I have to disagree with my friend state Sen. Tom Davis about the status of Advanced Practice Nurses (APRNs) seeing patients in South Carolina.
I have been a surgeon in the Lowcountry for almost 35 years. I have been going to Hampton to see patients three to four times per month for almost 20 years. And I speak on behalf of the S.C. Medical Association as its immediate past president.
I have seen firsthand how effectively and efficiently physicians and APRNs work together in a rural health clinic, and how satellite offices in even smaller communities can be staffed by APRNs working as a part of the rural health team. I believe the majority of APRNs in our state are happy and productive in that model of health care.
Current laws require APRNs to practice with a licensed physician while both see patients as a part of a physician-led team. The word in the current statute that is at issue is the word "supervision."
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Nurses are to be supervised by a physician, and it is the S.C. Board of Nursing that has been tasked with the responsibility to see that the statute is being followed.
Some APRN leaders argue that they are not being supervised and they don't need to be. They feel that they do just as good a job as physicians, and that if they are given independence, it will increase the access to care. I would disagree.
I would agree that with many clinical problems that are encountered, they do an excellent job and don't need much supervision. The medical association believes that increasing the number of nurses that can be supervised and increasing the distance they may practice in a satellite office will address the access issue.
A bill we endorse, which is supported by the S.C. Board of Medical Examiners and, for the most part, the Nursing Board itself, also allows relaxed rules in regard to nurses writing prescriptions for some narcotics.
Physicians have agreed to the relaxation of the current statute because we want the nurses to have greater practice flexibility. But we accept these new rules as long as the Advanced Practice Nurse remains in a physician-led team.
We do not believe many nurses would open an independent practice, assume practice costs and malpractice payments in rural areas where payer mix is not conducive to small, independent practices for nurses or physicians.
Many APRNs are now being encouraged to get their doctor of nursing degree, which makes them a doctor but not a physician. Some nurses want to practice independent of physicians. The physicians of our state are opposed to this practice model. We respect our nurse colleagues greatly, and we believe patients are served better when APRNs and physicians practice together.
In regard to training, physicians have a much more intense training regimen. We start with a baccalaureate degree, then four years of medical school, then residencies that consist of three to seven years of being on call every three to four nights and every three to four weekends.
This training is intense, structured and involves comprehensive patient care with gradually less supervision. It also allows many more patient encounters, preparing us for the always possible worst-case scenario in the clinical setting.
It is this training that prepares us for the responsibility of independent practice.
Nurses have an RN degree, which focuses on nursing, then they have at most three to four years of mostly 9 a.m. to 5 p.m. clinical training after obtaining their baccalaureate degree. Their training is much less structured, and they have far fewer opportunities for clinical decision-making. They currently enter the clinical realm without any formal residency.
No one is infallible. We all can make a mistake. But intense training and credentialing minimizes that possibility.
Nurses argue their training is adequate for what they wish to do. I agree that it prepares them perfectly for working with physicians. I do not believe it is adequate for the responsibility of the independent care of patients.
A bill supported by the medical association proposes an individualized practice agreement that would be signed by doctors and nurses. In that way, experienced nurses can have a formalized agreement that involves minimal supervision but would include chart review for quality assessment similar to what physicians do for each other all the time. Younger, more inexperienced nurses would need a closer period of supervision that can be relaxed with time.
The legislature is currently evaluating the two bills which address this issue with opposing views. As Rep. Anne Parks said to the nurses at the conclusion of a subcommittee hearing on March 17, "You (nurses) come here in a white coat and call yourselves doctor. I believe that is misleading to the patient." I would agree.
I hope this issue can be resolved soon. Doctors believe the public wins when APRNs and physicians work together and are not in conflict. In most parts of our state that relationship is working very well every day.
H. Tim Pearce MD of Beaufort is immediate past president of the South Carolina Medical Association.