The Scope of Practice Battle: Does it Do More than to Divide and Conquer Us?

Hanging Boxing Gloves

***  Primary Care Physicians vs. Nurse Practitioners  ***

It’s the marquis turf battle that’s sexy and exciting for journalists, politicians, and healthcare groups.  State-by-state changes have been giving nurse practitioners (NPs) more and more (sometimes less) ability to practice more medicine with less supervision.

In many states and federally, expansion of NP scope of practice has, by the viewpoint of many physicians and physician groups, become the Pandora’s Box that will reshape primary care for the worse, challenge the future of the profession of primary care physicians, increase healthcare costs, and cause great harm to patients and communities.  Full legal independent scope to practice medicine is the line in the sand that most states yet have not crossed, requiring NPs to have a “collaborative agreement” with a physician who “supervises” their care of patients.

I won’t go into the detailed arguments made by physician groups about education and training differences between primary care physicians, nurse practitioners, and physician assistants (“physician extenders”, or “mid-levels” providers).

What I question, however, is if this battle really matters and is the best use of resources.


Are Any of Us Really in Independent Practice?

As the Medical Director of my organization, overseeing 9 health centers, I have around 20 primary care physicians reporting to me (plus as many mid-level providers, dentists, and sub-specialists).  I credential these doctors.  I oversee periodic chart reviews for each doctor.  I work with my doctors and other providers to put in place medical practice guidelines, expectations for care of all our health centers’ patients.  None of my providers–physician, NP, or PA–including myself are really in “independent” practice.

The trend is that less and less primary care physicians, let alone nurse practitioners and physician assistants, are practicing completely unsupervised.  About 80% of new family physicians are in employed practice.  Someone (their CMO/Medical Director, their site director, their colleagues, etc.) is supervising the care they give patients.

Few doctors are owning and running their own small business practice, and those who do own their practice would likely roll their eyes at you if you called them “independent.”  More health insurance companies evaluate and pay providers for outcomes.  Federal and state agencies are increasing their regulations left and right (often first with incentives, then with a mix of incentives and penalties, think electronic health records and Meaningful Use).  More private practices are joining one of the alphabet soup of care coordination programs (ACO, ACE, CCE, etc.), affecting what little autonomy they retained.

Why should primary care physicians be worried if NPs were to have “independent” legal status?  What does “independence” that really mean when no one in primary care is practicing in a vacuum anymore?


Don’t new physicians want the same thing new nurse practitioners want?

One of the perks of my work as Medical  Director of an FQHC in Chicago is that I get to talk with primary care physicians and nurse practitioners daily, and interview new and experienced MDs/DOs and NPs regularly.  I can’t speak directly to what any of them want in their practice (and acknowledge that I interview a self-selected group), but I do notice a lot from what they say.

The physicians and nurse practitioners I meet, including those with some experience under their belt, want a collaborative, team-based approach with support and leadership from their provider colleagues.  To be honest, I see the same look of fear in new NP grads who worry about being thrown into the fire of patient care without enough support that I see on the face of third-year physician residents looking for their first position.

“Who can I show that weird rash or EKG to?”  “Who can I call when I have clinical questions?”  “Who is in my shared call pool?”

These same questions come from my nurse practitioner and physician candidates.

There are some physicians coming out of residency that feel comfortable with and prefer going into solo or nearly-solo practice.  And if all NPs had full legal independent scope of practice in Illinois (where I currently reside, they do in AZ where I’m heading), there will likely be some nurse practitioners (probably those with years of experience) that go into some semblance of “independent” practice.

If a nurse practitioner wants to hang his or her own shingle and go at it alone, good luck to him or her!  They’re probably few and far between, and much braver than I.  If they feel prepared to practice solo, and ready for the billing and liability, let alone trying to get on staff at hospitals which many insurance contracts require, and convince patients and payers and regulators to utilize them (beyond just the state licensing requirements that physician and nursing groups are fighting over)…  have at it!  Good luck!

I would say the same to any primary care physician.


Workforce Needs

There are not enough providers today — physician and mid-level — to meet primary care medicine demands in the U.S.  As baby boomers age and more and more of the newly insured through the ACA (aka Obamacare) seek access, this problem will only get worse.

If every medical student who will graduate next year and the year after and the year after chose to go into primary care, there aren’t enough residency spots available for them, and that still wouldn’t dent the primary care workforce shortage.

If someone thinks that we can provide all the primary care America needs with physicians in the years ahead, then that person is looking at different numbers than I am.  Regardless of how one feels about primary care nurse practitioners and physician assistants, they’re here to stay and the U.S. primary care workforce could sure use them.


Divide and Conquer

Do battles like these do more than divide and conquer primary care?  Instead of professional medial groups fighting amongst each other, could we expend that time and energy holding accountable legislators, insurance companies, governmental agencies, consumer groups, and others, to benefit the health of our patients and communities.

Primary care physicians bring value to our health care infrastructure with education and training not found with any other group of providers, and physician groups should be promoting this to consumers, payers, legislators, and whomever we need to in a positive way.

But when it comes to legislative agendas, there is so much going on with the health of the public that is prematurely killing and disabling our dads, sisters, children, friends, and fellow Americans.  Bottled soda is cheaper than bottled water, a bag of chips is cheaper than an apple.  Our patients can’t get their 30 minute walk because they don’t have safe streets.  Youth shoot other youth.  Particulate matter from soot increases asthma.  Racial disparities are pervasive, from breast cancer survival rates to the prevalence of low birth-weight infants.

Every moment physicians and physician groups spend on fighting independent scope of practice for nurse practitioners is a moment that they’re not working cohesively with all stakeholders in health care to impact these issues.

What’s best for our patients and communities?


2 thoughts on “The Scope of Practice Battle: Does it Do More than to Divide and Conquer Us?

  1. Dr. Grivois-Shah makes some sense in some parts of this article but he still shows he doesn’t get the point that nurse practitioners are trying to make. NPs are not asking for ” Full legal independent scope to practice medicine.” We are asking for legal recognition of our “Full legal independent scope of practice as nurse practitioners.” Nurses practice nursing. Medical doctors practice medicine. NPs have acquired the educational and legal legitimacy to use some of the traditional tools that physicians use to care for patients and we use them well. We are just asking to be untied from the legal requirements that require us to practice an advanced form of nursing, as we are educated to do. Perhaps when physicians gain the confidence to understand that many professions besides theirs can provide safe, high quality compassionate care, they will stop worrying about the false ideas that nurses are trying to become medical doctors.

  2. I am an ‘independent’ PNP with a private practice that is 18 months old. I have a collaborative agreement with a physician that is not working in my office. I have had privileges at a hospital since 2002 when I worked with another group. I have board certified for nearly 17 years in pediatric primary care.

    It’s worth every minute of it.

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