Dr. Richard Feldman: To practice independently, APRNs need more training

Once again, this legislative session, advanced practice registered nurses (nurse practitioners) will continue their quest to gain “full practice authority,” commonly referred to as “independent practice.”

Currently, Indiana law requires APRNs who write prescriptions to maintain a collaboration agreement with a physician, which includes the physician auditing of a small percentage of their charts. APRN prescriptive authority in Indiana was never legislatively anticipated to be used without physician supervision or as a stepping stone to independent practice. This collaboration is the last remaining required clinical oversight between physicians and APRNs.

Physicians consider APRNs valuable colleagues in the delivery and expansion of medical care but as part of a physician-led team. APRN political leadership claims physician opposition to APRN independent practice is a competitive “turf” issue. Not true. It’s about quality and safety of care. Any physician who has trained or worked with APRNs will tell you they have limitations due to insufficient clinical training, knowledge and experience, especially as new graduates.

The clinical training experience of physicians ranges roughly between 12,000 and 16,000 hours, compared with 500 to 750 hours for APRNs. APRN training varies widely by school, and some are even partly internet-based. Many schools have inconsistent and poorly organized and poorly vetted clinical rotations. Their student experience is largely observational.

There are also important qualitative training differences. Physicians receive much more rigorous experiences, depth of responsibility, and intensive knowledge acquisition. Physician trainees have years of direct structured shoulder-to-shoulder supervision and mentoring with faculty. Practice collaboration agreements between APRNs and physicians are no substitute.

Patients come to a physician or an APRN in an undifferentiated manner. A symptom like chest pain or back pain could be of minor significance but could also be a life-threatening condition. APRNs must have the clinical training, experience and judgment to recognize and appropriately address all such clinical scenarios and the subtleties and complexities that might be present. There is danger in not recognizing what one does not know.

If APRNs desire independent practice (I confidently believe most do not), they should receive the additional clinical training, either in professional school or post-graduation, necessary to better assure readiness and competence.

APRN political leadership asserts that APRN-independent practice is essential to increasing health care access in underserved rural areas. This is refuted by using Centers for Medicare and Medicaid objective geographic mapping, which demonstrates a very similar practice location distribution of physicians and independent-practice APRNs.

APRN leadership claims to have research proving that the quality of care in independent practice is equivalent to or better than that of physicians, despite the disparity in training. The physician community has repeatedly pointed out the problematic nature of APRN’s research, much of which is of poor quality, confounded and old—conducted at a time when physician supervision was required.

Many studies in the medical literature—including research by the National Bureau of Economic Research, the Mississippi State Medical Association and the Mayo Clinic—demonstrate care provided by APRNs in comparison to physicians is more inefficient, of lower quality and more costly. APRNs order more expensive diagnostic tests, request more specialty referrals, are responsible for more avoidable hospitalizations, and overprescribe antibiotics and opioids.

I know of an Indiana family physician who was previously an APRN. She reflected that, after attending medical school and residency, “I realized how much I did not know.”

Let’s continue to expand patient access through increasing the number of physicians and non-physician providers working in physician-led collaboration.•

__________

Feldman is a family physician, author, lecturer and former Indiana State Department of Health commissioner for Gov. Frank O’Bannon. Send comments to ibjedit@ibj.com.

Click here for more Forefront columns.