Compare the Educational Requirements of Family Physicians and Advanced Practice Registered Nurses

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1 Per your request, LBB has reviewed material distributed by the Texas Academy of Family Physicians relating to the scope of practice of advanced practice registered nurses. This memo responds to specific points made in these fact sheets, relying on the cited source material and (when noted) additional research. Compare the Educational Requirements of Family Physicians and Advanced Practice Registered Nurses This fact sheet cites a survey of 562 nurse practitioners who were asked to reflect on their first years of practice as evidence that advanced practice nurses are not rigorously educated. The source report cautioned against reading too much into its results for a number of reasons, including: It relied on a convenience sampling of conference attendees, not a random sample It was asking NPs to recall how they felt an average of 11 years earlier. The fact sheet suggests that 46 percent of respondents felt unprepared by their pharmacology education. The survey s actual findings were that 54 percent of respondents felt well prepared, 28 percent felt somewhat prepared, and 7 percent felt minimally or unprepared. Other aspects of practice (such as management of acute and chronic care, and mental health diseases, differential diagnoses, and pathophysiology) were correlated with a general sense of being at least somewhat or well prepared. For context, a 2001 Journal of the American Medical Association (JAMA) article found, from random sampling of 2,626 resident physicians, more than 10% of family practice, OB/GYN, and internal medicine residents felt unprepared for a variety of conditions they would encounter in their professional life. The survey considered responses of somewhat prepared and very prepared as prepared. 1 When comparing the educational curriculum of medical students and advanced practice nursing students, the fact sheet states: Because family physicians throughout the United States follow the same highly structured educational path, complete the same coursework, and pass the same licensure examination, you know what you re getting with a physician. APRN educational programs also must comply with standards established by accrediting boards: All APRN education programs are housed within nationally accredited graduate programs and are accredited by a nursing accrediting organization recognized by the U.S. Department of Education and/or the Council for Higher Education Accreditation. The curriculum at all APRN schools includes graduate level content in advanced assessment, pathophysiology and pharmacotherapeutics that build on the content learned in the undergraduate nursing education programs (which includes Anatomy and Physiology). Content also includes preparation to practice in the APRN role 1 Journal of the American Medical Association, Preparedness for Clinical Practice, September 5, 2001, page 1027.

2 (e.g., nurse practitioner) and includes content appropriate for formulation of differential diagnoses and determination of appropriate pharmacologic and nonpharmacologic management of patients for a particular patient population (e.g. pediatrics). All APRNs practicing in a given role and population must pass the same licensure exam. Additionally, not all physicians in the United States, or in Texas, have been through the same education, coursework or exams. According to the American Medical Association, in 2007, 141,000 practicing physicians in the United States were educated and trained in another country, under different educational curriculum and standards. About 60 percent of these practiced in Family Practice and Internal Medicine. 2 In Texas, about 13,250 physicians (about 24 percent of the physician workforce) were educated by an international medical school. 3 Other sources cited by the fact sheet are also taken out of context. An American Journal of Medicine survey of practitioner records did find that nonphysician practitioners were more likely to prescribe antibiotics for some respiratory diagnoses, but allowed that some of the difference may be attributable to the way the practitioner described the diagnosis (e.g., sinusitis vs. respiratory infection ). In most other instances, the survey found few differences between how physicians and non-physician practitioners prescribed antibiotics. A study on antibiotic prescribing in the Journal of the American Academy of Nurse Practitioners found that nurse practitioners misused antibiotics at rates comparable to physicians and advocated nurse practitioner schools follow medical schools in considering adoption of a supplemental module on anti-microbial resistance developed by the CDC. Other points in the fact sheet rely on out-of-date information There is no such standard to achieve nurse practitioner certification educational requirements vary from program to program o Core competencies for nurse practitioner education have existed since 1990 and are key components for a school s accreditation. Alternate pathways exist for an RN without a bachelor s degree to enter some master s programs. o All NP schools in Texas require a bachelor s degree in nursing and licensure as an RN

3 Nurse Practitioners Are Not More Likely Than Physicians to Practice in Rural and Underserved Areas This sheet contrasts the tendency of physicians and nurse practitioners to practice in rural areas. It cites a 2007 survey that found 23 percent of nurse practitioners practiced in rural areas A 2002 JAMA article found that only 9% of the nation s physicians practice in rural areas. 4 The sheet also compares the statewide distribution of physicians and nurse practitioners in four states that allow APRNs to practice autonomously and finds that the nurses and physicians are each more likely to have practices in metropolitan and suburban communities. In all the states cited in the fact sheet, including Texas, there are substantially more physicians than nurse practitioners. As a result, there will be also more of them per 100,000 population and more of them throughout the state. 5 Idaho: 4,541 current physician licenses; 584 nurse practitioners Oregon: 10,554 active physicians; 2,317 nurse practitioners Arizona: 28,820 active physicians; 2,989 nurse practitioners Utah 8,057 physicians; 1,259 nurse practitioners In Texas, it is expected that primary care physicians and nurse practitioners would be practicing in the same areas, since the delegated, site-based prescriptive authority requires an nurse practitioner to work within 75 miles of their delegating physician. Nonetheless, twenty-eight Texas counties designated as health professional shortage areas (HPSAs) have no physician as of February They are shown in Figure 1. The ten counties with an asterisk (*) have at least one licensed nurse practitioner and/or other licensed APRN. Figure 1: Table 1: Whole County HPSAs Without a Physician County 2010 population County 2010 population Armstrong* 2,279 Kent 860 Borden 768 King 376 Carson* 6,772 Lipscomb 3,167 Cottle* 1,873 Loving 65 Dallam* 6,758 McMullen 878 Delta* 5,330 Mason 3,837 Dickens* 2,795 Motley 1,422 Duval 12,041 Oldham* 2,341 Foard* 1,582 Real 3,351 4 Journal of the American Medical Association, January 2, 2002, page All professional license counts are from each states boards of medicine and nursing

4 Glasscock 1,525 Roberts 948 Hall* 3,840 Sherman* 3,361 Hudspeth 3,812 Sterling 1,473 Irion 1,824 Kenedy 470 Source: Texas Department of State Health Services Contain Health Care Costs: Encourage Collaboration Between Physicians and Nurse Practitioners This information sheet cites one study purported to show that relying on nurse practitioners may actually be the opposite of cost-effective. The study, from 1991, and published by the American College of Physicians, compared 150 primary care patients seen by a nurse practitioner to 150 primary care patients seen by a physician in a Veterans Affairs medical center. It seemed to show slightly higher rates of hospitalizations and specialist referrals among nurse practitioners. Its conclusions were qualified. The study focused on the practice of relatively few providers. The study also could not control for an unmeasured difference in comorbid conditions or severity of illness that was not captured through our chart review in the nurse practitioner charts. o This is relevant because the scope of practice for nurse practitioners is relatively narrow, and referring patients whose conditions fall outside that scope to another provider is what they are trained to do. Studies that are both more recent and more rigorous (as well as published by more objective parties) have consistently found that the quality of care provided by nurse practitioners and physicians is comparable, and on some measures outcomes favor the nurses. The RAND Corporation 6 : Given widespread agreement that there is a critical shortage of primary care physicians in the Commonwealth, expanding scope-ofpractice laws could be a viable mechanism for increasing primary care capacity and reducing health care costs. The Cochrane Collaboration 7 : this review found that quality of care is similar for nurses and doctors but it is not known if it decreases the doctor s workload. Nurses tend to provide more health advice and achieve higher levels of patient satisfaction compared with doctors. 6 RAND Corporation, Controlling Health Care Spending in Massachusetts: An Analysis of Options, August The Cochrane Collaboration, Substitution of doctors by nurses in primary care, 2009

5 Journal of the American Medical Association 8 : In an ambulatory care situation in which patients were randomly assigned to either nurses practitioners or physicians, and where nurse practitioners has the same authority, responsibilities, productivity and administrative requirements, and patient population as primary care physicians, patients outcomes were comparable. Institute of Medicine 9 : Beyond the issue of pure numbers of practitioners, a promising field of evidence links nursing care to a higher quality of care for patients, including protecting their safety. 8 Journal of the American Medical Association, Primary care Outcomes in Patients Treated by Nurse Practitioners or Physicians: A Randomized trial, January Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing at the Institute of Medicine, The Future of Nursing: Leading Change, Advancing Health, 2010