16 Dec Nurse Practitioner Diploma Mills Not the Answer to Physician Shortage
Rebekah Bernard MD
The United States is facing a looming physician shortage. While efforts to increase physician training programs (including H.R. 2267 and S.1301) slog through the political process, some groups have embraced the idea of fixing the doctor shortage by replacing physicians with nurses.
The nurse-as-doctor agenda made its debut in the Institute of Medicine’s 2011 Future of Nursing report, which called for a radical change to the nursing structure in the United States, including a push towards higher levels of education and a plan to achieve “full” nurse partnership with physicians. Nursing organizations eagerly responded with a goal of doubling the number of nurses with a doctorate degree, or “Doctor of Nursing Practice (DNP),” by 2020.
Nurses’ Aggressive Marketing Campaign
To advance independent nurse practice, the American Association of Nurse Practitioners (AANP) invested in an aggressive multi-media campaign, including a recent onslaught of television commercials promoting nurse practice in states like Pennsylvania, which is currently debating scope of practice laws. Nurses’ associations also spent over 5.3 million dollars on lobbying and donated 2.1 million dollars in 2016 to congressional candidates to promote unsupervised practice.
This public relations campaign and lobbying has reaped benefits for nurse practitioners (NPs). The Veteran’s Administration, for example, recently granted full practice authority to advance practice nurses, allowing veterans to receive medical care from nurses without physician supervision. In addition, twenty-three states and Washington DC allow nurses to practice independently, with ongoing political battles in other states.
Unfortunately, this agenda of increasing nursing scope of practice has led to two very dangerous consequences. First, a decline in bedside nurses, one of the most critical components of our health care system, and second, the growth of diploma mills.
Consequences: Decline in Bedside Nursing and Nurse Educators
The decline in bedside nurses is happening in several ways. First, as nursing programs encourage masters level and doctorate programs, fewer students are entering associate level training, a shorter and less expensive track for becoming a nurse.
Secondly, the rapid expansion of BSN to NP programs is causing critical shortages in essential nursing care, as nurses leave the bedside to practice “advanced” nursing. As nurse Brie Gowan puts it in an article on why nurses are leaving the bedside, “fewer nurses are staying in the trenches” and instead are “pursuing higher education off the bat.”
Finally, we are also seeing a shortage in nurse educators. Doctoral nurses are more likely to enter clinical practice than academia, a far less lucrative career track, which is leading to a decrease in the training of bedside nurses.
Consequence: NP Diploma Mills
The second dangerous trend in promoting nurse practitioner autonomy is the recent tremendous growth of diploma mills, programs that “graduate” minimally trained nurses who are nowhere near ready to care for patients independently.
I’m referring to the dozens of direct to DNP programs, many of which boast a 100% acceptance rate. I’m talking about programs that promote “as little as fifteen months from MSN to DNP,” or “use work hours to apply to your clinical training.” There are multiple accelerated programs that allow students who have never even worked one hour as a nurse to become a nurse practitioner, and also direct entry programs that allow students with a non-nursing bachelor’s degree to become a registered nurse and a nurse practitioner “seamlessly.”
Once in attendance, coursework for these nursing programs may be 100% online. And while a certain number of clinical experience hours are required, they are often on the honor system and often involve simply shadowing a doctor or nurse, many of whom the students have to find themselves. There are simply not enough clinical preceptors to train nurse practitioner students, and the number of preceptors can only be expected to decline as the number of students seeking training increases.
Consequences: Poor Practice Patterns
And unfortunately, this lower quality of clinical experience is beginning to become apparent. While early studies showed that NPs working under physician supervision were able to produce similar outcomes in the management of already diagnosed chronic conditions, these NPs were mostly trained at brick and mortar schools, with a high level of clinical experience in nursing before advancing their career.
Newer studies are demonstrating that removing standardized curriculum and physician supervision from nurse practitioner training and practice is impacting the quality of patient care, including poorer quality referrals to specialists compared to primary care physicians, more unnecessary skin biopsies than physicians, increased diagnostic imaging, increased prescriptions including increased antibiotic prescribing and higher opioid prescribing shown in the states of Connecticut and New Hampshire.
Payouts for malpractice claims against NPs are also on the rise, as are claims for the improper prescribing and management of controlled substances. As training programs continue to churn out NPs at a rate of 23,000 per year, compared to about 19,000 physicians graduating from medical school per year, these trends are likely to continue.
NPs SHOULD Care
If you are a NP reading this, you should be outraged. Your profession is being diluted and abused by your leadership and your teaching institutions. Ultimately, the nurse-as-doctor agenda will backfire as the market becomes saturated with diploma mill grads, and as patients realize that their lives are being sold to the lowest bidder to hospital and organizations who employ new nurse grads ill-prepared to care for them.
Physicians Should Care
If you are a physician, you should be outraged. Your years of work and sacrifice are being alarmingly devalued as you are replaced by an online graduate. There is no online medical school. There is no “honor system” in med school – no one graduates without passing a rigorous evaluation process. There are no shortcuts to the 20,000 hours minimum of clinical experience that physicians receive during training. And yet you will rarely meet a physician with complete confidence, because even with all this training, most realize that there is so much they don’t know.
Politicians Should Care
NPs are Not Filling a Void in Primary Care
If you are a politician, you should be outraged. And worried. Because your constituents will see that you have fallen for the lobbyist lines. NPs lobby that they will enter primary care practice to ease the shortage of physicians, but this has proven to be untrue. CMS data from 2012 showed that NPs are moving more and more into subspecialty practice, where they are practicing independently having received little to no supervised practice in that specialty. Because unlike physicians, who must complete a separate residency of at least three years to change specialty, NPs can jump from one field to another without any additional formal training.
The Rural Access Fallacy
You have also fallen for the hype that NPs will provide care in rural areas, where physicians supposedly “won’t” go. Also, untrue. In Arizona, where NPs have been unsupervised since 2001, only 11% of all non-physicians (NPs, PAs, CNMs) work in rural areas, and serve only 15% of Arizona’s rural population.
The Financial Advantage Fallacy
And if you have believed the line that NPs save money, well, you may not have seen that the goal of the American Association of Nurse Practitioners is pay parity1 – that NPs be paid the same as physicians – a goal which was achieved legislatively in Oregon in 2013. Not to mention that NPs may cost the system more, with a rigorous ten-year study showing that unsupervised CRNA practice in rural areas was more expensive than hiring physician anesthesiologists.
Patients Should Care
If you are a patient, you should be outraged. And scared. But also, hopeful. Because physicians like me really do care about you. I am part of a group called Physicians for Patient Protection (PPP). We recently traveled to Washington DC on our own dime to talk to legislators about our concerns for the future.
For most of us, it’s not about the money. If I wanted to be rich, I wouldn’t have chosen Family Medicine. I wouldn’t have worked in an underserved area for years. And I wouldn’t have opened a low cost Direct Primary Care practice.
It’s also not about a turf war. There are many, many jobs out there for good docs.
It really and truly is about patient safety. We worry about our own health and that of our family. We want the best care for our future too.
What Can You Do?
Join me in this discussion and this fight. Physicians, JOIN US. Patients, ask your “provider” about their training and credentials. Demand a physician or physician-supervised practitioner for your care. It’s not too late.
1. Reference linked may now be hidden behind member-only paywall on AANP site.
Rebekah Bernard MD is the daughter of two Registered Nurses and a Family Physician in Fort Myers, Florida. She is the author of “How to Be a Rock Star Doctor” and a member of Physicians for Patient Protection. She can be reached at RebekahBernard.com.