What Can We Do? The Scope of APP Practice Patterns

Certified nurse practitioner at the Cleveland Clinic in Cleveland, Ohio

As I opened the door to the exam room one sunny morning in Cleveland, Ohio, a patient stood to greet me.

“Congratulations, you’re finally a doctor!” The patient and his wife were beaming with joy.

I had just completed my PhD in nursing science and clinical research, and, I must admit, I was thrilled to have accomplished the goal and was pleased that they were so happy for me.

“Can I call you ‘Dr. Faiman’?” the patient asked me the very minute I walked into the room as he extended his hand to shake mine – which was full of hand sanitizer. He and his wife knew me even before I embarked on the six-year journey to obtain my doctorate. Ten years ago, I had diagnosed him with multiple myeloma and I would see him (usually with his wife) every month for routine follow-up. He would ask me how I was juggling family, work, and school responsibilities.

“I guess you can call me ‘doctor,’” I replied, as we sat in our respective chairs, “but please continue to call me ‘Beth,’ if you prefer.”

I saw the wheels turning in his head as he planned his response. “I hope you don’t take this the wrong way,” he said, with a contemplative look on his face, “and I mean no disrespect to my other [medical oncologist] doctor, but do I have to see the other doctor anymore, or can I just see you now?”

I have heard this question many times over the last few years. Because we perform similar functions as an MD or DO, patients are often unclear as to the role of the advanced practice provider (APP). In 2015, does a well-trained nurse practitioner, especially one with a PhD, supersede the need for a medical oncologist? Legally, can an APP function in the MD/DO role?

I thought carefully for a moment and then asked him a question: “Why would you think you don’t need to see a medical doctor anymore?”

“Well, you’ve been my nurse practitioner for 10 years now,” he replied. “You schedule my appointments, prescribe my medications, and check my labs. I barely ever see the other doctor and I don’t feel like I need to. He can take care of the ‘sick’ patients. You do everything for me and I trust you. I would like you to be my doctor since you are now an official ‘doctor.’”

Now, my state allows NPs to practice somewhat independently. I work at a large hospital that supports APP independence, while also emphasizing a team approach to care. Given the complexity of hematologic cancers, I think the team approach is necessary. Are there any states that allow an APRN or PhD to independently manage hematologic cancers without “official doctor” supervision?

In the debut Advanced Practice Perspectives column, I reviewed the history and roles of various advanced practice registered nursing (APRN) and physician assistant (PA) groups.

After more than 40 years since the APP role – a combination of APRN and PA roles – was born, confusion about just what we can do remains. APPs are highly trained individuals who play an integral role in the diagnosis and management of hematologic conditions, but their scope of practice differs greatly from state to state.

Let’s review some key points about APP practice and levels of autonomy.

Who Determines Practice Laws for the APP?
Advanced practice providers include APRNs (nurse practitioners, clinical nurse specialists, and certified nurse midwifes) and PAs. The extent of physician oversight or involvement for APRN and PA services varies greatly from state to state, which leads to confusion about what job functions the APP can or cannot perform. Although APRNs and PAs perform similar job functions, there are two different regulatory bodies at the state level.

The Scope of Practice for APRNs
Nurse practice laws in each state are regulated by the state boards of nursing. According to the American Academy of Nurse Practitioners, there are three levels of oversight and autonomy of practice: full-practice, reduced practice, and restricted practice.

  • There are currently 21 “full-practice” states, including Washington, DC. These states allow APRNs to diagnose, prescribe, and essentially run their own independent practices.
  • Another 19 states have a relational agreement, where a “collaborating physician” is required for APRN providers. These “reduced-practice” states mandate that the APRN have a documented formal relationship with a physician and that this relationship be renewed annually, although institutions can delineate the extent of physician involvement.
  • Seven states are restrictive in practice authority, requiring the APRN to have more direct physician oversight in patient care.
  • The remaining three states – Nebraska, New York, and Connecticut – are currently in various stages of allowing APRNs the autonomy to practice without physician supervision.

Because of the heterogeneity of each state, it is best to refer to the American Association of Nurse Practitioner’s State Regulatory Map to learn more about state-specific regulations.

The Scope of Practice for PAs
Similar to APRN practice, state laws and regulations also guide PA practice. According to the American Academy of Physician Assistants, all states require PAs to practice under a physician’s supervision, but as with APRNs, the extent of the relationship varies from state to state (FIGURE 2). Six key elements are mandated to be part of every state PA practice act:

  • Licensure: How does a state authorize PAs to practice?
  • Scope of practice determined at the practice site: State laws determine the extent of the PA’s autonomy or need for supervision.
  • Adaptable supervision requirements: PAs, similar to most APRNs, must have a supervising physician available. Some states require on-site supervision, while others allow telecommunication in certain circumstances.
  • Full prescriptive authority: All PAs are required to complete extensive training in pharmacology, but some states allow physicians to delegate prescriptive authority (for example, PAs may even prescribe chemotherapy and controlled substances in some cases).
  • Chart co-signature requirements determined at the practice level: Some physician-PA teams use co-signature to ensure that the supervising physician is providing oversight, but this may or may not be required depending on the practice site.
  • Number of PAs a physician may supervise determined at the practice level: The supervising physician may decide the appropriate number of PAs to supervise, depending on the specialty and clinical setting.

Visit the AAPA’s website to learn more about the six key elements of PA practice and specifics of your state.

So, What Can We Do?
As you can see, the complexities of what an APRN can do vary greatly from state to state, and by institution. Astute APPs and physicians will learn the state- and institution-specific regulations and work together to the full extent of the law.

So, when my patient asked me if I, as an APRN and PhD, could replace his medical oncologist as an “official doctor,” there were many factors to take into consideration. I had to respond: “I appreciate your confidence and the trust you have in me as your provider. And, frankly, I am honored that you want me to be in charge of your care. However, although I have been well-trained as a hematology/oncology practitioner, I do not have a medical doctorate but a research doctorate. I am not a medical doctor. We – the treatment team – all play an important role in your care. Your medical oncologist, the other team members, and I will continue to work together as we have all these years, to provide you with the best care we can.”

“That sounds good,” he replied. “I’m just glad you aren’t leaving the hospital.”


References

  1. American Association of Nurse Practitioners. “State Practice Environment.” Accessed from ww.aanp.org/legislation-regulation/state-legislation-regulation/state-practiceenvironment.
  2. American Academy of Physician Assistants. “Six Key Elements.” Accessed from www.aapa.org/threecolumnlanding.aspx?id=303.

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