As NPs push for expanded practice rights, physicians push back
This the second in a series on the expanding scope of practice of clinicians who are not fully licensed physicians. The first article explored the evolving practice rights of naturopathic doctors.
Of all the nonphysician clinicians seeking additional practice rights, nurse practitioners worry physicians the most, notes AOA 2nd Vice President Joseph M. Yasso Jr., DO, who chairs the AOA Bureau of State Government Affairs. Under appropriate physician supervision, NPs provide indispensable care to patients and help redress the worsening physician shortage, acknowledges Dr. Yasso, a family physician from Lee’s Summit, Mo. But a vocal segment of NPs has relentlessly and pervasively pursued practice autonomy and other expansions of practice rights despite having training unequal to that of physicians.
Outnumbering DOs 2-to-1, nurse practitioners have secured broad prescribing authority in most states. Many states allow NPs to have collaborative practice agreements with physicians rather than requiring physician oversight. And 12 states and the District of Columbia permit NPs to independently practice and prescribe. (See table.)
Beyond their strength in numbers and pursuit of practice autonomy, NPs stir up concerns because of their likelihood of being mistaken for fully licensed physicians, points out Joel A. Kase, DO, MPH, the vice chairman of the Bureau of State Government Affairs.
Unlike naturopathic doctors, who typically work in alternative medicine clinics and offices, NPs work in conventional health care settings, Dr. Kase notes. “People who go to see naturopaths typically realize that they are seeing alternative medicine providers, whereas patients who are examined and treated by nurse practitioners—in medical offices, clinics and hospitals—are apt to assume that these NPs are physicians or have equivalent training to physicians,” he says.
“Every day I observe patients calling nurse practitioners ‘doctor,’ ” adds Dr. Kase, the president of the Maine Osteopathic Association and a family physician in Auburn, Maine. “Most people are not health care literate. They don’t understand the difference between physicians and physician extenders. Nurse practitioners have used this to their advantage.”
Apprehensions about nurse practitioners being confused with physicians—and taking their place in primary care—have become magnified with the growth of NP-staffed retail health clinics and the emergence of the doctor of nursing practice (DNP) degree, which will be required of all newly licensed NPs as of 2015.
Many DOs and MDs fear that DNP graduates, who now number in the hundreds, identify themselves as doctors when treating patients, exacerbating the public’s bewilderment over the credentials of various types of health care professionals, according to Dr. Yasso. In a study conducted by the Global Strategy Group in 2008, 38% of respondents hearing the title doctor of nursing practice inferred that this health care professional went to medical school. And when nurse practitioners say they are “doctors” without first clarifying that they were trained as NPs, the potential for confusion becomes all the greater, Dr. Yasso says.
The rise of the DNP degree is one of the main reasons the Bureau of State Government Affairs submitted Resolution 298 (A/2009)—on who has the right to be identified as a doctor or a physician—to the AOA House of Delegates last July in Chicago. Eventually approved as AOA policy, this resolution triggered an hour-long debate, marked by a series of amendments to amendments to amendments—the most extensive and heated discussion of the 2009 House.
Proposing that the resolution’s title be changed from “Use of the Term Doctor” to “Use of the Term Doctor As It Relates to Physicians,” Kentucky delegate Gail D. Feinberg, DO, successfully argued that the House cannot take away the right of individuals with doctorates to call themselves doctors but can oppose misleading uses of the term in advertising and in clinical settings.
New York delegate Robert B. Goldberg, DO, was among those calling for stronger language in the resolution. “Allied health professionals don’t use kid gloves when they attack our profession and take away our practice rights,” he declared.
As finally approved, Resolution 298 stipulates that the AOA opposes the misuse of doctor by nonphysician clinicians “because such use deceives the public by implying the nonphysician clinician’s education, training or credentialing is equivalent to a DO or MD.”