UP FRONT
Advanced Practice Perspectives
In this column, we will hear from an increasingly represented and crucial
component of hematology/oncology care: advanced practice professionals/
advanced practitioners. In this edition, ASH Clinical News Associate Editor Beth
Faiman, PhD, MSN, APN-BC, AOCN, addresses the confusion about exactly
what an APP can do, and who decides.
What Can We Do?
The Scope of APP Practice Patterns
As I opened the door to the exam room
one sunny morning in Cleveland,
Ohio, a patient stood to greet me.
“Congratulations, you’re finally a doctor!”
The patient and his wife were beaming
with joy.
I had just completed my PhD in
nursing science and clinical research,
and, I must admit, I was thrilled to have
accomplished the goal and was pleased
that they were so happy for me.
“Can I call you ‘Dr. Faiman’?” the
patient asked me the very minute I
walked into the room as he extended his
hand to shake mine – which was full of
hand sanitizer. He and his wife knew me
even before I embarked on the six-year
journey to obtain my doctorate. Ten
years ago, I had diagnosed him with
multiple myeloma and I would see him
(usually with his wife) every month for
routine follow-up. He would ask me how
I was juggling family, work, and school
responsibilities.
“I guess you can call me ‘doctor,’” I
replied, as we sat in our respective chairs,
“but please continue to call me ‘Beth,’ if
you prefer.”
I saw the wheels turning in his head as
he planned his response. “I hope you don’t
take this the wrong way,” he said, with
a contemplative look on his face, “and I
mean no disrespect to my other [medical
oncologist] doctor, but do I have to see
the other doctor anymore, or can I just see
you now?”
I have heard this question many times
over the last few years. Because we perform
similar functions as an MD or DO, patients
are often unclear as to the role of the
advanced practice provider (APP). In 2015,
does a well-trained nurse practitioner,
especially one with a PhD, supersede the
need for a medical oncologist? Legally,
can an APP function in the MD/DO role?
I thought carefully for a moment and
then asked him a question: “Why would
you think you don’t need to see a medical
doctor anymore?”
“Well, you’ve been my nurse
practitioner for 10 years now,” he
replied. “You schedule my appointments,
prescribe my medications, and check my
labs. I barely ever see the other doctor and
I don’t feel like I need to. He can take care
of the ‘sick’ patients. You do everything
for me and I trust you. I would like you to
be my doctor since you are now an official
‘doctor.’”
Now, my state allows NPs to practice
somewhat independently. I work at a large
hospital that supports APP independence,
while also emphasizing a team approach
to care. Given the complexity of
hematologic cancers, I think the team
approach is necessary. Are there any
states that allow an APRN or PhD to
independently manage hematologic
cancers without “official doctor”
supervision?
In the debut Advanced Practice
Perspectives column, I reviewed the
history and roles of various advanced
practice registered nursing (APRN)
and physician assistant (PA) groups.
After more than 40 years since the APP
role – a combination of APRN and PA
roles – was born, confusion about just
what we can do remains. APPs are highly
trained individuals who play an integral
role in the diagnosis and management of
hematologic conditions, but their scope of
practice differs greatly from state to state.
Let’s review some key points about APP
practice and levels of autonomy.
specialists, and certified nurse midwifes)
and PAs. The extent of physician oversight
or involvement for APRN and PA
services varies greatly from state to state,
which leads to confusion about what
job functions the APP can or cannot
perform. Although APRNs and PAs
perform similar job functions, there are
two different regulatory bodies at the state
level.
Who Determines Practice Laws
for the APP?
Advanced practice providers include
APRNs (nurse practitioners, clinical nurse
• Another 19 states have a relational
agreement, where a “collaborating
physician” is required for APRN
providers. These “reduced-practice”
FIGURE 1.
The Scope of Practice for APRNs
Nurse practice laws in each state are
regulated by the state boards of nursing
(FIGURE 1). According to the American
Academy of Nurse Practitioners, there are
three levels of oversight and autonomy of
practice: full-practice, reduced practice,
and restricted practice.
• There are currently 21 “full-practice”
states, including Washington, DC.
These states allow APRNs to diagnose,
prescribe, and essentially run their own
independent practices.
APRN State Practice Environment
■ Full Practice: State practice and licensure law provides for nurse practitioners
to evaluate patients, diagnose, order and interpret diagnostic tests, initiate
and manage treatments—including prescribe medications—under the exclusive
licensure authority of the state board of nursing. This is the model recommended
by the Institute of Medicine and National Council of State Boards of Nursing.
■ Reduced Practice: State practice and licensure law reduces the ability of nurse
practitioners to engage in at least one element of NP practice. State requires a
regulated collaborative agreement with an outsid