Renewing the dialogue between the medical and nursing professions

A recent post observed that the “highly charged scope-of-practice” fight between the medical and nursing professions has resulted in social media hate speech – too often, from physicians directed at other physicians. “Like bees to nectar, a post on the topic is sure to draw dozens of anonymous, hate-filled comments” write the authors.  They propose the following “principles for civil discourse” which I believe should apply more broadly to all social media commentary, not just on the physician versus nurses conflict:

“Anecdotes are fine, but avoid drawing generalizations from one story. (‘We had that dumb NP once. She didn’t know where the gallbladder is located. So NPs must all be dumb.’)

Identify the underlying emotion of a comment that irks you, and name it when you respond. (‘Doctor Strangelove, it sounds like you’re frustrated that NPs have fewer hours of training and are asking for the same salary as MDs. Here’s my take: ….’)

Name-calling is out. Polite, respectful comments are more likely to be taken seriously, and to stimulate a productive conversation. ( ‘SJ, I appreciate hearing your viewpoint. Here is WHY I disagree with you.’)

Own your comments. Instead of making broad generalizations, make it clear that you are offering your opinion. (Rather than saying, ‘NPs simply should not be practicing without some sort of physician supervision,’ say ‘I don’t think NPs should practice without any physician supervision.’)

Consider phrasing your comment in the form of a question. (‘I’m troubled by the thought of NPs working in a rural area with no access to collaborating physicians. Does anyone have experience with that?’)

Go for the win-win. (‘The demographics, economics and politics of health care reform suggest there’s enough pie for all of us in the primary care world. We are all undervalued and overworked. By uniting in cause and working with each other, both groups stand to gain in terms of creativity, relationships, and (dare we say) income.’)

Find the best alternative to a negotiated agreement (known as “BATNA” — taken from the classic tome, Getting to Yes). (‘NPs are here to stay, with increasing autonomy across more and more states. Let’s find a way to work together — whether you’re a doctor or NP, our end goals are the same.’)”

If such principles were broadly accepted by all of us involved in social media commentary, they would result in a much better informed, respectful and constructive discussion than name-calling and personal attacks. Civil discourse, though, by itself won’t be enough to end the uncivil war between the nursing and medical professions.  What’s needed is a way to get to the “win-win” point where the legitimate interests and concerns of both professions are recognized and addressed.

Recently, the Annals of Internal Medicine, ACP’s flagship peer reviewed journal, published a paper titled, “Principles Supporting Dynamic Clinical Care Teams: An American College of Physicians Position Paper” which I believe could become the basis of such a win-win outcome. (Full disclosure: I am the principal author of this paper, along with my co-author and colleague Ryan Crowley, which was written by us on behalf of ACP’s Health and Public Policy Committee and Board of Regents).

Our goal in developing the paper was to constructively address the legitimate concerns of both professions as a step toward renewed dialogue between them.  Nurses have legitimate concerns about being held back by restrictions on their licenses and physician supervision arrangements that limit their ability to provide care to patients, that is within nursings’ skills and competencies.  Physicians have legitimate concerns that their unique and more extensive years of medical training are being devalued by the calls to substitute independently practicing advanced practice nurses for primary care physicians.  Both professions assert that their views are based on what is best for patients.

Our paper asserts that professionalism is the answer to resolving such differences. “Professionalism” we wrote “requires that all clinicians — physicians, advanced practice registered nurses, other registered nurses, physician assistants, clinical pharmacists, and other health care professionals — consistently act in the best interests of patients, whether providing care directly or as part of a multidisciplinary team. Therefore, multidisciplinary clinical care teams must organize the respective responsibilities of the team members guided by what is in the best interests of the patients while considering each team member’s training and competencies.”

The goal, then, must be to assign, “specific clinical and coordination responsibilities for a patient’s care within a collaborative and multidisciplinary clinical care team should be based on what is in that patient’s best interest, matching the patient with the member or members of the team most qualified and available at that time to personally deliver particular aspects of care and maintain overall responsibility to ensure that the patient’s clinical needs and preferences are met. If two team members are both competent to provide high-quality services to the patient, matters of expedience, including cost and administrative efficiency, may contribute to division of that work.”   While we affirm the importance of, “patients having access to a personal physician who is trained in the care of the ‘whole person’ and has leadership responsibilities for a team of health professionals, consistent with the Joint Principles of the Patient-Centered Medical Home” we also state that, “Dynamic teams must have the flexibility to determine the roles and responsibilities expected of them based on shared goals and needs of the patient.”

“Although physicians have extensive education, skills, and training that make them uniquely qualified to exercise advanced clinical responsibilities within teams…well-functioning teams will assign responsibilities to advanced practice registered nurses, other registered nurses, physician assistants, clinical pharmacists, and other health care professionals for specific dimensions of care commensurate with their training and skills to most effectively serve the needs of the patient.”  We observe that, “especially in physician shortage areas, it may be infeasible for patients to have ‘an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care” and that, “in such cases, collaboration, consultation, and communication between the primary care clinician or clinicians who are available on site and other out-of-area team members who may have additional and distinct training and skills needed to meet the patient’s health care needs, are imperative.”

On the debate over each profession’s role in solving the primary care workforce shortage, our answer is, “a cooperative approach including physicians, advanced practice registered nurses, other registered nurses, physician assistants, clinical pharmacists, and other health care professionals in collaborative team models will be needed to address physician shortages.”

And on the most divisive issue — state regulation of nursing scope of practice — we state that, “Clinicians within a clinical care team should be permitted to practice to the full extent of their training, skills, and experience and within the limitations of their professional licenses as determined by state licensure and demonstrated competencies. All clinicians should consult with or make a referral to other clinicians in disciplines with more advanced, specific, or specialized training and skills when a patient’s clinical needs would benefit from such consultation and referral.”  We assert that,  “Licensure should ensure a level of consistency (minimum standards) in the credentialing of clinicians who provide health care services” and called on state legislatures and licensing authorities, “to conduct an evidence-based review of their licensure laws” and “consider how current or proposed changes in licensure law align with the documented training, skills, and competencies of each team member within his or her own disciplines and across disciplines and how they hinder or support the development of high-functioning teams.”

Now, I know that the paper will not please everyone in the medical and nursing professions, but we hope that it can be the starting point of a renewed dialogue between the professions.  We end the paper by noting that, “ACP offers these definitions, principles, and examples to encourage positive dialogue among all of the health care professions involved in patient care—in the hope of advancing team based care models that are organized for the benefit and best interests of patients. ACP also hopes to inform policymakers to ensure that regulatory and payment polices are aligned with, rather than creating barriers to, dynamic team-based care models. ACP encourages discussion of dynamic clinical care teams that puts patients first.”

Let’s get this dialogue started — with civility, of course.

Bob Doherty is senior vice-president, governmental affairs and public policy, American College of Physicians and blogs at The ACP Advocate Blog.

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