David J. Shulkin, who as undersecretary for health at the Veterans Health Administration is the agency’s top doctor, spoke with PowerPost on Wednesday about the controversial new policy, which mirrors a debate and turf battle that has been roiling the medical community for a decade.
For VA, the country’s largest health-care system, the change comes on the heels of a scandal over veterans’ long waits for medical appointments and the agency’s efforts to cover up the resulting delays in treatment.
Shulkin has only been in his job 11 months, but he has made expanding the scope of practice for advanced-care nurses a priority. He told us the policy will not be ironclad throughout the system, but rather up to the discretion of local hospitals.
And despite furious opposition from anesthesiologists, Shulkin said that nurses will not take on a larger role in this specialty.
PowerPost: Wow, more than 10,000 comments and the ink on this proposed regulation is barely dry. How do you explain the response?
Shulkin: I’m not aware that we’ve received anything like this before. We’re hearing a lot from nurses and a lot from physicians. We haven’t even started to go through the comments yet.
PowerPost: You’ve been in your job a short time. How has getting this policy change through figured into your list of priorities?
Shulkin: The single issue I was contacted on before I was even confirmed was this. The Veterans Health Administration had started the process of changing what we call the nurses handbook in 2009. The [change] has taken seven years. So I understood the depth and magnitude of the issue, which is a constant debate in health care. Whenever you have this strong a conviction on both sides, it’s obviously harder to reach consensus and develop policy.
PowerPost: This policy seems like a response to the wait-times scandal: Veterans could not get medical appointments because there were not enough doctors to see them. Is that why you’re pressing forward?
Shulkin: My number one imperative is to address the access issue among veterans. What we know about American medicine is that our supply of health-care professionals is not equally distributed. In rural areas, we have severe shortages. I’ve seen firsthand how difficult it is to recruit to some of the areas where our veterans live. We have a shortage of both nurses and physicians. We are recruiting thousands of doctors and advanced-practice nurses.
PowerPost: Will VA, by its sheer size, lead the way in prompting the 29 states that have not given nurses this authority to act?
Shulkin: The Department of Defense has had this policy in place for a while. I do think that VA, as the largest employer of nurses and the largest health system in the country, often does become a place where we can demonstrate advances in medical practice.
PowerPost: What does research say about the quality of care when it’s delivered by a nurse rather than a physician?
Shulkin: My assessment of the literature, which is vast on this subject in general, is that it has shown that nurses are able to deliver high-quality care, particularly when they are delivering care in settings that are within their competencies and scope of responsibilities. The literature shows very good outcomes.
PowerPost: You’ve gotten heavy pushback from the American Medical Association, the most prominent physicians’ organization. Does this give you pause?
Shulkin: I do not believe they [physicians] understand what our intent in going into this rule-making is. We have embraced team-based health care. We believe in the model. We are not looking to destroy that. We are looking to add to our ability to deliver heath care to veterans in places that don’t frankly have health care for them right now. In areas where it is working, we are not planning on changing that. In fact, we embrace the concept of team-based health care.
PowerPost: So are you saying that not every VA hospital or clinic will expand nurses’ scope of practice?
Shulkin: Privileging and credentialing are done through a medical center. We have 168 of them. Everyone will make an assessment about what’s the right thing, given their medical professionals and the needs of their patients. Maybe in one part of the country, in a big city, the medical staff does grant broader practice authority to nurses to meet the needs of their patients, [while] in a rural area they have an adequate supply of physicians. Or the opposite. This is meant to be a living, breathing document that changes all the time.
PowerPost: The physician view is that veterans, in general, are in poorer health than active-duty military or the general population. So if there is a complication with a patient, a nurse may not have the training to address it alone.
Shulkin: Part of what any good health-care professional does, including an advanced-practice nurse, is know when it is time to seek help from more experienced professionals. I’m a primary care doctor. It doesn’t mean I know everything. When something is beyond my competency or expertise, I seek consultation from my colleagues.
PowerPost: The American Society of Anesthesiologists held a press conference on Wednesday to denounce the policy change to replace physicians with nurses who specialize in this area in surgery. They say this would be dangerous to patients.
Shulkin: I’ve looked at the data in the VA, and I do not assess that we have an access problem in anesthesia. We are using team-based approaches. I do not plan on implementing any change in current policy to our workforce [of advanced care nurses who administer anesthesia].
PowerPost: Okay, but the regulation, as proposed, does not exempt advanced-care nurses from acting independently in anesthesia care.
Shulkin: If at a later point in time, whether it’s me or another undersecretary, there becomes an access issue in anesthesia care, I don’t want another undersecretary [in my position] to have to sort through the issue again.