Keeping My Former Profession Honest: A Refutation of AANP Position Statement on Educational Effectiveness


Honesty is defined as “free of deceit and untruthfulness; sincere.”1 Honestly, I had a great nursing career being a Registered Nurse (RN) for 15 years followed by 8 years of being a Nurse Practitioner (NP) before embarking on my journey to become a Physician.  I will say it again, I love bedside RNs and thoroughly enjoyed my time as an NP on Physician led teams on inpatient units. In reference to the American Association of Nurse Practitioners (AANP) position statement on Educational Effectiveness titled “Clinical Outcomes: The Yardstick of Educational Effectiveness,”2 I find it somewhat less than honest. As such, this hurts the Nurse Practitioners (NPs) that are out there on the front lines on Physician led teams doing the daily grind. My former profession is being led astray and harming those NPs that are out there doing good work. This is evidenced where it says:

“In the more than 100 studies on care provided by both nurse practitioners and physicians, not a single study has found that nurse practitioners provide inferior services.”2

First of all, the source for this statement is an opinion paper and not a meta-analysis nor systemic review.3   Secondly, it is unclear as to where the notion of inferiority and superiority is coming from. Thirdly, the opinion paper itself states:

“Of more than 100 published, post- OTA reports on the quality of care provided by both nurse practitioners and physicians, not a single study has found that nurse practitioners provide inferior services within the overlapping scopes of licensed practice.”3

Which is confusing on a number of fronts. One practitioner practices medicine and the other practices nursing, so is there really overlapping scopes of practice? On one hand no because nursing is nursing and medicine is medicine, but on the other hand yes, because some of the Physician’s roles have been hijacked by the nursing profession and nurses are practicing medicine under the guise of advanced practice nursing. But taking a deeper look, this statement isn’t even referenced. This opinion paper3 further references:

“The internationally respected Cochrane Collaboration has recently produced a detailed review of this cumulative literature, citing more than three dozen objective studies that suggest patient care outcomes are similar.  (The Cochrane review also suggests that nurse practitioners consistently score better on subjective measures of quality, such as patient satisfaction.)” 3,4

However, upon review of this literature summary, it states:

“The findings suggest that appropriately trained nurses can produce as high quality care as primary care doctors and achieve as good health outcomes for patients. However, this conclusion should be viewed with caution given that only one study was powered to assess equivalence of care, many studies had methodological limitations, and patient follow-up was generally 12 months or less.”4

So to summarize, the AANP Position2 statement references an opinion paper3 which references a literature summary4 which concludes:

“this conclusion should be viewed with caution given that only one study was powered to assess equivalence of care, many studies had methodological limitations, and patient follow-up was generally 12 months or less.”4

Furthermore, a 2014 literature review titled Substitution of physicians by nurses in primary care: a systematic review and meta-analysis,”5 states in it’s conclusion:

“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.”5

Another review6 which is an update to an earlier review4  lists several outcome measures but lists the evidence as a certainty level of low to low-moderate and concludes:

“The effects of nurse-led primary care on the amount of advice and information given to patients, and on whether guidelines are followed, are uncertain as the certainty of these findings is very low.”

Lastly, in the AANP statement where it states:

“In fact, these studies have shown that NPs have the same or better patient outcomes when compared to physicians.”

The actual statement was plagiarized from the opinion paper,3 but was done so incorrectly and not cited. The actual statement from the opinion paper3:

“The paper presents extensive, consistent evidence that nurse practitioners provide care of equal or better quality at lower cost than comparable services provided by other qualified health professionals.”

What’s important to note is that the opinion paper does not state comparable to physicians. This whole AANP Position Statement is a dishonest manipulation of literature. I have many other issues with this position statement such as it’s premise of not considering educational preparation in evaluating primary care, and others, but will save that for another time. Have a great day.

REFERENCES

  1. https://www.merriam-webster.com/dictionary/honest
  2. https://storage.aanp.org/www/documents/advocacy/position-papers/ClinicalOutcomesYardstick.pdf
  3. Bauer, J.C. (2010). Nurse practitioners as an underutilized resource for health reform: Evidence-based demonstrations of cost-effectiveness. Journal of the American Academy of Nurse Practitioners 22 (2010) 228–231. doi:10.1111/j.1745-7599.2010.00498.x
  4. Laurant MReeves DHermens RBraspenning JGrol RSibbald B. (2005). Substitution of doctors by nurses in primary care. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD001271.
  5. 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
  6. Laurant M, van der Biezen M, Wijers N, Watananirun K, Kontopantelis E, van Vught AJAH. Nurses as substitutes for doctors in primary care. Cochrane Database of Systematic Reviews 2018, Issue 7. Art. No.: CD001271. DOI: 10.1002/14651858.CD001271.pub3.

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Robert Duprey

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 

  6 comments for “Keeping My Former Profession Honest: A Refutation of AANP Position Statement on Educational Effectiveness

  1. Ellen Luse
    May 8, 2019 at 1:41 pm

    I love to read these dissertations!! I am a retired pharmacist and as such, found it my job to always assess my patients and discern the appropriateness of medications prescribed … not just for dosages, frequencies, etc, but even for appropriateness of disease states!! Was I overstepping my position?? There were times when I found a physician entirely incapable of treating a particular patient!! My only recourse was to confiscate said prescription, and after consulting with another trusted physician, send the patient to said trusted physician!! Did any of you physicians realize I was out there working to save your license and your patient’s life? The prescribing physician cursed me and threatened to have my license!! He was not successful if he even tried!! The physician I consulted with, thankfully, had my back, but should I have needed that?? All I can say is you MD’s spent one term studying the same pharmacology text that I spent 3 years and more studying!! I spent a good bit of time studying anatomy, physiology, and the knowledge of disease states even investing in further medical tomes about disease states and treatments on my own time!! Am I an M.D. … no!! Just a lowly pharmacist who cared to learn a whole lot more about diseases, etc so I could better take care of YOUR (and my) patients!!

    I don’t know how this fits in with the above discussion because I have no idea about Flexner??? I’ve been retired for quite a while so maybe I’m out of line, but I just couldn’t sit here and say nothing!

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    • Ellen Luse
      May 8, 2019 at 2:08 pm

      PS. My extra background is that my grandfather (whom I never knew) was a generalist physician who met my grandmother who was a nurse assisting in the surgical ward at the time. He had a brother who was a surgeon and one who was a dentist both of whom I met after I became a pharmacist.

  2. Martha Oreilly
    May 6, 2019 at 1:45 pm

    It is my understanding that the AANP bases their “equal or superior to physician care” statements on flawed studies based on short term care of patients with a known diagnosis managed by supervised NPs! No bearing on unsupervised practice. No bearing on dianostic acumen. Timelines are incredibly brief. But AANP extrapolated this weak evidence to mean that NPs are able to practice medicine unsupervised and without full medical training over the lifetime of the patient.

  3. PW
    May 6, 2019 at 10:38 am

    I don’t believe “position statements” anymore.

  4. Steve O'
    May 6, 2019 at 9:16 am

    Congratulations, welcome, and best wishes! Your mind is independent, something that is increasingly rare today. You may gain great satisfaction from learning from teachers in the golden age of American medical practice, which occurred over several decades in the 20th century. What is now, and what was before then, is vastly inferior to those great days of medicine.
    One of the most-cited and least-understood readings is The Care of The Patient, by Dr. Francis Peabody. It is a condensation of Peabody’s bedside teachings into a speech. It only became a written essay because Peabody was dying of sarcoma at the age of 45, and his students and friends begged him to publish his thoughts.
    Medicine is, and always will be, an oral tradition. It is centered on the interview, the dialectic of patient and physician. Psychiatry discovered the truth, “Take a history until the patient gets better.” The presence of testing instruments and certain treatments has never supplanted the ability to listen. Moderns in scientific medicine are frustrated by this core truth, and strive to supplant the dialectic with the algorithm.
    Modernist medicine is in fact superstitious, not scientific. Essential skills are not learned, while irrelevant trivia is memorized. It has come full-circle to become again the sort of medical education criticized in the Flexner Report. There, Flexner found endless classroom lecturing, recitation and regurgitation, with no practical bedside experience. Given your path into medicine, which started at the bedside and only then came to the classroom, you may understand some of your less-fortunate colleagues who were poorly educated in some of the best schools in the nation.
    I caution anyone who reads the Flexner Report that it is biased, full of prejudice of the times, and especially boring. His next long work was a study on prostitution in Europe. I read part of it, but could not plow very far into it. Flexner can make sex boring.
    People are eager to cheapen the coin of medical practice, adding the pretense that the Nurse Practitioner, and then the Physician Assistant, and next the EMT and Nurse’s Aides, can practice just as well as the physician. That is not originating in some internecine squabble between licensed professionals. It is a consequence of the rapid decline of American Medicine, which is unable to deliver adequate and affordable care. That is due to the decline and fall of American Medicine into a third-world model, which is rapidly coming.
    So congratulations, and excel! But do not expect to excel in a crowd. The tide is receding.

    • Taz
      May 6, 2019 at 1:12 pm

      I would agree with much of what you are saying. Where I disagree is that the medical education taught is reminiscent of the days when Flexner traveled around the U.S. and Canada to find the “ideal” medical school. Back then, medical education was not structured. The models ranged from apprenticeships to formal medical school training and versions in between. Today it is and remains based on the John Hopkins model. Much of medicine is redundancy, the more one sees a particular disease process the more likely one is to remember it and and the various presentations of that process. I submit that the redundancy is necessary. However, I also agree that algorithmic medicine is becoming the status quo in clinical practice because of the metric hoops we are required to jump through. By default, med students are becoming more used by attendings to meet those metrics, attendings who are not reciprocating with the teaching that is required. What I’m saying is the structure for medical education is there and remains sufficient, but if those within that educational format choose to allow the business of medicine to guide their teaching(or not) rather than the inherent obligation expected by students matriculating at a particular institution, it is they who add significantly to the deterioration of medical education as we know it. It is they who are guilty of devaluing our education….by choice.

      Permitting those from outside the discipline of medicine to practice medicine with their respective training is more reminiscent of the pre-Flexner era. No consistency, no regulation, no structure, no accountability.

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