NPs Getting More Independence Raises Debate

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 an article from Dr. Jonathan Leffert on the Department of Veterans Affairs giving nurse practitioners (NPs) more authority as well as an article from earlier this year on the uncertain role of NPs and physician assistants (PAs) from Gabriel Perna. The articles have been edited for space and are followed by comments made by readers at PhysiciansPractice.com.

The VA Giving NPs Practice Independence is a Mistake

By giving nurse practitioners full independence, the VA tells us that cost and political expedience is more important than quality in relation to Veteran's health. The VA has been under fire due to the inability of veterans to access the system in a timely manner. The solution is to empower a lower cost group of providers to render care to a complex group of patients without supervision.  

The consequences of this decision are dire. The NPs role in the healthcare system is to extend the physician's reach in areas of routine medical problems under direct supervision. From my experience, the VA patient is a complex patient with multiple medical problems that require an extensive base of knowledge and judgement. Without supervision, the consequences of under and over diagnosis are likely and significant.

Quality should never be sacrificed for cost or access. As a physician, my ethics always guide me to consider the patient's health above all other concerns. This demands that quality of care is paramount. By allowing NP's full independence in the VA system, it is clear that cost and access are more important in the VA administration's mind.

David cites statistics: "'One in 10 diagnoses are incorrect. Diagnostic error accounts for 40,000-80,000 U.S. deaths annually - somewhere between breast cancer and diabetes. Chances are we will all experience a diagnostic error in our lifetime.' (US Institute of Medicine 2015, BMJ Quality & Safety 25-Year Summary of US Malpractice Claims, 2013.)...'In some ways, we have a perfect storm for diagnostic innovation in primary care - nearly a billion visits to ambulatory physicians in the U.S. each year, and misdiagnosis is the most common cause of malpractice lawsuits' (Spotlight on Point-of-Care Testing; Innovation, Expansion Evident at AACC Clinical Lab Expo in Los Angeles…)

So tell me again how are [physicians] doing in the area of patient safety? Perhaps it is the physicians who need to fix their own lack of effective supervision problem instead of diverting attention to NPs. Food for thought..."

Susan comments: "…I suppose it would help the VA's bottom line not having to ensure qualified individuals are taking and using radiation (X-rays) for our veterans and their families, but what about the bottom line in healthcare costs when the incorrect examination is ordered or has to be repeated?..."

Pauline says: "Very short sided view. We in the UK practice independently alongside our medical colleagues, which in every survey of patient satisfaction shows not only equal quality care but increased holistic input for patients."

The Uncertain Role of NPs and PAs in Today's Practice

"Nurse practitioners … only need 600 hours [of training]. If they worked a 40-hour week for 12 weeks, they'd be done with clinical training. Think about a doctor. It's almost 25,000 hours," says Christ, who claims the key to solving the primary-care physician shortage is making the profession more lucrative to physicians, who come out of medical school with a lot of debt.

Cooke does not dispute physicians have more hours of training, a critique she has heard often. Despite this, she says, "Most NPs become a nurse first and the expertise from working as an RN for many years actually augments what [NPs] do every day in clinical practice. It's important to note that we all bring things to the table. Even though our education is different, it doesn't make one worse or better."

This holds true in Seymour's practice, where she manages each NP to a certain degree, overseeing their charts depending on their experience. For the most part, she says she works side by side with them. They give Seymour recommendations, read X-rays, take care of lab and radiology reports, and more. For some issues, she is more hands on and for minor issues, she lets them take the lead.

But for people like Christ, nurse practitioners can't provide substitute care because there is a difference. She says being a doctor is a "calling" and they take patients on as part of their lives, while being a NP is a "job." "That is a vastly different way of looking at things," she says.

Deborah writes: "I find it offensive that Dr. Mary Christ makes the blanket statement that nurse practitioners think of our professions as 'jobs' and not a 'calling.' Being a nurse practitioner for me is a calling. I find many, not all, physicians I work with who treat their professions as 'jobs,' high tailing it out of the office at the close of the clinic day while many dedicated NPs stay after hours or come in on the weekends to make calls to patients following up."

Shannon responds: "Very well stated...and so true. We are a team it takes all of us…I was angered at the same statement. It's my life and I sacrifice family time for my patients. I work as hard, or harder, than many of my colleagues because I practice where I live and they commute so I never have a moment out of my patients' eyes and requests."

Parveen says: "As a physician, I will never agree to back up an independently practicing PA or ARNP and deal with their inferior skill and misdiagnosed or botched up cases."

Stephen agrees: "Agreed. They should know their level of incompetence and when to walk away/and refer just like a PCP will with a specialist to help."