The Medical Society of Virginia (MSV) serves as the voice for more than 30,000 physicians, residents, medical students, physician assistants and physician assistant students, representing all medical specialties in all regions of the Commonwealth. These clinicians deliver health care each day to the millions of residents of the Commonwealth. The MSV appreciates the opportunity to provide comment on House Bill 793. 

House Bill 793 will allow nurse practitioners the ability to transition to practice without maintaining a practice agreement with a patient care team physician.  Our members work with their nurse practitioner colleagues each day and believe they are valuable members of the patient care team. The MSV believes the regulations must ensure all practitioners are prepared to deliver care that meets Virginia’s standard of care requirements. Patients deserve to be assured that every health care provider that practices autonomously has the requisite experience to provide safe and high quality care. With the wide variation in nurse practitioner programs, the regulations must require that a nurse practitioner who seeks to practice autonomously is appropriately prepared and can meet the necessary core competencies. Thus, MSV surveyed physicians and physician assistants across practice settings, practice size, and specialties for feedback.

Physicians and other clinicians provided feedback on the following issues:

• Strongly support matching identical or similar physician specialty to a nurse practitioner specialty;
• Identifying the core competencies, educational requirements, and clinical experience needed for nurse practitioners through the attestation process;
• Statutory requirement on physician relationship for emergencies or referrals; and
• Physician liability for attestation.

Similar specialties and patient care population

First, it is important to note lines 341-344 of the law provide that a nurse practitioner seeking to practice without an agreement must have worked with “a patient care team physician who routinely practiced with a patient population and in a practice area included within the category for which the nurse practitioner was certified and licensed.” The medical community believes it is of the utmost importance that the regulatory standards ensure that the physician-nurse practitioner training must require alignment either between similar patient population and/or the national certification category for each practitioner. The MSV has developed a crosswalk for consideration as a basic framework. For those nurse practitioners without a nationally certified specialty, the Joint Boards must create a strong process to consider their educational and practical experience.

We also have concerns that any one physician will be able to provide the requisite training. In the current process of practice agreements, the nurse practitioner practices in a given clinical location where many resources are available and new situations can be immediately addressed by a practicing physician.

Core Competencies

Physicians are prepared to practice autonomously after four years of medical school, five to seven years of a specialized residency program, and standardized national testing that ensures their ability to safely care for patients. Only after rigorous training, testing, and supervision by expert clinical faculty, are physicians permitted to practice independently. Medical school was revolutionized after the Flexner Report[i] in 1910 which found that medical schools as a for-profit enterprise did not yield positive results. Under this model, physicians’ level of practice was variable at best, and incompetent and harmful at its worst. This is relevant as we consider the impact of various education models on patient care. The medical community is very concerned about achieving and maintaining a sufficient standard for core competencies for all practitioners who practice autonomously.

Understanding these core competencies such as differential diagnosis, clinical pharmacology, identifying and managing multiple co-morbidities and referral protocol are vital in practicing independently. Further suggestions are attached in Appendix A for your consideration. The medical community requests that you develop a robust standard that defines competencies that should be met and are equivalent of at least five years of full-time clinical experience.  It is important that such a knowledge base be determined by the Joint Boards of Medicine and Nursing in order to provide full confidence in public safety.  Annual review of hours and monitoring of a nurse practitioner as they move through the attestation process would ensure that their training has met these high standards.  This knowledge base and a plan for transition to practice should be specified at the onset of the transition to practice period of training.

To ensure the required clinical experience meets the aforementioned standards, a nurse practitioner at the start of the five year period, should submit to the Joint Boards of Nursing and Medicine a plan that outlines how they will meet the education and training requirements as established in the final regulations.

Emergency Referrals and Liability

Under the current system of care, the patient care team physician and nurse practitioner have an established partnership to address complex cases or emergencies. As individual nurse practitioners transition on their own, they will be required to “establish a plan for referral of complex medical cases and emergencies to physicians or other appropriate health care providers.” The MSV strongly supports patients having access to the most appropriate health care provider, especially for complex or emergency issues; there is concern about how this will be accomplished. Physicians are concerned about the management of this relationship. Will they unknowingly be designated as part of a nurse practitioner’s plan? Who would be accountable for the care of the patient?  Do these physicians have to be readily available at all times?  Is the physician able to review the patient panel and records regularly? These questions all lead to concerns of patients’ well-being.

Physicians are also concerned about the potential for liability.  As illustrated in the questions above, what legal responsibility are they incurring as a result of being unofficially associated with a nurse practitioner? Further, there are concerns about their potential liability regarding attestation. The attestation must be carefully constructed so that physicians are attesting only to the completion of the required time while being of the same specialty and/or treating the same population; it is the responsibility of the Joint Boards to ensure competency for nurse practitioners. Currently, Virginia statute provides that a physician is not liable solely for being a patient care team physician; the regulations need to extend this same liability protection to physicians for signing off on attestation.

The Medical Society of Virginia appreciates the opportunity to provide comments on this important issue. Should you have questions or need additional information, please do not hesitate to reach out to Ralston King (rking@msv.org).

Sincerely,

Kurtis S. Elward, M.D., M.P.H., FAAFP

President

Medical Society of Virginia

[i] Cooke, M., Irby, D., Sullivan, W., Ludmerer, K. (2006) American Medical Education 100 Years After the Flexner Report. New England Journal of Medicine, 355:1339-1344. Retrieved from  https://www.nejm.org/doi/full/10.1056/NEJMra055445