re: Defeat the Nurse Practitioner scope of practice expansion - Louisiana SB 187

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But if I have strep, I go to the doc, the doc looks at me and says yes I think you have strep, then the nurse comes in and swabs my throat, then 20 min later the doc comes in and says yes you have strep and here is some amoxil, see you later.

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But you come to the doc with a sore throat, not a diagnosis of streptococcal pharyngitis. You could just as easily have a retro pharyngeal abscess. Then you would need much more then amoxicillin.

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NP students determine their patient populations at the time of entry to an NP program. Population focus from the beginning of educational preparation allows NP education to match the knowledge and skills to the needs of patients and to concentrate the program of academic and clinical education study on the patients for whom the NP will be caring. For example, consider a primary care Pediatric NP. The entire time in didactic and clinical education is dedicated to the issues related to the development and health care needs of the pediatric client. While medical students and residents spend time learning how to manage adult clients and complete surgery rotations, a primary care pediatric nurse practitioner student’s educational time is 100 percent concentrated on the clinical area where the NP clinician will actually be practicing.

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The letter the MSMS is trying to get doctors to send to legislators, an effort that the Wayne County Medical Society is supporting by including a link to the form on its website (even going so far as to refer to SB2 as a “dangerous bill”), is no better, repeating the same point about fewer years of education, asking:


Consider this: if nurses were given this broad expansion of scope, what would happen if something went very wrong in the course of treatment–something that a nurse doesn’t have the education or training to handle? Are you willing to put patients in this precarious situation?

This is a transparently weak argument. To illustrate what I mean, let me ask: What happens when a physician encounters something in the course of diagnosis or treatment that goes very wrong and he doesn’t have the training to handle? He calls in other physicians who can handle it! Seriously, by this reasoning, no gastroenterologist should ever be allowed to do colonoscopies because he can’t repair a colon if he perforates one, and no cardiologist should be allowed to do angioplasties because he has to call in a heart surgeon to fix the problem with an emergency bypass if he messes up a coronary artery during a balloon angioplasty, a known risk of the procedure. The key is not being able to handle everything, as every physician specialist knows. The key is to be able to recognize when you’re in over your head and can’t handle a problem and not to be too proud or stubborn to call for help from someone who can handle it. You know who taught me that? Pretty much every surgeon I ever trained under. To quote Harry Callahan, “A man’s got to know his limitations.” This is true whether that person is a physician or an APRN, and APRN training pounds a knowledge of those limitations home.

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I’m not likely to win friends among my peers by saying this, given that multiple Michigan medical societies oppose the bill, but, as a member of the MSMS myself, I do not support the stance of the MSMS, and I was particularly disturbed by the faulty reasoning and fear mongering being used to defeat this bill. Indeed, I’m actually rather embarrassed for Dr. Elmassian, who sounds more like a TV pundit or a politician running for office than a physician with that insulting bit about “special interests.” Seriously, I expect the President of my state medical society to make better arguments than that, even if I happen to disagree with his position. After all, I could equally argue that Dr. Elmassian is protecting physicians’ special interests against competition, which I rather suspect the MSMS is. Next, the whole argument about “reducing educational requirements” is disingenuous, particularly the nonsense about “sending the signal to health care providers that medical education simply doesn’t matter.” By that reasoning, I suppose the 17 states in which NPs can practice without physician supervision and the Institute of Medicine, which recommends that NPs be allowed to practice to the full extent of their training don’t care about medical education. The main reason that NPs don’t have as many educational requirements as physicians is because they specialize from the very beginning, unlike physicians, and they deal with a more limited scope of common problems. The AANP actually has a retort to this argument that I fully agree with:


Head-to-head comparison of educational models is not the appropriate measure of clinical success or patient safety. The appropriate measure is patient outcomes. Forty years of patient outcomes and clinical research demonstrates that nurse practitioners consistently provide high-quality and safe care.

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Unfortunately for the MSMS, the evidence isn’t with it. In fact, I find it rather telling that none of the physicians’ groups arguing against laws expanding NP scope of practice seem able to cite any science. The reason, of course, is because they likely know that existing outcomes research looking at the effects of NPs on quality of care does not support their position.

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I support increasing the scope of practice of APRNs/NPs commensurate with their education and training. Existing science and my own personal experience that began when I first started working with NPs in 1999 lead me to that conclusion. If there were strong arguments against this from a patient safety standpoint, believe me, I would have grave doubts. (After all, I am a physician, and I recognize that my inherent bias would almost certainly be that physicians provide better care, making me more inclined to take such arguments seriously if they were evidence based.) There aren’t, at least none that are scientifically supported by outcomes data, which is why the reaction of my fellow physicians to such measures, which occurs in every state where such bills are introduced, saddens me. It’s pure turf protection, nothing more. My recommendation to my state medical societies would be to spend less time trying to shut out APRNs and more time trying to prevent naturopaths from being licensed in Michigan. That would prevent far more harm to patients than the worst fears the MSMS can conjure up about expanding the scope of practice of APRNs.

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While medical students and residents spend time learning how to manage adult clients and complete surgery rotations, a primary care pediatric nurse practitioner student’s educational time is 100 percent concentrated on the clinical area where the NP clinician will actually be practicing.

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Wat? This is exactly what a residency is, yet he tries to spin what the NP is doing as unique and more comprehensive.

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My biggest problem with MDs is that they spend most of their time filling out paperwork / EMRs rather than actually being with the patient

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It is the only industry where you can literally not know the cost of a service until it is complete

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