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Long Island

A fight to let nurses practice without doctor oversight

Nurse practitioner Margaret

Nurse practitioner Margaret "Peg" O'Donnell does an ear examination in her Lynbrook practice on Carol Croce of Oceanside. (June 9, 2010) Photo Credit: KEVIN P. COUGHLIN

Marion Golden specializes in family practice, treating patients with a wide range of conditions -- diabetes, high blood pressure and Lyme disease. She has 1,000 patients in her care.

But she isn't a medical doctor.

Golden is a nurse practitioner with a doctorate in nursing practice. Yet under state law, she must have a physician regularly review her patients' charts and the medications she prescribes. Such review, known as a "collaborative agreement," must be filed with the state Department of Education.

Golden and other nurse practitioners are hoping that will change. A bill in the state legislature is one of several measures across the country that are part of a move toward more health care being administered by nurse practitioners, whose ranks have grown nationally from 125,000 two years ago to 140,000 now.

The state bill would allow the state's 14,000 nurse practitioners -- some 2,800 of them on Long Island -- to work without physician oversight.

Supporters say strengthening nurses' roles will reduce health care costs while still providing good medical care in a system flooded with new patients under health care reform, and a shortage of primary care physicians.

Opponents, including the American Medical Association, say it would compromise health care by putting it in the hands of lesser trained professionals. If the legislation passes, New York would become the 14th state to allow nurse practitioners to work without supervision by physicians. Similar measures are making their way through legislatures in 27 other states.

Many physicians note medical doctors still undergo far more years of education and training. "It's like saying someone who took a short course can have the same knowledge as someone who went through years and years of training," said Dr. Leah S. McCormack, president of the Medical Society of the State of New York in Lake Success.

About 4.7 percent of nurse practitioners have doctorates, said Mary Jo Goolsby, of the American Academy of Nurse Practitioners. The rest hold master's in advanced practice nursing.


Where the bill stands


The proposed change to the New York law is sponsored in the Assembly by Richard Gottfried (D-Manhattan) and in the Senate by Velmanette Montgomery (D-Brooklyn). Both measures are before each house's higher education committee.

Barbara Bartoletti, legislative director of the League of Women Voters, said the fact that the legislation has yet to be taken up by either the full Senate or Assembly makes passage this year extremely unlikely.

But she said because of the health care reform bill passed by Congress, the need for additional primary caregivers will boost the chances of the nurse practitioner legislation in next year's Albany session. "This is a bill whose time has come," she said.

Seth Gordon, president and chief executive of the Nurse Practitioner Association of New York State, representing the state's 14,000 nurse practitioners, said these people are filling "a gaping hole" created by a shortage of primary care physicians.

Sen. Brian Foley (D-Blue Point), a co-sponsor of the measure, said it would help patients by expanding options, and "recognize the advanced level of training and certification these professionals obtain in order to practice."

Yet even as the nurses push for change they've opened a turf war with doctors. Medical organizations including the American Medical Association have mounted a potent counterattack against the pending legislation here and in other states.


Arguments for and against


McCormack sees the move as part of an age-old problem: Members of allied health fields expand their scope of practice by having state laws rewritten. "If they wanted to practice medicine they should have gone to medical school," McCormack said.

McCormack says for the sake of patient health and safety, it's important to maintain the status quo. "Why are they so bound and possessed, so adamant to get the right to practice independently?" she asked. "Is it really so onerous to have a physician checking on them? I would think they would want that."

Peg O'Donnell, a Lynbrook nurse practitioner certified to treat adults, countered: "We don't want to take spots away from anyone. It's not really us against them. We just our want our piece of the health care pie." She said any illness that requires a specialist -- from cancer to heart disease -- is immediately referred to one.

O'Donnell, who is in practice with a primary care physician, sees mostly patients with diabetes, high cholesterol and high blood pressure. "I am educated to diagnose and treat," she said. "With the collaborative agreement, the physician only reviews what I've done retrospectively."

Nurses like O'Donnell cite research confirming nurse practitioners provide care comparable to primary care physicians. A decade-old Columbia University study, still the only one of its kind, compared primary care services administered to 1,300 patients seen in a Manhattan emergency room over six months. Half were assigned to nurse practitioners; the others to primary care physicians. Results showed patient outcomes were similar, and that patients were pleased with services provided by both.

But McCormack said nurse practitioners are not as well-equipped as physicians to understand the nuances of human disease that lead to proper, sometimes difficult, diagnoses. "They don't know what they don't know," she said.


The cost of care


Whatever the arguments for or against, nurse practitioners cost the health care system less. Medicare and Medicaid pay for nurse practitioner services, but 15 percent lower than physicians, according to the Center for Medicare and Medicaid Services.

Many private insurers also reimburse nurse practitioner services at a lower rate. Aetna announced earlier this month it would align its reimbursements with the federal center, paying for practitioner services at 85 percent the rate paid to physicians.

Pat Sullivan, a nurse practitioner in Long Beach, makes house calls. "I am not a visiting nurse. My specialty is geriatrics and family medicine," she said. "I am board-certified in both."

But physicians argue that nursing is different from medicine and that the depth and science behind human disorders take years to learn. Medical education in the United States requires a bachelor's degree with a strong emphasis in the sciences, then four years of medical school and residencies ranging anywhere from three to five additional years.

"We believe that allowing [nurse practitioners] to increase their scope of practice without also increasing their level of education and postgraduate training will ultimately be detrimental to the health and safety of patients in the state of New York," wrote Dr. Sonia Rivera-Martinez, president of the New York State Osteopathic Medical Society, and Dr. Larry Wickless, president of the American Osteopathic Association, urging a defeat of the bill.

Golden believes her patients appreciate the care she provides. "They don't understand why I need a collaborative agreement when I have a private practice. I introduce myself as Dr. Golden, nurse practitioner. I want to let patients know I can function autonomously."

With Martin C. Evans and James T. Madore


Who are nurse practitioners?





  • Registered Nurses (RN) who earn a baccalaureate degree from an accredited college nursing program.



  • In addition, they are required to have a master's degree from an accredited institution in advanced practice nursing.



  • Must become certified by New York State, by passing a series of examinations, to diagnose, prescribe and treat a variety of patient conditions.



  • They are licensed to prescribe medications, including controlled substances, administer immunizations, flu shots and other injections.



  • Nurse practitioners order, perform and interpret diagnostic tests such as X-rays and lab tests.



  • The practitioners do not perform surgery or complex invasive procedures, like angiograms.



  • In addition to treatment, nurse practitioners focus on prevention and patient education.



SOURCE: Nurse Practitioner Association of New York State


How many nurses?


2,800: The approximate number of nurse practitioners here on Long Island, the largest concentration in the state

8,000: The number of new nurse practitioners who graduate each year in the U.S. Most are trained as primary care providers

14,000: Total number of nurse practitioners in New York State

140,000: The estimated number of nurse practitioners in U.S.


Areas of specialty


Nurse practitioners broken down by field of medicine:

Family practice: 49 percent

Adult medicine (ages 18-64): 18 percent

Women's health: 9.1 percent

Pediatric: 9.4 percent

Geriatrics: 3.0 percent

Acute care: 5.3 percent

Psychiatric/mental health: 2.9 percent

Neonatal: 2.3 percent

Oncology: 1.0 percent

SOURCE: American Academy of Nurse Practitioners

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