Multi-organizational response (AAFP, AAP, ACP, ACOG, and the AOA) to the IOM's Future of Nursing report.
January 19, 2011
Harvey V. Fineberg, MD, PhD
Institute of Medicine
Risa Lavizzo-Mourey, MD, MBA
President and CEO
Robert Wood Johnson Foundation
Susan B. Hassmiller, PhD, RN, FAAN
Senior Advisor for Nursing and Director of RWJF Initiative on the Future of Nursing
The recently released Institute of Medicine Report on the Future of Nursing: Leading Change, Advancing Health calls for new and expanded roles for nurses in a redesigned health care system. The undersigned physician organizations compliment the IOM and the Robert Wood Johnson Foundation on the breadth of the report; we are in general agreement with its vision for a transformed health care system. However, we are concerned that some of the important recommendations of the report may be subject to misinterpretation.
We concur with the recommendations relating to improving educational opportunities for all nurses. We also share the IOM committees concerns about the inadequacy of the nations workforce of health professionals to meet the increasing demand for primary care, particularly in light of future needs and expanded health insurance coverage for millions of Americans as a result of the Affordable Care Act. We recognize that nurses, including Advanced Practice Registered Nurses (APRNs) certified registered nurse anesthetists, certified nurse-midwives, clinical nurse specialists, and certified nurse practitioners are already important providers of health care and will continue to be critically important along with physicians, physician assistants, and other health professionals in meeting the health care needs of the U.S. population.
However, we believe there needs to be clarification and further interpretation of the recommendation that scope of practice barriers for APRNs be removed in all states. We feel strongly that physicians and nurses are not interchangeable, and that optimal care for patients is provided by physicians, nurses, and other health professionals working together in a team-based model of care delivery. This is well-illustrated in the delivery of primary care services. Primary care includes a wide variety of clinical responsibilities preventive (wellness) care; diagnosis and management of straightforward, acute illnesses; diagnosis of undifferentiated presentations that are not straightforward; ongoing management of a single, chronic problem; ongoing management of a patient with complex and interacting medical problems, etc. We believe that some aspects of primary care such as the diagnosis of undifferentiated presentations that are not straightforward, and the ongoing management of patients with complex and interacting medical problems require more extensive clinical training, exposure, and experience, and are most appropriately handled by a physician with in-depth training throughout medical school and residency.
Both the effectiveness and the efficiency of patient care are best served when the scope of practice for all health professionals includes those components of primary care that correspond to, but do not exceed, the full level of their training and experience. Non-physician clinicians should be able to provide those aspects of care for which they are well-trained and that do not require the higher level of scientific background and training of a physician. Adhering to this framework means that each health care professional can focus on those aspects of care that are most appropriate for his or her level of training, background, and experience. This model is best applied in a team-based system of care, such as that provided by the patient-centered medical home, in which physicians,
nurses, and other members of the team work collaboratively and distribute different aspects of care to the professionals best suited to handle them.
At present, the term scope of practice in the first recommendation of the IOM report is being viewed as a red flag by some readers of the report, since it can be interpreted as advocating solo independent practice of nurses to replace physicians in the delivery of all components of primary care. Because of the potential for confusion, we believe it is important that the IOM clarify its intentions in this regard, emphasizing that recommendations about scope of practice of nurses relate to those areas that are consistent with their training and experience, and that the term independence should not be misinterpreted to suggest that all aspects of primary care can be provided by a nurse practitioner in the absence of a team-based system that also includes one or more physicians. Today, optimal care is best provided in a team-based setting with different health care professionals working together. Therefore, the goal should be to develop collaborative, team-based models that allow every member of the team to practice to the full level of his or her training while recognizing important differences among team members in background and skills.
In most instances, members of the IOM committee and RWJF have indicated that APRNs can provide some core primary care services with quality and outcomes similar to physicians, but in other instances, such as at the recent National Summit on the Future of Nursing and during the November 17th webinar of the National Conference of State Legislatures, remarks have been less precise. Consequently, many physicians have perceived that the IOM is saying that APRNs can provide all primary care. We are concerned that some nursing advocates will assert that this is the case, citing the IOM report as support for this position. Wording is very important, and the IOM should clarify its recommendations in this regard.
We are also concerned that the impression is being given that solely educating more nurses will solve the nations health workforce needs. The increasing demand for primary care will require more primary care physicians, more nurses (including APRNs), and more physician assistants. A shortage of primary care physicians already exists, and as noted in the IOM report, a critical shortage of bedside practicing nurses also exists. By 2020 our nation will face a more serious shortage of both primary care and some specialist physicians to care for an aging and growing population. According to the AAMCs Center for Workforce Studies, there will be 45,000 too few primary care physicians in the next decade. Another study estimates the shortfall of generalists for adult primary care will be 35,00044,000 by 2025, and even with greatly increased production of APRNs and PAs, the nation will be unable to meet the demand for primary care. The pediatric patient population also faces a provider shortfall. A number of areas across the country currently are underserved by primary care pediatricians, and some regions lack pediatric medical subspecialists and/or pediatric surgical specialists entirely.
In conclusion, we urge the IOM and the RWJF to:
Clarify that the education and training of physicians and advanced practice nurses are substantially different, not equivalent or interchangeable, and that although APRNs can provide some core components of primary care in the context of team-based care, the training and skills of physicians practicing in a primary care specialty are necessary to provide the full range of patients primary care needs.
Affirm that the IOMs vision is for all the professions to work collaboratively in team-based models like patient-centered medical homes. The goal should be to encourage models that use every member of the team to the full capacity of his/her training and skills, rather than promote changes that could lead to divisive relationships with more physicians, nurses, and other health professionals practicing independently of one another.
Acknowledge that the evidence shows that the United States is facing a critical shortage of primary care physicians and that the training of more APRNs and other non-physicians will not by itself solve the nations primary care shortage. Rather, public policies should promote the recruitment, training, and retention of more primary care physicians, nurses, and physician assistants to meet the increased demand.
We understand the IOM Committees report is in final form, but we suggest that the requested clarifications be expressed in the ongoing public relations and implementation initiative to promote acceptance of the reports recommendations. Unfortunately, some aspects of the report allow a blurring of the distinctions in training between physicians and nurses and promotion of independent practice by nurses. This can undermine the IOMs vision of collaborative, team-based care that uses all of these professionals to the full extent of their skills and training a vision we share.
J. Fred Ralston, Jr., MD, FACP
American College of Physicians
Roland A. Goertz, MD, MBA, FAAFP
American Academy of Family Physicians
O. Marion Burton, MD
American Academy of Pediatrics
Karen J. Nichols, DO
American Osteopathic Association
Richard N. Waldman, MD, FACOG
American College of Obstetricians and Gynecologists