AMA House of Delegates

AMA meeting: Physician supervision of nurses sought in all practice agreements

AMA delegates also debated the National Board of Medical Examiners' role in a new doctor of nursing practice certification exam.

By Amy Lynn Sorrel — Posted June 29, 2009

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Citing patient safety concerns, the American Medical Association House of Delegates wants to ensure physician supervision of advanced-practice nurses in practice agreements.

The move comes as APNs continue to play a greater role in addressing access-to-care shortages. Some state laws mandate that nurses practice in collaboration with physicians, often under a written agreement.

While doctors agree that can be a good thing, delegates expressed concern that APNs often interpret the term "collaborative" to give them authority beyond their expertise.

"If we don't address this, it will give additional ammunition to APNs to seek scope-of-practice expansions," said Alfred Herzog, MD, a psychiatrist and an alternate delegate for the Connecticut State Medical Society.

Delegates said any practice agreements should emphasize physicians' roles in leading the health care team.

In response, they directed the AMA to develop advocacy tools to help doctors address practice agreements with nurses and respond to state legislative and regulatory activities on the issue. The Association will support the development of research comparing various physician-nurse practice agreements and their respective effectiveness.


Carol E. Rose, MD, said advanced-practice nurses have an important role to play. But it must be a supervised one.

Carol E. Rose, MD, an alternate delegate for the American Society of Anesthesiologists, works regularly with nurse anesthetists, who she said play an important role in patient treatment. "But we have supervision. We talk before a case. I'm there for input ... and I'm called when things happen. That's the way patients get the best care," said Dr. Rose, a Pittsburgh anesthesiologist. "Collaboration the way nurses see it ... is not supervision."

But some delegates worried that a lack of emphasis on cooperation could alienate nurses. "We need to find ways to build bridges with all the other people providing care," said alternate delegate Lynn Parry, MD, a neurologist from Colorado.

Nurses tout new test

The debate hits at a time when some nursing organizations are touting a new doctor of nursing practice certification exam -- backed by the National Board of Medical Examiners -- as comparable to physician testing. The DNP exam relies, in part, on Step 3 of the U.S. Medical Licensing Examination.

Fearing patients could be misled, organized medicine has urged the NBME to spell out the differences between the DNP and physician tests, and then correct nurses' inaccurate claims. "These are not equivalent providers," said American Academy of Family Physicians President and delegate Ted E. Epperly, MD.

But delegates said the NBME has ignored doctors' pleas. A resolution before the house called on the AMA to withdraw representation from the NBME if the testing organization fails to act to safeguard the integrity of the physician licensure process. The resolution also sought to explore other physician testing options.

Because conversations with the NBME are ongoing, the house agreed to refer the issue. Some delegates worried that cutting ties with the NBME could jeopardize physician licensure, particularly with no other option in place.

But the fight is not over, said American Society of Anesthesiologists delegate John B. Neeld Jr., MD. "We have communicated very directly with the NBME and ... we will continue to push them."

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Meeting notes: Medical practice

Issue: Guidance and policy is needed on the use and release of physician data.
Proposed action: A Board of Trustees report provides physicians guidance on the release and use of their data, including patient privacy safeguards, data accuracy and security safeguards, transparency requirements, review and appeal requirements, physician profiling requirements, quality measurement requirements and patient satisfaction measurement requirements. [Adopted]

Issue: Solutions are needed to address overcrowding in hospital emergency departments.
Proposed action: A Council on Medical Service report congratulates the American College of Emergency Physicians for developing solutions to the problem of overcrowded emergency departments. The report also supports collaboration between organized medicine and ED staff, and the dissemination of best practices, in efforts to reduce ED boarding and crowding. [Adopted]

Issue: Certain specialists are required to be in-house on a 24-hour basis at some hospitals. Some are not paid for this in-house coverage while others are.
Proposed action: The AMA work with the American Hospital Assn. to require the equitable treatment of all specialists required to provide in-house coverage. [Adopted]

Issue: The growth of the hospitalist movement has resulted in less hospital volume for some physicians. This has made it difficult for low-volume physicians to demonstrate clinical competencies in a hospital setting, as required by some credentialing rules.
Proposed action: The AMA adopt guidelines to assist medical staffs with credentialing and privileging physicians with low activity. [Adopted]

Issue: As employees of physicians, allied staff, including nurse practitioners and physician assistants, have little contact with the activities of organized medical staff, especially concerning patient care, safety, quality and ethical issues.
Proposed action: The AMA study how hospital medical staffs can involve allied staff in oversight activities. [Adopted]

Issue: Radiology benefit managers interfere with patient care and place an unnecessary burden on physicians and compromise patients' health by substituting tests or denying approval for tests.
Proposed action: Oppose routine denials or substitutions by RBMs working for third-party payers, study the prevalence of forced substitution of one study over the one requested, support the use of appropriate-use criteria developed by physicians with expertise in the specialty that pertains to the patient's condition. [Adopted]

Issue: Electronic medical records place the purchaser at the mercy of a vendor when the system needs fixing or upgrading. Open-source coding allows users to make changes and update as necessary.
Proposed action: Ask the AMA to develop open-source EMRs that meet "meaningful use" criteria, and make them available at a nominal cost to physicians. [Adopted]

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