Innovate with clinical care teams, not APRN independent practice

Our health care system needs to incorporate Advanced Practice Registered Nurses (APRNs) more effectively, and they should be allowed to practice within the scope of their training and education. But the limits of that training and education must be acknowledged. Those limitations should preclude the independent practice of APRNs in Connecticut. Innovations in Connecticut’s health care system are already evolving to expand the role of APRNs in clinical care teams and do not require their independent practice. That should be our focus.

Our health care system needs to deliver better access to care of whatever sort is needed: routine preventive care, simple illness, management of complex multiple chronic conditions and specialist care. Sometimes a patient knows exactly which of these types of care is needed in a given situation, but that is not always the case.

Many have publicly stated that APRNs are adequately trained to practice independently in those areas of primary care that are within the scope of their training and education. But what does that really mean? The Institute of Medicine has defined “Primary Care”  as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing the large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.” A primary care clinician’s practice should be the point of first contact for a medical problem or question. What “scope of training and education” is adequate to serve this role well?

It might be easy to determine that a given APRN or doctor cannot perform surgery because it is not within a certain scope, but primary care is more difficult to define since it spans a spectrum from simple illness to complex multisystem conditions, all with the same presenting symptoms.

Exactly what “scope of practice” enables a clinician to differentiate a little sick from really sick? Does a clinician with just a couple of years of clinical training have the clinical judgment to adequately evaluate, diagnose and treat a typical primary care problem like several weeks of cough in an elderly patient with multiple medical problems like diabetes, a history of congestive heart failure and chronic lung disease? That is potentially quite different from treating a healthy young adult with a cough from a couple weeks of a viral respiratory infection. Yet, these two situations have the same presenting symptoms and might erroneously get placed into the same protocols of management. That is not the good care we want to provide to our patients.

Without adequate clinical training and judgment, a clinician CANNOT know when he or she is beyond his/her scope of practice or expertise. The explosion of medical knowledge in recent decades requires that physicians have extensive education and training. A primary care doctor needs many years of basic science training and hands-on experience to develop the clinical judgment to become a good diagnostician and caregiver. Yes, certain aspects of straightforward mild illness and preventive care can be delivered just as well from an APRN as from a seasoned doctor. But does that warrant completely independent practice for APRNs in primary care without limitations?

A patient does not necessarily have the ability to determine that her symptom can be adequately managed by an APRN or needs the greater diagnostic acumen of a doctor. Therefore, APRNs must be practicing in situations where consultation is readily available. To ensure that different types of clinicians are able to practice effectively to the “top of their licenses,” the concept of clinical teams has evolved.

The physician community does not deny that APRNs have a valuable role to play in delivering excellent care to all our patients. We need to figure out how to better fit APRNs as well as physician assistants and other clinical colleagues into situations to deliver good patient care. That requires a better health care delivery AND payment system with teams of different professionals providing coordinated and efficient care. This strategy will improve access for patients. We must move forward to encourage the development of effective clinical care teams as ways to deliver the highest quality, most coordinated and safest care for our patients.

Focusing on legislation to give APRNs independent practice may appear on the surface to be a solution to our problems with access to primary care. But in reality, it is not. This issue merely serves as a distraction in the halls of the General Assembly in Hartford and prevents our legislators from spending time on the real challenges facing health care delivery in our state.

Robert J. Nardino, M.D., is an internal medicine residency program director in New Haven and current governor of the Connecticut Chapter of the American College of Physicians. Robert M. McLean, M.D., practices internal medicine and rheumatology in New Haven and is immediate past governor of the Connecticut Chapter of the American College of Physicians.

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