There been a lot of heated and sometimes unprofessional discourse about the VA Advanced Practice Registered Nurses proposed rule (open for comments until July 25th) but not many folks have actually read the full rule language. In my opinion, it contains nothing to provoke anger or disrespect. There is nothing to take personally. There are no insults to any professional groups’ abilities or intentions. It is just a policy proposal, with which you may agree or disagree. Many people have strong feelings on the policy, but there is no need for vitriol.

Let’s take a look:

anesthesiologists save lives


First, what is the scope of the proposal? “VA is proposing to exercise Federal preemption of State nursing licensure laws” meaning the rule would replace physician oversight “regardless of individual State restrictions that limit such full practice authority”. Maybe I am a political nerd, but I personally find this an interesting federalism issue – that is, a potential conflict of national vs state powers. The VA represents the largest single healthcare system in the US, so the outcome – whatever it is – will have broad impact in all 50 states.

Second, what does “full practice authority” without “physician oversight” mean? It is spelled out nicely. Here’s the description:

“In proposed § 17.415(d)(1)(i), a Certified Nurse Practitioner would have full practice authority to provide the following services: comprehensive histories, physical examinations and other health assessment and screening activities; diagnose, treat, and manage patients with acute and chronic illnesses and diseases; order, perform, supervise, and interpret laboratory and imaging studies; prescribe medication and durable medical equipment and; make appropriate referrals for patients and families; and aid in health promotion, disease prevention, health education, and counseling as well as the diagnosis and management of acute and chronic diseases.

In proposed § 17.415(d)(1)(ii), a Certified Registered Nurse Anesthetist would have full practice authority to provide a patient’s anesthesia care and anesthesia related care, to include planning and initiating anesthetic techniques (general, regional, local) and sedation, providing post anesthesia evaluation and discharge; ordering and evaluating diagnostic tests; requesting consultations; performing point-of-care testing; and responding to emergency situations for airway management.

In proposed § 17.415(d)(1)(iii), a Clinical Nurse Specialist would have full practice authority to provide diagnosis and treatment of health or illness states, disease management, health promotion, and prevention of illness and risk behaviors among individuals, families, groups, and communities within their scope of practice.

Lastly, in proposed § 17.415(d)(1)(iv), a Certified Nurse-Midwife would have full practice authority to provide a full range of primary health care services to women veterans, including gynecologic care, family planning service, preconception care (care that women veterans receive before becoming pregnant, including reducing the risk of birth defects and other problems such as the treatment of diabetes and high blood pressure), prenatal and postpartum care, childbirth, and care of a newborn… [and] include treating the partner of the female patient for sexually transmitted infection and reproductive health. We would include the services of a CNM in this rule making in anticipation that VA would hire CNMs at a future date to improve access to health care for the increasing number of female veterans.”

So, in my mind, instead of attacking one another, let’s consider the actual policy implications. Some relevant questions are 1) whether the federal rules should pre-empt state laws about physician oversight, and 2) whether you think the above four paragraphs describe the practice of medicine or not.

laws determine scope of practice

The practice of nursing vs the practice of medicine

Many people are surprised to learn that legislation and rules like this actually determine scope of practice for just about all clinicians (physicians, chiropractors, nurses, etc). As part of the proposed rule, the “VA may grant full practice authority…and define the scope of full practice authority… VA intends that the services would be consistent with the nursing profession’s standards of practice.” So, as long as the official bodies of the nursing profession say that certain activities are the practice of nursing, this VA rule can make it so, and they will overrule any existing laws in your state that say otherwise. This is the same general process for establishing scope of practice for most healthcare professionals in their own domains (ex chiropractors, optometrists, podiatrists, pharmacists), although usually at the state level.

If those four definitions above describe nursing, then there is no reason to debate. If the activities are the practice of medicine, then someone with a medical degree and medical training should be involved. Obviously, not all clinicians agree on this, and I’m not sure what the patients think. But without question, both medicine and nursing have evolved considerably over time, and will continue to do so forever.

What is the practice of medicine? Here’s a New England Journal of Medicine article from 1937 on that subject, and a more recent discussion in JAMA. We can consult everyone’s favorite – Wikipedia – or just turn on the TV and be inundated with ads reminding you that “this product is not intended to diagnose, treat, cure, or prevent any disease” – which are among what the FDA considers to be markers of “medicine”.

emergency surgery


Other key issues in healthcare are access to care and cost of care, which is clearly a problem. As the rule emphasizes, cost and access are among the chief driving forces in the proposal: “This rulemaking would increase veterans’ access to VA health care by expanding the pool of qualified health care professionals who are authorized to provide health care… without the clinical supervision of physicians.”

This conversation gets so easily derailed into insults about one professional group vs another, which I think dishonors us all. The goal is to make healthcare better, safer, and easy to obtain when needed. Bonus points for controlling cost. We all want to give the very best care possible to our patients, regardless of education, training, or initials after our names. Teamwork.

Just two weeks ago, at the IARS meeting, we were discussing the state of healthcare quality and safety research. In a somewhat paradoxical conversation, we agreed that the very best outcome of our work would be to make the practice of medicine and healthcare systems so safe and so good that we essentially make ourselves (doctors) obsolete. It would be fantastic to live in a world in which no one is harmed as a result of well-intended healthcare. Yet, just recently, there were major headlines about the study indicating that error is the #3 cause of death in the US.

If we can ever achieve a level of wellness, health, and healthcare safety such that physicians are no longer needed, it will be a great day for humanity. I don’t think we are there yet. But we are working on it.

The VA wants input on this issue. If you have an opinion, you must comment before July 25, 2016 at (be sure to reference to “RIN 2900-AP44-Advanced Practice Registered Nurses”). You can also submit comments via or

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