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| NP Signing Physician Prescriptions: An Unusual Situation |
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by David Mittman, PA - October 26, 2010
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 Provided by Clinician 1
An interesting situation arose and was posted on a list serve this week. I would like to present it here in generalities (with some of the situation changed) as it brings up so many questions that we NPs and PAs usually do not consider. Take a few minutes out to read this story and review the questions it raises.
A nurse practitioner has been working at the same federally run health rural clinic for over 14 years. She is quite good and really enjoys her job. One day she gets a new collaborating physician who she finds out is NOT licensed in the states as she has not passed the required Boards but can work in the Federal system. This physician can prescribe whatever medications they stock in the pharmacy at the clinic but they do not stock controlled substances. So both the administrator and the physician approach the NP and ask/tell/inform her she will have to sign the prescriptions of her “supervising/collaborating” physician so patients can fill them. More than that, these will not be for amoxicillin or cortisone cream but as we said for controlled meds. The MD would come in and tell the NP that she had some one who needed Valium and could she please write a script for it.
WOW. The questions this raises are amazing.
The first one is that this is NOT the way any NP or PA legislation was intended to be practiced. Obviously to me anyway, my opinion would be that she is putting her license on the line every time she would sign one of these prescriptions. I am not a lawyer but I doubt that the legislation or Boards of Nursing or Medicine would support this.
On the other hand, if she has her own license, does it not cover her choice on how to practice? If she had an NP student who was good and diagnosed a patient with simple anxiety, would she write the script for her? Would she examine each patient the student saw? If the explanation sounded fine and the student either tested for or ruled out all the things one should, would she do it? And how about the problem of saying “no”. Can you lose your job? Will they find someone possibly more willing to do this if you say no?
You love the patients, and love the area. Where did this come from?
Turning the tables could someone actually argue that this could be a “delegated” task from physician to NP? On the other hand, a story like this one recognizes that an experienced NP (or PA) could actually be more than an equal colleague to a physician, but it is a bizarre situation.
Forgetting the legal problems for a minute, the most interesting part of the story to me is that the NP was put into a situation that many MDs and DOs are put into every day. Someone they do not know (a new NP or PA) is thrust upon them by an administrator who has not a clue about medicine. Suddenly as part of their job, they have to trust that the NP or PA is good and “knows their stuff”. When it is YOUR license on the line, it gets more scary and complicated. Yes, when physicians do it the regulatory and legal system backs them, but what an awkward spot to put anyone in. How many of us would want to do it? And if we did, would we want extra compensation? It makes me thankful to the physicians who stood up for PAs and NPs years ago and trusted us. I never really felt their side of it before. It also leads one to consider that after a number of months of collaboration or supervision, all of us should either be able to practice what we do or not. Not saying everyone should be in independent practice, but the myriad of different supervisory/collaborative requirements are ridiculous, arbitrary and none have been showed to improve care. On the contrary, they present some barriers to care that prevent NPs and PAs going where we are needed. But that’s another subject.
As I said, this story brings up questions many of us have never considered.
Dave
Dave has been a PA, and later NP, leader for thirty years. He strongly believes that NPs and PAs must work together to insure a better future for both professions. Most recently Dave has been busy launching another dream; Clinician 1, the first internet community for PAs and NPs. In October 2008, Dave was honored by the New Jersey State society of PAs with its “Lifetime Achievement Award”.
The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.
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| NC (North Carolina) |
on 24 May 2011 at 8:25 pm |
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| Is it illegal for a PA to sign a MD controlled substance Rx even if the PA did not see the patient. The PA has a different supervising MD. The MD was added to the clinic and does not yet have a DEA??? |
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| NC PA (North Carolina) |
on 30 Nov 2010 at 3:16 pm |
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It's an interesting story, but the answer seems quite clear-cut.
If the physician can't prescribe scheduled drugs, then her 'dependent practitioner' can't either. In North Carolina this is clearly defined by the medical board (a 'supervising physician' can only supervise what they themselves can do), so the NP should first consult her licensing agency (her home state? the feds?) to see what laws apply to her relationship with her 'supervising physician'.
If this NP is not 'dependent', then she would be obligated to see and examine the patient before writing ANY prescription, controlled or otherwise.
I don't think it matters if you went to PA or NP school, becuase, as someone said, it's work experience that counts, though I agree that NP's should be required to do more CME and recertify, like PAs do (in this state, NP's need 8 hours of CME a year, PAs need 50).
However, if you want to be a doctor, go to medical school. Requiring all NPs to attain a PhD in nursing is a ridiculous idea. |
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| Ohio PA (Ohio) |
on 04 Nov 2010 at 2:12 pm |
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Thank you Missouri PA for your insightful and well-articulated thoughts. Our veiws on the PA/NP relationship, though well-founded and based on cold, hard reality, aren't politically correct in these "feel-good" PA/NP forums. The longer that that we as PA's keep silent about the fundamental differences between PA's and NP's the greater the opportunity for the nursing lobby to advance the illusion that they are "physician extenders". Have we,as PA's, not yet yet learned that, given the opportunity, the nursing lobby will push their agenda to absurdity e.g. "nursing doctorates".
I'm not trying to be antagonistic- I simply can't support deception and pretense. I am grateful for nurses and the vital role they play in health care- but don't blur the lines. If you need a doctor seek the services of a doctor or a physician assistant; if you need a nurse seek a nurse or nurse practitioner. |
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| Missouri PA (St.Louis) |
on 03 Nov 2010 at 11:49 am |
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| I have been a PA for well over a quarter century. I have worked with numerous NP's, some of whom were very good clinicians but I notice a definite difference in our knowledge base and practice. There is something lacking in their training be it our > 3000 hours of direct patient care in training compared to their 800 hours, or the fact that they are Nurses training Nurses. Most of their classes are on-line or nurse-delivered lectures, and it doesn't compare with being on a team with interns and resident physicians admitting and being on-call every 3rd night and answering to an attending on rounds on 2 hours sleep if you were lucky, or the hours in surgery or the emergency room. I have absorbed as much through my close relationships with training physicians as I have in lectures or books. hands-on is still the best way to learn. I have respect for their profession but rankle at their air of superiority and their huge mass, influencing legislation and taking PA jobs. |
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| Deb Graber (Kokomo) |
on 31 Oct 2010 at 11:37 am |
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| I am disappointed in Ohio Pa. comment. I work in dermatology plus family practice; derm I work with 2 PA's and another NP. There is no differentiation in how we practice with DR. in this practice. The only difference comes from our experiences and the types of medical exposures we have had. Training curriculum seems quite similar to me. We have compared the studies done, classes, etc. for the 2 programs. I hear comments such as this and find it is frequently because the commenter is not familiar with NP's in general. We all need to learn to appreciate each others strengths as "midlevel practitoners" and work together to give superior patient care. |
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| Deb Graber (Kokomo) |
on 31 Oct 2010 at 11:14 am |
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| This is interesting and can also be a concern when working with an elderly collaborating physician. Many days I feel the tables are turned who collaborates with who. I count myself fortunate to have 27 years of nursing experience to rely on, palm pilot, 5 minute clinical consult, and numerous other references. I am still learning so much; and my elder Dr. has made me see another side of rural care that books can't teach. I take it a day at a time and long for final independence, we all long for.I do love being an NP! |
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| Andrea (LA) |
on 30 Oct 2010 at 12:18 pm |
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Great points Dave, I would suggest that the NP call the Advanced Practice Nurse on call for the BRN for her state and run this by them from a legal point of view. I agree that MD's have had to take similiar risks for us and I appreciate it, but they do seek legal counsel generally.
As for Ohio PA's comments, I am deeply saddened that he feels it is them against us, We work so much better together than against one another. AK |
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| CG (Denton, TX) |
on 28 Oct 2010 at 12:44 pm |
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-Has she been reviewing the cases? Has she been limiting her liability by indicating that she was an RN carrying out verbal orders when she agreed
with the treatment plan & expressinig that she was not comfortable or was prevented by her licensing board when she didn't? |
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| Ohio PA (Ohio) |
on 27 Oct 2010 at 10:27 pm |
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Great points Dave. Glad to see you recognize the importance of a close working relationship between physician and "midlevel practioner". Unfortunately you neutralize your points the moment you suggest that PA's and NP's have the same kind of relationship with physicians and face identical problems. PA's are dependent practitioners trained in the same medical model as the physician which provides the necessary foundation for strong, trusting collaborative relationship. The trust between physician and PA is well-deserved.
NP's, on the other hand, have, from the outset, pushed for independent practice advancing an agenda antagonistic to physicians and PA's yet pose as "physician extenders" when it is politically advantageous. I simply can't understand how any physician could feel comfortable working in a "collaborative" role of any type with these individuals.I attribute the physician's use of NP's to a lack of awareness of the type of training an NP recieves and the potential negative consequences an NP could have on a medical practice and the physician/ PA community.
As I've mentioned before Dave, there is still a great need to educate physicians regarding the role and benefit of the PA. Let's let the nurses fight their own battles (against us PA's and our physicians). Let's strengthen our relationships with the physician community and the public, educating them about who we are as PA's and informing them that all "midlevels" are not created equal. |
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