April 24, 2020
By Dr. Murray Feldstein
Alice Smith, like many other healthcare workers, is exhausted these days. She starts in the morning at 6am, and she doesn’t stop for the next 12 hours—she’s either treating patients with COVID-19 or teaching others how to do it. A highly skilled nurse practitioner, she came to Arizona in the 1970s and worked on the Navajo and Hopi reservations in northern Arizona, and she met her husband, a physician, at an Indian Health Service hospital. Alice, who is both a certified Nurse Family Practitioner as well as a Certified Nurse Midwife, delivered babies and provided outstanding care to sick patients living in one of the most isolated places of our nation, often hours away from doctors and hospitals over unimproved roads.
Alice Smith is a pseudonym. Out of undeserved modesty and an aversion to celebrity, Alice refused to let me use her real name or anything that would allow people to identify her. I met her when I held a specialty clinic on the reservation several times a month over 40 years ago.
Alice and her husband left the reservation and moved to Flagstaff in the 1990s. She started her own community family practice. She semi-retired after her family had grown, and then she took a position with a community health clinic that cares for underserved, uninsured, and marginalized patients. She also began to focus on teaching and became active in local and statewide volunteer Medical Response Team services.
That was before the COVID-19 pandemic struck. As Alice puts it, she’s now again fully clinically engaged and “back in the trenches.” Navajos have been particularly hard-hit by the virus, and her community clinic is in the county with the highest death rate in the state.
The focus of Alice’s teaching is in developing an interprofessional curriculum for students from multiple health disciplines. Students from medical, osteopathic, pharmacy, physician-assistant, and nursing schools rotate for several months to the health clinic to learn community medicine firsthand. They work under supervision in mobile health clinics at shelters and schools, as well as health fairs for the homeless. The students attend classes together, learning about the growing number of areas where patient care is enhanced by a multi-disciplinary team approach. The didactic portion of their training is taken together in the same classroom from a team of nurse practitioners and physicians.
Alice has been an active member of the American Association of Nurse Practitioners for decades. She fights tirelessly in the struggle to enable certified nurse practitioners to practice at the top of their license—to permit them to legally provide the full spectrum of their desperately needed skills in a nation where many people don’t have access to affordable healthcare, even in the best of times.
Arizona is now among the 21 states where nurse practitioners have the won right to practice independently: They can write prescriptions and see their own patients without physician supervision. (However, they are compensated less than physicians for the same services.) Nurse practitioners are widely admired and enjoy high public approval ratings. Other states aren’t so lucky. More than half of states place needless restrictions on nurse practitioners’ “scope of practice.” This is because influential physician organizations oppose liberalizing the regulations, claiming that nurse practitioners are not competent enough to practice without physician oversight. Their assertions are unsubstantiated. They are not only inconsistent with numerous published studies to the contrary, but also with the experience of states like Arizona. Alice Smith is living proof that the medical doctor associations’ claims are wrong. Tellingly, in times of crisis, most states relax their arbitrary regulations.
New York and Louisiana, two states hit particularly hard by COVID-19, have temporarily suspended their regulations that prevent nurse practitioners from working independently. So have New Jersey, Kentucky, and Wisconsin. Of the 29 states that currently restrict nurse practitioners from independent practice, only 11, including California, have seen fit not to scale back at least some of the provisions that prevent nurse practitioners from bringing all of their skill and training into the battle against the virus. They choose to fight the virus with one hand tied behind the back rather than bringing them all on deck.
In New York City, people are emerging from their homes and apartments at the 7pm hospital change of shift to applaud doctors, nurses, and other healthcare providers. Alice is hopeful that the public’s admiration and respect for these heroes will carry over when the current emergency passes—but she isn’t holding her breath. Louisiana relaxed nurse practitioner regulations during Hurricane Katrina, only to reimpose them afterwards. While the federal government has done away with these unnecessary regulations in their veterans, army, and public health hospitals, she knows her profession still faces an uphill battle in state legislatures where century-old licensing restrictions are still enforced.
Until common sense prevails, Alice resigns herself to this absurd possibility: Some of the medical students she is now training during the pandemic will graduate with a medical doctor or doctor of osteopathic medicine degree and find themselves supervised by a more experienced nurse practitioner in one of the restrictive states. Once the emergency is over, that same nurse practitioner will not be able to practice unless a physician, even one with less experience, nominally supervises him or her. I know that there are thousands of capable of nurse practitioners just like Alice, and it is a dispiriting, tragic loss to our nation that politics prevents us from fully taking advantage of their talents and dedication.
Dr. Murray Feldstein is a Visiting Fellow at the Goldwater Institute.