ill children. To do so, they have to have training and certification as a pediatric nurse practitioner in acute care(PNP-AC). Ideal workplaces for PNP-PCs are outpatient clinics or elementary schools. For those who desire a broader scope, it is better to be dual-certified. A PNP who is both PC and AC can work in UC centers or ERs as well as pediatric clinics. Or if the PNP wants to be able to see adults, he/she must obtain a certificate as a FNP, Adult Nurse Practitioner(ANP) or Adult-Gerontology NP(AGNP).

The majority of NPs today are family nurse practitioners(FNPs). The FNP curriculum is an OUTPATIENTcurriculum, yet many FNPs work in cardiology, urology, neurology, as “hospitalists” and in emergency departments. Depending on the state, this may be permitted by their boards of nursing(BONs)–or not. Whatever the case may be, the NP has to be practicing within the guidelines of the state Nursing Act. No physician or medical institution can supersede this law. The problem is no one usually does the necessary checking. Thus, the information cannot be shared with patients. This presents a problem since a significant number of FNPs graduating today do so from online degree mills. Physicians, who have the mistaken idea that if an NP possesses a certification they are certified to work anywhere, allow them to work in their offices, EDs, medical floors, etc. and/or perform procedures outside of their scope of practice(SOP). A well-trained, seasoned, skilled NP knows his/her SOP and if they don’t, they find out. The degree mill graduates have no idea of their SOP, they may presume it is whatever the physician decides. That is an incorrect presumption. Physicians cannot determine or expand the SOP of nurse practitioners, they have no authority to do so. Standardized procedures(SPs) enable NPs to perform functions that would otherwise be considered the practice of medicine. It is the physician and NP’s responsibility to know if their state, clinic, hospital, etc. have these standardized procedures. Physicians, by permitting NPs to function outside their SOP and/or beyond the limitations of the standardized procedures, are in essence, aiding and abetting the illegal practice of medicine. Medical malpractice/negligence that occurs as a result of these acts may lead to medical as well as criminal ramifications. The onus is on the physician and or medical facility to know exactly who they are hiring, if the individual’s program was accredited, if their training included duties or procedures the physician or institution plans on granting the NP privileges to perform and if the state BON permits it. Bottom line, vet the NPs just as one does physicians, carefully and meticulously. Your license depends on it. In the aforementioned report, Betty Wattenbarger had a PNP tending to her who was certified in pediatric acute care but did not recognize that Betty was critically ill. As a result, she did not escalate her care as she should have and Betty was discharged home. Alexus Ochoa was “managed” by a FNP who was neither trained to work in the ER nor did her SOP allow her to work in the hospital. She had no business there. Both the hospital and medical director presumed that because she was a FNP with a prior history as an ER registered nurse and a paramedic, she was qualified. Wrong. Neither was relevant because neither RNs nor paramedics are providers. The NP was unaware of her SOP, although she admitted in her deposition that she knew her curriculum did not include any training in emergency medicine. 

I submit that it is this ignorance about NP education that creates an enormous loophole for NPs to practice beyond their SOP. Urology, neurology, cardiology, nephrology, dermatology, “hospitalists” NPs do not exist. There are only NPs who work in these areas although many self-declare themselves “experts” after having worked in a field for a few months. There are no nationally standardized curriculums or competency exams that exist in the U.S. under any of the specialties mentioned above. These are the current NP “specialties” in which curriculums do exist: What is not included in the list but should be are: Certified Registered Nurse Anesthetists(CRNAs) and Certified Nurse Midwives(CNMs).

To add to this convolution is the perception precepting and/or supervising physicians have that their training of NPs is as good as a formalized, structured, medical program. That is also incorrect. For example, when a cardiologist trains a NP in cardiology, the NP’s training is only as good as that cardiologist. Therefore, the training is not only subjective, it is limited to that cardiologist’s practice and the demographic in which he/she works. A physician is neither a nationally accredited, standardized and approved educational program nor does he/she administer a nationally standardized competency exam to assess the quality of said NPs “training”. Therefore, the training amounts to an apprenticeship with the individual physician using his/her subjective opinion as the litmus test to conclude that a particular NP/PA is qualified or “competent” to perform as the cardiologist believes they should. If that type of training were consistent with quality education, the Flexner Report would not have been warranted. When specialists use NPs or PAs in their practice to perform initial consults, knowing the NP(or PA) does not possess the breadth of medical training to assess if a new consult presenting to their office requires the specialists’ evaluation, they are passing the buck. Being dismissive of both the patient and the referring physician. The referring physician has already determined that a higher level of care and/or evaluation is required. The specialist, by assigning an individual with less to no formal medical training to a new consult to perform the initial assessment, is stating by his/her action that the referring physician, who actually has the appropriate medical training, is inept and incapable of determining what is best for his/her patient. It is blatantly offensive and disrespectful. And arrogant.

Along this same vein, physicians, who in their attempt to mollify and appease, advise medical students, residents or even patients to refer to a NP possessing a Doctorate of Nursing Practice(DNP) degree as “Doctor” need to cease and desist. Every single state in the union has a business and professions code(B&PC) for the majority of professions in the state. Some medical boards make it very clear who can refer to themselves as “Doctor” in a medical or clinical setting. It should be apparent that this law exists to prevent people who are not medical doctors from perpetrating them. Legal consequences associated with professional misappropriation can range from misdemeanors to felony charges. Thus, if a physician or NP does not know if the NP can use the title “Doctor”, it would behoove them to find out. Patients can most certainly sue if they believe a non-physician is misrepresenting him or herself as a physician. The BONs typically do not address this particular issue at all and some have agreed to concur with their state BOMs decision. There is something to be said about cultural norms. I daresay, when one uses “Doctor” in the clinical setting, most laypeople presume physician. Throughout the world. It is very unlikely that a Doctor of Veterinary Medicine(DVM) will be confused for a medical doctor since they work in a setting with animals. It is doubtful that a dentist(DDS) would be conflated with a medical doctor as they have a specific SOP and work within their own realm. To have NPs and physicians in an ER both be referred to as “Doctor” is intentionally misleading. Unscrupulously taking advantage of the public’s natural assumption that “Doctor” indicates a medical doctor, because that presumption falsely elevates the deceiver’s status. Many people entering an ER are fearful and apprehensive. It is improbable that they would note the differences that one “doctor” is a nurse practitioner and the other a physician when they are under physical and/or emotional stress/strain. And it is unconscionable to expect them to make that distinction when they are at their most vulnerable. No physician should be endorsing this duplicity for the sole purpose of ingratiating themselves to non-physician practitioners, especially if they are unaware of the law. It is foolish to endorse anything that skirts a legal statute or edict. It is also important to note that 85% of DNP degrees are non-clinical. The majority are academic.

One last note. I want to emphasize that there should be no conflation of nurse practitioners and physician assistants(PAs). It is comparing apples and oranges. PA programs remain competitive and standardized. Physician assistants are trained in a medical model, same as physicians. They are licensed under the medical board. NPs are licensed under the nursing board. Physician assistants are procedure-oriented and their understanding of medical terminology more in depth. It is why in the past, before they were pushed out of the landscape by the FPA movement, they worked in areas that were highly procedure oriented: ER, surgical specialties/sub-specialties and the ICU. NPs worked in outpatient clinics that were either FM, IM, its subspecialties and Pediatrics and its subspecialties. CRNAs, NNPs and CNMs, who are highly specialized NPs, worked in hospitals. In the past, there was minimal conflict because everyone worked in the roles for which they were designed. Everything changed when medicine became corporatized and the Institute of Medicine(now National Academy of Medicine) introduced its paper on the “Future of Nursing” which would change the course of nursing. That campaign subsequently led to FPA, the mentality that NPs could practice medicine without supervision and the myth that NPs were equivalent to physicians. Thus began the enmity between physicians and NPs who expected(and still expect)physicians to train them while they simultaneously believe they are equivalent. That mindset was confirmed by the AANP president, Sophia Thomas, in the recent WGN report. There was no issue with PAs until they decided to pursue Optimal Team Practice(OTP) and expected physicians to support that nonsense while it throws physicians under the legal bus. I will not go into detail about OTP( here, except to advise physicians that the Delegation of Services Agreement(DSA) was your friend because it allowed individual physicians to have a say as to what duties they would delegate to PAs under their supervision. The practice agreement that is now part of OTP does not do that. It has to be an agreement amongst a “group” of physicians. So if a single physician in said group does not agree with the practice agreement, they are s**t out of luck. It goes forward whether they like it or not. Their individual voice has no place. I will never support OTP. That is my stance.

Everybody wants to practice medicine by contorting the law and education in any way possible, by professional misappropriation of titles and at times, by blatant deceit rather than follow the path that we know works and has worked for over 100+ years. Because it is just too damn long and expensive. Forgetting that despite the arduous path, there remains a number of people whose desire it is to come to the U.S. for a medical training because our model remains a beacon of high quality education. When you short-cut medical education, you short-cut the public. Do not expect the majority of physicians to sanction rubbish that is not in the best interest of the public.

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