DOCTORS AT WAR WITH NURSE PRACTITIONERS

When Your Doc Is Not a Doc: Should Nurse Practitioners Be Autonomous?

By Dianna Wray

Houston Press
July 3, 2017

Standing in the neurologist’s office alongside her mother’s wheelchair, Ann Livy goes over the symptoms once again in her head. Livy (not her real name) is a doctor herself — she works as a pathologist in a hospital near their home in Central Texas and asked that she remain anonymous. She knows the neurologist will have a finite amount of time. So she thinks through the problems that her 70-year-old mother has been experiencing since her medication was changed in November 2015. The shaking and the hallucinations are simply a part of living with Parkinson’s disease, but Livy is concerned about intense hallucinations and the weakening limbs that have confined Frances Johnson (also a pseudonym) to a wheelchair.

A women in a white coat sweeps into the room, announcing that she is a doctor. She begins examining Johnson, using deft hands to check her motor skills and asking informed questions. It is only when Livy catches sight of the name tag pinned to the white coat and sees the letters APRN, short for Advanced Practice Registered Nurse, that she realizes her mother is being treated by a nurse practitioner — a highly qualified nurse who is trained to treat certain medical conditions and holds a doctorate but who is not a physician.

Livy explains how Johnson has been losing feeling in her legs and has become more mercurial and emotional. But the nurse practitioner dismisses these concerns, saying this is the reality of Parkinson’s. Gently, trying to avoid being offensive, Livy asks if they can be seen by the neurologist instead. The nurse practitioner tells her there is no point in doing that since the doctor will only repeat what she has just said. (Nurse practitioners, unlike physician’s assistants, are allowed to treat patients without a doctor’s on-site supervision.)

“It was exasperating,” Livy says now. “I know the difference in the training and I was very aware she was not a doctor. We’d come to see the guy who had gone to school for years studying neurology, and we weren’t getting to see him.”

A month later Livy found her prim, proper mother, who had always behaved with the well-brought-up grace of a Texas southern lady, in her wheelchair on the front lawn letting out a seemingly endless stream of profanity, words Livy wasn’t even aware Johnson knew. Then Johnson started having violent hallucinations, screaming about rooms full of blood, her young grandchildren with nails in their skin. Livy gave up trying to get in touch with the neurologist and rushed her to the hospital.

Once Johnson had been admitted, the neurologist came by to examine her. (Parkinson’s is tricky, so it is often easier to have the main provider oversee things even in the hospital, Livy says.) He started off by performing a basic reflex test while firing off a series of questions. Within minutes he’d concluded that while the hallucinations were likely part of the disease, Johnson’s paralysis was not. The doctor ordered an MRI, and within hours they knew the weakness in her limbs was due to the medication, not Parkinson’s.

After weeks in the hospital, Johnson stabilized, but owing to the nature of Parkinson’s, a disease in which, once you lose ground, it is difficult if not impossible to regain it, she now requires more care and Livy was forced to move her into a nearby nursing home. For Livy, this encapsulates the problem with nurse practitioners treating patients at the same level as doctors without direct supervision.

“The nurse practitioner came across as very intelligent and educated, but she didn’t have the training to look at the whole issue with my mother, to superimpose this symptom on top of that one and see how it works in that complicated biological system,” she says. “Nurse practitioners don’t have the same training as someone who was trained for 10,000 hours.”

Nurse practitioners are one of the fastest-growing fields of primary care medicine in Texas, where more than 16,000 are currently practicing, and around the country, where the number of nurse practitioners has doubled to more than 200,000 in the past decade alone. As they have become more prevalent, nurse practitioners have started pushing to become increasingly independent practitioners of medicine. So far they are autonomous in the District of Columbia and 22 states — but not Texas. But there has been a pronounced effort to give nurse practitioners the right to practice to the “full extent of their license and education” in recent years.

This has been met with frustration and anger by medical doctors, who insist nurse practitioners are good at what they do but should not be allowed to work independently since they have less medical training and their education is handled in an entirely different way. (It’s such a controversial subject that most of the doctors the Houston Press spoke to for this story agreed to do so on condition of anonymity, because they say they could lose their jobs.)

However, nurse practitioners counter that studies have shown there is no significant difference in outcomes between patients who are seen by nurse practitioners and those who are seen by medical doctors.

Nurse practitioners say they are better at establishing bonds with their patients and have found this makes a difference in patient care. They say that allowing nurse practitioners more autonomy will help deal with the physician shortage and the lack of access to primary care in rural areas.

This has created deep divides and tensions in the medical community. Nurse practitioners try to keep things officially cordial and physicians attempt to stay quiet, but when they are talking among themselves on social media, things can get pretty vicious. Both sides have Facebook groups that feature an abundance of griping about the lack of respect either side has for the other. When the subject comes up on Reddit or is touched on in the news, comments sections will explode with people sniping at each other.

Despite resistance from doctors, nurse practitioners made significant headway in gaining autonomy from both doctors and the Texas Medical Board during this year’s state legislative session, according to Texas Nurse Practitioners, one of the main lobbying organizations for nurse practitioners in the state.

But the Texas Medical Association has remained adamantly opposed to making nurse practitioners independent operators. In the wake of the 85th Legislative Session, the TMA once again issued a statement maintaining that nurse practitioners are not medically trained physicians and should not be afforded the same rights as medical doctors.

Lobbyists are already gearing up for another push when the Texas Legislature convenes again in 2019. “I’m proud of being a nurse and am very proud of what I do. Nurse practitioners want to practice to the full extent of their license in Texas, but I don’t think that means we want to be doctors,” Sara Wood, a nurse practitioner employed in the University of Texas Medical Branch Health System, says. “We want to be allowed to do the most we can do for people. That’s all.”

Meanwhile, some hospitals are already moving toward a new care model in which nurse practitioners run the ERs. In December, the U.S. Department of Veterans Affairs changed its regulations to allow nurse practitioners the authority to treat patients up to the full extent of the practitioners’ training, education and licensing, regardless of most state restrictions, a move aimed at giving veterans more access to health care. Hospitals are also increasingly using nurse practitioners. Rules about how they work within hospitals are left deliberately loose so officials can customize their job duties.

Memorial Hermann has replaced primary care physicians with nurse practitioners in its clinics, according to Houston doctor Latisha Rowe (she was replaced by a nurse practitioner when she left one of the Memorial Hermann clinics, she says), and Houston Methodist already has a special emergency team that is led by nurse practitioners, according to its website. The U.S. Department of Labor Statistics predicts that nurse practitioners will be used even more in coming years since they are cheaper to hire and help both hospitals and medical offices cut costs while increasing the number of medical providers.

Dr. Kara Baker (not her real name) is a hospitalist, a doctor who sees patients only in hospitals, in the Memorial Hermann Health System. Baker says that Memorial Hermann has been quietly considering moving to a system in which each physician will oversee two or three nurse practitioners at a time both in hospital emergency rooms and within the hospital system itself.

If that happens, Baker says, she will have no choice but to take on nurse practitioners — and the liability that comes with any mistakes they may make — because it is in the contract Memorial Hermann has doctors sign. But it will be difficult, she says, because so much of what nurse practitioners do is vaguely defined.

“There’s no definition of what their actual scope of practice is. It’s so vague, they can do anything. They’re essentially practicing medicine under nursing. Because the rules are vague, it all becomes very unclear what the rules are, how independent they are,” Baker says. “I’m not saying that a physician doesn’t make mistakes — that would be silly; we’re only human — but there’s a reason physicians do what we do and that nurses do what they do. The two are supposed to work together.”

***

There have been tensions between doctors and nurses since the days of Florence Nightingale, but the strain began to increase exponentially in the 1950s. Over the first half of the 20th century, scientific discoveries, from penicillin to organ transplants, had advanced the possibilities of medicine at a breakneck pace. Suddenly physicians were going into increasingly specialized fields instead of primary care, and there were not enough primary care doctors to go around.

In 1965, the same year the federal government established Medicare and Medicaid, a new educational program was created to train nurses who already had hands-on experience to provide basic health care, diagnosing and treating everyday maladies and advising on family health. These nurse practitioners were supposed to go to rural and impoverished areas, the places where people were lacking even the most elemental health care, across the country.

Over the following decades, the nurse practitioner program became more professional. Gradually nurse practitioners were required to have a nursing bachelor’s degree and bedside nursing experience before they could attend master’s programs or, in recent years, doctorate programs, and take a national certification test to become a nurse practitioner.

While becoming a medically licensed physician requires getting a bachelor’s degree and spending four years in medical school and then three to seven years in a residency program, nurse practitioners go through only six to eight years of training on average. But, in the midst of yet another physician shortage in the 1980s, nurse practitioners were allowed to start practicing in Texas, albeit only with the supervision of a physician.

When Sara Wood quit her job as an electrical engineer at Compaq to become a nurse practitioner in 1996, the concept was still fairly new in Texas, but she knew she wanted to work in psychiatric hospitals and have the opportunity to directly help her patients, so it made sense. She insists she has never wanted to be a physician. “Nursing is a biosocial science. It involves caring for people and listening to them. It’s different than being a medical doctor. Sometimes people can connect with a nurse practitioner like me instead of a doctor. I wanted to be able to diagnose them, prescribe some medications, do some therapies and help them.”

And when it comes to patient care, there is something to be said for nurse practitioners, as even doctors can admit. Dr. Lauren Irving (not her real name) is now a primary care doctor in Houston who oversees geriatric patients at various nursing homes in the area. She realized early on that the way nurse practitioners approach patients can have a huge effect.

In the 1990s Irving worked at a low-income clinic a few times a week as part of her residency program in family medicine at Duke University.

One day, a boy came in complaining of a cough. Looking over his chart, Irving noticed that he had been coming in regularly for months with the same problem and the nurse practitioner at the clinic had been treating him for bronchitis, not asthma, even though multiple doctors had diagnosed him with asthma. Examining the boy, Irving explained his coughing was not due to bronchitis. She bluntly told his mother, an African-American woman, that he needed to use an inhaler or his lungs would be permanently damaged.

The woman nodded, but did not seem to take in what Irving was saying. The next week Irving was called into her supervisor’s office to respond to a scathing letter from the mother. The next day she had brought her son back to the clinic, where they were seen by the nurse practitioner, who gave prescribed steroids and bronchitis medicine instead.

“I was so confused at the time, but eventually realized I had screwed up. I was a young white woman, a stranger, bluntly telling her she had let her child suffer from a lung disease that might scar him for life. The nurse practitioner was someone from her neighborhood who spent time in the room and knew her. Of course she listened to the nurse practitioner,” Irving says now.

She still thinks of the boy, reminding herself to be careful in how she handles her patients. The nurse practitioner missed the diagnosis, but she had the mother’s trust, Irving says. “Having that trust, whether you’re a doctor or a nurse, is important. The problem is, doctors just don’t have time now.”

The Affordable Care Act, signed into law in 2010, opened up access to medical care, but it also injected even more patients into a system already short on primary care physicians in Texas, which ranks 47th among the states in its supply of such physicians. While physicians maintain the solution to this problem is to train more doctors and increase government funding for residency programs in the state, nurse practitioners contend that allowing them to practice without doctor supervision is the answer to the primary care shortage.

Nurse practitioners say that they are already overseen by the Texas Nursing Board and their licensing board, and stand to lose their licenses if caught practicing outside of their training. Having to pay a doctor — who is usually not even on site — to officially oversee their work costs money and makes it more difficult for nurse practitioners to open up their own clinics.

Melissa Herpel is a nurse practitioner who has run her own clinics in Spring and Conroe for about five years. Herpel decided to open her own clinic after she got a job in a family practice. The job started out well, but about six months in, she noticed she was not getting as many patients because insurance companies balked at paying the full rate for an office visit to a nurse practitioner.

“I’ve always seen myself as part of the health-care team. I’m not a doctor, I’m a nurse practitioner, but we all have the same goal, the good of the patient. Insurance refusing to pay for the work I was doing really pulled the rug out from under me,” she says now.

To start her own practice, Herpel found a physician she had worked with before who agreed to become her supervising prescriber for about $100,000 a year.

Herpel says the fees make some sense because the physician is ultimately responsible and liable if anything goes wrong. Liability is so heavily weighted on the physician that most nurse practitioners don’t even have malpractice insurance in Texas.

But these fees, paired with the supervisor requirement, can make it difficult for other nurse practitioners to open their own practices. Both of Herpel’s clinics, which serve the uninsured and underinsured, are constantly busy, and Herpel has considered opening more clinics. But she cannot do so without finding another doctor who will supervise the nurse practitioners at the clinic — doctors are allowed to supervise only seven nurse practitioners in a clinic setting — and that has proved difficult.

“I think there’s a lot of fear about nurse practitioners becoming doctors. This scares a lot of physicians, but we’re not trying to squeeze people out of their specialties or any other part of medicine; we just want to be able to help more people, to help as many as possible.”

***

David Frazier, of Houston, has dealt with countless doctors and nurse practitioners since his daughter, Molly Frazier, now 35, was diagnosed with a genetic disorder that left her with a below-average IQ and unable to walk or speak. “It’s tricky, because she can’t tell us what hurts or what’s wrong,” Frazier says.

About three years ago Molly went to the hospital for a hip problem — her condition has caused numerous health issues and she has been wheelchair-bound her entire life. While she was in the hospital, she gradually stopped eating, even refusing fried fish, sweet potato fries and other foods she had always liked.

Her weight dropped from about 150 pounds to 110 pounds within days, and she grew so weak the hospital doctors started discussing hospice options with Frazier and his wife. They refused to consider it, and Molly was discharged and settled back into the group home she lives in on the suburban outskirts of the city, but her appetite was still almost nonexistent.

Frazier took her to various doctors, including a gastroenterologist, but no one could figure out what was wrong. Finally, he took Molly to an appointment with a nurse practitioner who was going to be Molly’s new source for primary care. The woman sat down and talked through Molly’s various health issues, and asked questions and listened as Frazier described how his daughter wouldn’t eat, the way she rejected food, any detail he could think of. And then she ordered a blood test and diagnosed Molly with a bacterial infection in her stomach.

The infection was causing Molly pain whenever she ate, so Molly stopped eating, the nurse practitioner explained. The nurse practitioner put Molly on a round of antibiotics. She started gaining weight and her energy returned within days, Frazier says.

“We’d been to a lot of doctors and no one could figure it out, but this nurse practitioner sat down and really listened to us,” Frazier says. “It was such a small thing to do, but I believe it saved my daughter’s life. If they can do something like that for other people, they should be allowed to.”

Each meeting of the Texas Legislature seems to inch nurse practitioners a little closer to their goal. This session, nurse practitioner lobbyists filed multiple bills — including the usual proposed legislation to end the physician supervision requirement — but got only a few of them through. However, when the session wrapped up, nurse practitioners had been awarded the right to treat Medicaid patients and sign birth and death certificates. Texas Nurse Practitioners even counted the bill to end the supervision requirement a success since it made it further through the legislative process than it ever has before, according to the group.

These developments have left many doctors incensed. Irving dismisses the idea that freeing nurse practitioners from physician supervision will result in more medical care in rural areas.

Even though Texas lawmakers loosened the prescriptive supervision requirements in 2013, the number of nurse practitioners working in metropolitan areas of the state has remained about the same, according to Texas Board of Nursing statistics. “They’re not going to move out into the middle of nowhere. Why would they when they can make so much money in the city?” Irving says.

Still, it is looking increasingly likely that nurse practitioners will be even more involved in the health-care system going forward. With the new care system being considered at hospitals, nurse practitioners will handle all the basic stuff and come to the doctor with any problems, Baker, the Memorial Hermann hospitalist, explains. The tricky part will be when there’s a medical issue that doesn’t neatly add up.

A few years ago, a young woman came into the emergency room where Baker was working, short of breath and complaining of pain. The nurse practitioner gave her morphine for the pain. However, the woman, young and outwardly healthy, was actually experiencing heart failure, and the morphine the nurse practitioner prescribed could have killed her. “They’re great at looking at a grid and seeing what’s there and drawing conclusions, but since they’re only trained to look for those surface things, if it’s not presenting as it should on a grid, they are going to miss it,” she says.

As the supervising doctor, Baker will be responsible for both ten to 15 patients she will handle herself and five to eight patients each nurse practitioner cares for.

This type of scenario has frustrated a number of physicians, who insist the decrease in control over nurse practitioners means the patients will ultimately be the ones to suffer.

“The first patient I ever diagnosed with cancer, it wasn’t an algorithm and it wasn’t based on checking boxes on a chart,” Rowe, the doctor who left Memorial Hermann, says. “It was because of all those hours I spent in the hospital, all of that training. When you need it, it comes back to you and you look at the patient in front of you and suddenly know what you’re seeing. I knew it and I saved a life. When we start compromising on our standards of training and knowledge, then we will have to be prepared as a nation for a huge sacrifice, because when you stop investing in medical education at the highest levels, there is a price.”

Lutricia Harrison, who’s been a nurse for more than 20 years and a nurse practitioner for 12 years, and run her own clinic in Greenspoint for the past nine, says she is focused on the patients.

With her clinic within walking distance of the impoverished community she serves, Harrison is able to keep a close preventive watch on her patients’ blood pressure issues, to prescribe medications to combat infections early on and to give HIV-positive patients the access to steady medical attention that helps them stay reasonably healthy.

“They’ll talk to me because I know how to talk with them. I can make a difference in how someone handles their diabetes. I’m not trying to be a doctor; I only want to provide care, to work to the full extent of my education and training. I think doctors aren’t getting that,” Harrison says.

***

Despite all this, most doctors note they have worked with great nurse practitioners, defining a great one as someone who practices up to the level of the nurse practitioner license and his or her own skill and knowledge, doesn’t think he or she is a doctor and thus comes and gets help when it’s needed.

Irving partners with a nurse practitioner to see nursing home patients. They’ve built a partnership in the practice, with Irving trusting the nurse practitioner to know what she is doing. Irving’s part is to always be on hand to talk with her, by phone or in person if the nurse practitioner runs into an issue she doesn’t know how to deal with.

“It’s not that I find advanced midlevel providers to be intrinsically bad, but there is very little standardization in their education, and there’s very little oversight,” Irving says. “The nurse practitioner I work with now is great at what she does and we work together as a team, but that’s partly because she always comes to me when she’s dealing with something that is above her pay grade. I can trust her to do that, so I can trust her.”

Rowe says the same thing. She now manages a telemedicine clinic where she and two other doctors oversee nurse practitioners, but Rowe hires only nurse practitioners with experience, and every medical chart chronicling patient complaints and treatment choices is checked by a physician.

The mistrust is still there. “I think it’s really about money,” Wood, the psychiatric nurse practitioner, says. “And I can’t blame them. Nobody wants to lose money, not us and not the doctors. But the thing is, we’re not doctors, and I wish they would understand that we really are not trying to be.”

Livy sees her mother, Johnson, as often as she can, but Johnson’s health decline has snowballed since then. Each visit Livy notes how Johnson has lost some other ability to Parkinson’s. “It’s a weight of guilt and regret. Maybe it would have been the same even if I had asked more and pushed more, but I didn’t,” Livy says. “People that want to practice medicine without a lot of training, whatever level you’re at, you don’t know enough to know what you don’t know. You know just enough to be dangerous. The humility is important.”