Moving beyond scope of practice

The arguments surrounding nurse practitioner scope of practice have been heated from both the NP side and the physician side but some in these fields are pushing for conversations that move beyond the rhetoric.

Instead of fighting about training levels, research supporting or not supporting the quality of care provided by NPs and other non-physician clinicians, expanding scope of practice for non-physician clinicians and who is best to lead team-based care (physicians versus others), NPs and doctors should be leading the way toward effective team-based care said a trio of practitioners during a live web presentation in July sponsored by the Alliance for Health Reform and the Robert Wood Johnson Foundation.

[See also: Nurse practitioners hemmed in by scope of practice laws and payment policies]

“No nurse practitioner I know is saying their training is equal to mine,” said Kavita Patel, MD, a primary care internist at John Hopkins Medicine and fellow in the economics studies program at the Brookings Institution. “The problem is, I think, we’ve unfortunately – and it’s a disservice to ourselves as professionals – we’ve been put into these little cages to battle each other because we’ve been made to perceive that we can be substituted for each other.”

Doctors and nurses are not the same, agreed Reid Blackwelder, MD,  president-elect of the American Academy of Family Practitioners (AAFP).

“In order for America to realize the promise of team-based care, we all have to come to a better and shared understanding of what it means for medical providers to work together,” Blackwelder said. “As with any team structure, we must define roles. Each team member is critical but they’re not interchangeable.”

But defining roles means allowing for some flexibility for the type of care being delivered. Each member of the team should be able to fully use their knowledge and training without having to seek permission from someone else on the team, said Geraldine “Polly” Bednash, CEO and executive director the American Association of Colleges of Nursing, and it shouldn’t be assumed that a physician should be the person who always leads the team.

[See also: AAFP: PCMHs should not be led by nurse practitioners ]

It is a mistake to treat all primary care models the same way – with a doctor always being the leader, agreed Patel. “What we need to do is to have team-based care with physicians leading these efforts for when we need a physician to be involved in the first place,” she said.

“I can’t think of anybody who doesn’t want to be part of a high-functioning team,” she added. “Most doctors I know – including myself – will say ‘I don’t care what label you use on me. I just want to know that the patients that I get to see really need to be seen by me and the work that I’m doing isn’t just in a silo.’”

Many of the primary care models that put physicians as the default leader of the team do so because of payment structures, Patel said. Figuring out how to move away from fee-for-service and who gets paid what in evolving primary care models will be a challenge. There is evidence that team-based care models in which the team members are salaried are those that are demonstrating the most success, she said.