Physician-Led Care: Opinion From a Seasoned Former PMHNP now MD
I was a seasoned psychiatric mental health nurse practitioner (PMHNP) in practice for 12 years with 15 years prior bedside registered nurse (RN) experience prior to becoming a medical doctor (MD). I have written inpatient psychiatric nursing policies, procedures, and SOP’s on multiple units. I fully know the role, scope, and standards of practice of nursing at all levels. I’ve been licensed as a PMHNP in about 8 different states with and without full practice authority (FPA). I’ve always had physician collaboration and supervision and never practiced outside of physician-led multidisciplinary healthcare teams. I firmly believe in physician collaboration and supervision for PMHNP and disagree entirely with the concept of full practice authority (FPA). I think I’m in the most unique position to comment on the state of PMHNP education and training, especially as it compares to that of a medical doctor (MD/DO). Length, depth, breadth, clinical training hours, and critical thought process are quite different in these two different disciplines. My main point here is that advanced practice nursing (APN) and medicine are entirely different disciplines and multi-disciplinary healthcare teams should always be physician-led.
Advanced Practice Nursing is Not Medicine
The American Nurses Association (ANA) defines nursing as “the protection, promotion, and optimization of health and abilities; prevention of illness and injury; facilitation of healing; alleviation of suffering through the diagnosis and treatment of human response; and advocacy in the care of individuals, families, groups, communities, and populations (1).” I grew up with this definition. Key words diagnosis and treat human responses – i.e. the nursing diagnosis. The definition of “advance practice nursing” has no standard definition that is credible as the term has been bastardized by political ideology of special interest groups seeking FPA. However, the advance practice nurse (APRN) can set the nursing care plan and nursing diagnosis in accordance with nursing theory and the nursing process, the only theory and process taught within the discipline of nursing. Some will have you believe they are educated to practice medicine. They are not. The discipline of nursing is distinct and different from medicine. While there is overlap, such as knowing some facts, drugs, and data, etc., the process and critical thought model is distinct to nursing.
The definition of medicine: “The practice of medicine is a pursuit very generally known and understood, and so also is that of surgery. The former includes the application and use of medicines and drugs for the purpose of curing. mitigating, or alleviating bodily diseases, while the functions of the latter are limited to manual operations usually performed by surgical instruments or appliances (2).” Another source, the “Practice of medicine means the diagnosis, treatment, prevention, cure, or relieving of a human disease, ailment, defect, complaint, or other physical or mental condition, by attendance, advice, device, diagnostic test, or other means, or offering, undertaking, attempting to do, or holding oneself out as able to do, any of these acts (3).” Whereas nursing focuses on nursing diagnoses of human responses, medicine focuses on human disease, medical diagnosis, and medical treatment. They are not the same.
Critical Thought Models: Medical Decision-Making Process & the Nursing Process
The critical thought process/model of each discipline is unique and distinct to each discipline. The nursing process (1): “A critical thinking model based on a systematic approach to patient-centered care that nurses use to perform clinical reasoning and make clinical judgments when providing patient care.” The nursing process is based on the Standards of Professional Nursing Practice established by the American Nurses Association (ANA) (1). No matter what their field or specialty, all nurses utilize the same nursing process; a scientific method designed to deliver the very best in patient care, through five simple steps (1):
Assessment – nursing assessment
Diagnosis –nursing diagnosis
Outcomes / Planning – realistic goals for the patient’s recovery.
Implementation – accurately implementing the care plan.
Evaluation – By closely analyzing the effectiveness of the care plan (1)
The Medical Decision Making Process (MDMP): “The MDMP is a Socratic, systematic, and analytical process of analyzing and understanding each health problem/disease of each of the body’s systems and organs, down to the microscopic, genetic, biochemical, cellular, bio, psycho, and social level and understanding the normal physiology, the pathophysiology, and abhorrent vs normal presentations and look alikes, all towards formulating a differential diagnosis set, a workup and treatment plan.”(4,5)
Clinical Training Hours
My graduate Master of Science in nursing was 624 clinical advanced practice nursing hours. Nursing theory, with theory papers and courses. Very little advanced physiology, pathophysiology. Medical school itself was approximately3000 hours or more. My post-graduate year (PGY) 1 internship year in residency was 3500 clinical hours in medicine. Literally 5 times the clinical nursing hours I had in my NP program. And keep in mind, they are not comparable, as all PMHNP clinical training hours are considered APN while medical school and residency are considered medical training clinical hours. These are different.
Length, Depth and Breadth of Training
See the sample curriculums or arbitrarily chosen USA based PMHNP program compared to medical school/residency curriculums. My PMHNP program was 2.5 year in length. Medical school is 4 years alone and residency is 4 years. Thus 2.5 years of graduate level education and training compared to 8.
1. PMHNP curriculum
2. Psychiatrist medical school and residency curriculums
a. Sample medical school
b. Sample psychiatry residency
FPA & Collaboration/Supervision
I practiced as an NP in many states with both full practice authority and without requiring physician collaboration. There was literally no difference. This is nothing more of a farce than the words “providing care at the top of their education and skill.” Smart people have smart people to go to always. Even as a physician, I have smarter people to collaborate with and a clinical supervisor and it should always be this way. Again, smart people have smart people to go to.
All in all, I hope you can see there are vast differences in these two distinct disciplines. If physician level care is based on length, breadth, depth or education and training to include actual training hours in medicine, and the critical thought models, then there is no comparison. There is no argument that physician level care and physician-lead multidisciplinary healthcare teams should be the gold standard and standard of care respectively. No offense is meant to my former profession brethren, but I suspect some will be offended anyway, but remember, I write this based on a background of extensive nursing background and now as a physician. I’ve been through both levels of training, and unlike most readers, I have the most unique perspective. Though much of this is based on my anecdotal experience, it is precisely this experience which gives me a unique paradigm from which truth can be inferred and generalized. Best regards.
Nursing : Scope and Standards of Practice. Fourth edition. Silver Spring, Maryland: American Nurses Association, 2021. Print.
Medicine. The Law Dictionary, Your Free Online Legal Dictionary, Featuring Black’s Law Dictionary. (2nd Ed.)
Michigan Legislature, PUBLIC HEALTH CODE (EXCERPT)Act 368 of 1978 333.17001 Definitions; principles of construction.
Masic I. Medical Decision Making – an Overview. Acta Inform Med. 2022 Sep;30(3):230-235. doi: 10.5455/aim.2022.30.230-235. PMID: 36311160; PMCID: PMC9560052.
Gabrielli, Andrea., A. Joseph. Layon, and Mihae. Yu. Civetta, Taylor and Kirby’s Critical Care. 5th ed. Philadelphia: Wolters Kluwer Health, 2017. Print.