DATE

ADDRESSEE

Dear LEGISLATOR,

On behalf of the(STATE DERMATOLOGY SOCIETY), we are writing in strong opposition to Bill #. This legislation would authorize nurse practitioners to practice independently. We are very concerned this will significantly undermine the delivery of good patient care and for the reasons set forth below, we urge members of the COMMITTEEto opposeBill #.

Physicians Are Uniquely Qualified to Lead the Health Care Team

There are substantial differences in the education of a physician as opposed to a nurse practitioner in both the depth of knowledge and length of training. After finishing a rigorous undergraduate academic curriculum to gain admission to medical school, physicians receive an additional four years of education in medical school. This is followed by 3 – 7 years of residency and 12,000-16,000 hours of patient care training. In stark contrast, nurse practitioners only receive 2 – 4 years of education (some of which can be completed online) and 500 – 720 hours of patient care training. By any measure, the differences in training are significant. Given the wide array of challenges that confront the independent practitioner, physicians’ additional training and expertise allows them to substantively reduce the incidence of complications and to recognize and treat them appropriately when they do occur.

Medical students who attend schools accredited by the Liaison Committee on Medical Education are required to care for patients in both inpatient and outpatient settings in the following clinical rotations: family medicine, internal medicine, obstetrics and gynecology, pediatrics, psychiatry and surgery.[1] Similarly, students at colleges of osteopathic medicine that are accredited by the American Osteopathic Association’s Commission on Osteopathic College Accreditation must receive education in the following clinical disciplines: internal medicine, family medicine, pediatrics, geriatrics, obstetrics and gynecology, preventive medicine and public health, psychiatry, surgery, radiology, and basic knowledge of the components of research.[2] All medical students must also select a number of specialty elective rotations to round out their exposure to the branches of medicine, ensuring a broad and comprehensive medical knowledge base upon which they build by choosing an area of practice specialization for graduate medical education, commonly known as residency.

While the role nurse practitioners play in a physician-led coordinated care environment is critical to the overall care provided to a patient, the education and training programs of nurse practitioners simply cannot match the clinical judgment and training of physicians, which is developed over numerous years through medical school and subsequent residencies. The American College of Nursing only recommends that nurse practitioners have a minimum of 500 hours in direct clinical practice during their educational training. Most nurse practitioners have just two-to-three years of postgraduate training and less clinical experience than is obtained in the first year of a three-year medical residency.

The differences in education and training are significant and should not be overlooked. There has been a recent rapid increase in malpractice claims filed against nurse practitioners and other non-physicians, particularly for botched cosmetic procedures.[3] Further, a 2015 study from the University of Wisconsin comparing malignancy rate of biopsies performed by dermatologists versus non-physicians suggests that an increased use of biopsies may increase the morbidity and cost of care provided when provided by non-physicians.[4] This is a public health hazard which will be aggravated by this legislation.

The Public Supports Physician-Led Team Based Care

As members of the health care delivery system, it should be a common goal of both physicians and nurse practitioners to ensure that patients receive the highest quality care. We believe this is achieved when health care is delivered by a physician-led team. This model is also supported by the public. According to three nationwide surveys, 84% of respondents prefer a physician to have primary responsibility for their diagnosis and management of their health care and 91% of respondents said that a physician’s years of medical education and training are vital to optimal patient care, especially in the event of a complication or medical emergency.[5] The enactment of BILL # would move away from the goal of delivering health care in a coordinated, cost-effective manner toward a fragmented system that unnecessarily jeopardizes patient safety.

Independent Practice Leads to Fragmented Care Without Improving Access

Nurse practitioners are valuable members of the health care team. However, independent nurse practitioner practice, which would sever the tie between physicians and nurses, would lead to fragmented care and is antithetical to the team-based approach. All members of the health care team are important, but the roles are not interchangeable in a physician-led health care team. Physician and nurse practitioners have long worked together to meet patient needs because the physician-led team approach to care works. The model established by BILL # will result in fragmented patient care where nurse practitioners’ complete autonomy results in isolation. Today we rely on a coordinated approach; independent nurse practitioner practice is both challenging and risky for patients.

Studies show that in states where nurses do practice without a collaborative agreement, physicians and nurses continue to work in the same urban areas, so increasing the independent practice of nurses has not helped solve the shortage in rural areas. The parallel geographic distribution of physicians and nurses is further illustrated by a geographic mapping initiative of the American Medical Association which demonstrates that non-physician health care providers are not located in rural or underserved areas, but rather, are concentrated in the same geographic areas as physicians. There are currently no legal or regulatory hurdles that prevent nurse practitioners from practicing in rural areas within the context of a collaborative agreement.

The rationale to provide independent practice to nurse practitioners ironically comes at a time when physician-led team-based care is most essential. In fact, new health care models including Accountable Care Organizations require increased teamwork among physicians, nurse practitioners, and other providers of care. Legislating completely independent practice for nurse practitioners would only serve to further compartmentalize the delivery of health care.

The STATE DERMATOLOGY SOCIETY appreciates the opportunity to provide written comments on this important public health issue. As physicians, our number one priority is the health and welfare of our patients. We respectfully urge you to carefully consider the ramifications of granting nurse practitioners independent practice. Eliminating physicians with their 12,000 – 16,000 hours of clinical training with the enactment of BILL # will jeopardize patient care. For further information, please contactNAME.

Sincerely,

STATE DERMATOLOGY SOCIETY

[1] Web, Liaison Committee on Medical Education (LCME). LCME Accreditation Standards with annotations.

[2] Web, American Osteopathic Association (AOA). College of Medicine Accreditation Standards and Procedures.

[3]Jalian H. R., Avram, M.(2013,October 16). Increased Risk of Litigation Associated With Laser Surgery by Nonphysician Operators.JAMA Dermatol.doi:10.1001/jamadermatol.2013.7117.

[4] Bennett, D., Xu, Y (2015, August). Biopsy Use in Skin Cancer Diagnosis: Comparing Dermatology Physicians and Advanced Practice Professionals, JAMA Dermatol. August 2015 Volume 151, Number 8.

[5]Surveys of nearly 1,000 adults on behalf of the AMA Scope of Practice Partnership were conducted in 2008, 2010, and 2012.