Tuesday, May 14, 2013



First, the facts

In a stunning victory for Nurse Practitioners SB 491 (Hernandez) cleared the Senate Appropriations Committee by a 4 to zero vote (DeLeon, Hill, Lara, and Steinberg). There were
no votes against the bill (Walters, Gaines, and Padilla were not recorded to have voted). No matter, the measure needed only the 4 votes it got.  

The California Medical Association, opposed to the bill, said in its Hot List that "this bill gives nurse practitioners independent practice" because "nurse practitioners will no longer need to  work pursuant to standardized protocols and procedures or any supervising physician and  would basically give them a plenary license to practice medicine."

One of the arguments by Senator Hernandez that proved particularly attractive to proponents was his assertion that allowing Nurse Practitioners to practice medicine "can reduce the cost of medical care by allowing lower-cost workers to  do more routine tasks in place of higher-paid MDs." In this blog, we have already asserted why this fanciful concept may well prove to be illusory. The nurses are well organized and have a strong union. In the opinion of this author the nurses' unions would be asleep at the switch were they to stand idly by while their colleagues got paid less than physicians for doing the same work.

Milton Lorig, MD, Union of American Physicians and Dentists, wrote in the Sacramento Bee that "physicians like myself have undergone far more rigorous training" and that he doubted that a mid-level practitioner "would have made the diagnosis of NMDA-Receptor Autoimmune Encephalitis" that he recently treated. Lorig argued that "patients deserve ready access to providers who are adequately trained." He did not, however, persuade DeLeon, Hill, Lara, or Steinberg -- just one would have been sufficient to save the day for optimal care.

Author's amendments may still be introduced, for instance, a provision to delete the authority for nurse practitioners to make diagnoses of patients and to perform procedures. Allowing expanded use of skilled nurses should not be done by lowering practice standards that physicians, nurses, and scientists have worked centuries to develop.


  1. Genie is out of the bottle and cannot be put back. First blow was stuck when Arnold Schwarzenegger signed the bill in 2009 allowing the nurse anesthetist(CRNA's) to practice without physician supervision . Some of the hospitals are already replacing Anesthesiologist MD with Nurse Anesthetists.
    California Supreme court in july 2012 upheld former Governor Arnold Schwarzenegger's 2009 decision to opt out of the 47-year-old federal Medicare facility reimbursement rule requiring physician supervision of CRNAs, denying review of a lawsuit filed by the California Medical Association opposing the ruling.
    We are looking at long range changes in Medicine. We will start seeing trained technicians doing endoscopies, Respiratory therapists managing ventilators, Pharmacists prescribing medicine, optometrists doing cataract surgery , Dietitians prescribing TPN in hospitalized patients, Podiatrists doing lower extremity surgeries etc, etc,
    Mainstream physician groups have failed in their advocacy. Only solution is for physicians to unionize. Unfortunately this will take another 5 years

  2. We have to recognize that physicians have different agenda which will be opposed to other non physician healthcare providers . I have failed to convince the UAPD members in the last meeting to restrict membership to physicians only .What is the view of our senior statesman Dr Weinmann on this issue of UAPD membership ?

  3. Thank you, Dr. Rao -- this blog is independent of unions and other special interest groups. All the same we have opinions! One of 'em is that mixed unions have a problem, for instance, a parent union can sometimes not take a position if its locals are split. AFSCME has both nurses and physicians whose testimony on SB 491 was opposed to each other. That's supposed to be enough to keep AFSCME off the bill, but that doesn't mean that AFSCME can't advise the California Labor Federation. Last year, for instance, AFSCME and Cal Fed supported SB 863 in defiance of an AFSCME international resolution adopted in 2006 to require utilization review doctors to be licensed in the states where they file their opinions. The UAPD has successfully combined physicians and dentists. The California Society of Industrial Medicine and Surgery (a professional association, not a union) has successfully combined MD physicians and chiropractors. MDs have contributed to their own problem by retaining nurse practitioners and physician assistants under often lax supervision. The UAPD successfully opposed a physician assistant expansion bill several years ago. Attendees at that hearing will remember the explosive epithet that a staffer blurted out as their ship sank and the bill went down to defeat. A recent UAPD publication told how the doctors' union got a raise for physicians when it showed that the nurses in a parallel union were already being paid more. This time it turned out to be a victory for both the doctors' union and and the nurses' union. If SB 491, 492, and/or 493 become law we'll see more of our professionals turning to unionization.

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