Patti loved bowling night, and that was before she knew bowling helped save her life.
Patti (a pseudonym to guard the patient’s privacy) was a patient of Martha Gray, MD, an Ann Arbor-based independent primary care physician. One day, Patti called Doctor Gray’s office to complain.
“Patti told me, ‘I still have this earache and the treatment the nurse gave me just isn’t working,’” Doctor Gray remembers. “So I began asking more questions. Patti said every time she went bowling she would get an earache. It was only when she bowled, but it was troubling. She called my office earlier and spoke to one of the nurses, but the treatment my nurse recommended just wasn’t working.”
As Doctor Gray would later explain, she knew Patti didn’t have what would be typically known as an earache. “Adults don’t get earaches,” she said.
When Patti would go bowling, the lifting and the rolling of the heavy ball was creating pressure in her ears and neck. Doctor Gray, a 40-year physician and leader within the Washtenaw County Medical Society, knew that what felt like an earache to Patti was the onset of angina, a condition marked by severe pain in the chest, often also spreading to the shoulders, arms, and neck, caused by an inadequate blood supply to the heart.
“I didn’t look in her ears,” Doctor Gray recounts. “I ordered an EKG.”
The EKG showed blockage in Patti’s coronary artery, and Patti was taken to the emergency room for treatment.
Doctor Gray has other stories, too. Stories of patients misdiagnosed by well-meaning and caring nurses whose training and experience hadn’t prepared them for the situation or condition presented.
“Nurses are critically important to the delivery of health care,” Doctor Gray says. “They have been a vital part of my practice and the treatment and care of our patients. But doctors and nurses are different. We have different training, different experiences, different roles and different responsibilities.”
Unsupervised Practice for Nurse Practitioners
“Independent practice” is a nurse practitioner’s (NP) ability to provide treatment without required supervision from a physician. A NP who works in a state that has granted unsupervised practice—and, so far, Michigan is not one of these states—can assess, diagnose, interpret images and treat a patient, as well as prescribe medication, in the same way physicians do.
For many years, the Michigan Legislature has, like its peers in many other U.S. states, wrestled with issues related to the safe practice of medicine and the appropriate scope of practice for non-physicians working in the health care field.
Just last year, the Legislature endured a contentious and deeply controversial debate over legislation to allow nurse anesthetists to administer anesthesia without the supervision of a physician. Long a priority for nurse anesthetists in Michigan, lawmakers in 2021 took up and passed a compromise version of House Bill 4359 after months of tense negotiations and advocacy by the physician community in opposition to the bill as originally introduced.
“Scope of practice debates are not new,” says Kate Dorsey, manager of state and federal government relations for the Michigan State Medical Society (MSMS). “Our experience with HB 4359 is an important reminder that our job as advocates for patients and good public policy never ends, and that while the legislation did ultimately pass, it was the relentless involvement of the physician community that brought needed changes to the final bill.”
And that involvement from physicians remains critically important.
On October 6, 2021—just three months after Governor Gretchen Whitmer signed HB 4359— Senator Rick Outman (R-Six Lakes) introduced controversial legislation continuing the push for scope of practice expansion in Michigan. Senate Bill 680 would allow for full unsupervised practice for NPs, including prescribing authority of opioids and other medications. The bill was referred to the Senate Committee on Health Policy and Human Services where it has yet to receive a public hearing.
“By allowing increased scope expansions, lawmakers are allowing for-profit entities to shape our health care system – regardless of what patients want – while also reducing patient choice in who provides their care,” says Rose Ramirez, MD, a Grand Rapids family physician and past president of the Michigan State Medical Society. “Patient-centered, physician-led care is the best way to increase health care access without compromising patient safety or quality of care, and that is why limiting legislation like this is the top priority for MSMS.”
Michigan for Advancing Collaborative Care Teams
Coming off the contentious legislative fight over physician supervision of anesthesia care and looking ahead to the anticipated introduction of legislation allowing for the unsupervised practice for NPs, physician and staff leaders of the MSMS knew more work was needed to communicate to the public and to lawmakers about the negative health implications resulting from scope of practice expansions.
MSMS was not alone, however, in understanding this need. Dozens of organizations representing a diversity of health care providers saw the real threat to care posed by these public policy proposals, and these organizations came together to advocate for their patients.
Under the leadership of MSMS, and at the same time Senate Bill 680 was being introduced in the Michigan Senate, Michigan for Advancing Collaborative Care Teams, or MiACCT, was formed. MiACCT is a coalition of health care providers united and committed to growing, strengthening, and preserving the physician-led health care team patients rely on for care.
“Physicians spend over a decade of their lives pursuing intense training in order to acquire the necessary knowledge and skills to treat patients. Physician-led healthcare results in effective, safe medical care at lower cost to the patient, as it has been shown to decrease unnecessary medical visits, lab work and radiology examinations.” says Leah Davis, DO, a radiologist from Traverse City. “All of these groups came together as part of the MiACTT coalition to educate patients and advocate for public policies that protect this proven health care model.”
Since its formation in the fall of 2021, more than 30 health provider organizations have joined MiACCT, including the American College of Physicians, American College of Surgeons – Michigan Chapter, Michigan Academy of Family Physicians, Michigan Psychiatric Society, Michigan Radiological Society, Susan G. Komen, and ten Michigan county medical societies.
In recent months, representatives from these groups have been meeting with lawmakers to answer questions, address claims made by proponents of SB 680 and share information about differences in training and education between physicians and NPs.
“Coalitions like MiACTT are critically important as we work to inform both lawmakers and the public,” Dorsey says. “Given the recent landscape on issues like this, we need a robust response from a diverse and broad coalition to show lawmakers why scope issues are such a problem. MiACTT is helping to fill that role.”
Rhetoric v. Research
As MiACTT, its member organizations, and MSMS staff are meeting with public officials on issues related to scope of practice and Senate Bill 680, a common theme has emerged. According to Dorsey, advocates for the unsupervised practice of NPs point to a shortage of medical professionals in Michigan and a lack of access to care for patients, especially in more rural part of the state.
“Proponents of scope expansion always point to addressing a lack of access to care,” Dorsey says. “But the research just doesn’t support the rhetoric.”
2020 data from the American Medical Association compared access to care in states that allow full unsupervised practice for NPs against those states that do not. The census of practicing physicians and NPs in each state shows that NPs did not choose to locate and practice in rural and underserved areas once unsupervised practice was permitted.
In fact, research showed the opposite to be true. Not surprisingly, both primary care physicians and NPs practice medicine in and around population centers. Comparing states like Oregon and Minnesota, which permit unsupervised practice, to Michigan, which does not, demonstrates no significant difference in the decisions of NPs to locate and see patients in areas of the state where access to care is a challenge.
“Access to care is a legitimate public policy concern,” Doctor Gray says. “States that have permitted unsupervised practice, however, have shown that it doesn’t actually address the concern.”
In addition to state data on access, recent studies have shown that extending unsupervised practice has led to a lessening in the quality of care, risks to patient safety, and an increase in health care costs.
For example, a 2020 study in the Journal of General Internal Medicine conducted a retrospective cross-sectional analysis to determine the opioid-prescribing patterns of physicians, NPs and physician assistants (PAs) who worked in primary care and prescribed at least 50 prescriptions.
Based on the analysis, the study found 6.3 percent of NPs and 8.4 percent of PAs prescribed opioids to more than 50 percent of their patients compared to just 1.3 percent of physicians.
They also found NPs and PAs in states with unsupervised prescription authority for schedule II opioids were 20 times more likely to overprescribe opioids than NPs and PAs in states with restricted prescription authority. Notably, the study also found from 2013 to 2017, when almost every medical specialty decreased opioid prescribing, NPs and PAs significantly increased opioid prescribing.
Public opinion research also points to the clear preferences of patients to maintain a physician’s role in their care. In fact, polling by the American Medical Association showed that 95 percent of voters in the United States believe that physicians “should be involved in medical diagnosis and treatment.”
Polling in Michigan shows the same. A survey conducted in 2021 by the non-partisan polling firm, EPIC MRA, asked Michigan voters “if nurse practitioners were able to have the full practice authority proposed, and if you, other family members or loved ones needed health care services, would you prefer to have it provided by a physician or a nurse practitioner?”
Sixty-two percent of people polled answered that they would prefer a physician, 13 percent said they would prefer a NP.
Patient-centered, Physician-led Care
When a person watches as a loved one heads into a serious medical procedure, his or her thoughts aren’t primarily on how the operation will be conducted, but when that loved one will be home again—safe, healthy, and healing.
“That’s human nature,” Doctor Ramirez says. “That’s at the core of patient care—fixing serious problems, healing people, and returning loved ones to their homes and families.”
According to Doctor Ramirez, patient- centered, physician-led care is the best care and state policy should protect it.
“And right now, that proven, tested, and trusted model of physician-led care that patients rely on and expect is at risk of being undermined by bad public policy if physicians don’t get involved and speak out,” she says.
Dorsey puts an even finer point on it. “This is priority number one for MSMS.”
She encourages physicians to get involved, contribute to the Medical Doctors’ Political Action Committee and utilize the MSMS Action Center to contact their lawmakers about the issue of expanded scope of practice.
“In our conversations with lawmakers, we are finding them to be open to conversation and hearing our concerns,” Dorsey says. “They look at the difference in training, in education, and in experience. They see the real potential for problems with the expansion of prescribing authority, especially when it comes to opioids, and they get it. But we have to keep at it.”
24/7
The phone rang in the middle of the night, and of course Doctor Gray answered it.
“We are all on call for our patients 24/7,” Doctor Gray says. “If you’re my patient and you call me in the middle of the night, I’ll answer.”
This time it was the patient from earlier in the day who had visited with a nurse complaining of a sore back. Now, the patient couldn’t sleep.
The pain had spread to under her right rib and shoulder.
Doctor Gray asked her a few more questions and then told her to make a middle of the night trip to the emergency room.
“You have acute appendicitis, and it has likely ruptured,” Doctor Gray recalls. “You have to go to the ER now.”
An hour later, the attending emergency room physician called Doctor Gray to share that her patient’s appendix had in fact ruptured, that she was heading into surgery and would be all right.
“Nurses are a vital partner in caring for and treating patients, and I have relied on them for decades in my practice,” Doctor Gray says. “My education and training as a physician have prepared me for my leadership role on each patient’s health care team, just as nurses rely on the education and training they have received.”
“It is important to recognize that these experiences are different and that these experiences depend on each other for the benefit of patients,” Doctor Gray continues. “Public policy in Michigan should acknowledge, respect, and protect Michigan’s patient-centered, physician-led health care model. It’s what patients want and what patients deserve.”
