Guest Author
There is no doubt that Florida’s shortage of primary-care physicians and nurses can make it difficult for patients to get access to health care.
While it is important for the medical community and lawmakers to seek solutions, doing so by lowering standards of care is not the answer. One proposal that Florida lawmakers are considering does just that.
The proposal expands the scope of practice of advanced registered nurse practitioners (ARNPs) by allowing them to prescribe medications and treatment regimens without any physician oversight. While we can appreciate efforts to address access to health care, the legislation does not have a patient’s best interest at heart. The patient’s best interest is always the highest quality care.
The proposed legislation fails to account for the difference in training and experience between physicians and nurses. Becoming a primary-care physician requires the completion of at least three years of graduate medical education after medical school, which includes 12,000 to 16,000 hours of clinical training.
To compare, ARNPs are not required to complete any graduate medical education after nursing school and obtain only 500 to 720 hours of clinical training during their graduate education.
Many studies have demonstrated that for an individual to become an expert in any field, it takes about 10,000 hours of training.
A former ICU nurse who went to medical school and became a pediatrician once told me that she hired several wonderful ARNPs and that they work well together. She then said that the gap between a physician and an ARNP is that the ARNP doesn’t know what they don’t know because of their shorter training.
The physician-led team-based healthcare model has been documented to deliver high quality healthcare at lower cost.
In addition, the average medical school graduate enters the physician workforce owing about $170,000 in education bills. Giving an ARNP the same privileges as a primary-care physician sends a message to prospective physicians that going to medical school for primary care isn’t necessary.
Becoming an ARNP would be a less expensive and quicker means to the same end.
Moreover, what about the great strides Florida has made in recent years to combat the pill-mill epidemic? The proposed legislation contradicts the intent of lawmakers and the progress our state has made in fighting prescription drug abuse.
Authorizing nurse practitioners to administer, dispense, and prescribe controlled substances will increase the number of people prescribing narcotics by about 10,000 — again, all without any physician oversight.
This legislative proposal will not fix Florida’s physician shortage. Rather, it will expand the problem and create greater issues elsewhere. Fortunately, the Florida Medical Association has a solution to address the physician and nurse shortage and improve access to quality care.
Visit the FMA’s website at http://www.flmedical.org/ to learn more about our five-pillar plan.
Dr. W. Alan Harmon is president of the Florida Medical Association. He is board-certified in internal medicine and gastroenterology and practices with the Borland-Groover Clinic in Jacksonville, Fla.
6 comments
Marc J. Yacht MD, MPH
February 12, 2014 at 12:26 pm
I cannot disagree with ALan. I like and respect him and know him personally for many years in various leadership positions with the FMA. However, there is an enormous need to beef up primary care services especially with the potential of millions of newly unserved patients elegible for care through the Affordable Care Act. ARNP’s do have post graduate training and to my knowledge have a Master’s degree. There are currently efforts to seek a doctoral degree for those nurses who seek independence for private practice. We all want the best quality medicine availabele but we cannot provide the best quality services when 10s of millions Americans and 4&1/2 million in Florida do not have equitable access for health services. The war between organized medicine and the Proffessional Nursing association relating to expanded services for ARNPs is decades old. It is time for leaders of both organizations to hammer out acceptable rules that work for both Asscoiations. It is critical and necessary to make our health care system more efficient. In the end what is necessary is what will be decided. Better the FMA and FNA sit down and find the solutions and not leave it to politicians. Marc
Janice Hess, DNP, FNP-BC
February 13, 2014 at 6:57 pm
Thank you Marc for your constructive comments. Allowing all healthcare professionals to function to the full extent of their education and training will improve patient access to care. This discussion should not be about what’s good for one profession or the other but should be patient centered as to what is good for the patient. Research for the past 4 decades, supports the fact that ARNPs provide safe, quality patient care with similar outcomes when compared to physicians. If ARNPs were not providing safe care, comprehensive care,the research findings would have been different. It is time for “fear mongering” to be put aside and replaced by an honest discussion that is patient centered not profession centered.
No healthcare professional(physician or nurse practitioner) practices in a vacuum. We all rely on each other for consultation or referral, when needed, to provide safe, quality care to our patients. It is time that a mutual respect is demonstrated by both professions toward the contributions and significant role each play in the delivery of healthcare. Removing the continued attempt to sway the public and legislature through erroneous comments needs to stop and a constructive discussion regarding ways to improve health care needs to begin.
Best regards
Jan
Janice Hess, DNP, FNP-BC
February 13, 2014 at 6:59 pm
Thank you Marc, for your constructive comments. Allowing all healthcare professionals to function to the full extent of their education and training will improve patient access to care. This discussion should not be about what’s good for one profession or the other but should be patient centered as to what is good for the patient. Research for the past 4 decades, supports the fact that ARNPs provide safe, quality patient care with similar outcomes when compared to physicians. If ARNPs were not providing safe care, comprehensive care, the research findings would have been different. It is time for “fear mongering” to be put aside and replaced by an honest discussion that is patient centered not profession centered.
No healthcare professional (physician or nurse practitioner) practices in a vacuum. We all rely on each other for consultation or referral, when needed, to provide safe, quality care to our patients. It is time that a mutual respect is demonstrated by both professions toward the contributions and significant role each play in the delivery of healthcare. Removing the continued attempt to sway the public and legislature through erroneous comments needs to stop and a constructive discussion regarding ways to improve health care needs to begin.
Angela Ritten, DNP, FNP-BC
February 13, 2014 at 10:58 pm
Dr. Harmon:
You are correct, the national shortage of primary care physicians will make it difficult for Florida’s residents to gain access to health care provided by a physician. Fortunately, physicians are not the only health care providers within our great state. In fact, patients are making choices everyday to see Advanced Practice Nurses (APNs) to manage their basic health care needs. Many of the patients choosing to see Advanced Practice nurses are making this choice within physician-staffed offices. Others are choosing to receive care at physician owned practice sites exclusively staffed by Advanced Practice Nurses.
I am sure that you realize, but perhaps your colleagues do not, that Florida is one of a few states in the union that requires Advanced Practice Nurses by statute to have a “supervisory protocol”, and the only state in the union that continues to decline us full prescriptive authority. Twenty-three states in the union, and the District of Columbia, have provided Advanced Practice Nurses full, unrestricted independent practice and full prescribing authority. They have done so to provide improved access to primary care for the residents of their state by use of qualified, safe Advanced Practice Nurses.
The evidence is in, and our esteemed legislature is reading it – many for the first time. As servants of the people, they are using the research evidence and needs of the population to guide their decisions. Fear mongering being presented by some physicians is ridiculous and flies in the face of the “do no harm” motto. Advanced Practice Nurses have been shown through systematic review and Cochrane review (high level research evidence) to be competent, capable providers with patient outcomes as good, and sometimes better, than physician colleagues.
Advanced Practice Nurses in the state of Florida, and physicians supervising them under written protocol, realize that the “supervisory” protocol established in the statutes is ineffective. There are no terms of “supervision” defined, reported or measured. In fact, physicians are free to do as little, or as much as they would like to, in terms of their obligation to “supervise”. In addition, there is no defined dollar amount that any one Advanced Practice Nurse would need to pay for a “supervisory protocol” or guarantee that payment would have a reciprocal mentoring benefit. In fact, some of your physician peers are extorting Advanced Practice Nurses across our state financially and professionally.
Inferring that Advanced Practice Nurses “lower standards of care” is ludicrous, and I challenge you to put forth the high-level research evidence that supports your claim. It is also unfair to infer that every physician in this state has the patients’ best interest at heart; if that were the case we would not have so many patients in the state of Florida addicted to controlled substances.
In regard to training, you are correct; we have not had the same training as physicians. We are not physicians, nor are we attempting to be physicians. We were trained as nurses first; in fact, all Advanced Practice Nurses have real-time work experience as Registered Nurses. We have all had experience with patient care, health care systems and family dynamics before we go to graduate school to become Advanced Practice Nurses. We are trained to look at patients’ needs differently and often seek to understand factors that are outside of medicine that contribute into individual patients’ pursuit of optimal health.
I personally loved your story about the nurse who became a pediatrician. I talk to my Nurse Practitioner students about the concept you shared all the time. The difference is that I warn them that all health care providers, physicians included, “don’t know what they don’t know”. I caution them that if they have a peer, or colleague, that professes through word or action that they know it all that they should distance themselves. Health care providers cannot and do not know it all…period.
The physician-led team is the same-old-same. It is what is being done now. The primary care access crisis will require shifting paradigms – this is part of the reason that the Institute of Medicine and the Federal Government is fully supporting the training of Advanced Practice Nurses. We need every capable health care provider to lead teams and generate fresh new ideas.
Advanced Practice Nurses have proven themselves capable, safe and effective. Citizens in the state of Florida deserve provider choice and the American public trusts nurses. I applaud the Florida legislature for considering use of all capable, qualified health care providers, and I commend them in recognizing the benefit of freeing physicians from the burden of supervision, thereby, enabling all of us to practice to the full extent of our education and training. Through synergy we will achieve much greater good, and provide much better service, to the citizens of Florida as they struggle with access, quality and cost of primary health care.
Dr. Angela Ritten is an Assistant Professor at the University of Central Florida. She has practiced as a Registered Nurse in the state of Florida for 30 years and as an board certified Family Nurse Practitioner for the past 18 years. Current clinical practice includes provision of primary care to medically uninsured patients accessing Shepherd’s Hope in Central Florida.
Edward Briggs
February 14, 2014 at 10:00 am
The commentary by Dr. Alan Harmon perpetuates a line of resistance held by organized medicine to Advanced Practice Registered Nurses (APRN’s). Unfortunately their arguments rely on anecdote and insinuation and is not supported by clinical evidence. Their arguments consist of three major themes:
First that APRN’s are not adequately educated or experienced to practice independently. Those in opposition will frequently compare the hours of training an APRN and an MD have to elicit fear in the public. What is glaring is their reluctance to cite large and significant research on the subject. Multiple independent studies looking at APRN’s have demonstrated that they are safe and effective health care providers with similar healthcare outcomes to their physician colleagues. APRN’s also demonstrate that they practice within their scope of training and follow approved healthcare guidelines.
The second theme is suggesting that if APRN’s can prescribe controlled substances the inappropriate prescribing of these medications will increase. 49 states allow APRN’s to prescribe controlled substances and there is no evidence to suggest it increases the illicit prescribing of narcotics. No state has considered restricting or limiting the ability to prescribe controlled substances once granted to APRN’s. More importantly the Florida Nurses Association and other nursing organizations adamantly supports the “controlled substances database” and moratorium on “Pill Mills” that has dramatically reduced the problem of prescription substance abuse in our state. The Florida Medical Association opposes both the database and the Moratorium.
Finally those who oppose expanded practice will argue that the system is currently working and they see no reason to change the “physician led team” as it currently exists. The simple fact is that for many poor and rural communities the system is not working. They do not have access to physicians and are only cared for by APRN’s. As APRN’s are not allowed to prescribe many necessary medications and treatments these communities are denied access to these vital services. The current system requiring APRN’s having a “protocol” with a physician does not equate to the physician being involved in the patients care. Physicians rarely supervise or oversea care APRN’s provide and the “protocol” requirement simply tethers the APRN economically to a physician. This “protocol” further restricts the ability of the APRN to consider creating innovative ways to provide care to meet their patients needs.
We have reached this point primarily because organized medicine has blocked any expansion of APRN practice in our state for 20 years, to the detriment of many of our citizens. The continued misinformation, fear mongering and opposition to APRN’s in our state, and our nation, has little to do with patient safety or outcomes. The independent data conveniently avoided by the opponents supports expanding APRN practice. The battle is an issue of economics and competitive markets. Were the issue truly about safety the medical community would be able to cite clear, impartial and convincing evidence to support their position. Such evidence does not exist and is proof enough that this legislation should be allowed to advance for the well being of our state.
Sincerely,
Edward Briggs ARNP DNP
President Florida Nurses Association
ross hoffman, md
February 15, 2014 at 3:03 pm
Let’s make healthcare work. This will only happen when practitioners come together to build a real system, comprised of team members: doctors, nurses, PAs, technicians, pastors, social workers, medical assistants, community worker..
We currently have a healthcare product which works well for no one. We need to empower consumers to have better access to higher value, convenient, cost effective health care. Or else, our country will go broke, spending more money, to insure more people, on a broken, wasteful ($800B spent annually on ineffective, unnecessary care), kludge, confusing system which dishonors (if not bankrupts) patients, frustrates practitioners, and increasingly under performs compared with the rest of the world.
We drive value when everyone operates at the tops of their licenses. Liberalizing ANPs practice in a measured, monitored, outcomes based manner, is one great step forward for all of us. Let’s break out of our silos and look critically at creating a clinically and financially integrated system which drives more value, better care at a lower cost. This means integrating across the entire spectrum of life, from the patient-centered perspective. Health care must be delivered in lower cost sites: drug store, supermarkets, churches, senior day centers, Assisted living facilities, community centers.
Physicians and nurses and all practitioners might stand as one and begin to fight for a system which delivers cheaper, better, faster care. This process is extremely disruptive, understandably resulting in fear and resistance. We are professionals who can collaborate in order to create a better future for the next generation. The healthcare we have right now is unsustainable. It is time for us to come together and make hard decisions about how we reengineer the entire ecosystem. Ross G Hoffman, M.D. Merritt Island, FL
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