In Dr. Mary Moller’s Guest Editorial “Advancing the role of advanced practice psychiatric nurses in today’s psychiatric workforce” (Current Psychiatry. April 2017, p. 15-16,18-20), she asserts that the American Psychiatric Association (APA) should take a stand against the American Medical Association (AMA) because AMA lobbyists pose a barrier to allowing advanced practice registered nurses (APRNs) to engage in autonomous practice. She argues that physician supervision is nothing more than a means of earning extra money for some physicians, calling it a “cottage industry.” Although she states that psychiatric APRNs provide skilled psychiatric care from a “nursing perspective” and argues that we “come together to respect our given scopes of practice,” the implication is clear: “to remove unnecessary barriers to practice and promote a unified and collegial workforce” is to assert that APRNs can do anything psychiatrists do. As physicians, we all know this is not the case. To support autonomous practice is to promote a reckless endeavor that endangers our patients.
Dr. Moller cited a source from the Federal Trade Commission1 that encourages the autonomous practice of APRNs to increase competition. This again implies the false equivalency between physicians and APRNs. Competition implies that the players are providing the same service. If, as nurse practitioners argue, they practice “nursing,” then they are not practicing “medicine.” Physicians and APRNs do not have the same background. Although both are charged with the care of patients, nursing is not medicine, nor should it be. Both are important and needed, but nursing was never designed to be an autonomous practice. According to the American Association of Colleges of Nursing, “Nursing and medicine are distinct health disciplines that prepare clinicians to assume different roles and meet different practice expectations.”2 In fact, the curriculum and requirements to become an APRN vary depending on the program, and some programs do not even require a BSN.3 There are online programs available for earning an APRN degree. Additionally, APRNs are only required to have 500 to 700 total hours of patient care,4 compared with the >10,000 hours physicians have once they have finished a 3-year residency, which when combined with their education amounts to >20,000 hours.5 This doesn’t account for those who have longer residencies or fellowships to further specialize in their area of training.
Dr. Moller’s main argument is that there is a dire shortage of psychiatrists and that the only way to meet this need for more providers is to make APRNs autonomous. However, no data indicate that autonomous practice of mid-level providers leads to an influx of these providers in rural areas, where the need would be greatest. Although current data on this are quite sparse, some studies indicate that the majority practice in urban areas, even in states with independent practice authority.6,7 Dr. Moller cites a source that only reviewed home zip codes of psychiatric APRNs but did not include zip codes of employment.8 Only 13% of psychiatric APRNs live in rural areas across the United States. Therefore, it is a false assertion to state that these APRNs are found primarily in rural and less populated urban areas. It is also false to imply and assume that these APRNs practice in the rural areas.
In 2017, there were 43,157 registered physician applications, with 35,969 active applications for 31,757 residency positions in the United States, and at least 11,400 medical school graduates were unmatched.9 Imagine how much more we could serve our patients by matching these graduates, whose training far surpasses that of a mid-level provider. The Resident Physician Shortage Reduction Act of 2017 aims to address this problem by increasing Medicare-funded graduate medical education (GME) residency programs in the United States.10 We can make a difference by contacting our members of Congress to encourage them to support this bill. In addition, the AMA is advocating to save funding for GME and provides an easy-to-use Web site (https://savegme.org/take-action) to contact your legislators directly to show your support for GME.
Nurse practitioners have tremendous value when their role is a part of a team; however, they should not practice without supervision, and physicians who supervise them absolutely should be providing adequate supervision. I applaud the APA and the AMA for standing up for the practice of medicine and for our patients. I hope that they continue to do so, and I encourage them to increase their efforts.
Laura Kendall, MD
Assistant Professor of Clinical Psychiatry
Department of Psychiatry and Behavioral Sciences
Keck School of Medicine
University of Southern California
Los Angeles, California
1. Koslov T; Office of Policy Planning. The doctor (or nurse practitioner) will see you now: competition and the regulation of advanced practice nurses. Federal Trade Commission. https://www.ftc.gov/news-events/blogs/competition-matters/2014/03/doctor.... Published March 7, 2014. Accessed July 26, 2017.
2. American Association of Colleges of Nursing. DNP talking points. http://www.aacnnursing.org/DNP/about/talking-points. Updated July, 2014. Accessed August 12, 2017.
3. Keyes L. MSN without a BSN? MastersInNursing.com. https://www.mastersinnursing.com/msn-without-a-bsn. Accessed August 12, 2017.
4. Iglehart JK. Expanding the role of advanced nurse practitioners—risks and rewards. New Engl J Med. 2013;368(20):1935-1941.
5. Primary Care Coalition. Issue brief: collaboration between physicians and nurses works. Compare the education gaps between primary care physicians and nurse practitioners. http://www.tafp.org/Media/Default/Downloads/advocacy/scope-education.pdf. Published November 1, 2010. Accessed October 11, 2017.
6. American Medical Association. Issue brief: independent nursing practice. https://www.ama-assn.org/system/files/media-browser/premium/arc/ama-issu.... Updated 2017.
7. Tabor J, Jennings N, Kohler L, et al. The supply of physician assistants, nurse practitioners, and certified nurse midwives in Arizona. University of Arizona. http://azahec.uahs.arizona.edu/sites/default/files/u9/supply_of_pa_np_cn.... Accessed October 11, 2017.
8. Hanrahan NP, Hartley D. Employment of advanced-practice psychiatric nurses to stem rural mental health workforce shortages. Psychiatr Serv. 2008;59(1):109-111.
9. 2017 NRMP Main Residency Match the largest match on record [press release]. Washington, DC: National Resident Matching Program; March 17, 2017. http://www.nrmp.org/press-release-2017-nrmp-main-residency-match-the-lar.... Accessed October 11, 2017.
10. Resident Physician Shortage Reduction Act of 2017, HR 2267, 115th Cong, 1st session (2017).