We Need More Collaboration in Healthcare, Not Less

Op Ed By JOHN W. HALE, JR., MD


We Need More Collaboration in Healthcare, Not Less | Healing Arts Scope of Practice Task Force, Scope of Practice, Advanced Practice Registered Nurses, APRN, TMA, Tennessee Medical Association, Physician Supervision, TNA, Tennessee Nurses Association, John Hale, Carole Myers

JOHN W. HALE, JR., MD

Tennessee Public Chapter 1046 created an equally balanced task force of advanced practice nurses and practicing physicians to "make recommendations to the general assembly for the improvement of Tennessee residents' health by providing access to quality and cost effective care." The group first met in June 2016 and, after several meetings and other deliberations, will issue a few recommendations to the General Assembly for legislators to consider in 2017.

One thing the task force agreed on is that there are physicians and nurses in our state who are not following protocols for collaboration. These providers, regardless of the letters beside their names, are jeopardizing patient safety and quality of care and contributing to our state's prescription drug abuse epidemic. We need to remove "in name only" physician/APRN relationships and do a better job enforcing rules that are in most cases working well.

To achieve this, we need to increase communication and collaboration between the Board of Medical Examiners, Board of Osteopathic Medical Examination and the Board of Nursing. We need to increase funding to give these boards the lawyers, investigators and other resources they need to identify and prosecute bad actors. And we need to make it easier for APRNs to establish and maintain a collaborative relationship with a physician.

What we cannot do, however, is allow APRNs to practice without a collaborative relationship with a physician.

Doctors and APRNs serving on the task force struggled to find consensus in discussions that were masked as increasing patient access to care, but in fact centered on independent practice for APRNs in Tennessee.

Sometimes called "full practice authority," independent practice means giving APRNs the legal authority to treat and diagnose patients, prescribe medication, order tests, manage chronic illnesses and deliver other healthcare services, including those currently reserved for physicians, without physician supervision, oversight or collaboration. Current state laws require APRNs to establish and maintain relationships with physicians to make sure safe, appropriate care is delivered on a consistent basis, including the prescription of opioids and other controlled substances. Nothing in current state law prevents APRNs from performing APRN duties.

APRNs on the task force - mostly academicians - were direct and unwavering in their efforts to modify or remove mandatory collaboration laws so they can practice beyond the scope of their education and training.

I, along with my physician colleagues in the Tennessee Medical Association, will not support nurse independent practice because APRNs and physicians simply don't have a comparable level of education, training or experience, even in primary care. There is too much at stake with patient safety and quality of care to remove physician collaboration.

I applaud Sen. Becky Massey of Knoxville for her efforts toward compromise. Sen. Massey sponsored a bill that would have created APRN independent practice in Tennessee but ultimately created the task force and facilitated the group meetings and email discussions between participants.

I also appreciate the opportunity to serve alongside my physician colleagues, APRNs and state lawmakers in important discussions about how to improve healthcare access, quality and safety for patients in Tennessee.

We need more collaboration in healthcare and more integrated delivery teams, not more silos.


John W. Hale, Jr., MD is a family physician in Union City, Tenn. He is immediate past president of the Tennessee Medical Association and served as co-chair of the legislative task force on scope of practice.

For the past two years, TMA has advocated for a team-based approach to healthcare delivery that strengthens relationships between healthcare providers, including doctors, APRNs, PAs and others. The organization's position is clearly laid out at tnmed.org/teambasedcare.