ability (ASA, 2004), although the AAFP supports nurses and physicians working together in collaborative teams (Phillips et al., 2001). The AAFP recently released a press packet—a “nurse practitioner information kit.”19 The kit includes a set of five papers and a new piece of legislation “clarifying” why NPs cannot substitute for physicians in primary care, although as Medicare and Medicaid data show, they already are doing so. There are also new guidelines on how to supervise CNMs, NPs, and physician assistants. The AAFP notes that its new proposed legislation, the Health Care Truth and Transparency Act of 2010, “ensures that patients receive accurate health care information by prohibiting misleading and deceptive advertising or representation of health care professionals’ credentials and training.” The legislation is also endorsed by 13 other physician groups.

Action has been taken at the state level as well. For example, in 2010, the California Medical Association (CMA) and the California Society of Anesthesiologists (CSA) sued the state of California after Governor Schwarzenegger decided to opt out of a Medicare provision requiring physician supervision of CRNAs (Sorbel, 2010). At the time of release of this report, the case had not yet been heard.

Reasons for Physician Resistance

The CMA and CSA both cited patient safety as the reason for protesting the governor’s decision—although evidence shows that CRNAs provide high-quality care to California citizens, there is no evidence of patient harm from their practice, and 14 other states have taken similar opt out actions (Sorbel, 2010). A study by Dulisse and Cromwell (2010) found no increase in inpatient mortality or complications in states that opted out of the CMS requirement that an anesthesiologist or surgeon oversee the administration of anesthesia by a CRNA. As noted earlier in this chapter, the contention that APRNs are less able than physicians to deliver care that is safe, effective, and efficient is not supported by research that has examined this question (Brown and Grimes, 1995; Fairman, 2008; Groth et al., 2010; Hatem et al., 2008; Hogan et al., 2010; Horrocks et al., 2002; Hughes et al., 2010; Laurant et al., 2004; Mundinger et al., 2000; Office of Technology Assessment, 1986).

Some physician organizations argue that nurses should not be allowed to expand their scope of practice, citing medicine’s unique education, clinical knowledge, and cognitive and technical skills. Opposition to this expansion is particularly strong with regard to prescriptive practice. However, evidence does not support an association between a physician’s type and length of preparation and the ability to prescribe correctly and accurately or the quality of care (Fairman, 2008). Similar questions have been raised about the content of nursing education (see the discussion of nursing curricula in Chapter 4).



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