The Inbox: Battling Over Scope of Practice

August 5, 2016

In our recurring blog "Inbox" we share comments from physicians and practice administrators telling us what keeps them awake at night.

Editor's note: We work hard to write about issues that will help physicians run their practices in a manner that is both prosperous and efficient, while still delivering quality patient care. And we are delighted when our readers let us know what they are thinking. This month we are excerpting a blog by managing editor Gabriel Perna that was written about the VA's plan to expand scope of practice for advanced practice nurses to address long wait times for treatment. The article has been edited for space and is followed by comments made by readers at PhysiciansPractice.com.

This Battle Over APRNs Feels Familiar

… In case you were under a rock during the spring of 2014, a Veterans Affairs internal investigation revealed that more than 1,000 veterans had waited months to see a doctor to receive care at the Phoenix VHA facility. Of the 1,000-plus veterans, at least 40 had died while on the waiting list, CNN reported at the time. The number was later revised to 35, but the CNN report turned this issue into a full-blown scandal. You couldn't flip on cable news channels without someone weighing in about the VHA's failure to care for veterans.

… About one day after this latest snafu, the VHA announced a proposal that aims to quiet its doubters and fix the issue, once and for all. The proposal would expand the scope of practice for advanced practice registered nurses (APRNs), giving them full practice authority when they are acting within the scope of their VA employment.

Seeing as the VA is the country's largest health system, this move could have major ramifications. … The nation's largest doctor group, the AMA went on the attack: "While the AMA supports the VA in addressing the challenges that exist within the VA health system, we believe that providing physician-led, patient-centered, team-based patient care is the best approach to improving quality care for our country's veterans."

The American Association of Nurse Practitioners (AANP), on the other hand, applauded the move: "Veterans stand to significantly benefit from this essential VA policy update, which gives them unencumbered access to nurse practitioners and the excellent, compassionate, and patient-centered care they provide," said AANP President Cindy Cooke in a statement.

* Editor's note: The comment period closed July 25, 2016. The VA will make a decision in the next few months, according to The Washington Post.

Elise, a board-certified family physician, says: I volunteer with several universities as a nurse practitioner (NP) preceptor [instructor]. An NP has a number of hours to complete, between 90-180 hours for the whole semester. They do not need an hour more. I agree that new NP grads are smart and capable, but they don't have the number of patient hours required to have those instincts to detect whether some other underlying problem exists. They are very protocol driven. I recommend that any new NP grad work directly with a physician who can guide them, continue to teach, be a resource for questions about complicated cases, for at least three years before venturing out on their own to a retail clinic or similar. By then, they will have a good grasp on the issues before them. At five years with the above the conditions, by all means, give them license to practice independently. PA's are trained to think like doctors, but they don't have the same experience as physicians either. They also need more time after graduation to develop those instincts. I think a similar amount of time working directly with a physician should be required before giving them independence. However, PA's recognize their limitations and are not fighting for the right to practice independently.

Dana writes: Absolutely no. When nurses undergo four years of medical school training, at least three or more years of residency (1,000s of hours), not to mention hundreds of thousands of dollars in medical school loans, then it could be considered. How can anyone compare the level of training, hours and months of sleepless nights in residency, and need to make life and death decisions at a moment's notice - doctors' experiences throughout their career - in any way to the much shorter, much abbreviated, and significantly superficial training nurses experience. I make this comment not to be derogatory to nurses, who do have a role in healthcare, but instead to underscore the significant difference in experience. … Would you trust your life, or that of your loved ones, to someone who has such a narrow scope of differentials and lack of hard-earned experience? You be the judge.

Peter comments: Supporting NPs and PAs with telemedicine is one way to ensure they can provide appropriate care in lieu of a physician, who may be too expensive to be deployed in a small, rural community. Within the VA, mid-levels conduct many intake functions and provide routine follow-up care. For mid-levels trained in emergency medicine, they can be front-line triage managers.

Elise responds: Peter, I completely agree with you. The VA definitely needs to utilize PAs and NPs, but with physician oversight of each provider. In Texas, one physician can supervise up to seven PAs or NPs, and no longer needs to review 10 percent of charts.

David writes: I would estimate that 95 percent of what enters a primary-care office can be appropriately handled by an APRN or PA. The 5 percent that need additional work can be handled by specialists' consults. It is time for the MD world to primarily focus on specialty care where their medical school background can be best utilized. Primary care, population health, chronic care, are venues for APRNs and PAs. Even in the PCMH model, many MDs are handing off the follow-up treatment to their APRNs and PAs. Embrace the future and let go of the past.

Cheri says: David, you obviously don't practice primary care. Advanced practice nurses and physicians assistants are great at following checklists and being nice while doing that, but put the really tough puzzles in front of them and they don't even see how hard it really is. Cough in 63-year-old diabetic trucker in December = bronchitis or [gastroesophageal reflux disease] according to the checklist, but in the real world it also includes heart failure secondary to metastatic cancer - missed by half a dozen midlevels before he saw me, they never even checked for edema. People are killed by what we don't know that we don't know, primary care REQUIRES an astute diagnostician.

David responds: I think would could agree that even among MDs there are various levels of expertise. I am very familiar with a NP who runs a headache clinic for the VA within neurology. She started her practice under family medicine but has worked in neurology for over 13 years. The patients she receives have been seen by primary care (MD), seen by a neurologist and then sent to her because the patient has not responded to [his] treatment recommendations. 65 percent of her patients have a diagnosis of occipital neuralgia as a component of their headache that was missed by all previous providers (MDs). Some of her patients have been having headaches for over 30 years. She performs occipital blocks, BOTOX, acupuncture and educates the patients on self-help techniques. She relieves their headache on the first visit and then establishes appropriate follow up intervals. My point being, given the ability and authority to work at the top of their license, NPs will surprise you on their diagnostic and treatment skills.

Nikhil comments: David, Let us not forget that the NP you have mentioned has 13 years of mentoring with neurologists. Fresh NP graduates have a very limited idea of complexity of medical diagnosis. Their training is only for two and a half years. I feel sorry for the patients. They get overly investigated! When one does not understand pathophysiology well they end up over-investigating and over-referring.

Cheri says: The midlevel you describe is asking functioning in a narrow range, while she thrives there, what happens when someday she decides to do heart failure clinic. Does she return for a three-year cardiology fellowship? No - she just switches jobs. In my state where midlevels are allowed full scope practice they open their door as an "allergist" or "endocrinologist" then have free range to change specialty on a whim, and they DO! It's just downright scary

Geoff writes: I would agree that probably 80 percent to 85 percent of the patients that come in to primary care on any given day can be appropriately managed by a competent, well-precepted midlevel. But determining which of the patients are the ones in that population that they CAN'T [manage well], and knowing what to do is the problem.

What is your policy on expanding scope of practice for APRNs to address the physician shortage within the VA? Tell us what you think; join the conversation at bit.ly/battle-scope-practice.