0:00
Not going to get into some of the things I heard today, I will just tell you the arrogance is obnoxious. I think that shows you what kind of joke we're dealing with here. You

0:24
Kate today on physicians taking back medicine, you'll meet four physicians who are speaking out against legislation that they believe will harm patients, despite facing critical anti Doctor rhetoric from lawmakers you just heard part of the closing testimony from a Florida legislator and sponsor of a law that would allow psychiatric mental health nurse practitioners to treat patients with psychiatric conditions without the oversight or supervision of a psychiatrist. The legislator described the three physicians who testified, one of whom was a resident as being obnoxiously arrogant, and he went on to characterize them as greedy and profiting off of the work of nurse practitioners

1:12
and honestly folks, each of these doctors gets around $2,400 per nurse practitioner off the top. Now, if you, you look at that and you, you say, Okay, I've got 20 nurse practitioners that are all paying me $2,400 a month. Well, I can just do what doctors do and buy a plane and go to the Bahamas. So I completely reject what was said here today.

1:38
Let's take a listen to the testimony that has this lawmaker so fired up. First, you'll hear from Dr Vicki Norton. She is the president elect of the American Academy of Emergency Medicine and the current president of the Palm Beach County Medical Association.

1:54
Thank you, Madam Chair and members of the committee. Thank you for the opportunity to speak today. I want to address three simple but critical points regarding psychiatric scope of practice, training, patient safety and compliance with existing law. First, training matters, a psychiatrist completes at least 15,000 hours of supervised clinical training before practicing most psychiatrists then complete an additional one to two years of specialty training before treating children and adolescents. In contrast, psychiatric nurse practitioners complete a minimum of 500 hours, including just 100 hours caring for children, yet are certified to treat patients across the entire lifespan. There are programs that allow psych nurse practitioners to complete 100% of their clinical hours via telemedicine. These pathways are simply not equivalent, and they can lead to poor quality of care for some of Florida's most vulnerable patients. And just to put it in perspective, a dog groomer certification course is 600 hours versus 500 hours for a psych nurse practitioner. For example, research shows that psychiatric nurse practitioners are more likely than physicians to prescribe antipsychotic medications to children and sedatives to nursing home residents. According to the DEA, nurse practitioners are now the leading prescribers of amphetamine class, Stimulant medications and ketamine, these are not benign drugs. They carry significant risks and require extensive medical training to prescribe safely, particularly in complex psychiatric patients with comorbid condition. Third, Florida's existing law is already being disregarded. Florida legislators specifically restricted autonomous practice to primary care nurse practitioners. The Florida Board of Nursing has explicitly ruled that psychiatry is not primary care. Yet, a cross sectional survey of Florida autonomous APRNs found that almost 60% are not practicing primary care, with most working in psychiatry or cosmetic and anti aging clinics, they're not following the current statutes when existing statutory limits are already being ignored. The Responsible response is not further expansion, it is oversight and enforcement. Please protect Florida's most vulnerable patients by ensuring that a psychiatrist remains the head of the care team. Thank you.

4:23
Dr Norton took time off from work and drove seven hours each way from her home in South Florida to Tallahassee for that two and a half minutes of testimony. I asked her how it felt to hear the bill sponsors closing statement. I watched your video regarding the differences in training and education of physicians compared to nurse practitioners, to explain why allowing unsupervised practice is unsafe, I was struck by how matter of fact and calm and unemotionally that information was presented, and I thought you did a. Spectacular job. And so I was really shocked when the bill sponsor, at the end, during his summary, really attacked all of the physicians that spoke. He called you all, and all of us, I guess, arrogant, obnoxious. He said that we were profiting off of nurse practitioners so that we could buy and fly private jets off to the Bahamas. He also complimented the nurse practitioners on canceling their days of patients to come to testify. Meanwhile, so did you as physicians? How did it feel to hear that commentary?

5:40
It definitely didn't feel good. It was infuriating. But at the same time, I try not to take those kind of comments personally, because I know it's a game. It's all a game. It's the same way with medical malpractice litigation. You know, you go into a deposition, or you go into trial, and they are vilifying you and and then they walk out of the room and they're laughing and shaking hands with your attorney, you know? So it's like seeing that and having colleagues talk about that, I realized, like, it's the same thing in the political arena, because it's all theater, right? Like they they have to say things like that to kind of sell the narrative Right? Like the narrative is always going to be that it's the arrogant physicians, the greedy physicians, against the the poor, hard working nurse practitioner. And it's not about that physicians work really hard too, and I don't have a jet and I definitely am not getting any kind of supervision money from a supervision agreement with my non physician practitioners in the emergency department. We hire them as employees, and I've never had the experience where I'm not fully supervising them in my current employment model. Like I've never had that experience. I don't think most emergency physicians can say that, though, basically, they're getting nothing for supervising in the emergency department, they are getting added medical, legal liability for supervising, and there's no benefit, basically, to them. And they're being told, you have to supervise this person. They have no say over what that person's qualifications are or whether they hire the person in the first place. The narrative that they're selling the rest of the legislature is not true.

7:22
Hi everyone. My name is Ankush bonsal. I am an internal medicine and lifestyle medicine board certified physician in Palm Beach, Florida. I work as a hospitalist and telemedicine physician for the last 19 years. I am president of the Florida Chapter of the American College of Physicians. I'm the National President of Physicians for Social Responsibility, and I'm the chair of advocacy and legislation for Palm Beach County Medical Society.

7:49
Here's part of Dr Ankush bansell's testimony against unsupervised practice for psychiatric nurse practitioners.

7:57
You've heard some of my colleagues talk about the difference in education and experience. I want to reiterate this. For physicians, it is a minimum of 11 years of education after high school, followed by minimum of 12,000 clinical hours. You heard one of my colleagues say that for psychiatrists, it is 15,000 clinical hours. For nurse practitioners, however, it is a minimum of six years of education. Therefore, physicians have 16 times the number of clinical hours before they go into practice. They have learned pharmacology, pathophysiology, the complexities of how different psychiatric disorders interplay with their medical diagnoses, how to manage the different medications. We're talking about safe care as well as access to care. Yes, there is an access issue. I work with nurse practitioners every day. They are fantastic. They are part of the team, but they are not leading the team. They are not making the final decision because I've got that extra education and that experience now saying that because there's a doctor shortage and, frankly, a nursing shortage as well, that someone in a rural area, and I work mostly in rural areas all over the country, that because there is a shortage, we should have a patient see somebody who is inadequately educated and experienced compared to a physician, is unethical. It creates a double standard. Why should a patient who is in an area that has a shortage see somebody who's got less education and experience than somebody who is lucky enough to live in an area that has enough physicians, that's not fair. And finally, I'd like to leave you with this thing to ponder for all of you, would you let a paralegal practice law independently? Would you let a flight attendant fly the plane independently? Thank you.

9:58
I asked Dr bansell If he. Was surprised by the comments from the bill's sponsor at the end of testimony.

10:04
So we had some idea that we were going to lose on this effort. However, we had to make our voice heard. I was surprised that the sponsor took several minutes to directly attack us and insult us. It's one thing if you disagree, and that's the point of these of these testimonies, is that you hear a difference of opinions and then, and then they are the ones that are elected. They make the decision, and if they disagree, that's fine. They disagree. It just seems strange that they went out of their way to directly attack us.

10:38
I'm imagining you don't own a private jet. Dr banchal, I don't own a private jet. I don't know any doctors these days. I mean, they might be a few that have a little Cessna or something.

10:46
Look, even though I'm a physician and I earn more than the average American, I don't have funds to own a private jet. I don't take weekend trips to the Caribbean or other countries. I don't have the time or the money for that. He had also said that we all hire a whole bunch of nurse practitioners, don't oversee them, and get $2,600 per nurse practitioner. It has to come out of the nurse practitioner's own funds. I've never earned $2,600 per nurse practitioner, and I've never, ever heard a nurse practitioner say that if they work with a doctor, they have to pay the doctor to see patients.

11:29
Yeah, I think in most hospital settings or clinical settings where physicians employed, usually, nurse practitioner fees, if there are any for oversight, are coming from that employer. And I imagine you have to pay malpractice associated with that supervision and oversight. That's not free, right?

11:46
Yeah, that's That's true every hospital where I've ever worked at across the country where there are nurse practitioners, even if that state has full independent practice of nurse practitioners, at least the hospitals I've worked at, they require in their own medical staff bylaws, that the physician needs to oversee that nurse practitioner. So I'm seeing the same patients that my nurse practitioners are and reviewing their note, adding an addendum or writing my own note. So I'm still seeing all those same patients, at least in the inpatient setting,

12:17
and thank you for that as a as not just a doctor, but as a patient, I want to know that there is a highly trained physician that is overseeing my care, and that's one of the reasons I'm passionate about this, because I'm seeing in many parts of the country that physicians are being taken out of the care team, and patients are losing, I mean, they're gaining access to nurse practitioners, they're losing access to physicians, and that includes our patients that are underserved, patients with mental illness, some of the most vulnerable Americans. When you heard that diatribe, did it hurt you in any way, or did you just feel like this is just politics?

12:54
I mean, I won't lie. Initially, I did feel insulted and that, why was this person going out of his way to do this. But look, I've, I've, I've participated in politics long enough I understand this is politics, and more importantly, this makes that member look bad in front of all of his colleagues, in front of the public, and maybe, maybe we'll see in front of his constituents that okay, fine. You disagree on this issue, but to attack a Floridian on on something like this is unacceptable and unnecessary.

13:32
Bringing back civility and relationships in politics is something that's very important to another physician advocate. Dr Mays DeBose is the past president of the South Carolina Medical Association, or scma. He was part of a group of physicians who went to the state capitol to advocate against unsupervised practice laws that were being considered in the South Carolina legislature.

13:57
I used to not like to talk about this topic, but the more I've been involved with this type of advocacy, the more I've realized it needs to be said, humility is not our friend. Specifically on this front I think people have always respected physicians. We have a little bit of an image problem right now, and I think we need to be careful with that. But I think most legislators know that physicians get a lot of training. I don't think they know how much training physicians routinely get, and we need to find good ways to respectfully, politely convey that message, they're not bad people. They only know what they know. And we have to find ways to communicate with them and work with them and build relationships with them. You know, you make some enemies along the way, and you hope that personal relationships prevail. We're not always going to see eye to eye with different things like this. It's hard, and hopefully we can avoid the devolving into the kind of left, right politics that we see all over the place today. Hopefully this can be a conversation, this can be a discussion. This can be reasonable, and see what the outcome. Will be but this is not the area the doctors are very good at. This is the area the doctors like to avoid that we've done ourselves a disservice over the years by avoiding it, because you have to be in the game.

15:11
Unfortunately, just as in Florida, South Carolina, legislators have characterized Physician Advocacy for team based care as being a turf war. Here's a proponent for unsupervised Nurse Practice in South Carolina.

15:26
What my concern is, and what I hope I'm not going to hear, is everybody trying to protect my turf and don't, don't let it's about the pump. It's about access to health care.

15:39
Here's Dr DuBose on what he experienced during the committee hearing.

15:43
That was my first day that I really got a taste of the gamesmanship that happens in those committee hearings. So my opening statement got postponed until well after lunch near the end of the day, and after lunch and all that, my mouth was so dry, I just, you know, there was a little bit of home field advantage

16:02
another physician who testified in South Carolina was Dr Phil Schaefer. He was invited to speak about the lack of data on unsupervised nurse practitioners. Dr Schaefer faced a somewhat condescending comment from one of the committee members,

16:18
you supervised nurse practitioners?

16:20
Well, I'm a radiologist, so we don't directly interact with nurse practitioners much indirectly. Some You about to be out of a job because the AI bots are gonna run you out. We can have a nice discussion about that over beer.

16:37
You can program these machines to outreach human every time, I guarantee you.

16:42
So when you heard a legislator say to you, well, you're going to be replaced by an AI, you're going to be out of a job, how does that make you feel?

16:52
I don't know that the people who are saying that have an in depth knowledge of what AI is or even what we do. I don't suppose the man that ever set foot in a radiology department, they seem to think that our job is to find little white spots on things. And that's not it at all. And it's more like seeing the picture and then being able to construct the scene of the crime. Because, you know, all of the components which go into the problem. So the people who are saying these things are very naive and are speaking without really any in depth knowledge of what radiologists do.

17:36
Think that's a lot of what I ascertain when I listen to these legislative hearings that there will be very knowledgeable experts giving information, and then some of the legislators will just kind of say, yeah, yeah, yeah, but I think it's easy.

17:51
Yeah, they they think it's easy. And I'll tell you, the radiologists don't think it's easy, and a lot of our referring physicians know it isn't easy, so it's only the people who don't know medicine who think it's easy.

18:06
They think that the shortcuts are just going to solve all the problems, and they don't seem to take it seriously when we talk about our concerns. For example, let's go back to Florida and that psychiatric mental health nurse practitioner unsupervised practice bill. Here's the bill sponsor giving closing testimony after the bill's second committee hearing.

18:27
Thank you, Madam Chair. I'll keep it real brief. You've heard both sides. You've seen this bill. It passed the House last year. I'd ask for your support. This is already legal and ongoing in 28 states in this country. If the sky was going to fall, those 28 states would be wiped out. Already. Everything is fine. It's going to be cool. It's a good bill. Thank you.

18:50
You heard the legislator say that the bill would be cool and that the sky would not fall. I asked Dr Schaefer if it's easy for legislators to be somewhat cavalier about these issues because they're not physicians, and they're not practicing in health care.

19:06
They've never been in it, and they don't know it. It's very hard being a physician, having people from the outside telling you that they know what's what's going on, and you don't when it's pretty obvious to us, they don't know what's going on. The legislators don't know what's going on. In medicine, they only know what they're told, and without real experts telling them what's actually going on, they will believe the other side. And unfortunately, a lot of times, the other side works against patients.

19:46
The physicians that you've heard in this podcast all agree on one thing, and that is the importance of physicians advocating for patients. I asked Dr Vicki Norton how doctors can get started. There's a couple of things. That I imagine would hold back a physician. There's taking your time, your energy, your expense, canceling patients, et cetera, drive a long way or fly, spend your own money to go up there. So that's one you think, why am I bothering with that? Then number two, you get up there and you tell the truth and you give the facts, and you're accused of being an arrogant, greedy doctor. And then number three, there's this feeling of, well, if this is all a game, then what's the point? And does me showing up really make a difference? So how do we learn as physicians not to take these attacks personally and overcome that?

20:34
I think it's through having those like one on one conversations with the legislators that you kind of see that it's not personal. I mean, even with the some of the bill sponsors, some of their comments were the most like caustic. But then I've had people say, but I've met with that legislator, and that's not like how they are, but you just have to remember that that it's it's a little bit for show and and you're doing the right thing, you have to have confidence in yourself that you're doing the right thing, you're stating the facts, and you're doing what's best for patients, and in the end of the day, that's what matters, like that. That's what we took our Hippocratic oath and trained for. You know, we we're trying to help our patients. So as long as you keep that in your mind and in your heart, that that's why you're there, that's what's most important. They can't take that away from you, no matter what they say,

21:23
and we need more doctors to do that. So what advice do you have for doctors that might be listening, that might feel like they want to do something, but they're not sure, maybe they're scared, maybe they're not sure if it makes sense. What advice do you have for physicians that would like to start getting more involved in advocating for our patients?

21:41
It just takes speaking up. It's, it seems hard and it seems scary to do, and not everybody's in an employment situation that they can be very vocal. But it's, it's so important if you can't testify in a committee, because that is a more public setting, and it's being broadcast a lot of times, the least you can do is go meet your legislators one on one, because nobody's recording that conversation, and I guarantee it's going to feel a lot more friendly and productive than than a committee meeting a lot of times. But that's how you start. You just meet them, and you don't have to travel to the Capitol to meet them a lot of times, like when they're not in legislative session, you can make appointments to meet them in their district offices, and it just takes one or two conversations, and that's how you get your feet wet. A lot of people think that they don't have the expertise to talk about this stuff. Yes, you do. You're a physician, you have the expertise to talk about these things, and you shouldn't be nervous or worried that you're going to misrepresent something, because, like you, you have the knowledge base to have these conversations. So don't be afraid. Start small. Those are things I would tell people.

22:48
Dr Ankush Bansal had this advice.

22:52
I would say, pick one topic that you see in your everyday practice. It doesn't have to be something like scope. It doesn't have to be something at the state level. It could be something at the local level or at the hospital level. You know, we advocate in the hospital. We advocate to our employers, if we're outpatient doctors as well, if you're employed. So pick an issue there. Start with advocacy, because everything, all politics, starts locally, hopefully, like the the incident that happened, that's a rare incident. I'm not going to say it's never going to happen to you, but it's pretty rare. Most of the time, if people disagree with you, they'll just disagree with you and they'll thank you for your testimony, especially because you're a physician and you're respected, and they understand that you took time out of your day, from your family, from your practice, from your patients, to come and advocate for something that you feel is important.

23:43
Here's Dr Schaefer on why physicians often struggle to get involved.

23:48
In part, it's because we're also terribly busy. And I'll speak for myself, when I was working full time, I come home and I was wrecked. The thought of spending another four or five hours and doing some lobbying was just like, you know, I'm not really good for this. It also wasn't my forte. My forte was science and not politics, and I felt out of my element. And I also want to spend time with the kids and taking time away from them to do this. Just, you know, I was of the mindset, I'll let somebody else do it. So now I'm trying to pay it back and try, trying to do more than my share now, because I didn't

24:30
before. Here's Dr Mays DeBose,

24:33
if you don't want to personally do it, you need to support the people that are willing to do it. I'm thankful to be independent so that I can do that without that fear of retribution or being blocked from advancing in my career, my career doesn't depend on hospital C suite, pat me on the back and give me attaboys, but some doctors do, and not every, not every specialty in medicine can be independent there. There are plenty of specialty. Is where you pretty much have to work with the hospital system. That's a reality, but, but again, I think that goes back to that collective voice. We have to support the people that are willing and can speak on your behalf for those things.

25:13
If you can't speak out, support the people that can. And that's what scma is all about. That's what you're there for, and I just think you have done a tremendous, incredible job of advocating for your physicians and the patients that they serve. You guys are really, to me, setting such a model of saying, well, we may not win this, but we are not going down without a fight. And that is so important, because I think so many doctors, and I talk to them, it's like this sense of like, it's too late, the horse is out of the barn, and it's almost like this learned helplessness. And so when I see people like you guys fighting and saying, Well, we're gonna we're just gonna do what's right, and we're gonna fight, it's so inspiring to me, and I think, I hope it's going to inspire other physicians to say it's not too late. We can still make a difference.

26:05
You know, I've not always been an organized medicine mindset type of person. I was not that person in medical school. I did some leadership stuff, but I didn't do AMA. I just didn't feel like that was wired that way. But older doctor in my area, asked me to been in his spot for the Board of Trustees for the scma. And that was really my first introduction. And just learned so quickly how invaluable it is, and it saved me from that, that learned helplessness that you referenced, Dr Bernard. I know you have them. I have them doctors that say it's too late. We can't do any good. You can't move the needle. It happens. I do believe you know it with the scma, we have so many things we want to do better. There's so many things that we want to tackle and conquer and and improve on. But I think we are one of those shining lights, and I think we can hopefully show by the states that you can build this, that if you put the right people in place, the physicians passion is almost always there. You don't go through medical school and residency and fellowship because you don't care about your patients and and the science behind it. I mean, we love what we do, we hate the system oftentimes. But if you're going to be that limbing, running off a cliff with the rest of your fellow physicians and not trying to do something different, the system will get worse. I'm thankful to be part of a group that is passionate about it and has seen successes in medicine. If physicians are not being heard by hospitals, by state organization, by legislators, by CMS, insurance companies, or even their own colleagues. It's a very hopeless feeling, and so that's that idea of a collective voice that's really resonated with me. We need that across the country. We need that, and I'm thankful that scma Is that, you know, American culture is not really wired for membership and organizations nowadays. We're all very independent. We do our own thing. But I think, I think the pendulum will swing back, and people will see that you need a group, you need you need a voice.

28:20
I would say to anyone listening, to take this as a sign that you can also get involved, either through just joining or reaching out to somebody that is already in organized medicine, in whatever capacity that is, and just starting by showing up, because I'm sure amazed that that person reached out to you because they knew you. And so you, you have to make connections. We have to make connections with each other, lift each other up and work together. And so I think everybody should be, at a minimum, a member of your local medical society, certainly on your state level, because that's where a lot of these things are happening. And if you can do more, that's great,

28:59
too. Amen. That deserves an amen.

29:02
Thank you so much for listening to this episode of physicians taking back medicine, a new podcast by medical economics. I'm your host, Dr Rebecca Bernard, bringing you true stories of day to day physicians, just like you who are fighting to improve the health care system. I hope to see you On the next episode. You you.