AAFP Objects to Subspecialty Nurse Practitioner Referrals, Thoughts?

As nurse practitioners, we’re all well aware that there can be tension between NPs and MDs, particularly when it comes to organizations representing these professions. While nurse practitioners and physicians typically get along well in the workplace, a war wages behind the scenes as to the rights and privileges NPs should be granted. Physicians fight to keep a superior stake in the ground and maintain a hierarchy in medicine. A recent op-ed, I Referred My Patients to Subspecialists; So Why Did They See NPs?, posted on the American Academy of Family Physicians website takes an angle in the argument against nurse practitioners that I hadn’t previously considered.

Kimberly Becher, a physician working at a federally qualified health center in Clay County, WV, expresses frustration that she often refers patients for specialty care only to discover their specialty appointment is handled by a nurse practitioner. Rural patient populations like hers, she explains, have difficulty with access to care and go to great lengths, often traveling three hours in each direction, for a higher level of care. When patients have geographic and financial barriers to overcome, it “upsets” her to know that although she has worked hard to coordinate a visit to a subspecialist, the patient has a “less-than-ideal” experience. Dr. Becher continues on to say that she “finds it insulting when the patient is not evaluated by a fellowship-trained physician” when she has arranged a referral. Dr. Becher reasons that as a family practice physician she has more training than a nurse practitioner and doesn’t feel that evaluation or diagnosis by anyone other than a subspecialty physician “does [her] patients justice”.

In general, I tend to take a pretty balanced stance when it comes to the nurse practitioner-physician debate. I believe NPs overall provide excellent care. I acknowledge, however that we as nurse practitioners haven’t been to medical school. Our training is less extensive than that of physicians, so naturally we are not at the same level clinically. With experience, however, NPs do continue to grow and become increasingly stronger in the clinical setting where they practice. It’s for this reason that I take issue with Dr. Becher’s argument.

Many of my former nurse practitioner classmates have worked in highly specialized environments and have a substantial specialized knowledge base. A friend and former NP classmate of mine, for example, works in cardiology subspecializing in electrophysiology. Her experience in the field frequently puts her in the position of consulting with physicians. While these MDs have more formal medical education than this nurse practitioner, she has knowledge and experience in an area they do not, or at least not as extensively, making her a valuable resource.

The same phenomenon holds true for physicians themselves. An orthopedic surgeon friend of mine, for example, has years of medical school, residency and fellowship training under his belt. When his children suffer from rashes and common illnesses, however, he second guesses his diagnosis and treatment plan – primary care isn’t his wheelhouse.

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Medicine is a broad field and there’s an endless amount to learn. Physicians are trained differently than nurse practitioners. However, this doesn’t mean that NPs cannot become proficient working in subspecialties and provide helpful consultations and quality care for patients referred from primary care. Rather, we need to accept that providers of all kinds working in settings different than our own have valuable experience and specialized knowledge to share. In some cases, nurse practitioners will have a higher level of knowledge in certain areas than physicians working in other fields.

Just like nurse practitioners can practice proficiently in primary care, they can also receive the education, training and experience necessary to excel in specialty settings. What are your thoughts on the opinions published by the AAFP?


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5 thoughts on “AAFP Objects to Subspecialty Nurse Practitioner Referrals, Thoughts?”

  1. Buzz Jeansonne FNP

    What bothers me the most is the absolute hypocrisy. As the health policy chairperson for my state of Louisiana, I hear physicians rebut our education constantly in legislation. However when I refer Medicaid patients or indigent patients to our charity hospital those physicians that are contracted with the state for a better reimbursement of these underserved/ lower socioeconomic status patients send the nurse practitioner that works with them to evaluate them on a specialty reference. This also happens in private practice. So where are these physicians when we go to the state capitol attempting to remove collaborative practice agreement. Where are they arguing about educational levels when nurse practitioners are evaluating subspecialty patients for the first time? I’m guessing our educational level is good enough when the physician deems it necessary.

  2. I ran into that problem when I was an ENT nurse practitioner. I patient complained to her PCP and then her PCP contacted the CEO of the company I worked for. I then couldn’t see new patients after that and had to do follow ups which in ENT can be scarce. I ended up quiting my job when I was sitting around most of the day.

  3. Ellen Mitchell FNP

    I agree with Buzz. However, I have been on both sides of this argument. As the referring provider it goes back to feeling responsible for my patients welfare and my belief that speciality certification somehow provides some “vetting” of the provider in question. The bottom line always has to be patient welfare. We provide a service the primary care and ER can not provide. Our physician specialists and sub specialists cannot keep up with the work load without our help. We save lives, and based simply on that fact we are due gratitude and faith that we will provide the needed care for patients sent to us.

  4. What I find so shocking is the inability to recognize we all have limitations. At this stage of the game, we utilize all resources in order to ensure the highest possible outcomes for our patients. Is it the letters behind the providers name that are the most insulting? I’m curious if the reaction is the same when a patient referred sees a provider with DPT or PharmD behind their name. When a wound consult is placed & a certified wound care nurse decides the course of treatment for the largest organ in the body there isn’t any reaction but relief. How many times have we as providers looked at a CT or MRI technician and said , “what do ya think?” My response to her would simply be you need to develop a defined relationship with your referred providers to ensure your patient has the type of referral appointment you are expecting. However, a QA of referrals and results I have no doubt will show the same level of outcome. Shame…

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