ACP urges doctors and NPs to work together

The internists group says physician shortages are hindering access to primary care.

By Brian Hedger — Posted March 2, 2009

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The theme of a paper released Feb. 17 by the American College of Physicians is simple -- doctors and nurse practitioners must collaborate to improve primary care.

The policy paper emphasizes that physicians should lead in caring for patients and warns against replacing primary care physicians with nurse practitioners. It also opposes licensing nurse practitioners via Step 3 of the U.S. Medical Licensing Exam, having the National Board of Medical Examiners certify them for doctor of nursing practice degrees, and referring to DNPs as "doctor."

At the same time, the paper acknowledges that in an era of physician shortages, nurse practitioners are crucial to primary care access. It recommends that any demonstration project of the patient-centered medical home model should include one run by an NP.

"This is simply the college being pragmatic," said ACP President Jeffrey P. Harris, MD. "Even with [an increase in physicians], there will still be areas of the country where there's not going to be any physicians. Those will be areas where nurse practitioners will administer a lot of the care."

He said there were three main reasons for crafting the policy paper: a request from the ACP's board of governors to look into DNP degrees, the realization that both professions have a lot in common, and the shortage of primary care physicians.

Dr. Harris said testing medical homes run by NPs is important because of the physician shortage. Some states allow NPs to practice medicine without the supervision of a physician; others don't require the supervising doctor to be present at all times.

"In reality, there are going to be some [medical homes] that are run by nurses," Dr. Harris said. "Given that, we are simply saying that if you're going to test the patient-centered medical home, we ought to see how they work with both physicians and nurses leading them."

The American Medical Association's House of Delegates adopted policy at its Annual Meeting in June 2008 that DNPs must practice under physician supervision as part of a medical team. The Association said it would lobby against laws that allow advanced-practice nurses to provide medical care without physician supervision.

"Without a doubt, advanced-practice nurses play a vital role in the delivery of health care, but they are not the answer to the physician shortage," Joseph M. Heyman, MD, chair of the AMA Board of Trustees, said in a statement. "In order for patients to receive optimal quality care, their health care professionals must have the appropriate clinical education and training to provide the service they perform."

"A good step forward"

The paper was met with mostly open arms by nurse practitioner groups, who viewed it as evidence that physicians recognize their value to primary care. The ACP consulted nursing associations when researching the paper.

"The ACP and nurse practitioners' organizations have worked together and exchanged ideas, the result of which is this publication that recognizes the contributions of both professions to primary care," said Thad Wilson, PhD, FNP-BC, president of the American College of Nurse Practitioners. "In that essence, we're really pleased with it."

He said a group of NP organizations is working on a response to the paper.

"It has been contentious about who should or should not be included in addressing the primary care needs of America," said Wilson. "But the ACP just said, 'It's going to take us all.' Contentious or not, I believe that's true."

Others agree.

"It's a good step forward," said Jan Towers, PhD, NP-C, director of health policy for the American Academy of Nurse Practitioners. "To have a [physicians] group come out and say, 'We think this is valuable. We recognize what you're doing. We understand what's happening and that nurse practitioners have something to offer and we're supportive of that' -- that is a step forward when you look at some of the stuff that has come out in the past."

While the paper is filled with terms such as "collaboration" and "teamwork," the ACP remains opposed to DNPs being substituted for physicians. The paper said all DNP licensing and certification tests should be created "under the discipline of nursing," based on training received in DNP programs and scope-of-practice laws in each state.

Meanwhile, the primary care shortage needs to be addressed by both physicians and nurses, Dr. Harris said. "We're going to have to expand the primary care work force, but we're also going to need more nurses, as well."

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Working with NPs

The American College of Physicians released an 18-page policy paper on Feb. 17 that emphasized the importance of nurse practitioners and physicians cooperating to provide better access to primary care. Here is a synopsis.

  • The training of physicians and NPs is not the same but is complementary. Both share a commitment to providing high-quality care, but physicians are often the best practitioner for many patients.
  • Collaboration is needed for coordinated care between physicians and NPs to improve overall quality of care.
  • NPs should not take Step 3 of the U.S. Medical Licensing Exam for the National Board of Medical Examiners to certify them for doctor of nursing practice degrees. Licensing and certification of DNPs should be developed by the discipline of nursing.
  • Dual demonstration projects for patient-centered medical homes should be conducted, one physician-led and one led by an NP. Both should be held to the same standards, and patients should be informed whether a physician or NP is leading the model home.
  • Research should be done about the best models of collaboration, referral and co-management of patients between NPs and physicians.
  • Training for all health care professionals should be reformed, specifically in teaching teamwork and collaboration among multiple medical disciplines.
  • Access to quality primary care through physicians and NPs must be ensured, with the understanding that training more NPs doesn't substitute for increasing the number of primary care physicians.

Source: "Nurse Practitioners in Primary Care," American College of Physicians (link)

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External links

American College of Physicians policy monograph, "Nurse Practitioners in Primary Care," in pdf (link)

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