After the Journal of Medical Education was renamed Academic Medicine in the mid-1980s, the journal began to publish articles (both essays and research reports) focusing on a much wider range of topics than before. Although health policy was identified as one of those topics, very few policy-oriented articles have appeared in the journal over the years, primarily because the members of the health policy community have not viewed Academic Medicine as one of the journals to which they should submit their work. Given that, I was delighted when Tim Garson, MD, vice president and dean of the School of Medicine at the University of Virginia, offered to help pull together a collection of articles addressing some of the important contemporary health policy issues facing the country. I was also pleased when Tim agreed to serve as the guest editor for these articles, which appear in this issue of the journal.
We hope these articles will offer the leadership of academic medicine useful information and ideas about some of the major health policy issues facing the country. Each of the authors was asked to provide not only an analysis of a particular policy issue, but also, importantly, to give some recommendations for how the academic medicine community might contribute to the development of a solution for that issue. I hope the journal’s readers will pay special attention to those recommendations, in particular, those that urge the medical education community to do a better job educating students and residents about the important health policy issues confronting this country’s leaders. I don’t see how we can expect the next generation of physicians to become effective participants in shaping policy solutions that will serve the public if medical educators don’t do a better job exposing students and residents to the critical issues involved. I hope this collection of articles will be a valuable resource as they strive to do so.
One of the policy issues currently receiving a great deal of attention within the academic medicine community is whether the future size of the physician workforce will be adequate to meet the needs of the public for medical care services. The article by Salsberg and Grover provides an excellent overview of the topic and sets forth a number of specific issues that the academic medicine community must confront if the needs of the public are to be met. The authors focus attention on what I believe is a particularly critical question: How much of the future demand for medical services will be met by physicians? If the projections of physician shortages are even close to being accurate, more and more of the services now being provided by physicians will have to be provided by nonphysicians. This presents a major challenge that the profession and policy-makers alike will have to confront to bring about this change in roles, one that I explore in the rest of this editorial: How will the roles of advanced practice nurses (APNs) and other health professionals be defined in the future? In this regard, it is worth noting that the nursing profession is currently reconceptualizing how it views APNs’ roles and is redefining the educational requirements to become an APN. Since I suspect that few of the journal’s readers are familiar with this movement within the nursing profession, a few introductory comments are in order.
APNs fall into one of four major categories: nurse anesthetist, nurse midwife, nurse practitioner, and clinical nurse specialist. At the present time, a registered nurse can become an APN by completing an accredited, advanced training program in one of those fields. Most of the programs are based in colleges and universities and offer a masters degree in nursing. In most states, licensing bodies define the scope of practice that the APNs can engage in. In many states, completion of the advanced training program and certification as an APN by a professional certifying body is required to allow a program graduate to be licensed, or otherwise authorized, to engage in a specific scope of practice.
The major nursing organizations have now agreed that in the future a nurse who wishes to become an APN will have to complete a doctoral program (DNP – Doctor of Nurse Practice). A large number of universities are now developing those programs, and accrediting bodies are formulating criteria to be used in accrediting the programs. There are a number of critical issues yet to be resolved regarding the nature of the programs, how the scope of the graduates’ practices will be defined, and how program graduates will be licensed or authorized to engage in a particular scope of practice. Nevertheless, it seems virtually certain that the graduates will provide a number of services that have traditionally been viewed as being solely within the domain of physicians, and will do so in independent practice settings. Therein lies a major challenge for the leadership of the medical and nursing professions, as well as for government officials.
How each of those groups responds to the APN movement now under way will have a major impact on how health care will be provided in the future. Because the shortage of physicians projected by many physician workforce analysts will likely affect primary care medicine most dramatically, the scope of practice privileges awarded to APNs with doctoral degrees will certainly overlap those held by family physicians, general internists, and general pediatricians. But many APNs will continue to provide primary care services (using the IOM’s definition of primary care*) to patients currently being cared for by specialists and subspecialists in other disciplines as well. Thus, it seems likely that APNs engaged in independent practice will become fully integrated throughout the health care delivery system. As this movement progresses, it is critically important that the leadership of the nursing profession be responsible in deciding on the nature of the programs that will prepare APNs for an expanded scope of practice. Perhaps most important, that leadership must ensure that the programs provide clinical experiences that will adequately prepare their doctoral candidates for the scope of care they will be responsible for in their future practices.
So what should the academic medicine community do to help address this critical issue? I think the leadership should begin meeting with their counterparts in the academic nursing community to explore ways to work together to ensure that APNs will be adequately trained to carry out the scope of practice they will be authorized to conduct, and at the same time ensure that future physician practitioners are prepared to work with APNs in a highly collaborative manner. This will require a willingness on the part of department chairs and program directors to design clinical training experiences to allow APNs and resident physicians to train together. For example, as academic medical centers develop chronic disease management programs, it will be important to ensure that APN doctoral students and resident physicians can train together. This approach would go a long way to providing the kinds of interprofessional educational programs that have been called for by the IOM and others to ensure that patients will be well served in the future by teams of health professionals working collaboratively.
Finally, I think the academic medicine and nursing communities should attempt to see to it that the medical profession as a whole responds to this issue in a highly responsible manner. I am aware that some state medical societies are actively opposing the development of DNP programs by colleges and universities and the granting of an expanded scope of practice to APNs by state officials. While I understand the objection that many practitioners have to this movement, I believe it is wrong for the profession to try to block the APN movement. Since the supply of physicians will not be adequate to care for the increasing population of patients with chronic diseases, academic medicine’s leadership must place the needs of patients in the forefront and work with the leadership of nursing to determine how best to provide the care those patients will need. It is simply unacceptable to have the needs of those patients go unmet.
Michael E. Whitcomb, MD
1 Institute of Medicine Committee on the Future of Primary Care. Primary Care: America’s Health in a New Era. Washington, DC: National Academy Press, 1996.
* “Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”1