Kevin R. Campbell, MD, FACC
Cardiologist and CEO, K-Roc Consulting LLC
Contributor, Washington Examiner
In January of this year, the Veteran’s Administration (VA) made the decision to allow Nurse Practitioners (NP) to practice without any physician supervision. While NPs have a vital role to play within the healthcare system, they are NOT doctors and they are not qualified to replace physicians—even in a primary care environment. Those in leadership within the VA system argue that the physician shortage has left them with no choice but to allow NPs to practice unsupervised. However, I believe that we should be addressing the physician shortage by actually recruiting more physicians to care for primary care in the VA system. Our veterans deserve the very best care—and while NPs are caring, competent members of the healthcare team, they do not have the same training as physicians and are not equipped to fill the role of an independent physician. According to current VA statistics, there are roughly 93,500 nurses employed by the VA—of these 5,700 of them are advanced practice, meaning they have a master’s or doctoral degree in a nursing specialty. In the past, individual states are able to determine whether or not NPs are able to practice independently and 22 states already allow unsupervised practice.
How are NPs and Physicians Different?
Nurse practitioners and physicians are trained in very different ways. Physicians first must obtain a four-year undergraduate degree and then attend a four year medical school. Following medical school, physicians must complete an Internship and Residency with more than 21,000 hours of a standardized educational and training process. The minimum residency program is three years, and some specialties require almost 10 years of post-graduate training—all before ANY independent and unsupervised practice is allowed. By contrast, advanced practice nurses obtain around range from 3,500 to 6,600 hours of coursework and formal training—including Master’s or Doctoral degrees.
Physicians complete endless years of “in house” training in hospitals (taking overnight call as frequently as every third night). During these overnight shifts, physicians learn—while being supervised by an endless hierarchy of medical professionals—how to diagnose and manage very complex diseases. Nurse practitioners do perform time training in a clinical setting but they do not have the same responsibilities nor autonomy. Residency and other practical on the job training teaches young doctors judgment and improves clinical acumen—and this takes years of practice. Nurse practitioners simply do not have the same opportunity to gain these insights.
Before The Angry Response Begins—Everyone Has an Important Role to Play on the Healthcare Team
When I write articles such as this, I am often met with harsh criticism from professional organizations that represent advance practice nurses. Let me say at the outset that this is not a turf war—it is about making sure that every patient has access to BOTH a competent caring and well trained physician as well as an exceptional advance practice nurse. Rather I am arguing that we should continue to develop the idea of a TEAM approach to healthcare. Advance practice nurses are very good at developing meaningful relationships with patients and they are very good at treating common ailments and disease. Patients enjoy the time that NPs are able to devote to them in the office or hospital. Physicians are often rushed from patient to patient and procedure-to-procedure and do not have the same luxury of time to spend with the patients who need us. Physicians are exceptional at recognizing clues and symptoms and DIAGNOSING disease. Advance practice nurses, while exceptional in their role as caregivers and in the treatment of common primary care ailments, they simply do not have the experience needed to make complex diagnoses. While many NPs will argue that there are data from 2014 to show similar outcomes in patients managed by NPs versus physicians, the devil is in the details. The studies did not report whether or not the NPs were consulting with physicians in the management of their patients or whether they were practicing alone. In addition, none of these studies actually looked at DIAGNOSITC accuracy. Making the correct diagnosis and choosing the most appropriate treatment is the most important job of primary care physicians. As diseases do not always present as they do in a textbook, this is where experience and extensive training can make all the difference in the life of a patient. Physicians are used to working in packs—different doctors have different specialties and areas of expertise—we refer to others when we are outside of our specialties. Nurse Practitioners are asked to work with a wide variety of patients and often, in my experience, they do not know when to refer for a higher level of care or for more advanced treatments by a specialist physician—these instincts come from years of experience—like the experience gained during post graduate residency training.
The Bottom Line—Don’t Replace Physicians, Augment the TEAM
The VA and other states that are allowing independent NP practice are looking for a quick fix for the doctor shortage. However, those in charge are not putting the best interests of patients first—they are simply “filling coverage holes”. Rather than allowing NPs to practice outside of their scope of training (ie without MD supervision) we should be working to figure out why doctors are leaving the healthcare industry. We need to examine quality of life and burnout and we need to begin to listen to the needs of our healthcare providers. We must recruit more young dedicated primary care doctors AND, at the same time, expand the role and significance of NPs on the healthcare team. Until we do this, doctor shortages will continue to mount. Inadequacies in the VA system such as long wait times, fraud and abuse are more about the VA leadership and administration than they are about physician shortages.
We must also work to promote more understanding between physicians and advanced practice nurses. We must all work with a single goal in mind—providing patients with outstanding care and improved health outcomes.
So, for now, I must strongly object to the decision made by the VA system. Patients definitely need nurses—and advance practice nurses—BUT they also deserve access to a licensed, board certified, residency trained Doctor as well.
(image via screenshot of VA.gov website)