1. TAFP
POLICY
BRIEF
The Question of Independent
Diagnosis and Prescriptive
Authority for Advanced Practice
Registered Nurses in Texas: Is the
Reward Worth the Risk?
By Marie-Elizabeth Ramas, M.D.
Texas faces a growing demand for primary care to extend independent diagnostic and prescriptive
services, particularly in rural and underserved regions. authority to APRNs in the state of Texas. While such
The Texas Department of State Health Services re- action may be politically expedient in the short term,
ports that 16,830 primary care physicians were in active the risks outweigh what may be a hollow reward.
practice in Texas in 2009, or approximately 68 for ev- Many reforms implemented by the Texas Legis-
ery 100,000 people. The national average is 81 primary lature in recent sessions are successfully shifting the
care physicians per 100,000 population. This short- state’s health care delivery system in a direction sup-
age is compounded by a prevalent maldistribution of ported by acclaimed medical and economic research,
physicians across the state. Of Texas’ 254 counties, toward the integration of care in a collaborative, team-
118 were considered whole county health professional based model in which all aspects of a patient’s care
shortage areas, or HPSAs, and 71 contained either spe- are coordinated across multiple settings and various
cial populations or geographic areas that qualified for health care providers. Such an efficient system based
the designation of partial-county HPSA. Twenty-six on a solid primary care foundation leads to improved
counties had no primary care physician in 2009.1 quality, reduced errors, and fewer instances of unnec-
In recent years, organizations representing ad- essary care and duplication of services, resulting in
vanced practice registered nurses, or APRNs, have lower costs.2, 3, 4, 5 Allowing APRNs to practice medical
pursued policy changes that would allow these practi- acts independently would fracture that transition, in-
tioners to provide medical services independently, ar- creasing the fragmentation of care Texans experience.
guing that such changes would help alleviate physician Furthermore, redefining the educational and li-
shortages. Despite assertions that APRNs function as censure standard required to conduct medical acts so
effectively as physicians, there exists little if any sub- that APRNs can practice independently will not guar-
stantial objective information to support these claims. antee that Texans will have greater access to primary
Given the impending addition of even greater care. No data exists to support claims that APRNs are
stress on the state’s health care delivery system, it is more likely to practice in underserved areas, though
clear that a comprehensive discussion of how to in- significant evidence shows they tend to preferentially
crease access to primary care throughout the state is distribute in metropolitan and suburban communities
necessary. One seemingly logical solution would be at a similar rate to other health care providers.
Published by the Texas Academy of Family Physicians, Feb. 16, 2011. This research was made possible in part by the
TAFP Foundation through the James C. Martin, M.D. Scholarship. © 2011 Texas Academy of Family Physicians.

2. Should the Legislature decide to grant APRNs The term “nurse” usually encompasses all levels
independent practice, the state may experience an of nursing training. This includes certified nurs-
unintended erosion of its primary care workforce, ing aides, who perform non-medical acts mostly in
as students interested in primary care eschew the a supportive role for patients incapable or unable to
rigorous educational requirements and financial in- perform basic activities of daily living, and licensed
vestment of medical education in favor of the easier, vocational nurses, or LVNs, who usually obtain cer-
shorter, and less costly pursuit of nurse practice. tification within one year, as described in the Texas
Occupations Code, and who may work in medical
Definition Under the Nurse Practice Act settings with the ability to administer medications
To properly discuss the prospect of expanding the or treatments as ordered by a physician. One who
scope of practice of APRNs, it is important to clarify works with a bachelor’s degree in nursing, a BSN, has
the roles of the different levels of nursing in the state completed a four-year degree including the basic sci-
of Texas. Not all nurses are created equal. By defini- ences, limited pharmacology, some clinical exposure,
tion under Title 3, Subtitle E, Chapter 301, Section and has completed a standardized test.
301.002(2), Occupations Code (Nurse Practice Act): APRNs include a variety of subcategories of nurs-
ing that require extended training, usually on a mas-
“Professional nursing” means the perfor- ter’s level, which comprises up to two additional
mance of an act that requires substantial years of school and more clinical exposure. Examples
specialized judgment and skill, the proper of APRNs include certified nurse midwives, nurse
performance of which is based on knowledge anesthetists, and nurse practitioners. Nurse practi-
and application of the principles of biologi- tioners are further grouped into subspecialties that
cal, physical, and social science as acquired range from general or family practice to hematology
by a completed course in an approved school and oncology. Although many unofficial subspecial-
of professional nursing. The term does not ties for nurse practitioners exist, nine are recognized
include acts of medical diagnosis or the by the most widely used credentialing service, the
prescription of therapeutic or corrective American Nursing Credentialing Center: acute care
measures. Professional nursing involves: (A) NPs, adult NPs, adult psychiatric and mental health
the observation, assessment, intervention, NPs, diabetes management NPs, family NPs, family
evaluation, rehabilitation, care and counsel, psychiatric and mental health NPs, gerontological
or health teachings of a person who is ill, NPs, pediatric NPs, and school NPs.6
injured, infirm, or experiencing a change Requisites to obtain an advanced degree are del-
in normal health processes; (B) the mainte- egated by each state nursing board, but generally re-
nance of health or prevention of illness; (C) quire at least one year of extra schooling that focuses
the administration of a medication or treat- on pathophysiology and pharmacology, and some
ment as ordered by a physician, podiatrist, clinical exposure. For the purposes of this paper, at-
or dentist; (D) the supervision or teaching of tention will focus on primary care nurse practitio-
nursing; (E) the administration, supervision, ners, which represent general, geriatric and pediatric
and evaluation of nursing practices, policies, NPs. While obstetrics is considered a primary care
and procedures; (F) the requesting, receiving, service, certified nurse midwives cover this aspect of
signing for, and distribution of prescription nursing rather than nurse practitioners.
drug samples to patients at sites in which
a registered nurse is authorized to sign Comparing the Education of Nurse
prescription drug orders as provided by Sub- Practitioners and Family Physicians
chapter B, Chapter 157; (G) the performance Little data exists comparing the quality and cost of
of an act delegated by a physician under care provided by nurse practitioners, but the difference
Section 157.052, 157.053, 157.054, 157.0541, in training is starkly evident. Nurse practitioner training
157.0542, 157.058, or 157.059; and (H) the programs vary greatly in the quality and requirements of
development of the nursing care plan. their curricula and lack national standardization, espe-
cially in comparison to the highly standardized process
It is important to note that by definition, a nurse’s of medical training. While one NP program may allow
scope of practice does not include independent diag- for a degree online with a few hours of clinical expo-
nosis and treatment of disease processes. These two sure, another, such as the UT-Austin Nurse Practitioner
functions are distinctly reserved for physicians under program, requires 48 credit hours and 720 hours of ad-
Texas law, and are considered medical acts. ditional clinical exposure with a licensed provider.7
page 2

3. Figure 1: DEgREEs REquiRED anD TiME To CoMplETion
Undergraduate Entrance exam Post-graduate Residency TOTAL TIME FOR
degree schooling and duration COMPLETION
Family physician Standard 4-year Medical College 4 years, doctoral REQUIRED, 11 years
(M.D. or D.O.) BA/BS Admissions Test program 3 years minimum
(MCAT) (M.D. or D.O.)
Nurse practitioner Standard 4-year Graduate Record 1.5 – 3 years, NONE 5.5 – 7 years
BA/BS* Examination (GRE) master’s program
& National Council (MSN)
Licensure Exam for
Registered Nurses
(NCLEX-RN) required
for MSN programs
MEDiCal/pRofEssional sChool anD REsiDEnCy/posT-gRaDuaTE houRs foR CoMplETion
Lecture hours Study hours Combined hours Residency hours TOTAL HOURS
(pre-clinical years) (pre-clinical years) (clinical years)
Family physician 2,700 3,000** 6,000 9,000 – 10,000 20,700 – 21,700
Doctorate 800 – 1,600 1,500 – 2,250** 500 – 1,500 0 2,800 – 5,350
of Nursing Practice
Difference between 1,100 – 1,900 750 – 1,500 4,500 – 5,500 9,000 – 10,000 15,350 – 18,900
FP and NP hours of more for FPs more for FPs more for FPs more for FPs more for FPs
professional training
* While a standard 4-year degree, preferably a BSN, is recommended, alternate pathways exist for an RN without a bachelor’s degree to enter some
master’s programs.
** Estimate based on 750 hours of study dedicated by a student per year.
Sources: Vanderbilt University Family Nurse Practitioner Program information, http://www.nursing.vanderbilt.edu/msn/fnp_plan.html, and the Vanderbilt University School
of Nursing Handbook 2009-2010, http://www.nursing.vanderbilt.edu/current/handbook.pdf.
American Academy of Family Physicians, Primary Health Care Professionals: A Comparison, http://www.aafp.org/online/en/home/media/kits/fp-np.html.
During their education, nurse practitioners experi- for practice and suggests several areas where NP edu-
ence between 500 and 1,500 hours of clinical training. cational programs need to be strengthened.”9
At the completion of medical school and residency
training, a family physician has experienced between Geographic Distribution and Primary
15,000 and 16,000 clinical hours.8 (Figures 1, 2) Care Productivity of Nurse Practitioners
A 2007 study published in the American Journal Compared to Family Physicians
of Nurse Practitioners reported that more than half Organizations hoping to win independent practice
of practicing nurse practitioners responding to a sur- for NPs argue that with such an expansion in their
vey believed they were “only somewhat or minimally scope of practice, NPs would be more likely than other
prepared to practice” after completing either a mas- health care providers to practice in rural and under-
ter’s or a certificate program. In the area of pharma- served regions, though no evidence exists to support
cology, 46 percent reported they were not “generally the claim. In Texas, NPs can practice nursing in any
or well prepared” for practice. “In no uncertain terms, location they choose with total independence. Should
respondents indicated that they desired and needed they wish to practice medical acts, they must do so by
more out of their clinical education, in terms of con- receiving standing delegation orders from a supervis-
tent, clinical experience, and competency testing,” ing physician. Depending upon where they wish to
the authors wrote. “Our results indicate that formal practice, requirements to satisfy the supervisory rules
NP education is not preparing new NPs to feel ready vary. If the clinic is in an underserved region, the su-
page 3

4. Figure 2: clINIcAl TRAININg houRs DuRINg A FAmIly PhysIcIAN’s eDucATIoN
Medical school Medical school Family medicine residency
Undergraduate degree years 1 & 2 years 3 & 4 3 years
4 years (pre-clinical years) (clinical years) 9,000 – 10,000 clinical hours
6,000 clinical hours
Year 1 2 3 4 5 6 7 8 9 10 11
Physicians are not allowed to diagnose,
clINIcAl TRAININg houRs DuRINg A NuRse treat, or prescribe independently until they
PRAcTITIoNeR’s eDucATIoN have logged 15,000 to 16,000 clinical hours.
Master’s program Nurse practitioner organizations argue
Undergraduate degree or Doctor of Nursing Practice
that APNs are prepared to diagnose and
4 years 1.5 – 3 years
500 – 1,500 clinical hours
prescribe independently after logging
between 500 and 1,500 clinical hours.
pervising physician must visit the clinic during busi- terns are no different than that of Texas, with vast
ness hours at least once every 10 business days for the expanses of HPSAs where patients have scant access
purpose of observation, and must review at least 10 to primary care.11, 12, 13, 14, 15 (Figures 3 and 4)
percent of the NPs’ patient charts. Even these meager Proponents of independent diagnosis and pre-
safeguards can be waived by the Texas Medical Board scriptive authority for NPs frequently argue that NPs
if petitioned. Yet the distribution of NPs across Texas can alleviate the lack of access to primary care services
follows the same pattern as that of physicians, with the many Texans experience. In reality, NPs across the
vast majority choosing to practice in metropolitan and country are choosing to enter more lucrative subspe-
suburban communities. cialties rather than remaining in primary care, a trend
DSHS reports that in 2009, 5,745 NPs were in ac- prevalent among physicians as well. One recent study
tive practice in Texas, though the report does not published in the journal Health Affairs estimates that
distinguish how many of these practiced primary fewer than half of all nurse practitioners in the United
care and how many practiced in subspecialties. The States practice in office-based primary care settings,
number of NPs per 100,000 population was 25.1 in and reports that 42 percent of patient visits to nurse
metropolitan non-border areas, but only 8.3 in rural practitioners and physician assistants in office-based
border regions.10 practices are in the offices of specialists.16
States that have granted NPs the authority to in- Robert C. Bowman, M.D., professor of family med-
dependently diagnose patients and prescribe phar- icine at the A.T. Still School of Osteopathic Medicine
maceuticals for treatment have not experienced in Arizona and noted expert on the nation’s physician
significant migrations of NPs into underserved re- workforce, reports that since 2004, the number of
gions. The American Medical Association has con- nurse practitioners entering primary care has dropped
ducted extensive geographic distribution studies by 40 percent. To measure the productivity of various
in all 50 states, concluding that NPs and physicians health care providers over their careers, Bowman de-
tend to distribute in the same patterns, regardless signed a formula to calculate what he calls the standard
of the states’ levels of supervisory safeguards on the primary care year. Using this measurement, Bowman
practice of medicine by NPs. Evidence of these simi- found that family physicians deliver 29.3 standard pri-
lar practice patterns is demonstrated in AMA geo- mary care years over an expected 35-year career, while
graphic distribution maps in Figure 4. Utah, Oregon, nurse practitioners deliver only three standard prima-
Idaho, and Arizona are four states that allow NPs to ry care years. According to Bowman, it would take al-
diagnose and prescribe without ever collaborating most 10 nurse practitioners to equal the primary care
with physicians, and their practice distribution pat- productivity of one family physician.17
page 4

5. Figure 3: geogRAPhIc DIsTRIbuTIoN oF PRImARy cARe PhysIcIANs comPAReD
To ADvANceD PRAcTIce RegIsTeReD NuRses IN TexAs
The location of one
or more actively
practicing primary
care physicians
(n = 14,837)
The location of one
or more actively
practicing advanced
practice registered
nurses
(n = 6,560)
Full Health Profes-
sional Shortage Area
county
Partial Health Profes-
sional Shortage Area
SOURCE: American Medical Association, American
Osteopathic Association, and the Texas Board of Nursing.
“Texas Primary Care Physician to Advanced Practice
Registered Nurse Distribution Comparison.” National Center
for the Analysis of Healthcare Data. 2008.
A Lack of Credible Research Comparing Care The Fallacy of Possible Cost Savings
Delivered by NPs to Physicians Delivered by NPs
Supporters of expanding scope of practice for nurse Proponents of independent practice for NPs also ar-
practitioners quote studies that suggest a higher level of gue that such a policy change would result in reduced
patient satisfaction and no difference in outcomes when health spending, presumably based on the knowledge
comparing primary care services delivered by NPs to that NPs earn less than physicians. The Cochrane re-
those of family physicians. In 2004, the Cochrane Review view suggests that this differential may be offset by in-
analyzed this literature, screening 4,253 articles, and find- creased utilization of services and referrals by NPs.19
ing 25 that related to 16 studies that met their inclusion This assertion was confirmed in a study by the
criteria. While the authors concluded the review sug- American College of Physicians that compared utili-
gested that “appropriately trained” nurses could produce zation rates among physicians, residents, and nurse
as high of quality of care as primary care physicians, “this practitioners in the journal Effective Clinical Prac-
conclusion should be viewed with caution given that tice. Researchers showed that utilization of medical
only one study was powered to assess equivalence of services was higher for patients assigned to nurse
care, many studies had methodological limitations, and practitioners than for patients assigned to medical
patient follow-up was generally 12 months or less.”18 residents in 14 of 17 utilization measures, and higher
Because the phenomenon of states granting in 10 of 17 measures when compared with patients
APRNs independent practice is relatively young, these assigned to attending physicians. The patient group
studies measure the work of NPs who have practiced assigned to nurse practitioners in the study expe-
for some amount of time in collaboration with physi- rienced 13 more hospitalizations annually for each
cians. There simply are no studies that measure the 100 patients and 108 more specialty visits per year
quality of care provided by NPs who never learn from per 100 patients than the patient cohort receiving
or work with physicians. care from physicians.20
page 5

6. Figure 4: geogRAPhIc DIsTRIbuTIoN oF PRImARy cARe PhysIcIANs comPAReD To
ADvANceD PRAcTIce RegIsTeReD NuRses IN IDAho, oRegoN, ARIzoNA, AND uTAh
The location of one or more
actively practicing primary
care physicians
The location of one or more
actively practicing advanced Portland
practice registered nurses
Full HPSA county
Partial HPSA
Boise
Salt Lake City
Phoenix
Tucson
SOURCES: American Medical Association, American Osteopathic Association, and the Idaho Board of Nursing. “Idaho Primary Care Physician to Advanced
Practice Registered Nurse Distribution Comparison.”
AMA, AOA, and the Oregon State Board of Nursing. “Oregon Primary Care Physician to Advanced Practice Registered Nurse Distribution Comparison.”
AMA, AOA, and the Arizona State Board of Nursing. “Arizona Primary Care Physician to Advanced Practice Registered Nurse Distribution Comparison.”
AMA, AOA, and Utah Division of Occupational and Professional Licensing. “Utah Primary Care Physician to Advanced Practice Registered Nurse Distribution
Comparison.” National Center for the Analysis of Healthcare Data. 2008. All maps courtesy of the American Medical Association.
page 6

7. Policy Considerations
In deciding whether to allow NPs to practice In other words, isn’t some level of health care bet-
medicine without medical degrees, or the knowledge ter than none at all? We believe short-term solutions
and skills acquired over thousands of hours spent in will harbor long-term consequences. For instance, if
residency training, legislators should consider the fewer physicians practice primary care, leaving those
following policy questions. valuable services to NPs, who will provide general
surgery and other complex procedures in the small
1. Does the Texas Board of Nursing have the capac- safety net hospitals providing care to rural commu-
ity and the expertise to regulate the practice nities? Today, those hospitals depend on family phy-
of medicine by NPs? Is the Nurse Practice Act sicians to perform such services. The answer to the
a sufficient statutory document to contain the scope-of-practice question therefore must encom-
regulation of medical practice by nurse prac- pass a distinct and deliberate vision for creating a
titioners? If granted the authority to practice better landscape for primary care delivery for Texas.
medicine, should nurse practitioners do so under The American Academy of Family Physicians
the regulatory aegis of the Medical Practice Act, may have described this vision best in a January 2011
and should they receive licensure and oversight letter to the Institutes of Medicine and the Robert
through the Texas Medical Board? Wood Johnson Foundation: “Today, optimal care is
best provided in a team-based setting with different
2. In the interest of safety and quality, should the health care professionals working together. There-
state set a minimum standard of education and fore, the goal should be to develop collaborative,
training to receive an APRN degree and license? team-based models that allow every member of the
Today, a medical school graduate cannot receive team to practice to the full level of his or her training
a license to practice medicine independently. He while recognizing important differences among team
or she must complete residency training before members in background and skills.”
being granted a license to practice independently. While APRNs are trained to emphasize health
However, newly licensed NPs have only complet- promotion, patient education, and disease preven-
ed about the same number of years of education tion, they lack the broader and deeper expertise
as a third-year medical student, and many would needed to recognize cases in which multiple symp-
argue that the education obtained during those toms suggest more serious conditions. The primary
years is far from comparable. care physician is expertly trained to provide complex
differential diagnosis, develop a treatment plan that
3. If the Legislature grants NPs the authority to prac- addresses multiple organ systems, and order and in-
tice medicine independently and without achiev- terpret tests within the context of the patient’s over-
ing the standard of training, examination, and all health condition.
licensure currently required to do so, what will APRNs are a vital part of Texas’ health care work-
become of the state’s future supply of primary care force. As part of a team dedicated to improving the
physicians? Put bluntly, why would anyone choose health of our citizens, nurse practitioners collaborate
to enter medical school after earning a bachelor’s with physicians to increase access to well-coordinat-
degree, to work 80-hour weeks for little pay for ed medical care in communities across the state. It is
three years in a primary care residency, to incur all no secret that Texas suffers from a shortage of pri-
of the educational debt required to achieve such mary care physicians, and that we must find ways to
a high level of education, all while delaying their increase the number of physicians, nurse practitio-
optimum earning potential for seven or more ners, and registered nurses practicing primary care
years when all they have to do to practice medi- to meet that need. But granting nurse practitioners
cine is become an NP? If the state elects to grant the authority to diagnose, treat, and prescribe with-
the privilege and responsibility of medical practice out any physician collaboration is not the solution to
to people other than physicians, what damage will Texas’ primary care workforce shortage.
be done to what is already a depleted primary care Rather, the Legislature should continue to sup-
physician workforce? port the numerous programs past Legislatures initi-
ated to encourage our best and brightest to become
As Texas grapples with the implications of inad- primary care physicians, and to increase integration
equate access to primary care in some parts of the and coordination of our health care delivery system
state, it is easy to consider whether lawmakers should so that every Texan has a primary care medical home.
agree to settle for something rather than nothing. That is the right answer for Texas.
page 7

8. eNDNoTes: 12. American Medical Association, American Osteo-
1. “Supply Trends Among Licensed Health Profes- pathic Association, and the Oregon State Board
sions, Texas, 1980 – 2009, Fourth Edition.” Texas of Nursing. “Oregon Primary Care Physician to
Department of State Health Services Health Advanced Practice Registered Nurse Distribution
Professions Resource Center. Accessed Feb. Comparison.” National Center for the Analysis of
11, 2011. <http://www.dshs.state.tx.us/CHS/ Healthcare Data. 2008.
HPRC/09trends.pdf> 13. American Medical Association, American
2. Baicker, Katherine and Chandra, Amitabh. Osteopathic Association, and the Idaho Board
“Medicare Spending, the Physician Workforce, of Nursing. “Idaho Primary Care Physician to
and Beneficiaries’ Quality of Care.” Health Affairs Advanced Practice Registered Nurse Distribution
Web exclusive w4.184 (7 April 2004): 184-197. Comparison.” National Center for the Analysis of
Healthcare Data. 2008.
3. Starfield, Barbara, et al. “The Effects of Special-
ist Supply on Populations’ Health: Assessing the 14. American Medical Association, American Osteo-
Evidence.” Health Affairs Web exclusive w5.97 (15 pathic Association, and the Arizona State Board
March 2005): 97-107. of Nursing. “Arizona Primary Care Physician to
Advanced Practice Registered Nurse Distribution
4. Beal, Anne C, et al. “Closing the Divide: How
Comparison.” National Center for the Analysis of
Medical Homes Promote Equity in Health Care:
Healthcare Data. 2008.
Results From the Commonwealth Fund 2006
Health Care Quality Survey.” The Common- 15. American Medical Association, American
wealth Fund. 2007. Osteopathic Association, and the Texas Board
of Nursing. “Texas Primary Care Physician to
5. Kravet, Steven J, et al. “Health Care Utilization
Advanced Practice Registered Nurse Distribution
and the Proportion of Primary Care Physicians.”
Comparison.” National Center for the Analysis of
American Journal of Medicine 121.2 (2008): 142-148.
Healthcare Data. 2008.
6. American Nurses Credentialing Center. Accredi-
16. Colwill, Jack M; Cultice, James M; and Kruse,
tation Board for Specialty Nursing Certification.
Robin L. “Will Generalist Physician Supply Meet
Accessed Feb. 11, 2011. <http://www.nursecreden-
Demands of an Increasing and Aging Popula-
tialing.org/certification.aspx#specialty>
tion?” Health Affairs, 27, no. 3. 2008: w232-w241.
7. The Univeristy of Texas at Austin School of
17. Bowman, Robert C. “Measuring primary care:
Nursing. Accessed Feb. 11, 2011. <http://www.
The standard primary care year.” Rural Remote
utexas.edu/nursing/html/prospective/programs_
Health. 2008 Jul-Sep;8(3):1009.
graduate.html>
18. Laurant, Miranda et al. “Substitution of Doctors
8. “Education and Training: Family Physicians and
by Nurses in Primary Care.” Cochrane Database
Nurse Practitioners.” Greg Martin. American
of Systematic Reviews. 2004, Issue 4. Art. No.:
Academy of Family Physicians. Accessed Feb. 11,
CD001271. DOI: 10.1002/14651858.CD001271.
2011. < http://www.aafp.org/online/etc/medialib/
pub2.
aafp_org/documents/press/nurse-practicioners/
nurse-practicioners-training.Par.0001.File.tmp/ 19. Ibid.
NP-Kit-FP-NP-UPDATED.pdf> 20. Hemani, Alnoor, et al. “A comparison of resource
9. Hart, Ann Marie, and Macnee, Carol L. “How utilization in nurse practitioners and physi-
well are nurse practitioners prepared for practice: cians.” Efficient Clinical Practice. 1999 Nov-Dec;
results of a 2004 questionnaire study.” Journal of 2(6):258-265.
the American Academy of Nurse Practitioners.
2007, Vol. 19, No. 1, p. 37. Marie-Elizabeth Ramas, M.D., is a third-year resident
10. Ibid. 1. at the Conroe Family Medicine Residency Program in
Conroe, Texas. As a National Health Service Corps
11. American Medical Association, American Osteo-
scholar, she is dedicated to serving the underserved.
pathic Association, and Utah Division of Occupa-
tional and Professional Licensing. “Utah Primary
The Texas Academy of Family Physicians Foundation
Care Physician to Advanced Practice Registered
supports educational and scientific initiatives for the
Nurse Distribution Comparison.” National Cen-
specialty of family medicine to improve the health of all
ter for the Analysis of Healthcare Data. 2008.
Americans. Visit www.tafp.org/foundation.
page 8

9. Primary Care Coalition Issue Brief: COLLABORATION BETWEEN
PHYSICIANS AND NURSES WORKS
Primary Care Coalition | 401 W 15th Street, Ste. 682, Austin, TX 78701 | (512) 370-1516
Compare the Education Gaps Between
Primary Care Physicians and Nurse Practitioners
While nurse practitioners are trained to emphasize health promotion, patient education, and disease
prevention, they lack the broader and deeper expertise needed to recognize cases in which multiple symptoms
suggest more serious conditions. The primary care physician is trained to provide complex differential
diagnosis, develop a treatment plan that addresses multiple organ systems, and order and interpret tests within
the context of the patient’s overall health condition.
This expertise is earned through the deep, rigorous study of medical science in the classroom and the thousands
of hours of clinical study in the exam room that medical students and residents must complete before being
allowed to practice medicine independently.
Because primary care physicians throughout the United States follow the same highly structured educational
path, complete the same coursework, and pass the same licensure examination, you know what you’re getting
with a physician. There is no such standard to achieve nurse practitioner certification, as their educational
requirements vary from program to program and from state to state.
Degrees requireD anD Time To CompleTion
Undergraduate Entrance exam Post-graduate Residency TOTAL TIME FOR
degree schooling and duration COMPLETION
Family physician Standard 4-year Medical College 4 years, doctoral REQUIRED, 11 years
(M.D. or D.O.) BA/BS Admissions Test program 3 years minimum
(MCAT) (M.D. or D.O.)
Nurse practitioner Standard 4-year Graduate Record 1.5 – 3 years, NONE 5.5 – 7 years
BA/BS* Examination (GRE) master’s program
& National Council (MSN)
Licensure Exam for
Registered Nurses
(NCLEX-RN) required
for MSN programs
meDiCal/professional sChool anD resiDenCy/posT-graDuaTe hours for CompleTion
Lecture hours Study hours Combined hours Residency hours TOTAL HOURS
(pre-clinical years) (pre-clinical years) (clinical years)
Family physician 2,700 3,000** 6,000 9,000 – 10,000 20,700 – 21,700
Doctorate 800 – 1,600 1,500 – 2,250** 500 – 1,500 0 2,800 – 5,350
of Nursing Practice
Difference between 1,100 – 1,900 750 – 1,500 4,500 – 5,500 9,000 – 10,000 15,350 – 18,900
FP and NP hours of more for FPs more for FPs more for FPs more for FPs more for fps
professional training
* While a standard 4-year degree, preferably a BSN, is recommended, alternate pathways exist for an RN without a bachelor’s degree to enter some
master’s programs.
** Estimate based on 750 hours of study dedicated by a student per year.
Sources: Vanderbilt University Family Nurse Practitioner Program information, http://www.nursing.vanderbilt.edu/msn/fnp_plan.html, and the Vanderbilt
University School of Nursing Handbook 2009-2010, http://www.nursing.vanderbilt.edu/current/handbook.pdf.
American Academy of Family Physicians, Primary Health Care Professionals: A Comparison, http://www.aafp.org/online/en/home/media/kits/fp-np.html.
• over •

10. CliniCal Training hours During a family physiCian’s eDuCaTion
Medical school Medical school Family medicine residency
Undergraduate degree years 1 & 2 years 3 & 4 3 years
4 years (pre-clinical years) (clinical years) 9,000 – 10,000 clinical hours
6,000 clinical hours
Year 1 2 3 4 5 6 7 8 9 10 11
Physicians are not allowed to
CliniCal Training hours During diagnose, treat, or prescribe
a nurse praCTiTioner’s eDuCaTion independently until they have logged
15,000 to 16,000 clinical hours.
Master’s program
Undergraduate degree or Doctor of Nursing Practice
4 years 1.5 – 3 years
Nurse practitioner organizations argue
500 – 1,500 clinical hours that APNs are prepared to diagnose and
prescribe independently after logging
between 500 and 1,500 clinical hours.
Nurse practitioners can achieve certification by completing an associate’s degree program or nursing diploma
program, and go directly into a master’s degree program—some of which can be completed online—or they can
complete their Bachelor of Science degree in nursing. At the point of certification, a new nurse practitioner has
acquired between 500 and 1,500 hours of clinical training, fewer than a third-year medical student. A new family
physician has acquired more than 15,000 hours of clinical training.
• A 2004 survey of practicing nurse practitioners published in the Journal of the American Academy of
Nurse Practitioners reported that in the area of pharmacology, 46% reported they were not “generally or
well prepared.”1
• From the study: “In no uncertain terms, respondents indicated that they desired and needed more out of
their clinical education, in terms of content, clinical experience, and competency testing.”1
• Also from the study: “Our results indicate that formal NP education is not preparing new NPs to feel ready
for practice and suggests several areas where NP educational programs need to be strengthened.”1
The complex chemistry and powerful therapeutics of modern pharmaceuticals require substantial expertise to
carefully titrate dosages and account for the very real risks of toxicity, therapeutic failure, chemical dependency,
adverse side effects from drug interactions, and simply wasting scarce health care resources through over- or
under-prescribing. Pharmacology and pharmacotherapy are closely integrated into every aspect of medical train-
ing, providing an educational foundation that far exceeds the nominal exposure nurse practitioner programs offer.
• A study on antibiotic prescribing published in the American Journal of Medicine in 2005 found that non-
physician clinicians were more likely to prescribe antibiotics than were practicing physicians (26.3% and
16.2%, respectively) in outpatient settings.2
• Another study suggested that many nurse practitioners had not received enough education in microbiology,
knowledge integral to effective treatment for bacterial, fungal, as well as viral disease.3
• A six-year study published in 2006 found that rural nurse practitioners were writing more prescriptions
than their urban nurse practitioner counterparts, physicians, and physician assistants.4
1. Hart A and Macnee C. “How well are nurse practitioners prepared for practice: results of a 2004 questionnaire study.” Journal of the
American Academy of Nurse Practitioners. 2007, Vol. 19, No. 1, p. 37.
2. Roumie C and Halasa N. “Differences in antibiotic prescribing among residents, physicians and non-physician clinicians.” American
Journal of Medicine. June 2005, Vol. 118, No. 6, pp. 641-648.
3. Sym D et al. “Characteristics of nurse practitioner curricula in the United States related to antimicrobial prescribing and resistance.”
Journal of the American Academy of Nurse Practitioners. September 2007, Vol. 19, No. 9, pp. 477-485.
4. Cipher D and Hooker R. “Prescribing trends by nurse practitioners and physician assistants in the United States.” Journal of the Amercian
Academy of Nurce Practitioners. June 2006, Vol. 18, No. 6, p.6.
The Primary Care Coalition is a partnership comprised of the Texas Academy of Family Physicians, the Texas Pediatric Society,
and the Texas Chapter of the American College of Physicians.

11. Primary Care Coalition Issue Brief: COLLABORATION BETWEEN
PHYSICIANS AND NURSES WORKS
Primary Care Coalition | 401 W 15th Street, Ste. 682, Austin, TX 78701 | (512) 370-1516
Primary Care Physicians Are the Most Likely Health Care
Professionals to Practice in Rural and Underserved Areas
According to the Robert Graham Center, people in non-metropolitan areas, especially in rural areas, depend on
family physicians more than any other specialty. Despite claims by nurse practitioners that they will practice
in rural and underserved communities if granted the ability to diagnose and prescribe independently, the data
suggest otherwise.
• Practice-mapping research conducted by the American Medical Association shows that patterns in practice
locations for nurse practitioners in states with independent practice are no different from those in states
that require collaboration between nurse practitioners and physicians.
• If granted independent practice, nurse practitioners would be practicing in the same economic
environment as family physicians, and the factors that make opening and maintaining a rural medical
practice will discourage nurse practitioners as well.
GeoGraphic DistributioN of The location of one or more actively practicing
primary care physicians (n = 14,837)
primary care physiciaNs aND
Nurse practitioNers iN texas The location of one or more actively practicing
advanced practice nurses (n = 6,560)
In Texas in 2009, the ratio of Full Health Professional Shortage Area county
primary care physicians per Partial Health Professional Shortage Area
100,000 people in counties
designated as Health Profes-
sional Shortage Areas was
32.8, while the ratio of nurse
practitioners per 100,000
people in those same counties
was 10.4.
Number of Nurse practitioNers per 100,000
populatioN iN texas iN 2009
Metropolitan non-border areas: 25.1
Metropolitan border areas: 17.0
Non-metropolitan non-border areas: 15.5
Non-metropolitan border areas: 8.3
• over •

12. Nurse Practitioners Will Not Be More Likely to Serve Rural and Border Areas
Than Primary Care Physicians if Granted Independent Practice
Sixteen states allow nurse practitioners to diagnose and prescribe without any physician collabo-
ration. Four of those that feature metropolitan areas and large, rural areas like Texas are Idaho,
Oregon, Arizona, and Utah. As is evident by the AMA practice distribution maps below, granting
independent practice to nurse practitioners does not change their tendency to practice in metro-
politan and suburban communities. According to a 2007 survey performed by Advance for Nurse
Practitioners, of 6,162 respondents, 77% reported that they practiced in cities or suburbs, while
only 23% practiced in a rural setting.
The location of one or more
actively practicing primary
care physicians
Portland
The location of one or more
actively practicing advanced
practice nurses
Full HPSA county
Partial HPSA
Boise
Salt Lake City
Phoenix
Tucson
The Primary Care Coalition is a partnership comprised of the Texas Academy of Family Physicians, the Texas Pediatric Society,
and the Texas Chapter of the American College of Physicians.

13. Primary Care Coalition Issue Brief: COLLABORATION BETWEEN
PHYSICIANS AND NURSES WORKS
Collaboration Between Physicians and Nurse
Practitioners Contains Health Care Costs
Bringing down the cost of care must be a major goal of any change in health care policy in Texas. The
integrated, well-coordinated care provided in a physician-led, patient-centered medical home has
proven time and again to result in healthier populations while saving money. The patient-centered
medical home depends on the skills, education, and expertise of a team of health care providers,
including nurse practitioners, caring for patients under the medical direction of primary care
physicians to succeed.
Contrary to the claims of nurse practitioner organizations, independent practice by nurse
practitioners would not lead to more efficient or cost-effective care; in fact, studies show the
opposite would be the likely outcome.
Because they lack the training and medical education of physicians, nurse practitioners tend to refer
patients to specialists and order expensive diagnostic tests at a higher rate when they are not working
with physicians.
A comparison of utilization rates among physicians, medical residents, and nurse practitioners in the
same setting showed that:
• Utilization of medical services was higher for patients assigned to nurse practitioners than for
patients assigned to residents in 14 of 17 utilization measures, and higher in 10 of 17 measures
when compared with patients assigned to attending physicians.1
• There was a 41% increased hospitalization rate in the nurse practitioner group, or 13 more
hospital admissions per 100 patients per year than the group receiving care from physicians.1
• There was a 25% increase in specialty visits in the nurse practitioner group, or 108 more visits
per 100 patients per year than the group receiving care from physicians.1
The researchers stated that the findings suggest that increased use of nurse practitioners as primary
care providers may lead to increased ordering of expensive diagnostic tests and higher rates of specialty
visits and hospital admissions for patients assigned to nurse practitioners.
• From the study: “The higher number of inpatient and specialty care resources utilized by
patients assigned to a nurse practitioner suggests that they may indeed have more difficulty with
managing patients on their own (even with physician supervision) and may rely more on other
services than physicians practicing in the same setting.”1
1. Hemani A, Rastegar DA, Hill C, et al. “A comparison of resource utilization in nurse practitioners and physicians.” Eff Clin
Pract. 1999 Nov-Dec; 2(6):258-265.
• over •

14. To Improve Access to High-quality, Cost-efficient Health Care,
Invest in Team-based, Integrated Care Led by Primary Care Physicians
When patient care is well-coordinated, as it is when provided in a patient-centered medical home led
by a primary care physician, it has proven to be of better quality and of lower cost. This model features
a team-based approach that relies on the appropriate use of nurse practitioners and other health care
providers in a collaborative practice designed to offer coordinated, efficient, and effective health care.
Consider the evidence represented by these results from across the country.
• Washington-based Group Health Cooperative implemented the patient-centered medical
home in 2009 and after one year, ER visits were reduced by 29% and ambulatory sensitive care
admissions were down by 11%.1
• Community Care of North Carolina has experienced a 40% decrease in hospitalizations for
asthma and a 16% lower ER visit rate after implementing the primary care medical home model
for Medicaid and SCHIP beneficiaries. Total savings in those programs are $135 million for TANF
populations and $400 million for the aged, blind, and disabled population.2, 3
• A leader in the delivery of high-quality, cost-effective health care, the Geisinger Health System in
Pennsylvania has shown a 14% reduction in total hospital admissions relative to controls, and a
9% reduction in total medical costs after only 24 months of operation under the PCMH model.4
• Intermountain Healthcare Medical Group began implementing a PCMH model in 2001. The
group has experienced a 10% relative reduction in total hospitalizations, with an even greater
reduction among patients with complex chronic illnesses. The net reduction in total costs was
$640 per patient per year, and $1,650 per year for each of the highest-risk patients.5
• The list of successes for communities implementing the physician-led, patient-centered primary
care medical home continues to grow. For more information, consult the Patient-centered
Primary Care Collaborative at www.pcpcc.net.
Advanced practice nurses are a vital part of Texas’ health care workforce. As part of a team dedicated to
improving the health of our citizens, nurse practitioners collaborate with physicians to increase access
to well-coordinated medical care in communities across the state. But allowing nurse practitioners to
diagnose, treat, and prescribe without any physician collaboration will only serve to further fragment the
chaotic and poorly coordinated health care delivery system Texans encounter.
Nurse practitioners and physicians have the same goal: to keep Texans healthy and productive, and
to ensure that when they need it, patients have access to safe, high-quality medical care. Nurses and
physicians provide the highest quality health care when they work together for the well-being of their
patients. They are a team, striving each day for the better health of Texans. This team should be supported
and kept together by state policies that have the best interests of the patient in mind.
1. Reid R, Fishman P, Yu O, et al. “A patient-centered medical home demonstration: a prospective, quasi-experimental, before and after
evaluation.” American Journal of Managed Care, September 2009.
2. BD Steiner et al, “Community Care of North Carolina: Improving care through community health networks.” Ann Fam Med 2008;6: 361-367.
3. Mercer. “Executive Summary, 2008 Community Care of North Carolina Evaluation.” Available at http://www.communitycarenc.com/
PDFDocs/Mercer%20ABD%20Report%20SFY08.pdf.
4. Geisinger Health System, presentation at White House roundtable on Advanced Models of Primary Care, August 10, 2009.
5. Dorr DA, Wilcox AB, Brunker CP, et al. “The effect of technology-supported, multidisease care management on the mortality and
hospitalization of seniors.” J Am Geriatr Soc. 2008;56(12):2195-202. Findings updated for presentation at White House roundtable on
Advanced Models of Primary Care, August 10, 2009.
These and other studies demonstrating the benefits and successes of the patient-centered medical home can be found in a study entitled,
“The Outcomes of Implementing Patient-Centered Medical Home Interventions: A Review of the Evidence on Quality, Access and Costs
from Recent Prospective Evaluation Studies,” published August 2009 by Kevin Grumbach, M.D., Thomas Bodenheimer, M.D., M.P.H.,
and Paul Grundy, M.D., M.P.H. It can be found online at http://www.pcpcc.net/content/pcmh-outcome-evidence-quality.
The Primary Care Coalition is a partnership comprised of the Texas Academy of Family Physicians, the Texas Pediatric Society,
and the Texas Chapter of the American College of Physicians.