Rebekah Bernard, MD, on the importance of physician-led care [Podcast]

In today’s COVID-19 Update, a special episode with Rebekah Bernard, MD, co-author of the book Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare about scope creep and how it can affect patient care. AMA Chief Experience Officer Todd Unger hosts.

Learn more about the AMA’s work to fight scope creep as a critical part of our Recovery Plan for America’s Physicians.

Learn more at the AMA COVID-19 resource center.

Speaker

• Rebekah Bernard, MD, physician and co-author, Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare

Unger: Hello. This is the American Medical Association's COVID-19 Update video and podcast. Today we're bringing you a special episode on a very important topic and a key part of AMA's Recovery Plan for America's Physicians. And that scope of practice creep or scope creep for short and how it affects patient care.

I'm joined today by Dr. Rebekah Bernard, co-author of the book, "Patient's at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare." And she's talking to us today from Fort Myers, Florida. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Bernard, thanks so much for joining us today.

Dr. Bernard: Thank you so much for having me.

Unger: We know that scope of practice creep or scope creep is a critical issue for both physicians and patients and really been brought, I say, into even more sharp relief following the pandemic. I'd like to start out just by talking to you a little bit about what prompted you to write a book about this particular issue.

You're a physician, you grew up with parents who are both registered nurses. I'm curious, as you're trying to navigate, what is a sensitive subject, anything along the way that you've learned or you want to talk about what prompted this.

Dr. Bernard: Yeah, for sure. So when I graduated residency 20 years ago, I really had very little training or knowledge or experience about nurse practitioners or physician assistants. And I had absolutely no formal training on how to supervise. So it was a real surprise to me when I got my first job at a federally qualified health center and I was told on day one, here's your NP, here's your PA, you're in charge.

So that was a rude awakening and it was a big learning experience for me because I had to understand what they knew, what their training was and also how to be legally responsible. And I found a lot of challenges along the way. And I thought maybe that was just my experience.

But then years later, I stumbled upon a social media group called Physicians for Patient Protection. And it was a group of doctors talking about concerns that they had and questions that they had about what was happening with an increase of nurse practitioner and physician assistant autonomy.

And I realized that really we weren't having this dialogue nationally. And partly because of the sensitive issue that you mentioned, sometimes if you even ask the question, you're accused of not being a team player or about being disruptive. And it's really important that we do have these discussions so that we can make sure that patients are being kept safe.

Unger: You really mentioned that keyword there, team. And I think what we're talking about here is physician-led team-based care. One of the things that you lay out in the book is a pretty devastating story about a young college athlete where things went very wrong. Tell us a little bit more about that case and what it illustrates in terms of the concerns that we're focusing on here.

Dr. Bernard: This case is really a classic example of what can happen when a person that doesn't have the proper training and experience is put in a position that they're really not prepared for. And in this case, 19-year-old Alexis Ochoa, who was a college honor student and athlete developed sudden shortness of breath, chest pain and a fainting spell.

She arrived at the emergency room and there was only a family nurse practitioner there, no physician on site. And that was just a standard thing that was done throughout this multibillion-dollar health care organization. And through a variety of problems that came up, nurse practitioner was not able to properly diagnose Alexis with a pulmonary embolism or blood clot in her lungs.

She took care of her for 11 hours in the emergency room and really never once reached out to a supervising physician. And really sadly, Alexis did die of that blood clot in her lungs. And what's so hard about this case is that we're seeing the examples of this across the country. This is a good case to talk about because it did go to trial and so there is a lot of public record about what went wrong.

But unfortunately, we know that these types of situations are happening across the country and they don't always come to light. And so this is why we use this case as an example because it is demonstrative of so many things that are happening across our health care systems across our country.

Unger: It's a heartbreaking story and sadly not an isolated case. How pervasive do you think this problem is and is it getting worse?

Dr. Bernard: It really is. Nurse practitioners and PAs, the profession came about in 1965 and we have seen an explosion of these professionals, especially in about the last 20 years. In fact, it's estimated that there are now more than 300,000 nurse practitioners. Compare that to physicians, which have remained pretty steady at a million, going back for at least the last 10 or 15 years.

And physician assistants are growing quickly as well. And what we're seeing, unfortunately, is that many corporations and organizations in an effort to keep costs contained or to save money, or in some cases in these for-profit organizations to make money are preferentially hiring professionals that can be graduated a lot quicker, can be paid perhaps somewhat less. And so we're seeing physicians being replaced increasingly.

Unger: You cite a lot of AMA research throughout the book as well as a 2019 study titled "Potential Crisis in Nurse Practitioner Preparation in the United States." What's that study illustrate?

Dr. Bernard: This is such an important study because it was published by Mary Mundinger who has actually been an advocate for increased practice for nurse practitioners. She's one of the researchers that is cited the most in advocacy for increased nurse practitioner practice rights.

And yet she wrote a study in 2019 discussing her concerns that this Doctor of Nurse Practice curriculum which was something she advocated for has really turned into almost what's a joke in the sense that only 15% of all DNP curriculum are clinical. The rest are non-clinical like administrative research, computer use, things like that.

But what we're seeing is that this DNP is being used as an excuse to call someone a doctor or to lend credibility. But in most cases, it is not clinical. And Dr. Mundinger was pretty upset about this because her vision has always been to see nurses gain more training and experience and become clinical leaders. But she's reporting her own concerns that that is not what's happening.

Unger: And that echoes a lot of the AMA research on the topic as well. That really does point out the difference. And just the hours and frankly years, of course, for physicians of training and learning relative to other professions there as well as the research about where non-physician providers are locating, they're generally in the same areas where physicians are, there are other issues too about patients just not being able to recognize whether it's a physician or not. So you raised that issue in your book. That's very, very important.

And the AMA has a Truth in Advertising campaign that's designed to ensure that health care providers are clearly and honestly state their level of training, education, licensing. Some patients, they don't know the difference. How do we increase that knowledge among patients to know and ask for who's treating them.

Dr. Bernard: We know the AMA really has been a leader in research and in education and sharing this information with physicians and with the public and patients at large. And one of the things that you mentioned is the difference in educational hours and training. And really just standardization. Knowing that physician education is very standardized whereas especially for nurse practitioner education we're seeing a lot of variability to the point where nurse practice leaders and researchers have sounded the alarm that there is so much variability.

In fact, just last year, a paper was published saying that nurse practitioners should not be working independently in emergency rooms because the training is really haphazard. And another study that was produced last year showed that about 50% of nurses are getting their nurse practitioner education online. About 20% are attending these direct entry programs, which means that they may have never worked a day as a nurse and they don't have a nursing undergraduate degree or experience.

And what that leads to is a lack of having opportunities to even work in a nursing field or setting. And one study showed that up to 30% of nurse practitioner graduates are coming out with having minimal exposure to things like writing prescriptions, ordering lab tests, just really basic health care.

So it's really great that the AMA is sounding the alarm and talking about this. It's so important. You ask me about how patients can find out more about who is taking care of them. Well, first of all, they have to know enough to ask. And the AMA has done a great job in just finding out that patients don't know, they make a lot of assumptions. You see someone in a white coat, with a badge on. You see a bunch of initials and you don't know what that necessarily means.

So patients need to be aware that there are different types of health care practitioners and they need to ask and they need to understand what that means. And in many cases they're told, sometimes by the person answering the phone when you call to schedule an appointment, oh, don't worry, the doctor and the nurse practitioner, they know the same thing, the PA is just as good.

And they need to question that and say, why is there different education and training if they're all the same thing? They're really not.

Unger: As you clearly point out and that's a pretty long list of potential issues, what are some of the other solutions you'd like to see implemented to address this issue around scope creep.

Dr. Bernard: I think patient awareness is really important, which as the AMA is doing it's the reason why my co-author and I wrote this book because we wanted to just start having the dialogue and raising awareness about this. And also it's important to have other groups sounding the alarm.

And we're seeing that the Florida Medical Association and the Florida Academy of Family Physicians has created a pro-physician campaign called thephysiciandecision.com. And it's just explaining to patients what is the training of a physician and letting them know that it's okay to ask for a physician to be hopefully involved at a minimum but certainly the leader of your health care team.

The other thing would be legislative efforts to increase the requirements for truth and transparency. Recently Indiana and New Jersey passed stronger legislation requiring clear signage and that patients be informed about who is taking care of them. It would be great for patients to know, is there even a physician there on-site or is there someone available if things are not going well or if there is additional information that is needed to evaluate their case.

Unger: Well, we talked upfront about the reality of health care today. It is a team-based environment but one where it's so important to be physician-led. It's a sensitive topic and I think far too often, the issue does get framed in an “us versus them” type approach. How do we get out of that framework and work together on behalf of patients?

Dr. Bernard: It's so important because the truth is, whenever I speak to my colleagues, physicians, nurse practitioners, physician assistants, what I hear over and over again is that we're all interested in the same thing, which is giving patients great quality care safely and cost-effectively. And although I have had some backlash from my writing, both the book and articles that I've written, it really is coming more from leadership of the organizations and not so much from rank and file.

NPs and PAs, I get a lot of email and a lot of discussion with them telling me that they totally support the idea of physician-led care. They want to work together with physicians and physicians want to work together with them. In fact, this is what the model was based on. Studies show over and over again that when physicians and nurse practitioners and physician assistants work together, patients can get great care.

But what has not been shown is that care is the same when physicians are removed from the equation. And it's been many years that almost half the states in the union have allowed legislatively the unsupervised practice of medicine by non-physicians. And yet in all those years, where are the data, where are the randomized controlled trials saying that that's safe and effective? It doesn't exist.

But what does exist is that we work really well together. So this is not an us versus them, this is a team-based approach. And I really think that a lot of NPs and PAs feel that way but sometimes they're afraid to speak out. And in fact, the American Association of Nurse Practitioners, at their closing 2019 meeting, they had a lecturer put up a slide. It had a smiley face with a zipper for the lip.

And it said, sometimes the strongest voice is silent. And the message that they were giving to their listeners was, if you are opposed to full practice authority, you're opposed to independent practice, you need to stay quiet because you're hurting our profession. Well, it should be the other way around.

So I think what needs to change is that we are leadership. All of our organizations needs to come together to really talk about how we can give patients the best quality care. Take ego out of it and look at it more of, who has the training, the education and how can we work together to make sure that patients get the best care.

Unger: I think you said that so perfectly. It's about the patient. And it's important to speak out on issues like this.

Dr. Bernard: And because we're all going to be patients, I always say that—people sometimes say it's a turf war. I'm a family doctor, I have a full practice, I am busy. I don't need more patients. This is not about me and my ego, this is about the fact that one day I'm going to be like Alexis Ochoa. I'm going to be looking up from a gurney and I'd like to know that there's going to be a physician there to take care of me.

And if things don't change, there's a possibility that that won't be the case.

Unger: Dr. Bernard, thank you so much. That was an incredible episode to learn more about the AMA’s work to fight scope creep as a critical part of our Recovery Plan for America's Physicians. Make sure to check out ama-assn.org/recovery. We'll be back soon with another episode. You can find all our podcasts and videos, ama-assn.org/podcasts. Thanks for joining us today and please take care.

Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.