x-sender: governor.haley@sc.lmhostediq.com x-receiver: governor.haley@sc.lmhostediq.com Received: from mail pickup service by sc.lmhostediq.com with Microsoft SMTPSVC; Mon, 25 Jan 2016 15:40:59 -0500 thread-index: AdFXsLLnzc7N43pMTWW+4zpho6Jf0A== Thread-Topic: Bills H. 3078 & S.246 From: To: Subject: Bills H. 3078 & S.246 Date: Mon, 25 Jan 2016 15:40:59 -0500 Message-ID: MIME-Version: 1.0 Content-Type: text/plain; charset="iso-8859-1" Content-Transfer-Encoding: 7bit X-Mailer: Microsoft CDO for Windows 2000 Content-Class: urn:content-classes:message Importance: normal Priority: normal X-MimeOLE: Produced By Microsoft MimeOLE V6.1.7601.17609 X-OriginalArrivalTime: 25 Jan 2016 20:40:59.0988 (UTC) FILETIME=[B306C140:01D157B0] CUSTOM Miss Kathryn R Rawlings 441 Meeting Street 305 Charleston SC 29403 rawlingk@musc.edu HEAL Bills H. 3078 & S.246 73.131.84.2 Dear Governor Haley, My name is Kathryn Rawlings, and I am a student in the College of Medicine at the Medical University of South Carolina (MUSC). I am writing to you this evening to express my thoughts on the Advanced Practice Registered Nurse supported bills, H.3078 and S.246. I can appreciate that CRNAs and NPs have a greater degree of training than many of their other nurse counterparts and serve a vital role in medicine. As such, those people would be completely entitled to a different designation, which would adequately set them apart and signify their accomplishments in the medical arena, but the reality is- they are not doctors. It is a fact that selection for entry into the nursing educational programs are less selective with fewer requirements and these programs require significantly less training, are less comprehensive, and take far less time to complete. I can concede it is not fair to give CRNAs and NPs a title that is not befitting their roles in medicine, but it is equally insulting to those of us who spent 8 years in school, will spend 3-10 years training after med school, a half million dollars, and have endured all the extreme rigors of our future Medical Doctorate when those same CRNAs and NPs think they are just as deserving of the doctoral responsibilities. We all have very important roles to play within medicine, but it cannot be denied that a doctor should be the most qualified person in the room to assess, diagnose, and treat. Therefore, they should continue to stand alone in title and reverence. I read an article recently which did an excellent job of getting to the heart of the issue: "Dr. Jane Fitch, recently elected First Vice President of the American Society of Anesthesiologists, began her career as a nurse anesthetist with a master's degree. Troubled by her limited knowledge compared to the physicians she worked with, she soon went back for eight more years of education-completing medical school, residency, and then a fellowship in cardiac anesthesiology. While she was a nurse anesthetist, "I didn't know how much I didn't know," Dr. Fitch says." http://www.kevinmd.com/blog/2011/11/unsupervised-anesthesia-care-nurse-anesthetist-threat-patient-safety.html Frequently APRNs cite research showing similar outcomes for their patients as those who are cared for by physicians. However, upon closer inspection these studies have all shown basic design flaws, inferior methodology in data analysis, confounding biases, blatant conflicts of interest, and an inability to accurately assess outcomes. They also often emphasize their ability to refer difficult cases out to specialists or order more tests to improve diagnostic precision - both of which significantly increase the cost of healthcare. The APRNs are well intentioned and to the general public, passing this bill would seem like a reasonable option to improve access to care and increase available providers. To a trained professional, it is understood that it is simply not feasible to expect providers with their level of training to be able to independently recognize their gaps in knowledge. The 27 months of total training they receive cannot possibly prepare them in the same manner as the 7-year trained Family Physician or the 8-year trained anesthesiologist. APRNs are proficient technicians with exceptional skills, but they do not possess the in-depth understanding of anatomy, physiology, pharmacology, pathology, etc. required to practice medicine independently. They are instructed in pattern recognition and have the ability to carry out specific procedures by following protocols that have been proven by years of research resulting in Evidence Based Medicine guidelines. For instance, the majority of the US population is familiar with Beta Blockers or ACE inhibitors, both frequently used to treat patients with high blood pressure, which seems like a fairly benign condition. What about a patient with asthma, chronic kidney disease, history of drug use, clotting factor deficiencies- how do the presence of these factors alter your drug choice and why? To answer these questions one needs a detailed understanding of which receptors these drugs bind and where, what downstream effects they have on altering the normal physiology, how they are metabolized, for starters. It is not possible to learn these subtleties in such a limited training window and it would unreasonable to expect them to perform at this level. Understanding the 'why' is what separates MDs from APRNs. The blessing and curse of higher education is the more you know, the more you realize how much you do not know. In relation and through no fault of their own, APRNs are unaware of their deficits, and this is precisely why it is vital to allow them to practice to the full extent of their training while under physician supervision. There is a bill currently being proposed in Missouri suggesting an alternate method to increase the number of available providers which includes allowing medical school graduates to begin practicing independently immediately after receiving their MD. Prior to beginning MUSC, I would have seen no problem in approving this piece of legislation- It is equally as dangerous as the current bill under discussion regarding independent practice of APRNs. You would be hard pressed to find a medical student at any level who would feel comfortable practicing upon graduation, it is not something the medical community is pushing for because they have an intimate understanding of the consequences to patient safety. We are very aware of how unprepared we are at that level for the immense responsibility involved in making life and death decisions on our own, and at that point, we have already received 2+ more years of training than APRNs. Practicing medicine is a privilege bestowed upon those who dedicate themselves to learning both the science and the art of the field; these privileges are not and should not be granted lightly. In conclusion, I do believe the pursuit and completion of advanced degrees merits the extension of medical practice in some matters. As such, I would like to express my support for the South Carolina Medical Association supported bill, H.3508, extending to APRNs the same practice changes enacted for PAs in 2013, including reasonable increases in autonomy and prescribing power. Thank you for your time and attention in this matter. Sincerely, Kathryn Rawlings, MPH College of Medicine, Class of 2017