A Commentary on: “As Nurse Practitioners Try To Shake Free Of Doctors, Kansas Physicians Resist”

This article has been floating around various news feeds for a couple days now and I thought it could use a more formal response. In my opinion, the Kansas State Legislature, The Kansas Medical Society, and Kansas Physicians (MDs), have it right by requiring collaborative practice agreements between Nurse Practitioners (NPs) and MDs. However, I believe this article as with so much rhetoric and political bias against MDs, attempts to gain the sympathy of the NPs in lieu of objective data. I mention objective data for a reason. It’s lacking. It’s lacking in this article. It’s lacking in sources mentioned2in the article, and it’s lacking in general in the argument against collaborative agreements for full practice authority (FPA). It’s lacking in describing exactly how NPs are not able to practice to the full extent of their education and scopes of practice. One example I’d like to highlight is where the article references the National Academy of Medicine: 

“No studies suggest that (advanced practice nurses) are less able than physicians to deliver care that is safe, effective, and efficient,”2

What’s the point of this statement anyway? Because no studies exist, we have to accept the antithesis of this statement suggesting equality, superiority, or safety? Isn’t that like being asked to accept the null hypothesis without data? Am I having a research flashback about Type II errors3? That would be erroneous on a number of fronts. From a 2014 systemic review4:

“The available evidence continues to be limited by the quality of the research considered”……”The slowly growing number of studies, assessing substitution of physicians by nurses is still substantially limited by methodological deficiencies.”3

Thus could it not be equally stated in an alternative hypothesis?:

No studies suggest that (advanced practice nurses) are a viable substitution to physicians to deliver care that is safe, effective, and equally efficient to that of residency trained board certified physicians

Just saying. On a closer look at the referenced source from the article from the National Academy of Medicine,The Future of Nursing Focus on Scope of Practice, the actual quote is as follows:

No studies suggest that APRNs are less able than physicians to deliver care that is safe, effective, and efficient or that care is better in states with more restrictive scope of practice regulations for APRNs. In fact, evidence shows that nurses pro­vide quality care to patients, including preventing medication errors, reducing or eliminating infec­tions, and easing the transition patients make from hospital to home.

This is worth mentioning because you could paraphrase it like this:

No studies compare the ability of APRNs to do the MD’s job but there is evidence that nurses can do a nurse’s jobs. 

However, none of this is cited evidence in this consensus model opinion. I’m finding this typical in various writings on the topic. Literature is not supported by evidence or facts. The terms “evidence shows….”is often not backed up with actual evidence. As if it’s a strong thing to say assuming no one will look deeper than face values for the actual evidence. In this case, both the news article and reference lack objective evidence. But back to the original article, it attempts to offer anecdotes and snippets as support for ceasing collaborative practice agreements. This non-evidence is not even worth further mentioning. 

In summary, there is a general lack of objective evidence supporting the discontinuation of NP/MD collaborative practice agreements. As stated earlier, I believe the Kansas State Legislature, The Kansas Medical Society, and Kansas Physicians have this one right. Have a great day. 

REFERENCES

  1. https://www.kcur.org/post/nurse-practitioners-try-shake-free-doctors-kansas-physicians-resist#stream/0
  2. http://nationalacademies.org/hmd/~/media/Files/Report%20Files/2010/The-Future-of-Nursing/Nursing%20Scope%20of%20Practice%202010%20Brief.pdf
  3. Banerjee A, Chitnis UB, Jadhav SL, Bhawalkar JS, Chaudhury S. Hypothesis testing, type I and type II errors. Ind Psychiatry J. 2009;18(2):127–131. doi:10.4103/0972-6748.62274. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2996198/
  4. Martínez-González et al. Substitution of physicians by nurses in primary care: a systematic review and meta-analysis. BMC Health Services Research 2014, 14:214 http://www.biomedcentral.com/1472-6963/14/214

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Robert Duprey MD

Robert P. Duprey Jr studied medicine as a 2nd career medical student who went to medical school in his 40’s after honorable discharge and ‘retirement’ from 25 years in the US Military (USCG & US Army). He was a registered nurse (RN) with specialty training as a psychiatric RN in the US Army for 15 years. During this time he also became a Master’s level psychotherapist in 2002. While on US Army active duty he also became a Psychiatric Nurse Practitioner while working full time in 2011. He served as a Psych NP on active duty, to include a combat tour in Iraq, until his ‘retirement’ in 2014 and moved to Philippines with his 3 children. At this time he started medical school overseas at Oceania University of Medicine based out of Samoa accredited by Philippine Accrediting Association of Schools, Colleges and Universities (PAASCU). He continued to work as a Psych NP throughout medical school to support his children and to not have to take out loans for medical school tuition. Originally from Rhode Island, he completed medical school clerkship rotations throughout the USA with a graduation in May 2019 earning the esteemed credential of MD. He has successfully completed USMLE Steps 1, 2CS, and 2CK. He will take Step 3 this September as he applies for Psychiatry Residency. Having been and RN, NP and now MD, he is a believer of Physician led multidisciplinary healthcare teams 

  8 comments for “A Commentary on: “As Nurse Practitioners Try To Shake Free Of Doctors, Kansas Physicians Resist”

  1. May 15, 2019 at 7:59 am

    agree completely. I am finding myself repeatedly considering how I would feel about the subject of NP independence if they included tort reform in their pleas for independent practice. In other words, “let the buyer beware – that NO physician pocket will be available when your health goes sideways while a nurse watched it – or helped it – to happen.”

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  2. Dave
    May 14, 2019 at 2:58 pm

    I think it was one of the true elder statesmen in my specialty, Greg Henry (although I’m having a hard time finding a citation), who said, in effect: “The PAs and NPs I work with are excellent, and can do 90% of what I do. It’s that 10% which makes me invaluable.”

    …and as Doug has always said, “Your training and experience does matter!”

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  3. Jaclyn Nadler MD
    May 14, 2019 at 8:30 am

    Thanks for your commentary Robert. Every time I come across this article it irks me more and more. The comment about errors and physician’s living in glass houses particularly. What most don’t realized is that although anyone can make an error, it’s a very different thing when you make an error due to lack of knowledge or experience. Yes, physicians makes errors all the time, for a multitude of reasons, but it should not be from lack of a medical education. Our patients are human and we are human so errors will always occur. My concern is the commonplace errors and mismanagement that are happening with the exponential growth of midlevels completing watered down online educational programs and completing superficial clinicals (shadowing) that will only exacerbate this issues and place on top of that lack of supervision from an experienced physician and you have a recipe for disaster. Having been an NP prior to physician like you, I have witnessed firsthand the differences in education of an NP and MD. I did not understand the basic science behind what I was doing and to some extent had to relearn pathophysiology since medical school provided me those critical tools for better understanding. Upon completion of my training I was very fortunate to have worked with an amazing physician who took me under his wing and helped to round out my knowledge base. I would have been totally unprepared to safely manage patients without his mentoring and oversight.

    The NP organizations and educational institutions are driving a wedge between the nursing and medical professions which will only hurt future NPs who will not have collaborative support from a physician. These same organizations also argue that physicians are overeducated and our additional time in training and residency was useless. Anyone who trivializes education is very shortsighted. They don’t understand the repetition of seeing common things over and over gives us the confidence to manage these conditions appropriately and independently upon completion of our training. It also allows us to be more aware of subtle signs and symptoms of a more elusive and potentially fatal diagnosis that a midlevel is not equipped to identify or manage.

    Unfortunately our society had been pushed to believe it is okay to do more with less as we see in many other areas of business, and now society has allows this philosophy to infiltrate the care of Americans with the support of weak and narrow minded lawmakers.

  4. bbneo
    May 14, 2019 at 7:34 am

    Basic strategy here is 4 people to get used to the idea that the nurse practitioner or PA is best they can do for primary Care. Eventually, memories of physician care will fade and we will be stuck with what is left.

    That is, and until, models like DPC grow to provide the reasonable free-market alternative.

  5. James Tinsley
    May 14, 2019 at 6:59 am

    Their independence is inevitable and it is our fault. The AMA and AAFP have done nothing to help us. However there must be truth in advertising if they are to operate independently. Where is the AMA and AAFP on this?

    • bbneo
      May 14, 2019 at 7:30 am

      Where they usually are.

    • May 15, 2019 at 7:59 am

      agree completely. I am finding myself repeatedly considering how I would feel about the subject of NP independence if they included tort reform in their pleas for independent practice. In other words, “let the buyer beware – that NO physician pocket will be available when your health goes sideways while a nurse watched it – or helped it – to happen.”

  6. Thomas David Guastavino
    May 14, 2019 at 6:51 am

    “In times of economic stress, jobs will flow down to the person who it is perceived will be able to do the job for the least amount of money”

Comments are closed.