[NPInfo] St. Louis Post Dispatch

[David or Diane Dito]

Ah, Dave,

Hopefully you know I love and respect you for all the efforts you've made on
the behalf of both the NP and PA professions. That said, sometimes things
aren't black or white, or what they might appear.

My understanding is that the context of these comments were made in response
to a meeting of SNAP the previous week, SNAP being the St. Louis Nurses in
Advanced Practice. A business writer was either in attendance at that
meeting or asked to cover it...and the subject was prescriptive authority
for advanced practice nurses, with several prominent politicians and area
physicians speaking. This reporter's column ran just below the commentary
you forwarded to the list. (I will attach the reporter's column at the
bottom of this post.)

Given that fact, the three respondents probably were asked to comment
specifically on advanced practice nurses and prescriptive authority. As you
know with the media, if you're asked to respond to one thing--especially one
as complex as this--you need to stick to the topic or risk having your words
edited with the result possibly something you didn't mean to say. There are
strict space considerations in the newspaper. Further, you don't KNOW
without speaking to the two advanced practice nurses (yes, both were female)
listed whether in fact they omitted mention of PAs. Another possibility is
they DID mention them and were edited for space.

I will tell you that when I replied to Dr. Hawatmeh's comments (my letter
ran in yesterday's Post-Dispatch in the business section), I debated long
and hard how I would respond and whether to discuss PA prescriptive
privileges as well. Because of space and the context in which the whole
discussion was presented, I chose to stick to the issues of the profession I
know best...right or wrong. I stuck to the point at hand, which is something
newspapers look for when determining which letters to run. Being a former
newspaper reporter and business writer, I know this from experience and
fact.

So, flame away, but please know that I don't think there was a deliberate
effort to exclude or slight PAs. I KNOW that wasn't my intent. And hopefully
you realize that in the vast majority of cases, I discuss our two
professions jointly and with utmost respect for my PA colleagues.

Diane Dito

See below for Mary Jo Feldstein's column from 10/31/07 followed by my reply
to Dr. Hawatmeh on 11/4/07:

Drug question part of bigger debate over independent nurses
By Mary Jo Feldstein
ST. LOUIS POST-DISPATCH
10/31/2007

Mary Jo Feldstein
[More columns]
[Mary Jo Feldstein's biography]

(P-D) 

Missouri is one of only three states that do not allow nurse practitioners
to prescribe controlled substances. So these medications, which include some
prescription cough syrups and pain relievers, must be prescribed by the
doctor supervising the nurse practitioner. 

Nurse practitioners and some physicians say this makes care less efficient.
In some rural areas where doctors are scarce, they say it prevents patients
from getting the medications they need.

Not everyone agrees. Other physicians say nurse practitioners don't have the
training to prescribe addictive medications and allowing them to do so could
harm patients. On several occasions, those physicians have convinced
legislators to shoot down bills changing the law.

So the nurse practitioners, through their political action committee, St.
Louis Nurses in Advanced Practice or SNAP, arranged a dinner last week. They
invited local state legislators.Advertisement
A few pharmaceutical companies, that might benefit from more people being
able to prescribe their drugs, helped pick up the tab.

The speakers included some of the region's most well-respected physicians -
Dr. Thomas Hale, chief executive of Mercy Medical Group, two Washington
University School of Medicine professors and an internist who has received
one of the government's top quality awards for doctors.

The physicians referenced reams of academic research. The data showed
patients cared for by nurse practitioners fared as well as those cared for
by physicians. 

After dinner, the legislators spoke. Many said the physicians' lobby is so
powerful the bills would be tough to pass.

Dr. David Campbell, who didn't attend the dinner, thinks nurse practitioners
should be able to prescribe most controlled substances and he thinks most
physicians agree. But doctors fear if nurse practitioners are able to
prescribe more medications, they'll want to become autonomous, he said. 

Next, they'll want to end the geographic restrictions that require them to
practice within a certain distance of an overseeing physician. Then, they
might want to practice, as some states allow, with no physician supervision.


Campbell would not support any of these scenarios. He believes physicians
and nurse practitioners must work in close collaboration. He fears those
arrangements already have become too loose, existing almost solely on paper.

Patti Sohn, who runs the Insta-clinic offices in many area Schnuck Market
Inc. stores, also helped organize the dinner. SNAP is focused on improving
access to health care, she said. Right now, that means expanding
prescriptive authority. SNAP won't rule out moving onto other issues later,
but there are no plans to do so at this time.

The push from nurse practitioners is occurring as nurse midwives and
psychologists want broader responsibilities as well.

"The legislature has just been barraged with what we refer to as scope of
practice issues," said Campbell, who also is president of the Missouri
Academy of Family Physicians. "Everybody's at the table wanting to be a
doctor with less training."

There's also a financial component. Family physicians, for example, get paid
almost the same for an ear infection as counseling a diabetic with heart
disease. Nurse practitioners can see those easier cases, receive the same
fee from the insurance company and earn less - boosting the physicians'
income. If nurse practitioners gain more autonomy, they'll take the extra
revenue with them.

So why not give nurse practitioners the responsibilities they can handle and
work for a payment system that compensates physicians for their higher level
of expertise?

"You have to try and deal with the cards you're dealt," Campbell said.
"You're talking about major change at a national level." 

Who should prescribe

controlled substances?

Dr. Sam Hawatmeh should check his facts before providing his "expert
diagnosis" ("Should nurses be able to prescribe controlled drugs in
Missouri?" Oct. 31). Advanced-practice nurses in Missouri must have a
master's degree in nursing and board certification by a state-approved
national organization, plus licensure and recognition by the Missouri Board
of Nursing, in order to practice. His statement, "State approval via the
Board of Nursing is not required!" is incorrect.

Further, Dr. Hawatmeh asserts that the Missouri General Assembly's "wisdom"
in refusing to allow advanced practice nurses the ability to prescribe
controlled substances "has withstood the test of time." However, he fails to
provide any objective evidence or data to support his statement. What has
been tested? To the contrary, several studies have demonstrated that nurse
practitioners deliver high-quality care in a safe manner. 

Nurse practitioners have passed "the test" for prescribing controlled
substances in 47 other states, including Illinois. Advanced-practice nurses
are well-versed and knowledgeable about the pharmacology and dangers of
prescribing not only controlled substances, but any other drug. 

It's time for Missouri legislators to wake up to the fact that patients are
the only ones suffering from their capitulation to the well-funded
physicians' lobby and its rhetoric. It's time to allow Missouri nurse
practitioners to adequately alleviate patients' pain in the same careful,
safe manner in which they address their other health care needs.

Diane Dito, RN | O'Fallon, Ill.

Diane Dito, RN, MSN, BC, ACNP, ANP-C, is a staff nurse practitioner in
emergency medicine at Washington University School of Medicine and a member
of the clinical faculty in the acute-care nurse practitioner program at St.
Louis University School of Nursing.


-----Original Message-----
From: npinfo-bounces at nurse.net [mailto:npinfo-bounces at nurse.net] On Behalf
Of David Mittman
Sent: Monday, November 05, 2007 3:33 PM
To: NPinfo
Subject: Re: [NPInfo] St. Louis Post Dispatch


As long as we don't oppose each other I am happy, when we work arm in arm I
am happier...... 
I also understand the realities of politics.
On the other hand, pointing out that PAs can prescribe schedule II drugs in
most states and I presume can not in MO  shows that this is not JUST about
NPs (one profession) and their ability/inability to practice from a medical
model (which the doc said) and moves it into the reality of turf protection.
Again, I think it's interesting that she did not point out that there are
other professions being kept from this along with APNs/NPs. And he did not
even acknowledge that PAs should NOT be able to at all. I hate being
invisible!!!! 
Dave 

On 11/5/07 3:59 PM, "Patty Summerford" <Patricia.Summerford at coxhealth.com>
wrote:

> Dave:
> 
> While you are absolutely right about the mention of PAs, I must come to
> this NP's defense.  We (NPs) are in a major legislative effort to obtain
> prescriptive authority for controlled substances and are in our 4th year
> in coming before the legislature.  We have gained many inroads but have
> a lot farther to go to combat the mis-information that a lot of the
> opposing physicians are spouting.  It is not that we have forgotten to
> include PAs in this fight , it is that we did not want to bring in any
> extraneous information to muddy the information we are trying to get out
> to the public.  The PAs  in our state realize that their authority
> usually follows our legislative actions.  I have found in Missouri that
> NPs and PAs  work very closely  together but each group tends to stay
> quiet regarding the other groups legislative efforts.
> 
> Patty Summerford, FNP
> Buffalo Family Health Care
> Buffalo, MO
> -----Original Message-----
> From: npinfo-bounces at nurse.net [mailto:npinfo-bounces at nurse.net] On
> Behalf Of David Mittman
> Sent: Monday, November 05, 2007 2:42 PM
> To: NPinfo
> Subject: Re: [NPInfo] St. Louis Post Dispatch
> 
> 
> Sorry about one thing.......this could be a male also. I jumped the  gun
> in
> my thinking.
> Dave
> On 11/5/07 3:36 PM, "David Mittman" <dmittman at comcast.net> wrote:
> 
>> 2 things caught my attention:
>> One-the docs letter which I presume was first.
>> Two-no mention of the PA profession in either letter-We need to teach
> this
>> lady the value of coalitions.
>> Dave
>> Should nurse practitioners be able to prescribe controlled drugs in
>> Missouri?
>> 
>> 
>> 10/31/2007
>> 
>> 
>> With a shortage of physicians, nurse practitioners can help fill the
> void.
>> 
>> Terry McQuaide, advanced nurse practitioner, Esse Health
>> 
>> As an advanced nurse practitioner with offices in Illinois and
> Missouri, I
>> have a unique perspective. My Illinois patients receive more efficient
> care
>> for issues such as bronchitis and acute back pain based on that
> state's law
>> regarding prescribing authority.
>> 
>> It is well established that care coordinated by a primary care
> physician or
>> nurse practitioner is higher quality and less costly for the patient
> and the
>> insurer. There is a shortage of primary care physicians, and nurse
>> practitioners are part of the solution to increase access to quality
> care. I
>> work in collaboration with a physician to manage all aspects of care
> for
>> hundreds of patients with chronic and acute illnesses.
>> Advertisement
>> 
>> 
>> It should be emphasized that restrictions are in place to curb abuse
> of
>> narcotics < not because nurse practitioners do not have the skills to
>> prescribe. In fact, nurse practitioners have in-depth training in
>> pharmacology and are scrutinized, as are physicians, to ensure
> appropriate
>> protocols are followed when prescribing any medication.
>> 
>> To put this in perspective: treatment for bronchitis can include cough
> syrup
>> with codeine, and back pain may require a pain medication. In
> Illinois,
>> after examination and diagnosis, I can write these prescriptions. In
>> Missouri, I need to delay the patient and interrupt the physician to
> have
>> him prescribe the medications. This creates unnecessary delays and may
>> require extra trips for the patient.
>> 
>> Allowing nurse practitioners to practice fully in partnership with
>> physicians will benefit patients by increasing access to quality care
> with
>> no negative impact in quality or safety.
>> 
>> Restrictions to nurse practitioners writing prescriptions hurts health
> care.
>> 
>> Karen Kelly, associate professor and coordinator, Continuing Education
> at
>> the School of Nursing, SIU Edwardsville
>> 
>> In 47 states, including Illinois, nurse practitioners are licensed
> under the
>> states' nurse practice acts to prescribe scheduled drugs. Illinois
> advanced
>> practice nurses gained prescriptive privileges for schedule III-V
> drugs in
>> 1998. In Illinois, the Nurse Practice Act "sunsets" every 10 years and
> must
>> be reviewed and renewed by the Illinois General Assembly.
>> 
>> The 2007 Illinois Nurse Practice Act, a product of the most recent
> "sunset,"
>> includes expansion of the prescriptive privileges of advanced practice
>> nurses to include schedule II drugs, for example Ritalin or narcotic
> pain
>> medications such as Demerol and Darvon. According to the American
> Academy of
>> Nurse Practitioners, only Missouri, Alabama, and Florida do not grant
>> advanced practice nurses scheduled drug prescriptive privileges. Even
>> Georgia, the last state to grant prescriptive privileges, grants
> scheduled
>> drug prescriptive privileges.
>> 
>> A significant body of research demonstrates the safety and efficacy of
> the
>> drug prescribing practices of advanced practice nurses. This
> restriction on
>> prescriptive privileges creates barriers to access to health care for
> those
>> patients who receive their care from advanced practice nurses. This
>> restriction, for example, prevents nurse practitioners who care for
> hospice
>> patients from managing patients' pain with narcotics. Additional
>> intervention by a physician is required for pain management, adding to
> the
>> cost and time needed to provide pain relief for hospice patients.
>> 
>> It is time for the Missouri legislature to allow nurse practitioners
> and
>> other advanced practice nurses, such as nurse anesthetists, to
> prescribe
>> scheduled drugs as allowed in all the states that surround Missouri.
>> 
> ------------------------------------------------------------------------
> ----
>> 
> ------------------------------------------------------------------------
> ----
>> ------------
>> Wisdom of Missouri's restrictions on nurses prescribing passes test of
> time.
>> 
>> Dr. Sam Hawatmeh, internist, St. Louis
>> 
>> Controlled substances are essentially narcotics and other addictive
> drugs;
>> they are dangerous. They must be prescribed only after a thorough
> medical
>> evaluation < not a nursing evaluation and with continued medical
>> re-evaluation < to consider dangerous interactions and side effects.
> The
>> Missouri General Assembly decided 12 years ago to not allow nurses to
>> prescribe these drugs. That wisdom has withstood the test of time.
>> 
>> Current law defines an advanced practice nurse as one with education
> beyond
>> basic nursing education certified by a nationally recognized
> professional
>> organization as having a nursing specialty. State approval via the
> Board of
>> Nursing is not required!
>> 
>> This means that any "nationally recognized" professional organization
> could
>> produce certifications for various nursing specialties, and
> immediately
>> qualify advanced practice nurses in Missouri. All would have
> controlled
>> substance prescriptive authority.
>> 
>> The nurses argue they would prescribe only pursuant to a collaborative
>> practice arrangement with a physician. However, it is important to
>> understand that such arrangements have no common standards and are not
>> closely regulated.
>> 
>> There also is a very real concern about illegal diversion of these
> drugs. At
>> a time when we're doing everything possible to restrict the
> availability of
>> dangerous drugs and substances used to manufacture meth?amphetamines,
> it is
>> incongruent to dramatically expand the number of individuals who can
>> prescribe these substances.
>> 
>> But the bottom line is patient safety. Controlled substances should be
>> prescribed only by licensed physicians, podiatrists and dentists.
>> 
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