APRN Full Practice Authority States

[Dr. M Toboggan]

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I am sure this has been discussed within other threads, but I have had trouble finding an adequate answer to the following question.

For those of us in a state that gives APRNs full practice authority, but work in an organization that does not allow APRNs to practice without a protocol/practice agreement, if a lawsuit is filed against the APRN, how likely is the physician to be named in the lawsuit or found guilty of vicarious liability or negligent supervision? My presumption would be the physician is less likely to be found guilty in an APRN full practice authority state versus the alternative.

I am sure the answer is state and case dependent, though I am having a trouble finding any specific literature from my state from my state's medical board. I am finding so many job opportunities in more rural areas are expecting APRN supervision, and I really have little appetite for it.

 

[comp1]

I guess if you're really looking for some sort of quantitative idea, sure "less" likely. But how much less? Probably negligible, particularly for being named. In my experience, lawyers of all kinds don't really read charts or learn hospital flow when crafting a lawsuit. Instead, they name everyone they can find in a chart. This includes people who covered on the weekend, after hours, trainees, answered a phone call, etc. It's possible some people might get dropped weeks to months to later, but they still could end up at least subpoenaed. When you're looking at a job, I'm not really sure this should be at the top of your priorities. Remember you're getting paid 2-3x more than the NPs. Expecting them to just do your job with no extra support isn't all that reasonable. You're right that most jobs are going to expect you to offer at least some NP support. If liability if really your top priority, you should consider a job with the feds. You can't be named in a civil lawsuit directly there, regardless of NPs.

 

[Dr. M Toboggan]

I guess if you're really looking for some sort of quantitative idea, sure "less" likely. But how much less? Probably negligible, particularly for being named. In my experience, lawyers of all kinds don't really read charts or learn hospital flow when crafting a lawsuit. Instead, they name everyone they can find in a chart. This includes people who covered on the weekend, after hours, trainees, answered a phone call, etc. It's possible some people might get dropped weeks to months to later, but they still could end up at least subpoenaed. When you're looking at a job, I'm not really sure this should be at the top of your priorities. Remember you're getting paid 2-3x more than the NPs. Expecting them to just do your job with no extra support isn't all that reasonable. You're right that most jobs are going to expect you to offer at least some NP support. If liability if really your top priority, you should consider a job with the feds. You can't be named in a civil lawsuit directly there, regardless of NPs.

I appreciate the response. I wouldn’t say it’s my top priority, but obviously if I was choosing between similar jobs, one requiring APRN supervision versus the other not, I would choose the one that allowed for lessened liability.

 

[Sushirolls]

Pretending I'm a lawyer... I think any supervision is same liability.

Think of an alternative? A surgeon looking to do a new procedure, or get signed off for something they haven't done in awhile or just get credentialed at hospital XYZ.

They might require supervised X number of procedure before it circles back to med staff and they get it added to their hospital credential card.
Surgeon Supervisor is definitely getting sued, too, IMO.

 

[splik]

For those of us in a state that gives APRNs full practice authority, but work in an organization that does not allow APRNs to practice without a protocol/practice agreement, if a lawsuit is filed against the APRN, how likely is the physician to be named in the lawsuit or found guilty of vicarious liability or negligent supervision? My presumption would be the physician is less likely to be found guilty in an APRN full practice authority state versus the alternative.

The physician is ALWAYS named in the suit. In terms of whether the suit is successful, it hinges on whether supervising physician knew or should have known what the supervisee was up to. The reasons for the practice agreement is almost always to bill under your name at the physician rate, so yeah you're responsible for what's billed under your license even if you don't enjoy the fruits of that labor.

 

[michaelrack]

The physician is ALWAYS named in the suit. In terms of whether the suit is successful, it hinges on whether supervising physician knew or should have known what the supervisee was up to. The reasons for the practice agreement is almost always to bill under your name at the physician rate, so yeah you're responsible for what's billed under your license even if you don't enjoy the fruits of that labor.

That's a good point regarding employment situations in which the NP bills under the physician.

 

[dl2dp2]

Seems that practices that employ NPs have wildly different standing practices. Some use MDs to do weekly (daily, if inpatient) review (i.e. "run the list"). Others have on MD supervising 50 NPs and rarely look at their chart, and just bill insurance up a storm. Latter of course is more liable, but they might not care and just deal with the hit as they rake in millions in fees.

People who end up doing the latter arrangements are also the type who see 10 patients an hour. Yes it exposes you but perhaps in psychiatry the risk there isn't high enough to make any sort of difference.

The quality of practice, of course, sucks. That's a different story. I would never do this. Never over my dead body. I'd quit medicine before I do this. But this happens in the real world and I've verified personally the stories. So as you can see this has nothing to do with regulations or insurance, or anything like that.

Another matter - liability is highly related to documentation thoroughness. The reality is if you have an army of NPs and do QA on their charts and make sure they document things, even if they didn't actually do them and have horrible actual practice in reality, if you get sued the plaintiff won't get much out of it. Like, if you say in MS SI checked and non-reported. The patient dies. Chart gets audited. Patient never reported SI at our visit. No malpractice. Meanwhile, the NP might spent 2 min with a patient and forward a Prozac script and billed 99214 for $150 by writing down that they asked 1000 questions (maybe they did by reading a script) and dealt with 5 problems.

You see how this works?

 

[Sushirolls]

In the spirit of election day today ... good thing Biden admin specifically earmarked millions for expanding ARNP education and "residencies."

 

[Merovinge]

In the spirit of election day today ... good thing Biden admin specifically earmarked millions for expanding ARNP education and "residencies."

You do realize how partisan you are making this issue? There was also JUST legislation introduced by Republicans to expand nursing scope of practice in one of the heavily red states in the south. Neither political party caters to MDs, we have probably the single worst run lobby of any major profession. Also, there are no longer any politic points to be earned supporting MDs who are increasingly seen in a disfavorable light by society with the left putting us into the wealthy elite camp and the right being increasingly anti-science.

 

[calvnandhobbs68]

In the spirit of election day today ... good thing Biden admin specifically earmarked millions for expanding ARNP education and "residencies."

I'll just leave this hereeee....again if you don't want people complaining about your political views stop wearing them on your forehead

Nurse Practitioners Commend Trump Administration's Recommendations on Scope of Practice Laws

The report further notes, "economic analysis indicates that expanding APRN [advanced practice registered nurse] SOP, consistent with APRN education, training and experience, would have clear consumer benefits, particularly in rural and poorer areas." "We commend the administration's efforts to…

www.aanp.org

 

[Sushirolls]

I do. That's why I said in the spirit of election day. But could you PM me a link on that article of that state. I'd be interested to read it. I missed that one.

Agreed, Docs aren't viewed as well anymore. One of many institutions being rusted away.

@calvnandhobbs68 Thank you for the link.

 

[comp1]

Oh NPs are definitely bipartisan. You can spin them in all sorts of directions depending on what you want them to represent.

 

[ridethecliche]

Not sure if this has been said here, but the term APRN is disingenuous. There's nothing advanced about their training. They're just mid-level providers, no matter what they'd like to be called.

Edit: And that's not an insult... it just is. You can start 'residencies', or whatever you call them, and add all sorts of letters after your name... but nothing is going to change the fact that you are not a physician.

I always come back to the words of Ronnie Coleman.... "everyone wants to be a bodybuilder, but nobody wants to lift the heavy ass weights".
Want a seat at the table as a member of an advanced healthcare team? Cool. Put in the work. We'll save you a seat for if/when you make it.

In the spirit of election day today ... good thing Biden admin specifically earmarked millions for expanding ARNP education and "residencies."

More like... in the spirit of your being a partisan hack imho. Stop it lol.

 

[Sushirolls]

More like... in the spirit of your being a partisan hack imho. Stop it lol.

The "LOL" doesn't absolve you of the direct attack on another poster. Yet again, as I often have to do on SDN remind people to attack the points not the person.

 

[ridethecliche]

The "LOL" doesn't absolve you of the direct attack on another poster. Yet again, as I often have to do on SDN remind people to attack the points not the person.

It was actually 'lol' not 'LOL'.

But similarly, the 'in the spirit of election day' doesn't absolve you of something you've become known for... You legitimately deflected when called out for it. So like... stop it 'lol'.

If you'd like me to rephrase... your point was hackishly partisan... is that better?

I have no issue with you. Your 'starting a private practice' thread is something I've directed people to multiple times. I just don't log into SDN to talk politics. That's all.

 

[Sushirolls]

SDN is skewed heavy in left leaning politics. Academic medicine and the process to get through medical training is heaped in mountains of left leaning ideology crammed down trainees throats at every turn. I'm helping to add a counter point here and there.

You are uncomfortable by just a single poster. Imagine the plight of the conservative posters who read a majority of opposing politics in far greater frequency every day, and most every venue in medicine?

Medicine in the eyes of the public is fast crumbling as an institution of ill repute. The stronger ties to left leaning progressive politics isn't helping. There are bigger consequences to medicine as whole, with silencing, distancing from conservative views - then a single poster being uncomfortable.

 

[Cath Up]

SDN is skewed heavy in left leaning politics. Academic medicine and the process to get through medical training is heaped in mountains of left leaning ideology crammed down trainees throats at every turn. I'm helping to add a counter point here and there.

You are uncomfortable by just a single poster. Imagine the plight of the conservative posters who read a majority of opposing politics in far greater frequency every day, and most every venue in medicine?

Medicine in the eyes of the public is fast crumbling as an institution of ill repute. The stronger ties to left leaning progressive politics isn't helping. There are bigger consequences to medicine as whole, with silencing, distancing from conservative views - then a single poster being uncomfortable.

Some of this distancing may be attributable to the rejection of expertise and devaluation of training coming from the right which is extremely problematic. It is not one sided. If half the electorate believes vaccines cause more harm than good, they should be spurned.

 

[Just D.O. it]

rejection of expertise and devaluation of training coming from the right which is extremely problematic.

I think you’re oversimplifying this. At least part of said devaluation is a result of academia openly getting into bed with far left identity politics. Time and time again legitimate experts on hard science topics are deplatformed and discredited by their institutions because they made a non-Politically correct twitter post. Conferences seem to mandatorily have at least one speaker dedicated to the racial/gender breakdown of the field and why somehow the only reason for this could be internalized or well hidden externalized racism/sexism among current members of the field. Speaking out against that or hell even not being enthusiastic about it can get you softbanned by the movers and shakers. When less educated conservatives see this constantly happening why wouldn’t they “otherize” major academic institutions and the people and ideas propped up by them.

 

[Cath Up]

I think you’re oversimplifying this. At least part of said devaluation is a result of academia openly getting into bed with far left identity politics. Time and time again legitimate experts on hard science topics are deplatformed and discredited by their institutions because they made a non-Politically correct twitter post. Conferences seem to mandatorily have at least one speaker dedicated to the racial/gender breakdown of the field and why somehow the only reason for this could be internalized or well hidden externalized racism/sexism among current members of the field. Speaking out against that or hell even not being enthusiastic about it can get you softbanned by the movers and shakers. When less educated conservatives see this constantly happening why wouldn’t they “otherize” major academic institutions and the people and ideas propped up by them.

I don’t think less educated conservatives “see this happening” very much. I think they
A) hear about it from sycophants who tell them how to think about it
B) are turned off by the principle of more education having value in a way that less educational attainment does not which makes them feel ignored
C) fall in line with right wing leaders (including the Supreme Court striking down chevron deference) so that “my team” wins.

I agree academia has take some of the identity movement too far but I do not think that is what shapes a typical person’s opinions about the value of expertise.

 

[Sushirolls]

*Chevron most definitely should have been struck down. Good riddance. Continue on...

 

[ridethecliche]

SDN is skewed heavy in left leaning politics. Academic medicine and the process to get through medical training is heaped in mountains of left leaning ideology crammed down trainees throats at every turn. I'm helping to add a counter point here and there.

You are uncomfortable by just a single poster. Imagine the plight of the conservative posters who read a majority of opposing politics in far greater frequency every day, and most every venue in medicine?

Medicine in the eyes of the public is fast crumbling as an institution of ill repute. The stronger ties to left leaning progressive politics isn't helping. There are bigger consequences to medicine as whole, with silencing, distancing from conservative views - then a single poster being uncomfortable.

Academia has historically been liberal. Academic medicine often leans left because most of us do this to help people and aren't as acutely aware that our society has decided that some lives aren't really worth saving. It becomes even more complicated in academic medicine, because without the poor and uninsured, our training would be trash since they wouldn't have anything without us but realistically we'd have no training without them. I guess some of us don't love the transphobic rhetoric coming out that paints some of the serious issues our patients deal with as having the goal of preying on kids in bathrooms. So if you'd like to boil this down to some conspiracy of academia being anti conservative, then sure go for it. But if you think that the rhetoric that's being shown on evening news networks and broadcast ad nauseam doesn't have consequences then um... there's more to this than just economics.

I'm really worried about the patient population I work with and with children in general learning that it's okay to act the way certain people getting lots of airtime are able to act and 'get away with it' in a way that hurts others.

Narrative is a pretty powerful thing so if you want to talk about perception. I dunno man, I just feel like it's pretty american to want to criticize the group of people that want to rewrite things and claim that teaching american history is teaching critical race theory because oh you know slaves were pretty happy to be here relative to being in africa and oh you know tribal history in the US was just filled with good times. It was actually called the trail of happy tears! You know!

So dude... call out things all you wish... but don't hide behind your BS when you knowingly say something provocative and get called out for it. If you have a problem with policy, call it out. No one cares about people criticizing policy, but you choose to go out of your way to let everyone know that you picked a side and you feel like they're all treating you oh so unfairly. This place exists for us to shoot the ish and learn from each other so we can make our lives better as well as that of our patients.

I honestly had no idea what your political leaning was till the post on this thread. Or I've probably thought about it when you said something hamboned like that and then moved out and I honestly don't even remember it now and I've been on this site for just about as long as you have dude.

You're cool. It's fine. We value your input and experience and appreciate what you have to sure. Well, I sure as heck do. So just share your thoughts on how things affect others and keep the jabs to a minimum. We care what you think. We just roll our eyes when you try to reach and do whatever it is you did here bruh.

*Cue fist bump*

 

[Sushirolls]

No there is no fist bump. This isn't fist bump reciprocation worthy when in the same breath saying my points are "BS."

[I'll skip rebuttals for point by point break down of your corollaries to focus on the below]

@calvnandhobbs68 and @Merovinge and @comp1 at least in their own way tried to say, nay, it is a bipartisan issue, and not entirely one political admin or party. There was room for improvement in how 2 conveyed that message though.

The problem is this default: "we just roll our eyes when you try to reach and do whatever it is you did here bruh." The acceptance and multiple thumbs up here showing support, that this is acceptable, is the problem. This smugness, and elitism is the real problem. Once more, attack the points, not the people. Perhaps adding that as a signature would help reinforce this simple message.

Whether I were an extreme left person, espousing pure marxist ideology, or libertarian purist, these points should still be reflected upon, and then refuted if needed - but with modicum of respect, and perhaps a pinch of jab - but the emphasis on addressing the point first and foremost. I hypothesize if there were 3 or 4 Sushi's and each angled a particle political angle to their intersection of healthcare and posted - ideologies further from the left - would be most likely attacked. That's a problem; it warrants a spot light.

My own corollary, no need to respond to this topic:
Beyond psychiatry and this forum, a state I have a license in routinely sends emails about how to communicate with people in rural communities about vaccine hesitancy and offering training sessions or forums to assist. It really is laughable. Such a forum completely misses the mark of what has taken place in the past 4 years and why rural communities are even more vaccine averse - and it isn't the right solution. It is a waste of time for any 'provider' participating and most likely won't yield desired results of increased vaccination. It wreaks of the same issue of smugness, and elitism. And the consequence are now we might have some one like RFK contribute to the topic of vaccines. Failing to take peoples political views seriously - no matter how distant from one's own core beliefs - leads to bad things.

Second corollary, loosely related to the OP, no need to respond to this point either:
ARNPs filled a role. We physicians originally created, signed off and supported the ground zero moment. We pushed forward the wrong solution to a problem. We didn't consider that keeping intern GPs was valuable, or allowing them to cross pollinate jobs like what an ARNP does. We built the better mouse trap, with pushing for more residency years, more board certified specialties, the creation of FM to stamp out GPs, and have a lot of blame for the ARNP issue. Or perhaps give special exception to RNs and allow them to apply/enter medical school without a bachelors, and without the usual pre-reqs. We failed to take seriously different solutions to the problem that ARNPs originally infilled.

 

[Bartelby]

...It wreaks of the same issue of smugness, and elitism. And the consequence are now we might have some one like RFK contribute to the topic of vaccines. Failing to take peoples political views seriously - no matter how distant from one's own core beliefs - leads to bad things.

This point made me curious. Trump is considering appointing RFK to lead HHS, or at least to "go wild" on health. I have watched a clip of RFK himself talking about how he came across a mother with a young child and after talking with her for a couple minutes she chose not to vaccinate her child (he clearly tells this as if it is a story to be proud of). As you mention, having him gain tremendous influence over vaccine policy in the U.S. seems to be a bad thing.

How is RFK quite possibly getting appointed to head up Health and Human Services the fault of liberals being smug or not taking peoples' views seriously? It seems more like a consequence of electing Trump.

 

[Sushirolls]

In order to answer that question, one would have to wade into the management of covid, which SDN made clear in their policies and moderator actions, as have numerous state medical boards, it is our way or there are consequences. And that is part of the problem, state medical boards, public health and various med societies clearly said step in line - agree with us - and any other view points are wrong. We will take your license.

As long as these organizations are pushing draconian enforcement and leaving no room for discourse, or even post hoc analysis that maybe things were handled really, really wrong; and that there could have been a different handling means a very large swath of the country is aggrieved. Door ways open for RFK...

Conceptually people need to realize that covid era policies are similar to the Tuskegee experiments. An involuntary population that was experimented on without their consent. But this experiment was more than just an infectious agent, and it's disease course; it includes social, political, religious, parental, economics, etc variables. If you look at the previous 4 years from that lens, that viewpoint, you'll have a better grasp of how a massive chunk of the US population is simply pissed. Door ways open for RFK...

But as you question, how is this related to liberals being smug or not taking other's views seriously - it is the defining hallmark - the inability to think otherwise, that on one hand saying we are science. You don't know what you are talking about. Trust the science. Then on the other hand have data that clearly shows social distancing of 6ft was complete garbage but yet still pushing it - and not having the academic integrity to pivot quickly and say "we are sorry" 6ft social distancing is completely wrong. This disconnect - people notice and that leads to mistrust.

A similar topic, that illustrates mistrust. Your kids come home from public school, and now they have climate anxiety, or talking about colonizers and oppressors in their lexicon. Whiskey Tango Foxtrot. Parents don't send their kids to school to be the next privates in the Social Justice Warrior army. And when their voices aren't heard to their calls to knock it off, dial back the extreme rhetoric and keep things in the center - people get pissed. They over react because they met the smugness, and elitism that for you to disagree with our school curriculum you are a racist, fascist, etc and now we have rising numbers of home schooling. And secondly, rising numbers of movements to shift tax funds to private entities or home schooling - away from public schools. I.e. metaphorically they want to "burn down" the public schools that aren't teaching but indoctrinating. Door ways open for RFK...

Simply put - dems/liberals should have won the election. Hands down - but as long as elitism, and smugness persists where liberals can't even discuss the basics of addressing people's points directly - without attacking them verbally - and trying to at least go thru the exercise of donning the glasses of others - they will continue to have a pissed off population.

In some ways I shouldn't be trying to point out the conservative value with medicine in this forum, the basics of arguing people's points, because it will continue to provide political life to Trump et al and other conservative goals within the country.

Should dems/libs/left drop the elitism and smugness - they would be an unstoppable political juggernaut.

 

[Bartelby]

Fair enough, I actually agree with some of those points. I think the divided political landscape we have in the US lends itself really well to inflexible and unproductive policies on both sides. During the pandemic I think the right's vaccine skepticism and push back against basic steps likely to decrease mortality during a time-limited public health emergency were a real problem. At the same time, the left took restrictions too far. For example, keeping in-person school closed for as long as it was in many blue areas was a big mistake. And while I think mandatory masking during the most acute waves was reasonable, policies extended beyond reasonable limits. That includes at least some blue state areas still requiring masking in all healthcare facilities during the flu season to this day, which I think is absurd overreach.

Still, if you are worried about RFK having a great deal of influence over health policy it should make you very nervous that Trump has shortlisted him to head up HHS. If he does wreak havoc these next four years we should all remember who, at the end of the day, formally handed him that power.

 

[ridethecliche]

I actually agree that medical boards shouldn't exist as this undemocratic close door draconian force as their decisions have real consequences. In our work, this shows up very often when folks are scared to get mental health/substance use treatment because they're terrified that they're going to be forced into a board mandated treatment program which ruin lives.

I also truly wonder if you can actually call it elitism now when the issue isn't whining about people not having a college education and being stupid, but about being so drastically misled about basic principles of science that there's disagreement on established fact. Disinformation and misinformation are powerful things and it is scary when a political party makes it a part of their campaign and promises. It's hard to have any sort of educated political discourse in a nation that is divided on facts. That's the scary part. Our political parties have always argued over the interpretation of facts and of systemic ideas but this is far from that. Is it elitist to point out that it's ridiculous to support someone running on a platform that states that an election was stolen and that there's a deep state conspiracy? It's shocking how the stolen election posts started to vanish with closing polls.

Calling what happened during COVID vaccination analogous to Tuskegee is disgusting and shows moral relativism that is divorced from any understanding of American History. Come on... Also, I did not call your points 'BS'. I said you were hiding behind BS which was a reference to your BS 'in the spirit of the election' comment. I'm happy to have conversations about ideas and policy, but you seemingly couldn't help yourself from making political statements. Do you honestly see yourself as a victim here Sushi?

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On the topic of the thread, the oldheads found a good way to make a quick buck and got lazy and wanted to keep making money so ceding power to APRN's was the easy thing to do. Nurses have always been better at organizing than physicians and have taken over social media in doing so. Healthcare changing to a service industry isn't helping things along as the 'customer' isn't always right... they are more often than not wrong, no matter what tiktok diagnosed them with.

 

[ridethecliche]

Just wanted to add something i've been thinking about since hearing it in a didactic lecture recently. The speaker basically shared that in her work with college students, she found that the idea of shared experience was pretty limited. I.e. with access to so much media and such, there's almost no overlap about things like TV shows that different groups of people can watch and talk about together.

This struck me a bit in terms of how social media and tech has brought so much information so much closer, but has also worked really well to create divergence.