Journal of Advanced Practice Nursing

MD Blogger: How I Would End the War Between Nurses and Doctors


By Dr. Kevin Pho

A number of publications, including The Wall Street Journal, have been providing information about nurse practitioners -- largely spurred by rising concerns about the access to primary care services anticipated with the Affordable Care Act.

Many of the articles, have dealt with increasing the autonomy of nurse practitioners so they can practice, using the phrase in a recent Institute of Medicine report, "to the full extent of their education and training."

Nursing organizations have been proposing changes in state licensing laws that would permit "full practice authority" but only 19 states and the District of Columbia have achieved it.

According to the American Association of Nurse Practitioners, full practice authority is achieved when "state practice and licensure law provides for nurse practitioners to evaluate patients, diagnose, order and interpret diagnostic tests, initiate and manage treatments—including prescribing medications—under the exclusive licensure authority of the state board of nursing."

This is the model recommended by the Institute of Medicine and National Council of State Boards of Nursing.

Much of the opposition to this change has been attributed to medical organizations and, while organizations such as the American Medical Association have voiced their opposition, we propose another explanation: the social injustice that continues to typify American business and politics, the repression of women.

Social injustice is a relative concept about the claimed unfairness or injustice of a society in its divisions of rewards and burdens and other incidental inequalities based on one's worldview of humanity.

Social injustice, as we are using the term, means the unfair distribution of advantages, disadvantages and protection of opportunities and responsibilities.

In this case, it means the repression of nurse practitioners and their ability to be fruitful in healthcare business and practice related to the inability to pass full practice authority legislation.

We believe that this unfairness stems from the fact that most nurse practitioners (96 percent) are women while most of those who make decisions about the legal basis for their practice are men (76 percent).

Across the country, the percentage of women legislators is not representative of the number of women they represent or who vote. The United States ranks 69th in the world in terms of the percentage of women in government.

Nurse practitioners' authority is regulated through legislative action state by state. We continue to see women disadvantaged in government representation as well as disadvantaged in areas such as earning potential compared to their male counterparts performing the same work, especially in professional roles.

Traditionally, the nursing role is viewed as complementary to that of medicine; nurses care for patients, physicians cure them.

This worldview goes back to nursing's inception in the Victorian period of the 19th century. Originating then, it was inevitable that nursing would evolve separately from medicine, a male-dominated occupation.

The traditional nurse's role encompasses following doctors' orders, administering medications, caring for patients, making beds, dressing wounds, and assisting patients with the activities of daily living.

One of the more contentious topics on my site is the scope of practice for non-physician providers, such as nurse practitioners. This echos the debate on the national stage where leaders of physician organizations, who want to protect their scope of practice, conflict with those of nurse practitioners’, who want to perform the tasks that physicians traditionally have.

Simply Google “nurse practitioner” on this site, for instance, and you’ll see what I mean.

So the results of a recent New England Journal of Medicine survey comes as no surprise.

According to the study

Nurse practitioners were more likely than physicians to believe that they should lead medical homes, be allowed hospital admitting privileges, and be paid equally for the same clinical services. When asked whether they agreed with the statement that physicians provide a higher-quality examination and consultation than do nurse practitioners during the same type of primary care visit, 66.1% of physicians agreed and 75.3% of nurse practitioners disagreed.

And that’s a problem, considering these two groups will soon be working together in patient-centered medical homes, the supposed future of primary care. Most nurse practitioners believe they are qualified to lead them. Physicians disagree.

The president-elect of the American Academy of Family Physicians makes it clear: “Family physicians work with nurse practitioners across the country. They are critical players on the health care team — but they are not physicians. A physician-led patient-centered medical home ensures we have the health care professionals we need and that every patient gets the right care from the right medical professional at the right time.”

Given the shortage of primary care doctors, we should give nurse practitioners the opportunity to earn the responsibilities of physicians. But how can we ensure that the differences in training (physicians receive almost 4 times as many hours) doesn’t impact patient care?

Unify primary care certification. Make anyone who wants the responsibilities of a physician and lead a medical home, doctor or nurse, pass the same test.

Consider the Doctor of Osteopathy. Osteopathy is still viewed with suspicion by some, like this writer at Forbes who says, “osteopathy started out as little more than pseudoscience,” and that, “students enrolling at colleges of osteopathy have lower grades than students entering medical schools, suggesting (though this is not proof, of course) that D.O. schools provide an alternative route to a medical degree for those who aren’t good enough to get into normal medical schools.”

But despite the differences in training, osteopaths have generally been viewed by both the medical community and the public as equal to allopathic physicians. Why? Osteopaths have to pass the same exams MDs do in order to be board certified.

According to the NEJM survey, most nurse practitioners want to lead medical homes, admit patients, and receive the same pay for performing similar clinical services as doctors. And given the shortage of primary care clinicians, they should be given the chance to.

Require primary care doctors and nurse practitioners to pass the same certification test. In the eyes of some doctors, this will “legitimize” the ability of nurse practitioners to lead medical homes. And nurse practitioners who pass this hypothetical test can finally receive the physician responsibilities they want.

Everybody wins.


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