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.
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?
- Duodenal resection
- Gallbladder removal
- Ileal resection
- 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.
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.
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
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
Very well put. Way too many NPs and legislators equate proficiency in procedures as proficiency in medicine overall. “I can do colonoscopies, therefore I am on the same level as a GI fellow,”. The cognitive aspect of medicine is far bigger than the procedures we do. It is time for the cognitive side to be respected for the huge investment it demands and the years required to obtain it
BRAVO! So thrilled to see a physician speak up! As an RN, the proliferation of mid level providers is not the panacea for healthcare most would like to believe. In the rush for provision both legislators and patients have zealous escalated and expedited the use of NPs ( and PAs) to a critical concern. There is room for everyone in the health care model…but until patients and legislators wake up, physicians quit extending their practice sizes by utilizing these providers and my own nursing profession gets humble about their true practice capability and reach we will see this watered down version of care akin to using a 7-11 for all your grocery needs. Keep up the fight…and I salute you!
Thank you for responding and know that your profession is truly valued! Please keep speaking up to educate people about the difference between the professions and the importance of physicians and nurses staying in their lanes and doing what they do best!
This!! This bill and push for independent practice is too early.
For the sake of cost cutting, we are diluting the quality (physician and non physicians alike). For now, medical schools and medical residencies have quality metrics that they have to meet. Unfortunately the nurse practitioner schooling does not have this established.
The danger and allowing this is giving non-medical Personnel like the administration in the hospitals the power to substitute quality with quantity and to meet metrics that we all know do not matter at the end of the day. Why do nurses have to chart fall risk twice a shift instead of just having enough staff available to actually help the patient…
Let’s face it. Nurse practitioners are practicing medicine. They are NOT practicing nursing. How a nurse can essentially be a physician without medical school is beyond comprehension. Further nurse practitioners will erroneously argue that their outcomes are the same if not better than physicians. If so, then what they are stating is that less training is better. Who believes this to be true?
Our political system is FUBARed thats why. We cannot make decisions. We have NO LEADERSHIP… ZERO..
Physician SHortage!! Solution: Lets make Nurses DOctors. Well call them doctors and that will solve the problem.. What can possibly go wrong??
Thank you for this blog. You are very brave as a resident to speak up. As a physician and as a patient, I can relate to your story and the feeling of complete vulnerability during an acute health crisis. I experienced something similar when out of the blue my eyes could not focus two images while driving on the highway. I saw several physicians who referred me to an ophthalmologist (an eye specialist). I made an appointment with they eye specialist and confirmed that I was seeing a real physician with front desk staff and schedulers. But they pulled a bait and switch on me. I saw a “Doctor” who was NOT an ophthalmologist. Bait and Switch is real and it’s wrong.
Very well said. You have aptly described the fundamental difference between a NP and MD/DO. The problem is that difference is no longer respected. It is ridiculed. Not respecting the complexity of medicine is a disaster waiting to happen.
Wonderfully put and clearly stated. I absolutely agree. Patients deserve the best of care, in a physician led model.
My future colleague, unfortunately the writing is on the wall. Corporations, legislators and even some of our colleagues see NPs a cheaper way to provide “basic” healthcare. The advent of urgent cares fostered this. NPs have been put in positions that have them believing that they give an adequate standard of treatment. If you ask them why they gave a specific treatment for certain symptoms, they either dont know or they regurgitate basic scut monkey responses. Unfortunately, the patients will suffer, as the corporate “leaders” are not concerned with “quality of care” or “patient safety”. They want quantity and a way to increase profits. I have been out of residency since 2008 and have worked for multiple companies and would consider myself an expert at what has become the degradation of medicine. Our “leaders” have been reactive rather than proactive about recognizing what is going on and educating legislators and the public about the different roles physicians, NPs and PAs have not to mention the vast differences in training that take place. You can thank your predecessors for the state of medicine as they bicker between each other rather than fight the forces that work hard to degrade or profession. A house divided has already lost. So here we are! Keep up the good fight. You will soon see how much you have to fight for yourself, your profession, your colleagues and for the best interests of your patients.
As a patient with serious health problems I can honestly say I will never see a pa or np they are not qualified to diagnose, Dr’s had a difficult time trying to diagnose me for years, but hospitals are passing them off as Dr’s which is illegal. Its illegal to practice medicine without a license. I’ve had a few bad experiences with a pa and np. scary and dangerous. I can’t believe that they have taken a well earned degree in medicine and downgraded it. STAND YOUR GROUND DO IT FOR THEY PATIENTS NOT ABOUT SAVING MONEY.
This is a great breakdown. I’m a PA and have the same concerns. Personally, I enjoy my relationship with Physicians but fear as NPs continue to encroach upon the term “Doctor”, PAs and NPs will be seen as the same entity.
I can assure you we are not.
I’d love for the author to provide the same comparison with PAs. We are certainly not on the academic level of Physicians but we have far greater capacity than NPs.
I feel the PA community needs to foster our already strong relationship with Physicians To do so, Physician groups should solely hire PAs. We are licensed by state medical boards and complete exams with similar 3rd and 4th order questions.
I don’t want to be a Doctor, I want to be a PA and work alongside the Physician. Please separate us from the NP conversation.
I would argue your thought that Physician Assistants have superior education to Nurse Practitioners. I know many PA’s who have no medical experience who simply passed a 2 year course and became licensed. Most APRNs are nurses who have been in their specialty for many years and choose to make that leap in order to provide better care. I am an NP student and have been in my specialty (Nephrology) since 2005, and I can say that the PAs and NPs that round are more attentive to patients than the MDs because of the additional duties physicians have such as research and residents.
I, however, do not support full practice authority right now. I agree that NPs should have a fellowship program and require additional testing or board certification for full practice authority.
Instead of having an “Us against Them” tone, why not have a team mentality and open up conversations with groups like AANP about placement of NPs as most NPs would be best utilized in undermanned areas like primary care settings rather than acute care. I acknowledge the hard work it takes to be a doctor, but all I see a divisive comments and no solutions.
We don’t want to sit down with the AANP because they are a bad faith organization. They have been misrepresenting NP credentials to the public for over a decade in their effect to equivocate MD/DO education with NP/DNP education. Maybe a decade ago I would have supported efforts to bridge the gap between physicians organizations (such as this one) and the AANP; unfortunately, I am now of the opinion that compromise is impossible with the AANP. It would be irresponsible and immoral for physicians organizations to compromise with an organization that so clearly does not care about patient safety or honesty.
From here on out, as far as I’m concerned, there should be no compromising with the AANP. Let the legislators decide our fate (God help us).
I am currently in school to become a certified nurse midwife (CNM), which falls under the APRN umbrella. I cannot speak for NPs or other APRN specialties. I agree there needs to be more universal standards that all APRN programs must follow. It is still a relatively new model of care, and thus the kinks are still being worked out. I actually love the idea of a mandatory residency for all APRNs. As for midwifery, this is a profession that’s been around about as long as people have. The role of a CNM of course has changed a bit, more intensive training is required. Most CNMs work in a hospital or clinic setting, some work at birth centers or do home-births. I do, for a fact, know that in other developed countries where a midwifery model of care is the norm, there are much better outcomes. The United States actually has one of the worst maternal and infant mortality rates of any DEVELOPED nation, which is truly appalling. When we look at other nations like the UK, we see that midwives are used for almost all low-risk, healthy pregnancies with excellent outcomes. It is reasonable to assume that a similar model in the US would improve our outcomes as well. Oh, did I mention we spend the MOST on healthcare, and still we have an incredibly high maternal and infant mortality rate, especially for black mothers. Again, I don’t speak for all APRNs, but as a midwifery student we are extensively trained in how to manage NORMAL pregnancies and birth (as well as general well-woman care). We are also taught extensively the signs of worsening condition, when to consult an MD, and when to transfer care. We know we are not at the level of an MD or DO. We know our scope of practice and are thoroughly trained to practice within it. I would like to be able to practice to the full extent of my training, and hopefully improve the current broken system; alongside Dietitians, MDs, DOs, PAs, and all other healthcare workers. It will take us all working as a team, together, respecting one another and being aware of our roles.