Unsurprising News of the Week: Another Doc Is Against Full Practice Authority

Another week, another physician calling into question the ability of advanced practitioners to treat patients as the primary care shortage looms.

“Nurse Practitioners Can’t Do What Primary Care Docs Can Do” reads the headline of an MD-penned op-ed published this month by Managed Care Magazine.

The piece, written by Alan Adler, MD, a recently retired senior medical director for utilization management and precertification at Independence Blue Cross in Philadelphia, begins by setting forth three patient cases he had encountered: a 72-year-old man exhibiting concentration and memory issues, who Adler was able to diagnose with a large meningioma; a 50-year-old male who was experiencing loose stools, which Adler tied to a sugar-free candy habit after myriad GI testing; a man with an irregular heart rhythm, who had been suffering from fatigue and dizziness, who Adler had been able to help by identifying it was a case polypharmacy.

Adler then goes on to say the cases are “the intensely satisfying, salient episodes of intuition informed by our long hours of medical training,” before bringing up Nurse Practitioners and their quest for full practice authority in the face of the ballooning primary care physician shortage.

“[W]ould a nurse practitioner have recognized, diagnosed, and addressed the issues in the three cases I have just described? Are they comfortable delving into complex polypharmacy issues and stopping medications prescribed by physicians? Can they recognize Wencke-bach and its importance on an ECG in the office? I would argue probably not,” Adler debates in the piece, calling into question the ability of NPs to practice independent of physicians.

It is certainly clear that Adler, like many other physicians who have penned similar op-eds in recent months, opposes NPs as a viable solution to the physician shortage. However, like many others who have voiced their opposition, he falls short of offering an alternative, concluding his piece by calling for a model of care that has already been implemented across America and is proving to fall short of solving the problem: “I am not against new models of primary care. A primary care physician overseeing several nurse practitioners and physician’s assistants is an excellent way of increasing access to care without sacrificing quality.”

How do you feel about the op-ed and the constant opposition NPs and PAs face from physicians? Tell us below, or submit an op-ed of your own here.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Physicians vs. Advanced Practitioners: Where Do You Stand?

A battle has been brewing between advanced practitioners seeking to expand their scope of practice and the physicians who oppose them. Where do you stand?

A battle has been brewing within the medical community for quite some time. As the physician workload has steadily multiplied due to physician shortages and increased documentation requirements, advanced practice nurses and physician assistants have upped their fight for full practice authority in an effort to boost productivity, lower health care costs, and increase access to care. This hot-button issue has split the physician community down the middle, into those who are glad for the assistance and those who greatly oppose non-doctors treating patients as if they are doctors. And, lately, for those who oppose APNs and PAs, the gloves have come off, so to speak.

Despite study after study after study after study finding that APNs and PAs provide care comparable to or even better than physicians, multiple doctors have taken to the internet to speak out against expanding their scope of practice.

“With all due respect to our healthcare team, I beg to differ that going through four years of college and completing an additional two years – sometimes online, no less – can truly be “just as effective”,” wrote Starla Fitch, MD, in an op-ed entitled NPs/PAs ‘Just as Effective’ as Physicians? I Don’t Think So.

In another posting, an open letter penned by the Presidents of the American Academy of Emergency Medicine Resident and Student Association directed at the American Medical Association Board of Directors called for the AMA to implement a public awareness campaign that “advocates for physician-led care and educates the public of the discrepancies in nurse practitioner care” and increase “resources on state-level legislative operations that combat independent practice bills introduced by midlevel providers.” The authors of the open letter went on to state, “These efforts should be a priority for the AMA. Waiting for the complete devaluation of our medical degrees and the resulting significant harm to our patients’ safety as they actively pursue less capable “providers” is not acceptable. We must work together to directly combat this pressing issue in order to protect our profession, our future physicians, and most importantly our patients.”

“There are absolutely patient safety concerns associated with NP and PA care. We don’t diminish the fact that physicians make mistakes, of course, but the type of mistake is often very different from those of non-physician practitioners. We have had many physicians and patients share stories with us of missed diagnoses and misdiagnoses by NPs and PAs, as well as excessive and inappropriate testing, prescribing, and treatment,” said another physician—Carmen Kavali, MD, who is also a board member of Physicians for Patient Protection.

There is no shortage of opposition. However, as Alison Moriarty Daley, MSN, APRN, PNP, put it as far back as 2011, “There are too many people who need high-quality, dedicated providers; we are such providers and deserve the appropriate respect, recognition, and support from the healthcare community.”

The physician shortage is not getting any better. The Association of American Medical Colleges predicts a shortage of between 21,100 and 55,200 primary care physicians by 2032, and physicians are burning out and, sadly, dying by suicide at an alarming rate. So, why the fight?

Where do you stand on the issue? Tell us in the comments below.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

NPs Touted as Primary Care Shortage Solution—Yet Again

Nurse practitioners are the solution to health care provider shortages, or so said a rally cry of an op-ed published by The Hill this week.

Nurse practitioners are the solution to health care provider shortages, or so said Sophia L. Thomas, President of the American Association of Nurse Practitioners, in an op-ed published by The Hill this week.

The op-ed, which can only be described as a rally cry for full practice authority, points out the strain of the primary care physician shortage, one that is estimated to fall short of patient demand by 120,000 physicians by the year 2030.

In contrast, however, the NP profession is growing, expected to increase by 6.8 percent annually between 2016 and 2030, with more than three-quarters of NPs trained in primary care areas.

“There are more than 270,000 nurse practitioners (NPs) licensed in the United States, and they are an under-utilized asset in the struggle to strengthen and expand primary care access,” said Thomas. “While 40 percent of U.S. states authorize full practice authority (FPA) for NPs providing patients with full and direct access to NP care, unfortunately a whopping 60 percent of states have yet to modernize their state licensure laws to grant the same access. In those states, outdated regulations restrict NP practice rights, which in turn reduces access to care for patients.”

In addition to expanding FPA laws, Thomas calls for states to allow NPs “to sign the forms for the care they deliver instead of being forced to get redundant third-party signatures,” as well as to “create flexible and sustainable reimbursement methods to ensure that NP care is covered and reimbursable.”

Thomas closes the piece by saying, “NPs are uniquely qualified to provide high-quality, comprehensive and cost-effective primary health care to all patients. It’s time that policymakers at both the federal and state level take the steps needed to ensure that all Americans, regardless of where they live, have access to the primary care they deserve.”

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

NPs Bite Back at Physicians’ Call for Public Advocacy Campaign

Physicians and Nurse Practitioners have been battling it out online in the form of open letters this past week, with both calling on the AMA to step in.

An open letter penned by the President of the American Association of Nurse Practitioners, Sophia L. Thomas, DNP, FNP, PNP, FAANP, was posted to the AANP website this week, and in it, calls for the American Academy of Emergency Medicine and its Resident Student Association to retract their own open letter, which they released last week, asking “Where is the Public Campaign Advocating for Physicians?”

The AANP’s letter stated that the AAEM’s letter, which was written by Haig Aintablian, MD, President of the AAEM/RSA, and David A. Farcy, MD FAAEM FCCM, President of the AAEM, “was riddled with blatant inaccuracies and self-serving statements that seek to undermine the NP profession and devalue the health care needs of patients nationwide.”

One of the inaccuracies pointed out in the AANP’s letter is where the AAEM’s said, “the American Association of Nurse Practitioners (AANP) has put forth a significant public campaign challenging physician education and compassion with slogans such as “brain of a doctor, heart of a nurse” going so far as airing commercials recommending patients actively choose a nurse practitioner over a physician for one’s health care.”

Thomas said in the NP letter, “AANP is proud of its public awareness campaign that highlights the role of the NP as well as the patients who choose them as their primary care providers. Our goal is to expand public awareness of the NP role and to encourage more patients to consider an NP.”

She went on to explain, “To be clear, AANP never conceived of nor sponsored “brain of a doctor, heart of a nurse” as a tagline in any advertising campaign or as content in any official social post issued from our organizational social accounts. In fact, we find the entire premise insulting, as 50 years of research clearly demonstrate, the “brains” of NPs drive health care outcomes equivalent to physicians, year in and year out.”

The AANP letter closes by saying, “It is time for the American Medical Association (AMA), AAEM and AAEM/RSA to put patients first and let them choose their own provider. Only then can we make patient-centered, accessible health care available to all. AANP stands ready to work with medicine to find reasonable solutions to the issues where we differ and promote high-quality health care together for all of our nation’s citizens.”

The AAEM/RSA letter can be found here, and the AANP’s reply can be found here

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

NP Role Expansion Bill Passes Pennsylvania Senate

Nurse Practitioners saw another victory in their quest for full practice authority on Wednesday in the Pennsylvania Senate.

Nurse Practitioners saw another victory in their quest for full practice authority on Wednesday in the Pennsylvania Senate, when they voted by a margin of 44 to 6 to advance legislation to allow certified NPs to practice independently of physicians.

Senate Bill 25, sponsored by Senator Camera Bartolotta, aims to amend the Professional Nursing Law, and will allow certified NPs to practice independent of a physician after they fulfill a three-year, 3,600-hour collaboration agreement with a physician. The law as it currently stands requires NPs to practice under a collaboration agreement at all times.

Similar legislation was approved by Pennsylvania’s Senate in April of 2017; however, the bill did not receive a vote in Pennsylvania’s House of Representatives. The bill will now be moved to the House for a vote.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Fight to Expand Advanced Practitioner Roles Fails in Florida

House Bill 821 sought to grant autonomy to Advanced Practitioners in the state of Florida in an effort to expand access to care and affordability.

A bill that would have allowed non-physician practitioners to work independent of physician supervision met defeat in the Florida Senate this month.

House Bill 821 sought to grant autonomy to Advanced Practice Registered Nurses who meet certain criteria to practice advanced or specialized nursing without physician supervision, and to authorize PAs to practice primary care without physician supervision. Florida, which currently ranks 41st in access to health care and affordability, allowed the cost-effective measure to die in Health Policy, and it is now considered indefinitely postponed and withdrawn from consideration.

However, the fight is long from over.

Brandon Miller, legislative assistant to bill sponsor, State Rep. Cary Pigman (R-55), is quoted as saying, “We’ll try again for the 2020 legislative session.”

Currently, there are 22 states that have granted full practice authority to Advanced Practice Registered Nurses, and 18 states have adopted barrier reduction measures.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

44 Million Reasons to Expand Scope of Practice

13% of the population of the U.S. now lives in a county that is experiencing a primary care physician shortage. Advanced practitioners could very well be the answer.

Forty-four million Americans, or 13% of the total population, now live in a county in the United States that is undergoing a primary care physician shortage, according to a new report from UnitedHealth Group, one of the nation’s largest insurers.

When considering the findings of the report, entitled Addressing the Nation’s Primary Care Shortage: Advanced Practice Clinicians and Innovative Care Delivery Models, expanding scope of practice laws in the 28 states still restricting NPs from full practice authority is one clear answer to the shortage, which is only expected to get worse over time.

As cited in the report, the U.S. population is expected to increase 8%, from 328 million to 355 million, by 2030. Meanwhile, the number of primary care physicians is expected to only increase 6% from 288,000 to 306,000 by 2025, leaving a significant gap in care that could be filled by the scores of NPs practicing primary care, which will increase 47% from 204,000 to 299,000 during the same time.

By removing barriers to practice and allowing NPs to practice at the full capacity of their training and education, the report finds that the number of U.S. residents living in a county with a primary care shortage would decline 70%, from 44 million to less than 13 million.

To read the full findings of the report, please click here.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Both Political Parties Can Agree on Working to Solve the Looming Nurse Shortage

Without an effort from both sides of the aisle, America’s health system may be pushed past the breaking point.

from The Hill

The largest component of the healthcare workforce, nurses play an indispensable role in the provision of healthcare. But in the years to come, the demand for nursing services will dramatically outstrip the supply — all the more so because of the 20-plus million people who gained access to healthcare under the Affordable Care Act. In this new healthcare environment, the skills of nurses — and specifically, advanced practice nurses — will be especially valuable.

Read More →

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

According to This Doctor, NPs Are Not the Cure for Rural Health Woes

““Apples and oranges” does not even come close to comparing the levels of knowledge and training between nurse practitioners and physicians,” says Dr. Sudhakar Madakasira.

from Clarion Ledger

Allowing nurse practitioners to practice without oversight of physicians could help address access to care shortages in Mississippi, particularly in rural areas. However, physicians, including those in the state of Mississippi and American Medical Association, say there is no substitute for the advanced education and training doctors receive.

What are your thoughts? Share them below.

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Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

This Month, Everything Changed for PAs

After days of debate and years of dreaming, collaboration and study, an entire profession has embraced their future.

by Beth Smolko, MMS, PA-C

After days of debate and years of dreaming, collaboration and study, the resolution called “Optimal Team Practice” (OTP) came up for a vote in the American Academy of PAs (AAPA) House of Delegates (HOD). I remember hearing the Speaker call for all votes in favor and although there was a good response, I couldn’t tell if it was a majority. Then, the Speaker called for “all opposed” and there was silence. Pure, beautiful, silence. It was in that moment that an entire profession embraced their future.

In years past, a determined and legendary PA leader, David Mittman, started saying we needed Full Practice Authority/Responsibility in order for the PA profession to survive and thrive. Many PAs did not want to risk future PA legislation by angering physicians with FPA. We saw the fierce battles the NPs had to engage in and realized that we would have to fight the state Board of Medicine in almost every state without the same level of protection that comes from having your own state board (like nursing). As the years went on, we saw our nurse colleagues fight battle after battle, state after state, and even though the physician groups bemoaned their success, they didn’t cease to hire NPs. In the past year, it became clear that physician groups were actually preferentially hiring NPs due to the reduced administrative burden, over “dependent” practitioners like PAs. PAs who felt that physicians would continue to hire them due to PAs practicing in the same “medical model” or staying “in our place” were sadly mistaken. As physicians had increasingly become employees instead of solo practitioners, they no longer wanted the professional liability that comes from having to “supervise” another professional.

Almost two years ago, I led an advocacy team for primary care PAs (AFPPA) joining with the PAs for Tomorrow (PAFT) and Brian Sady (a passionate educator from Nevada who wrote a comprehensive white paper on FPA for PAs) to address PA practice authority. We worked diligently to create a resolution to bring to the 2016 AAPA HOD to introduce Full Practice Responsibility (FPR). There was vigorous debate on the house floor but ultimately the resolution was referred for further study. From this point, the HOD and AAPA Board of Directors (BOD) formed the Joint Task Force on the Future of PA Practice Authority (JTF). The JTF reflected the diversity found in our profession. It was made up of clinically practicing PAs, educators, state PA leaders, and two PAs who work for the Veterans Administration. It was a group that would have to come to consensus on ideas and language that would be best for our patients, our profession, and our stakeholders.

Over the past 10 months, the JTF worked with AAPA staff to create the most transparent and member-engagement driven process in our organization’s history. They sought to understand the wishes, needs, and will of their constituents. The concept was named Full Practice Authority and Responsibility (FPAR) and consisted of four “pillars”:

  1. Emphasize the PA profession’s continued commitment to team-based practice.
  2. Support the elimination of provisions in laws and regulations that require a PA to have and/or report a supervisory, collaborating, or other specific relationship with a physician in order to practice.
  3. Advocate for the establishment of autonomous state boards, with a voting membership comprised of a majority of PAs, to license, regulate, and discipline PAs.
  4. Ensure that PAs are eligible to be reimbursed directly by public and private insurance.

A survey was released on FPAR with over 12,000 PAs responding and over 71% in favor of the concept. The AAPA held calls with state chapters, specialty organizations, students, program directors, PA Administrators, past presidents and a variety of other PA leaders, as well as external stakeholders to field questions and explain the concept of FPAR. The AAPA also received thousands of emails, comments on social media, and letters regarding FPAR. PA leaders met with multiple physician organizations to discuss the proposal under consideration. By March, it appeared clear that this would be the way forward, but slow deliberation is the hallmark of PA leadership. During the Leadership and Advocacy Summit held in March 2017, we heard concerns from some attendees, including PA educators, which led to rethinking the name and some of the language originally proposed by the task force. As the pillars would directly impact AAPA’s Model State Legislation, they were added to the guidelines document as opposed to creating a “stand alone” resolution. The pillars were given a new name — “Optimal Team Practice” (OTP). This change in language gave some assurance to PAs that felt teamwork was important to emphasize. They wanted it to be clear that PAs weren’t going “rogue”, but rather wanted to be better teammates by not burdening any other teammate with “supervision”.

So, once again, I found myself on the floor of the HOD last week, asking for my colleagues to consider the future of our profession and the impact OTP would have on patient access to care. And after two days of debate, it ended in silence… followed by cheers, tears, and emotion unlike anything I’ve ever seen from our profession. It was a moment that changed everything – how PAs see themselves as a profession, where we belong in the healthcare landscape, and how we can expand access to care for our patients.


Beth Smolko is a certified PA with experience in primary care and occupational health and wellness. While in PA school, Beth volunteered in a mobile medical unit in Tucson, AZ which ignited her passion for bringing quality medical care to the underserved outside the walls of a clinic. Beth is a recognized leader in primary care with professional roles that include: Director-at-Large, American Academy of PAs (AAPA); Past President of the Association of Family Practice Physician Assistants (AFPPA); PA Representative at the 2013 and 2014 World Hepatitis Day meetings held at the White House; HCV Testing Recommendations Implementation Panel – Healthcare Providers (Centers for Disease Control). Participant representing PAs in the discussion on the Implementation of Hepatitis C Screening Recommendations for Patients born between 1945-65; Preceptor for George Washington University, Franklin Pierce and Salus University PA Programs. Preceptor for LECOM. Preceptor for University of Michigan Nurse Practitioner program; Guest lecturer for Mary Baldwin – Murphy Deming and George Washington University PA program speaking on “Pulmonary Disease” and “Family Medicine”; President and Founder of The Heart of Medicine, a non-profit connecting healthcare providers with patients desperately in need of care in Haiti.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.