COMMENTARY

APRNs and the VA: Wave of the Future

Susan Apold, PhD, ANP-BC; Yul D. Ejnes, MD, MACP

Disclosures

July 15, 2016

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A Quality Proposition

Susan Apold, PhD, ANP-BC: My name is Dr Susan Apold. I am a clinical professor of nursing at the Rory Meyers School of Nursing at New York University. I have served as an officer of the American Association of Nurse Practitioners, and I also have a small private practice in New Rochelle, New York, where I am a nurse practitioner (NP). I am joined by my colleague, Dr Yul Ejnes.

Yul D. Ejnes, MD, MACP: My name is Yul Ejnes. I'm a practicing internal medicine specialist at Coastal Medical Incorporated. My office is in Cranston, Rhode Island. Coastal is a large, mainly primary care private practice. I am also a former officer of the American College of Physicians, but I'm speaking today as an individual; I am not speaking for any organizations.

Dr Apold: We are here today to talk about the proposed regulation put forward by Veterans Affairs (VA). The VA is proposing that all advanced practice registered nurses (APRNs) within the VA system practice to the full extent of their license and education. This ruling would affect NPs, clinical nurse specialists, nurse midwives, and certified registered nurse anesthetists (CRNAs) practicing within the VA system. The VA proposes that APRNs would be able to practice without supervision by any other healthcare professional, including physicians.

In 21 states and the District of Columbia, APRNs are already able to practice independently. State legislation governing practice of CRNAs varies, but many of the states already allow for full independent practice for CRNAs.

What the VA is proposing is no different from what is happening in many states across the nation. However, some physician groups are concerned about allowing APRNs to practice without supervision from physicians. Yul, why do you think physicians have concerns about this issue right now?

Dr Ejnes: It's a hard time for physicians; there is perception that they are under siege. Many changes have taken place over the past several years, such as how Medicare is paying physicians, electronic health record (EHR) implementation, maintenance of certification, ever-growing hassles, prior authorization, and so forth. There has been a lot of rhetoric relating to competition and substitution by APRNs. I underline "rhetoric" because, in the mainstream, neither the physician side nor the nurses side is seeing it that way. But this announcement by the VA was perceived by some as yet another attack—another attempt to replace us with other providers, which is not how I see it.

One thing that doesn't change with the proposed rule is the reality that we all have to deal with—that, independent of licensing boards or state regulations, we have a responsibility to practice within the boundaries of our training, knowledge, experience, and not go beyond that. All that the VA's proposal would do is remove some of the barriers that get in the way of APRNs doing their jobs.

The proposal is not unlike what goes on in many states, including this one. I've been practicing in Rhode Island all my life, and it's one of the states that does not have those restrictions on APRN practice. We do things the way one would expect: as a team, with each of us helping others out when we need it. We don't have NPs doing brain surgery here in Rhode Island, for example.

Supplementation, Not Substitution

Dr Apold: I'm glad to hear that, Yul. Thank you for making the point that the reality is that no healthcare provider can provide care without working with others. There is no such thing as "independent practice." None of us are practicing without the collective wisdom of the team. This has always been the case. No nurse, no physician, no physical therapist, no occupational therapist, nobody in the system can go out on their own and practice without the help of anybody else. It's very important to say that none of us can replace the other. A NP can't substitute for a physician. A physician can't substitute for an NP. A CRNA cannot substitute for an anesthesiologist.

This is about a team. This is about providing patients—and in this instance, our veterans—with the highest quality of care available. We have been aware over the past few years of some problems within this VA system in terms of access to care. I see this as the VA's sincere and concerted effort to open that up and increase access to care, as many states have done with NPs, midwives, CRNAs, etc.

The more providers that you have available to patients, the easier it is for patients to access care. No one is proposing that we go off and practice by ourselves, and not collaborate or communicate. In fact, that is an ethical violation for physicians, and it's an ethical violation for NPs and for anybody else in the healthcare system.

We are not proposing to practice outside our scope. I don't intend to ever practice neurosurgery. In fact, I would venture to guess that you don't, either. We know the limits of our scope of practice. The law tells us what we can and cannot do. All APRNs and physicians abide by that and practice within their scope.

This is about removing a barrier to practice so that APRNs can do what they do, physicians can do what they do, and so that physicians don't need to look over our shoulders to supervise us. They can be practicing medicine. NPs can be practicing nursing. At the end of the day, the veterans can get the best care available.

Dr Ejnes: We look at this as removing hassles not just for APRNs but for the supervising physicians as well. It removes a hassle on their side as well. Why should the physician have to sign off on every little thing an NP does when that NP is perfectly capable of doing those things? In private practice, when a provider (whether it's a physician or an APRN) runs into an unfamiliar situation, he or she goes down the hallway, knocks on the door, and gets someone to take a look at a rash or answer a question.

Physicians do that doctor to doctor, and once or twice a day our NPs approach us with a question about a patient. That has nothing to do with state regulations. That just has to do with good patient care.

A Two-Way Street

Dr Apold: You have NPs in your practice, correct?

Dr Ejnes: Yes, we have three NPs right now.

Dr Apold: How does this work in your practice? You practice and live in a state that does not have any statutory requirement for oversight of APRNs. How does that work in your practice setting?

Dr Ejnes: Our NPs see patients for a variety of reasons, sometimes follow-up of chronic conditions such as diabetes, sometimes for acute problems like a respiratory infection or back pain. They have access to the EHR that has all of the information that the provider needs. Our NPs see the patients pretty much on their own, except for cases about which they have a question, either because they don't know the patient (and we do) or because the situation is a little more complicated than what they are comfortable dealing with.

They can approach any of us, either while a patient is in the office if it's something that can't wait, or afterwards. We look at the charts primarily to keep us in the loop, because these patients are designated a primary care physician, and we want to know what's going on even when we don't see the patient.

Of interest, we have offered the NPs the opportunity to have a panel of patients of their own, and so far they have declined. That's not something they want to do, speaking to the point about independence. But certainly that's something that I would feel comfortable with, because they are not operating alone in a vacuum. Our organization is looking out for quality—not just from NPs or physician assistants, but from physicians as well.

For example, we have an initiative to reduce unnecessary antibiotic use, for which we are all being evaluated. All of the concerns that are being raised about what an APRN might do without a requirement for supervision aren't relevant. What needs to be done is to make sure that we are practicing the best we can, and this is implicit in how a highly performing practice functions, independent of regulations.

Dr Apold: I practice in the state of New York, and we do have some statutory restrictions on our practice, although they are minimal. I must sign an attestation statement that says I will collaborate with physicians. How that translates in my practice is that the physician with whom I practice and I are a team.

Sometimes I need to go to him, and sometimes he needs to come to me. An example that pops into my mind is that I am frequently called upon for such issues as obesity management, nutrition, and adult immunization. I have been educated to do those things. I'm good at those things. My physician partner would rather do other things in his practice. This actually works out beautifully, because each of us is able to do what we like and are good at, while providing the best care to the patient. We often consult with one another on patient cases.

Abandoning the Script

Dr Apold: Nurse practitioners have been around for 50 years, and in the 1800s, nurses provided anesthesia to patients. Change is slow, and this represents a new way of providing care in the United States. When I first joined my practice, it had been in existence for 17 years. My physician colleague and I had some very intentional conversations about what it would mean for our patient population. And we talked about making sure that the patients knew who I was and what I did. We were both very dedicated and committed to making sure that patients understood that he was a physician, an "MD,", and that I was a NP and a PhD doctor, and what we could or could not do for our patients.

We developed a rather lengthy script, but ultimately the patients didn't want to hear it. They just wanted to know whether we could give them what they needed. So we dropped the script. We still are very clear that he is a physician and I am an NP. We still provide patients with the option of seeing either him or me. Some prefer to see him because they are longstanding patients of his. Some prefer to see me because they are longstanding patients of mine. And sometimes they want to see whoever is available because they want to get in quickly.

Nurses and physicians have had many conversations about this issue. But here's the key: In my practice, in your practice, and in practices across the country, where NPs and physicians are providing care together, the center of the conversation is the patient. What is best for our patients? And that is how we practice.

When we talk about what's best for our patients, and in this case we are talking about what is best for veterans in our country, we are talking about what is in their best interests. How will they get the best care? How will veterans get increased access to care? How will we shorten wait times? How will we make sure that we are providing comprehensive care to the folks who have served our nation so well and so diligently?

There are states that already have this practice model. So we are not talking about something that is vastly different from what is happening in states across the country. I always like to point out that none of the states that grant practice authority to APRNs are looking to retract that. There are no data that support that this is anything but a safe and effective model for providing care. What the VA is proposing is not so different from what is happening across the nation.

Lesson One: Patients Are Central

Dr Apold: As we come to the conclusion of this conversation, maybe we can leave our audience with some best-practice strategies. What are some lessons in working within this collaborative model with APRNs that you might offer to our audience?

Dr Ejnes: The point that you just raised about putting the patient at the center is important. We need to make sure that patients know who they are seeing, what the level of training of that person is. We found over the years that patients often will select who they want to see based on what their needs are. If they are interested in seeing somebody quickly for a problem that they think can be managed by whoever they see, they will take an appointment with an NP if that is the first available appointment. If their need is related to a problem that I have been working on with them for years, they may prefer to wait to see me. Some folks have a preference for a particular NP out of the three. And some patients, frankly, prefer to see the NP rather than me.

The fact is that it's a patient choice. They are getting quality care from whomever they see. There is communication among all of us because the primary doctor is always in the loop, even if it's just reading the note at the end of the work day. We don't do that for any legal requirements, but just to be connected to what is going on.

Creating an environment where all of the providers, no matter who they are and what their degrees are, can feel comfortable consulting with one another, and setting that as an expectation is important. Don't get in over your head. Don't exceed your level of knowledge and experience with a problem, because there is always help. Doctors get that kind of help all the time. I can take care of heart patients to a degree, and then when I can't, I refer them to a cardiologist.

Create that kind of environment, work on quality together, and measure what you do as providers, rather than trying to make distinctions between one category of provider and another. Team-based care is the wave of the future, along with value-based purchasing where we have to prove our worth. But that worth is going to have to be proven regardless of what letters follow our names.

Dr Apold: I would agree with that. At our practice, we sat down and decided how we were going to explain this model to our patients. Even though we no longer have our script, patients know who I am and what I can do, and who the physician is and what he can do. Educating patients about who is taking care of them is of prime importance to both APRNs and physicians.

It is important for patients to understand education and training. Although I am increasingly hearing patients refer to me as "my NP" in the same way that they refer to their physician as "my doctor," it's important for patients to understand that APRNs have education and degrees beyond initial nursing preparation, that we are masters or doctorally prepared, and that we have additional clinical experience.

21 States and Counting

Dr Apold: It's also important for patients to understand that we have come to advanced practice nursing with a background in nursing. I practiced as a nurse for 17 years before I became an NP. We bring with us that wealth of experience. You made a good point that hadn't occurred to me about the collaboration among and between physicians. I also initiate a referral when I have not exhausted the diagnostic or treatment possibilities for a patient, or if I think the patient needs more than I can offer.

In those instances, I can make a quick consultation down the hall to the internist. And when the internist needs assistance, we can refer to one of the vast array of specialists who are available to us. Patients need to know that NPs do that. We seek out consultation when necessary.

We need to emphasize the reality that the proposed regulation in the federal register by the VA system is no different from what at least 21 states and the District of Columbia already have in existence. It's very important for folks to understand that this will improve access to care for our veterans, something that every American wants to see.

Finally, and equally as important, is the fact that every day in this nation, APRNs and physicians work side by side as colleagues. We do what we do to provide patients with the best care possible, so that they can live healthy lives and understand the joy that exists when you have your health, and when you can have confidence in the people who are taking care of you. Any final thoughts?

Dr Ejnes: I keep thinking about the real-world, private-practice model. When we want to improve access to our patients, we add physicians as partners in the practice, but we also welcome APRNs, including NPs, because they help us achieve that goal without sacrificing quality. In fact, they improve quality because of the timeliness of the access and the skills that they bring to the practice.

What the VA is doing is no different from what we do when we look at our schedules, our phone is ringing off the hook, and we want to serve more people. In fact, a lot of the talk over the past year or two has been about the VA adopting practices that the private sector uses to try to improve the quality of and access to care, and I see this as another step in that direction. We aren't blazing new ground, because at the end of the day we are still obligated as professionals to not extend ourselves beyond our abilities. That still is the case.

Dr Apold: Not only are we obligated to not practice beyond our capabilities, we are held to the same standard of care, so that when we are treating diabetes, for example, physicians and NPs have to meet the same metrics for every patient with diabetes, even though we have different scopes of practice. It's important to remember that we are all practicing according to quality standards and standards of practice for our patients.

I would like to end with a sentiment from Dr Steven Weinberger in the Robert Wood Johnson Foundation's conversation around this very issue of NP and physician collaboration. He said, essentially, that when physicians and nurses are talking about patients, at the center of the care, that is when they are providing the best care possible.

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