In September 2017, the Department of Veterans Affairs granted nurse practitioners the right to treat patients without physician supervision at VA hospitals and clinics across the country. According to this rule, nurse practitioners working at VA sites are permitted "to practice to the full extent of their education, training, and certification, without the clinical supervision or mandatory collaboration of physicians."

While most VA sites implemented what the VA terms "full practice authority" for nurse practitioners, about 10% elected to maintain physician supervision. But on October 31, 2019, the VA made it clear that this resistance to nurse practitioner independence was unacceptable. A memorandum was sent to all VA sites mandating immediate compliance, including at those centers where the physician majority voted to oppose nurse practitioner independent practice.

One of those centers is in Palo Alto, California, where the medical staff voted three separate times on the issue. The first vote occurred at an all-staff meeting in October 2017, with physicians electing to maintain supervision of nurse practitioners.

According to Palo Alto physicians, the hospital administration was not satisfied with the initial vote. "The chief of staff called an urgent second meeting to ask us to re-vote, without even telling us the results of the first vote," says one staff physician, speaking anonymously because he fears retaliation.

In April 2018, the VA sent a memo to the Palo Alto facility requesting a "reexamination of granting Full Practice Authority to APRNs." To prepare for the vote, the VA sent lead nurse practitioner Penny Jensen to Palo Alto to address concerns from medical staff members. After the educational session, the medical staff again voted to maintain physician supervision for the third time.

Now physicians at the Palo Alto site have no choice but to accept nurse practitioner independence. Many are disheartened by the mandate, which they believe disrespects the wishes and judgment of the medical staff. I spoke with a physician who has been on staff with the Palo Alto VA for over five years and is now planning on leaving the VA system. Speaking anonymously because he fears retribution, the physician told me that he feels mistreated by the VA. "They treat us poorly, but then they use the excuse of a physician shortage to justify nurse practitioner independence."

Physicians at the VA in San Antonio also voted twice against nurse practitioner independence. According to staff physicians, the chief operating officer disregarded the medical staff vote. Citing a "federal mandate" the CEO unilaterally granted nurse practitioners membership on the medical staff and required the chief of the medical staff to enter mediation with nurses.

One physician who was involved with the process said that mediation "was a terrible experience." Speaking anonymously because she fears repercussions from administration, she told me that nurse practitioners felt "personally insulted" by a presentation during mediation that compared the statistics on nurse practitioner training to physician training. She says that the presentation was "rudely interrupted and shut off," and that the outside mediator allowed interference despite near-unanimous objection by physicians.

Most physicians believe that allowing nurse practitioners to treat veterans without physician supervision is a bad idea. In July 2016, a group of nearly 100 major physician groups signed a letter asking the VA to reconsider its stance on nurse practitioner independence. Instead, they urged the VA to focus on team-based care with nurse practitioners and physicians working together to provide optimal medical care for veterans.

Nurse practitioners are not permitted to practice independently in more than half of the states in the nation. Physician groups point out that by overriding state law, the VA is offering a different standard of care for veterans than that received by civilian patients. Physicians train for a minimum of 15,000 hours before they are permitted to treat patients independently, while nurse practitioners receive from 500 to 1,500 clinical hours.

While nurse practitioners can offer excellent care as part of a team following protocols, there is no evidence that independent practice is safe and effective for patients. Even the VA's own evidence brief, published in 2014, reported that studies on the quality of care provided by advanced nurses were insufficient to make conclusions about safety and efficacy of these care providers.

By allowing nurse practitioner independence, the VA is ignoring the desires of Americans, who say that they want physician-led care. A 2012 American Medical Association survey found that "four out of five patients ... prefer a physician to have primary responsibility for leading and coordinating their medical care, and 78% of patients agree that nurse practitioners should not be allowed to run their own medical practices without physician involvement."

Jacob Ryan is one such patient. The 38-year-old veteran told me that he was concerned about the care he received from an unsupervised nurse practitioner at the Palo Alto VA. "I was subjected to multiple unnecessary blood tests that had no indication, including a prostate screening test." Prostate screening is not recommended for young men with no family history of prostate cancer.

Ryan also says that he felt treated "by a cookie-cutter algorithm or protocol," rather than receiving the personalized care that he believes all veterans deserve. "Our veteran population is one of the most at-risk in our nation. They deserve the highest level of physician-led care. Instead, this directive creates a two-tier healthcare system for soldiers, sailors, airmen, and marines who fought to give and maintain our country's freedom."

Rather than allowing nurse practitioners to independently treat patients, medical groups like the American Academy of Family Physicians instead advocate for policy changes such as allowing civilian family physicians to provide primary care to veterans. Another policy suggestion is to provide civilian doctors treating veterans the same malpractice protection that VA doctors -- and nurse practitioners -- receive under the Federal Tort Claims Act.

While the VA argues that allowing nurse practitioners to treat patients independently will increase access to care for veterans, the quality of that care is unclear. In addition, costs may rise, as studies show that nurse practitioners order more imaging tests, perform more unnecessary skin biopsies, have poorer quality of referrals, prescribe more medications, and utilize more health resources than physicians.

Our veterans deserve the nation's gratitude for their service, including access to high-quality healthcare. Now, nurse practitioners will be providing care to our veterans, without physician supervision -- whether veterans like it or not.

Rebekah Bernard, MD, is a family physician in Fort Myers, Florida, and president of Physicians for Patient Protection.