Florida Medical Association Resident/Fellow Physicians Oppose HB 607,
Which Allows for Advanced Practice Registered Nurse (APRN) Autonomous Practice

An essay serving as a voice of young physicians to communicate the fundamental reasons we oppose APRN independence

By Alexander D. Lake, DO
Chair of Florida Medical Association Resident and Fellow Governing Council

What is our main goal as medical practitioners? Is it to argue about a patient’s care, scold another practitioner for his or her decisions, or to undermine another practitioner’s education and training? No, this is would be a waste of our valuable resources. I believe that at the end of the day, our goal coincides with our patients’ thoughts: “I want to get better, go home and get back to my life.”

Being the patient is often frightening. Patients feel vulnerable and completely at the mercy of someone else. I know this firsthand, as I suffered a traumatic brain injury one year prior to medical school and was told I would fail to become a doctor. It is absolutely terrifying to realize your life lies in the hands of someone who is often a complete stranger to you. There is no other situation that I am aware of that makes you quite so vulnerable and dependent on another person.

This is why there have to be rigorous standards required to practice independently as a medical professional.

Would you expect a private pilot to fly you commercial from Tampa to Dubai? Or would you expect an internal medicine first-year/second-year/third-year resident physician be the only doctor caring for you in your life-threatening situation? The simple answer to these questions is no. I would never expect a private pilot, with around three months of training, compared to a commercial pilot with 2 years of training, to fly me 7,807 miles. Likewise, I would never expect a resident physician to manage my medical care without the supervision of an attending physician, and as I certainly would never expect an APRN to manage my medical care without the supervision of a physician. There is a standard in medical education that has been in place well before I was born.

As young physicians, we wholeheartedly respect the work APRNs do as part of the medical care team with the goal of making patients healthy and getting them back to their lives. We enjoy working on the same team, making decisions for our patients and providing exceptional evidence-based care. However, there is a simple concept I would like to introduce:

Graduates of Medical Schools in the United States are required by law to undergo a residency program under physician supervision to practice medicine independently, but APRNs are seeking independence and do not believe they require the same standards.

American Association of Nurse Practioners (AANP) Position Statement:
The American Association of Nurse Practitioners® (AANP) opposes mandated residency and fellowship as a condition of licensure for nurse practitioners.

This is what truly confuses me. And let me explain why.

To become a physician, one must obtain an undergraduate degree, attend a 4-year medical school and another 3+ years of residency prior to achieving the ability to practice independent care. This education includes three medical license entrance (USLME) examinations and a board certification exam. I took my Step 3 USLME examination last year; it was a 2-day examination with 420 multiple-choice questions and 26 clinical decision-making questions. I am a freelance question writer for a few medical licensing test prep companies, and I was curious about the content of APRN licensing exams, so I reviewed the qualifying examinations for both physicians and APRNs.

A typical question that you will find on the United States Medical Licensing Examination (USMLE) is:

54-year-old male with a history of hypothyroidism, gastroesophageal reflux disease, gout and Crohn’s disease presents with worsening fatigue and pallor. Patient states he noticed his symptoms over the past year, but have been worsening over the past few months. He reports associated symptoms of dyspepsia and intermittent paresthesia’s in his lower extremities. He has had GERD for the past 5 years and also the Crohn’s disease for 15 years requiring resection of a part of his intestines he cannot remember. His gastroenterologist had him on unknown vitamin supplement post resection, but he stopped taking these a few years ago. Vital signs are within normal limits. Physical examination reveals glossitis. Labs reveal a hemoglobin of 10.1 g/dl and MCV of 101 fL. What is the most likely cause of this patient’s underlying disorder?

  1. Duodenal resection
  2. Gallbladder removal
  3. Gastrectomy
  4. Ileal resection
  5. Thyroid nodule resection

Critical Thinking Process Necessary to Answer Question (Higher-ordered thinking):

  • Crohn’s Disease -> Most commonly affects Ileum -> Macrocytic Anemia, Fatigue, Glossitis-> Likely B12
  • Macrocytic Anemia -> B12, Folate -> Has Crohn’s and HX of Surgery -> Crohn’s affects Ileum.

Pretty detailed, right? Well, this is how it is. This is a multiple order question that requires the mind to use an advanced thought process. This is what medical school and residency work towards over the 7+ years of education.

On the other hand, becoming an APRN is also not an easy feat. It starts with becoming a registered nurse (RN), typically, but not always, a bachelor’s degree. To become licensed, an RN must take the National Council Licensure Examination – Registered Nurse (NCLEX), which is unique and between 75 and 265 questions, depending on how the previous question was answered. Further education is required to become an APRN (NP), typically a Masters in Nursing (MSN).  An NP can then choose to go on to earn a Doctor of Nursing Practice (DNP) to complete the highest level of nursing training, but it is not required to practice as an NP. Either an MSN or DNP can take the entrance examination to become a licensed Advanced Practice Registered Nurse (APRN).

Admittedly naive to the examinations the NPs are required to take, I spoke to some nursing colleagues and was directed to the typical materials used to study.  I surveyed the most utilized nurse practitioner question banks and even sampled questions from the Advanced Practice Education Associates (APEA) question bank and Barkley Review for nurse practitioner certification examination. The question banks broke down questions into “Management,” “Prescribing,” “Assessment,” and “Pathophysiology.”  I found this helpful, as it reminded me of doing notecards during my first year of medical school. These were absolutely essential to my base of medical knowledge. These questions were consistently ‘first-order questions’, which mainly requires regurgitation from memorization. Examples:

  • Macrocytosis? B12/Folate deficiency.
  • Bruit when palpating thyroid gland? Hyperthyroidism.
  • Albuterol causes bronchodilation by stimulating? Beta2 receptors.

These topics are extremely high yield to know and are needed to formulate a base knowledge of medicine. But obtaining this knowledge is just the first step in medical education and not enough for autonomous practice.

A first-order education teaches how to respond to the immediate problem but does not consider the future or the consequences of the response.

Everyday medical decisions require higher-order thinking to make informed and appropriate decisions. Learning through simply first-order education can limit clinical reasoning and may lead to poor patient outcomes in the future.

To understand this in detail, it may be important to understand the cornerstone of medical teaching philosophies in Bloom’s Taxonomy and specifically the cognitive domain. Acquiring the “knowledge” is the first step, and is typically achieved through first-order questions to recognize or remember facts—answers without truly understanding the underlying concept. This does not teach critical thinking that a qualified, independent medical provider must possess in order to make clinical decisions. Critical thinking goes far beyond first-order thinking, and requires application of acquired knowledge, formulating a plan with proper analysis of outcomes, and synthesizing and evaluating medical management.  First-order medical decision making is limited, and our patients will suffer.

This essay is in no way meant to discredit our nursing colleagues. Nurses are beyond valuable, and without them medical care would be definitely be compromised.

I am not sure why it feels now as though our teammates don’t want to be on our team anymore. 

Why we are we trying to fix something that is not broken? The standards to practice medicine are for the safety of our patients. 

Take Home Message

Medical decision making will be limited, and our patients will suffer. But, what does this mean to legislators and to patients?

I predict this will play out in two distinct ways:

Scenario #1 ‘Trepidation’:  Clinical knowledge and judgement limitations will lead to more specialist referrals, more diagnostic imaging studies ordered, more patients referred to the emergency department, all adding up to greater costs for healthcare.

Scenario #2 ‘Overconfidence’:  A false sense of security may initially mean fewer referrals, fewer diagnostic imaging studies ordered, fewer ER visits, and reduced initial costs.  But overconfidence can mean missed diagnoses or misdiagnoses, and improper clinical decisions will lead to dire patient outcomes, which result in involuntary diversion back to scenario one.

With both scenarios, the end outcome will be the same.

Nursing education does not fulfill fundamental requirements and therefore should not be allowed to practice independently.

The ball is in your court, legislators.

Alexander D. Lake, DO
PGY-2 Internal Medicine Resident
Tampa, FL
Chair of Florida Medical Association Resident and Fellow Governing Council

I will use treatment to help the sick according to my ability and judgment, but never with a view to injury and wrong-doing – Hippocratic Oath 1923