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Posted on Sun, Dec 2, 2012 : 8:05 a.m.

Advanced practice registered nurses could be valuable asset to Michigan health system

By Guest Column

Some aspects of U.S. Affordable Care Act may be challenging for states to implement, but there is one very easy step Michigan legislators can take right now to improve health care access and delivery in our state. This action will minimize the impact of a growing physician shortage, especially with primary care and in underserved areas. It will catch Michigan up to 18 other states and the District of Columbia that already have enabled an important group of health professionals to practice to the full extent of their training.

What Michigan needs to do is pass Senate Bill 481, now pending, which will authorize advanced practice registered nurses (APRNs), such as nurse practitioners, to continue doing the work they now do — but to do it under their own licenses and accountability.


University of Michigan Health System file photo

Currently, APRNs in Michigan are required to have a signed agreement with a physician who oversees their practice. While on the surface this may appear innocuous, this policy geographically ties physicians and APRNs together, contributing to geographic mal-distribution of providers - leaving rural and other areas of the state without the primary care providers they need.

The current policy also essentially ties APRNs to a consulting relationship with a physician who may not know the patients as well as the APRNs do themselves. Moreover, many studies have demonstrated that APRNs’ practice is safe and high quality, and that this type of oversight is not necessary; instead, it produces costly redundancy.

APRN education at the University of Michigan and elsewhere is extensive and carefully regulated through national standards for curriculum and certification examinations. In practice, APRNs must prove their proficiency through national boards, similar to how most medical specialties are regulated.

When the Affordable Care Act becomes fully enacted in 2014, nearly 900,000 more Michigan citizens will be eligible for insurance exchanges or Medicaid expansion. In order to extend good care to them, health services will need to expand. But recent reports indicate Michigan already is facing a physician shortage much larger than the national average, even before the nearly a million more citizens become newly qualified for insurance.

Our state’s health professional crisis likely will worsen in another way if legislators don’t act quickly. Highly employable APRNs tiring of Michigan’s stalling out on making good regulatory sense already are leaving and going to states where regulation is in alignment with national standards.

All providers, MDs and APRNs alike, must be able to deliver care to the full capacity of their education, training, and national certifications in order to support the needs of the public. A 2010 Institute of Medicine report describes laws limiting the practice of APRNs as barriers to providing the optimal health care, and it finds nurse practitioners and other APRNs highly competent in providing primary care.

So why does Michigan law prevent the professionals who could best mitigate the state’s health care shortage from doing so? Why does it continue to prohibit APRNs from using the full extent of their education to treat patients?

I encourage you to join me and many medical professionals in calling for a stop to politicking and pressure tactics from powerful interest groups. It’s time to do what’s right for the citizens of Michigan.

Kathleen Potempa is the dean of the University of Michigan School of Nursing.


UM Doc

Tue, Dec 4, 2012 : 12:19 a.m.

First, I think at this point, we can all agree that the training between physicians and NPs are simply not comparable. Beyond the differences in the sheer quantity of training, more important is the fact that NPs spend this time learning nursing, not medicine. Second, the question of whether all of this extra training that physicians receive is necessary for a primary care provider is critical. The answer that the nursing lobby proposes is "no": that an NP education is sufficient for most primary care visits. They claim that studies show equivalent outcomes between care rendered by physicians versus that rendered by NPs. This is simply false. All of the care delivered by NPs in these studies have been provided under the supervision of a physician. No trials have compared the health outcomes of patients treated solely by an NP versus patients treated only by physicians. To use a mathematical argument, where (a) = physician and (b) = NP, most studies would support this: a + b > a The biggest falsehood that the nursing lobby promotes is that based on the above finding, that a = b.

E Claire

Tue, Dec 4, 2012 : 4:38 p.m.

You note "supervision of a physician". You do understand that this means a physician's name is attached to the office, not that the physician is actually sitting in that office reviewing everything the NP does before its done, right? I think the biggest issue is that most drs get such a big head, they can't believe anyone can do even the simplest of tasks that they, the drs, would normally preform. You are not God.

E Claire

Mon, Dec 3, 2012 : 9:48 p.m.

I haven't read the bill or read through all posts but... I went to the same doctor for years. I was happy but he didn't always listen to what I was saying and I always felt rushed and a bit looked down upon). I moved here to AA and started seeing a NP (I have a not serious condition that requires twice yearly checkups). The NP actually takes the time to listen to me and really looks into what's going on. The normal arrogance of drs was not there...I no longer have to go more than once to get the person to understand that, although they have the education, its my body and I know when something is wrong. I'll never go back to using a dr and will stick with NPs.

patient advocate

Mon, Feb 4, 2013 : 2:07 a.m.

It is interesting you mention this E Claire. Many people share your feelings regarding superior outcomes with nurse practitioners as opposed to physicians. This may be in part, due to the patient centered nature of the interaction. Patients are often more involved with treatment plans when they are designed in conjunction with the patient, not dictated to the patient. This may be one reason nurse practitioner interventions are often well perceived and also very successful. As more studies, evidence, and analyses regarding the comparison of practitioners come to the forefront, more and more knowledge will become available to help people make choices regarding their medical care. The Cochrane Database of Systematic Reviews provides evidence based recommendations, based on the highest level of evidence available. In 2004 an analysis was performed comparing patient outcomes in situations where advanced practice nurses were substituted for primary care physicians. The conclusion was that there were no differences were found between doctors and nurses in health outcomes for patients, process of care, resource utilisation or cost. Nurse practitioners provide safe, high quality care. They have excellent outcomes and extremely high patient satisfaction ratings.

E Claire

Tue, Dec 4, 2012 : 4:32 p.m.

UM Doc, you prove my point. You assume to know what my condition must be by the little I wrote and you assume that "listening" means we chat about holiday plans. Total arrogance. Is your opinion based on the fact that most NPs are women? My condition requires a simple pill every day. The dosage may be adjusted according to the results of blood tests and how I feel. The dr only looked at blood tests and assumed that, if he couldn't see them, other things going on in my body were not due to incorrect dosage. Now that I go to a NP, SHE, yes SHE, looks at everything and my condition has never been managed better. And please, don't be ignorant; if I have chest pains or something similar, I know to go to the emergency room, not to my NP (or a primary care dr for that matter).


Tue, Dec 4, 2012 : 3:32 a.m.

Ann Arbor Nurse - that's absolutely not true about primary care doctors. Primary care doctors DO know how to take care of sick patients. That's a huge part of residency training and one of the big differences between an MD and an NP. Even family practitioner residencies are mostly inpatient training for their intern year, internal medicine is virtually entirely inpatient training. Specialists aren't better equipped to take care of sick patients, they just have the luxury of being able to focus all of their time on one problem and have the additional training to do so. As I said above, NPs are a fundamental part of our health care system and a great resource for many patients but the role of the MD is critical for making sure that rare or difficult to diagnose conditions that are outside of the scope of the NP training don't get missed.

Ann Arbor Nurse

Tue, Dec 4, 2012 : 2:21 a.m.

Primary care doctors also don't have to the training to handle very sick patients, so you don't have much of a point. NP's are capable of handing diabetes or hypertension as well as another primary care Dr. If the case becomes too complicated they would refer to endocrinologist for a diabetic or a cardiologist for hypertension. For basic management they are qualified. I'm not sure if any of you realize this, but medicine is constantly changing and the latest research on disease management is as easily accessed by a NP as an MD. Additionally, there are studies showing equal patient outcomes even when NPs practice independently. I really think you all are missing the point. NPs are NOT trying to be MDs, but they truly are qualified to provide excellent and safe patient care.

UM Doc

Tue, Dec 4, 2012 : 12:28 a.m.

That's unfortunate that you have had a negative experience with your physician. However, your fundamental reasons for preferring your NP over your physician, while important, have little to do with how well you are being managed medically. When you walk out the door, it may feel nicer that your NP spends more time talking to you about your holiday plans. Unfortunately, the consequences of not optimally managing your hypertension or diabetes (or any number of chronic conditions) will not be realized for years into the future.

citizen kane

Mon, Dec 3, 2012 : 10:21 p.m.

we'll see when you really are sick with something. there won't be a nurse practioner for miles that will care for you. Why? because THEY DON'T HAVE THE TRAINING!


Mon, Dec 3, 2012 : 1:53 p.m.

These nurses have no where near the training a medical doctor does, nor even a physician's assistant. This bill is scary. It opens up being denied access to a physician in busy clinics.

patient advocate

Mon, Feb 4, 2013 : 1:45 a.m.

JK, You may find this helpful:

Sonja Greenfield

Tue, Dec 4, 2012 : 2:49 p.m.

As an NP student, I've been trained both physicians and other NPs. In my current site we have a great collaborative relationship with the physician, and we actively seek them out for consultation if need be.

Ann Arbor Nurse

Tue, Dec 4, 2012 : 12:38 a.m.

They don't feel that they practice medicine in the same fashion as an MD. They practice nursing, which is a different profession, not less competent profession. APRNs should be able to practice to the full extent of their training which includes health assessment, diagnosis and treatment of certain, but not ALL illnesses. They are not wishing to practice outside of their scope, which is where the confusion lies. APRNs are a great provider for basic primary care, which one an area they are needed most. A primary care physician refers to a specialist when a complex case comes in, which is exactly what an APRN would do.

citizen kane

Mon, Dec 3, 2012 : 10:28 p.m.

Miss Ann Arbor Nurse you definitely said correct. an NP is trained by other nurses. there isn't an MD in site. PA's are trained by MD's. Since when did nurses who go to nursing school taught by other nurses suddenly wind up with the notion that they can practice medicine in the same fashion as an MD? I just don't get it.

citizen kane

Mon, Dec 3, 2012 : 10:24 p.m.

true but a physician assistant ALWAYS has a physician he/she is connected to. period. any questions or difficulties and its now a team effort to care for you. Thats a huge difference.

Ann Arbor Nurse

Mon, Dec 3, 2012 : 2:19 p.m.

I am curious as to type what of training you think physicians assistants have? As far as I know, they hold a bachelors degree in anything (similar to an MD) and graduate with tho medical knowledge or patient care experience. They then enter a 2 year program and become a PA. An advanced practice nurse has a 4 year bachelors degree in NURSING, then at LEAST 2 more years getting an advanced practice degree. That is the shortest route to becoming an APRN, which equals 6 years. Could you explain to me how a PA has more "training". Also, FYI they are trained under the medical model, which is different than nursing. I will not comment as to which type of education is better for a mid-level provider because that is a matter of opinion, but they are definitely different.


Mon, Dec 3, 2012 : 5:05 a.m.

I'm a registered nurse with a bachelor's in nursing, I've worked as a critical care and emergency nurse since 1995. And quite frankly, when I go for healthcare, I want to go to my doctor, not a nurse practitioner. I think both AnnArborite and UM Doc have made some very good points. An advanced practice nursing degree is a masters degree, two years after undergrad, and is not nearly as in depth as the 4 years of medical school plus years of residency training that doctors receive. 2 years vs 6-8 years, how can you say that the two are equal? Now don't get me wrong, some APRN's are absolutely brilliant, while some of the dumbest people I've ever met were doctors - there will always be people on the outer ends of the curve in any profession. But APRN's have only a portion of the knowledge base that MD's do. The APRN's that I've felt the most respect for and been happy to work with are those that work in partnership with their MD colleagues, while those that have made me nervous are the ones that think they're as good as a doctor and can work alone. APRN's can very well fill a void in healthcare if utilized effectively, they can be extremely useful and effective in certain roles, but they don't have the capabilities that a full doctor does. I feel that the work and role of APRN's complements that of MD's, it does not replace it. Quite frankly, and I'm comfortable saying this as a registered nurse, the nursing profession, and especially the schools of nursing, need to be careful of their own arrogance. Nursing is not the same as medicine, they're two important but completely different roles in health care. I'm going to quote UM Doc here, I think he put it very well. "NPs are not dangerous because they are not equal to physicians, they become most dangerous when they convince themselves of their equivalence to physicians."


Mon, Dec 3, 2012 : 3:31 a.m.

In agreement with citizen kane, it is ironic that the Dean feels the nursing profession is feeling 'pressure tactics from powerful interest groups.' There is no doubt that nurse lobbying groups are extremely powerful and have been quite successful in pushing forward a political agenda. The issue regarding nurse anesthetists and medicare reimbursement serve as one example. Largely, this is less about anesthesiology and more about increasing scope of practice for nursing as a whole. The issue of rural medicine is simply a tactic to further the agenda; as any policy will not be limited to rural medicine but be applied globally across all demographics and regions. Dean Potempa was recently interviewed by the NYT this fall regarding nurse programs providing PhD credentials and hence the title 'Doctor' to the individual graduating from the program-University of Michigan has a such a program. This only makes the environment more confusing. Who is a doctor? Is it important to have a "doctor" provide clinical services? Obviously Dr. Potempa believes so as she supports the program under her leadership as Dean of Nursing. But, only to make it more confusing, she argues here that a masters of nursing is what entails the 'full extent of training,' and to be quoted in the NYT article further supporting this noting "Dr. Potempa said that nurses with master's degrees were every bit as capable of treating patients as those with doctorates." So what gives? What is the "full extent of training?" This appears to be the most significant question of all. Who is best suited to deliver medical care? Even further, will nursing develop surgical programs eventually? This seems an appropriate extension of the scope of practice argument, especially as General Surgeons are becoming more sparse. Shouldn't we determine the appropriate credentials and then work to fill our ranks accordingly, rather than simply 'filling a need' because we don't number eno

citizen kane

Mon, Dec 3, 2012 : 2:15 a.m.

Hmmm, let me see "pressure tactics from powerful interest groups" you are including the nursing lobbyists, right? I am sure they explaining all the reasons including lack of medical school training needed to treat a patient? maybe they are and the congress is listening.

citizen kane

Mon, Dec 3, 2012 : 2:10 a.m.

Kathy, Aren't you referring to Physician Assistants?


Sun, Dec 2, 2012 : 11:49 p.m.

There is definitely an element of turf war; however, we need to determine what is appropriate training. Kathleen states in the first paragraph that we should "[enable] an important group of health professionals to practice to the full extent of their training." Thus, the full extent of training is that of an APN. Why, then , are we wasting crucial dollars and time overtraining physicians to perform the same function? What is the appropriate level of training? This is not an silly question. Much time, energy, stress, and financial resources are devoted while enduring MD/DO training; often upon the back of the individual. It is not as much a turf war as a level of frustration at the rules of the game being changed mid-game. As a physician, based upon this new push, I would urge 'pre-med' students to not take on more debt, and go the nursing route. It is less stressful, the debt load is a great deal less, and the country is telling us that the MD level of training is not necessary to perform a large majority of medical care. That is the message that most concerns me most; disguised as a concern for paucity of care and lack of access.


Sun, Dec 2, 2012 : 4:54 p.m.

Maybe it's true that we need more and cheaper health care deliverers given the aging and growing population and the coming Medicare cuts. However, let's not kid ourselves that that replacing doctors with nurses is going to provide the same quality of care. Nursing schools are nowhere near as selective as medical schools and nurses get nowhere near the amount of training that doctors get. I know this, having doctors, nurses and advanced practice RNs in my family. No comparison at all.

UM Doc

Sun, Dec 2, 2012 : 4:31 p.m.

One of the biggest dangers with these studies that "demonstrate" equal patient outcomes is that all of the care delivered by NPs have been supervised by physicians, with more complex cases being handled almost exclusively by physicians. Therefore, the effective comparison is physician-only care versus physician + NP care. Therefore, it should not be surprising that there are small differences in outcomes since ultimately a physician was responsible for the care being delivered. Twisting these conclusions to say that NPs deliver equal care to physicians is simply irresponsible and dangerous. Simply look at the amount of training required to produce a family physician (relatively short training compared to specialists) versus that of an NP: Physician: 4 year Bachelor's degree + 4 years Medical School + 3 years Residency Training NP: 2-4 year Associate or Bachelor's degree + 2 years of NP training Of the 11+ years spent training for a physician, roughly 20,000 hours are spent in clinical training. In the 4-6 years of training for NPs, clinical training encompasses roughly 3,000-5,000 hours. There is not even a remote resemblance of equivalence here. As independent practitioners, NPs are not dangerous because they are not equal to physicians, they become most dangerous when they convince themselves of their equivalence to physicians. The recent trend of expanding the scope of NP responsibilities is a result of the well organized nursing PAC presence in Washington rather than being informed by evidenced-based outcomes research. That other states have passed similar laws is not a convincing reason for Michigan to make the same mistakes.


Mon, Dec 3, 2012 : 1:01 p.m.

Look at undergrad, all the MDs I know took zero patient care or other medical training in undergrad. Not so for my nursing friends, they had ~1yr max of standard undergrad. So take 4 years off of your 11 year total please... You also fail to mention the scope of services offered by each. For 90% of my DR office visits, I don't need a MD or DO... They have different skill sets. Someone who flies a twin seat plane needs less training than a 747...


Mon, Dec 3, 2012 : 6:19 a.m.

@UM Doc. In regards to the education requirements you stated I believe that the 4 year Bachelor's degree that Physicians have should not be counted as "training." Premed students spend little to no time "training" to become doctors in the course of the bachelor's degree coursework. Sure some may spend some time volunteering to boost their applications, but for the most part premed students have little to no hands on patient care and don't even step inside a patient's room until year 2 of med school. Also you can not enter NP school with an associates degree so nurses have at least 4 years of undergrad prior to entering NP school. I am not discrediting the education the Physician's have I just don't think that they learn anything significant in regards to practicing medicine in their undergrad.


Mon, Dec 3, 2012 : 4:10 a.m.

I'm a physician as well and work with many midlevel providers including NPs and PAs. Virtually all of the NPs I have worked with do excellent work. But as UM Doc pointed out, the length of training is significantly shorter than that of a physician. More importantly however, the training is different. The skills taught in nursing school and masters programs are not the same as those taught in medical school and residency. It goes beyond the total hours or number of years spent in training. As a physician, I could not even come close to doing a nurse's job because I don't have the training that a nurse does. Nursing requires every bit as much hard work and intellect as being a physician but focuses on different aspects of patient care. A two-year masters degree (some of which are done online) does not change that. Nurse practitioners are a vital part of the medical system and provide excellent care to their patients in the proper setting. I would happily let my family members be cared for by an NP, but only one who has proper oversight.

UM Doc

Sun, Dec 2, 2012 : 8:06 p.m.

The semantics of whether the path to become an NP is called "training" or "education" is a non-issue. Call it what you want, but you seem to miss the broader point: the path to become an NP is nowhere near extensive enough to warrant equal responsibilities to a physician.

Melissa M.

Sun, Dec 2, 2012 : 7:12 p.m.

I'm not going to engage your entire argument here, because I have a huge paper to write as part of my NP "training" that I have to get to, but I have to point this out: That NP "training" you describe is a masters' degree, and a fully packed one at that. Before you get a masters' you must have a bachelors; as such there are no APRNs practicing with an associates in nursing (there are still some with post-baccalaureate certificates). APRN education includes education in public health, health policy, research methodology, data analysis and statstics, pharmacology, anatomy and physiology, pathophysiology and health asssessment, as well as extensive clinical practicums. Most of us also have years of experience as registered nurses from which we derive an extensive knowledge base. To describe our education as "training" is incredibly dishonest and insulting.

UM Doc

Sun, Dec 2, 2012 : 5:31 p.m.

brian123: Several points here. 1) A projected physician shortage should be met with an expansion of physicians. There is already some headway on this in the area, with a new medical school at Oakland University with their clinical training to be completed at Beaumont. Furthermore, an argument for an expansion of current class sizes could be made. Also, the number of qualified physicians who graduate from foreign medical schools and pass the same licensing exams US physicians are required to take far exceed the demand. Bottom line, physicians should never be replaced with nurses. 2) With respect to rural and underserved areas, physicians need to be incentivized to practice in these areas. Even if you expand the scope of NPs, they will make the same decisions with respect to where they live, and you'll see more of an oversaturation of primary care providers in already oversaturated areas. There are some programs out there, such as loan forgiveness for those who practice in these areas, but more can be done. Efforts should be made at incentivizing physicians to expand their practices into geographic areas that are underserved.


Sun, Dec 2, 2012 : 4:45 p.m.

*particularly in rural or medically underserved areas where attracting doctors is especially difficult.


Sun, Dec 2, 2012 : 4:43 p.m.

UM Doc - - you definitely have a point about extent of education. And i'm sure most people would rather be seen by a physician with many more years of education than a NP. However, the issue here is the reality we live in. There is a severe shortage of docs in the primary care setting, practicing preventative medicine. Many of these minor issues or "well visits" can be seen sufficiently by a trained NP. With millions more people about to come on the grid (after ObamaCare comes into full effect), how else are we going to meet demand?


Sun, Dec 2, 2012 : 3:02 p.m.

DBH: Would you like more? This is an excellent article about collaborative care in obstetrics, published in the Green Journal: Let me know when you need more reading! Happy to accommodate, since, luckily, there's a wide research base to choose from.


Sun, Dec 2, 2012 : 3:20 p.m.

Thank you, @Meg, I expect those will suffice.


Sun, Dec 2, 2012 : 2:50 p.m.

When writers (including the author of this opinion piece, as well as (as of now) @Meg below) cite research supporting their stances, I wish they would include links to such research so readers could evaluate the evidence themselves.


Sun, Dec 2, 2012 : 3:22 p.m.

Sorry, that should have been "...(as of now) @Meg **above**)..."


Sun, Dec 2, 2012 : 2:40 p.m.

As the comment about how nurses make mistakes is true, but does not mention how many mistakes the doctors make. After watching mistakes by doctors personally for thirty plus years, the idea that they are much better than nurses is pretty funny. That is a very large part of why malpractice insurance is so bloody high.


Sun, Dec 2, 2012 : 2:17 p.m.

Dean Potempa, thank you for this column. As a certified nurse-midwife who was educated and practiced in Washington State, where ARNPs have independently practiced since 1994, I have been mystified by Michigan's refusal to look at the evidence supporting ARNPs as safe and effective providers of care. Ann Arborite: I'm assuming that you've never seen an error by a physician. As a nurse for over a decade before I began practicing as a CNM, I've seen a lot. More than that, I've seen differences in practice opinions, which may be considered by those with less willingness to consider the research evidence to be "mistakes". Do ARNPs make mistakes? Absolutely. Do physicians? Absolutely. But two decades of outcomes research supports ARNPs as safe providers. Ann Arborite, this shouldn't be about turf wars, or how threatened one profession feels when their monopoly on care is challenged. This should be about the patients, and the research supports the use of ARNPs as well as physicians. You may want to consider the experiences of physicians and patients in states like Washington, where ARNPs in independent practice are considered colleagues and equals by the physicians. Our scope of care is different, our discipline is different, but "different" is not "lesser". Getting out of Michigan to see how things are done elsewhere is a refreshing -- and educational -- experience.

citizen kane

Mon, Dec 3, 2012 : 2:20 a.m.

Meg, if its so great out there why aren't you still practicing there? you aren't hiding from anything are you?


Sun, Dec 2, 2012 : 11:34 p.m.

Ann Arborite, I say again. Your argument of 'less training" is completely flawed. It is equal training in a different field. How is it you find that so hard to understand. Meg isn't saying she doesn't need doctors. She is saying that to continue to work in this archaic style of healthcare where physicians view NP's as subordinates with less training which in turn limits access to high quality care is unacceptable. She is saying, and I agree with her, that in order for things to move forward and to accomodate the inevitable 1 million new patients, you and your like-minded peers need to get over your 1980's nostalgia and accept that your philosophy is no longer relevant. Sorry.


Sun, Dec 2, 2012 : 4:21 p.m.

Nurses can, actually, practice nursing just fine without physicians. It's not a subspecialty of medicine; it's an independent discipline with its own research and theory. You aren't citing anything to support your claims of "lesser" care, so the assumption must be that you're using yourself as a research authority -- which is always questionable.

Ann Arborite

Sun, Dec 2, 2012 : 4:16 p.m.

Actually, Meg, I have practiced in two other states other than Michigan. And yes, I have seen physicians make mistakes. The whole goal here is to DECREASE the probability of error. And giving ARNPs, who have less training, more independent responsibility, is not going to accomplish that. You're right that the issue should not be about turf wars. It should be about working together to serve a population. However, that's not what you're advocating - you want to work completely independently. You will be hard pressed to prove to me that LESS training is as good as MORE training. When you have a breach baby that you cannot deliver vaginally, what do you do? I would hope you contact a physician & surgeon who is capable of performing a c-section if necessary. Advanced practice nurses provide a very useful and necessary part of our health care delivery system. Yes, they can provide very competent care. Doctors can't function without nurses. But, it would be folly for nurses to feel they can function without doctors. If a nurse wishes to practice independently, there is certainly a well-established path for her/him to take: it's called medical school. ARNPs already have a fairly independent practice system in this state. Maintaining at least a formal, if be it loose, coordination with a physician, can only help the public good.

Ann Arborite

Sun, Dec 2, 2012 : 1:48 p.m.

While I can understand the author's stance on this subject as the Dean of the Nursing School, I respectfully disagree with her. As a physician who has practiced for about 20 yrs, I have practiced with many "physician extenders" in several states. I think it is important for the public to realize how much shorter their education is compared to a formal medical training. Furthermore, there is a fundamental difference between the field of nursing and the field of medicine. Just tacking on a couple years at the end of a nursing education does not make them a doctor. Yet, this is exactly what they seek - they want to see patients independently without having any oversight. It's interesting that PAs, the other group of "physician extenders" haven't tried to do this - their education is much more similar to an MD/DO's, and I feel that they, as a profession, understand the key differential the 5+ years of training difference makes. Nurses who are advocating this bill don't seem to get this. I have seen many, many mistakes by NPs in my practice. These were honest mistakes made by good NPs. However, had it not been for the backup of well trained physicians, real harm could have come to patients. Yes, it's true that the ACA is going to worsen access to health care for all of us. More people are going to be insured (which is good), but there aren't enough doctors to go around. Furthermore, the ACA is essentially forcing physicians to sell out their practices to large hospital systems just to stay in business, due to provisions within the bill such as ACOs, which only very large institutions will be able to afford. Just look at what's happened here in town - St. Joe's has gone on a buying spree and bought up a huge chunk of the primary care doctors & specialists. An employed physician just is not going to work as hard as an independent one. We should fix the ACA, not settle for more quantity/less quality care.


Mon, Dec 3, 2012 : 12:51 p.m.

Monopoly anyone? I have seen many MD/DOs also make mistakes that were caught by Nurses... A Nurse or NP is YOUR last line of defense for a DOCTOR killing/harming you. Id rather have a NP from UM treat me than a DO from a Caribbean BS school... You forget to mention that NPs also do not do ALL of the same services MD/DOs do...


Mon, Dec 3, 2012 : 5:18 a.m.

Dr Annarborite is correct here. This is nothing new, expanding NPs has long been recommended as a method of resolving two important problems that add to the cost of health care, the lack of doctors, especially in the area of general practitioners and the high cost of paying Drs. However his points on education is on point. An NP degree is achieved by obtaining a Masters degree, not a Phd. They should work under the guidance of a physician. Terri this is why NPs are exactly physician extenders, as are physicians assistants. I do not like that term however but it is exactly what they do and it is a way to attack health care issues.


Sun, Dec 2, 2012 : 11:23 p.m.

If you are a physician, which I have no way of knowing if you actually are, you are exactly the type of physician that is the problem. I agree that med school is different than nursing school. But your comment about "just tacking on a couple years" shows how uninformed and out of touch you really are with contemporary education. Most nurse practitioners are becoming DOCTORS of nursing. And I have seen MANY mistakes and caught MANY mistaked made by good doctors. If you can't accept the fact that healthcare needs this change, then maybe it's time to pack your bags and allow yourself and your arrogance to retire.


Sun, Dec 2, 2012 : 4:20 p.m.

@Meg, I never said you were oatmeal. You understand the concept of analogies, do you not? As for the rest of your reply, see my previous postings. I wish you the best of luck.


Sun, Dec 2, 2012 : 4:02 p.m.

I'm not oatmeal. "Physician extender" is inherently disrespectful to non-physician providers, because we're not practicing the same discipline. By your rationale, physical therapists and speech-language pathologists are also physician extenders, but you'd be hard-pressed to find a physician who called them that. "Physician extender" is applied primarily to nurses -- particularly those uppity ones who don't know our place, apparently.


Sun, Dec 2, 2012 : 3:57 p.m.

All right, @Meg, I'll take one more stab at this. We appear to disagree about two different things. I am explaining what the definition of "physician extenders" IS, whereas you are writing about what the definition of "physician extenders" SHOULD be. The definition is the definition, like it or not, appropriate or not. I didn't make it up, it is not my opinion, and the definition is widely used. Personally, I have no opiniion on the appropriateness of the definition as it pertains to nurses with advanced degrees though clearly you do, and I respect that. Regarding the appropriateness of using the word "extender" attached to the word "physician" for someone who doesn't practice medicine (in a formal sense, at least), I don't see the problem. There is no conflict that I can see. The essence of an extender does not need to be identical to the thing extended. In cooking, for example, oatmeal can be used as an extender for meatloaf, even though oatmeal and meatloaf are quite two different things.


Sun, Dec 2, 2012 : 3:21 p.m.

Why should inappropriate and disrespectful language be used at all, regardless of whether it's used in the antiquated Michigan law? I don't practice medicine, so it's actually impossible for me to be a "physician extender".


Sun, Dec 2, 2012 : 3:19 p.m.

@Meg, I am not questioning your degrees, certifications, qualifications, or anything else. I am simply pointing out that the definition of "physician extenders" includes nurse practitioners and others with advanced nursing degrees. You may object to being included in the definition, but in those states that require physician supervision of nurse practitioners, it is a reality, like it or not.


Sun, Dec 2, 2012 : 3:07 p.m.

DBH: I'm not an extender. I'm a licensed professional, educated in both nursing and midwifery, and board-certified to practice my specialty. The lack of progress made by MI state law is the problem, not my qualifications to provide care to women throughout the reproductive lifespan. Independently, by the way, in 18 states.


Sun, Dec 2, 2012 : 2:54 p.m.

@Terri Eagen-Torkko, I think you are incorrect about this, at least in Michigan and other states that legally require physician supervision. "Definition: "Physician extenders" is a category name for nurse practitioners (NPs), physician assistants (PAs) and clinical nurse specialists (CNSs). Also Known As: nurse practitioners, physician assistants or clinical nurse specialists"

Terri Eagen-Torkko

Sun, Dec 2, 2012 : 2:31 p.m.

You've got this wrong from the get-go: Nurse practitioners are not "physician extenders."


Sun, Dec 2, 2012 : 1:34 p.m.

I think freeing Advanced Practice nurses to do legally what they have been trained for is an excellent idea, but I fear that they will find it very difficult and prohibitively expensive to obtain the malpractice insurance that would be essential to opening a clinic or practice of their own. Possibly using APRNs as the primary-care provider in county or regional government-run clinics would be more successful in rapidly improving access to routine medical care for many more Michigan citizens, especially those in rural communities.


Sun, Dec 2, 2012 : 3:45 p.m.

AMOC, ARNPs in Washington have found their malpractice coverage quite affordable, unless they're practicing in a high-risk specialty like pregnancy/birth care.