Defining the Scope of Practice

MDNG Primary Care, March 2011, Volume 13, Issue 2

Increasingly, mid-level practitioners are a patient%u2019s primary point of contact, changing the nature of primary care delivery and starting a heated debate over who is most qualified to manage patient care in the United States.

Increasingly, mid-level practitioners are a patient’s primary point of contact, changing the nature of primary care delivery and starting a heated debate over who is most qualified to manage patient care in the United States.

By Bradley Schmidt

In a recent editorial (http://HCP.LV/d0sB8p), we highlighted the growing role of non-traditional or mid-level care providers in the United States; what we discovered is that this is a rather touchy subject among physicians.

A number of your colleagues wrote in to tell us just how much they think that the scope of practice for “physician extenders” like nurse practitioners (NP) and physician’s assistants (PA) should be limited largely to non-complex patients.

James A. Taylor, MD, wrote that “the main point of contention is that some nurses want to be doctors without having to go to medical school, plain and simple. We have seen the results of diluting professional standards in education, and organized nursing will now use Obamacare to do the same thing in medicine.”

James Chillcott, MD, contends that if mid-level providers “are as knowledgeable as us, let them prove it to us by writing the same board examination as the family practice physicians or internists.”

This line of thinking, however, is a major point of contention for Jan Towers, PhD, NP-C, CRNP, FAANP, FAAN, Director of Health Policy/Federal and Professional Affairs, American Academy of Nurse Practitioners.

Towers asserts that nurse practitioners are not, nor are they attempting to be, internists, family physicians, MDs, or DOs. NPs, she says, are NPs, and that means they are primary care providers.

“NPs do not birth babies, do not remove appendices, and do not become sub-specialists,” she says. “They don’t have that kind of training, which is part of a physician’s preparation, but they are prepared to be primary care providers, and they do that well.”

Further, Towers says, the intense focus on differences in education is misguided. “There’s an aura in this culture which creates a mindset that there’s a hierarchy in medicine, and that’s probably not real effective,” she says. “We need to be able to create, collaborate, and work together based on our skills, not create unnecessary barriers in order to practice and provide care for patients and give them access to care.

“You can’t accomplish things in that linear way of thinking anymore,” Towers continues. “You have to look at all the kinds of people that can help with patient care. It’s not just NPs, but nutritionists, psychologists, health educators, etc. There are a whole group of providers that are highly skilled that can provide care to patients.”

Outdated regulations

According to Towers, the main position of NPs should in no way be construed as a desire to replace primary care physicians. NPs’ main gripe, she says, is that they are unable to practice according to the full scope of their license because of outdated state and federal laws. “The Medicare Conditions of Participation were written in 1965 and don’t really take into consideration people like NPs who are trained to do many things that are in the purview of primary care.”

Towers points out the contradictory reimbursement situation that allows an NP to order long-term care for a patient, but does not permit them to do an admitting physical examination for long-term care without a physician’s signature.

“There are unnecessary laws in existence that make it so we can’t do things we are authorized, educated, and prepared to do, simply because there’s an obsolete law in place that does not let us function because the word ‘physician’ is in there, yet it is something that clearly is within the scope of practice of an NP.”

Burdensome regulations

NPs are not the only ones who feel that laws governing health care delivery do not apply equally to them. A number of physicians indicated that for the level of independence that NPs are allowed, they do not share the same burden when it comes to malpractice suits.

Charlene Zhao, MD, an internal medicine specialist with the Greenville Hospital System University Medical Group in Greenville, SC, gets “an uncomfortable feeling” whenever she considers that her standing as an MD authorizes an NP’s orders for a patient who she has never seen and whose chart she has never read. “I always worry that something is going to come back and haunt me.”

Catherine Remus, MD, a pediatrician and former nurse in private practice in St. Louis, MO, feels the same way. “NPs are not taking the medical liability risk that physicians take. An NP may be dragged into a lawsuit, but they’re not carrying insurance to the level of an MD and they’re not the one that the lawyer is going to go after.”

However, according to Dean Moews, MD, a family medicine specialist practicing in Des Moines, IA, this fear of litigation leads to “blind loop thinking.”

“If you’re nervous about what your PA or NP might be doing, you need to review their care however much you think you need to, to be comfortable that they’re doing what you think they’re supposed to be doing.”

A question of supervision

Rather than worrying over potential malpractice suits, Moews feels that physicians should concern themselves with the level of autonomy that NPs have while under their supervision.

“I think that any discussion that does not involve using PAs or NPs is not realistic,” Moews says. “Does a qualified PA or NP need to work where the physician is in the same building, available to see their patients all the time? I’m not sure that that’s necessary. But they do need to be in a situation in which a primary care doctor is available by phone pretty much any time if they’re seeing a patient, and their records and care need to be reviewed by a physician on a regular basis.”

Moews concedes that not every patient needs to see a primary care physician or a specialist. Treating the average ear infection with antibiotics, he says, is going to be the standard-of-care whether a patient sees an NP or an ENT. The difference comes, he says, when an NP tries to “take care of pediatrics and difficult pediatric cases, adults and difficult adult cases, do OB, go to the nursing home, all of that, because quite frankly it took medical school and residency to get to a point where I would be able to practice safely on my own.”

Outcomes, outcomes, outcomes

Regardless of how competent our physician readers felt mid-level practitioners to be, they were overwhelmingly of the opinion that mid-levels could not ultimately do what those who went to medical school can do for patients with complex health conditions without supervision.

For example, Don Milligan, MD, commented on his “concern that moving to primary care provision by NPs and PAs will actually increase costs by increasing the number of specialty referrals by people who are not equipped to manage the wide variety of problems seen in primary care.”

And Nolan C. Snider, MD, feels “that much of the need for prior authorization for imaging studies comes from the inappropriate ordering of MRIs for every neck, back, knee, and shoulder problem by inadequately trained NPs and PAs.”

There is some validity to Snider’s claim, according to a 1999 comparison of resource utilization between NPs and physicians (, but what to make of published works demonstrating that NPs provide care equivalent to physicians in a cost-effective manner?

Just to highlight two examples:

“Comparable controlled blood pressure rates were observed among patients with hypertension receiving care from a NP vs. a comparison group receiving care from a physician” in this 2011 study (http://HCP.LV/fGG1Ff).

In a one-year study on the effects of lifestyle counseling by NPs on physical activity and diet, compared with usual care from a general practitioner, researchers found that “with the exception of an increase in walking (based on self-reported data) in the NP group, no intervention effects on PA and diet occurred. Positive changes in nutrient intake were seen in both groups.” (http://HCP.LV/fBz2Wi)

In the first study, NPs managed hypertension in obese patients, those who had diabetes, or both; in the second, NPs attempted to bring about positive lifestyle changes in patients “with overweight or obesity and either hypertension or dyslipidaemia, or both.” Neither case is simple or straightforward, yet both studies conclude that NPs were up to the task.

For Jan Towers, this data trumps all arguments against NPs operating as independent primary care providers. “A service is a service,” she states. “Treating someone with strep throat, a UTI, diabetes, hypertension—whatever it takes to provide that service, should be of the same quality regardless of who provides that service.

“We should be talking about skills and knowledge, and go from that framework. If you do not look at outcomes, then you can’t look at education. The bottom line is with that preparation, [NPs] make excellent PCPs and they provide outstanding care; results of all studies show that.”

The Tale of the Tape

Physicians and Nurse Practitioners: Do they Provide Equivalent Health Care?

“Nurses appeared to have more success in handling obesity and to achieve somewhat better control of hypertension” (http://HCP.LV/fMqdwG).

Is it Economically Viable to Employ the Nurse Practitioner in General Practice?

“The economic viability of the nurse practitioner has proven difficult to achieve in every day health care practice. This study provided insight into the complex interaction of the cost parameters that result in economic viability and feeds a further discussion about the content of the nurse practitioner role in general practice based on optimal quality of care vs. efficiency” (http://HCP.LV/hKIGnP).

Substitution of Doctors by Nurses in Primary Care

“Findings suggest that appropriately trained nurses can produce as high quality care as primary care doctors and achieve as good health outcomes for patients”


Embryo Transfer by Midwife or Gynecologist

“Similar clinical pregnancy rates between embryo transfers performed by midwives vs. gynecologists, 31% vs. 29%, respectively, were seen. Subject experience as judged by a questionnaire also showed high acceptance of ET by a midwife” (http://HCP.LV/hj5vKn).

Adherence to a Guideline on Cardiovascular Prevention

“Practice nurses adhered better to the Dutch guideline on cardiovascular prevention than general practitioners did. Lifestyle intervention advice was more frequently given by practice nurses. Improvement of cardiovascular prevention is still necessary. Both caregivers should inquire about patient adherence on a regular basis” (http://HCP.LV/dS9lR3).

A Randomized Controlled Trial in Children with Eczema

“The level of care provided by a nurse practitioner in terms of the improvement in the eczema severity and the quality of life outcomes was comparable with that provided by a dermatologist. In addition, the parents were more satisfied with the care that was provided by a nurse practitioner” (http://HCP.LV/dHXiZg).

Retrospective Comparison of Emergency Department Length of Stay for Procedural Sedation and Analgesia by Nurse Practitioners and Physicians

“Overall length-of-stay and time to sedation were significantly improved when NPs independently managed patients requiring procedural sedation and analgesia without an increase in documented severe airway complication rates” (http://HCP.LV/eAOHoD).