Published: Sep 17, 2013

By David Pittman, Washington Correspondent, MedPage Today

The American College of Physicians took a nuanced position on the role advanced nurse practitioners play in clinical care teams in a position paper published Monday.

The college believes patients should have immediate access to a physician who oversees their care, but care teams should be organized and managed in a way that best meets patients’ interests, stated the position paper on team-based care, which was published in the Annals of Internal Medicine.

Nurse practitioners “cannot substitute” for doctors, but patients should be matched with the member of the care team most qualified and available at the time, stated the paper, entitled “Principles Supporting Dynamic Clinical Care Teams.” It was written by Robert Doherty and Ryan Crowley of the ACP on behalf of the college’s Health and Public Policy Committee.

The position paper comes at a time when ACP says the current model of healthcare delivery must change to meet the coming demands of patients. To do so, the healthcare system therefore must shift from a individual-clinician model to that of team-based care, the paper stated.

The paper marks ACP’s entry into the scope-of-practice controversy — what authority nurse practitioners and physician assistants should have in treating patients.

The internal medicine group tipped its hat toward nurses, physician assistants, pharmacists, social workers, and other health professionals, saying responsibilities in a team must assure that patients receive the care they need at any given time.

But later, the paper placed doctors at the top of the team’s pecking order, saying, “Advanced practice registered nurses and physician assistants cannot substitute for or replace the skills and expertise of physicians within their discipline, but when they practice to the top of their licenses, they can provide complementary and unique approaches, as well as additional skills in the service of patients and families.”

The policy paper later states patients deserve access to a personal physician who “has leadership responsibilities for a team of health professionals.”

Thomas Huddle, MD, PhD, of the University of Alabama at Birmingham School of Medicine, noted in one of three accompanying editorials the apparent contradiction in the ACP’s position. “Readers are left wondering whether physicians must lead clinical care teams or whether nurses and other professionals may lead,” Huddle wrote in the editorial “Fumbling Toward the Future.”

Leaders of the American Association of Nurse Practitioners disputed many of the ACP’s principles. The association believes team-based care should be non-hierarchical, centering around the patients’ needs, co-Presidents Angela Golden, nurse practitioner, and Kenneth Miller, PhD, wrote in an accompanying editorial.

“These needs and the patient’s preferences should determine which provider leads a healthcare team,” Golden and Miller wrote. “Team leadership should not be defined by a particular professional nor by a regulatory or licensing body.”

The American Medical Association and American Academy of Family Physicians have more clearly asserted that physicians should led care teams, while other bodies, like the Institute of Medicine and the National Committee for Quality Assurance, have stated they’re fine with nonphysician leadership.

The ACP’s position “will not inspire high-fives from our nurse practitioner colleagues,” Anna Reisman, MD, director of Yale University’s Standardized Patients Program, wrote in a third editorial Monday.

“Although solving the scope-of-practice controversy may be beyond the reach of the college’s position paper or of this editorial, failure to resolve this issue hinders the development of dynamic clinical-care teams, particularly in states where nurse practitioners can practice autonomously,” Reisman wrote. “It is heartening, then, to find the college rising above the familiar negative rhetoric by acknowledging the effectiveness of nurse practitioners in some settings, such as nurse-managed health centers in underserved areas.”

ACP said exceptions to the physician-as-leader model should be made for communities with physician shortages, although in such cases, doctors should still have a “virtual presence on clinical-care teams.”

However, it is unrealistic to think this will happen everywhere, Huddle wrote in his editorial, since nurse practitioners can treat a patient without physician involvement in 17 states.

“Given the breadth of primary care, licensure and regulation cannot restrain nonphysician primary caregivers from offering primary care services that they are not qualified to provide,” Huddle said. “Only professionalism will keep such caregivers operating within their sphere of competence — as is the case for all clinicians, including primary care physicians.”

The policy paper also calls for research on liability in team-based care, and suggests that future outcome studies examine teams rather than individuals.

The paper also suggested that training of students and residents should involve team-based care — a method of instruction not currently done — and that states should review their licensure laws.