AMA House of Delegates

AMA meeting: Physicians demand greater oversight of doctors of nursing

Delegates also voted for increased supervision of midwifery practice.

By Amy Lynn Sorrel — Posted July 7, 2008

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Citing patient safety concerns, members of the AMA House of Delegates protested the unregulated expansion of doctors of nursing practice and urged organized medicine to ensure transparency in and supervision of their role in medical care.

The outcry comes amid concerns about a shortage of primary care physicians and a surge in DNP programs.

The National Board of Medical Examiners this fall plans to offer a voluntary DNP certification test based on the medical licensing exam. In addition, many nursing schools and other health care professional training programs have incorporated doctorate degrees and used the titles "resident" and "doctor" despite their nonphysician status.

Delegates said patients could wind up confused and have their treatment compromised because DNPs and other advanced practice professionals do not share the same level of knowledge and training as licensed physicians. Delegates also worried the movement could lead to other scope-of-practice expansions.

In response, delegates at the AMA Annual Meeting in June passed a resolution calling on the Association to advocate that professionals in a clinical setting clearly identify their qualifications and degrees to patients. Delegates directed the AMA to develop model state legislation to that effect and to support other state legislative efforts to make it a felony for nonphysician health care professionals to misrepresent themselves as physicians.

"This is not to impugn [nurses'] training and important contributions to the care team. But in an era of transparency, we have to insist on complete openness in the qualifications and licensure of all caregivers," said AMA Board of Trustees member Steven J. Stack, MD. "Patients have a right to know."

The house also adopted policy that DNPs must practice under physician supervision and as part of a coordinated medical team. Delegates voted to oppose the NBME's participation in any DNP exam and directed the AMA to refrain from producing test questions.

"We're talking about quality of care and excellence," said delegate Ted E. Epperly, MD, of Boise, Idaho, president-elect of the American Academy of Family Physicians. While advanced nursing education can help facilitate better patient care, the NBME exam would "give an implicit legitimacy that DNPs are subject to the same eyes of the medical board that credentials doctors," despite the differences in education, he said.

More doctors of nursing expected

The DNP degree requires two years of schooling versus five to seven years for medical training. About 200 nursing schools are expected to offer the program by 2015.

Dr. Epperly warned that patients may not be able easily to discern whether they are being treated by a "doctor doctor" or a "doctor nurse."

Such a scenario could prove dangerous should a patient experience an acute condition, said delegate Neil Winston, MD, an emergency medicine physician from Chicago.

Because of such risks, alternate delegate Donald W. Hatton, MD, an internist from Lawrence, Kan., and chair of the board of governors of the American College of Physicians, said "we need a team-based approach where nurses are in collaborative practice with physicians."

But some delegates feared that pursuing criminal actions could have unintended consequences. Such efforts "might lead to a movement to have additional practitioners certified by law," said Albuquerque, N.M., nephrologist Steven Kanig, MD, speaking on his own behalf.

Representatives of the American Nurses Assn. who testified in opposition to the proposed policies said their goal is to improve patient care, not add confusion.

"We are trying to work together in a spirit of cooperation to fill the gaps [in medical care]," particularly in rural areas, said Eileen S. Carlson, RN, associate director of the ANA's government affairs department. Increased supervision requirements could harm access to care, nurses said.

Tackling other scope-of-practice issues, delegates adopted two resolutions demanding more oversight of midwifery practice.

Fearing a host of patient safety risks associated with home births, such as unexpected complications, delegates voted to have the AMA support state legislation calling for physician and regulatory oversight of midwifery. Twenty-one states license certified professional midwives to deliver babies without requiring formal nursing training or physician supervision, and a number of states pursued similar legislation in 2008.

A second resolution says the AMA will advocate for state legislation recognizing that the safest settings for deliveries are accredited freestanding birthing centers or hospital-based birthing units that meet American Academy of Pediatrics and American College of Obstetricians and Gynecologists standards.

"We are all trying to find the best, high-quality ways to provide care," said Erin E. Tracy, MD, a Stoneham, Mass., ob-gyn and ACOG delegate. "Giving licenses to those without adequate training is not the answer."

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Meeting notes: Access to care

Issue: More procedures are being performed in ambulatory surgical centers because of cost and quality benefits, but varying state regulations pose barriers to the doctor-owned facilities.

Proposed action: Review data on the effectiveness of ambulatory surgical centers and advocate for federal and state legislation aimed at removing obstacles such as certificate-of-need laws. [ Adopted ]

Issue: Physicians are concerned that the shortage of psychiatric services and beds is gravely impacting emergency department crowding and boarding.

Proposed action: Support efforts to facilitate access to both inpatient and outpatient psychiatric services and care for mental illnesses and substance use disorders. Also, address the psychiatric work force shortage and provide adequate reimbursement for the care of patients with mental illnesses. At next year's Annual Meeting, the House of Delegates will get a report on the effectiveness of the measures implemented. [ Adopted ]

Issue: Health plans are denying claims for physician-directed treatment of gender identity disorder.

Proposed action: The AMA supports public and private health insurance coverage for physician-recommended treatment of gender identity disorder. [ Adopted ]

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