Race Car Model 2: AANP President Weighs in on Full Practice Authority Laws

I’m disheartened by the dishonesty and rhetoric being put out there by my former profession. I wrote about the Race-Car-Model (2) previously whereby simply having a driver’s license doesn’t automatically qualify you to drive a racecar. Driving a car is the practice of nursing. Driving a racecar is the practice of medicine. Let me add to this by saying that advance practice nursing is like driving a motorcycle – you need a driver’s license first then you can get a motorcycle license. You need an RN license first then you can get an APRN license. The analogy of driving a car is now emerging in literature often, and now inappropriately references permission slips:

“Imagine for a moment what it would be like if you owned your car and had a state-issued driver’s license, but had to obtain a permission slip from a neighbor before you could drive?”

            Permission slips are supposedly collaboration agreements, which are viewed as a barrier to full practice authority. Hold on a minute if I disagree on a number of fronts. Your permission slip is your nursing (RN) license and APRN license. Like needing a driver’s license (RN) license to practice professional nursing, then having an APRN license, as an extension of the RN license to practice advance practice nursing. It allows you to drive in accordance with state standards on all kinds of roads (professional nursing or advanced practice nursing). What it doesn’t allow you to do is to drive a racecar (practice medicine). For this you need a NASCAR license i.e. a medical license. 

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“Each state issues individual nursing licenses that are just like driver’s licenses, which authorize individuals to drive automobiles — except for the fact that authorization for practice can end at the state line (1).”

What’s the problem? That’s the same for RN, APRN, and medical licenses too. 

“These permission slips also could limit your ability to drive on the highway or even make right-hand turns. Sounds pretty ridiculous, right? (1)”

No they don’t! Your nursing license allows you to practice nursing.  RN license to practice professional nursing. APRN license to practice advance practice nursing. How is this not understood? Obvious confusion on scope of practice going on here. 

The practice of medicine: driving the racecar. What this article does is hijack the definition of practicing medicine and is now calling it the practice of advance practice nursing. It says:

“State practice and licensure laws permit all NPs to:

  • Evaluate patients
  • Diagnose, order and interpret diagnostic tests
  • Initiate and manage treatments, including prescribing medications and controlled substances, under the exclusive licensure authority of the state board of nursing (1)”

Looks a lot like the practice of medicine right? Using the driving analogy, this article is saying that having a motorcycle license is now by default a racecar license. Taking one thing and redefining it with someone else’s definition / discipline. Full practice authority is the code word for practicing medicine without a medical license. How about we all stay in our own lanes?

And speaking of staying in your lane, the primary care physician shortage is a physician problem to solve, not a nursing problem. The article says it’s now a nursing problem. More hijacking:

One of the most profound ways outdated laws affect patients is in geographic health disparity areas or health provider shortage areas (1).

There’s so much more wrong and dishonest in this article, I’ll save it for another blog. I’m sure militant members of my former profession will scorn, insult, ascribe hatred and project vitriol onto me. I’m not hating. I have respect for both professional nursing and advance practice nursing as team members and team players on physician lead multi-disciplinary health care teams. I formerly practiced advance practice nursing in both full practice states and those requiring collaborative agreements and you know what? There was no difference in what I could and couldn’t do – the difference was just how I could do it. Funny thing though, I understand where APRN’s today are coming from. I disagree now, but there was a time where I didn’t disagree. Using the driving analogy – the above pictured motorcycle was my actual Harley (the one I sold to pay medical school tuition J). When I got my motorcycle license and my first Harley, I felt super human. I would race up I95 from Daytona Bike Week doing 130 MPH and I felt like a racecar driver. But feeling like one and acting like one on the interstate didn’t make me one. Like when I first received my APRN license, I felt like that superhuman racing up I95 at 130 on my Harley. But I quickly and humbly learned that it’s better and safer if I stayed in my lane and drove the speed limit. I wasn’t a racecar driver. I wasn’t an MD (not yet anyway). As an MD now I understand what I didn’t know as an APRN. It’s not a ding on APRN education (that’s another hot topic), but rather a fact on the notion of breadth, depth, and critical thinking methodology inherent in medical education not seen in the APRN education. Here’s the irony – as a new APRN, I felt superhuman and unafraid. As a new MD, from what I know now, I am more cautious and scared then ever before as I fully understand the ramifications of responsibility bestowed upon me.  Driving my Harley, I was at times reckless, fearless, and unsafe but I didn’t know any better. It’s the culture and what is taught. Yes I took the requisite training courses, but it didn’t train me to be a racecar driver. Racecar drivers are considered professional drivers, the most educated, the highest trained, safer, and better equipped to manage disasters at high speeds. You just simply can’t be a racecar driver or call yourself one if all you’re trained to do is drive a Harley. 

The dishonesty needs to stop (3).

REFERENCES

  1. https://www.nurse.com/blog/2019/09/10/np-shares-insight-full-practice-authority-laws/?fbclid=IwAR3EC0tW1IRyKqy1w_s9DsHERKUrR5eOGoJEnpHetUD4ZqS3aBRYXdZw0yw)
  2. https://authenticmedicine.com/race-car-model-nurse-practitioners-fight-for-more-freedom/
  3. https://authenticmedicine.com/straw-man-the-dishonesty-needs-to-stop/

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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 

  5 comments for “Race Car Model 2: AANP President Weighs in on Full Practice Authority Laws

  1. Celia B Entwistle MD
    September 18, 2019 at 9:35 am

    Thank you for your article and fighting the good fight.

  2. Pat
    September 18, 2019 at 9:01 am

    ARNP’s wanting unlimited, unsupervised practice are fakes, pure and simple. F-A-K-E-S.

    That said, this entire trend underscores why there should be no government sanctioned medical licenses (I’m serious). Let real doctors be certified by their respective boards, let hospitals hire who they please, and let any patient go to any physician, chiropractor, ARNP, witch doctor, crystal salesman, aroma therapist, midwife/doula/advanced feminist studies professor, buttocks silicone injection specialist, or auto mechanic they please. Let the buyer beware, and to hell with all of this.

    • Kurt
      September 19, 2019 at 2:05 pm

      Yeah, but try to get insurance to pay for it!! 🙂 (attempted humor)

    • JoAnne Fox
      September 21, 2019 at 6:24 pm

      Pat – surprise here – this APRN basically agrees with you. We were not trained to have unlimited practice, but to recognize and manage the common, the usual, the typical, AND to recognize when this horse wasn’t quite acting like a horse, acknowledge it was likely a zebra and send the patient on. We each (at all levels) have our own personal scopes of practice. An APRN with lots of pulmonary experience and education may well be comfortable with a patient I personally would seek collaboration for. An MD who’s dealt with exclusively womans’ health and pregnancy probably shouldn’t w/u a suspected neurological issue without collaboration. My personal objection to my “collaborative agreement” is that’s not what it does. The government mandates a paperwork exercise after the fact that does nothing for anyone. What I would ask is the respect to allow me to function within my personal scope, and the trust that if I need to collaborate with someone, I will seek out an appropriate party regardless of whose name is on the government mandated paperwork agreement.

      • Pat
        September 22, 2019 at 10:53 pm

        Bravo JoAnne. I’ve had great relationships and experiences with some excellent APRN’s, none of whom would ever claim to be something they were not. The dishonesty of the organized “independent practice” NP’s is infuriating.

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