Without that kind of consensus, “It’s a rather hollow promise to say, ‘Now we’re going to provide these 33 million people with insurance’ and not be able to provide them that care,” Rowe says, pointing to what happened in Massachusetts when expanded rolls of insured sought care but many couldn’t get timely appointments because physicians were so booked up.
On a practical level, both sides say, the war is not being fought in the physicians’ offices or the hospital’s hallways. In areas where there are barriers to nurse practitioner practice, doctors and nurses have found ways to work collegially.
Nevertheless, a coalition of physician groups, including the AMA and the AAFP, is opposing efforts to relax limits on nursing scope of practice, saying that the IOM’s recommendations were not sufficiently evidence-based.
Roland Goertz, MD, is CEO of the Waco Family Health Center in Texas and this year’s AAFP president. He declined to say what he thinks these nurses should or shouldn’t be able to do. But he insists that nurses should not be thought of as replacements for physicians.
For starters, he says, there is too much variation in the way nurses have been educated, and standardization among nursing colleges—setting up minimum requirements that were established for medical colleges for 100 years—has only been put in place in the past five years.
“Do they really do have the same level of education, and how has that standardization of education been applied?” asks Goertz, whose center operates a large family medical residency program.
“I don’t deny that there’s a shortage of primary care physicians, and there’s a need to care for their patients. But the question remains: What’s the model of care that should work together in a team approach to provide that care? Should it be based on whoever is available? Or should it be based on a rational approach to a model of training and education, and on what level of training, knowledge, and skill they should have?”
One of the loudest objections to relaxing scope-of-practice rules comes from the California Medical Association, which went to court to appeal a decision by former Gov. Arnold Schwarzenegger to waive CMS’ requirement that advanced practice nurse anesthetists be required to have physician supervision when administering sedation to a patient.