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Editor’s Comments
Collaboration Needed in Team-Based Care Are doctors safe? Depends on who you ask. Are physicians still necessary, important? Depends on who you are. If it sounds like I’m a little unsettled, I am. Why? Well, something happened in healthcare recently, and based on your point of view, it was either good, bad, or neither: Senate Bill 717 moved out of committee. Originally cosponsored by State Sen. Pat Vance, the proposed legislation would grant independent practice authority to Certified Registered Nurse Practitioners (CRNPs), as well as “strongly encourage” hospitals to “consider” making them full voting members of their medical staffs, a decision that under current law remains the purview of each individual institution. Last year, I wrote an article challenging the claims of the Pennsylvania Coalition of Nurse Practitioners that CRNPs were equivalent to physicians and that fragmenting the healthcare team by removing the requirement for collaborative agreements would improve patient safety, access, outcomes and satisfaction. The committee disagreed, and by the time this article comes to press, the bill will likely have moved to the Senate floor for a full vote. (Update: On July 12, the Senate passed Senate Bill 717 – legislation which would allow CRNPs to practice independently and eliminate the requirement that they collaborate with physicians – by a vote of 41-9. The bill now goes to the House of Representatives for consideration, where it has been referred to the Professional Licensure Committee.)
Don’t Take it Personally: Hard Not To
So why am I bringing this back up? Two reasons—one, to demonstrate the potential consequences to physicians should this legislation pass, and two...well, you’ll just have to keep reading. Full disclosure: on May 31 of this year, after a half-decade as a hospitalist at a long-term acute-care facility in southeastern Pennsylvania, the administration made a decision to move away from an on-site physician model to one primarily featuring
community-based physicians, all of whom have their own outpatient practices and can only dedicate a limited number of hours per day to in-house coverage of the hospital’s medicallycomplex, chronically-critically ill patients. Their solution? A critical care nurse practitioner, who will take the place of a board-certified physician. Why was this done? The answer, of course, is obvious — money. And if Senate Bill 717 becomes law, it will only get worse for physicians, especially those in primary care. From urgent-care clinics to hospitals, physicians may very well find themselves displaced. Undoubtedly, some of you will read this and think “Hmm, this sounds personal” and you would be right. It’s disconcerting when a hospital CEO posts a memo stating that moving from dedicated in-house physicians to nurse practitioners will improve coverage, safety, quality, and outcomes. But there’s a bigger issue here, and that is “what will happen to the patients?” Technically, it’s now outside my purview, but I can’t help but worry. Now, I know what you might be thinking: “Nonsense! We’ll always need doctors. You’re being paranoid.” One would hope, but maybe not. Despite the urging of the Pennsylvania Medical Society (PAMED), the Hospital Association of Pennsylvania (HAP) came out in support of SB 717. Money? Yes, but perhaps something more. As I previously stated, a provision in the bill would allow hospitals to admit CRNPs to their medical staffs, a decision which may seem harmless on its face until you consider the fact that traditionally, while nurses are ubiquitous in administrative positions, they usually don’t serve in medical staff leadership. Given that akin to the trend amongst physicians, CRNPs in hospital settings are also likely to be employed, this gives hospitals the opportunity to further diminish the power and influence of doctors, the leaders of the healthcare team. And the PA Coalition of Nurse Practitioners is fully on board.
Is This Debate Now PC? So where does that leave us? Right now, the zeitgeist in America is one of disruption, of feeling unsettled, of willingness to embrace radical change—sometimes without thinking through the consequences of what that change will bring. As a general rule, the word ‘disruption’ conjures up feelings of uncertainty, even chaos. The opposite of stability, it
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