The trouble with “supervision”

Nurses Pulling During Tug of War Competition

I’m a nurse practitioner, or NP. You may have heard of my kind.

We come up a lot in the media these days. Maybe it’s because NPs are going to save health care by filling the looming provider gap. Or because we’re going to ruin health care by filling that provider gap with undertrained, incompetent clinicians. MAYBE BOTH.

The volume’s been turned up lately on this line of dialogue because of the looming full implementation of the Affordable Care Act. Apparently, NPs* will either be the salvation or the undoing of the ACA, with its flood of new patients demanding health care services. As if there were millions of people who didn’t exist previously, and the ACA has willed them into existence. Even though I’m pretty sure it doesn’t extend coverage to zombies. If so, my apologies. The backlash makes a lot more sense now.

It could also be because it’s more likely than ever that you’ve seen one of us as your very own health care provider at some point. After all, there are 171,000 of us in practice here in the U.S. In fact, I’m willing to bet it’s 50/50 whether that inappropriate antibiotic prescription you got last week for your cold – oh, I’m sorry, bronchitis – came from an MD or an NP.

What I’m saying is, we’re everywhere. And once we’re in practice, we’re really not all that different from physicians when it comes to delivering primary care.


People in the “NPs need constant supervision, like small children – I’ve definitely seen them eating paste and coloring outside the lines and misdiagnosing and over-referring to specialists WITH MY OWN EYES” camp seem unwilling to admit that there are some pretty mediocre-to-lousy physicians out there too. Everyone makes mistakes; some people make them more often than others.

And people on the “NPs are sunshine and light and won’t kick your puppy on their way to a golf game after dismissing your puny concerns about your blood pressure” side are hesitant to admit that there are plenty of cold, rushed, and/or unpleasant NPs out there too.

What I’m saying is, we’re all just people.

Which is why I sort of hate the heated debate over the question of MD supervision of NPs, which is what every legislative battle over NP practice has been about since the profession came into existence. As a recap for those who might be unfamiliar with this concept, according to The Law, NPs can work with varying degrees of independence from physicians, depending entirely on the state where they’re licensed. In most states, NP practice is either completely independent or is expected to exist in “collaboration” with medicine, but in 12 states, your practice needs to be “supervised” by an MD. See how I put “supervised” in quotes there? Not an accident.

Now obviously, the very idea of mandating the supervision of an independently-licensed professional is somewhat condescending, but it’s also misleading. The phrase “MD supervision” suggests a physician peering over my shoulder constantly, wearing a hand-knotted white coat and one of those hats with the light on the front, checking all of my notes and prescriptions and probably reexamining my patients to ensure a certain level of quality of care.

This NEVER HAPPENS. Not even close.

When I’m caring for a patient, it’s just me and that patient in the room. I examine them. I diagnose them. And then: I write the prescriptions, and the note, using my name and my license. The only place my supervising physician’s name comes up on a daily basis is as an automatic attachment to each of my prescriptions – which, if you think about it, is kind of unfair to that MD, who was completely powerless over the decision to write it.

And yet, I can’t imagine practicing medicine (because let’s just be honest for a second, that’s what NPs are doing) in the vacuum of my own mind. I need to be able to walk out of that exam room and run a challenging clinical scenario by a trusted peer, whether that peer is an MD or an NP. I need to be able to collaborate with other providers, because collaboration makes everyone’s practice stronger. Whether I’m trying to decide if I should send a patient with probably-nothing-but-maybe-a-PE chest pain to the ED and want to run it by my MD officemate, or the physician down the hall comes to me for advice on managing abnormal vaginal bleeding in a patient who just started the pill, collaboration goes both ways.

I was reading an article today by a woman who left medicine because she just couldn’t deal with the pressure – the constant worry over “did I make the right call?” or “did I write the right dose?” or, ultimately, “will the patient get better or worse because of my care?” I, and every single clinician I know – regardless of their educational background or the letters at the end of their name – feel exactly the same way, all the time.

So when I hear about some new legislation to restrict or extend MD supervision of NP practice, my first (lazier) thought is to say, Well, this doesn’t really apply to me. I don’t particularly want to “hang my own shingle” anyhow. Thanks, but I’ll just keep reading HuffPo and watching the Real Housewives marathon instead of writing that letter to my state rep about HB29378130sdi293832b.

But writing that letter matters. And it doesn’t matter because I want to take a job away from a deserving physician, or because I plan to open my own practice, or BECAUSE SOCIALISM. I just want The Law that describes what I can and can’t do to reflect reality.

And if your provider is still eating paste, whether they have NP or MD after their name, I think we can all agree that they’re the ones that need a little more supervision.

*I don’t take the time to mention PAs here nearly as much as I should. But I would apply pretty much everything I said here about NPs to PAs as well. And on that note: is Physician Assistant not the most inappropriate name ever for what you do? It is absurd that your name wasn’t changed to Physician Associate years ago. You guys should get on that.


4 thoughts on “The trouble with “supervision”

  1. Pingback: Safe and Less Safe Breast Milk Sharing, Plus Some Notable New Blog Posts by Nurses | Off the Charts

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  3. NB: I am the least likely in my practice (myself the NP, and 3 physicians) to prescribe an antibiotic. I find a little extra explanation serves as a workable trade-off.

    • Seriously! Drives me crazy. Take the extra time to explain why/how/when we prescribe (or don’t prescribe) an antibiotic, and in the end the patient will often actually agree -> truly shared decision making

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