I must admit, when I heard that the American College of Physicians (ACP) had published a policy monograph1 relating to NPs, I groaned. I dreaded yet one more attempt by a non–nursing professional organization to weigh in on what they believe is the scope of nursing practice. When I read the document, I was somewhat surprised that in fact, I agreed with many of the tenets of the policy; I just had a different way of seeing how they should be applied.
Yes, NPs, PAs, and MDs have all been educated differently. But I disagree that the physician is “often the most appropriate professional” to provide primary care. With much of primary care geared toward health promotion, the strength of NP care is preventing disease and teaching patients about how to get healthy and stay healthy. That does not mean we’re incapable of caring for those who are ill or for those with comorbidities. It does mean that we work with our patients to prevent the untoward sequelae of their health problems. The educational guidance NPs provide in the course of care is, in my opinion, far more valuable and therapeutic than most of the prescriptions that are written.
I also want to point out that many of the skills physicians have obtained, they learned from, or with the assistance of, a nurse. I, for one, have not only mentored many interns and residents but have also been the person many of my physician colleagues have consulted because of my expertise and years of experience. So this discussion isn’t about our educational beginnings, but rather how we have developed our knowledge, skills, and abilities, and how we continue to hone them.
The comments in the ACP policy regarding the doctorate of nursing practice are not unique to the ACP. Many have vacillated on the degree and whether it should be an “entry-level” requirement for NPs. The ACP is accurate in noting that the competency areas of the DNP are focused on systems-based practice and policy. On this issue—at the risk of being ostracized by some of my colleagues—I will publicly acknowledge my opposition to the DNP as entry level into the NP role. Where I disagree with the ACP is its statement that the use of the title Doctor could lead to “confusion and misconceptions” among patients. I think it is more misleading when physicians refer to the medical assistants in their practice as “the nurse.” The title Doctor is used in academia, in psychology, and in pharmacy. For patients to be provided information about the different health care providers in the practice is important, but people who have earned their doctoral degree have every right to use the title. It is not owned by the medical profession.
The acknowledgment that NPs provide access to health care in both rural and urban areas is rather a left-handed compliment. As I read and reread the document, it appeared to me that the ACP believes the need for access to care is not a sufficient reason for reimbursement, prescriptive authority, or an “expanded role” for NPs. However, they do support NPs’ providing care in “underserved areas.” I agree that we provide that essential access, but we provide it in all areas and by patient choice—not just to the underserved. Moreover, we have continued to provide that care in locations that our physician colleagues have either avoided or abandoned.
What continues to be a barrier to providing NP services for those whose primary care provider is an NP is the issue of reimbursement. In my opinion, the system of paying for the provider, not the service, is one of the key reasons our health care expenditures have gotten out of control. That the reimbursement language is often “physician service”–based is problematic. I find it interesting that the ACP, though recognizing “the important role” NPs play in meeting the need for access to care, does not include a recommendation that reimbursement for NPs be standardized.
Research has been conducted repeatedly to determine whether the care we NPs provide is of high quality, safe, and affordable. While I agree that continued research on our professions may put to rest the ever-surfacing questions about patient outcomes, it is just as important to study all health care providers in that research and for the research team to include NPs, PAs, and MDs, rather than just one profession examining another. That the ACP recommends viewing “with caution” the research findings on patient outcomes amuses me. Apparently, many studies had “methodological limitations,” and only one study with sufficient power had been done. If that one study had examined outcomes for physicians’ patients, would the ACP have made the same cautionary remarks?
The recommendation that research is needed “to develop effective systems of consultation” leads me to question whether the authors of the ACP document have ever observed a nurse practitioner in action—or, for that matter, any of the other professionals with whom they consult and collaborate in their everyday practice. There are well-established systems already in place, and HMOs, college health services, and community health centers are shining examples. In all of these settings, the health care team functions as an efficient, effective body, offering patients excellent care and access to the professional most appropriate for their management and treatment. The research we really need is on how to replicate those successful systems and make them the paradigm for primary care throughout the United States.
The best health care system is one in which all the providers share the ultimate responsibility for the care provided. Each professional has the obligation to function to the fullest extent of his or her scope of practice and capability. The days of a hierarchical system in which the physician is the “captain of the ship” are gone. The idea that one profession can constrain another profession is ludicrous. In this regard, it appears the ACP agrees that the nursing discipline is the body to be charged with developing scope-of-practice statutes and regulations. I encourage the ACP to work with other physician groups to embrace this notion and to refrain from interfering with legislation that guarantees NPs the ability to function to the fullest extent of their profession.
I will be interested to read the ACP policy on physician assistants. I was appalled that in the current document, the authors referred to my PA colleagues in the possessive (“physician’s assistants”)—but I will leave it to PA Editor-in-Chief Randy Danielsen to deal with that faux pas.
1. American College of Physicians. Nurse Practitioners in Primary Care. Philadelphia, PA: American College of Physicians; 2009.