Role Of Nurses In Primary Care May Expand

Guests

Rosa Gonzalez-Guarda, assistant professor, University of Miami School of Nursing and Health Studies
Joan Trybulski, associate dean, Master's nursing program, University of Miami
Dr. Fred Ralston, president, American College of Physicians

The Institute of Medicine argues for expanding the roles of advanced practice nurses in providing basic primary care. For years, though, nurses and doctors have butted heads over the "scope of practice" debate — basically, who gets to order tests and prescribe medicine, among other tasks.

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NEAL CONAN, host:

This is TALK OF THE NATION. I'm Neal Conan, in Washington.

Expanded health coverage could bring millions of new patients into already crowded doctor's offices, and in a lot of places, primary care physicians are already scarce.

Last month, a report issued by the Institute of Medicine proposed that better-trained nurses can fill a big part of that gap and reignited an old debate about what's called scope of practice. Should nurses be authorized to order tests, write prescriptions and take on other responsibilities now reserved to doctors?

So, nurses, doctors: Should nurses with more education take on a bigger role? Our phone number: 800-989-8255. Email us: talk@npr.org. You could also join the conversation on our website. That's at npr.org, click on TALK OF THE NATION. Later in the program, we'll debrief NPR's Jackie Northam back from another trip to Kabul.

But first, the future of nursing. And we begin with Rosa Gonzales-Guarda, a member of the IOM committee that issued the report, and an assistant professor at the University of Miami School of Nursing and Health Studies. Nice to have you on the program with us today.

Professor ROSA GONZALES-GUARDA (University of Miami School of Nursing): Good afternoon. Thank you for having us.

CONAN: And why do nurses' duties need to be expanded?

Prof. GONZALES-GUARDA: Well, as you had mentioned, with the passage of the Affordable Care Act, which was passed in March, we're going to see 32 million new patients accessing the health care delivery system which previously weren't accessing this system. And currently, we don't have the capacity to provide high-quality, patient-centered care for this new expanded population.

CONAN: And we should point out that this recommendation is just one of those issued by the panel, but it's drawn the most attention. And we are talking about nurses, the so-called advanced practice nurses, in other words those with a master's degree.

Prof. GONZALES-GUARDA: Exactly. So as you had mentioned, one of the main recommendations, which was one of the eight recommendations that we made on the committee, was allowing nurses to practice to the full extent of their education and training. Unfortunately, there are many barriers that nurses -particularly advanced practice nurses, which are nurses that have a graduate education, meaning that they have a master's degree or they have a doctorate degree.

And they have the training to be able to fulfill a lot of their primary care responsibilities. The problem is is that there's a lot of variation in terms of the scope of practices across states here in the United States that don't permit nurses that are trained to provide primary care to actually provide that type of care.

CONAN: Unless they're supervised by a doctor.

Prof. GONZALES-GUARDA: Exactly.

CONAN: And are there enough of these nurses, first of all, to make a big difference?

Prof. GONZALES-GUARDA: Well, we do. We currently have about a little over 150,000 nurse practitioners.

CONAN: Mm-hmm.

Prof. GONZALES-GUARDA: And so the, you know, this is a relatively large workforce that is capable and well-educated to provide high-quality, patient-centered care.

CONAN: And the argument against it, as I'm sure you've heard, is doctors will say, even if they have more training it's not the right training. Doctors need to make these decisions.

Prof. GONZALES-GUARDA: Right. Well, one of the things that we looked at as we were making our deliberations - and the Institute of Medicine actually takes a lot of pride in this process - is that we don't make any recommendation that is not based on science or based on evidence. So we looked at a number of research studies that compared the quality and the outcomes of care provided by nurse practitioners and those provided by primary care physicians. And what - there's overwhelming evidence that there is very great outcomes with the type of care that nurse practitioners provide.

CONAN: And what kind - we mentioned writing prescriptions and ordering tests, what are the kinds of, well, things that doctors now do would nurse with these - advanced practice nurses be allowed to do if your proposal was enacted?

Prof. GONZALES-GUARDA: So advanced practice nurses and nurse practitioners in particular are trained to make diagnoses, to write prescriptions, to make certain referrals or order tests. They're trained to be able to assess the need of individuals to be admitted in hospitals, et cetera. And depending on where you practice, those scopes of practice might be more limited than in other places. So...

CONAN: The scopes of practice are limited by state law, correct?

Prof. GONZALES-GUARDA: Correct.

CONAN: Okay. So you are arguing that states need to change their laws to allow this.

Prof. GONZALES-GUARDA: Exactly. So we have very specific recommendations to governments, to Congress in specific, to state legislatures, to allow - to look at the scope of practice laws and either allow changes to their laws or provide additional incentives for states to adopt more favorable laws that would allow an expanded scope of practice for nurse practitioners that is in accord with their education and training, of course.

CONAN: And we mentioned, of course, there is a shortage of primary care physicians. It's been well documented. Isn't there also a nursing shortage?

Prof. GONZALES-GUARDA: Yes, there is. So we also have a nursing shortage as well, which is another issue of great concern that we need to be looking at.

CONAN: And this is, as I understand it, due to a shortage of nurses qualified to teach other nurses, nurse educators, because the nurses who are qualified to do that can also make a lot of money doing other things too.

Prof. GONZALES-GUARDA: Exactly. That's precisely one of the major contributors to the nursing shortage, the fact that we have little faculty that are available to accept the number of potential nursing students, because there is a great deal of interest from the community in terms of nursing as a profession. So every year, we turn thousands of nurses, of potential nurses, away from our educational system.

CONAN: So if that's the bottleneck, how would that be addressed?

Prof. GONZALES-GUARDA: So we actually - so this is one of the areas that we looked into. We don't have specific recommendations about the nursing shortage per se, but we do focus a good number of our recommendations around nursing education in general. And one of the major points that we're making in our recommendations is that we need to improve the education of our nurses. By allowing nurses to progress in their education to higher levels, then in essence we're building a greater cadre of well-educated nurses that could be faculty members in nursing schools.

CONAN: And one other question also: If nurses are going to be making independent medical judgments beyond - without being supervised necessarily by a doctor, aren't they going to have to also take up more malpractice insurance because they're liable for their mistakes? And mistakes, of course, will happen.

Prof. GONZALES-GUARDA: Well, this is - we didn't look at malpractice insurance in particular. What we are proposing is that nurses practice to their -according to their education and training, and that they of course practice in a team of health care providers, which also includes physicians. So advanced practice nurses could - the evidence shows that they're able to provide a lot of the same services and high-quality, patient-centered services to the general public. However, they have - they can't work alone, of course. They need to work and partner with physicians and other health care providers and acknowledge when it's important to refer to a partnering health care provider.

CONAN: We're talking with Rosa Gonzales-Guarda, a nurse herself and also a assistant professor and the - one of the authors or one - part of the panel that drew up this report on expanding the role of nurses. And we use the expression scope of practice, it's what nurses and doctors are allowed to do in various kinds of situations.

800-989-8255. Email us: talk@npr.org. Susan's calling us from Portland.

SUSAN (Caller): Hello.

CONAN: Hi, you're on the line. Go ahead, please.

SUSAN: Yes, thank you. I'm a registered nurse in Portland, Oregon. And I would just like to comment on the Institute of Medicine report. Two points I'd like to make. In Oregon, nurse practitioners have had independent practice authority since 1979. And we have a very long history in this state of positive outcomes from patients, increasing demand from Oregon consumers for the care provided by nurse practitioners. So we're very proud of it, and we think that is evidence that the Institute of Medicine is on the right track.

The second point I'd like to make is that the future health care demands of this country - our state and this country are going to require that all of us practice as broadly as we can. So it isn't a matter of there are insufficient nurses or physicians, and so we need to turn to someone else. There's simply going to be greater demands that any one discipline can meet. And so all of us need to be a part of the solution. We...

CONAN: I was just wondering, in Oregon - obviously, you say this has obviously been in place for some time there. Was there pushback from doctors, and how did that work out?

SUSAN: Well, initially, of course there was, but that really didn't last very long. And we do enjoy a very strong relationship with our physician colleagues in this state. And I think it has benefited our consumers.

CONAN: And what about that insurance question that I was asking, Rosa Gonzalez-Guarda about? Do nurses making independent medical decisions have to take out malpractice insurance?

SUSAN: Certainly, they do. The rates for nurse practitioners in Oregon and countrywide are not at the level that physicians pay. But as you become more independent in your practice, you certainly do face the risk of liability. And so I think our nurse practitioners - and nurses, as well - recognize that insuring your practice, like insuring your car, is just a fact of our professional life.

CONAN: Susan, thanks very much for the call. Appreciate it.

SUSAN: Thank you.

CONAN: Joining us also from the studios of member station WLRN in Miami is JoAnn Trybulski. She's an associate dean of Master's and doctor of nursing programs at the University of Miami, and an advanced practice registered nurse herself.

Nice to have you with us today.

Dr. JOANN TRYBULSKI (Associate Dean, Masters and Doctor of Nursing Programs, University of Miami): Thank you. Nice to be here.

CONAN: And as you just heard, that call from Oregon, is that the kind of situation that you would like to see in the other 49 states?

Dr. TRYBULSKI: Absolutely. I mean, there are multiple states in which nurse practitioners have been able to practice independently for quite some time. But if I - just would like to add something that might be helpful. The idea of nurses expanding or practicing at an increased scope of practice is really not new. The idea of advanced practice nursing has been around quite some time. And the different roles within advanced practice nursing, the most popular that people may know right now are nurse practitioners. But nurse anesthetists are also advanced practice nurses, nurse midwives and clinical nurse specialists.

And it's helpful to know that nurse anesthetists have been around since 1877, nurse midwives since 1925, CNS's - or clinical nurse specialists - since the '60s. And actually, nurse practitioners have been around since 1965. So there's a - this is not a new concept. This has been around for quite some time.

CONAN: And the arguments about it have been around some time, too. We'll hear more about that in a few minutes from a doctor. So nurses, doctors, should nurses with more education take on larger roles? 800-989-8255. Email us: talk@npr.org

Stay with us. I'm Neal Conan. It's THE TALK OF THE NATION, from NPR News.

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CONAN: This is TALK OF THE NATION, from NPR News. I'm Neal Conan, in Washington.

Despite a new report, many doctors do not agree that nurses should order tests or write prescriptions on their own. Even nurses with an advanced degree, they argue, are not trained as doctors and shouldn't act like one. We'll talk with the president of the American College of Physicians about those arguments in just a moment.

Our guests right now are Rosa Gonzalez-Guarda, who served on the panel on the Institute of Medicine Committee that issued last month's report, "The Future of Nursing: Leading Change, Advancing Health."

Also with us is JoAnn Trybulski, associate dean of the Master's nursing program and doctor of nursing programs at the University of Miami, an advanced practice registered nurse herself. So nurses, doctors: Should nurses with more education take on a bigger role? 800-989-8255 is the phone number. Email us: talk@npr.org you can also join the conversation at our website. That's at npr.org. Click on TALK OF THE NATION.

And JoAnn Trybulski, let me ask you: There is already sort of an intermediate category. You mentioned the nurse anesthetist, but there's also something called a physician's assistant. What's the difference between an advanced practice nurse and a physician's assistant?

Dr. TRYBULSKI: Okay. Well, an advanced practice nurse is a member of the nursing discipline. And as a discipline, nursing license credentials and accredits its own educational programs. And physician's assistants are - fall under the discipline of medicine, and as such, are regulated, licensed and supervised by medicine.

Nursing has always had what we consider a collaborative working relationship with our physician colleagues, and it's a relationship that we always seek to maintain and foster.

CONAN: So, in other words, there are two different disciplines. But if nurses are seeking to do medical things, like issue prescriptions, shouldn't they -and maybe the doctor would make this argument - shouldn't they be studying medicine?

Dr. TRYBULSKI: Well, actually, we prefer to think that they are studying nursing at an advanced practice level, which has many of the same functions that medicine may have at a given level, but it is still coming from the discipline of nursing with a nursing focus and carried out by nursing - nurse practitioners, practitioners who are nurses.

CONAN: Well, perhaps I should bring Dr. Fred Ralston into the conversation. He joins us from his office at Fayette Medical Associates in Fayetteville...

Dr. FRED RALSTON (President, American College of Physicians): Fayetteville, Tennessee.

CONAN: Fayetteville, Tennessee. Yes. He's President of the American College of Physicians, practicing internist at the Fayette Medical Associates. It's nice to have you with us today.

Dr. RALSTON: Well, glad to be with you.

CONAN: And is that your - is there some problem with nurses writing prescriptions and ordering tests?

Dr. RALSTON: Well, let me give you a little bit of my background, because I think perspective is always important. The American College of Physicians is the internal medicine specialty society, the second-largest physician group in the country with 130,000 members. And in my day job, I'm in an eight-doctor, primary care practice in Fayetteville, Tennessee. And we work with a nurse practitioner that we're very happy to have in our practice. And in some earlier time in my activities with the American College of Physicians, I chaired a committee that produced a paper on nurse practitioners in primary care. And we were the first medical organization to reach out to the nursing community, and we've had continuing dialogue since that time.

So I'd like to give a little bit of a response to the IOM report, and then answer questions, if that's okay.

CONAN: Well, all right. After that preamble, go ahead.

Dr. RALSTON: Okay. The - many of the recommendations in the IOM report are consistent with what we feel. There's some areas of concern only in part with the focus of the specific recommendations, but in particular a concern that others who don't read the full report or understand all the background may imply that physicians and nurses are virtually interchangeable. And we certainly don't feel like that's the case, and I think most people in the nursing community wouldn't either.

CONAN: That's not what I'm hearing from the nurses we have on the panel. But go ahead.

Dr. RALSTON: Well, I mean, we really feel that there are different types of training with different levels of knowledge, skills and abilities that are not equivalent, but complementary, and we really see that as a good thing. And one of the concerns that we had about the IOM report and its interpretation was the focus on independent practice. We really would prefer to turn that around toward the future of medicine, which we see as more of a team-based effort, and we really see existing models like the VA and a variety of groups such as Kaiser and Geisinger that use both physicians, nurse practitioners and other health care professionals to full advantage.

So we really feel like we would be better served by focusing on the particular clinical activities that the training makes appropriate, and then look to what's been happening in the world in places like VA where they've already been doing that with some success.

CONAN: As I understand, the report does address the idea of team practice, and they were just talking about that just a moment ago. But nevertheless, in terms of independence, are you saying that advanced training nurses, nurses with Master's degrees are - should be disqualified from writing prescriptions or ordering tests?

Dr. RALSTON: Well, actually, the writing the prescriptions and ordering tests within the proper medical setting is one of the things that we find all right. We just feel like as long as the training is appropriate and as long as there's some kind of quality feedback. That's the thing that we really like about physicians and advanced practice nurses in the Patient-Centered Medical Home. There's an opportunity in that setting to test new ideas and different ideas, but we really don't have to start from scratch because there are advanced practice nurses performing those functions within an established health care systems.

And if I were a state legislator and I was looking at practice activities, I would certainly want to look at those activities that have shown to work over time, and I would be more comfortable with either a doctor or an advanced practice nurse writing prescriptions or doing other activities where's there's a continuous quality monitoring process. That's why we're so excited about the future of medicine in the Patient-Centered Medical Home.

CONAN: JoAnn Trybulski, is that what this report urges, as far as you can see?

Dr. TRYBULSKI: I totally think that that's what the report urges. I mean, what - the scope-of-practice question just means that state to state, there is great variability in what nurse practitioners are allowed to do. And in many states, they do assume their full scope as my physician colleague eloquently stated. And I would echo that, you know, nurse practitioners work best, as physicians do, as part of a health care team.

CONAN: All right. Let's see if we can get some more comments. Here's an email, this is from Monica in Nampa, Idaho: I have nothing against nurses. However, the discussion about expanding the role of nurse, hiring more nurses, etc., completely avoids one of the reasons. We don't seem to have one of the reasons. We don't seem to have enough doctors, and that is the artificially low quota set on the amount of medical school students that could begin training in a given year. That keeps the supply of new doctors low, thus contributing to demand. Why not raise these quotas, get more doctors into the field?

And Dr. Ralston, what do you think?

Dr. RALSTON: Well, we've been having discussions with this for a number of years. There's almost no way to deal with shortages without talking about the particular issues facing primary care in this country. The - if you look at general internal medicine, family medicine and pediatrics, fewer medical school graduates are going into that because of some ways that we finance health care. And we certainly have a number of proposals to help improve that, and the Patient-Centered Medical Home is one of them. So simply increasing the number of medical school graduates, if they're all going to go into dermatology, radiology, orthopedic surgery, isn't going to change access to primary care.

And so we feel that there are going to need to be more nurses and more doctors, but we also want to make sure that those nurses and doctors have an appropriate place to go and have the incentive. I mean, we're seeing in our area many well-trained nurse practitioners that primary care people would love to have in their practices. They're going to those other specialties that the doctors are choosing, also.

CONAN: Let's get another caller on the line. Let's go to Phil. Phil's calling from Boise.

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PHIL (Caller): Yes...

CONAN: Go ahead, please.

PHIL: I'm a physician assistant in Boise, and I have about 10 years of experience, and 20 years prior to that as a paramedic. So I've got a lot of medical background, and I work with nurse practitioners. And I work with physicians on a daily basis. And it's - this isn't a simple issue, by any stretch. And the - you can find good doctors and bad doctors. You can find good NPs and bad NPs, good PAs, bad PAs. But what it seems to focus on is experience. And, I mean, I'm aware of at least a few colleagues, NP colleagues that have taken a, you know, four-year RN and then go directly into NP school and come out with a credential. Now I know PAs who have done, as well. So I'm not disparaging NPs.

CONAN: And again, NPs are nurse practitioners, PAs are physician's assistants. But go ahead.

PHIL: Correct. Thank you. That they come out with no experience. Now, physician training, you go through medical school. You do your rotations the last couple years of your medical training, then you go to a residency.

CONAN: Hmm.

PHIL: And there, you learn how not to kill people. And it's - you talk to any physician, that's where they learn how to practice medicine.

CONAN: It's interesting you mention that. Rosa Gonzalez-Guarda, does not this new report also argue that nurse practitioners should go - undergo a period of residency?

Prof. GONZALEZ-GUARDA: Absolutely. So one of the main areas of focus of this report is not only on the scope of practice but also, as I mentioned, on ensuring that nurses have more access to greater education. And one of the recommendations that we do have is to implement a nurse residency program, so that nurses that are graduating, whether they're graduating from a baccalaureate degree, they have the opportunity to engage in a residency program where they're able to apply a lot of the theory that they learned in the classroom in a real-life setting, with a little bit more support than they would regularly have in, you know, without a residency program.

We're also proposing that nurses when they move into any new role in general -so, for example, a nurse that has worked in an acute-care setting and moving to a community setting, which is a trend that we're probably going to see in the future, that they also have access to a residency program. So they have this opportunity to learn to provide a new type of specialty care in an environment that is more supported to them.

CONAN: Phil, if that was the case, would that allay your concerns?

PHIL: Well, yes, absolutely. And that's my biggest issue...

CONAN: All right.

PHIL: ...for NPs, PAs, you got to have some experience. I mean, I know NPs and PAs who come out of school who have a credential, but I practice medicine circles around them because of my experience. And so my main job is taking care of patients in the hospital after surgery. And it's - I have - I've had physicians tell me that I'm very competent, and, in fact, one guy said you're a better doctor than this other doctor. And I'm like, well, I'm not a doctor. You got to understand that. But it's a great option for people.

And I think in the future, you'll see that. It will be mid-level practitioners - PAs, NPs - who will - who you'll see for your general stuff, but those folks need to have a physician colleague - and most do. You know, even NPs who don't - in this state, don't require physician oversight. You know, the ones who are doing the right things are contacting their consultants and saying, you know, I got an issue I want to discuss with you, but there are some who don't. And it's...

CONAN: Phil...

PHIL: ...it's pretty amazing.

CONAN: Phil, thanks very much for the call. Appreciate it.

PHIL: Appreciate it.

Dr. RALSTON: I'd like - can I respond to that briefly?

CONAN: Very briefly if you could.

Dr. TRYBULSKI: Yeah.

Dr. RALSTON: I think he's pointed out that one of the key factors is for people to practice at their level of training, whether they're...

Dr. TRYBULSKI: Right.

Dr. RALSTON: ...physician's assistants, physicians or nurse practitioners, and then know when to ask for help. And that's not just nurses asking doctors for help. It may be doctors asking people in a different specialty, and I think your caller has pointed out one of the key elements of what we need to do in the future. And we need to have quality monitoring to sort of make sure that any individual practice is working well.

CONAN: That's Fred Ralston of the American College of Physicians, a practicing internist himself. Also with us is JoAnn Trybulski, who's associate dean of the master's nursing program and doctor of nursing programs at the University of Miami, and Rosa Gonzalez-Guarda, who's the assistant professor at the University of Miami School of Nursing and a member of the panel that came up with the IOM committee report "The Future of Nursing." You're listening to TALK OF THE NATION from NPR News.

And let's go to Sarah(ph). Sarah with us from San Francisco.

SARAH (Caller): Hi. Thanks for taking my call. Great show. I just want to get back to nursing since we're talking about nurses. This question is for Rosa and JoAnn. The Nursing Code of Ethics is pretty clear in distinguishing between collaboration between disciplines, not just cooperating. And in order to preserve nursing's unique contribution to health care, will a model for future health care systems utilizing nursing in a broader scope be a collaborative model or simply back to the medical model with nursing merely cooperating? I mean, does better-trained nurses mean training in the medical model and getting away from our nursing roots? And I'll take my call off the air.

CONAN: Okay. Thanks very much. Rosa, JoAnn, who wants to start with that?

Dr. TRYBULSKI: I think I'll start. Absolutely not. It doesn't mean that nurses will be trained more in the medical model. We have an excellent way of preparing our nurse practitioners, currently, that grounds them in the nursing discipline and teaches them and models collaboration with all types of health care providers. I think it's important to recognize that nurse practitioners are not educated in the classroom and merely turned loose. But over the course of their education, they have gradually-graded clinical experiences with increasingly expecting them to make independent decisions.

And at every juncture, faculty is monitoring their ability to assume an increasingly independent role. And if we do not see that as faculty, we take steps to make sure that that student does not progress to an advanced practice nurse. We recognize the difference and the really great responsibility that being an advanced practice nurse entails.

CONAN: Here's...

Prof. GONZALEZ-GUARDA: If I can add something.

CONAN: Rosa Gonzalez-Guarda, go ahead please.

Prof. GONZALEZ-GUARDA: Thank you. One of the things that we did look at during the process of putting together our recommendations was the current nursing educational system. And we did find evidence that there was a lack, currently, in terms of our ability to train interdisciplinary health care providers. We didn't see a lot of evidence of course work or opportunities for nurses to be in a classroom and in clinical experiences with medical students, physical therapy students, psychology students et cetera. So, one of the things that we are recommending is that nursing education, along with education for other health care providers, needs to bolster these opportunities that they provide to their students.

CONAN: Rosa Gonzalez-Guarda, a member of the panel for the Institute of Medicine that issued the report "The Future of Nursing: Leading Change, Advancing Health." There's a link to that report on our website. You can go to npr.org and click on TALK OF THE NATION. She's also assistant professor at the University of Miami's School of Nursing and Health Studies and joined us today from the studios of member station WLRN.

We're going to ask JoAnn Trybulski and Dr. Fred Ralston to stay with us for a couple more minutes to take a call and maybe an email about the future of nursing, and we'll also debrief Jackie Northam about her most recent visit to Afghanistan. Stay with us. I'm Neal Conan. TALK OF THE NATION from NPR News.

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CONAN: Right now, we're continuing our conversation about expanding the role of nurses. Our guests are JoAnn Trybulski, who's an associate dean of the master's nursing program and doctor of nursing program at the University of Miami. Also with us is Dr. Fred Ralston, a practicing internist and president of the American College of Physicians. And let's see if we can get another caller on the line. This is Katie(ph). Katie with us from Little Rock.

KATIE (Caller): Hi. Thanks for taking my call. I'm really enjoying this discussion on nursing.

CONAN: Go ahead.

KATIE: I'm a registered nurse here in Little Rock. I'm in school to finish up my bachelor's of nursing and taking some graduate courses to become an advanced practice nurse. My question is about, you know, the different levels of education of nurses. I know here in Arkansas, we have registered nurses, diploma nurses that are registered nurses all the way up to bachelor's-degree-educated nurses, and I was also interested in hearing about - I've heard that in order to get an advanced practice licensure, I believe, it's around 2015 that a Ph.D. in nursing will be required. I was wondering if the panel could comment on that.

CONAN: JoAnn Trybulski, that seems to be up your alley.

Dr. TRYBULSKI: Yes, it does. Actually, there has been this statement out that by 2015 nurse practitioners should be prepared with their DNP, or doctor of nursing practice degree. It was felt that as nurse practitioners were educated that their increasing educational experiences were far in excess of the credits that's normally required to receive a master's degree. And then - therefore, it was proposed that they be educated with this new practice-focused doctorate degree that would focus on nursing practice.

I think it's important to understand about the DNP degree that it's not just for nurse practitioners, that it really is a degree for nursing that focuses on nursing practice, on health care system delivery and creating innovation for health care reform and health care delivery.

So it is a very interesting degree. I believe there is a lot of discussion going on within the nursing community about when that degree will be required for what type of our nursing practitioners. And it's a very exciting movement because the DNPs currently complete a capstone project, and they're required to vision or create an innovation for nursing practice or health care. So it's a very exciting opportunity for nursing...

CONAN: Katie, is that something...

Dr. TRYBULSKI: ...to impact the discussion.

CONAN: ...you might be interested in?

KATIE: Yeah, it is actually one of the options. I think the closest to me would be the University of Memphis for a DNP program. But, yeah, it definitely seems like it's taking the profession a step forward, and that's really what needs to be done to advance ourselves and our profession because it is truly a profession. And I think that it will, you know, benefit not only our profession but society as a whole because, you know, it's needed. And it's the future of health care.

CONAN: Thanks very much for the call, Katie. Good luck.

KATIE: Thank you.

CONAN: And Katie's point: It's a long way from Little Rock to Memphis. The shortage of nurse educators, JoAnn Trybulski, is that going to be a bottleneck as you're trying to get more of these advanced degrees?

Dr. TRYBULSKI: Well, we're trying to be very creative in how we deliver and offer these degrees. For instance, our DNP program at the University of Miami is offered over one long weekend a month. That will allow students to travel to us from great distances, and we've been very successful with that model. We're also talking about how to change how we offer our master's degree programs to a similar executive model that would allow people to travel to the university to receive their education. And we feel that that might be a way of actually expanding opportunity for people to increase their level of education in the nursing discipline.

CONAN: And we have an email from Melissa that I wanted to get Dr. Ralston to come in. I am a geriatric and adult nurse practitioner in Arizona. Nurse practitioners in this state have a broad Nurse Practice Act partly due to the fact that there are many rural areas that have a lack of physician coverage. I'm able to write prescriptions, including controlled substances, order and interpret tests, and diagnose and treat common illnesses in the geriatric population.

I've been practicing for 20 years and have great relationships with both patients I've cared for and the physicians with whom I work, and specialists to whom I refer. Though there's always pushback from physicians that feel threatened by us, I've experienced little of that, fortunately. Particularly in geriatrics, there's a huge need for practitioners with geriatric experience as it's different than caring for younger forks. My hope is that nurse practitioners and physicians will go into geriatrics in the future.

And looking at the demographics of the country, Dr. Ralston, well, she's right. We're going to need a lot of both.

Dr. RALSTON: Well, first of all, I'd like to congratulate her for her dedication in her practice. And I believe that within the medical community and the nursing community, those of us who work together on a day-to-day basis generally have very good relations. And I think there are - while there are exceptions as pointed out by the earlier caller...

CONAN: Mm-hmm.

Dr. RALSTON: You know, we're all in this together. And we have a lot of challenges, and regardless of our background, doctors, nurses and everyone else needs to work together. But your emailer also points out the tremendous need for more people involved in geriatric care and just in primary care in general. And if we look at the crisis facing our country as far as health care costs, prevention is so much more cost-effective and is so much more appropriate with good quality of life for everyone, but particularly the elderly.

CONAN: Dr. Ralston, thanks very much for your time today. We appreciate it.

Dr. RALSTON: Thank you.

CONAN: Fred Ralston, president of the American College of Physicians. There's a link to the response from the American College of Physicians at our website. Again, you can go to npr.org. Click on TALK OF THE NATION.

He's a practicing internist at Fayette Medical Associates in Fayetteville, Tennessee. Our thanks also to Joan Trybulski, associate dean of the masters and doctor of nursing programs at the University of Miami, a licensed nurse practitioner and an advanced practice registered nurse. And she joined us from WLRN, our member station in Miami. Joanne, thanks very much for your time.

Dr. TRYBULSKI: Thank you.

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