Full Practice Authority Is Not Mentoring

There seems to be some general misconception about full practice authority and mentoring.  I have come across this confusion with both my physician colleagues as well as nurse practitioner students, so I feel compelled to write about it.

As the director of the acute care nurse practitioner program, I am responsible for assigning clinical placements.  As such, I also serve as the complaint center for students and preceptors alike. Just recently I had a physician call me to complain about a student he was precepting. His comment was something along the lines of:

“This student can’t write a SOAP note properly which makes me wonder why you think you can go for full practice authority.”

To me, this comment is totally loaded with things that are completely unrelated to the purpose of his call. He may as well have said, “you own a Honda, so why do you think you can be a chef?” To me, one thing has nothing to do with the other. But his comment made me think about the perception of full practice authority among physicians and think about what they are imagining it means.

On the other hand, I had one student in particular who vehemently wrote about how nurse practitioners shouldn’t go for full practice authority because we need physicians to mentor us.

Again, I’m confused by this concept because full practice authority doesn’t negate the need for mentoring, nor does reduced or restricted practice implies that we are mandated to have physician mentoring.

I work in Pennsylvania, which is a reduced practice state for nurse practitioners. We are in the process of attaining full practice authority, but at the moment of writing we do not have it, so I will use this state as an example.

What does Reduced Practice in Pennsylvania look like?

Well, in the hospital setting it’s really not a big deal.  I have to have a generic document–collaborative practice document–that the hospital legal team drew up that states I will consult with a physician if I come across an issue that I can’t handle.

I must have an agreement with every physician that I work with.  In a large practice, as I work for, I literally have over 30 physicians attached to my license. I am quite confident that these physicians have no idea they are on my license, but they are thanks to reduced practice.

Apparently, I can’t order something for Dr. X unless he is on my license, so the hospitals want to make sure I can help out any doctor who may ask me to do something.  Our department in the hospital handles this paperwork, so it’s not a big deal to me.

Whether we get full practice authority or not, doesn’t really affect me in the hospital. My job won’t change at all when we attain full practice authority. I will still continue to do the same exact things I did the day before. The workload on the administrative assistant and the hospital will change because they will no longer have to upkeep the paperwork of informing the board every time a new physician needs to be added or deleted from my license and pay the state for prescriptive authority licenses.

There is no mentoring or promise of an apprenticeship associated with physician oversight. In reduced and restricted practice there is no promise of physician mentorship at all.

So I struggle to understand how full practice authority and mentorship have gotten so intertwined that I have a student and a physician talking about both as one issue. In a reduced or restricted practice state, I am not assigned a physician who turns me from a nurse practitioner student who struggles with SOAP notes to an amazing nurse practitioner. Like I said, at least 25 of 30 physicians on my license are not aware they are on it.

The physicians in reduced/restricted states take no ownership and responsibility for mentoring all the nurse practitioners in those states. In fact, the ironic thing is that in the hospital system, any time there is a med student, PA or NP who needs to be oriented or precepted, the physician typically “dumps” them on the NPs to orient. Clearly, I am being facetious, because physicians obviously do a lot of teaching and working with students, residents, and NPs. But so do NPs and it has nothing to do with full practice authority.

What reduced and restricted practice does do is stifle opportunities and create barriers for patients. Now I’m sure there are some patients who don’t mind waiting 6–9 months to see a physician for five minutes, but the point is they don’t have to. It’s an iatrogenic problem.

There will be a shortage of 50,000 primary care physicians in the next 10 years, while at the same time we will graduate more than 70,000 primary care nurse practitioners. Get out your calculators to do this math!

Take for example, as a nurse practitioner in the state of PA, if I wanted to have my own practice, let’s say in the Middle of Nowhere, PA, this would be very difficult.  First, in the great state of PA, I would need to find 2 (not 1 but 2) physicians to agree to be my collaborating partners on my license.

This “collaboration” which in PA is by NP request only has a market value of $1500–2000 per physician per month. So essentially before I even open the doors or consider any type of business model, I am out 3–4k dollars a month in collaborative physician fees.  That is close to $50,000 a year!! I’m not sure if you are aware of this, but primary care is not exactly a cash cow type of business.  And when you are working in poor, rural towns that have no one, this type of business has profit margins that are barely sustainable.

So guess what, most NPs who have tried to start a business in the state of PA has failed, not because of bad practice or a poor business model, but because they couldn’t sustain the physician tax. And what is more? Your physician decides to move or doesn’t like you anymore or increases the collaborative fee to $5000 a month (yes it’s been done), you have to shut down your practice until you can replace that person.

The hope that NPs have had since the inception of retail healthcare is that industry would be able to work with us to remove collaborative practice as a barrier to care. We had this vision that retail health would see how silly and expensive the whole process is and lobby for its removal.

Collaborative practice is essentially taxation without representation. But most big retailers would rather pay the tax then stir up any trouble.  In fact, retail health for the most part just pays out the fees to collaborating physicians as part of a tax of doing business in those states.

Because of their economies of scale, retail health has the luxury of not really caring all that much if they have to pay collaborating physicians or not. If retail healthcare has contributed anything it’s creating a fair market value for a collaborating physician, which didn’t exist before. But this just reinforces the notion that we as NPs actually derive some benefit from having collaborative practice, which is not true, we simply pay for the privilege that brings us nothing.

According to reduced practice in PA, physician consultation is only required by NP request. So all this time, we have been working “independently” if you will. I am only required to consult a physician if I feel the need. When we get full practice authority, I will still only consult a physician if I feel the need. The difference is that I now don’t have to pay the physician $2000 a month for that luxury.

Hmm, I wonder if money has anything to do with physician resistance to removing barriers to care and access?  Nah . . . I’m sure physicians padding their practices on the backs of nursing would never really happen and that they have a true altruistic, albeit distorted concern for us and the patients, which is very nice.

In other restricted practice states, there is a requirement for a monthly meeting, review of 10% of the charts, physical proximity of the NP to the physician, etc.

What I don’t get is this:

How is skimming a bunch of charts a month later by a physician collaborative practice?  And how much do any one of us truly believe that the physician is actually taking the time to carefully review each one of the charts?

In Texas, a restricted state, the physicians can “supervise” seven NPs, but must review 10% of all their charts. In retail health, we see upwards of 40 patients a day, 7 days a week.  Let’s do some math here.  If we see 40 patients a day, 7 days a week, 30 days a month, that’s 8400 patients. Now they only need to “review” 10% and presumably one NP isn’t working every day of the month, so we will cut that number in half and arrive at oh, well, about 420 charts a month.

Tell me pray tell, how long would it take to look over 420 charts a month? Now the retail health clinics are staffed by NPs, there is no physician on site, just this physician who is “reviewing” 420 charts a month for the safety of our nation. The NPs are working like full-practice authority NPs, in one of the most restricted practice states in the nation! Those authorities are what full practice looks like, minus the poor sap who has to read 420 charts.

And what I want to know and have never seen is research that shows that this kind of oversight adds any value whatsoever to the care of the patients. It’s very costly.

Ironically there is no such literature, but physicians want to put on this ridiculous show of “reviewing charts” in restricted states to make extra money. And NPs in those states are forced to pay to watch the show. In reduced practice states, the physicians can just take their monthly check and not have to bother putting on a show, which to me seems like the better deal.

Note to physicians in restricted states–You got a really bad deal!

And in full practice authority states there is no show but there is also no check.

The American Association of Nurse Practitioners has delivered a stack of research, literally a body of literature that shows that Nurse Practitioners provide safe, quality and cost-effective care. Plus we have 21 states (soon to be 22 and the VA system), which show that NPs are safe, cost-effective and patients like us.

What a nurse practitioner does in a full practice authority state is the SAME EXACT JOB that a nurse practitioner does in the most restricted state minus the physician tax.

There is no difference in the job itself. And there is no difference in how NPs are mentored in any state. Physician mentoring isn’t guaranteed in Virginia (a restricted state) any more than mentoring is completely abolished in Vermont (a free state!). Both are absurd statements. What is different in these states are the hoops you have to jump through and the cost associated with the paperwork.

In conclusion, what I want to say to the physician who complained about the student who struggles with SOAP notes and the student who is scared to graduate and practice all by herself with no one to help her–neither of these things are related to full practice authority and should not be confused with it.  Both students will need mentoring, guidance and support.

This mentoring may come from nurse practitioners, this may come from physicians or more likely it will be a combination of both providers. Full practice authority does not eliminate the need for mentoring, nor does reduced/restricted practice guarantee it.

Simply put, they are two different issues altogether and need to be addressed separately.