We soon will see the full flowering of the march of the nurse practitioner profession toward full independence in clinical practice, perhaps with physician endorsement. While the NP profession has long maintained that its scope of practice is "collaborative" and does not require the supervision of a physician, in fact most NPs have some form of legal and practice connection to physicians.

Now with the prospect that NPs, along with the other advanced practice nurses (APNs), will attain a clinically based professional doctoral degree (doctorate in nursing practice, DNP) at the completion of their training, there is evidence that NPs are increasingly likely to establish themselves as independent practitioners and share with physicians the domain of medical practice.

'Licensed Independent Providers'

One such indication is a document recently drafted by the National Council of State Boards of Nursing titled "The Future Regulation of Advanced Practice Nursing," which clearly states, "Fully licensed APRNs will be independent practitioners. After licensure, there will be no regulatory requirements for supervision."¹ The document outlines how DNP graduates would become licensed as independent providers by state boards of nursing. It is tantamount to a formal declaration of independent medical practice by the NP profession.

Such a posture is not entirely unexpected, since NPs and other APNs have been moving in this direction for many years. However, what is of interest is physicians' malaise in response to aggressive moves that likely would place NPs in direct competition with primary care physicians. Now, it is not only malaise but also open encouragement in support of this step.

In a recent editorial on workforce policy, commenting on the future need for increased medical care services, Academic Medicine editor Michael E. Whitcomb, MD, appears ready to cede a sizable portion of medical practice activities to APNs.² He acknowledges that physicians are unlikely to be able to meet the anticipated demand for medical care services in the future, and that APNs, armed with the planned DNP degree, are very likely to seek to deliver medical care services independent of physicians. He notes that "it seems virtually certain that the [APN] graduates will provide a number of services that have traditionally been viewed as being solely within the domain of physicians, and will do so in independent practice settings."

With many workforce experts calling attention to a crisis in primary care, and with declining interest in primary care among recent medical graduates, it appears to be a wide open field for nonphysicians. Moreover, PAs also are exhibiting less interest in primary care, with as much as 60% of the profession now working in specialties.

The door would appear to be open for NPs prepared with doctoral degrees to enter and perhaps dominate primary care delivery. The recent utilization of NPs in for-profit medical clinics set in large retail chains is but further evidence of this trend.

Whitcomb soft-pedals the opposition that such moves surely will evoke among some physician groups, noting, "I am aware that some state medical societies are actively opposing the development of DNP programs by colleges and universities and the granting of an expanded scope of practice to APNs by state officials. I believe it is wrong for the (medical) profession block the APN movement."²

What About PAs?

Sadly, in his paper Whitcomb makes no mention of PAs, a segment of the health workforce that could continue to augment physicians in meeting future demands for medical care services. If the root issue is a need for more medical care services, why would he omit mention of the role that PAs could play? It seems lost on Whitcomb that PAs are providers who are not seeking independent practice, or that the PA concept in the United States was originally created by medicine as a means to supplement physician services.

It seems curious-and annoying-that the PA profession's long-held policy of physician dependence has borne such meager fruit among those in the medical profession. When the call is for more medical care services, it seems logical for the response to include the participation of the PA profession.

Whitcomb's journal is the official house organ of the Association of American Medical Colleges. The AAMC has advocated for the expansion of medical school enrollment, and indeed, a large number of medical schools are doing just that. At least 50 of the nation's 134 PA educational programs are sponsored by academic medical centers. Would it not be at least as effective a workforce policy, and perhaps a less contentious one, to encourage those medical schools that sponsor PA programs to expand enrollment, and for those that do not to consider opening new programs?

Rather than advocating meekly handing over a segment of medical practice to groups that have been at times overtly hostile to physicians and sometimes militant in their assertion of independent practice, it seems reasonable and entirely appropriate workforce policy to also consider those nonphysicians who are trained in the medical model, who have sought a practice relationship that is not threatening to physician groups and who are equally effective in providing quality and cost-effective medical care.

James F. Cawley is director of the PA/MPH program and professor and vice chair of the Department of Prevention and Community Health, School of Public Health and Health Services at The George Washington University in Washington. He also is professor of health care sciences at the university's School of Medicine and Health Science.

References

1. National Council of State Boards of Nursing. Vision Paper: The Future Regulation of Advanced Practice Nursing. 2006.

2. Whitcomb ME. The shortage of physicians and the future role of nurses. Acad Med. 2006;81:779-780.