Saturday, September 11, 2010

APNs, Midwives, And Physicians

This started as a reply to a comment on my previous post.  It got long enough that I made it a separate post.


Regarding the tensions between nursing/midwifery and medicine, there is enough there to discuss that it merits a separate post. In terms of nursing, I'll limit my comments to advanced practice nurses (APNs: nurse practitioners, and the newly-created Doctor of Nursing Practice DNP). This has become a significant issue in Virginia, where APNs  are seeking increasingly autonomous practice

In my mind, the strengths and limits of both models involved the fact that the training for APNs and midwifes comes from the nursing perspective, with a strongly patient-centered, holistic and preventive focus. This is an approach to which I am sympathetic, and it stands in stark contrast to the increasingly impersonal, test-and-technology heavy nature of much current medical practice. For both APNs and midwifes, this approach leads to patient-centered care and an emphasis on wellness. This is a strength.

The counterpoint is that the depth and extent of training for APNs and midwifes is less than that for physicians. The time involved in medical school and a medical residency is far more than that of APNs and midwifes. In my opinion, this leads to increased ability to deal with complicated illnesses, patients with multiple co-morbid diseases, and patients with undifferentiated symptoms.

I think APNs and midwifes have very relevant roles, but I feel that the nature of the training is more applicable to focusing on certain areas or certain conditions, or working with patients who have established diagnoses. For midwives, this area is that of pregnancy, childbirth and postpartum care--although unexpected problems can arise, many of the complications or problems can be anticipated or more easily monitored for because the underlying condition is defined. In the case of APNs, working with acute problems or patients with defined illnesses allows the provider to focus more directly on the anticipated complications or concerns related to these conditions.

I think that midwives and APNs are valuable members of the care team. I also feel, though, that physicians are best qualified to lead the care team. This is my bias (as evidenced by the fact that I chose to pursue my MD), but I believe it is based on the fact that physicians' training is more likely to allow successful evaluation of undifferentiated problems or complicated conditions, or unanticipated complications.

Physicians have a lot to learn from APNs and midwives in terms of the patient-centered, holistic, wellness focus of care. And I think that an experienced midwife or APN is probably more qualified in many areas than many young physicians. But I do not think that APNs and midwives can take the place of physicians.


Geek2Nurse said...

So far I have, amazingly enough, agreed with every word I've read of your writings, except for these seven: "physicians are best qualified to lead the care team." It may be just a difference in how we define "lead," but what I hear you saying is that because ARNPs might encounter patients with issues outside our (speaking as a soon-to-be PMHNP) scopes of practice, we are not qualified to provide care for patients independently of physicians.  

Do you think this same standard should apply to other care professionals as well, or only to nurses? Other professionals are trusted to know their own scopes of practice and operate within them, referring / consulting as needed, while ARNPs cannot be lead providers simply because someone else's scope of practice might be broader than our own? Professional judgment is not exclusive to physicians, after all.  

If a family practice MD refers a patient to a cardiologist, he doesn't relinquish the lead role in that patient's care in order to do so. But you seem to be saying that since I, as a PMHNP, might at some point need to refer my patient to an endocrinologist, or consult with a psychiatrist about a complicated medication issue, I am therefore not qualified to lead his psychiatric care team? And, just for the sake of complicating the issue, what about the family practice MD who refers a patient to me for treatment of her depression and anxiety issues? ;)

If breadth of individual scope of practice is the standard, and not expertise in one's own practice area combined with professional judgment and collaboration with other providers, then...who out there IS really qualified to lead a care team?    

mark said...

Let me start by noting my own biases: 1) I'm trained as an MD, which means that I have a specific perspective on the value of my training, and 2) in Virginia there is a movement among NPs to try and establish independent practice; some of my comments are likely influenced by dicussions I've had on that issue.

The phrase that you commented on--"physicians are best qualified to lead the care team"--is my attempt to say that training as a physician better equips one to assess an undifferentiated problem and determine the starting point for evaluation and treatment. If a patient presents with fatigue, dysphoria, or chest pain I think the breadth of a physician's training puts us in a better position to determine the best course of care. I think this is also true if a patient has multiple comorbidities and is taking multiple medications. The longer training and the wider scope involved in physician training makes me believe that physicians are better equipped to handle these undifferentiated or complicated patients.

This is not my opinion alone: some insurance companies will not allow APNs see patients for their first visits, presumably because of concerns similar to those above.

I think you're right in that all professionals need to have an understanding of their scope of practice: cardiologists should not be providing general primary care services, just as I should not perform cardiac catheterizations. And I have worked with PAs and NPs who I trust implicitly and who I have sent my family members to for care. But I don't feel APN training is equal to that of a physician.

I think APNs can work independently to a great extent, but I also support requirements that there be physician oversight of APN practice. This is not because APNs are bad clinicians, because they will make bad judgements, or because they cannot be trusted. It is because the scope of training is so different as to become an issue.

If I refer a patient to a specialist, it is usually because I need help with a specific issue. However, unless I am going to refer patients to specialists for help evaluating numerous concerns, I have to be comfortable simultaneously assessing problems across multiple areas: endocrine, cardiovascular, mental health, etc. I question how prepared APNs are to take on that breadth of concerns all at the same time. I think NPs learn those skills once in practice, but I do not think those skills are as well developed as an MD's when they enter their respective practices.

I hope I haven't offended, and that I have explained how valuable APNs are in providing care. But I'm not personally comfortable taking the next step and stating that APNs can practice independently of a physician's oversight--however that oversight is defined.

I am not enough of an expert to discuss how APNs have done in states where they do have independent practice. My understanding is that they have higher rates of referral and consultation and are more likely to order tests and studies than a physician would be. I think that reinforces my claims that the breadth of training makes a difference.

mark said...

A couple other thoughts I posted on Twitter:

--I am writing my comments from the perspective of a primary care provider. I think having an APN in a specialized area (mental health, cardiology, etc) is a different situation: a tentative diagnosis has been made already and the issues have been a little better defined.

--Some additional thoughts and statistics discussing the difference in NP and MD training, written by a thoughtful family doc I know, are discussed in this Op/Ed he wrote:

Geek2Nurse said...

I have read the Roanoke editorial before -- I think @BurbDoc posted it on Twitter. I've already commented on some of it in choppy 140-char snippets over there, but maybe I can do it more smoothly here. ;)

I haven't read the studies the editorial refers to, but I wonder if they took into account the very different career paths of MDs vs. ARNPs? MDs generally go into medical school straight from college, with no previous medical experience. In contrast, most ARNPs have practiced as RNs for at least a few years before (and while) earning their advanced degrees. If the study did not take this into account, I would consider it flawed.

The editorial compares the clinical "hands-on" experience gained in the course of becoming an ARNP to that gained in medical school without considering the years of clinical experience an RN has already gained before embarking on an advanced degree (and do I need to point out the important role RNs fill in teaching "baby doctors" during their clinical training, while keeping them from killing our patients? )

If you look ONLY at the ARNP portion of our training in determining our level of skill, knowledge, and expertise, you're missing a large and very important part of the picture.

Geek2Nurse said...

I left out of my previous comment, although it's implied, that probably the reason ARNPs spend less time practicing is that they become ARNPs later in life, while most MDs start medical school straight out of college. I will be 50 by the time I become licensed as an ARNP next year, so I doubt I'll spend 30-40 years in practice. I disagree with the editorial's author that this indicates a lack of long-term commitment, or that it precludes my ability to provide excellent care. Both of these are erroneous conclusions, as they do not take into account the different career paths of MDs and ARNPs, and the amount of time ARNPs have already spent providing care *before* pursuing their advanced degrees.

Now on to your reply to my previous comment. As a nurse, naturally I am biased as well, and as a soon-to-be ARNP is a specialty field (psych-mental health) I probably have a slightly different perspective than a PCP. That said, I place a great deal of value not only in my nursing education, but also in the experience I've gained working as an RN in the acute care setting. The idea that doctors are infallible final authorities on medical issues or that nurses do not have the clinical expertise to recognize a wide range of issues has been refuted many times in my own experience when I've questioned a flawed order or brought symptoms to a doctor's attention that resulted in a change of diagnosis or plan of care for the patient. Nurses are an important part of the care team; our contributions, however, aren't tagged with our names and titles, so the credit for them goes to the doctors who sign off on them. As a result, our expertise tends to be overlooked in discussions like these.

Nurses, at least in the hospital environment where I work, have a lot to do with determining a patient's actual diagnoses and selecting the best course of treatment. Just because it's not our signature on the order doesn't mean the MD came up with it all by him/herself. It's not at all unusual to have an MD ask us what we think would be the best medication or course of action for one of our patients, and then give their orders accordingly.

The mindset that says nurses can't be trusted to work outside a doctor's supervision, I think, comes out of the paternalistic notion our culture has adopted that says doctors are all-knowing and nurses are just there to fetch bedpans and carry out doctors' orders, when the truth is that our own educations are also extensive and rigorous. Doctors who argue that ARNPs don't have sufficient clinical experience to practice independently have forgotten that once upon a time those ARNPs were the RNs who patiently pointed out their mistakes and taught them, as interns/residents, how not to kill our patients. ;)

All of that aside, I don't consider ARNPs to be "doctor replacements." If I had wanted to replace a doctor, I would have just gone to medical school and become one. I chose nursing because of its holistic focus on the individual (something you described rather brilliantly in this blog post, by the way). My interest is not primarily in the disease; my focus is on the patient's overall well-being. That made nursing the right choice for me.

Apparently I am too long-winded; I'll have to post the rest of my response in yet another comment. ;)

Geek2Nurse said...

Continued from previous comment

My decision to go on to an advanced degree and become an independent practitioner also had nothing to do with replacing doctors; rather it had to do with filling a need. My chosen patient population, the chronically mentally ill, is by definition underserved. They are uninsured, or at best covered by Medicare/Medicaid, and are the population least likely to have access to care, especially with the increasing number of doctors now closing their practices to M/M clients.

I disagree with the notion that ARNPs should only practice under physician oversight. We are professionals, and capable of operating autonomously as members of the care team. Like any other provider we can be trusted to use our professional judgment to recognize when problems are beyond our expertise/scope of practice, and draw upon the same resources any other professional would, collaborating and/or referring to best meet the needs of the client.

My view of physician supervision is probably marred by the experience of ARNPs in Washington State before autonomy was gained here. "Physician supervision" generally became a paperwork issue, and boiled down to an exchange of money for the physician's stamp of approval on an ARNP's practice. Although I'm sure many physicians were conscientious, or at least made an effort to randomly scan a few charts now and then, many more never had any contact with the ARNPs they "supervised" beyond the periodic exchange of money for documentation. The arrangement was simply another impediment to practice for ARNPs. It did nothing to improve the quality of care received by patients, and was just a way for MDs to "pad their pockets" at the expense of ARNPs.

I might not be opposed to some sort of mandatory supervision for ARNPs for a limited amount of time (1-2 years?) after they enter practice, IF that can be done without impeding clients' access to care and with some sort of controls to ensure that quality supervision is actually taking place that is beneficial to the ARNP educationally/experientially. I'm not convinced, however, that MDs are the only ones capable of providing such supervision.

Although I haven't dug up the research myself, reports I've seen by others who have indicate that quality of care provided by ARNPs is at least comparable to that provided by MDs. I don't think that increased numbers of referrals and consultations are necessarily a bad thing -- what that tells me is that ARNPs are being conscientious about acting as part of a TEAM to provide the best possible care for their clients. Which is, after all, what the whole discussion is about in the first place, isn't it? If the research is showing that we can be relied upon to consult with more knowledgeable others when there's a question, doesn't that imply a that says we can be trusted to know our own boundaries?

mark said...

A few thoughts in response to your comment. I know you realize that I am *not* talking from a paternalistic perspective, and that I agree that ARNPs provide a great deal of much-needed care.

--Some ARNPs (like you) have extensive clinical experience as RNs before pursuing the advanced degree. But more young students are getting their BSN, then going straight into ARNP programs. They don't have the same experience you did and I don't think we can presume the same comfort w/ clinical care. Physicians need 3 additional years of supervised clinical care and education after medical school. Shouldn't ARNPs be held to a similar standard?

--I value the input and care nurses provide, and I acknowledge the debt I personally owe to many. I don't think, however, that nursing training is equivalent to medical school. In some ways, it is better (the holistic approach that medical school often marginalizes). But I still believe that in approaching a complicated patient or a patient with an uncertain diagnosis that the experience medical school and medical residency provide are very different from that many nursing students experience.

--No denying that filling a need is a noble calling--I have spent my career working with underserved communities. And at this point, ARNPs fill a critical space in providing care in these communities. That does not mean that they are doing the work of a physician--you noted that your goal is not to replace physicians.

--If ARNPs operate under physician oversight, then what you describe in Washington State is a travesty.

--I mention the issue of referrals and consults and tests b/c it does affect another issue re: ARNP care. In an environment of escalating medical costs, if a physician's training allows fewer tests and referrals to be used I think that should lead to more efficient care. By making more referrals and using more tests, it implies that the level of training is not equivalent.

--I'm going to throw the ball back in your court: if ARNPs are trained and capable of practicing independently, how far should that independence go? Where does a physician-level presence become necessary?

Geek2Nurse said...

Posting in parts again...I'm just too verbose for your blog!


NO, my comments on paternalism were NOT directed at you, I hope it didn't come across that way! I just think that the combination of our society's general lack of any real understanding of what nursing even IS as a profession, combined with the culturally-accepted paternalistic view of nurses, tends to influence these sorts of discussions to a great extent. "The doctor is your boss" is a commonly-held misperception. The doctor is NOT my boss; we are colleagues who both have important roles in patient care. I think the view that ARNPs must be supervised by doctors can't help but have been influenced by that attitude.

Nurses in the US were independent practitioners until the Great Depression, when nursing schools shut down and no longer provided hospitals with nursing students to provide care for patients. Nurses moved into hospital care at that point, to fill the gaps. The cultural attitude that nurses are subservient to doctors dates back to that, from what I can tell.


Actually, in the interest of full disclosure, I don't have extensive clinical experience compared to many of my MSN student peers. I was in the tech industry until the post-9/11 downturn, so my move into nursing as a career came later in life. I've only worked in the nursing field since the beginning of 2004. I've always tried to approach patient care with a learning attitude, though, which I think has helped me to "catch up." Nurses are teachers by nature, and even doctors can be persuaded to explain things if you can get them to stand still long enough, so I've gained a lot of knowledge from those around me who are more experienced. When I started working on my MSN, I made an effort to start approaching patient care in my RN job with the mental attitude of an ARNP. How would I diagnose this patient? Would I do anything different with their medications / treatment, and if so, why? Evaluating psych patients in the ED for 2 years gave me lots of great opportunities to come up with my own diagnoses / treatment plans and then compare them to what the consulting psychiatrist or ARNP recommended, and in some cases, if they were admitted to our units, to see what the end results were. It also gave me opportunities to collaborate with those other disciplines about the patients, which was a great learning experience.

I wouldn't be opposed to a limited period of supervision for new ARNPs, and although it's not a requirement in either of the states I'll be licensed in, I fully intend to seek out supervision for my first few years in the field. That's actually something that is strongly recommended by my MSN program. I'm likely to seek out supervision by more experienced ARNPs rather than MDs, though, depending on where I end up working at first and who's available to me.


To be continued...

Geek2Nurse said...



I agree that our training is not equivalent to medical school training. If it were, there would be no difference between doctors and nurses, which (from my point of view) would be kind of sad. :) I also agree that, as an ARNP, there will be patients whose problems are too complex for me to take on, at least without help. I think where you and I differ is that I feel my education has given me enough knowledge and discrimination to make that determination myself, and that I can be trusted to use my professional judgment and not overstep the bounds of my education and expertise.


Granted that fewer tests and referrals would make patient care more efficient. Until we achieve a perfect world where efficient patient care is available for all patients, however, we have to settle for realistic. The existence of ARNPs means that more patients have access to care. The fact that the patients most in need of access to care often have the most complex needs speaks to the failure of our system to provide adequate preventive care to begin with. ARNPs may have to do more referrals/testing as a result (which leads me to wonder if the study results were corrected for patient population & complexity of needs), but that's still better than those patients only having access to care via EMTALA and much more expensive emergency care.

When we achieve that perfect-worldness, the complex patients can all go to MDs and those with more straightforward needs can be addressed by ARNPs, and only true emergencies will end up in emergency departments. Until then, I think we're all stuck doing the best we can with what we have to offer. That means I may have to provide care to a complex patient via consultation who otherwise wouldn't have any care at all. (I was going to say "consultation/referral," but patients without access to primary care aren't likely to be referable, are they?)


Ball's in my court, huh? ;) The ability of an ARNP to practice independently is based on the ARNP's education and skillset, and their own judgment in knowing where their boundaries are. We are capable of recognizing complexity even though we may not be trained to fully address it; that's the reason for the advanced pathophysiology and assessment requirements of our programs. Family practice docs don't have to be supervised by cardiologists, endocrinologists, orthopedists, etc. to make sure they aren't overstepping their professional bounds, and vice versa; they are trusted to use their own judgment. I believe ARNPs are just as capable of using professional judgment to determine the bounds of our own practices, without being policed by others. Physician-level presence becomes necessary when a patient's problems extend beyond the boundaries of our education and experience, and we will go looking for it at that point. It doesn't have to be forced on us.

mark said...

I didn't feel your concerns about paternalism were directed at me. It's just something I wanted to be careful about--we're each discussing pretty key issues re: the other's life/profession and I wanted to make sure I wasn't offending you.

I don't agree that requirements that ARNPs need physician supervision are inherently due to a paternalistic perspective (though I don't doubt that plays some role). I think that there is a concern (which is likely fading and may be less of an issue in the near future) that traditional nursing education is more focused on patient CARE and less focused on establishing a diagnosis and appropriate plan of care. MSN and ARNP training are presumably designed to address those concerns, but I think there are many people who remain unconvinced that the nature/extent of MSN/ARNP training are sufficient.

I do think that, if ARNPs are looking to establish independent practice as a standard practice across the board, requiring additional supervised clinical training is an absolute necessity--even if this delay's one's entry into practice. I cannot imagine a 4th year medical student taking an intern year and then entering practice--the additional 2 years are necessary experience. ARNP's should complete at least the same requirements.

I also feel that if ARNPs end up taking on roles similar to those of physicians (diagnosis and treatment plans), then they should be required to complete the same qualifying board exams. ARNPs in independent practice will face the same diagnostic challenges physicians do, and I think they should need to show similar proficiencies in Dx/Rx. Unfortunately, 50% of DNPs who took the medical licensing exam recently failed it, making me further question whether ARNP training adequately covers the ground physician training covers.

As an individual, *you* very likely do have the self-awareness to know when you might be working with a patient outside of your comfort zone. However, can we safely assume that *all* ARNPs have the same self-awareness? Medical students, interns and residents have many stages during which their skills are assessed and can be found lacking; do the classroom and clinical rotations ARNPs complete enough to fully assess those skills? At this point, in most states in the US, legislatures have decided that this is not yet the case.

(continued below)

mark said...

(continued from above)

At Virginia Commonwealth University (VCU), BSN RN students complete 91 credit hours if they enter the program in their second year, and do not need as much of a science-based foundation to their undergrad education as pre-med students. VCU's Family Nurse Practitioner (FNP) MSN program requires 55 additional credits with only 13 credits hours being in practicum situations. By comparison, VCU's School of Medicine requires more undergrad science courses, and the MD students take 41 additional courses in the first three years (with additional clinical training in the fourth year)--which must then be followed by the internship and residency requirements.

So: VCU's RN NP students take 55 credit hours to complete their ARNP requirements, after which they can take their licensing exams and enter practice. Meanwhile VCU's MD students take 41 additional courses (not credit hours--courses) and then have to complete at least a one-year internship before sitting for the licensing exam. And almost all practicing physicians take at least two additional years of residency training.

I don't think ARNPs receive bad or inadequate training. It is just clearly very different. I am bothered when, on the basis of such training, ARNP organizations seek the same scope of practice as that earned by physicians after much longer and more extensive training. Although your comments indicate that you would not take on the same role as a physician, I fear many other ARNPs and ARNP organizations might seek a physician-level scope of practice. And I can't reconcile myself to that.

The outcome studies that you mention, in which ARNPs and physicians had similar outcomes, were (to my understanding) studies looking at very limited and specific conditions--the sorts of conditions all of us agree ARNPs are well-trained to address. And despite similar outcomes, costs of care with ARNPs were still higher.

Finally (for now!?): it is fair to note that ARNPs should be trusted to consult once they realize the are outside of their comfort zones. But part of physician training is focused on teaching those boundaries. I do worry that some ARNPs might draw that boundary too close (and refer too often) or too far away (and not refer when they should).

Also, a self-evident statement: there are a lot of physicians out there who don't do a good job; medical training is not a guarantee. However, I do believe that on average medical school prepares one for independent practice the way that ARNP training does not.